Systemic Treatment of Patients With Metastatic Breast Cancer: ASCO Resource-Stratified Guideline.

PURPOSE: To guide clinicians and policymakers in three global resource-constrained settings on treating patients with metastatic breast cancer (MBC) when Maximal setting-guideline recommended treatment is unavailable. METHODS: A multidisciplinary, multinational panel reviewed existing ASCO guidelines and conducted modified ADAPTE and formal consensus processes. RESULTS: Four published resource-agnostic guidelines were adapted for resource-constrained settings; informing two rounds of formal consensus; recommendations received ≥75% agreement. RECOMMENDATIONS: Clinicians should recommend treatment according to menopausal status, pathological and biomarker features when quality results are available. In first-line, for hormone receptor (HR)-positive MBC, when a non-steroidal aromatase inhibitor and CDK 4/6 inhibitor combination is unavailable, use hormonal therapy alone. For life-threatening disease, use single-agent chemotherapy or surgery for local control. For premenopausal patients, use ovarian suppression or ablation plus hormone therapy in Basic settings. For human epidermal growth factor receptor 2 (HER2)-positive MBC, if trastuzumab, pertuzumab, and chemotherapy are unavailable, use trastuzumab and chemotherapy; if unavailable, use chemotherapy. For HER2-positive, HR-positive MBC, use standard first-line therapy, or endocrine therapy if contraindications. For triple-negative MBC with unknown PD-L1 status, or if PD-L1-positive and immunotherapy unavailable, use single-agent chemotherapy. For germline BRCA1/2 mutation-positive MBC, if poly(ADP-ribose) polymerase inhibitor is unavailable, use hormonal therapy (HR-positive MBC) and chemotherapy (HR-negative MBC). In second-line, for HR-positive MBC, Enhanced setting recommendations depend on prior treatment; for Limited, use tamoxifen or chemotherapy. For HER2-positive MBC, if trastuzumab deruxtecan is unavailable, use trastuzumab emtansine; if unavailable, capecitabine and lapatinib; if unavailable, trastuzumab and/or chemotherapy (hormonal therapy alone for HR-positive MBC).Additional information is available at www.asco.org/resource-stratified-guidelines. It is ASCO's view that healthcare providers and system decision-makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Evaluation of Galanin Expression in Colorectal Cancer: An Immunohistochemical and Transcriptomic Study.

Colorectal cancer (CRC) represents around 10% of all cancers, with an increasing incidence in the younger age group. The gut is considered a unique organ with its distinctive neuronal supply. The neuropeptide, human galanin, is widely distributed in the colon and expressed in many cancers, including the CRC. The current study aimed to explore the role of galanin at different stages of CRC. Eighty-one CRC cases (TNM stages I - IV) were recruited, and formalin-fixed paraffin-embedded samples were analyzed for the expression of galanin and galanin receptor 1 (GALR1) by immunohistochemistry (IHC). Galanin intensity was significantly lower in stage IV (n= 6) in comparison to other stages (p= 0.037 using the Mann-Whitney U test). Whole transcriptomics analysis using NGS was performed for selected samples based on the galanin expression by IHC [early (n=5) with high galanin expression and late (n=6) with low galanin expression]. Five differentially regulated pathways (using Absolute GSEA) were identified as drivers for tumor progression and associated with higher galanin expression, namely, cell cycle, cell division, autophagy, transcriptional regulation of TP53, and immune system process. The top shared genes among the upregulated pathways are AURKA, BIRC5, CCNA1, CCNA2, CDC25C, CDK2, CDK6, EREG, LIG3, PIN1, TGFB1, TPX2. The results were validated using real-time PCR carried out on four cell lines [two primaries (HCT116 and HT29) and two metastatic (LoVo and SK-Co-1)]. The current study shows galanin as a potential negative biomarker. Galanin downregulation is correlated with advanced CRC staging and linked to cell cycle and division, autophagy, transcriptional regulation of TP53 and immune system response.

Breast-Gynaecological & Immuno-Oncology International Cancer Conference (BGICC) Consensus and Recommendations for the Management of Triple-Negative Breast Cancer.

Background: The management of patients with triple-negative breast cancer (TNBC) is challenging with several controversies and unmet needs. During the 12th Breast-Gynaecological & Immuno-oncology International Cancer Conference (BGICC) Egypt, 2020, a panel of 35 breast cancer experts from 13 countries voted on consensus guidelines for the clinical management of TNBC. The consensus was subsequently updated based on the most recent data evolved lately. Methods: A consensus conference approach adapted from the American Society of Clinical Oncology (ASCO) was utilized. The panellists voted anonymously on each question, and a consensus was achieved when ≥75% of voters selected an answer. The final consensus was later circulated to the panellists for critical revision of important intellectual content. Results and conclusion: These recommendations represent the available clinical evidence and expert opinion when evidence is scarce. The percentage of the consensus votes, levels of evidence and grades of recommendation are presented for each statement. The consensus covered all the aspects of TNBC management starting from defining TNBC to the management of metastatic disease and highlighted the rapidly evolving landscape in this field. Consensus was reached in 70% of the statements (35/50). In addition, areas of warranted research were identified to guide future prospective clinical trials.

