Eman Alkhalawi^1,2, Amal Al-Madouj³, Ali Al-Zahrani³

¹ Department of Family and Community Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
² Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
³ Gulf Centre for Cancer Control and Prevention, King Faisal Special Hospital and Research Centre, Riyadh, Saudi Arabia.

Background: Cervical cancer is the ninth most common female malignancy in the Gulf Cooperation Council (GCC) States. We describe trends in cervical cancer incidence among GCC nationals. GCC states include Bahrain, Kuwait, Oman, Saudi Arabia, Qatar and the United Arab Emirates; which share similar demographic, socioeconomic and cultural backgrounds.

Methods: The Gulf Centre for Cancer Control and Prevention (GCCCP) has maintained a database of cancer in the GCC states since 1998. Women diagnosed with invasive cervical cancer during the 15 years 1998-2012 were included (N=2,332). Age-specific incidence over three periods (1998-2002, 2003-2007 and 2008-2012) are presented for all states combined. Trends in the frequency of registered cases, age-standardized incidence rates (ASRs) and in the distribution of stage at diagnosis for the six member states are compared between the three periods.

Results: Over the 15-year period, the peak age of cervical cancer diagnosis has slightly shifted towards older age. While the number of cases in the GCC has increased, the ASR has decreased. 39% of women were diagnosed in localized stage. The proportion of unknown stage ranged between 10% in the UAE and 58% in Oman, and has increased over time in Kuwait, Oman and the UAE.

Conclusion: The present study indicates some success in cervical cancer preventive measures but the GCC may still see an increase in the number of cases in the coming years. More efforts should be directed towards documentation of stage and towards early diagnosis.

Keywords: Cervical cancer, Gulf Cooperation Council, Saudi Arabia, Kuwait, Qatar

Background: The proposed role of Vitamin D Receptor (VDR) in various cancers underscores the importance of vitamin D compounds as a novel therapeutic agent in the prevention of occurrence and progression of cancer. Vitamin D Receptor (VDR) expression in gallbladder cancer (GBC) has not been widely analyzed yet. In the present study, an attempt has been made to study VDR expression and the role of vitamin D supplementation during palliative chemotherapy in advanced GBC.

Methods: Expression of VDR was analyzed in benign cholecystectomy specimens (n=11), and GBC specimens (n=32). Thirty patients with advanced GBC were subjected to palliative chemotherapy. Out of them, 19 patients were supplemented with Vitamin D and 11 patients were not. Effect of vitamin D supplementation on the change in vitamin D scores and improvement in quality of life (QOL) were assessed by EORTC QLQ c30 version 3.0. and the difference in outcome between the two groups were studied.

Results: Mean intensity, staining and immunoreactivity scores signifying VDR expression were decreased in the studied population of GBC when compared to benign disease. In palliative setting, vitamin D supplementation significantly improved the quality of life. However, the effect on disease- specific survival, although present, was not statistically significant.

Conclusion: VDR expression downregulation is associated with increasing malignant process. Vitamin D may act as sensitizers for tumor cell death besides downplaying potential harmful effects of palliative chemotherapy thus reducing the associated morbidity. This study assumes importance as the first clinical study reporting VDR expression in GBC tissue and the possible role of vitamin D supplementation in patients with advanced disease.

Keywords: calcitriol receptor, gallbladder neoplasms, vitamin D supplementation, quality of life

Elie Rassy¹, Tarek Assi¹, Ziad Bakouny¹, Rachel Ferkh¹, May Fakhoury², Hanine Elias2, Aline Tohme³, Fadi El Karak¹, Fadi Farhat¹, Georges Chahine¹, Fadi Nasr¹, Marwan Ghosn¹, Joseph Kattan¹

Purpose: The use of total parenteral nutrition (TPN) in terminally ill cancer patients is considered an aggressive approach with very limited benefits. We examined the practice of TPN in our end of life cancer patients and we investigated the patient and tumor characteristics that justify this practice. To our knowledge, this is the first study describing TPN administration of Middle Eastern patients with advanced cancer.

