High P16INK4A Expression, Keratinizing Features, and Surgical Margin-Free Status are Associated with Improved Survival in Patients with Oral Squamous Cell Carcinomas.

BACKGROUND: Oral squamous cell carcinoma (OSCC) continues to prevail as a highly prevalent cancer in Southeast Asia and causes a significant health burden. Stratification of patients with high risks of recurrence and mortality is important in the planning of treatment and surveillance. METHODS: Formalin-fixed paraffin-embedded (FFPE) tissues of OSCC were immuno-stained and analyzed for p16 expression. Risk factors and clinical parameters of OSCC patients were collected and compared to identify factors associated with recurrences and overall survival. RESULTS: After a median follow-up of 32 months, OSCC recurrences and mortality were observed in 82% and 78% of patients (N=60), respectively. Larger and more extensive tumors (T3 and T4) were significantly associated with both recurrences and cancer-associated mortality (OR = 3.967, 95% CI = 1.007-15.618 and OR = 5.885, 95% CI = 1.541-22.47, respectively). P16INK4A positive staining was found in 31% of tumors. Patients with p16INK4A positive staining were significantly associated with better recurrence-free and overall survivals (medians of recurrence-free survivals were 31.2 vs 19.0 months, P=0.038 and overall survivals were 39.0 vs 28.8 months,  P=0.048; respectively). Some other clinical characteristics including early stages, non-keratinizing tumors, negative cervical node, and free-surgical margin were significantly associated with better recurrence-free and overall survivals (log-rank tests, P<0.05). CONCLUSION: P16INK4A positive staining, early stages, negative cervical lymph node infiltration, and free-surgical margins are associated with better prognosis in OSCC patients. The study emphasizes the importance of early detection and the potential use of p16INK4A and other clinical variables to stratify OSCC patients with high risks of recurrence and worse overall survivals.

Right Thigh Mass Metastasis from Lung Cancer Mimicking Primary Soft Tissue Sarcoma: A Case Report.

BACKGROUND Soft tissue metastases (STMs) are less common than bone metastases and sometimes misdiagnosed as primary soft tissue malignancies. Skin, lungs, and breast are the most common primary lesions of STMs and rarely the presenting symptoms. We present an STM from lung adenocarcinoma that became a presenting symptom in nonsmoking woman. CASE REPORT A 47-year-old woman presented to our hospital with a painful mass in her right thigh and weight loss of 10 kg for 4 months. Femoral radiograph revealed a lesion suggestive of bone sarcoma. However, magnetic resonance imaging (MRI) showed it was more likely a primary soft tissue sarcoma. A small mediastinal mass was noticed on preoperative chest radiograph, and the patient denied any symptoms except the mass in the right thigh. Our clinicopathological conference team decided to perform a biopsy of mediastinal and right thigh masses. Histopathology examinations confirmed the right thigh mass as soft tissue metastasis from mediastinal mass, confirmed as lung adenocarcinoma. We treated the patient with palliative care with zoledronic acid and gefitinib. At the 6-month follow-up, the patient's symptoms significantly improved, and MRI showed a marked size reduction. CONCLUSIONS Diagnosis of STM can be difficult when presenting as the primary manifestation. Failure to identify promptly can lead to rapid disease progression and unfavorable prognosis. Failure to diagnose primary malignancy during biopsy occurs in approximately 28% of cases. This report has the potential to facilitate the avoidance of unnecessary procedures and highlight the importance of using a multidisciplinary approach in managing cases with malignancy.

Associations between pesticide exposure with biomarkers of stroke risk factors in farmers.

The extensive use of pesticides may cause acute and chronic intoxication. Therefore, this study aimed to reveal the associations between pesticide exposure and serum markers for stroke risk factors in farmers. A cross-sectional study was conducted with farmers, who used chemical pesticides in Seloprojo Village, Ngablak District, Magelang Regency, Central Java Province, Indonesia. A questionnaire containing demographics, pesticide use, and aspects related to work was employed. Measurements of serum cholesterol, uric acid, glucose, cholinesterase, and fibrinogen levels were also conducted. Of the 106 subjects, 31 (29.2%) used organophosphates as chemical pesticides. There was a significant difference between organophosphate and nonorganophosphate groups in plasma fibrinogen levels. The organophosphate group had higher levels of fibrinogen (292.29 ± 67.56 mg/dL) than the non-organophosphate group (255.24 ± 38.90 mg/dL). Of the studied risk factors for stroke, there is a significant association between organophosphate exposure and increased plasma fibrinogen levels.

