A Rare Case of Cutaneous Metastasis of Unresectable Rectal Adenocarcinoma.

Colorectal cancer (CRC) is the third most common malignancy. Common metastatic sites for colorectal carcinoma are the lung and liver while cutaneous metastases are extremely rare. Skin metastasis may be an early manifestation of metastatic disease and represents a poor prognosis. Here we present a case of metachronous skin metastasis during chemoradiation treatment in a patient with locally advanced rectal cancer. A young boy aged 19 years presented to our hospital with radiological TNM staging of T3c N1 M0 with circumferential resection margin (CRM) involved. The treatment plan was defunctioning colostomy with neoadjuvant chemotherapy and radiotherapy with a later plan for surgery. Seven months later, there is a focal skin nodule in the nape of the neck. A core biopsy of this cutaneous nodule was done and proved metastatic. Surgery for the primary tumor and oligometastatic site was planned but due to extensive primary tumor, surgery was terminated and continues with chemotherapy and reassessment.

Questionable research practices of medical and dental faculty in Pakistan - a confession.

PURPOSE: Intellectual honesty and integrity are the cornerstones of conducting any form of research. Over the last few years, scholars have shown great concerns over questionable research practices (QRPs) in academia. This study aims to investigate the questionable research practices amongst faculty members of medical and dental colleges in Pakistan. METHOD: A descriptive multi-institutional online survey was conducted from June-August 2022. Based on previous studies assessing research misconduct, 43 questionable research practices in four domains: Data collection & storage, Data analysis, Study reporting and Collaboration & authorship were identified and investigated. Descriptive (Frequencies, Percentages, Mean, SD) and Inferential (chi square) statistics were calculated. RESULTS: A total of 654 faculty members responded. Every respondent reported committing at least one QRP in their career. The most common QRPs included deliberately failing to mention funding, publishing program evaluation data not meant for research purposes or approved by an ethical body, inappropriately storing identifiable information and non-disclosure of any conflicts. There was significant association of age, gender and academic rank with QRPs in 'Data collection and storage' and 'Data Analysis' domains. CONCLUSION: Medical and dental faculty members participating in this study are involved in a range of questionable research practices (QRPs) in Pakistan. Their confession might have contributed to the faculty developing self-awareness and reinforcing academic integrity. There is a need for reviewing policies and practices to improve research culture. Future research should explore the factors resulting in such practices.

The Association of Research Quantitative Measures With Faculty Ranks of Australian and New Zealand Dental Schools.

INTRODUCTION: The scholarly productivity of a faculty member can be measured through several indicators including annual appraisals, feedback, and the number of publications per year. The present study aims to assess the association of quantitative research measures and academic ranks in Australian and New Zealand dental schools. METHODS: It was an analytical observational cross-sectional study. Full-time faculty members working in Australia and New Zealand's dental schools were discovered on official websites. Various bibliometric parameters including h-index, total number of citations, total number of publications, and maximum number of sources of a single publication were analyzed. Spearman rank correlation was used to determine the correlation between bibliometric variables and academic ranks (lecturer, assistant professor, professor). The Mann-Whitney U test was used to compare bibliometric parameters among departments (Basic and Clinical) and gender (male and female). RESULTS: Through the present search strategy, 207 full-time faculty members were identified, of which 12 were from New Zealand, and 195 were from Australia. Among them, 130 (62.8%) were male and 70 (33.8%) were female faculty members. There was a positive correlation of all bibliometric parameters with academic ranks (p = 0.001). There was no statistical difference between the two countries for academic parameters (p > 0.05). Male faculty members showed significantly higher academic productivity than female members in Australian dental schools (p = 0.001). CONCLUSION: These bibliometric parameters and other educational parameters can be considered for determining faculty promotions. These bibliometric parameters appear to be suitable metrics for assessing research productivity, impact, and visibility.

A Rare Case of Primary Intracerebral Malignant Melanoma.

