The first Middle East and North Africa expert consensus recommendations for management of advanced gastric cancer.

Gastric cancer (GC) ranks as the fifth most prevalent cancer and the fourth deadliest cancer worldwide. In the Middle East and North Africa (MENA) region, GC represents about 4.8% of cancer cases with more than 35,000 new cases in 2020. To strengthen and improve the management of this cancer in the region, a group of MENA experts in the field of GC developed the first MENA consensus recommendations for the management of advanced GC. A total of 28 statements were drafted, discussed and voted on, using a modified Delphi process, during a virtual consensus meeting. The statements addressed the areas of epidemiology, biomarkers and treatment.

The first Middle East and North Africa expert consensus recommendations for the management of advanced colorectal cancer.

Colorectal cancer (CRC) is ranked as the third most prevalent and the second deadliest cancer worldwide. In the Middle East and North Africa (MENA) region, the number of CRC cases increased over the past decades and will nearly double by 2030. The lack of clear MENA guidelines for the management of patients with CRC represents a step backwards in the fight against this burden. Therefore a panel of 24 MENA experts in the field of gastrointestinal oncology developed, using a Delphi process, the first consensus recommendations for the management of patients with advanced CRC. Forty-seven different statements were formulated in the areas of epidemiology, screening, biomarkers and treatment. These recommendations will guide, standardize and unify the management of this cancer in the MENA region.

Turning the tide: pembrolizumab's triumph in adjuvant RCC therapy.

In recent years, kidney cancer has shown an increased worldwide incidence of more than 400 000 novel cases annually. Although more than half of patients are diagnosed at a localised stage, this disease presents a high-risk of relapse after surgery. Thus, there is a need for adjuvant therapy post-resection to reduce cancer recurrence and prolong disease-free and overall survival. Thorough investigation of adjuvant drugs for renal cell carcinoma (RCC) has shown little promise in the last fifty years, with no recorded overall survival benefits. This was the case until pembrolizumab, an immune checkpoint inhibitor, was introduced into the adjuvant RCC space through the KEYNOTE-564 trial. The adjuvant administration of this novel anti-PD-1 drug demonstrated a significant overall survival benefit which has led to an update in the current treatment guidelines of RCC. This substantial change in the standard of care also caused an investigation of possible treatment combinations and an adoption of innovative predictive biomarkers. In this review, we will present the evolution of past adjuvant ICI trials for the treatment of RCC, the implications of pembrolizumab's overall survival benefits and a discussion of future directions concerning new RCC drug trials and liquid biopsy-based biomarkers.

Treatment Patterns and Recommendations for Improving the Management of Hepatocellular Carcinoma in Saudi Arabia.

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer in the world associated with high morbidity and mortality. Despite being a significant healthcare burden there is limited information on the unmet needs and current treatment practices for intermediate and advanced-stage HCC in Saudi Arabia. This article analyzes the gaps and provides expert consensus on the management strategies for unresectable HCC in Saudi Arabia. A pre-meeting online questionnaire, comprising 20 objective questions about the treatment landscape and diagnosis of HCC in Saudi Arabia, was distributed to experts in the field of HCC management. An advisory board meeting including a panel of 13 experts was held in September 2022 where the responses to the survey questionnaire were reviewed and discussed. The survey results and experts' discussion highlighted the growing incidence of liver cancer in Saudi Arabia. HCC comprised the majority of all liver cancer cases due to rising rates of chronic viral infections and lifestyle-related risk factors. Most physicians in Saudi Arabia follow the Barcelona Clinic Liver Cancer guidelines as a prognostic tool for the detection and staging of patients with HCC. Most of the patients with HCC in Saudi Arabia are diagnosed in the intermediate or advanced stages with poor prognoses and limited therapeutic options. Establishing evidence-based surveillance techniques, a multidisciplinary approach to diagnosis, and better accessibility of treatment options is vital for the management of HCC in Saudi Arabia.

Efficacy of Chemotherapy Rechallenge Versus Regorafenib or Trifluridine/Tipiracil in Third-Line Setting of Metastatic Colorectal Cancer: A Multicenter Retrospective Comparative Study.

