Rafal R. Iskanderian^1,2,3, Ahmed Karmstaji², Baraa Kamal Mohamed², Shayma Alahmed², Mohamad H. Masri^1,3, Elie Choufani^1,3, Naveed Ahmed^2,3, Humaid O. Al-Shamsi^4,5,6, Stephen R. Grobmyer^1,3

¹ Oncology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
² Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
³ Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Ohio, United States of America
⁴ Medical Oncology Department, Alzahra Hospital Dubai, Dubai, United Arab Emirates
⁵ College of Medicine, University of Sharjah, Sharjah, United Arab Emirates 6 Emirates Oncology Society, Dubai, United Arab Emirates

Introduction: COVID-19 has become a serious hazard worldwide in a relatively short time. Scientific evidence supports that cancer patients infected with COVID-19 had a higher risk of developing severe complications. COVID-19 patients can be asymptomatic during part or all of their disease course, therefore it is a compelling need to develop universal pre-interventional COVID-19 screening guidelines. The aim of this study is to is review COVID-19 positive rate among asymptomatic cancer patients since the implementation of universal policy at our institution, and assess the impact of diagnosing COVID-19 on delay of oncologic interventions.

Materials and Methods: The study population comprised of all cancer patients planned for high risk interventions between April 1, 2020 – May 14, 2020 at Cleveland Clinic Abu Dhabi [CCAD] after implementing universal COVID-19 screening policy.

Discussion: Nosocomial transmission of COVID-19 among cancer patients could result in poor outcomes. Universal screening for high-risk populations may facilitate earlier diagnosis of COVID-19 and implementation of control strategies. Our review demonstrated that [7.5%] of asymptomatic cancer patients tested positive for COVID-19 after implementation of universal prospective screening policy. The overall evidence supporting universal COVID-19 screening of cancer patients is limited, yet as tests become more widely available, it may be reasonable to screen all cancer patients for COVID-19 before anticancer therapies. While such policy may delay and affect the timing of anticancer therapy as shown in this report, it should improve the safety of care for oncology patients and help protect healthcare workers.

Conclusion: COVID-19 infection rate is higher in cancer patients than general population and can present without symptoms. Universal COVID-19 screening of cancer patients before high risk interventions is supported by the present findings.

Keywords: COVID-19, Oncology, Asymptomatic, early identification, high-risk interventions and aerosol generating procedures

Onset of Arterial and Venous Thrombosis and Safety of Antithrombic Therapy in Patients with Gastrointestinal Cancer

Sayuri Hashimoto^1,2,3, Yoichiro Yoshida¹, Daisuke Kato¹, Fumihiro Yoshimura¹, Suguru Hasegawa¹

¹ Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka/Japan
² Department of Cell Biology, Faculty of Medicine, Fukuoka University, Fukuoka/Japan
³ Veterans Affair Greater Los Angeles Healthcare System, Los Angeles, CA, USA

Background: The objective of this study was to clarify the onset of arterial and venous thrombosis and the safety of antithrombic therapy in patients with gastrointestinal cancer.

Patients and Methods: In a retrospective cohort study of adults aged ≥ 18 years, 1187 patients with gastrointestinal cancer were admitted to our hospital between January 1, 2015 and December 31, 2017. We investigated the incidence of arterial thromboembolism (ATE) and venous thromboembolism (VTE) and serious bleeding following antithrombotic therapy.

Results: In the 1187 patients diagnosed with gastrointestinal cancer, VTE occurred in 4.5% of cases and ATE in 2.8% of cases, and in 7.2% of cases overall. Among 239 patients who received antithrombotic therapy, the combination antithrombotic therapy group (n = 43), such as dual antiplatelet therapy, had more major bleeding events than the monotherapy group (n = 196; 49% vs. 17%, p < 0.01).

Discussion: In our gastroesophageal cancer patients, arterial thrombosis occurred more frequently than venous thrombosis (17/393, 4.3% vs. 9/393, 2.3%, respectively). This result may be affected by chemotherapy or radiation therapy and needs further analysis.

