Obesity and High Risk Pathological Features of Papillary Thyroid Carcinoma: A Retrospective Analysis of a University Hospital in Pakistan

Shakeel Uz Zaman¹, Mohammad Sohail Awan², Mohammad Ahsan Sulaiman¹

1. Department of Otorhinolaryngology-Head and Neck Surgery, Liaquat National Hospital and Medical College, Karachi, Pakistan

2. Department of Otolaryngology-Head and Neck Surgery, Aga Khan University Hospital, Karachi, Pakistan

Background: Incidence of papillary thyroid carcinoma (PTC) and the frequency of obesity is increasing globally. In literature, relationship between excessive body weight and bad prognostic features of PTC is still debatable. In this study, we aimed to explore the association of obesity with high risk pathological features of PTC in a population treated by total thyroidectomy +/- neck dissection.

Materials and methods: Retrospective analysis of patients at Aga Khan University Hospital from January 2013 to December 2014, who underwent total thyroidectomy +/- neck dissection due to PTC. Patients were grouped according to World Health Organization (WHO) classification of BMI. They were categorized into two groups, i.e. normal (BMI= 18.5 - 24.9 kg/m2) and obese (BMI = 30 kg/m2) as none of our patients lie in underweight and overweight category. Pathological features i.e. T-stage, multifocality, bilaterality, extrathyroidal extension, vascular invasion and N-stage were assessed. All tumors were staged according to TNM staging system proposed by 2010 American Joint Committee on Cancer (AJCC). Odds ratio (OR) with 95% confidence interval was used to examine the association between BMI & pathological characteristics of PTC.

Results: A total of 53 patients were treated for PTC in two-years period. There were 38 female and 15 male patients. Twenty-eight patients had BMI in normal while twenty-five in obese category. Patients who were in obese category had a significantly greater risk of having a multifocal tumor (OR=5.55, p-value=0.02) and bilaterality (OR=6.54, p-value=0.01) compared to normal weight patients. No positive associations were identified between BMI and extrathyroidal extension, high T-stage, vascular invasion and N-stage.

Conclusion: Obesity is not associated with high risk pathological features such as extrathyroidal extention, high T-stage, vascular invasion and N-stage in PTC. Although it has been correlated with multifocal and bilateral tumors in this retrospective study, the presence of these factors alone is not adequate to support the association conclusively.

Keywords: Papillary thyroid carcinoma, Body Mass Index, Pathological features, Total thyroidectomy, Obesity

Quantification of circulating plasma cell free DNA fragments in patients with oral cancer and precancer

Ami Desai¹, Shreenivas Kallianpur¹, Abin Mani², Manisha S. Tijare³, Samar Khan⁴, Megha Jain⁵, Vidhi Mathur¹, Rinky Ahuja¹, Vijay Saxena⁶

1. Department of Oral Pathology and Microbiology, People’s College of Dental Sciences and Research Center, Bhanpur, India

2. Centre for Scientific Research and Development People’s Group, Bhanpur, Bhopal, India

3. RRK Dental College and Hospital Akola, Maharashtra, India

4. Division of Maxillofacial Diagnostic Sciences, Dept. of Oral and Maxillofacial Pathology, College of Dentistry, Jazan University, Jazan (KSA)

5. Department of Oral Pathology and Microbiology, People’s Dental Academy, India.

6. Department of Medicine, People’s College of Medical Sciences and Research Center, Bhanpur, Bhopal, India

Purpose: Study was aimed to quantify plasma level of total, short and long fragmented cell-free DNA (cfDNA) along with DNA integrity in patients with oral cancer, oral precancer and tobacco users without lesions and normal controls. In addition, study evaluated the correlation of cfDNA with clinicopathologic parameters of oral cancer.

Methodology: Plasma samples were collected preoperatively from 44 patients with oral cancer, 40 patients with oral precancer, 40 tobacco users without any oral lesion and 40 healthy controls without any tobacco habit. cfDNA extraction was carried out from the plasma followed by quantitative and qualitative assessment of extracted DNA. Quantity of short and long fragmented DNA was assessed by using PCR with two different primer sets for the beta-actin gene, amplifying short (102 bp) and long (253 bp) products. The DNA integrity index was measured by calculating the ratio of quantity of long fragmented to short fragmented DNA. All quantitative
cfDNA parameters were statistically analyzed to verify their correlation with clinicopathologic parameters.

