Toward standardization of laparoscopic resection for colorectal cancer in developing countries: A step by step module.

BACKGROUND: Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in developing countries. Also a steep learning is one of the causes of its limited adoption. OBJECTIVE: To explore the learning curve of single surgeon experience in laparoscopic colectomy and feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles. PATIENTS AND METHODS: This prospective study included 50 patients with carcinoma of the left colon and rectum recruited from the department of surgical oncology at National Cancer Institute, Cairo University in the period 2012-2016. All the procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed. RESULTS: The mean age was 49.7±10.6years (range: 33-74years). They were 29 males and 21 females. The mean operation time was 180min (range 100-370min), and the mean blood loss was 350ml (60-600ml). Six patients (12%) were converted to a laparotomy. The median lymph nodes harvest was 12 (range 7-25). The mean time of passing flatus after surgery was 2days (1-4days) and the mean time of passing stools was 3.3days (2-5) days. The median hospitalization period after surgery was 4days (3-12). 5 patients (10%) had postoperative morbidity, major morbidity occurred in one patient. CONCLUSION: Laparoscopic colorectal surgery for colorectal cancer is safe and oncologically sound, standardized well-structured laparoscopic technique masters the procedure even in early learning curve setting.

The profile of extremity and trunk soft tissue sarcoma in a tertiary referral center.

BACKGROUND: Proper surgery with adequate safety margin and adjuvant radiotherapy is the main line of treatment of extremity and trunk soft tissue sarcoma (STS). In spite of improved management, the long term follow up is still not satisfactory. OBJECTIVE: To evaluate long term outcome of STS of extremities and trunk regarding adequacy of resection, recurrence and survival. PATIENTS AND METHODS: This prospective study included 25 patients with STS involving extremity and trunk. All patients were treated with wide radical excision and had adjuvant irradiation and followed up for a median of 26months. RESULTS: The mean age was 40.0±15.3years. They were 16 males and 9 females. Eight patients (32%) had positive or close surgical margins. The median overall survival (OS) was 26.5months. In univariate analysis, lower limb tumors, stage III and grade 3 were significantly associated with worse overall survival (OS) (p=0.007, 0.02, and 0.020, respectively) and disease free survival (DFS) (p=0.005, 0.001, and 0.001, respectively). On multivariate analysis the only independent factor that affects the OS and DFS was the stage (p value=0.029, Hazard ratio: 3.64, 95% confidence interval: 1.14-11.61 and p value=0.003, Hazard ratio: 5.75, 95% confidence interval: 1.82-18.18 respectively). CONCLUSION: Despite adequate surgery and adjuvant irradiation, 5years follow up results of treatment of extremity and trunk soft tissue sarcoma is still poor. This highlights the importance of early detection of small STS in extremity and trunk.

Outcome and surgical strategy in critical sites in cases of psuedomyxoma peritonei.

BACKGROUND: For a long time peritoneal neoplasms were considered beyond surgical intervention and beyond cure, till the concept of cytoreductive surgery (CRS) and adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) was introduced. However this surgical intervention is technically demanding and associated with considerable postoperative morbidity. OBJECTIVE: To describe the surgical strategy in resection of critical sites loaded by heavy tumor deposits and to evaluate short and long term results of CRS and HIPEC, in a cohort of Egyptian patients with pseudomyxoma peritonei (PMP) from appendiceal origin. PATIENTS AND METHODS: 21 patients with PMP, age ranged from 40 to 63years, 12 males and 9 females. All were recruited from the department of surgery at the National Cancer Institute (NCI), Cairo University over the period from February 2011 to February 2016. They were subjected to CRS and HIPEC with mitomycin-C. RESULTS: The median peritoneal carcinoma index (PCI) was 22 (range: 10-39). Optimal cytoreduction (CCR-0/1) was achieved in 19 patients (90.4%) of whom 17 patients (80.9%) had a complete cytoreduction (CCR-0). The median follow up period was 51.5months (range: 0.07-82.3months). The cumulative overall survival was 85.7% while the cumulative disease free survival was 76.9%. CONCLUSION: To the best of our knowledge, this is the first study reporting five years postoperative outcome of CRS and HIPEC in Egyptian patients with PMP from appendiceal origin. Our results support that although technically demanding this treatment modality is safe and associated with favorable outcome.