PURPOSE: Metastatic colorectal cancer (mCRC) is a significant global health burden. This retrospective study compared the effectiveness of trifluridine/tipiracil (FTD/TPI), regorafenib, and chemotherapy rechallenge for third-line mCRC treatment. MATERIALS AND METHODS: We reviewed the medical records of 132 patients with mCRC treated with regorafenib, FTD/TPI, or a rechallenge with the initial chemotherapy regimen in a third-line setting from four different institutions. The primary end point was progression-free survival (PFS). Secondary end points were objective response rate and overall survival (OS) across the three treatment approaches. RESULTS: Twenty-nine patients received chemotherapy rechallenge, and 103 received FTD/TPI or regorafenib. Patients' characteristics were comparable, except for a lower number of left-sided primaries and KRAS wild-type tumors in the FTD/TPI-regorafenib group. The median PFS for the entire group was 3.0 months, and the median OS was 13.7 months. Chemotherapy rechallenge has resulted in a median PFS of 3.1 months and a median OS of 21.2 months, compared with 2.9 months (PFS) and 12.6 months (OS) for the FTD/TPI-regorafenib group. Multivariate analyses identified male sex and an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-1 as independent prognostic factors for better PFS, whereas chemotherapy rechallenge, localized stage at diagnosis, and an ECOG PS of 0-1 were significant prognostic factors for better OS. CONCLUSION: This study suggests that chemotherapy rechallenge may provide a survival benefit in the third-line treatment of mCRC. However, patient characteristics, such as sex and ECOG PS, should also be considered in treatment decisions. Further prospective studies are required to confirm our findings.

Consensus Recommendations for the Diagnosis, Biomarker Testing, and Clinical Management of Advanced or Metastatic Non-small Cell Lung Cancer With Mesenchymal-Epithelial Transition Exon 14 Skipping Mutations in the Middle East, Africa, and Russia.

Mesenchymal-epithelial transition exon 14 (METex14) skipping mutations occur in about 3%-4% of patients with non-small cell lung cancer (NSCLC). This is an aggressive subtype associated with poor prognosis. METex14 skipping is a potentially targetable mutation. Targeted therapy is a promising treatment modality for patients with advanced/metastatic METex14-mutant NSCLC. Performing systematic molecular testing to detect the driver mutation is essential for initiating targeted therapy. However, there is a lack of guidelines on molecular testing for assessing the eligibility of patients for targeted therapy. Therefore, a multidisciplinary panel consisting of experts from the Middle East, Africa, and Russia convened via a virtual advisory board meeting to provide their insights on various molecular testing techniques for the diagnosis of METex14 skipping mutation, management of patients with targeted therapies, and developing consensus recommendations for improving the processes. The expert panel emphasized performing molecular testing and liquid biopsy before treatment initiation and tissue re-biopsy for patients with failed molecular testing. Liquid biopsy was recommended as complementary to tissue biopsy for disease monitoring and prognosis. Selective MET inhibitors were recommended as the first and subsequent lines of therapy. These consensus recommendations will facilitate the management of METex14 skipping NSCLC in routine practice and warrant optimum outcomes for these patients.

Impact of central nervous system (CNS) prophylaxis on the incidence and risk factors for CNS relapse in patients with diffuse large B-cell lymphoma treated in the rituximab era: a single centre experience and review of the literature.

Central nervous system (CNS) prophylaxis for diffuse large B-cell lymphoma (DLBCL) is controversial with even less evidence in the era of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy. We reviewed the impact of CNS prophylaxis in DLBCL patients treated with R-CHOP at a tertiary care centre over a 7-year period. CNS prophylaxis was recommended for 'higher risk' patients and consisted of intrathecal methotrexate and/or high-dose methotrexate. Of 214 patients 12·6% received CNS prophylaxis. With a median follow-up of 27 months, eight patients (3·7%) developed CNS relapse (75% isolated to the CNS and 62·5% as parenchymal brain disease) at a median time of 17 months. Patients who did not receive CNS prophylaxis had lower events (2·7%) than those who did (11·1%). Half of the CNS relapses occurred in testicular lymphoma patients, 75% of whom had received CNS prophylaxis. In multivariate analysis, testicular involvement was the only significant prognostic factor for CNS relapse (hazard ratio 33·5, P < 0·001). In conclusion, CNS relapse in DLBCL appears to present as a later, more isolated parenchymal event and at a lower rate in the rituximab era compared with historical data. R-CHOP may negate the need for CNS prophylaxis with the exception of testicular lymphoma.