Beyond invasive biopsies: using VASARI MRI features to predict grade and molecular parameters in gliomas.

BACKGROUND: Gliomas present a significant economic burden and patient management challenge. The 2021 WHO classification incorporates molecular parameters, which guide treatment decisions. However, acquiring these molecular data involves invasive biopsies, prompting a need for non-invasive diagnostic methods. This study aims to assess the potential of Visually AcceSAble Rembrandt Images (VASARI) MRI features to predict glioma characteristics such as grade, IDH mutation, and MGMT methylation status. METHODS: This study enrolled 107 glioma patients treated between 2017 and 2022, meeting specific criteria including the absence of prior chemotherapy/radiation therapy, and the presence of molecular and MRI data. Images were assessed using the 27 VASARI MRI features by two blinded radiologists. Pathological and molecular assessments were conducted according to WHO 2021 CNS Tumor classification. Cross-validation Least Absolute Shrinkage and Selection Operator (CV-LASSO) logistic regression was applied for statistical analysis to identify significant VASARI features in determining glioma grade, IDH mutation, and MGMT methylation status. RESULTS: The study demonstrated substantial observer agreement in VASARI feature evaluation (inter- and intra-observer κ = 0.714 - 0.831 and 0.910, respectively). Patient imaging characteristics varied significantly with glioma grade, IDH mutation, and MGMT methylation. A predictive model was established using VASARI features for glioma grade prediction, exhibiting an AUC of 0.995 (95% CI = 0.986 - 0.998), 100% sensitivity, and 92.86% specificity. IDH mutation status was predicted with AUC 0.930 (95% CI = 0.882 - 0.977), and improved slightly to 0.933 with 'age-at-diagnosis' added. A model predicting MGMT methylation had a satisfactory performance (AUC 0.757, 95% CI = 0.645 - 0.868), improving to 0.791 when 'age-at-diagnosis' was added. CONCLUSIONS: The T1/FLAIR ratio, enhancement quality, hemorrhage, and proportion enhancing predict glioma grade with excellent accuracy. The proportion enhancing, thickness of enhancing margin, and T1/FLAIR ratio are significant predictors for IDH mutation status. Lastly, MGMT methylation is related to the longest diameter of the lesion, edema crossing the midline, and the proportion of the non-enhancing lesion. VASARI MRI features offer non-invasive and accurate predictive models for glioma grade, IDH mutation, and MGMT methylation status, enhancing glioma patient management.

A renal aplasia case mimicking radiologically as unilateral renal agenesis in a child with spina bifida, atresia ani and unilateral undescended testis: a case report.

BACKGROUND: As a result of the failure of embryogenic kidney formation, a condition can occur where not a single kidney appears and this phenomenon is known as unilateral renal agenesis (URA). Both aplastic and dysplastic kidney are different from renal agenesis, atrophy and renal hypoplasia. However, from this case report it can be seen that there are similarities, both radiologically and macroscopically, between cases of unilateral renal aplasia and renal agenesis. CASE PRESENTATION: A 2 year old Javanese boy came to the health facility with complaints of recurrent fever and urinary tract symptoms such as dysuria and straining. Computerized Tomography (CT) scan of the abdomen and urography showed agenesis of the left kidney and a probable spina bifida. Cystourethrography examination was done and showed grade 5 voiding, then retrograde pyelography was performed with the diagnosis of unilateral renal agenesis was made because there was no visible left side collecting system even though there was a duplication in the left ureter. The next examination was carried out by histopathology and immunohistochemistry after resection of the left side of the ureter and the diagnosis increasingly pointed towards renal aplasia after primitive renal structures were found. CONCLUSIONS: Renal agenesis and aplastic kidney are difficult to differentiate macroscopically and radiologically. Nevertheless, from this case report, we try to provide some interesting points to differentiate cases of unilateral renal agenesis from Renal Dysplasia which presents as unilateral renal aplasia.