Conclusion: The risk of ATE also needs to be considered in gastrointestinal cancer patients. Combination therapy with antithrombotics increases bleeding events, so it is necessary to determine the risk of thrombosis as well as bleeding.

Keywords: Arterial thromboembolism, Venous thromboembolism, Thromboembolism, Cancer, Anticoagulant, Bleeding

Ahmed Abu-Zaid¹, Osama Alomar^1,2, Mohammed Abuzaid³, Mohannad Alsabban², Hany Salem^1,2, Ismail A. Al-Badawi^1,2

¹ College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
² Department of Obstetrics & Gynecology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
³ Department of Obstetrics & Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia

Background: Around two thirds of patients with ovarian cancer present to clinical attention with advanced-stage disease in the form of peritoneal carcinomatosis (PC) or distant metastasis, which is correlated with a poor fiveyear overall survival (OS) of less than 20%. The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to cytoreductive surgery (CRS) has been depicted to offer survival benefits in patients with PC arising from primary advanced ovarian cancer. However, no similar study was conducted from Saudi Arabia, specifically, or the Gulf region, generally. The primary aim of this study is to describe our pilot single-institutional experience (feasibility, safety and survival outcomes) with CRS plus HIPEC in managing PC arising from primary advanced ovarian cancer.

Materials and Methods: A retrospective cross-sectional study was conducted at Department of Obstetrics and Gynecology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia. From January 2016 to July 2019, the medical records of 16 eligible patients were reviewed for clinical, perioperative and survival data. Survival analyses of DFS were calculated according to the Kaplan-Meier estimates method and compared by using two-tailed log-rank test. Statistical significance was regarded as a p value <0.05.

Results: Cytoreduction completeness CC-0 (optimal) and CC-1 (suboptimal) were achieved in 10 (63%) and six (37%) patients, respectively. The median peritoneal cancer index (PCI) score was 11 (range: 6-18). Nine patients (56%) received combination cisplatin (50 mg/m2) plus doxorubicin (15 mg/m2) as HIPEC regimen whereas the remaining seven patients (44%) received intense single-agent cisplatin (100 mg/m2). No intraoperative morbidity or mortality occurred. Four patients (25%) developed grade III-IV postoperative adverse events based on the Clavien-Dindo surgical complications; no patient developed HIPEC-related renal or hematological toxicities. The median hospital stay was 13 days (range: 11–40). The median follow-up time was 16 months (range: 7-43). The mean OS and DFS were 38.7 months (95% confidence interval [CI]: 31.7–45.6) and 28.4 months (95% CI: 20.7–36.0), respectively. Eleven patients were alive and disease-free (69%). Disease recurrence occurred in five patients (31%). One patient died 30 months after CRS plus HIPEC due to distant brain metastasis. Univariate analysis of parameters related to DFS showed that advanced stage IV disease (p = 0.01), suboptimal CC-1 cytoreduction completeness (p = 0.01) and >11 high PCI score (p = 0.03) were independent factors associated with statistically significant poor DFS.

Conclusions: CRS plus HIPEC is technically feasible, largely morbid-free and correlates with enhanced survival outcomes in patients with primary advanced ovarian cancer.

Keywords: Cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, peritoneal carcinomatosis, ovarian cancer, primary locally advanced, Saudi Arabia

Frequency and Characteristics of Incidental Pulmonary Embolism in Cancer Patients: A Retrospective Study at a Large Oncology Center in Saudi Arabia

Mohammed W. Althobaiti ^1,2,3, Abdullah M. Al Jehani ⁴, Mohammed S. Alqarni ^2,3, Ziad M. Bukhari ^2,3, Azzam A. Khankan ^1,2,3

¹ Department of Medical Imaging, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia.
² King Abdullah International Medical Research center, Jeddah, Saudi Arabia.
³ King Saud bin Abdulaziz University of Health Sciences, Jeddah, Saudi Arabia.
⁴ Ministry of Health, Jeddah, Saudi Arabia.

Introduction: Oncology patients are predisposed to incidental-asymptomatic Pulmonary Embolism (PE) which has a substantial morbidity and mortality in untreated patients. As the cancer patients frequently undergo contrast enhanced Computed Tomography (CT) scanning for staging their primary disease, there is a higher chance of detecting unsuspected PE.