Malignant melanomas occurring in the central nervous system are mostly metastatic. Primary intracranial malignant melanomas are a rare entity, accounting for 0.07% of all brain tumors. In the central nervous system, melanocytes originate from the neural crest cells that are found in the leptomeninges. Only a few cases of malignant melanoma primarily arising from the brain have been reported in the literature to date. We report a rare case of primary intracerebral malignant melanoma in a 39-year-old female. Through this case report, our aim is to highlight the role of imaging in the early diagnosis and management of malignant melanoma.

Small Cell Neuroendocrine Carcinoma of the Vagina: A Rare Presentation.

Primary small cell neuroendocrine carcinoma of the vagina is a very rare disease. We present a case study of a 52-year-old female who presented to the hospital with complaints of urinary dribbling, burning micturition, pain, and per vaginal bleeding for three to four months. A firm globular mass of approximately 5-6 cm was felt in the anterior vaginal wall per speculum examination. Diagnosis of small cell neuroendocrine carcinoma was made with tissue biopsy and immunohistochemistry. Diagnostic imaging (MRI, positron emission tomography (PET)-CT) plays a vital role in reaching the diagnosis and understanding the treatment response. The patient received six cycles of chemotherapy with cisplatin and etoposide and radiotherapy, achieving a complete response, with complete regression of the lesion. The patient had no sign of tumor recurrence and locoregional or distant metastases after six months of follow-up. Nowadays, there is no need for surgery in the treatment of vaginal small cell neuroendocrine carcinoma, rather radiotherapy and chemotherapy are the treatment of choice. We report a case of neuroendocrine cancer of the vagina treated at our institution.

High Indoleamine 2,3-Dioxygenase Expression along with Low Bridging Integrator-1 Expression in Hepatocellular Carcinoma Patients.

BACKGROUND: Hepatocellular carcinoma (HCC) adopts several tumor immune escape mechanisms; therefore, it has the potential to be targeted by immunotherapy. Indoleamine 2, 3-dioxygenase (IDO) is an immunosuppressive enzyme that has been observed to be overexpressed in HCC patients with poor prognoses. Bridging integrator 1 (Bin1) loss promotes immune escape in cancer by deregulating IDO. Our aim is to investigate IDO expression along with Bin1 expression to find evidence of immunosuppression in HCC patients. MATERIALS AND METHODS: In this study, we investigated IDO and Bin1 expression in HCC tissue specimens and the correlation of IDO and Bin1 expression with clinicopathological characteristics and prognosis of HCC patients (n=45). Immunohistochemical analysis was performed to analyze the expression of IDO and Bin1. RESULTS: IDO was overexpressed in 38 (84.4%) out of 45 HCC tissue specimens. In addition, tumor size was significantly increased with an increase in the IDO expression (P=0.03). Low Bin1 expression was observed in 27(60%) HCC tissue specimens, whereas the remaining 18(40%) showed high Bin1 expression. CONCLUSION: Our data showed that expression of IDO along with Bin1 expression could be investigated for clinical evaluation in HCC. IDO might be used as an immunotherapeutic target for HCC. Therefore, further studies in larger patient cohorts are warranted.

Genetic analysis of ACE2 peptidase domain in SARS-CoV-2-positive and SARS-CoV-2-negative individuals from Pakistan.

BACKGROUND: The outbreak of coronavirus disease 2019 (COVID-19) has emerged as a serious public health emergency of global concern. Angiotensin converting enzyme 2 (ACE2) peptidase domain is important for the cellular entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Germline variants in ACE2 peptidase domain may influence the susceptibility for SARS-CoV-2 infection and disease severity in the host population. ACE2 genetic analysis among Caucasians showed inconclusive results. This is the first Asian study investigating the contribution of ACE2 germline variants to SARS-CoV-2 infection in Pakistani population. METHODS: In total, 442 individuals, including SARS-CoV-2-positive (n = 225) and SARS-CoV-2-negative (n = 217) were screened for germline variants in ACE2 peptidase domain (exons 2, 3, 9, and 10) using high resolution melting and denaturing high-performance liquid chromatography analyses followed by DNA sequencing of variant fragments. The identified variant was analyzed by in silico tools for potential effect on ACE2 protein. RESULTS: A missense variant, p.Lys26Arg, was identified in one SARS-CoV-2-positive (1/225; 0.4%) and three SARS-CoV-2-negative (3/217; 1.4%) individuals. No significant difference in the minor allele frequency of this variant was found among SARS-CoV-2-positive and SARS-CoV-2-negative individuals (1/313; 0.3% versus 3/328; 0.9%; P = 0.624), respectively. The SARS-CoV-2-positive patient carrying p.Lys26Arg showed mild COVID-19 disease symptoms. It was predicted as benign variant by in silico tool. No variant was detected in ACE2 residues important for binding of SARS-CoV-2 spike protein. CONCLUSION: The p.Lys26Arg variant may have no association with SARS-CoV-2 susceptibility in Pakistani population. Whole ACE2 gene screening is warranted to clarify its role in SARS-CoV-2 infection.