Neuropathy caused by pesticide exposure on farmers in Ngablak District, Magelang, Central Java, Indonesia: An electroneuromyography study.

Uncontrolled and unsafe use of pesticides can lead to acute and chronic toxicity in farmers, with neuropathy being one of the most common symptoms of chronic toxicity. However, the effects of this toxicity on farmers' electroneuromyography (ENMG) are still unclear. To address this, we conducted a cross-sectional study from July to October 2017 in Ngablak District, Magelang, Central Java, Indonesia. Eligible farmers who were exposed to pesticides underwent electrophysiology examinations, as well as additional tests such as physical examination and laboratory testing. We collected general information such as age and work history by interview. In total, 64 farmers were included in this study. Out of these, 44 farmers were found to have polyneuropathy, with 41 of them having motor polyneuropathy and 19 of them having sensory polyneuropathy. Our findings showed that low blood cholinesterase was associated with distal latency prolongation (p-value: 0.014). The group exposed to organophosphate/carbamate pesticides was also significantly associated with prolonged distal latency (p-value: 0.012). However, motor polyneuropathy was significantly associated with chronic exposure to organophosphate/carbamate pesticides (p-value: 0.009) and not with low blood cholinesterase levels (p-value: 0.454). The study concludes that chronic exposure to organophosphate or carbamate pesticides could result in polyneuropathy disease, particularly in the motor system.

Prognostic Value of Vimentin in Triple Negative Breast Cancer Patients Depends on Chemotherapy Regimen and p53 Mutant Expression.

Purpose: To determine the prognostic value of vimentin in triple negative breast cancer (TNBC) patients, specifically in relation to chemotherapy regimen and p53 mutant expression. Patient and Methods: We retrospectively analyzed the association of pre-treatment tumor expression of vimentin with 48-month overall survival (OS) of 72 all stages TNBC patients diagnosed between 2014 and 2018 in relation to chemotherapy regimen and expression of p53 mutant. Vimentin and p53 mutant expressions were examined using immunohistochemistry. Analysis was conducted on all patients collectively, then repeated on two cohorts divided according to the chemotherapy regimen. Sub-analysis was performed to determine the effect of p53 mutant expression on the prognostic value of vimentin. Results: Vimentin was expressed in 43.1% of patients and was not associated with clinicopathologic characteristics. Vimentin was associated with improved 48-month OS in all patients in univariate analysis but not significant in multivariate analysis. When analyzed according to chemotherapy regimen, vimentin was independently associated with improved 48-month OS in patients receiving non-platinum-based chemotherapy (80% vs 15.8%; HR: 0.17, 95% CI: 0.05-0.58, p: 0.005). Other independent prognostic factors include T (HR: 6.18, 95% CI: 1.38-27.7, p: 0.017) and M (HR: 5.64, 95% CI: 1.2-26.33, p: 0.028). On subanalysis, vimentin was significantly associated with improved 48-month OS in patients expressing p53 mutant (69.2% vs 22.2%, p: 0.006) but was not significant in patients not expressing p53 mutant. Conclusion: Vimentin expression was independently associated with improved 48-month OS in TNBC patients treated with non-platinum-based chemotherapy. Expression of p53 mutant significantly affected the prognostic value of vimentin.

Classic and rare manifestations of multiple osteoma: A case report.