Response to Induction Neoadjuvant Hormonal Therapy Using Upfront 21-Gene Breast Recurrence Score Assay-Results From the SAFIA Phase III Trial.

PURPOSE: Luminal, human epidermal growth factor receptor 2-negative breast cancer represents the most common subtype of breast malignancies. Neoadjuvant strategies of operable breast cancer are mostly based on chemotherapy, whereas it is not completely understood which patients might benefit from neoadjuvant hormone therapy (NAHT). MATERIALS AND METHODS: The SAFIA trial is a prospective multicenter, international, double-blind, neoadjuvant phase III trial, using upfront 21-gene Oncotype DX Breast Recurrence Score assay (recurrence score [RS] < 31) to select operable luminal human epidermal growth factor receptor 2-negative patients, for induction hormonal therapy HT (fulvestrant 500 mg with or without goserelin) before randomly assigning responding patients to fulvestrant 500 mg (with or without goserelin) plus either palbociclib (cyclin-dependent kinase 4/6 inhibitor) or placebo. The objectives of this interim analysis were to assess the feasibility of upfront RS determination on core biopsies in the Middle-East and North Africa region and evaluate the efficacy of induction NAHT in patients with an RS < 31. RESULTS: At the time of this interim analysis, 258 patients with relative risk were accrued, including 202 patients (RS < 31% to 78.3%) treated with induction NAHT and 182 patients evaluable so far for response. The feasibility of performing the Oncotype DX assays on core biopsy specimens was optimal in 96.4% of cases. Overall, 93.4% of patients showed hormone sensitivity and no difference in NAHT efficacy was noticed between RS 0-10, 11-25, and 26-30. Interestingly, patients with high RS (26-30) showed a trend toward a higher major response rate (P = .05). CONCLUSION: The upfront 21-gene assay performed on biopsies is feasible in our population and has allowed us to select patients with high hormone sensitivity (RS < 31). This approach could be an alternative to upfront surgery without significant risk of progression, particularly during pandemic times.

Diagnosis of Inflammatory Bowel Disease by Abdominal Ultrasound and Color Doppler Techniques.

BACKGROUND & AIMS: The utility of ultrasound and color Doppler in the diagnosis and evaluation of inflammatory bowel diseases (IBD) has not been studied enough. Therefore, the aim of the current study was to evaluate the importance of conventional abdominal ultrasound and color Doppler in diagnosing IBD and assessing disease activity. METHODS: The study was conducted at the National Hepatology and Tropical Medicine Research Institute (NHTMRI) between July 2018 and January 2019, in which 150 patients were suffering from diarrhea, dysentery, tenesmus, or rectal bleeding were evaluated by colonoscopy, high-resolution ultrasound, and color Doppler scans. RESULTS: The present study was conducted on 150 patients; 84 (56%) had ulcerative colitis (UC), 16 (10.7%) had Crohn's disease (CD), and 50 (33.3%) had normal colonoscopy results with a mean age 37.2 ± 9.059. The superior mesenteric Artery Peak Systolic Velocity (SMA-PSV) and End Diastolic Velocity (EDV) were significantly higher in both UC and CD than in the control group; however, pulsatility index (PI) was significantly higher in the control group than both UC and CD. However, there was no significant difference between UC and CD. The inferior mesenteric artery PSV and EDV were significantly higher in both UC and CD than in the control group. CONCLUSION: Doppler ultrasound findings of SMA and IMA correlate with the incidence of inflammatory bowel disease, the site of disease, and its activity.

Clinicopathological Features and Treatment Outcomes in Ewing's Sarcoma Patients: A 10-year experience of Alexandria Clinical Oncology Department.

BACKGROUND: Ewing's sarcoma (ES) is an aggressive tumor, which is usually associated with micrometastases in the circulation. Thus, systemic chemotherapy in addition to local control modality is essential to improve outcomes. The aim of this study was to evaluate clinicopathological features and treatment outcomes in patients with ES. MATERIALS AND METHODS: Medical files of 74 patients with nonmetastatic ES treated at our centers between 2004 and 2014 were retrospectively evaluated. The clinicopathological parameters were extracted and statistically correlated with event-free survival (EFS) and overall survival (OS). RESULTS: The median age of patients was 13 years. The median follow-up duration was 63.8 months. About two-thirds (58.1%) of patients were male. Pain (74.3%) was the most common presenting symptom. Extremities (48.6%) were the frequently affected sites. Thirty-two patients (43.2%) presented by tumors larger than 8 cm. All patients were treated with chemotherapy. Local therapies were surgery and/or radiotherapy. The 5-year EFS and OS were 44% and 57%, respectively. On multivariate analysis, EFS and OS were significantly associated with age, tumor site, and tumor size. CONCLUSIONS: Despite limited resources in a developing country, the survival rates of ES are comparable to that in developed countries, and prognostic factors are age, tumor site, and tumor size.