A Rare Case of Single Gallbladder and Multiple Pancreatic Metastases of Renal Cell Carcinoma.

Renal cell carcinoma (RCC) is the most common tumor to metastasize to uncommon sites. Synchronous metastases in the gall bladder and pancreas are rare entities. In this report, we present the case of a 43-year-old male with a complaint of hematuria presenting with a left renal mass. Contrast-enhanced CT revealed an arterially enhancing mass in the left kidney, a synchronous tiny polyp in the gall bladder, and multiple focal lesions in the pancreas. The patient underwent surgery and the tumor was histopathologically labeled as a clear cell RCC with metastases to the pancreas and gall bladder. Post-surgery, the patient has been followed up.

Pituitary Stalk Interruption Syndrome: A Case Report.

Pituitary stalk interruption syndrome is a congenital abnormality. The triad of this syndrome comprises a thin pituitary stalk, an ectopic posterior pituitary gland, and an absent or hypoplastic anterior pituitary gland. The patient typically presents with a spectrum of symptoms secondary to anterior pituitary hormonal deficiency. The etiology of this syndrome is not established but is likely due to a genetic mutation. The prognosis is good if the syndrome is diagnosed early and hormonal therapy is started promptly. Early diagnosis is crucial in preventing adverse effects on growth and development. The diagnosis of pituitary stalk interruption syndrome is based on magnetic resonance imaging (MRI) findings. This study presents the case of a young girl who presented with complaints of short stature and amenorrhea and was diagnosed with pituitary stalk interruption syndrome following an MRI.

Corpus Callosum Infarct in the Background of Varicella-Zoster Infection: A Report of a Rare Case.

Infarctions of the corpus callosum are rare due to a rich blood supply. Corpus callosum derives its blood supply from four vessels from the anterior and posterior circulation and for this reason, they have a rare, atypical presentation. There is scarce literature regarding this pathology. Corpus callosum infarcts usually present with non-specific signs and symptoms. Here, we describe a case of corpus callosum infarction in a 5-year-old boy who was a known case of acute lymphoblastic leukaemia. He presented with disseminated varicella infection and developed tonic-clonic seizures. MRI brain was performed and a diagnosis of corpus callosum infarct was made. The patient was treated conservatively.

A Rare Case of Bilateral Orbital Metastases From Rectal Adenocarcinoma.

Colorectal carcinoma is among the commonest malignancies in the World. However, metastases from rectal carcinomas to the orbit are extremely rare. Only a few such cases have been reported in the literature till date. We report a case of adenocarcinoma of the rectum in a 27-year-old male with bilateral orbital metastases who is currently undergoing palliative radiotherapy. Our aim is to highlight the role of imaging in the diagnosis and management of orbital metastatic disease.

COVID-19 in cancer patients with diabetes in Pakistan: Clinical features and management.