INTRODUCTION AND IMPORTANCE: Osteoma is a benign tumor that can arise from compact or cancellous bone and is more commonly found in the face or skull. The incidence of osteoma believed to be underreported as most are asymptomatic. To date, the best modality to diagnose osteoma is CT scan. We report a unique case of osteoma presenting with cranial and extracranial manifestations and highlight the importance of bone survey in evaluating patients with osteoma. CASE PRESENTATION: A 26-year-old female complained of bilateral pain in the jawbone and several areas of her head. On physical examination, there were several masses in the head with the largest on the left mandible measuring 5.6 × 6.0 × 4.5 cm from MSCT examination. Hemi-mandibulectomy, histopathological and cytopathology examination were performed on the tissue obtained from the left mandible which concluded osteoma. Post-operative bone survey was performed and found osteoma on left ulna and bilateral fibula. Suspected Gardner syndrome with multiple osteoma manifestation was excluded from normal results of colon in-loop examination. We conservatively monitored the patient and most recent 6-month follow-up found no complaint nor changes in the extracranial osteoma manifestation on left ulna and both fibulas. CLINICAL DISCUSSION: The benign tumor osteoma is incredibly uncommon to present both intra and extracranially. We suggest thorough skeletal studies such as bone survey to be performed as they are crucial in the full evaluation of patients with multiple osteomas. Osteoma treatment is based on the patient's symptoms, surgery for patients with symptoms and periodic monitoring for asymptomatic patients. CONCLUSION: It is necessary to consider radiological modality for diagnosing osteoma patients. The majority of osteomas are asymptomatic and the choice of radiological examination sometimes still misses the lesion. It is important to evaluate histologically if the lesion difficult to diagnose.

Association of Pesticide Exposure with Cognitive Function in Farmers.

INTRODUCTION: Organophosphate and carbamate are two types of pesticides that can induce cholinesterase suppression in humans. These lead to poisoning symptoms including muscle paralysis and respiratory depression in acute settings. In chronic settings, the mechanism of organophosphate and carbamate poisoning is still openly discussed. Accordingly, this study aimed to identify any correlations between erythrocyte cholinesterase and type of pesticides with cognitive performance of the subjects. METHODS: This cross-sectional study was conducted in two sampling periods (July 2017 and October 2018) in Ngablak Districts, Magelang Regency, Central Java, Indonesia. The study subjects were farmers with history of pesticide exposure. Cholinesterase levels (ChE) were analyzed from blood samples. Cognitive performance was assessed using the Mini Mental State Examination (MMSE) and Stroop Test. RESULTS: In total, 151 subjects aged between 23 and 91 years old were included. The long-term organophosphate exposure group had significantly lower MMSE scores compared with other types of pesticides, but not in carbamate (p = 0.017). After comparing "organophosphate only" and "carbamate only" groups, there were significant differences in MMSE scores (p = 0.018) but not in blood ChE levels (p = 0.286). Detailed assessment in MMSE domains showed significantly lower scores for orientation, attention, and registration domains (p < 0.05) in the organophosphate group. There were no significant associations between types of pesticides and blood ChE levels with the Stroop Test results (p > 0.05). CONCLUSIONS: Long-term organophosphate exposure could produce lower cognitive function and the insignificant association between blood ChE levels to MMSE could lead to non-cholinergic pathways as its underlying pathology.

Prevalence of pesticide related occupational diseases among Indonesian vegetable farmers - A collaborative work.

Objective: This study was done to understand the prevalence of various occupational diseases including dry eyes, nail dystrophy, and neuropathy related to pesticide exposure in Indonesian local vegetable farmers. Methods: The data were collected through questionnaires and physical examination involving dermatology, neurology, and ophthalmology domains at Ngablak District, Magelang, Central Java directed to local vegetable farmers. Ocular Surface Disease Index (OSDI) questionnaire and the Schirmer test were used. Analysis was done using descriptive statistics using the Statistical Package for the Social Sciences (SPSS 21.0) and presented in tables. Results: Inadequate spraying equipment and improper storage of pesticides were found. Out of 105 farmers, 41.9 % experienced occupational skin diseases (OSD). Definite cognitive impairments were found in 3.4 % of subjects but probable in 28.3 % of subjects. Neuropathies were found in 61.7 % of subjects, and dry-eyes syndrome were found in 28.78 % of subjects. Conclusion: There was a high prevalence of peripheral neuropathy and tremor, dry eyes syndrome in one-third of the population, and the most common skin problem was nail discoloration, with a low incidence of contact dermatitis.

Risk Factors, Patterns, and Distribution of Bone Metastases and Skeletal-Related Events in High-Risk Breast Cancer Patients.