Results: Results showed that total cfDNA level, short and long fragmented cfDNA concentration and DNA integrity was significantly higher in oral cancer group as compare to other (p=0.0001). Study demonstrated that there is no correlation total, short and long cfDNA and DNA integrity with tumor size and histologic type or grading. But positive correlation of total cfDNA was found with nodal metastasis (p=0.001) and clinical stages (p=0.006).

Conclusion: Quantitative analysis of total cfDNA may be applied as a screening marker for early detection of precancer and cancer as well as for prognostication of oral cancer. Additionally, plasma levels of short and long fragmented cfDNA and DNA integrity index can be applied for early detection of oral cancer.

Keywords: Oral squamous cell carcinoma (OSCC), Oral precancerous lesion, Cell-free DNA, Polymerase chain reaction (PCR), DNA integrity index, Beta-actin gene

Clinical and microbiological profile of infections during induction phase of acute myeloid leukemia

Sonia Parikh¹, Parijat Goswami², Asha Anand¹, Harsha Panchal¹, Apurva Patel¹, Rahul Kulkarni¹, Bhadresh Shastri¹

1. Department of Medical Oncology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

2. Department of Microbiology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Background: The primary objective of this study is to describe clinical and microbiological profile of infections during induction phase of acute myeloid leukemia (AML).

Patients and methods: We reviewed the case records of 50 hospitalized patients with AML undergoing standard dose induction chemotherapy from January to December 2015.

Results: Out of 50 cases, 34 were males 16 females with median age of 30 years. Most common presenting symptoms were fever followed by bleeding diathesis. The clinical sites of infections were gastrointestinal tract including oral cavity (48%), respiratory tract (4%), skin/soft tissue (4%) and genitourinary tract (4%). Clinically (58%) or microbiologically (30%) documented infections were 88%, while 12% had fever without identifiable source. Overall, in 21 episodes microorganisms were isolated. Common sites of isolates were blood stream (11), stool (8), sputum (1) and urine (1). Gram negative infections accounted for 81% of total isolates; Escherichia coli (E. coli) being the commonest. Gram positive microorganisms were isolated in 19% of which methicillin resistant staphylococcus aureus (MRSA) was the most common. Gram negative bacterial infections were associated with higher mortality.

Conclusion: Gastrointestinal tract is the most common clinical site of infection. Blood stream infection is the most common site for positive bacterial isolates. Gram negative bacilli were the predominant cause of infections with E. coli being the most common pathogen isolated. Empiric antibiotic treatment for febrile neutropenia should be tailored to the locally prevalent pathogens and their susceptibility patterns

Keywords: AML, induction chemotherapy, blood stream infection, Escherichia coli, E. Coli

Breast Cancer Risk factor awareness and utilization of screening program: A cross-sectional study among women in the Northern Emirates

Prashanth Hegde¹, Jyothi Pande², Hanaa Hosny Adly³, Padma V. Shetty⁴, Jayakumari⁵

1. Department of Obstetrics & Gynaecology, Gulf Medical College Hospital, Ajman, UAE

2. Department of Obstetrics & Gynaecology, Gulf Medical & Dental Hospital, Sharjah, UAE

3. Department of Obstetrics & Gynaecology, Gulf Medical College Hospital, Fujeirah, UAE

4. Department of Accident & Emergency, Gulf Medical College Hospital, Ajman, UAE

5. Research Division, Gulf Medical University, Ajman, UAE

Background: Breast cancer is the principal cause of cancer deaths among women worldwide. Among Emirati females, breast cancer ranked first accounting for 23.1% of the total cancers. Around 58% of the cases occurred were reported from northern emirates. United Arab Emirates is having higher percentage of expat female population than Emirati women. There is lack of data regarding the knowledge and attitude about breast cancer in this mixed population.

