The Use of Trimodality Treatment in Patients With Locally Advanced Oesophageal Squamous Cell Carcinoma: An Experience From a Large Cancer Centre in Pakistan.

Introduction Esophageal cancer is one of the most common cancers worldwide. Neoadjuvant chemoradiotherapy followed by surgery is the standard treatment for locally advanced squamous cell carcinoma (SCC). Pathological complete response (pCR) after surgery is associated with better outcomes in terms of overall survival and disease-free survival. We aim to determine the effectiveness of neoadjuvant chemoradiotherapy in patients with locally advanced SCC at our institute, the largest purpose-built cancer center in Pakistan. We also aim to identify various factors influencing pCR, such as chemotherapy regimen, total radiation dose, clinical stage at presentation, and gender. Materials and methods This is a retrospective review of all patients with esophageal SCC presented between January 2019 and 2021 to the institute for treatment. Patients received neoadjuvant chemoradiotherapy (nCRT) as per the CROSS trial protocol, followed by surgery. We assessed the pCR rate. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York). pCR was studied alongside associated factors such as age, gender, stage of disease, chemotherapy regimen, and total dose of radiotherapy. A p-value of <0.05 was considered statistically significant. The chi-square test was used to compare categorical variables. Univariate and multivariate logistic regression was employed to evaluate factors affecting pCR. Results A total of 218 patients were included in the study. pCR was achieved in 64.2% of the patients. The female gender was associated with better outcomes, as 70.4% (n=81) of female patients achieved a complete pathological response, compared to 57.3% (n=59) of males, with a p-value of 0.03. On univariate analysis, the complete pathological response was 69.6% (n=94) in the age group of 45 years and below, whereas it was 55.4% (n=46) in the age group above 45 years, with a p-value of 0.024. Though statistically insignificant, outcomes were slightly better for those with node-negative disease, as 67.2% (n=41) achieved complete pathological response compared to those with node-positive disease at 63.1% (n=99). Univariate logistic regression analysis identified gender (p=0.044, OR=1.77, 95% CI: 1.016-3.108) and age group (p=0.034, OR=1.844, 95% CI: 1.046-3.252) as significantly associated with pCR. Female patients were 77% more likely to achieve pCR compared to male patients (OR=1.77, 95% CI: 1.016-3.108). Younger patients (≤45 years) were 84.4% more likely to achieve pCR compared to the older age group (OR=1.844, 95% CI: 1.046-3.252). However, these did not maintain significance in multivariate logistic regression analysis. Conclusion Our study indicated a high rate of pCR with nCRT in patients with esophageal SCC compared to other studies. The achievement of pCR was higher among females and younger patients, which was statistically significant on univariate logistic regression analysis. Our study also concluded that a higher dose of RT (50Gy/25#) is not superior to a lower dose (45Gy/25#) in terms of pCR achievement but was statistically insignificant. Similarly, CARBO/PAC was not superior to CIS/CAP in terms of pCR achievement and was also statistically insignificant.

Sinonasal Teratocarcinosarcoma: A Rare and Highly Aggressive Neoplasm.

Sinonasal teratocarcinosarcomas (SNTCSs) are malignant and highly aggressive neoplasms arising in the nasal cavity and paranasal sinuses with extension into surrounding structures and intracranial extension in few instances. They are commonly found in males (7-8 times more than in females). They pose difficulty in diagnosis due to their diverse histology. Ideal treatment modalities have not been devised yet due to the rare and highly aggressive nature of SNTCSs as shown in this case report. A 29-year-old Asian male was initially misdiagnosed on biopsy. Surgical debulking was performed initially which showed SNTCSs with radiological evidence of residual disease for which gross tumor clearance was done. He presented within a short span of a month, post re-resection with gross local recurrence. Urgent palliative radiotherapy was planned and started but unfortunately, he developed pulmonary and hepatic metastasis during radiation therapy and was commenced on palliative care only due to significant deterioration of performance status. Treatment of SNTCSs is often delayed due to their difficulty in diagnosis. Its highly aggressive nature prompts an urgent and aggressive treatment approach with adjuvant chemoradiation. Any type of adjuvant therapy is better than surgical resection only given its timely administration and close surveillance.

Impact of Cancerous Pulmonary Involvement on Outcomes in COVID-19 Patients.

BACKGROUND: SARS-CoV2 is a highly contagious virus causing COVID-19 (Corona virus disease 2019), which has resulted in more than 6 million deaths worldwide as of June 2022. Mortality in COVID-19 has mainly been attributed to respiratory failure. Previous studies showed that the presence of cancer did not adversely affect the outcome of COVID-19. However, in our clinical practice, it was noted that in cancer patients with pulmonary involvement, COVID-19-related morbidity, and morbidity were high. Therefore, this study was designed to assess the impact of cancerous pulmonary involvement on COVID-19 outcomes and to compare clinical outcomes of COVID-19 in cancer and non-cancer population, with further discretion between cancers with and without pulmonary involvement. METHODS: We performed a retrospective study from April 2020 until June 2020 with a sample size of 117 patients with a confirmed diagnosis of SARS-CoV2 on nasal swab PCR. Data was extracted from HIS (Hospital Information System). Hospitalization, supplemental oxygen, ventilatory support, and death were compared between non-cancer and cancer patients with a particular focus on pulmonary involvement. RESULTS: Admissions, supplemental oxygen requirement, and mortality were significantly higher in cancer patients with pulmonary involvement (63.3%, 36.4%, and 45%, respectively) compared to cancer patients without pulmonary involvement (22.1%, 14.7%, and 8.8% respectively) (p-values: 0.00003, 0.003, and 0.00003 respectively). In the non-cancer group, there was no mortality, only 2% required admission, and none needed supplemental oxygen. CONCLUSION: We conclude that the cancer patient with pulmonary involvement was significantly at higher risk of complications and death from COVID when compared with the non-pulmonary cancer group and the general population.