Tamoxifen compared to best supportive care in advanced hepatocelluar carcinoma: A retrospective matched-cohort study.

BACKGROUND: Hepatocelluar carcinoma (HCC) is a common cancer worldwide as well as in Egypt with hepatitis B and C, alcohol and aflatoxins being the commonest risk factors. Tamoxifen was initially reported to confer a marginal survival benefit in advanced HCC. However, later reports declined any benefit. OBJECTIVE: To study the impact of tamoxifen on overall survival (OS) compared to best supportive care (BSC) in Egyptian patients with advanced HCC. METHODS: This retrospective matched-cohort study was conducted at Tanta Cancer Center (TCC), Egypt where 116 advanced HCC cases treated with tamoxifen were compared to TNM stage and Child-Pugh class matched 116 HCC cases who received BSC. RESULTS: The median OS in the tamoxifen group was 9.3 months (95% confidence interval [CI], 6.7-11.9 months) compared to 8.7 months (95%CI, 6.8-10.6) in the BSC group (p=0.758). With univariate analyses, it was shown that absence of fatigue, Child-Pugh class A, single tumors, less advanced tumors (T2), and absence of metastases (M0), had significantly better OS than their counterparts. Multivariate analysis showed that absence of fatigue, Child-Pugh class A and T2 tumors were independent prognostic factors affecting OS. Tamoxifen produced partial response and clinical stabilization in one% and 16% of cases, respectively. The median PFS with tamoxifen was 7.2 months (95%CI, 5.2-9.5). CONCLUSIONS: Tamoxifen did not show any OS advantage in Egyptian patients with advanced HCC. Use of this drug is discouraged.

Evaluation of BreastLight as a tool for early detection of breast lesions among females attending National Cancer Institute, Cairo University.

BACKGROUND: Breast illumination was suggested as a simple method for breast cancer screening. BreastLight is a simple apparatus for this purpose. OBJECTIVE: To evaluate the diagnostic performance of BreastLight as a screening tool of breast cancer in comparison to mammography and histopathology. MATERIALS AND METHODS: This hospital-based cross sectional study was conducted in the mammography unit of the radiodiagnosis department at National Cancer Institute, Cairo University. All participants were subjected to breast examination with the BreastLight tool, mammography and ultrasonography. Suspicious cases were biopsied for histopathological examination which is considered as a gold standard. RESULTS: The mean age of the participants was 46.3±12.4 years. Breast illumination method had sensitivity, specificity, positive predictive value, negative predictive value and total accuracy of 93.0%, 73.7%, 91.4%, 77.8% and 88.2%, respectively in detection of breast cancer. CONCLUSIONS: Breast illumination method with BreastLight apparatus is a promising easy-to-use tool to screen for breast cancer suitable for primary health care physician or at-home use. It needs further evaluation especially in asymptomatic women.

SEN virus infection in Egyptian patients undergoing maintenance hemodialysis: prevalence and clinical importance.

BACKGROUND AND PURPOSE: SEN virus (SENV) is assumed to be responsible for post-transfusion non-A to -E hepatitis. Phylogenetic analysis of SENV has shown 9 different strains. Two strains, SENV-H and SENV-D, were described as possible candidates for post-transfusion hepatitis. This study examined the prevalence of SENV infection and its clinical importance for patients undergoing hemodialysis. METHODS: Serum samples were obtained from 63 long-term hemodialysis patients, and examined for SENV-H and SENV-D viremia by polymerase chain reaction. Serum samples were also obtained from 20 patients with chronic kidney diseases (CKD) who were not undergoing hemodialysis and from 20 apparently healthy blood donors to act as controls. For SENV screening, a primer pair was used for the conserved ORF1 region among all SENV genotypes from A to I. RESULTS: SENV infection was significantly more frequent among hemodialysis patients (33/63; 52.4%) and those with CKD (10/20; 50.0%) than among the control participants (2/20; 10.0%) [p = 0.003]. Twenty three of 33 hemodialysis patients had SENV-H or -D, 61% of whom were positive for SENV-H only, 4% were positive for SENV-D only, and 36% were positive for both SENV-H and SENV-D. SENV infection was not associated with age, sex, amount or duration of hemodialysis, or liver function test results. Elevated alanine aminotransferase was significantly associated with HCV viremia, but not with SENV infection. CONCLUSIONS: Egyptian hemodialysis patients and those with CKD are at higher risk for SENV transmission. SENV-H is more prevalent than SENV-D.