Aim: The aim of this study was to determine the knowledge and attitude of women towards breast cancer, risk factors and the screening program in women above the age of 19 years residing in northern emirates of the UAE.

Materials and Methods: This is a multi-center based study conducted in selected northern emirates of the UAE. This study employed cross-sectional design involving women above the age of 19 years. The study was conducted among 400 women who attended three hospitals in Ajman, Sharjah and Fujairah. Pretested, content validated questionnaire was used for data collection. Descriptive and inferential analysis was performed.

Results: About 85.2% of participants had heard about breast cancer. Among all, 47.9% felt breast cancer is more frequent than other cancers. While inquiring about symptomatology, most of the respondents had incorrect knowledge (79.8% for painless breast lump, 78.6% change in breast size, 76.3% nipple discharge). Subjects were queried for breast cancer screening (BSE) and were observed to have poor knowledge. Regarding practice of those with correct knowledge on BSE 34.2% of the participants had correct practice.

Conclusion: The result shows that while substantial number still remains ignorant of breast cancer issues, a good number of those who have knowledge were yet to translate knowledge and attitudes into practice.

Keywords: Attitude, Awareness, Breast cancer, Knowledge, northern UAE

BRCA1 and BRCA2 Germline Mutation Screening in Western Algeria using High Resolution Melting Analysis (HRM)

Breast cancer is the leading cause of cancer deaths in Algerian women. Our aim is to analyze BRCA1 and BRCA2 genes mutations in 100 Algerian patients with a family history suggestive of genetic predisposition to breast cancer. BRCA1 and BRCA2 mutations were searched by High-Resolution Melting (HRM) analysis, followed by direct sequencing, and Multiplex Ligation-Dependent Probe Amplification (MLPA) for large deletions or duplications.

An unclassified variant c.5117G>C, p.Gly1706ALA and a pathogenic mutation c.2125_2126insA, p.Phe709TyrfX3 were detected in the BRCA1 gene. No large deletions or duplications were detected with MLPA. One deleterious mutation c.250C>T, p.Gin84X, and one unclassified variant c.9364G>A, p. Ala3122Thr were identified in BRCA2 gene. The pathological significance of this variant has to be specified and analysis of its segregation in the family and differs from those provided in the literature. Although on a limited cohort, our findings suggest a higher frequency of BRCA1/2 mutations in Algeria and it would be of interest to search for the presence of these pathogenic mutations in other family member for preventing the risk of cancer.

Keywords: Breast cancer, BRCA1, BRCA2, Western Algeria, High Resolution Melting Analysis, HRM

Colon Cancer in Patients below Age of 50 Years: Kuwait Cancer Control Center Experience

Mohamed Salah Fayaz, Gerges Attia Demian, Heba El-Sayed Eissa, Sadeq Abu-Zlouf
Department of Radiation Oncology, Kuwait Cancer Control Center

Background: This study was undertaken to analyze and evaluate the clinico-pathological profile and the outcome of young patients diagnosed with colon cancer.

Patients and Methods: Patients diagnosed with adenocarcinoma of the colon at or below the age of 50 years from January 2000 to December 2007 in Kuwait were analyzed. This study retrieved 130 patients diagnosed = 50 years, representing 22% of colon cancer patients in this period, 67 females and 63 males. Patients = 40 years were 48 while those 41-50 years were 82. Median follow-up was 61 months.

Results: According to the TNM system, 82% patients had T3 & T4 disease, 55% had node negative disease and 15% had distant metastasis at presentation. All patients except three underwent surgery. Chemotherapy was given in 82% of patients either for adjuvant or palliative intent. The 5-year overall survival (OS) and progression free survival (PFS) were 78% and 75% respectively. Survival was significantly affected by the disease stage and grade. The OS was 96%, 83%, 6% for stage I and II, III and IV respectively (p < 0.001). OS was 91% for grade 1 and 2 tumors vs. 60% for grade 3 tumors (p= 0.007). Patients who presented = 40 years had relatively more grade 3 (19% vs. 7%) compared to 41-50-years age group.

Conclusions: Colonic adenocarcinoma is frequently diagnosed below the age of 50 in our population. Younger age (= 40 years) seems to present more with high grade tumors. Clinicians should consider full colonoscopic evaluation while investigating symptomatic young patients.