Methodology: Our sample included a retrospective review of one-thousand consecutive oncology patients who had CT scan of the chest for reasons other than PE. We excluded females on oral contraceptives, patients who had a prior history of PE or deep veins thrombosis, and history of intensive care unit admission, surgery, trauma, or lower limb fractures within 6 months prior to the CT study. A positive case of incidental PE is considered if it was confirmed by CT pulmonary angiogram study within 24 hours of the staging CT or if there is an agreement for positive PE by two experienced radiologists. The overall incidence of asymptomatic PE in cancer patients, rate of incidental PE in different types and stages of cancer, and location of the PE within the pulmonary vasculature are described.

Results: 1000 cases included in the study, 588 females and 412 males. Incidental PEs were identified in 37 patients (3.7%). The incidental PEs were more common in female, identified in 24 patients (4.1%), compared with 13 male patients (3.2%). Most incidental PEs were encountered in breast cancer, while lung cancer had the highest rate of incidental PE (11.3%). Most of the incidental PEs identified in patients with advanced stage of cancer with metastatic disease (stage 4) 27 patients (73%), 5 patients were in stage 3 (13.5%), and 5 patients were in stage 1 or 2.

Discussion: The true incidence, prevalence, and mortality rates of incidental PEs in oncology patients is underestimated due to its silent nature. Since the mortality and morbidity are exceptionally high in cancer patients with incidental pulmonary embolism, staging CT chest examinations should include a meticulous search for incidental PE.

Conclusion: The rate of pulmonary embolism in oncology patients is higher in female and in the advanced stage of the disease. There are certain tumors associated with a higher rate of incidental PEs, which may be related to tumors characteristics or to its treatment.

Keywords: Pulmonary embolism, oncology patients, risk factors, computed tomography, incidental findings

Introduction: Thyroid cancer is a predominant malignancy in the Gulf Cooperation Council (GCC) states. Explicit regional assessments of incidence are crucial among countries that share similar demographic, cultural, and economic characteristics. This study provides an
assessment of trends in thyroid cancer in the GCC over fifteen years.

Methods: Data included cases in the GCC, reported to the Gulf Center for Cancer Registration during 1998–2012 (N=10,417). Age-specific rates, age-standardized rates (ASR), and stage at diagnosis are compared between the GCC states during 1998–2002, 2003–2007, and 2008–2012. Standardization of rates was performed using the World Standard Population.

Results: Between 1998–2002 and 2008–2012, the frequency of thyroid cancer in the GCC was approximately fourfold higher in females than males. The average ASR increased from 1.8 to 2.4/100,000 for males and 5.7 to 8.4/100,000 for females. Age-specific incidence showed a shift towards a younger age for women and an older age for males. During 1998–2012, the proportion of localized stage at diagnosis ranged from 18% in Oman to 57% in the UAE. The proportion of unknown stage varied considerably among states, ranging from 13% to 64%. Over the study period, the proportion of unknown stage increased in all but two states (Bahrain and Saudi Arabia).

Conclusion: The incidence of thyroid cancer in the GCC has generally increased. This could reflect improved testing, leading to enhanced detection and diagnosis of thyroid cancers, as well as a possible increase in exposure to risk factors. Improved ascertainment of stage data is essential to reflect changes in early diagnosis activities.

Keywords: Thyroid cancer, Gulf Cooperation Council, Bahrain, Saudi Arabia, Kuwait, Qatar, Oman, United Arab Emirates, incidence, stage

Jitendra Shete¹, Khaled Al Saleh¹, Reham Safwat², Ahmed Bedair³, Mustafa El Sherify¹, Amany Hussein¹, Marwa Nazeeh¹, Asit Mohanty⁴

¹ Department of Radiation Oncology Kuwait Cancer Control Center, Kuwait
² Clinical Oncology Department, Zaga zeg Faculty of Medicine Egypt,
³ Northwest Cancer Center, London Derry, North Ireland, UK
⁴ Department of Medical Oncology Kuwait Cancer Control Center

