Ahmed Atris¹, Issa Al Salmi^1,2, Fatma Al Rahbi¹, Bassim J Al-Bahrani³, Suad Hannawi⁴,

Background: Kidney disease has a major effect on global health, both as direct cause of morbidity and mortality and as an important factor for other comorbid diseases including malignancy. Different studies report a higher risk of cancer development in patients with chronic kidney disease (CKD), but the impact of less sever CKD on risk of cancer is uncertain. However, data concerning the cancer risk in Oman CKD including dialysis patients is scarce. More importantly, there is lack of information about the cancer-specific mortality in CKD and dialysis patients.

Methods: During January 2006 to December 2019, all patients with CKD and those on regular dialysis who are admitted or follow up in Royal Hospital were included for evaluation of malignancy.

Results: During the study, a total of 2500 patients with CKD were included, of which 25 patients were found to have different types of cancers, of which 13 were male (52%) and 12 were female (48%).Most of patients 13 (52%) were senior adult (>65 years), then 11 (44%) were adult (19:64- ys) and only one case (4%) was child (<18years.). Cancer was detected in the ovaries (16%), stomach, multiple myeloma and renal (12%) each, while breast and colorectal (1 male/1 female) (8%), parathyroid, thyroid, uterus, cervix, prostate, skin, liver, lymphoma, pituitary gland, and myelofibrosis were present in 4% each. In general population, the breast cancer is the most common cancer among females, followed by thyroid cancer, and colorectal cancer while the most common cancer types among males are colorectal cancer followed by the prostate and then the Non-Hodgkin lymphoma disease.

Conclusion: These epidemiologic findings should prompt clinicians and health authorities to assess strategies for cancer screening in high-risk population of CKD patients. Additional studies are needed to explain the reasons for this association and represent the potential use of cancer screening in patients with CKD in Oman.

Keywords: cancer, chronic kidney disease, epidemiology, hemodialysis

Clinical Characteristics of Urinary Bladder Cancer in the Sudan; Evidence of Pathoetiology Changes

Adil Ibrahim¹, Rayan Khalid², Samah Mohager³, Imad Fadl-Elmula⁴

Introduction: Bladder cancer (BC) is highly heterogeneous with regard to clinical course, etiology, histology, and geographic distribution. Recent clinical observations suggest changes in the pattern of BC in the Sudan perhaps due to lifestyle change following the massive displacement from rural to urban areas. The present study aimed to characterize the clinical profile of the BC among Sudanese patients and compare it with what has been previous reported.

Materials and methods: Demographic, habitual, clinical, and histopathology information of 1610 patients with BC were obtained from the hospital record of Ibn Sina specialized hospital, Soba University hospital, Khartoum North hospital and Khartoum teaching hospital during the period 2007-2019. The data was analyzed using SPSS program version 23.

Results: Of the 1610 cases of BC, 1480 cases (91.9%) were males and 130 cases (8.1%) were females. The most affected patients (39.3%) were those with age group ranging between 61-75 year-old. The vast majority of the patients (73%) were from urban and/or metropolitan areas of the capital Khartoum, whereas the remaining (27%) were farmers coming from rural areas. Although, smoking habits information were missed in 410 patients, 44% of the patients were smokers. History of hematuria was present in almost all cases (99.4%), whereas history of urinary bilharziasis was mentioned in 40.9% of the patients'records.The TCC histology type was seen in 77.4% of the cases, SCC in 21.1%, and adenocarcinoma in only 1.5% of all cases. The vast majority of the tumors were poorly differentiated tumors (700/52.6%), followed by moderately differentiated tumors (430/32.3%) and well differentiated ones (200/15.1%). Of the total tumors, 346/26% were Ta-T1, 456/34% were T2, and 528/40% were T3-T4a,b. Most of tumors were solid ones, accounting for 74% compared with the papillary ones (26%) with most (54.9%) of the tumor located in the lateral wall of the bladder. Although in 620 (38.5%) patients, the follow up information were missing from the records, still the recurrence of the tumors were recorded in 890 (55.3%) of the patients 6 month after the initial therapy.

Discussion: The results showed that poorly differentiated, muscle invasive, and high recurrent TCCs tumors dominate BC profile of Sudanese patients. It revealed also that the most affected population are those between 61-75 year old. These findings are in clear contrast with BC profile, previously, reported in which solitary muscle invasive Bilharzia-associated SCCs tumors affecting younger population was the dominated patterns as reported by Daoud el al (1968), Malik et al., (1975) and later by Sharfi et al., (1992). Thus clear change in BC profile in Sudan is evident, perhaps due to increased urbanization and style of life that led to change in the causative etiology, and eventually the histology type.