Background: Diabetes and cancer are the leading causes of mortality all over the world. Infectious diseases are more common and/or life-threatening in patients with diabetes. Cancer patients with diabetes are individuals that are more susceptible to the current COVID-19 pandemic. We investigated the clinical features of survivor and non-survivor COVID-19-infected cancer patients with diabetes. Patients and Methods: We did a retrospective study of 43 diabetic cancer patients with PCR-confirmed COVID-19 infection from Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan between March 03, 2020, and May 18, 2021. These patients either were discharged from the hospital or had died by Jun 16, 2021. Clinicopathological and radiological features were compared between survivors and non-survivors by fisher's exact test and chi-square test. Results: Forty-three diabetic cancer patients with SARS-CoV-2 infection were enrolled and the majority were males 26 (60.5%). The overall mean age was 61.67 ± 11.80. 39 (90.7%) had solid tumors and 3 (7.0%) had hematological malignancies. Fever (74.4%) and dyspnea (58.1%) were the most common symptoms. Complications were reported in 36 (83.7%) patients; during the course of the disease. Additionally, all the deceased patients (n=15) had acquired the complications. 11 (25.6%) patients were admitted to an intensive care unit (ICU). Furthermore, 29 (67.4%) out of 43 patients showed abnormal features in the radiological findings. We found significantly elevated levels of C-reactive protein (P=0.005), serum lactate (P=0.01), albumin (P=0.02), alkaline phosphate (P=0.03), and neutrophil count (P=0.04) in the non-survivors as compared to the survivors. Conclusion: Cancer patients with diabetes are a vulnerable population in the current pandemic. Identifying how diabetes in cancer patients affects the severity of SARS-CoV-2 infection is crucial for the clinical management of these patients. Rigorous scrutiny of clinicopathological features of COVID-19 infected cancer patients with diabetes especially values of C-reactive protein, lactate, albumin, alkaline phosphate, neutrophils, and regular monitoring of blood glucose levels may play a critical role in the outcome of the disease.

Unusual Presentation of Treated Colon Cancer with Extramural Venous Invasion: A Case Report.

Introduction: Colon cancer is one of the leading malignancies globally and continues to be one of the most typical causes of cancer-related mortality. The clinical outcome of the disease depends on the primary tumour stage, regional nodal involvement and distant disease dissemination. It often presents with haematogenous spread to the liver at the time of diagnosis. Another factor for increased mortality is the presence of extramural venous invasion. This is exceedingly important as it has significant prognostic significance and helps predict survival. Case Description: A middle-aged female with a recent history of caesarean delivery presented with abdominal pain and occasional constipation, which led to a series of investigations. Initial computed tomography scan showed proximal to mid-transverse colonic tumoural thickening with locoregional lymphadenopathy and solitary distant metastasis in the left hepatic lobe. This was followed by extended right hemicolectomy and hepatic metastasectomy. The patient remained on follow-up and later presented with thrombus formation in the splenoportal circulation. Initially, this was considered a bland thrombus, and the patient was advised a close follow-up. However, the patient was lost to follow and later presented with extensive thrombosis of the portal and splenic veins. Practical Implications: Confident differentiation of the bland versus malignant thrombosis is crucial to ascertain disease stage and appropriate management. Invasive tissue sampling gives a confident diagnosis of benign versus malignant thrombus. However, using a non-invasive imaging modality, we can still distinguish between the two with reasonable certainty.

Comparison between shear wave elastography and serological findings for the evaluation of fibrosis in chronic liver disease.

Aim: In this study, we sought to examine the optimal cutoff values for predicting different stages of liver fibrosis, and to determine the level of agreement between shear wave elastography and aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 index (FIB-4) scores in patients with chronic liver disease. Methodology: A descriptive, cross-sectional study was performed at the Radiology Department of Shaukat Khanum Memorial Hospital Lahore from 1 Jun 2019 until 1 June 2020. FIB-4 and APRI scores were determined by the following formula: FIB-4 = (age × AST) ÷ (platelet count × (√ (ALT)) and APRI = (AST÷AST upper limit of normal) ÷ platelet × 100. Data was analyzed with the help of SPSS version 24.0 and Microsoft Excel 2013. Results: Eighty individuals were conveniently selected, of which 62.5% were men and 37.5% were women. The mean age of the subjects was 43.47 SD ± 13.85 years. APRI and FIB-4 scores predicted F4 patients using the cutoff values of 0.47 (Sn. 72%, Sp. 70%) and 1.27 (Sn. 78%, Sp. 73%), respectively. The cutoff values of 0.46 for APRI and 1.27 for FIB-4 predicted F3-F4 patients (Sn. 74% and 77%; Sp. 76% and 76%), respectively. To predict F1-F4 compared to F0, the cutoff value was 0.34 (Sn. 68%, Sp. 75%) for APRI, while the cutoff value for FIB was 0.87 (Sn. 72%, Sp. 75%). The findings suggest that FIB-4 shows better diagnostic accuracy than APRI. Conclusion: This study provides optimal cutoff values for different groups of fibrosis patients for both serum markers. Also, the diagnostic accuracy of FIB-4 for predicting liver fibrosis was found to be superior to APRI in all disease stages.