Methods: We conducted this retrospective observational study at Hotel-Dieu de France University Hospital, Lebanon. Eligible cases included all cancer patients that died at our institution between the 1st of January and the 31st of December 2014. The patients and tumors characteristics were analyzed for their potential role as determinant of TPN administration. The patients’ hospitalization and causes of death were evaluated for the analysis of TPN benefits.

Results: Among the 129 patients enrolled, 39% had received TPN among which TPN administration correlated negatively to hyperlipidemia (OR= 0.33; 95% CI [0.12–0.87]) and to the presence of at least three cardiovascular risk factors (OR= 0.28; 95% CI [0.10 – 0.80]). However, it correlated positively to gastrointestinal tumors (OR= 3.9; 95% CI [1.3– 11.7]) and to imaging studies during the last month of life (OR= 3.4; 95% CI [1.3 – 9.0]). The TPN administration did not correlate to hospitalization during the last two weeks of life.

Conclusion: The adoption of an optimal palliative care approach in Middle Eastern cancer patients at the end of life remains challenging. Oncologists seem to consider cardiovascular risk factors as a probable surrogate to predict complications of TPN.

Keywords: Middle East; total parenteral nutrition; end of life; cancer; palliative care

Introduction: The objective was to implement the DynaLog file-based automated FractionCHECKTM software which verifies the delivery accuracy of all patient treatments without any measuring devices and evaluate this tool for dynamic IMRT delivery verification of 40 cases. The present work was aimed to find the generalized results with user-defined tolerances of all treatment deliveries and asses the delivery results in terms of Pass/Warn/fail analysis. In addition to this, an in-depth analysis of mean RMS error of each BANK of the MLC’s and mean 95th Percentile error of all the leaves and percentage of pixels passing Gamma between the planned and delivered fluences for all 40 dynamic IMRT cases.

Methods and Materials: The DynaLog files were analyzed from all 40 IMRT deliveries which include ten plans each of head & neck, brain, cervix and oesophagus patients treated using 6 MV X-ray beam at DHX linear accelerator equipped with Millennium120 multileaf collimator (MLC). Before processing actual patient data, we have validated the FractionCHECKTM software using routine DMLC QA test fields such as X-wedge, Y-Wedge, Garden fence test and Pyramid Test. The mean RMS error and 95th percentile of each leaf was studied in four different sites of dynamic IMRT and fluence delivery accuracy at 1%, 1mm gamma criterion was determined over the entire course of 40 patients.

Results: We have analyzed a total of 1134 fractions of dynamic IMRT cases of 40 patients in this study. Out of 25,166 log files evaluated for the entire course of these patients, 23,906 files have met pass criteria (Green), 1022 log files resulted in warning (Yellow), and 238 files have resulted in failure mode (RED) in the analysis. The overall mean RMS error for all 40 IMRT cases was found to be 0.34±0.08 mm, and the mean 95th percentile error of all leaves was 0.66 ± 0.18 mm, which was well below the recommended by TG142 as well with other published works.

Discussion and Conclusion: In a busy department where a large number of IMRT cases are being treated, the DynaLog analysis-based FractionCHECKTM software can be used as one of the efficient methods in verifying IMRT treatment deliveries. It can be implemented much quicker without long delay and can also be used for routine DMLC QA tests. We conclude that FractionCHECKTM is a fast, simple and powerful tool for routine QA of the IMRT fields and that based on our test field and patient data results, FractionCHECKTM could be used for treatment delivery assessment accuracy.

Keywords: MLC, RMS error, IMRT, DynaLog file, FractionCHECK

Background: Although its incidence has decreased over the last 20 years, gastric adenocarcinoma remains frequent (1,033,701 new cases worldwide per year, Globocan 2018). Its prognosis is still poor, with overall survival rates of 10 to 25% despite improvement in surgical and perioperative treatment. In Morocco, we do not have data on survival and predictors of mortality in our population, the present study aims to describe the epidemiological and clinicopathological features of gastric adenocarcinoma and the survival rate.