The diagnostic value of C-reactive protein, interleukin-8, and monocyte chemotactic protein in risk stratification of febrile neutropenic children with hematologic malignancies.

BACKGROUND AND AIM: Recent advances in febrile neutropenia have highlighted the value of risk stratification especially that it can have important implications in terms of management. We aimed to identify a serum marker that may help to stratify febrile neutropenic pediatric patients treated for hematologic malignancies at the time of first evaluation. Thus, C-reactive protein (CRP), interleukin-8 (IL-8), and monocyte chemotactic protein-1-alpha (MCP-1-alpha) were evaluated for their predictive and diagnostic relevance in febrile episodes of cancer patients. PATIENTS AND METHODS: Within 24 hours of fever, CRP, IL-8, and MCP-1 serum levels were measured and the levels of these markers were related to the clinical findings of the patients. For this purpose, we collected and analyzed clinical data of 85 fever episodes occurring in 76 patients with hematologic malignancies, presenting to the Department of Pediatric Oncology, National Cancer Institute, Cairo University, during a 6-month period. RESULTS: Neutropenic children with febrile episodes were classified into 2 groups, a group with unexplainable fever (group I, n=26) and another group with either blood culture positive, and/or fever periods with a documented clinical sepsis and/or local infection (group II, n=59). Clinically, local sites of infection were encountered in 39 cases (45.9%), whereas a positive blood culture was detected in 20 cases. CRP, IL-8, and MCP-1 levels were significantly lower in group I versus group II (P value <0.001). There were overlaps of values between groups. CRP > or =90 mg/L was significantly associated with chemotherapy-related neutropenia and fever owing to bacteremia (P=0.038). The sensitivity, specificity, negative and positive predictive values of CRP, MCP-1, and IL-8 were (70%, 73%, 51%, and 85%), (64%, 92%, 53%, and 95%), and (71%, 77%, 54%, and 88%), respectively. Combining 2 or 3 markers improved the diagnostic performance of these test, as 78% of group II had elevated 2 or 3 markers versus 16% of the group with no evident infection. CONCLUSIONS: Low levels of CRP, MCP-1, and IL-8 could identify patients with unexplainable fever; whereas, high levels of these markers were of help in the diagnosis of infectious episodes. A model combining more than 1 marker is recommended in the assessment of febrile neutropenia.

Viral genomes and antigen detection of hepatitis B and C viruses in involved lymph nodes of Egyptian non-Hodgkin's lymphoma patients.

Several studies have suggested an association between Hepatitis C and B viruses (HCV and HBV) and non-Hodgkin's lymphoma (NHL). In the present study we have searched for viral genomes and antigens in the malignant lymphoma tissues as well as their seroprevalence. Antibodies against Hepatitis C as well as HCV RNA and hepatitis B surface antigen (HBsAg) were determined for 29 newly diagnosed non-Hodgkin's lymphoma patients using an enzyme linked immunosorbent assay (ELISA), as well as RT-PCR and compared with 36 apparently healthy individuals as a control group for viral markers. Immunohistochemical staining (IHC) was performed on paraffin embedded tissues for the NS3 of HCV and for HBsAg of HBV using the immunoperoxidase technique. Paraffin embedded lymph nodes (LN) were studied for the presence of viral sequences. Ten non-metastatic lymph nodes (LN) from cancer cases other than NHL were used as a control for IHC and molecular studies. HCV was significantly more encountered in patients with NHL when compared to controls for both antibodies (27.6% versus 8.3% of serum controls; p = 0.04), and antigens studied by IHC in the involved LN (41% versus 10% of tissue controls; p = 0.06). Although HBsAg positivity was not different in NHL patients when compared to controls (6.9% and 2.7%); yet it was significantly more encountered in LN of NHL patients (p = 0.04). HBV-DNA was detected in 27.5% of patient's samples and none of the controls. In conclusion, overall our findings confirm the presence of HBV and HCV antigens and viral sequences in the involved LNs of NHL patients, except for HCV RNA which perhaps necessitates fresh and not paraffin embedded tissues. These results strengthen the assumption that these viruses may be involved in the development of NHL.