Clinical Characteristics of COVID-19-Infected Cancer Patients in Pakistan: Differences Between Survivors and Non-Survivors.

BACKGROUND: Cancer patients are considered as highly vulnerable individuals in the current COVID-19 pandemic. We studied the clinical characteristics of survivor and non-survivor COVID-19-infected cancer patients in Pakistan. PATIENTS AND METHODS: We did a retrospective study of 70 cancer patients with PCR-confirmed COVID-19 infection from Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore and Peshawar, Pakistan between April 13 and July 09, 2020. These patients were discharged from the hospital or had died by July 09, 2020. Clinical, pathological and radiological characteristics were compared between survivors and non-survivors by fisher's exact test and chi-square test. Univariable and multivariable logistic regression models were performed to explore the risk factors of mortality. RESULTS: Seventy cancer patients with SARS-CoV-2 infection were enrolled and the majority were males 38 (54.3%). 57 (81.4%) had solid tumors and 13 (18.6%) had hematological malignancies. Dyspnea (44 cases) was the most common symptom (62.9%). Complications were reported in 51 (72.9%) patients during the course of disease. 19 (27.1%) patients were admitted to an intensive care unit (ICU). A significant increase in the C-reactive protein level and neutrophil count was observed in the deceased patients as compared to the surviving patients. D-dimer values of ≥0.2 mg/L were significantly associated with mortality (P=0.01). We identified two independent risk factors associated with death, ICU admission (P=0.007) and D-dimer (P=0.003). CONCLUSION: Pakistani cancer patients with COVID-19 infection reported poor prognosis. Intensive surveillance of clinicopathological characteristics of cancer patients infected with COVID-19 especially D-dimer values may play a pivotal role in the outcome of the disease.

Anterior Abdominal Wall Synovial Sarcoma: A Rare Presentation.

Abdominal wall sarcoma belongs to a heterogeneous group of uncommon malignant neoplastic conditions with differentiated morphological patterns and originating from mesenchymal tissues. Soft tissue sarcomas predominantly involve the lower and upper limbs and retroperitoneum. We present a case of a 30-year-old patient, complaining of swelling in the left flank whose magnetic resonance imaging (MRI) revealed a solid tumour on the abdominal wall of the flank and biopsy turned out to be synovial sarcoma.

Sarcomatoid Carcinoma of the Maxilla: A Diagnostic Dilemma.

Sarcomatoid malignant neoplasm, are extremely rare and aggressive head and neck tumours characterized by twin microscopic differentiation of epithelial cell and mesenchymal cell tumours. The clinical and histopathologic features make it difficult to distinguish sarcomatoid cancer from epithelioid sarcoma; creating a challenge for the pathologist to arrive at a diagnosis. Squamous cell carcinoma is the second most common head and neck malignancy; of which only 3% show features similar to sarcomatoid cancer. We present a case of sarcomatoid carcinoma of the maxilla. This has previously only been documented in a few case reports.

Extraskeletal Mesenchymal Chondrosarcoma, a Rare Entity with Unusual Metastases: A Case Report.