Outcomes of Patients with Metastatic Colorectal Cancer Treated with Trifluridine/Tipiracil beyond the Second Line: A Multicenter Retrospective Study from Saudi Arabia.

Background: The outcome of patients with refractory metastatic colorectal cancer (mCRC) treated with trifluridine/tipiracil (FTD/TPI) beyond the second-line has not been studied in Saudi Arabia. Therefore, this multicenter retrospective analysis was conducted to evaluate the efficacy of FTD/TPI. Methods: This multicenter retrospective analysis included five centers in Saudi Arabia. FTD/TPI was administered to all the patients beyond the oxaliplatin- and irinotecan-based chemotherapy regimens. The electronic medical records were reviewed, and progression-free survival (PFS) and overall survival (OS) were determined. Results: The study included 100 patients with a mean age of 55.4 ± 11.8 years. The overall response to FTD/TPI was 4%. The median PFS was 4 months (95% confidence interval (CI) 3.487-4.513), and the median OS was 11 months (95% CI, 9.226-12.771). In a Cox regression analysis of the independent predictors for PFS, advanced stage of the disease (P = 0.037; HR, 2.614; and CI, 1.102-7.524), presence of lymph node metastasis (P = 0.018; HR, 3.664; and 95% CI, 1.187-8.650), and >2 metastatic sites (P = 0.020; HR, 1.723; and 95% CI, 1.089-2.727) were independent factors predicting disease progression. The Cox regression analysis confirmed that age ≥ 55 years (P = 0.046; HR, 1.667; and 95%, 1.097-3.100), advanced disease stage (P = 0.044; HR, 1.283; and 95% CI, 1.035-2.940), prior use of adjuvant chemotherapy (P = 0.037; HR, 0.892; and 95% CI, 0.481-0.994), liver metastasis (P = 0.025; HR, 2.015; and 95% CI, 1.091-3.720), >2 metastatic sites (P = 0.038; HR, 1.248; and 95% CI, 1.036-1.846), development of neutropenia after receiving first cycle of FTD/TPI (P = 0.042; HR, 1.505; and 95% CI, 1.064-2.167), and increased number of FTD/TPI cycles (P = 0.002; HR, 0.769; and 95% CI, 0.664-0.891) were independent variables for OS. Conclusion: Treatment with FTD/TPI is feasible and effective in daily clinical practice in Saudi Arabian patients. The risk of progression increased with advanced disease stage, lymph node metastasis, bone metastasis, and metastasis to >2 sites. Age ≥ 55 years, advanced disease stage, liver metastasis, metastasis to >2 sites, neutropenia after the first cycle of FTD/TPI, and increased number of FTD/TPI cycles were independent factors predicting mortality.

Management of Early-Stage Resected Non-Small Cell Lung Cancer: Consensus Statement of the Lung cancer Consortium.

BACKGROUND: Management of early-stage non-small cell lung cancer (ES-NSCLC) has evolved over the last few years especially in terms of work-up and the use of systemic therapy. This consensus statement was developed to present updated guidelines for the management of this disease. METHODS: Multidisciplinary team (MDT) of lung cancer experts convened to discuss a set of pertinent questions with importance relevance to the management of ES-NSCLC. ES-NSCLC includes stages I, II and resected stage III. The experts included consultants in chest imaging, thoracic surgery, radiation oncology, and medical oncology. Questions were discussed in virtual meetings and then a written manuscript with supporting evidence was drafted, reviewed, and approved by the team members. RESULTS: The Consensus Statement included 9 questions addressing work-up and management of ES-NSCLC. Background information and literature review were presented for each question followed by specific recommendations to address the questions by oncology providers. The Statement was endorsed by various oncology societies in the Gulf region. CONCLUSION: The Consensus Statement serves as a guide for thoracic MDT members in the management of ES-NSCLC. Adaptation of these to the local setting is dictated usually by available resources and expertise, however, all efforts should be excreted to provide the optimal care to all patients whenever possible.