BACKGROUND: More than a quarter of breast cancer patients are at risk to develop recurrent metastases to the bone. OBJECTIVE: This study was designed to identify risk factors and predilections of bone metastasis and skeletal-related events (SRE) in a population of breast cancer survivors initially diagnosed in advanced stages and with high-risks of relapse. METHODS: Associated risk factors, distribution, and attainable treatment of bone metastasis and SRE were analyzed in a cohort of 1,329 breast cancer patients. The association with dependent variables was subsequently analyzed using multivariable logistic regression. Sociodemographic and adverse clinical characteristics were included as covariates of progression into bone metastasis and SREs. RESULTS: Of 1329 breast cancer patients, 246 patients (18.5%) were diagnosed as metastatic breast cancer in which 232 of them (94.3%) had bone metastases. Spines were the most common sites of bone metastases (25.6%). In multivariable analysis, advanced stage at diagnosis (OR=1.840, 95%CI:1.198-2.826, P=0.005), luminal subtype (OR=1.788, 95%CI:1.206-2.652, P=0.045), lobular histology (OR=1.795, 95%CI:1.012-3/184, P=0.046), positive axillary lymph node (OR=1.771, 95%CI:1.087-2.886, P=0.022), multiple metabolic comorbidities (OR=2.193, 95%CI:1.371-3.508, P=0.001), early menopause (OR=2.136, 95%CI:1.116-4.464, P=0.046) were significantly associated with risk of recurrent bone metastases. SREs occurred in 89 (68.5%) patients. Several risk factors for SREs were early menopausal age (OR=2.342, P=0.024), advanced stages (OR=1.404, P=0.039), lobular histology (OR=2.279, P=0.007), and having multiple metabolic comorbidities (OR=1.728, P=0.039). CONCLUSION: Bone metastases and SREs are relatively high in breast cancer patients diagnosed in advanced stages. Luminal subtypes, having multiple metabolic comorbidities, and lobular histology are associated with higher risks of recurrent bone metastases. Living in rural areas and advanced stage at diagnosis as a risk factors for bone metastases might represent a social gradient of care delivery.

Dp71 and intellectual disability in Indonesian patients with Duchenne muscular dystrophy.

INTRODUCTIONS: Duchenne muscular dystrophy (DMD) is an X-linked recessive progressive muscular disease marked by developmental delays due to mutations in the DMD gene, which encodes dystrophin. Brain comorbidity adds to the burden of limited mobility and significantly impacts patients' quality of life and their family. The changes of expression of dystrophin isoforms in the brain due to DMD gene mutations are thought to be related to the cognitive and neurobehavior profiles of DMD. OBJECTIVES: This cross-sectional study aimed to characterize cognitive and neurodevelopmental profiles of patients with DMD and to explore underlying genotype-phenotype associations. METHODS: Patients with DMD aged 5-18 years from Dr Sardjito Hospital and Universitas Gadjah Mada Academic Hospital from 2017-2022 were included. Multiplex ligation-dependent probe amplification and whole exome sequencing were used to determine mutations in the DMD genes. Cognitive function was measured by intelligence quotient testing using the Wechsler Intelligence Scale for Children and adaptive function tests with Vineland Adaptive Behavior Scales. The Autism Mental Status Exam and Abbreviated Conner's Rating Scale were used to screen for autism spectrum disorder (ASD) and attention deficit and hyperactivity disorder (ADHD), respectively. RESULTS: The mean total IQ score of DMD patients was lower than that of the general population (80.6 ± 22.0 vs 100 ± 15), with intellectual disability observed in 15 boys (29.4%). Of the 51 patients with DMD, the Dp71 group had the lowest cognitive performance with a total IQ score (46 ± 24.8; p = 0.003), while the Dp427 group and Dp140 group's total IQ scores were 83.0 ± 24.6 and 84.2 ± 17.5 respectively. There were no DMD patients with ASD, while 4 boys (7.8%) had comorbidity with ADHD. CONCLUSION: Boys with DMD are at higher risk of intellectual disability. The risk appears to increase with mutations at the 3' end of the gene (Dp71 disruption). Moreover, Dp71 disruption might not be associated with ADHD and ASD in patients with DMD.

Cold abscess as a primary manifestation of thyroid tuberculosis.

