Background: Different craniospinal irradiation techniques are complex. The homogeneity of the dose to the target and the normal tissues at risk affect both the control rate and the level of adverse effects. Patients and methods: Thirty one patients were treated with CSI in the supine position. Custom-made Styrofoam was tailored for each patient to straighten the convexity and concavity of the spinal axis allowing better dose distribution uniformity during CSI technique. In the first 6 patients, CT simulation were performed twice: one time with the patient lying directly on the vacuum mattress without the foam (the conventional way) and the second while lying on the foam. Dose distribution was calculated using a 3D conformal planning. The gap between the fields was determined using isodose alignment method. All treatment portals were verified during the first 3 treatment sessions and once weekly thereafter using either cone-beam or portal image device. Weekly feathering (shifting of the junction between the 2 adjacent radiation fields) was routinely performed. Results: The 95% dose distribution had better coverage with the foam (p=0.042) while the hot volume of 110% and 105% dosage were significantly lesser than conventional technique (both p=0.028). The organs at risk received nearly similar radiation doses in the 2 positions. The CSI led to minimal immediate adverse effects that were reversible. Weight loss was experienced by 55% of patients. Conclusion: This modified technique of CSI is simple, ensuring better dose distribution to CSI target without increasing the dose to the surrounding organs at risk. It is tolerable and safe to apply.

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20-24

With an aim to analyze and document the outcome of Stage I Seminoma patients we undertook a retrospective analysis of patients treated between January 1990 and December 1998. The treatment charts of patients treated between January 1990 and December 1998 were reviewed. Patient and tumor characteristics, treatment details, relapse rates, late toxicities, or occurrence of second primary was noted. Royal Marsden Staging System was utilized because of its simplicity and wide-use in the above period. Out of 137 patients, 41 (30%) patients did not receive any further treatment, 96 (70%) patients received prophylactic radiotherapy to para-aortic and pelvic nodes. The observation group patients had a median follow-up 20 months, 9 patients had nodal relapse with 7 in retroperitoneal nodes and 2 patients in inguinal nodes. Of these, 7 patients received BEP chemotherapy and 2 patients Chemoradiation. Four patients had complete remission while remaining 5 patients had partial response. The histopathologies of all the 5 patients with partial response were reviewed to reconfirm the diagnosis. Patients of prophylactic radiotherapy group had a follow-up of 33 months, 6 patients relapsed, RP nodal disease in 5 patients and distant metastasis in 1 patient. All these patients received BEP chemotherapy. One had complete response and remaining 5 patients had partial response. The group of patients under observation had a significantly higher relapse rate and lower disease free compared to the adjuvant radiotherapy group (73.5% vs. 91% at five years, p value 0.004). Disease specific survivals for the two groups were however similar (89% vs. 93%) at five years, p value 0.18). We conclude that Stage I Seminoma patients treated with prophylactic radiation to paraaortic and pelvic region had better outcome.

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25-30

Comparison of Homogeneity Indices for Quantitative Evaluation of Dose Homogeneity for IMRT Treatments of Head and Neck Cancers

he purpose of this study was to evaluate different homogeneity indices for IMRT of head and neck cancers and to suggest the best representative homogeneity index for quantitative measure of dose homogeneity. In this study 3 different homogeneity indices were evaluated for 22 head and neck cancer patients receiving dynamic IMRT treatments on Clinac-DHX linear accelerator with 6 MV photon beam. IMRT planning was carried out with Helios software on Eclipse treatment planning system. H index, HI index and S index proposed by Yoon (2007) were calculated for these patients. The H-index, HI index and S index values varied between 1.024 to 1.112, 4.03 to 16.9 and 0.94 to 3.43 respectively. H index values for patient 5 and 10 are identical (H index-1.06) though different in DVH distributions but the S index values for these patients are different (1.36 and 2.01). Similarly the HI index for the patient 11 and 16 are identical in spite of different DVH distributions but S index values are different for patient 11 and 16. Since the S index represents the whole DVH curve unlike the conventional indices which depends on dose at a point, it is the better method to quantify the dose homogeneity. These results indicate that H and HI indices do not provide the accurate dose homogeneity information, but the S indices uniquely provide quantitative information about the dose homogeneity.