Reinfection, recurrence, or delayed presentation of COVID-19? Case series and review of the literature.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-cov-2), first described in December 2019, has now infected more than 28 million cases with almost one million deaths. Reinfection is not definitely established however disease recurrence is increasingly reported. CASES PRESENTATION: Four patients presented with a second episode of coronavirus disease 2019 (COVID-19) occurring 27-85 following their first illness. The initial episode was mild or asymptomatic while the second attack was severe requiring hospital admission. All four patients had a SARS-CoV-2 PCR test positive in the second episode. The chest-X-ray and/or computerized tomography (CT) scan showed bilateral alveolar shadows. Furthermore, the inflammatory markers were raised in the four patients. Three patients recovered following treatment with favipravir in addition tocilizumab and/or dexamethasone. CONCLUSION: Covid19 reinfection Recurrent COVID-19 is increasingly reported. However; other etiologies including superadded infection or pulmonary embolism should be ruled out, particularly if recurrence occurs less than 3 weeks.

Saudi lung cancer management guidelines 2017.

BACKGROUND: Lung cancer management is getting more complex due to the rapid advances in all aspects of diagnostic and therapeutic options. Developing guidelines is critical to help practitioners provide standard of care. METHODS: The Saudi Lung Cancer Guidelines Committee (SLCGC) multidisciplinary members from different specialties and from various regions and healthcare sectors of the country reviewed and updated all lung cancer guidelines with appropriate labeling of level of evidence. Supporting documents to help healthcare professionals were developed. RESULTS: Detailed lung cancer management guidelines were finalized with appropriate resources for systemic therapy and short reviews highlighting important issues. Stage based disease management recommendation were included. A summary explanation for complex topics were included in addition to tables of approved systemic therapy. CONCLUSION: A multidisciplinary lung cancer guidelines was developed and will be disseminated across the country.

Histopathologic characterization of prostate diseases in Madinah, Saudi Arabia.

AIMS: To delineate the histopathological pattern of prostate diseases and to highlight age variations in prostate specific antigen (PSA) values and histopathological features. MATERIALS AND METHODS: A retrospective review was made of all prostate biopsy reports seen between January 2006 and December 2013 at the King Fahad Hospital, Madinah, Saudi Arabia. Prostate lesions were tabulated and classified into benign and malignant groups. Histological scoring of adenocarcinomas was accomplished using the Gleason system. PSA values were correlated with Gleason scores. RESULTS: Of 417 prostate lesions reviewed, 343 (82.3%) were benign and 74 (17.7%) were malignant, giving a benign to malignant ratio of 4.6:1. Benign prostatic hyperplasia (both with and without inflammation) was the commonest prostatic lesion and accounted for 80.3% of all cases and 97.6% of all benign cases. The age range was 20 to 97 years with a mean of 69.2 years and a peak age group at 70-79 years. Seventy one cases of adenocarcinoma accounted for 95.9% of the total of 74 malignant tumors. It showed an age range of 44 to 95 years, a mean age of 70.9 years and peak prevalence in the 80-89 year age group. Gleason score seven was the most frequent (39.4%) in occurrence. Most adenocarcinomas, 41 cases (57.7%), were moderately differentiated (Gleason score of 5-7). PSA values ranged widely between 16-1,865 ng/ml with a mean of 363.4 ng/ml. Elevated PSA (>100 ng/ml) levels were found in 53 (81.6%) patients. There was a statistically significant positive correlation between serum PSA level and Gleason score (p=0.0304). CONCLUSIONS: Prostatic lesions constitute a significant source of morbidity among adult males in Madinah. Benign prostatic hyperplasia was the commonest benign prostatic lesion and adenocarcinoma was the commonest histological subtype of prostatic cancer.

Breast metastasis from renal cell carcinoma: rare initial presentation of disease recurrence after 5 years.

Metastasis to the breast from extra-mammary tumors is rare with only a few sporadic cases reported. We present a 58-year-old female patient diagnosed with renal cell carcinoma. Five years ago she had a radical nephrectomy and was free of disease, then discovered solitary breast mass following self-examination. The patient presented to the breast clinic for evaluation whereupon the breast mass was identified on physical and radiological examinations. Fine needle aspiration was diagnostic of metastatic renal cell carcinoma and subsequent imaging studies demonstrated multiple pulmonary deposits and recurrent renal mass in the tumor bed of the diseased site. In a multidisciplinary clinic, the patient was elected for excision biopsy followed by systemic tyrosine kinase inhibitor therapy. Six months later she had brain metastasis and received whole brain irradiation followed by palliative therapy. We are presenting this rare case with the aim of increasing awareness of breast secondaries.