Keywords: Bladder cancer, Squamous cell carcinoma, Transitional Cell Carcinoma, Post-bilharzial carcinoma.

Manu Paul¹, Subhanshu Gupta¹, Mira Wagh¹, Arun Peter Mathew¹, Kurian Cherian¹, Renu S², Preethi Sara George³, Paul Augustine¹, Chandramohan Krishnan Nair¹

Introduction: The purpose of this study is to assess the impact of revision surgery, after unplanned excision, on oncological outcome and surgical morbidity in soft tissue sarcomas and also to assess the relation between margin status and oncologic outcome.with NCCN guidelines.

Materials and Methods: We undertook a retrospective analysis of prospectively maintained database of 153 patients with peripheral soft tissue sarcomas treated in our institute from 2006-2010.

Results: Postoperatively, 111(72.5%) patients had negative margins, 20(13.1%) had close margins and 22(14.4%) had planned positive margins. Local recurrence rate was 19.8% in patients with negative margins and 28.6% for patients with close or positive margins (p= 0.007). There was no statistically significant difference in rates of distant metastases (18.9% vs 21.4%, p value 0.56) and five-year overall survival (82.5% Vs 79.8%, p value 0.41) between margin negative and close/positive groups. The five-year overall survival rates were 80.4 vs 77.8% (p =0.42) and five-year disease-free survival rates were 72.4% vs 70.2% (p=0.3), in the revision surgery group and primary surgery group respectively.

Conclusion: Margin status after excision of soft tissue sarcoma is not a direct predictor for overall survival or distant metastasis. Revision surgery after an unplanned excision does not carry worse survival compared to primary surgery group.

Keywords: sarcoma, reoperation, margins of excision,recurrence

Worse Outcome with Imatinib Mesylate as Neoadjuvant Therapy in Locally Advanced Rectal Gastrointestinal Stromal Tumors: Case Series of Four Patients

Lamiae Amaadour¹, Soumia Berrad¹, Karima Oualla¹, Zineb Benbrahim¹, Samia Arifi¹, Nawfel Mellas¹

Background: Rectal gastrointestinal stromal tumors are rare and optimal treatment is yet to be defined. The aim of this report is to highlight the possible aggressive behavior of four cases of rectal GISTs treated with neoadjuvant imatinib in a tertiary care medical hospital.

Methods: Four cases of rectal GISTs were retrospectively reviewed for patients demographics, clinical presentation, histology, and imatinib therapy.

Results: GISTs were common in men. Age ranged to symptoms were nonspecific. All cases were initially considered to have locally unresectable. Patients received preoperative imatinib. Course was unfavorable. 3 patients died of progressive disease, and one from infectious complications.

Conclusion: Rectal GISTs may be aggressive and resistant to medical treatment. Thus only early diagnosis may offer the best chance of recovery.

Keywords: Rectal - gastrointestinal stromal tumor - neoadjuvant imatinib - resistance.

Aims: lack of emotional connection and poor social support are the influential factors for developing suicidal ideation. Studies have established social cognitive deficit in patients with depression, autism, schizophrenia. However, no study so far has investigated about the status social factors in breast cancer patients who often suffer from suicidal thoughts. We hypothesized the relationship between social emotion recognition, social support and suicidal thoughts in breast cancer patients.

Method: The cross-sectional study was conducted at the Oncology department of a multi-speciality hospital in Kolkata. There were 176 breast cancer patients: depressed breast cancer patients having suicidal idea (Group-I; N=81), non-suicidal idea depressed breast cancer individuals (Group-II; N=48), and breast cancer with no psychiatric history (Group-III; N=47). Baron-Cohen's Reading the Mind in the Eyes Test and Multidimensional Perceived Social was used for comparing the performance of social support and mind reading abilities in these three groups.

Results: All groups performed poorly compared to GroupIII (29.1+/-1.27). RMT scores for study Groups I and II were observed as (17.9+/-0.14) vs (20.32+/-061). There was an interaction between suicidal thoughts and depression, was also significant ((F=69.5, sig=0.001). this difference remained significant after controlling for demographic variables.