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31-37

GIST in Saudi Arabia: Multicentric Histopathologial Genetic Study of 75 Surgically Excised Cases

The availability of CD117 (Ckit) immunohistochemical testing in most hospital laboratories has facilitated the diagnosis of GIST in cKit positive cases. The aim of this study was to describe the histopathological variations of GIST in Saudi Arabia. The study involved analysis of paraffin blocks of 75 surgically excised GIST and GIST-like stromal tumors obtained from four major referral hospitals in Saudi Arabia (Riyadh Military Hospital, King Abdulaziz Medical City, King Faisal Specialist Hospital & Research Center and Aramco’s hospital) between 1998 and 2009. Patient sex and age were noted in addition to the following tumor variables: size, site, histological grade and type, immunohistochemical profile and genetic analysis of the cKit mutation. The stomach was the commonest site for tumors and spindle cell type was the most frequently seen variant. Further sub classification of the histopathological type was made in order to recognize the morphological pattern of the tumor. The most common tumor grades seen were of low-risk and high-risk groups. There was one case of familial GISTparaganglioma syndrome and the youngest subject was an 8-year-old girl with high-risk spindle cell gastric GIST. Genetic study in 34 cases revealed exon 11 mutations in all of the cKit genes.

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38-44

Immuno-histochemical evaluation of Cathepsin D in malignant salivary gland carcinomas

Objective: Cathepsin D is a lysosomal acid protease secreted in increased levels in several malignancies. However, its role in salivary gland tumors has not been studied extensively. The present study aims to assess the expression of Cathepsin D in malignant salivary gland tumors and to compare its expression in these tumors. Study design: A total of 30 cases of malignant salivary gland carcinomas which included 16 cases of adenoid cystic carcinoma (ACC), 9 cases of mucoepidermoid carcinoma (MEC), and 5 cases of polymorphous low grade adenocarcinoma (PLGA) were evaluated immunohistochemically using anti-Cathepsin D antibody. Result: All the cases showed positivity (100%) for Cathepsin D with intense expression noted in ACC and MEC as compared to PLGA. Comparison of these tumors revealed statistical significant difference in expression between ACC and PLGA. Conclusion: Intense expression of Cathepsin D in high grade carcinomas may be a marker for invasive potential and aggressive behavior.

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45-49

Epidemiology of breast cancer patients at a tertiary care center in the Eastern Province of Saudi Arabia

Background: Breast cancer is the most common cancer in Saudi Arabia. However, detailed published epidemiologic data are scarce. In this study, breast cancer patients at a tertiary care hospital were characterized and compared with data from the United States. Methods: Medical records were retrospectively reviewed of female patients with confirmed diagnosis of invasive breast cancer who consulted with Saad Specialist Hospital between 2004 and 2011. Descriptive statistics were calculated and compared with published data. Results: Two-hundred and sixty-two female patients with cytologically or histologically confirmed diagnosis of invasive breast cancer were identified and analyzed. Compared to published American data derived from the SEER database, patients were diagnosed at a markedly younger age (<50 years: 57.5% versus 12.5%) and more advanced disease (localized disease: 28.6% versus 61.2%). The difference of the age at diagnosis could not be fully explained by the different age structures of the Saudi Arabian and American population in our analysis. Although the overall mastectomy rate was higher (58.2% versus 38.5%), no relevant difference in the mastectomy rates was found if analyzed by stage. Conclusion: Our data suggest that breast cancer in this part of Saudi Arabia is diagnosed at a much higher stage compared to the United States. More effort in awareness campaigns, easier access to screening and treatment are needed to improve the prognosis and to reduce the currently relatively high mastectomy rate.

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50-59

Expression of oestrogen progestrone and androgen receptors in salivary gland tumours: A review of literature

Hormone therapy is highly recommended on patients with breast cancer who show positive nuclear staining of the cancer cells. It is not known however whether salivary gland tumours can respond to hormone therapy. Twenty eight studies undertaken between 1980 to 2009 involving different types of salivary gland cancers were evaluated and taken into consideration the type of used antibody and the criteria to assess the intensity staining. This review has shown that estrogen progesterone and androgen receptors were detected in few cases of salivary gland tumours. Different types of used antibodies were identified, and the criteria of assessment of the staining intensity were different as well. The outcome of this review indicated that the growth of those tumours was not dependent on hormone function. It is recommended that sensitive and specific biochemical methods can be used to determine if estrogen and progesterone receptors can be detected in salivary gland cancers. It is necessary to use one criterion such as positive or negative nuclear staining to determine the existence of estrogen and progesterone receptors and to avoid any bias. The discrepancy in the results reflects a clear need for consensus on a protocol for scoring of immunohistochemical staining.