Awareness, understanding, attitude and barriers toward prescribing modern cancer immunotherapies in the Arabian Gulf countries

Humaid O. Al-Shamsi^1-2, Emad Tashkandi³, Nedal Bukhari⁴, Abdulaziz Al Farsi⁵, Abdulsalam Alnajjar⁶, Ahmad Alhuraiji⁶, Moteb Foheidi⁷, Ahmed Sagheir⁸, Khalid Bin Thani⁸, Bassim Al Bahrani⁹, Sadir Alrawi ¹⁰

1. Department of Internal Medicine, University of Sharjah, Sharjah, United Arab Emirates,

2. Alzahra Hospital, Dubai, United Arab Emirates

3. Medical College, Umm AlQura University. King Abdullah Medical City, Makkah, Saudi Arabia.

4.  Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

5. National Oncology Centre, The Royal Hospital, Oman

6.  Kuwait Cancer Control Center, Kuwait

7.  King Saud Bin Abdulaziz University for Health Sciences, Jeddah Saudi Arabia.

8. Department of Internal Medicine, Oncology and Hematology, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain

9. National Oncology Centre, The Royal Hospital, Oman

10. Alzahra Hospital, Dubai, United Arab Emirates

Introduction: The use of modern immunotherapy has been evolving over the past few years, and various new agents have been developed for new indications at multiple primary sites in oncology. It is important for physicians who are involved in cancer care to be aware and updated about new therapeutic agents and their indications, potential benefits, and side effects.

Patients and Methods: From October to November 2017, we conducted a survey on the awareness, understanding, attitude, and barriers associated with prescribing modern cancer immunotherapies among physicians in the Arabian Gulf countries. The study included practicing physicians who delivered chemotherapy; trainees were not eligible. A total of 460 physicians were contacted and invited to complete an online survey, of which approximately 74.8% did not respond, and 4 (3.4%) were excluded because they had not recently treated patients with cancer. 112 (24.3%) physicians completed the survey (completion rate = 25.2%). An online electronic survey questionnaire was developed via Planet Surveys. The survey was designed with multidisciplinary inputs of the study investigators practicing in the Arabian Gulf countries, piloted, and subsequently revised on the basis of feedback from 10 additional oncologists. The final survey included 23 questions and took 8–10 minutes for completion.

Results: All respondents were aware of modern immunotherapies, but 62.5% reported having limited experience in implementing them, whereas 31.3% reported good experience. The overall physicians’ attitudes toward modern immunotherapy were favorable, with a mean score of 7.4 (scale of 1–10, with 10 being extremely favorable). Efficacy, clear indications, and good safety profile were perceived as key potential benefits. Cost, lack of experience, and lack of access to specific testing were the major barriers.

Discussion and Conclusion: There was a high level of awareness and an overall positive attitude toward modern cancer immunotherapy among oncologists in the Arabian Gulf countries, but there was a limited experience in prescribing cancer immunotherapeutic agents. Efficacy, clear indications, and good safety profile were perceived as key potential benefits, whereas cost, lack of experience, and lack of access to specific testing prior to prescription were the major barriers.

Patients were likely to be receptive to modern immunotherapy as a therapeutic option for cancer treatment. Long-term efficacy data, financial support programs, and educational activities for prescribers may increase the access to modern immunotherapy.

Keywords: Immunotherapy, Personalized medicine, Arab World, Middle east, Mutation

The Need for Regulatory Reforms in the Use of Opioids for Pain Management and Palliative Care in the Middle East

Bassim Jaffar Al Bahrani and Itrat Mehdi
National Oncology Center, The Royal Hospital, Muscat – Sultanate of Oman

Palliative Care (PC) is an evolving oncology subspecialty in the Middle East (ME). Justified opioid use is an integral part of palliative care. Often, morphine consumption is taken as a quality indicator of palliative care services, but is it a reliable indicator to reflect the status of palliative care in current Middle East setting?