Materials and methods: We retrospectively reviewed data files of 265 patients with histological diagnosis of gastric adenocarcinoma between January 2007 and June 2017. Survival was estimated by the Kaplan Meier method and prognostic factors in multivariate analysis (Cox model).

Results: The mean age of our population was 54.48 ±15.53 with a sex ratio M/F of 1.76. Clinical symptomatology dominated by epigastralgia episodes in two-thirds of the cases and deterioration of the general state in most cases (61.7%). Proximal localization accounted for 17.4%. According to histological classification, poorly differentiated adenocarcinoma was the most common histological type (51.7%). Metastatic or locally advanced tumors accounted for 92% of cases. Only 11% of patients received curative resection. The 5-year survival was 6%. Multivariate analysis revealed three prognostic factors: vascular invasion, advanced stage and differentiation.

Discussion: The high mortality of gastric adenocarcinoma in our Moroccan series is probably explained by the late stage at diagnosis. Symptoms are nonspecific and endoscopy is usually performed for advanced symptoms such as anemia, bleeding or weight loss. The main identified prognostic factors in gastric adenocarcinoma are tumor subtype (Linitic forms), stage at diagnosis, vascular and lymph nodes invasion and general performance status which correlates to available data in the literature. Besides, the age distribution of GC in our series showed that the proportion of affected young adult is high (30.6%) compared to data from developed countries varying between 6 and 15%. This age distribution can be explained by the Westernization of diet, the increase of obesity in our population and more exposure to alcohol and tobacco.

Conclusion: Overall cancer survival in our population does not exceed 7%, a rate that remains low compared to studies published in the occidental literature. Recommendations have to be elaborated to make a strategy for screening and early diagnosis of gastric adenocarcinoma to improve the survival rate.

Keywords: gastric adenocarcinoma, epidemiology, survival

Fazal Hussain¹, Shazia Anjum¹, Njoud Alrshoud¹, Asif Mehmood¹, Shouki Bazarbashi², Aneela N. Hussain³, Naeem Chaudhri¹

Background: Primary hepatic carcinoma (PHC) is the 4th most common malignancy among males at King Faisal Specialist Hospital and Research center (KFSH & RC) and in Saudi Arabia. There has been a steady increase in the number of PHC cases since 1975 at KFSH & RC and the burden of hepatic carcinomas is growing in Saudi Arabia. The aim of this study is to explore the changing trends and patterns of PHCs at KFSH & RC and conduct a comparative analysis with local, regional and global trends.

Materials and Methods: Cancer incidence data was obtained from the King Faisal Specialist Hospital and Research Center Tumor Registry program as per the American College of Surgeons standards. Clinico-epidemiological data of 1174 liver cancer patients from KFSH & RC during 2000 to 2014 and Saudi Cancer Registry (SCR) between 2001-2015 with total of 5,796 cases was reviewed. Trends, patterns of occurrence and other prognostic factors of interest were sub-stratified by gender, age, stage, and grade.

Results: Temporal trends indicated a rising incidence of PHC from 2001 to 2014 in Saudi Arabia; from 323 cases in 2001 to 376 cases in 2015 as per SCR. A total of 2,779 new cases of PHC were seen at KFSH & RC between 1975 and 2014; the rate of PHC increased from 60 cases in 2004 to 80 cases in 2014. Majority of liver cancers were hepatocellular carcinomas (79.3%) followed by cholangiocarcinoma (11%), and hepatoblastoma (4.7%) with significantly higher incidence among males with a male to female ratio of 2:1 (p <0.01). The highest incidence by age was at 6th and 7th decade of life. Majority of patients were diagnosed in localized stage (44.6%) and had a past medical history (28.2%) of hepatitis (p < 0.001). The most common treatment for liver cancer at KFSH & RC was surgery (26.7%) followed by transplant (9.5%).