Tuberculosis remains the highest cause of infection-related mortality in low- and middle-income countries. Extra-pulmonary tuberculosis is often misdiagnosed because of the nonspecific clinical presentations and gaps in the laboratory assessment. Delayed and misdiagnosis can cause increased risks of morbidity and potential community transmission. Primary thyroid tuberculosis is very rare presentation even in the endemic area. We presented a Case Illustrated of a patient with cold abscess as a primary presentation of thyroid tuberculosis. Difficulty in the diagnosis and treatment were described. Although very rare, atypical presentation of extra-pulmonary tuberculosis in the thyroid gland requires thorough anamnesis and in-depth examination. Clinicians should put high-index suspicion on high-risk patients from endemic areas with medical comorbidity including immunocompromised disease and poor nutritional status. Our report underlines the importance of thorough medical assessment for unusual presentation of thyroid tuberculosis.

Association of Hormonal Contraception with Meningioma Location in Indonesian Patients.

BACKGROUND: Meningioma is the most common primary intracranial tumor. Previous studies have shown the possible association between hormonal contraceptive use and meningioma location. Therefore, this study aimed to analyze the association between the history of hormonal contraceptive use and the location of meningioma in the Indonesian population. METHODS: In total, 99 histologically confirmed female meningioma patients admitted to Dr. Sardjito General Hospital Yogyakarta, Indonesia, were included in this study. Data on hormonal contraception and other variables were collected from medical records. Meningioma locations were determined from brain Magnetic Resonance Imaging (MRI) or Computerized Tomography (CT) scan before surgery. RESULTS: Seventy-two (72.7%) patients had a history of hormonal contraceptive use. The subjects consist of 83 (83.8%) WHO grade I and 16 (16.2%) WHO grade II and III tumors. A total of 57 (57.6%) tumors were located in the spheno-orbital region. We found a significant association between hormonal contraceptive use and meningioma location in the spheno-orbital region (Odds ratio (OR) 2.573, p=0.038). This resulted in the patients in the hormonal contraception group having more visual impairment (p=0.044). CONCLUSION: The use of hormonal contraception is associated with the location of meningioma in the spheno-orbital region.

Hemi-mandibulectomy without bony reconstruction: A case report of mandibular metastasis from a silent differentiated papillary thyroid cancer.

INTRODUCTION: Distant spread to the jaw is a rare metastatic manifestation from papillary thyroid cancer. Complete resection of tumor extension in the facial and oral regions requires consideration to compromise mastication functioning and facial aesthetics. Current advances in the microvascular surgery have facilitated excellent restoration of patient's functioning. Inadequate expertise, facility, longer surgery time and inpatient care, and healthcare insurance disbursement are common challenges in developing countries to perform microvascular surgery. CASE PRESENTATION: A 54-year female presented in an oncology clinic with a rapid progressive lump in the jaw without inflammatory signs. CT-scan revealed a 5.9x5.3 × 5cm lesion with osteo-destruction in the left mandible body. Biopsy was performed indicating a papillary adenocarcinoma invasion. Neck sonography showed hypoechoic nodule with regular border in the thyroid lobes. Fine-needle aspiration biopsy revealed benign follicular cells with Bethesda class II. Total thyroidectomy with frozen section and left hemi-mandibulectomy without bony reconstruction were then performed. Histopathological examination showed papillary thyroid cancer with follicular variant in the thyroid and mandible lesion. Thyroid ablation, TSH suppression, and chewing rehabilitation programs were accomplished by the patient. DISCUSSION: Partial mandibulectomy without bony reconstruction might be an option for selected patients with careful consideration from multidisciplinary team members in which extensive surgery with immediate bony reconstruction is not possible.

Mutation spectrum analysis of DMD gene in Indonesian Duchenne and Becker muscular dystrophy patients.