Introduction: Medullary thyroid cancers (MTC) constitute about 5% of all thyroid cancers. The 10-year overall survival (OS) rate of patients with localized disease in thyroid for this pathology is 80% to 90% which is comparable with differentiated thyroid cancers, figures drop to 75% for cases with nodal metastases. Only 20% of patients with distant metastases at diagnosis survive for 10 years. In metastatic disease there are variations with smoldering less active disease to progressive active disease. Surgery is cornerstone of the management with total thyroidectomy and nodal dissection as main treatment. Adjuvant treatment with radiotherapy is case selective, varies from case to case. The management of residual, recurrent disease is possible re-surgery with external beam radiation therapy. The development of targeted therapy has brought in a major advantage in management of metastatic disease. Two drugs —vandetanib and cabozantinib— have been approved for use in metastatic MTC. The optimum management in this group of patients is a challenge and long-term use of TKI needs to be balanced with monitoring side effects of TKI and dose adjustments of TKI.

Materials and Methods: A retrospective review of cases with diagnosis of medullary thyroid cancers treated or registered at Kuwait Cancer Control Center was conducted. The data of patients registered between 1987 till 2017 was analyzed. The data was collected and analyzed using SPSS (version 20) software program. For analysis we considered date of surgery as the date of diagnosis. Final state of disease along with emphasis on prognostic factors was correlated with Kaplan Meyer survival curves.

Results: There were total 31 cases out of which 15(48.4%) were male and 16(51.6%) females. The median age at presentation was 51.6 years (range-28years-77years). MEN syndrome was diagnosed in 6(19.4%) patients. Staging revealed Stage I – 7/31 (22.58%), Stage II-3/31(9.67%), Stage III-7/31(22.58%), Stage IVA (nonmetastatic) -12/31 (38.70%), Stage IVC (metastatic) - 2/31 (6.45%). Total thyroidectomy and central compartment neck dissection was optimum surgery (29%). Total thyroidectomy with central compartment neck dissection and unilateral neck dissection was done in 38.7% patients, comprehensive neck dissection and total thyroidectomy was done in 32.2% patients. External beam radiotherapy (EBRT) with conformal or IMRT technique was used in 13 out of 31 patients. One patient was treated for bony metastasis with palliative intent. Four patients were treated by TKI for metastatic disease or at progression. Median follow up was 79 months. Median overall survival was 93 months. Median progression free survival irrespective of stage was 62 months. At the end of 5 years 61% patients were alive irrespective of stage of disease. Due to the small sample size and natural history of advanced MTC the observed p-value for several pathological variables in relation with survival was not significant.

Conclusion: Stage I and stage II cases of our study did well and were all alive and disease free till our last follow up. EBRT in our cohort of patient did not revealed any added benefits in survival. The use of TKI in metastatic disease was associated with many issues including availability of drug. Elevated serum calcitonin and CEA levels in absence of measurable disease should be dealt cautiously.

Keywords: Medullary thyroid cancer, TKI, calcitonin, RET.

Aalaa Mubarak, Eman Aljufairi, Sayed Ali Almahari

Salmaniya Medical Complex, Manama, Kingdom of Bahrain

Objectives: To define the histological types of primary lung cancer in Bahrain and to determine prevalence of EGFR and ALK mutation in patients with non-small cell lung carcinoma.

Methods: Data regarding Bahraini patients diagnosed with primary lung cancer between January 2013 and December 2018 were collected from the lab information system in Salmaniya medical complex, Manama, Bahrain.

Results: One hundred and forty-three Bahraini patients were diagnosed with lung cancer in the study period. 67.1% of the patients were male. The mean age at diagnosis was 68 years. The most common histological type was adenocarcinoma (58%), followed by squamous cell carcinoma (19%). EGFR mutation was found in 21.5% of non-small cell lung cancer cases with predominance of exon 19 deletions (29%) and exon 21 nucleic acid changes (21%). ALK mutation was found in 10.5% of EGFR negative patients.