Conclusion: Despite improvement in preventive measures, incidence rates of PHC has increased during the last decade with marked regional variation. Etiology of this escalating trend is multifactorial; predominantly, chronic infection with hepatitis B virus (HBV) and/or hepatitis C virus (HCV), heavy alcohol consumption, obesity, diabetes, and tobacco smoking. This exponential increase may also be due to early detection and diagnosis due to expanding health care delivery in the Kingdom. Further studies are indicated to comprehend the rising trends at the molecular and genetic levels.

Keywords: Primary hepatic carcinoma (PHC), Hepatocellular Carcinoma (HCC), age distribution, trends and patterns in Saudi Arabia

Background: Endometrial cancer occupies the 2nd or 3rd position in the hierarchy of common gynecological cancers in many low- and middle-income countries. However, little is known about its epidemiology, trend and characteristics in many African countries including Nigeria. The study aims to describe the trend in the prevalence, risk factors, symptomatology and types of endometrial cancers in Lagos, Nigeria.

Materials and Methods: A five-year descriptive retrospective study of the case records of women diagnosed with endometrial cancer at the Lagos University Teaching Hospital from 1 January 2008 to 31 December 2012. Relevant information was retrieved and data analysis was done using SPSS version 20.0.

Results: Endometrial cancer was the third most common gynecological malignancy (16.0%) with a rise in its prevalence rate, from 0.9% in 2008 to 1.4% in 2012. It occurred commonly in postmenopausal (81.8%) and parous women with mean age of 62.2 ± 5.5years, median parity of 4, and mean BMI of 32.3 ± 6.4kg/m2. Most women presented with postmenopausal bleeding (88.6%), vaginal discharge (36.4%), usually in stage I (45.5%) and III (22.7%) disease. The most common risk factors for endometrial cancer were advanced age (90.9%) and overweight/obesity (90.9%). Type 1 endometrial cancers accounted for 68.2% of cases, while serous papillary adenocarcinoma was the most common type 2 endometrial cancer.

Conclusion: There is a rising trend in the prevalence of endometrial cancer in Lagos, Nigeria, with type 1 endometrial cancer being the most common type. Most women present in the postmenopausal period with early stage disease.

Keywords: Endometrial cancer; Trend; Characteristics; Lagos; Nigeria

A. Fetahu¹ , Xh. Çuni¹, I. Haxhiu¹, R. Dervishi¹, L. Çuni¹, S. Manxhuka², L. Shahini²

Background: Nephron sparing surgery has become the standard treatment for small renal masses particularly in Western Europe, but in countries like Kosovo, the experience is much more limited. Our aim is to report our initial experience in managing small renal masses with nephron sparing surgery (NSS).

Materials and Methods: This is a retrospective study of patients who underwent Open Partial Nephrectomy (OPN) at our Clinic of Urology between January 2000 and December 2015.

Results: Of 216 patients with renal tumors, 33 underwent OPN. 11 (33%) were female and 22 (67%) were male. The mean kidney tumor size was 3.2 cm (range 3.1-4.0). The patients median age was 46 years (rage 24-61). The indications were elective in 29 cases and relative is 4 cases. There were no intra-operative complications and the post-operative complications were minimal. After a median follow-up of 34 months (range 24-41) there were no local recurrences or late complications.

Discussion: Well recognized modern guidelines on the treatment of small renal masses indicate the use of nephron sparing surgery. Our urological community needs to implement these guidelines and our urologists need to be provided with the necessary education and training and emerging treatment strategy.

Conclusions: Patients with small renal masses that are amenable for a technically and oncologically safe partial nephrectomy, even in presence of a normal contralateral kidney, should undergo nephron sparing surgery. This we showed to be feasible to provide excellent tumor control.

Keywords: ONSS, Open Nephron Sparing Surgery, T1a, Renal Tumors

Introduction: Disseminated intravascular coagulation or consumption coagulopathy is a well-recognized entity both in various malignant and non-malignant conditions. Most data in paediatric solid tumours are isolated case reports, while there is sparse data in paediatric acute leukaemia.