We need to understand that data on morphine consumption, represent the amount distributed of morphine per person in a country and does not refer the actual justified amount utilization of opioids. In addition, the currently used consumption data is not reflective of product and dosage employed. It includes opioid use in other conditions like post-operative pain, traumatic pain, and drug abuse as well. The population and cancer incidence is highly variable amongst countries. The opioid consumption reported at present in Oman is very low 0.5474 mg/person.

The opioid prescription must have an appropriate validated policy, well administered and enforced effectively. The policy must be balanced in such a way to eliminate the barriers of availability on one hand, and limit the probability of abuse on the other. Ideally there should be a national empowered competent control authority which should estimate the needs, license, distribute, monitor and report opioid use. There is an additional need to train health care workers in adequate pain assessment, effective pain management, and validated opioid prescribing practices.

The issues in the Middle Eastern (ME) countries are erratic and undependable cancer data, limited palliative care programs, non-effective or no palliative care/pain management policies, and almost non-existent prescription policies of controlled drugs. There is an urgent and essential need to work for comprehensive and integrated palliative care programs encompassing the subspecialties. It must include and care for local perspectives of psychological, social, spiritual, and religious issues in PC in addition to pain management. There remains a need for health education for population, advocacy for policy makers, and a political will at the appropriate levels to meet these challenges.

Keywords: Palliative care, PC, Opioids, pain, Oman, Royal hospital, GCC, Middle East

Sporadic colon cancer in Lebanon: A clinicopathological study

William A. Nehmeh^1,4, Marc Rassy^2,4, Claude Ghorra^2,4, Pamela Abdayem^3,4, Cyril Tohmé¹.

1. General Surgery Department, Hotel Dieu de France University Hospital, Beirut, Lebanon 4 Saint Joseph University Faculty of Medicine, Beirut, Lebanon

2. Pathology Department, Hotel Dieu de France University Hospital, Beirut, Lebanon 4 Saint Joseph University Faculty of Medicine, Beirut, Lebanon

3. Oncology Department, Hotel Dieu de France University Hospital, Beirut, Lebanon

4. Saint Joseph University Faculty of Medicine, Beirut, Lebanon

Colon cancer is a heavy public health burden. No data has been previously published on colon cancer epidemiology in Lebanon. The objective of this study was to report the clinical and pathological features of surgically operated colon cancer.

From July 2005 to July 2012, 187 sporadic colonic tumors were operated in Hotel-Dieu de France Hospital (Beirut, Lebanon). Demographic, clinical, pathological and staging data was collected.

The male: female sex ratio was 1.3 and the mean age at diagnosis was 66.0 years. Most tumors occurred at the right colon (54.0%). Histologically, conventional adenocarcinoma had the biggest proportion (88.2%), followed by mucinous adenocarcinoma (9.1%). Most cases operated belonged to stages II, III or IV, leaving only 8.0% of the cases in stage I.

Some characteristics were similar to western countries like the predominance of right tumors while others were similar to developing countries like the sex ratio and the high proportion of stage IV tumors at diagnosis. This study reports for the first time in the middle-eastern populations a clinico-pathological analysis of surgically operated colon cancer.

Keywords: Colon cancer, Lebanon, developing countries, western countries, clinico-pathological, middle-eastern, epidemiology.

Malignant Phyllodes tumor in a young female: A Case Report

Priyanka Anand, Namrata Sarin, Amul K. Butti, Sompal Singh
Pathology Department, Hindurao Hospital and NDMC Medical college, New Delhi, India.

Phyllodes tumor is a rare fibroepithelial neoplasm of the breast and constitutes 0.3-0.5% of all breast tumors. They are usually benign and only few of them undergo malignant transformation. Benign or borderline phyllodes tumor typically never recur however, malignant phyllodes tumors do have a recurrence and a metastatic potential. Differentiating these two groups is of prime importance for proper management of the patient. We report a rare case of Malignant Phyllodes tumor in an 18 year old female. She presented with a left breast lump which was gradually increasing in size. There was no significant past or family history. Physical examination revealed a 10x10 cm mass which involved the entire left breast. There was no axillary or supraclavicular lymphadenopathy. On fine needle aspiration cytology, a diagnosis suggestive of an atypical cytology (C3) was given and patient was advised to undergo urgent biopsy and on histopathological examination a possibility of malignant phyllodes tumor was rendered. Following this, lumpectomy was performed and a diagnosis of Malignant Phyllodes tumor was confirmed. Within two months of surgery patient had a recurrence of a huge breast lump with overlying skin ulcerations and underwent a left simple mastectomy. Patient is currently under follow up period and free of disease. A definitive preoperative diagnosis is of utmost importance in correct surgical management of the patient and in order to avoid local recurrences.