Linear accelerator-based stereotactic radiosurgery of intracranial meningiomas: results of the first 5 years of clinical practice.

Meningiomas are mostly benign but some are atypical or malignant. Surgical resection is curative when complete removal of benign meningiomas is contemplated. Incompletely excised and recurrent tumors are frequently treated with fractionated radiation therapy or stereotactic radiosurgery. The purpose of this study is to evaluate the short-term radiological and functional outcomes of a single center using linear accelerator (Linac) stereotactic radiosurgery for the treatment of intracranial meningiomas. Twenty-nine patients (12 males and 17 females) with 30 meningiomas, in different brain locations (skull base and non-skull base meningiomas), were treated with Linac-based stereotactic radiosurgery. The mean tumor volume was 6.3 cm³, and the mean tumor marginal and maximum doses were 10.9 and 15 Gy, respectively. The median prescribed isodose line was 80%. The patients were followed-up for a minimum of 3 years. Regarding radiological outcome, nine (30%) meningiomas demonstrated evident volume reduction, 19 (63.3%) meningiomas remained unchanged, and two (6.7%) meningiomas increased in size after radiosurgery. The local tumor control rates for skull base meningiomas and non-skull base meningiomas after radiosurgery were 90.9% and 100%, respectively. Regarding functional outcomes, 64% of patients presenting with cranial neuropathies showed improvement of their cranial nerve functions and 29% of patients remained unchanged. One patient had temporary trigeminal neuropathy. Although radiosurgery for meningiomas is generally effective and quite safe in achieving high control rates with minimum morbidity over short- and intermediate-term periods of follow-up, tumor progression might occur in a delayed manner after initial apparent control for few years. We recommend continued follow-up for longer periods to better assess the long-term outcomes.

Raising the Breast Health Awareness amongst Women in an Urban Slum Area in Alexandria, Egypt.

BACKGROUND: Breast Cancer (BC) is the most frequently occurring cancer among Egyptian women. This study aimed to determine the effectiveness of a health education program on raising the knowledge related to BC, its risk factors, and some related preventive practices among women living in an urban slum area in Alexandria. PATIENTS AND METHODS: A pre-/post-test interventional study was conducted during 2009-2010 on a random sample of women aged 30-65 years (n = 486) living in a slum area in Alexandria, Egypt. 20 health education sessions were carried out to educate the women on BC risk factors and some preventive practices. Previously trained nurses educated the sampled women on breast self-examination (BSE). The women's knowledge and opinion about BC and their practice of BSE were evaluated before and 3 months after the intervention. RESULTS: The findings indicated a significant increase in the mean knowledge score regarding BC and the mean opinion score regarding some BC risk factors. A significant increase in the practice of BSE was observed post intervention. CONCLUSION: This study confirms the effectiveness of intervention programs in improving the knowledge about BC risk factors and practice of BSE even in a group of women with a low literacy rate living in a slum area.

Modification and implementation of NCCN guidelines on breast cancer in the Middle East and North Africa region.

Published data from the Middle East and North Africa (MENA) region indicate suboptimal quality of cancer care, while the World Health Organization predicts an increase in cancer cases in developing countries. Major advances in breast cancer management mandate the development of guidelines to improve the quality and efficacy of oncology practice in the MENA region. A Breast Cancer Regional Guidelines Committee was organized and activated, comprising experts from various regional cancer institutions. The multidisciplinary team included 12 medical oncologists, 3 radiation oncologists, 2 radiologists, 2 surgeons, and 1 pathologist. The committee members agreed on adapting the current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) on Breast Cancer for use in the MENA region to achieve common practice standards for treating patients. The members suggested several modifications to the guidelines, especially those related to risk factor profiles. United States-based NCCN experts reviewed these recommendations before final approval. The MENA-NCCN Breast Cancer Guidelines modification process was the first initiative in the development of common practice guidelines in the region. This project may serve as a foundation for the development of evidence-based practice standards, and improve collaborative projects and initiatives.

Surgical management of breast cancer in Saudi Arabia before and after outreach activities.