Background: Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are allelic disorders caused by mutations in the DMD gene. The full mutation spectrum of the DMD gene in Indonesian patients is currently unknown. Mutation-specific therapies are currently being developed, such as exon skipping or stop codon read-through therapy. This study was conducted with the aim of identifying the mutation spectrum of the DMD gene in Indonesia to guide future development and application of feasible therapeutic strategies. Methods: This study is a cross sectional study that enrolled 43 male patients with a clinical suspicion of DMD or BMD. Multiplex ligation-dependent probe amplification (MLPA) reaction was performed to screen for the common mutations in the DMD gene. Results: Out of 43 subjects, deletions accounted for 69.77% (n=30) cases, while duplications were found in 11.63% (n=5) cases. One novel duplication spanning exons 2 to 62 was identified. Deletion mutations clustered around the distal (66.67%) and proximal (26.67%) hot spot regions of the DMD gene while duplication mutations were observed solely at the proximal region. Two false positive cases of single exon deletion detected through MLPA were attributed to sequence mutations affecting primer ligation sites, confirming the need to validate all single exon deletions when using this screening method. Analysis of available maternal DNA samples showed that the rate of de novo mutations (48.15%) appears higher than expected in this population. Out of 31 patients who were classified as DMD based on clinical and genotype characterizations, 60.47% (n=26) of cases were suitable for exon skipping therapy. Conclusion: This is the first comprehensive study showing the feasibility of implementing the MLPA method for routine screening of DMD patients in Indonesia. This is also the first study showing the potential applicability of exon skipping therapy in the majority of DMD cases in the country.

Diagnostic Accuracy of Immunohistochemistry in Detecting MGMT Methylation Status in Patients with Glioma.

BACKGROUND: The O6-methylguanine-DNA methyltransferase (MGMT) gene prevents mismatch in DNA replication and transcription by repairing mutagenic DNA lesions. MGMT is a predictor biomarker of chemotherapy in high-grade and low-grade gliomas based on high-risk clinical conditions. It also can be used for therapeutic decisions to predict hypermutation in recurrence in newly diagnosed low-grade gliomas. The gold standard  examination for the methylation is Polymerase Chain Reaction (PCR). However, this technique is not widely available in Indonesia for daily practice. Thus, an uncomplicated and simpler method such as immunohistochemistry (IHC) is needed as an alternative examination. This study aimed to predict the diagnostic accuracy of immunohistochemistry (IHC) in detecting the methylation status of O6-methylguanine-DNA methyltransferase (MGMT) in glioma. METHODS: This research was a cross-sectional study using formalin-fixed paraffin embedded (FFPE) tissue samples of glioma patients, dating between October 2017 until March 2021. Diagnosis of glioma was established based on clinical, radiological, and histopathological findings. MGMT methylation status was investigated using the IHC and PCR techniques. Diagnostic value of IHC was analyzed, with PCR as a gold standard method. Optimum threshold to determine positivity of IHC was determined by the Area Under the Curve (AUC) on Receiver Operating Characteristics (ROC) curve and Youden index. RESULTS: Among 75 samples examined, 29 (38.7%) patients were methylated. IHC detected MGMT methylation with sensitivity of 86.2%, specificity of 63.0%, positive predictive value of 59.5%, negative predictive value of 87.9% and accuracy of 72.0%. The AUC was 0.746, indicating moderate diagnostic value. Optimum positivity threshold of the IHC examination based on Youden Index was 10%. CONCLUSION: IHC examination can be used to detect MGMT methylation status of glioma patients in limited resources setting, where PCR technique is not available.

The Distribution of M2 Macrophage and Treg in Nasopharyngeal Carcinoma Tumor Tissue and the Correlation with TNM Status and Clinical Stage.

OBJECTIVE: This study aimed to identify the distribution of M2 macrophage and Treg in Nasopharyngeal Carcinoma (NPC) tumor tissue samples. The presence of these two groups of cells was further correlated to clinical stage, tumor size, the lymphatic node involvement, and metastasis. METHODS: The total of 50 formalin-fixed paraffin-embedded (FFPE) NPC tissue samples was collected retrospectively (27 samples) and prospectively (23 samples). Samples were FFPE tissue slices. Immunohistochemistry was done on the FFPE tissue slides using anti-CD-163 and anti-FoxP-3 antibodies for M2 macrophage and Treg detection, respectively. The M2 macrophage interpretation was performed by eye-balling method and the score was divided into 0 (negative), 1 (scant), 2 (focal), and 3 (abundant). The average number of Treg FOXP3+ cells in 5 high power fields (HPF) was calculated. The relationship of M2 macrophage and Treg was tested with Spearman's correlation. The relationship between M2 macrophage and Treg with clinical stage, tumor size, node involvement and metastasis was tested by chi square, with p<0.1. RESULTS: M2 macrophage and Treg were positive correlated (r=0.469, p<0.001). The presence of M2 macrophage and regulatory T cell (Treg) was significantly correlated to tumor size (p= 0.091 for M2 macrophage and p=0.022 for Treg) and clinical stage (p= 0.030 for M2 macrophage and p= 0.002 for Treg), but did not correlate with lymphatic node involvement and metastasis. CONCLUSIONS: In Epstein-Barr virus related NPC tumor microenvironment, the presence of M2 macrophage was correlated with Treg, and both types of the cells were correlated with tumor size and clinical stages.