Conclusion: Adenocarcinoma is the most common primary lung cancer in Bahrain. Genetic mutations of EGFR and ALK genes were found in 21.5% and 10.5% of adenocarcinoma cases, respectively.

Keywords: Lung cancer, adenocarcinoma, mutation, epidermal growth factor (EGFR), Anaplastic lymphoma kinase (ALK)

Fadi S. Farhat^1,2, Mohamed Tarabey¹, Feras Chehade³, Tarek Assi², Joseph Kattan⁴

¹ Department of Hematology-Oncology, Hammoud Hospital University Medical Center, Saida, Lebanon
² Department of Hematology-Oncology, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
³ Department of Nuclear Medicine, Hammoud Hospital University Medical Center, Saida, Lebanon
⁴ Department of Hematology-Oncology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon

Objective: This study aimed to evaluate the patients and health providers’ (doctors and nurses) knowledge and understanding of the disease-related pain, and the perception of pain drugs (opioids) in South Lebanon.

Patients and Methods: This was a pilot study conducted at different hospitals in South Lebanon among patients with confirmed cancer diagnosis and providers. Data was collected using patients’ and providers’ questionnaires.

Results: 43 patients and 42 providers were included. 22 (52%) patients were male. Nine (21%) patients were aware of their diagnosis and only 60% talked about their pain to their oncologist. Pain was not optimally controlled with 25 (58%) patients having uncontrolled pain and 18 (42%) patients having continuous pain. Morphine was negatively perceived with 55.8% of patients believing that morphine causes addiction and 59% taking pain medications only when the pain is maximal. This led to a 58% short duration control of intermittent pain. 60% of the providers were certain that cancer pain cannot be relieved by morphine while only 33% believed that morphine can cause complete relief. Addiction seemed to be the main obstacle for morphine use with 37 (89%) thinking that narcotics causes addiction and 51% considering morphine withdrawal if side effects appear. Finally, 30% suggested to discontinue morphine in the terminal stages of cancer.

Discussion and Conclusion: Major misconceptions in cancer patients are observed in the approach to antalgic treatment in our population. With good education, better knowledge and optimal palliative care units, misconceptions about opioids can be corrected with best management of cancer pain.

Keywords: Analgesics, cancer, management, health providers, pain, physicians.

Akanksha Solanki, Sri Harsha Kombathula, Sumanta Manna, Sanjib Gayen, Sweta Soni, Shekhar Anand, Puneet Pareek, Rakesh Kumar Vyas, Sonal Varshney, Amit Mohan, Sujoy Fernandes

Department of Radiation Oncology, All India Institute of Medical Sciences, Jodhpur, India

Objective: Adjuvant radiotherapy is required for most post MRM breast cancer patients. Aim of treatment is to target radiation to region of interest while sparing Organs at Risk (OARs). Attempts are being made to decrease dose to OARs without compromising target coverage by evolving radiation techniques. In this study, a comparison of traditional 3DCRT plans is done with semi-automated complex VMAT plans for dose received by OARs namely Contralateral Breast (CLB), Ipsilateral lung (I/LL), and Contralateral Lung (C/LL).

Materials and Methods: It was planned for 30 post MRM breast cancer patients for chest wall, ipsilateral axilla and supraclavicular lymph node. The PTV dose was 42.5 Gy in 16 fractions, 2.66 Gy/fraction, 5 days a week. For each patient traditional 3DCRT and semi-automated complex VMAT plans (conventional + tangential VMAT plans) were prepared and evaluated by radiation oncologists.

Results: Dose evaluation of CLB shows higher Dmax for 3DCRT plans, while, Dmean was lower for the 3DCRT plan. Difference between D2 was not significant. V2.5 was significantly less in 3DCRT, while, difference between V5 and V10 were not significant. For C/LL Dmean, V2.5, V5, and V10 were higher for the VMAT plan. For I/LL Dmean, V5 and V10 were higher, while V20 and V30 were lower for VMAT plans.

Discussion and Conclusion: The VMAT technique described here is a useful treatment option available for difficult planning situations. OARs stated above had a mixed result showing VMAT plans to be inferior at lower dose metrics, while, superior at higher dose metrics.