Introduction: Extraskeletal mesenchymal chondrosarcoma (ESMC) is rare, aggressive, and high grade malignant tumors originating from soft tissues. It carries a poor prognosis with a tendency for local recurrence and distant metastasis, necessitating long-term follow-up. The most common sites for metastasis are the lungs, bones, and lymph nodes. Meanwhile, pancreatic metastases are extremely rare. Case Description: A 35-year-old female presented with a history of wide local excision for the left upper limb mass; histopathology showed ESMC. She was on surveillance with a computed tomography scan of the thorax and magnetic resonance imaging of the left upper limb at 3-months intervals until she developed vertebral and pancreatic lesions after 6 months post-surgery. No pulmonary metastases were noted. Considering the unusual site for metastasis and to exclude the possibility of any second malignancy, bone biopsy, and endoscopic ultrasound-guided fine-needle aspiration was performed that confirmed metastases. Later she developed osseous metastases in the pelvis and femora. Practical Implication: Pancreatic metastasis from ESMC is extremely rare. In case of new visceral or osseous lesions in a patient with a past medical history of ESMC, the possibility of metastatic disease should be considered. A biopsy can be performed to confirm the diagnosis.

Primary Pharyngeal Flap With Palate Repair Improves Speech Outcome in Older Children and Adults: A Comparative Study.

BACKGROUND: Repair of cleft palate after 6 years of age is controversial in regard to the surgical procedure and the speech outcome. Primary repair alone may not be considered sufficient to achieve intelligible speech. The authors consider addition of pharyngeal flap at the time of primary repair to be a significant factor in improving speech. METHODS: Prospectively maintained data of all cleft palate patients operated from 2013 to 2017 (5 years) was analyzed to identify patients older than 6 years. Complete cleft palate, incomplete cleft palate, and cleft of the soft palate were further stratified according to different Randall types. They were divided into 2 main types: primary palate repair only and primary palate repair with pharyngeal flap. Speech was assessed preoperatively and 12 months postoperatively by Pittsburgh weighted speech scale. RESULTS: A total of 139 patients were analyzed. There were 78 males and 61 females. Their ages ranged from 6 to 60 years (mean age, 12.5 years). The overall preoperative speech score in palate repair-only group was 12.15, whereas the postoperative score was 7.32. In patients who underwent primary pharyngeal flap along with palate repair, the preoperative speech score was 11.3, and the postoperative score was 3.76. CONCLUSIONS: In select group of patients who report late for palate repair, addition of pharyngeal flap along with the primary palate repair improves the speech outcome in all Randall groups.

General Anaesthesia Versus Regional Anaesthesia For Lumbar Laminectomy: A Review Of The Modern Literature.

BACKGROUND: Lumbar spine surgery can be performed using different anaesthetic techniques such as general endotracheal anaesthesia (GA) or spinal-based regional anaesthesia (RA). Few of the studies have been done to compare the outcomes of spinal anaesthesia versus general anaesthesia for lumbar laminectomies as both having some advantages as well as disadvantages but still it is controversial. The objective of current study is to make a comprehensive review of literature for comparing the outcomes of lumbar laminectomy performed under general anaesthesia versus spinal anaesthesia. METHODS: Literature search was performed by using PubMed, Google scholar and bibliography of related articles. To compare groups of general anaesthesia versus spinal anaesthesia, the variables focused were mean heart rate (HR), mean arterial pressure (MAP), blood loss during surgery, duration of surgery, post-operative anaesthesia care unit (PACU) time, postoperative narcotic use/pain scale, post-operative urinary retention, and post-operative nausea/vomiting. RESULTS: Data of eleven studies were presented in current article, of these five were randomized controlled trials, three case-controls and four were retrospective cohort studies. 5/8 studies reported that SA group having more hemodynamic stability with postoperative outcomes as compared to GA. Likewise, majority of reviewed studies (7/8) reported better pain control or decreased requirement of analgesics in SA group. Additionally, more than half of the reviewed studies (5/8) reported lower incidence of postoperative nausea and vomiting among patients of SA group.. CONCLUSIONS: The current study concluded that SA has better outcomes than GA in terms of hemodynamic stability and decrease postoperative adverse effects. So special attention should be paid for SA as an alternative to GA for lumbar laminectomy.