We collected management information from the 1996 referral documents of 100 consecutive patients who came to us for continued treatment of breast cancer. Major deficiencies were noted with regard to clinical assessment, surgery, and pathology. Since 1997 we have intensified our personnel contacts with referring surgeons, and we have performed outreach visits. To measure the effect of our efforts, we repeated the same collection of information between March 2001 and March 2002. Correct performance of TNM (tumor, node, metastasis) classification decreased from 36%-16%. The use of mammography increased from 29%-56%, application of fine needle aspiration (FNA) increased from 46%-70%, and use of core needle biopsy (CNB) increased from 0%-6%. The rate of performance of triple assessment (including correct performance of TNM) was 9% and is now 10%. The number of patients who had surgery before referral decreased from 84%-46%. A proper metastatic work-up in the present study was performed in 10% of patients, and mammography was performed in 33% of the patients who had either modified radical mastectomy (MRM) or breast conserving therapy (BCT). Previously, 78 patients had 98 operations before referral and 75% of those needed additional surgery; now only 9 patients out of 39 who had incisional biopsy or lumpectomy needed further surgery. The median number of lymph nodes now is 10, whereas previously 42% of the axillary dissections yielded < 8 lymph nodes. Pathology reports mentioning both tumor size and surgical margins have increased from 29%-53%. These new data indicate that there is a need to join all hospitals in a national guidelines plan for the management of breast cancer.

Optic gliomas: a retrospective analysis of 50 cases.

PURPOSE: Gliomas of the optic pathways are rare childhood central nervous system tumors. The treatment approach is controversial because of its rarity and the slow and unpredictable growth rates of these lesions. METHODS AND MATERIALS: We reviewed 50 patients with the diagnosis of optic pathway low-grade gliomas treated between January 1980 and December 1995 at King Faisal Specialist Hospital and Research Center, Saudi Arabia. Thirty-five patients presented with chiasmatic/hypothalamic (posterior tumors), and 15 with optic nerve gliomas with or without chiasmal involvement (anterior tumors). Evidence of neurofibromatosis was present in 18 patients. Twenty-nine patients underwent surgery (total or partial resection), and 12 of these received postoperative radiotherapy (RT). Sixteen patients were treated with primary RT. The radiation dose varied between 42 and 54 Gy (median dose 50). RESULTS: The overall actuarial survival rate was 87.5% at 5 years and 75% at 10 years, and the corresponding progression-free survival (PFS) rates were 69% and 62%. Patients with anterior tumors fared better than those with posterior tumors, with a 10-year PFS rate of 72% and 58%, respectively; the difference, however, was not statistically significant (p = 0.58). A PFS advantage was found in favor of patients with posterior tumors treated with RT (primary or postoperative) compared with no RT, with 5-year PFS rates of 68% vs. 42% (p = 0.03). This, however, did not translate into a survival advantage because of the success of salvage treatment. CONCLUSION: In multivariate analysis, age (<3 vs. >3 years) emerged as the only significant determinant for PFS with patients <3 years old faring worse (p = 0.03). Neurologic and endocrine dysfunction are significant problems that need to be addressed.

Malignant fibrous histiocytoma: a retrospective study of 109 cases.

The purpose of this report is to assess the prognostic factors that could influence management and clinical outcome of malignant fibrous histiocytoma (MFH) of soft tissues. Between 1975 and 1998, 109 patients diagnosed with MFH of the soft tissues, seen at King Faisal Specialist Hospital and Research Center, have been reviewed. Of the 109 patients, 75 were men and 34 were women. The median age at presentation was 48 years (range: 3-94). Seven patients (6%) had regional nodal disease and 10 other patients (9%) with distant metastases were excluded from survival analysis. The remaining 92 patients had localized disease and had surgery as the primary treatment modality with or without radiotherapy and/or chemotherapy. Extremities were the most common location (58%). Tumors less than 5 cm represented 32%, whereas 68% had tumors 5 cm or more. Low-grade tumors constituted 46%, and the remaining 54% were high grade. Thirty-seven percent of patients had positive surgical margins histologically after complete gross resection. The 5- and 10-year relapse-free survival (RFS) rates were 39% and 36%, respectively. Isolated local recurrence occurred in 20 patients (22%), isolated metastatic disease without local recurrence in 9 patients (10%), and combined local and metastatic disease occurred in 20 patients (22%). The overall 5- and 10-year overall survival (OS) rates were 50% and 43%, respectively. On multivariate analysis, tumor size and radiation dose were significant factors for RFS (p = 0.04 and 0.0005, respectively). In terms of OS, size, histologic grade, and surgical margins were significant factors on multivariate analysis (p = 0.001. 0.006, and 0.0001, respectively). Complete surgical resection at the time of primary tumor presentation is likely to afford the best chance for RFS and OS. Radiation therapy plays an important role, in combination with surgery for better local control, particularly in high-grade lesions, and in cases with positive surgical margins after wide complete gross excision. The role of adjuvant chemotherapy remains investigational.