Keywords: 3DCRT, Semi-automated complex VMAT, Hypofractionated, Contralateral breast, Contralateral Lung, Ipsilateral Lung

Abdel Rahim Mahmoud Muddathir^1,2, Tarig A. M. Hamid³, Elwaleed Mohamed Elamin⁴, Omar F Khabour⁵

¹ Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Taibah University, Medina, Kingdom of Saudi Arabia
² Faculty of Medical Laboratory Science, Department of Hematology and Blood Transfusion, Alzaeim Alazhari University, Khartoum, Sudan.
³ Department of Hematolgy and Immunohematology, Sharq Elnile Collage, Khartoum North, Sudan
⁴ Department of Histopathology and Molecular biology, Alzaeim Alazhari University, Khartoum, Sudan.
⁵ Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid, Jordan

Background: Acute myeloid leukemia (AML) is a malignant disease of the myeloid line that caused by several chromosomal aberrations that include AML1-ETO and MLL-AF9. In the current study, the correlations of fusion gene quantitative RT-PCR and hematological parameters in patients with AML were examined to determine their prognostic value in clinical practice.

Methodology: This study was conducted at Alzaeim Alazhari University, Khartoum, Sudan. A total of 82 patients with AML (51 AML1-ETO and 31 MLL-AF9) were participated in the study. Quantitative RT-PCR was used to determine types of fusion genes

Results: The expression of MLL-AF9 was significantly higher than that for AML1-ETO (P < 0.01). In addition, with respect to FAB classification M2/M3 types were dominated in patients with AML1-ETO gene fusion, whereas M4/M5 types were dominated in MLL-AF9 subjects (P < 0.01). Finally, neither AML1-ETO nor MLL-AF9 quantitative RT-PCR gene expressions were correlated with the examined hematological parameters including: hemoglobin, total white blood count, platelets and blast cells (P > 0.05).

Conclusions: Significant variations in AML1-ETO and MLL-AF9 expression were observed in AML. No correlations between the expression of fusion genes and hematological parameters were detected.

Keywords: AML, RUNX1-RUNX1T1, MLL-MLLT3, RTPCR, clinical parameters

Abdul Hakeem Alrawahi¹, Asia Alnaamani², Najla A. Al-Lawati³

¹ Research Section, Centre of Simulation and Skills Development, Oman Medical Specialty Board, Muscat, Oman.
² Child Health Section, Department of Woman and Child Health. Ministry of Health, Muscat, Oman
³ Department of Non-communicable Disease, Directorate General of Primary Health Care, Ministry of Health, Muscat, Oman

Background: Studying risk factors for cancer is the way for prevention and control. This study aims to review analytic studies reporting the identified risk factors of cancer in Oman.

Methods: A comprehensive literature search was conducted on “PubMed database, Scopus database, and Google Scholar”, using appropriate key terms/words. No date limits were defined until March 2019. Both; keyword and MeSH term strategies were used to retrieve studies.

Results: This review yielded 10 analytic studies related to cancer risk factors in Oman, all of which utilized the case control design. Seven studies were related to various genetic factors, two were related to dietary factors and obesity, and one was related to diabetes as a risk factor. There was insufficient evidence available on essential modifiable risk factors such as smoking, use of alcohol, environmental factors and infectious agents.

Conclusion: The scanty local literature is focused on genetic, non-modifiable factors, and very little is related to modifiable factors which should be given more attention to allow prevention and control. Locally, this is challenged by training needs for health professionals, and availability of financial resources, emphasizing the need for multisectorial work.

Keywords: Cancer, malignancy, neoplasm, risk, risk factors, factors, predictors, gastric, stomach, prostate, colorectal, lymphoma, leukemia, breast, thyroid, Oman, Royal Hospital, Sultan Qaboos University Hospital.

Subbiah Shanmugam, Syed Afroze Hussain, Kishore Kumar Reddy

Centre for Oncology, Government Royapettah Hospital and Kilpauk Medical College, Chennai, India

Aim: To study bone sarcoma patients who underwent limb salvage surgery with an inappropriate biopsy site and their surgical management.