Necrosis Factor-α (TNF-α) and the Presence of Macrophage M2 and T Regulatory Cells in Nasopharyngeal Carcinoma.

OBJECTIVE: To investigate the correlation between TLR3 and pro-inflammatory cytokines (TNFα, IL6) expression with the distribution of macrophage M2 and Treg on Epstein Barr virus-encoded RNAs (EBER+) nasopharyngeal carcinoma (NPC) tissues. METHODS: A total of 23 FFPE NPC tissue samples were obtained from patients in Dr. Sardjito General Hospital, Yogyakarta, Indonesia in 2008-2010, which expressed EBER was collected. The expressions of TLR3, TNFα, and IL6 were examined using immunofluorescence assay. The distribution of macrophage M2 and Treg were examined by immunohistochemistry with anti-CD163 and -FOXP3 antibodies, respectively. The quantification of fluorescence intensity was analyzed by the RGB space method using ImageJ software. The M2 interpretation was done by the eyeballing method and the M2 scores were divided into 0 (negative), 1 (scant), 2 (focal), 3 (abundant). The average number of Treg FOXP3+ cells in five high power fields was counted. The relationship between variables were tested by the Spearman correlation test, and the coefficient correlation was used to see the correlation between variables. RESULTS: All EBER+ NPC specimens showed TLR3 expression intracellularly. The expression of TNFα could be observed in the cell membranes and secreted extracellularly, while IL6 was secreted to the extracellular area. The expression of TNFα was two times higher than IL6. Most specimens showed low M2 score (56.52%) and high Treg (52.17%). A positive correlation was found between TLR3 and IL6 (12.9%). TNFα was positively correlated with the M2 distribution of 13.7% and Treg distribution of 12.9%, while the rest were explained by other factors. CONCLUSION: TNFα has a positive correlation with M2 and Treg distribution,but mostly through a different mechanism other than EBER-TLR3 interaction. Possibly, other pro-inflammatory and anti-inflammatory cytokines are involved in the formation of the NPC microenvironment, especially related to the presence of M2 and Treg, which provide immunosuppressive effects in NPC tumors. 
.

Vigilance to misleading information is required to avoid delayed diagnosis: Case series of acral melanomas.

INTRODUCTION: Melanoma is considered a rare cancer among Asians with a wide range of mucocutaneous manifestations. Failure to recognize a lesion as melanoma at first presentation might delay surgery aimed at complete resection. Acral melanoma has been related with the highest rate of misdiagnosis (~30%) causing further delayed diagnosis. Reliability of patient' history taking in melanoma has not yet been systematically reported. PRESENTED CASES: Two patients visited our oncology clinic with pigmented lesions in their soles. A 66-year-old man disclosed it appeared since a year ago after accidently hitting a stone while farming. Physical examination showed a black-brown irregular 100 × 80 mm lesion covering the distal third of the right sole with ulceration in the central lesion. The second patient was a geriatric woman with a black-purple 25 × 27 mm lesion with slight protrusion and ulceration in the central, irregular border, and partial hyperkeratosis. She explained the lesion emerged two years ago after she accidently stepped on a nail. Both patients were then diagnosed with acral melanomas and were treated with wide-excision, closure with skin grafting, and inguinal dissection. DISCUSSION: Both patients reported history of traumas in lesions later confirmed as acral melanomas. Although history taking can provide up to 80% of the information for accurate diagnosis, in ambivalent cases, careful anamnesis, clinical examination, and biopsy are required to confirm diagnosis of acral melanoma. Early disease identification to establish definitive diagnosis of cancer is generally associated with better clinical outcomes. In suspected cases, vigilance toward misleading information in history taking is required.