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The hepatic arterial anatomy is highly variable. A 67 year female with pancreatic mass and replaced common hepatic artery originating from the superior mesenteric artery underwent pancreaticoduodenectomy (PD). The anomalous vessel was discovered on preoperative CT scan and MRI. The vessel was dissected and preserved as it passed dorsal to the pancreas. Preservation of the blood supply to the liver and biliary tree is important after PD to prevent biliary fistula and hepatic ischaemia.

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63-65

Lipoadenoma of the parathyroid gland – A rare cause of hyperparathyroidism

Lipoadenoma of parathyroid gland is an unusual morphologic variant of parathyroid adenoma in which the glandular elements are associated with abundant mature adipose tissue. The lesion has also been reported as parathyroid lipohyperplasia, parathyroid hamartoma, and parathyroid adenoma with myxoid stroma. Most cases are functioning and are associated with hyperparathyroidism. Lipoadenoma of parathyroid gland are difficult to diagnose as a cause of hyperparathyroidism because of rarity of these lesions and overlap with normal parathyroid tissue on microscopic evaluation. Only few cases have been documented in the literature so far. The lesion may be overlooked by both surgeon and pathologists alike, if they are not aware of this specific clinicopathologic entity.

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Multiple Ancient Schwannoma of the accessory nerve - A Case Report

We are reporting a case of multiple ancient schwannoma of the accessory nerve in a 57 year old male. Accessory schwannomas are rare with only 19 cases reported in literature so far. Ancient schwannoma is even rarer in the head and neck region with no other cases associated with the accessory nerve being reported in literature so far.

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Renal Cell Carcinoma (RCC) is a malignant tumor occurring in 5th-6th decade of life with an increasing incidence reported in the US but stable in Europe. The metastasis of RCC to head and neck region is infrequent and very rarely seen in larynx. Very few cases of RCC metastasizing to larynx are reported in literature. We report a case of RCC in a middle aged male with metastasis to larynx, 7 years after initial diagnosis and nephrectomy. These unusual tumor metastases have unique pathobiology and route of metastasis, and there can be a long interval from initial diagnosis of primary tumor. The diagnosis of metastatic RCC in unusual locations is often not easy. Treatment options include metastasectomy, radiotherapy and systemic chemotherapy but with a poor outcome. A differential diagnosis should always be considered in metastatic head and neck tumors. The need for prompt accurate diagnosis, risk stratification at initial primary diagnosis, surveillance, and long term regular follow up is emphasized.

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Fine Needle Aspiration Diagnosis of Ipsilateral Synchronous Neoplasm - Mucoepidermoid Carcinoma with Warthin Tumor in Parotid Gland

Warthin tumor (WT) owing to its heterogeneous appearance, biological behavior and multicentricity poses a diagnostic challenge to cytologists worldwide. We report a rare double pathology of mucoepidermoid carcinoma (MEC) with WT which was diagnosed by fine needle aspiration (FNA). Cytological smears revealed sheets of epithelial cells and small clusters of squamous cells in a background of mucoid material along with a few small groups and scattered oncocytic cells and inflammatory cells (mainly lymphocytes). In view of the cytological findings various differentials such as oncocytic lesions, benign lesions of the parotid with extensive lymphoid reaction, necrotizing sialometaplasia, WT with extensive squamous/mucoid metaplasia, metastatic squamous cell carcinoma (SCC) with or without cystic change, oncocytic variant of MEC and a possibility of a synchronous MEC with WT were considered. By means of extensive review of the smears and clinic-pathological meets as discussed below, 2 differential diagnoses were given- MEC with WT versus an oncocytic variant of MEC with “?” lymphoid (tumor response) reaction. Subsequent histopathological examination confirmed the diagnosis of MEC with WT. Recent discovery of t(11; 19) translocation generating a novel fusion gene CRTC1/MAML2 which has been demonstrated in both MEC and WT has helped in providing the missing link in confirming the genetic relatedness and proof of development of a subset of WT with concomitant MEC. The case discusses the FNA findings of a rare collision tumor (MEC with WT), its possible differentials and highlights the importance of noting the background material in a case of double pathology on FNA.

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