Materials and methods: There were 28 patients with bone sarcoma who underwent limb salvage surgery from 2015 – 2019, among them 4 patients had inappropriate biopsy scar. They were analyzed with respect to modification of incision, extent of flap elevation, difficulties in exposure of neurovascular structures, reconstructive methods and post-operative wound morbidity.

Results: In all cases biopsy was done in outside hospital. One patient had open biopsy, remaining all were core needle biopsies. Out of the 4, three patients had distal femur lesion and one patient had proximal tibial lesion. Patient with proximal tibial lesion had biopsy site placed anteriorly over tibia. Patient underwent proximal tibial resection with anteromedial incision. Remaining three patients had distal femur lesion. One patient had pathological fracture with internal fixation done with lateral incision, and biopsy site placed medially. During surgery lateral incision was taken to include internal fixation scar with the distal end curved medially and extended over leg after including the biopsy site. One patient had distal femur lesion with laterally placed biopsy site, surgery done with lateral approach and medial gastrocnemius flap used to cover the prosthesis. One patient had anteriorly placed biopsy site, so after including the inappropriate biopsy site the lateral incision was curved medially and extended over leg. Two out of these four patients had skin necrosis; one patient had partial thickness skin necrosis and the other full thickness skin necrosis which was managed conservatively.

Conclusion: In case of limb salvage surgery, skin incisions should be planned taking extent of lesion and biopsy scars into account. Good knowledge of vascular supply and incisions required if and when surgery is planned helps in selecting proper site for biopsy.

Keywords: Bone sarcoma, limb salvage surgery, biopsy site

Satesh Kumaran Ganeson¹, Jeyasakthy Saniasiaya¹, Irfan Mohamad², Norhaslinda Abdul Gani¹

¹ Department of Otorhinolaryngology, Hospital Tuanku Ja’afar, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
² Department of ORL-HNS, Health Campus, Universiti Sains Malaysia, 16800 Kubang Kerian, Kelantan, Malaysia

Introduction: Basaloid squamous cell carcinoma of the nasopharynx is a rare entity with only scarce cases reported in the English Literature. It is a histological variant of squamous cell carcinoma with aggressive nature and comprises of both basal cell carcinoma and squamous cell carcinoma.

Case presentation: Herein, we report on a middleaged male who presented with left-sided spontaneous epistaxis and aural fullness with no neck node which turned out to be basaloid cell carcinoma of nasopharynx.

Discussion and conclusion: We highlight high clinical suspicion of rare variant of nasopharyngeal carcinoma although no palpable node was evident upon presentation.

Keywords: Basaloid squamous cell carcinoma; nasopharyngeal carcinoma; high-grade

Turki Alhazmi¹, Ahmed Abduljabbar², Mohammed Alem³, Amr Mansouri², Khaled Bahubaishi²

¹ Division of Radiology, Umm Al-Qura University, Makkah, Saudi Arabia
² Division of Radiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
³ Division of Radiology, King Abdullah Medical City Hospital, Makkah, Saudi Arabia

Pancreatoblastoma (PB), also known as infantile pancreatic carcinoma, is an exceedingly rare pancreatic tumor in childhood, which is considered a malignant exocrine pancreatic tumor. Some cases have been reported in Saudi Arabia. Although PB primarily presents during childhood, it may occur in adults too. PB tends to be less hostile in infants and children when compared to adults. Histologically, PB is characterized by distinguished acinar and squamoid cell differentiation. Most of these tumors develop in the head of the pancreas and increase alpha-fetoprotein in up to 68% of patients. Ultrasound and CT scan play a significant role in preoperative diagnosis, which is often quite difficult. The best treatment is surgical removal of the pancreas. The role of adjuvant chemotherapy or radiotherapy is still under consideration due to a minor number of patients treated. Chemotherapy regimens consisting of cyclophosphamide, etoposide, doxorubicin, and cisplatin have been used in the neoadjuvant setting with anecdotal benefit. It was found that a poorer prognosis was associated with patients who had metastasis, and patients who could not be operated on surgically.

Keywords: Pancreatic neoplasm- Pancreatoblastoma