Barriers and Enablers to Joining the National Organ Donation Registry Among Patient Population at a Tertiary Care Hospital of Peshawar, Pakistan.

Background Organ transplantation is a life-saving therapy for patients with end-stage organ failure. However, the demand for organs far exceeds their availability, leading to longer waiting times and increased mortality rates. Pakistan faces a similar situation, with a shortage of organ donors and several barriers to therapeutic organ donation, including cultural, religious, and political ones. Objective The objective of this study was to understand the barriers and enablers to joining the national organ donation registry among patient populations at a tertiary care hospital in Peshawar, Pakistan. The findings can then guide targeted educational campaigns to improve the state of therapeutic organ transplants in the country. Methods A descriptive, cross-sectional study was conducted at the Outpatient Departments of Lady Reading Hospital, Peshawar, targeting all patients and visitors aged 18 to 60 who presented to the outpatient departments of the hospital. A modified and validated questionnaire was used to collect data, which were analyzed using Statistical Package for Social Sciences (SPSS) version 26. Results: The study analyzed the attitudes of 342 individuals, among which 82.18% had not heard about Pakistan's Organ Donation Registry, 58.09% agreed with organ donation, and 23.68% suggested they would like to join the registry someday. Religious beliefs and the lack of knowledge about the laws related to organ donation stood out as statistically significant barriers to joining the national organ donation registry of Pakistan (p<0.05). The study also found that the willingness to donate was significantly higher among those who themselves encouraged organ donation and were willing to do so if the country's system were to support it (p<0.05). Conclusion The majority of participants had not heard of the organ donation registry, and a lack of knowledge about the legal framework and religious beliefs were significant barriers to joining the registry. This is hindering the growth of therapeutic organ transplantation in Pakistan. In addition, the willingness to donate was higher among those who supported organ donation and believed in its benefits. Increasing awareness and promoting a culture of organ donation in Pakistan can help address the shortage of organ donors and improve the state of therapeutic organ transplantation in the country.

Survival Of Patients With Brain Metastases After Palliative Whole-Brain Radiotherapy - An Experience From A Single Institute.

BACKGROUND: Brain metastases are a common complication of cancer and approximately 20% of cancer patients develop them over time. Presently palliative whole-brain radiotherapy is used as a palliative treatment for brain metastases because of its cost-effectiveness and easy availability, especially in patients with multiple metastases who are not candidates for surgery or Stereotactic radiosurgery. This study aims to determine the survival in patients who have received palliative whole-brain radiotherapy for brain metastases and to evaluate some of the prognostic factors determining survival in patients with brain metastases. METHODS: It was a cross-sectional study conducted in Shaukat Khanum Memorial Cancer Hospital and Research Centre and all the patients with brain metastases who had completed palliative whole-brain radiotherapy between July 2015 and July 2020 were included. Data was retrospectively collected and analyzed using SPSS 21.0. Overall survival was calculated using the Kaplan-Meier method, taking into consideration the period from the date of diagnosis of brain metastases until death or to the date of last follow-up, whichever was applicable. p-value of <0.05 was regarded as statistically significant. RESULTS: Almost half (45%) of the brain metastases were secondary to breast cancer followed by lung and genitourinary cancers at 16.3% and 15.5% respectively. The median overall survival was lowest in breast carcinoma patients at 5 months followed by lung carcinoma at 7 months. The median overall survival was 5 months in patients having extracranial disease as compared to 12 months in those having no extracranial disease or those in whom the disease status was unknown. CONCLUSIONS: Our study revealed that the most common tumour to metastasize to the brain was breast cancer. The younger age group had a poorer prognosis because most of them had breast cancer with triple-negative disease. Controlled extracranial disease significantly prolonged overall survival in patients with brain metastases.

Central Pontine Myelinolysis in Pregnancy: A Case of Rare Occurrence.

Central pontine myelinolysis is a non-inflammatory neurologic deficit and can have a wide array of clinical features, predisposing risk factors as well as different patterns of onset along with a big difference in prognosis ranging from asymptomatic cases to encephalopathy and also mortality. Apart from the common risk factors like hyponatremia and sudden correction of electrolyte imbalances, sometimes, the least prevalent risk factors such as pregnancy seem to link with the central pontine myelinolysis. Mostly its onset is sudden after the inciting factors. However, it is also likely to have cases of central pontine myelinolysis with gradual onset of clinical features. The purpose of the case report is to highlight the link between pregnancy and central pontine myelinolysis. The slow onset of clinical features in pregnancy-linked central pontine myelinolysis can also be considered. The patient in the case report presented with gradual onset clinical features of osmotic demyelination syndrome during the last months of pregnancy and immediately postpartum. All the possible predisposing risk factors for central pontine myelinolysis were ruled out through history, physical examination, and relevant investigations. The case study of the patient hypothesized that: (1) pregnancy should be considered as a risk factor for central pontine myelinolysis in pregnant and postpartum patients presenting with clinical features of the disease, (2) clinical features of central pontine myelinolysis in pregnancy can have a more gradual onset of symptoms compared to other causes of central pontine myelinolysis. Although, this case report signifies a relationship between pregnancy and osmotic demyelination syndrome. However, further studies should be done to develop a causal relationship and preventive measures for the condition.