Objective: The study was conducted to analyze the incidence of DIC in our population of paediatric solid tumours.

Design: All records of children <15 years of age registered in the Paediatric Oncology department of our institute with a diagnosis of solid tumour malignancy were retrospectively reviewed for evidence of DIC.

Results: Out of the 73 children, 4 have developed DIC, an incidence of 5.5%. The mean age of children who developed DIC was 4.6 years (Range- 2months -15 years) and the majority (2/4- 50%) children were less than 1 year of age. Children with DIC had a male predominance (75%) and the majority (75%) presented in advanced stages of the disease. Of the 10 children with neuroblastoma, 2 (20%) had evidence of DIC. Statistical analysis was done to determine whether any patient characteristic had the propensity to develop DIC. The only factor that attained statistical significance was younger age.

Conclusion: Disseminated intravascular coagulation though uncommon in children should always be thought of in a child with advanced disease presenting with thrombocytopenia or clinical manifestations of bleeding tendency. An index of suspicion is important for early diagnosis and emergent treatment which eventually improves survival.

Keywords: DIC, Consumption coagulopathy, Paediatric solid tumours.

Langerhans cell histiocytosis (LCH) is a rare neoplasm that is caused by an uncontrolled proliferation of Langerhans cells. The clinical presentation of LCH is heterogeneous and can manifest as single or multiple osteolytic lesions, skin ulcerations, and involvement of single or multiple systems. Central nervous system (CNS) involvement is reported in 3.4-57% of patients with multisystem disease. In this article, we present the case of a young man with single system involvement (bone) of LCH who presented with seizures, headache, papilledema, and tinnitus. His magnetic resonance imaging (MRI) of the brain findings were reported as a normal study. The subtle signs of CNS involvement were missed by the radiologist. However, the high index of suspicion resulted in early diagnosis and treatment. The presence of empty sella turcica in neuroimaging could be the first sign of intracranial disease with chronic intracranial hypertension associated with LCH. This is especially correct if previous computed tomography (CT) scan of the brain was normal with normal appearance of the pituitary gland and the sella. Neuroimaging films should be reviewed by an expert neuroradiologist. In patients with new neurological symptoms who were diagnosed previously with LCH, intracranial disease has to be excluded. The workup in such case should include an MRI of the brain, CT of the brain and temporal bones, bone scan, cerebrospinal fluid analysis, ophthalmological assessment, and measurement of intracranial pressure. In patients with LCH who present with symptoms and signs of raised intracranial pressure, the term idiopathic intracranial hypertension should not be applied until an intracranial disease has been excluded totally.

Keywords: Langerhans Cell Histiocytosis; Central Nervous System Involvement; Neuroimaging; Intracranial Hypertension.

Ewing’s sarcoma are small round cell tumors belonging to Ewing’s family of tumors and the second most common bone tumor seen in children. The most common affected sites are long bones of extremities followed by pelvis and ribs. Primary arising in head and neck region is uncommon and maxillary Ewing’s sarcoma is rarely seen. Histologically it is one of many small round cell tumors found in children and therefore immunohistochemical and occasionally molecular studies are required to establish the diagnosis. Imaging features include aggressive bony destruction with periosteal reaction and associated soft tissue mass. Treatment of this tumor is a combination of induction chemotherapy followed by surgery and/or radiation with completion of chemotherapy due to aggressive nature and a high propensity for metastases. Our case is an 11year-old boy diagnosed with primary non-metastatic Ewing’s sarcoma of left maxilla. The tumor was positive for CD 99 and FLI-1 and negative for CD 45 and Tdt on immuno-histocytochemical examination. The patient was treated with induction chemotherapy comprising of alternating 3 weekly cycles of Vincristine, Adriamycin and Cyclophosphamide with Etoposide and Ifosfamide. This was followed by radical conformal radiation to a dose of 55.8Gy in 31 fractions with good response.

Keywords: Ewing’s sarcoma, maxilla, IHC, chemotherapy, radiation