Keywords: Phyllodes tumor, Malignant, recurrent.

Cutaneous Metastasis of Sigmoid Adenocarcinoma to Face and Scalp at Initial Diagnosis: Case Report

Mariam Alotaibi, Jaroslav Nemec
Department of Medical Oncology, Kuwait Cancer Control Center, Kuwait

Cutaneous metastases from colorectal cancer are very rare. They appear in less than 0.5% of colorectal metastatic cases at time of initial diagnosis. They indicate disseminated disease and poor prognosis. We describe a case of 54 years old patient who presented with scalp, face and upper back cutaneous metastatic lesions derived from sigmoid cancer, 9 months prior to his initial diagnosis.

Final diagnosis of cutaneous metastasis of sigmoid carcinoma was made based on fine needle aspiration cytology. An index of suspicion should be maintained with a low threshold for biopsy for any cutaneous nodule in patient with malignancy.

Keywords: scalp metastases, face metastases, sigmoid cancer, adenocarcinoma, cutaneous metastases

Cervical metastasis of testicular cancer: Case Report and Review of Literature

Guhan Kumarasamy^1,2, Anusha Balasubramanian¹, Baharudin Abdullah²

1. Dept. of ORL-HNS, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990 Ipoh, Perak, Malaysia

2. Dept. of ORL-HNS, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia

Testicular cancer is an uncommon malignancy of the male reproductive organ, accounting for 1% of all cancers in men. Distant cervical metastasis from testicular cancer has been reported in 5% of patients. We present 2 cases of non-seminomatous testicular cancers that were diagnosed retrospectively in patients who presented with pure cervical lymph nodes. A comprehensive approach bearing in mind the possible differentials, pathogenesis and treatment options are discussed.

Keywords: testicular cancer, cervical metastasis, chemotherapy, neck dissection, radiotherapy

Metachronous Testicular Seminoma After Testicular Tumor

Xh. Çuni¹, I. Haxhiu¹, Sh. Telegrafi², M. Berisha, N. Rexha¹, M. Myftari¹, P. Nuraj¹, S. Mehmeti¹, A. Fetahu¹, R. Dervishi¹, S. Manxhuka³, F. Kurshumliu³

1. Clinic of Urology, Faculty of Medicine, University Clinical Centre, Prishtina, Kosovo

2. Department of Radiology, NYU - School of Medicine, NY, USA

3. Institute of Pathology, Faculty of Medicine, University Clinical Centre, Prishtina, Kosovo

Testicular cancer represents approximately 1% of all cancers diagnosed in males. Testicular cancer is the most commonly diagnosed cancer in male adolescents and young adults between 15-35 years of age. Bilateral presentation is rare with a reported rate of 0.8% for every 1,000,000 men between the age 15-40 years from which 0.5% are synchronous and .2-3% are metachronous (1).

We report a case of 42-year-old man with metachronous testicular seminoma within 8 years from the first testicular tumor. Patient was treated at the urology clinic with a left testicular mass causing painful swelling. He experienced discomfort in left side of testis before two weeks. He was on anti-inflammatory treatment by his GP doctor with recommendation to visit a urologist. It is the first time in our clinic of urology to treat a patient with metachronous testicle tumor.

The follow-up of patients with testicular tumor is very important for early detection of metachronous testicular tumor. In routine, after surgery treatment the strict follow-up of patients continue in Oncologic Institute. In the first 5 years it is biannual, then yearly with tumor markers and images of thorax, abdomen and pelvis. In our case the patient continued the follow-up for two years until he stopped by himself.

Keywords: TT, Testicular cancer, Kosovo