Conclusions: Suicidal ideation was associated with impaired social emotion recognition and social support. This affects their ability to prop up for social support. This needs to be signified urgently to make sure a better quality of life.

Keywords: Breast cancer, theory of mind, suicidal thoughts and depression

Sandya C Jayasankaran¹, Prameela G Chelakkot², Aarathi Suresh¹, Smitha N V¹, Krishnakumar Thankappan¹, Subramanya Iyer¹, Srikanth Moorthy¹

Introduction or Background: This prospective analysis of patients with squamous cell carcinoma of the buccal mucosa, aimed to analyze the correlation between depth of invasion (DOI) observed in pre-operative imaging and the post-operative histopathological findings, and to assess the predictive value of magnetic resonance imaging.

Patients and Methods: All cases of squamous cell carcinoma of buccal mucosa, planned for primary surgery followed by adjuvant treatment, between June 2017 to December 2019 were included in the analysis. All patients were taken up for imaging using 3 Tesla MR imaging system and subsequently had undergone surgery. The imaging parameters and the histopathological data were analyzed statistically.

Results: Of the 45 patients analyzed, 86.7% were males. Mean age at presentation was 60.62 years. All had squamous histology, with 62.2% being moderately differentiated. 68.9% were T4, 46.7%, N0 and 31.3%, N3. Six node positive patients showed perinodal invasion on histopathology. The mean DOI observed in MRI was 16.54mm, while that in histopathological evaluation was 20.24mm.

Discussion: A significant correlation was observed between imaging and histopathology values in terms of the DOI, with Spearman's Rho correlation coefficient showing 0.693 (p-<0.001). Nodal positivity observed in the imaging and the histopathological findings showed only a moderate correlation of 0.409, with p values of 0.005 (Pearson, Spearman's rho) and 0.007 (Kendall's tau_b). A significant correlation was not observed between nodal involvement and DOI assessed by imaging nor with histopathological assessment. With a cut-off value of 5mm as imaging DOI, the positive predictive value (PPV) for nodal positivity was only 37.14%, while the negative predictive value (NPV) was 95%. The sensitivity was 96.3%, and specificity 30.16%. When the cutoff was raised to 10mm, the values for PPV, NPV, sensitivity and specificity were, 44.07%, 61.29%, 68.42% and 36.54%.

Conclusion: Despite being a histopathological parameter, accurate or near accurate evaluation of DOI can be achieved using MR imaging. Our study convincingly shows that magnetic resonance imaging can be considered the imaging of choice for the evaluation of depth of invasion of the tumour in squamous cell carcinoma of the buccal mucosa, though it fails to show any predictive value for nodal involvement.

Keywords: MRI, Squamous cell carcinoma of buccal mucosa, Depth of tumour invasion, Histopathology.

Zaki Boudiaf^1,2,, Chafik Bouzid^1,2, Karim Cherchar^1,2, Aissam Chibane^1,2, Mohand Kheloufi^1,2, Ihsene Hatem Boutekedjiret^1,2, Zakia Hattou^1,2, Kamel Bentabak^1,2

¹ Department of Oncological Surgery, Centre Pierre et Marie Curie, avenue Bouzenad Salem, 16000 Algiers, Algeria
² Faculty of medicine, University of Algiers Benyoucef Benkhedda, Algeria.

Summary: Combined surgery for colorectal cancer with synchronous liver metastases (CRCSLM) is addressed to selected patients. Technically, by conventional surgery this simultaneous approach raises a problem of adequate access. The purpose of this study is to assess the feasibility and safety of the laparoscopic approach in combined surgery.

Methods: From August 2016 to January 2020 a monocentric prospective comparative study was conducted. Short and long-term outcomes of simultaneous laparoscopic surgery (SLS) were evaluated. Short-term outcomes of SLS were compared to those of laparoscopic colorectal surgery alone (LCRS).

Results: Forty patients were included in each arm. In SLS group, the median age was 62.5 years. Hybrid surgery was performed for 60% of patients, down staging laparoscopic surgery for 22.5% of patients and totally laparoscopic surgery for 10% of patients. The conversion rate was 7.5%. Mean operating time was 323 minutes. Overall morbidity rate was 27.5%. Multivariate analysis showed that anemia (p = 0.046) and number of liver resections (p = 0.018) were independent factors of morbidity. Ninety-five percent of colorectal resections were R0, 90% of liver resections were R0. The mean length of hospital stay was 5.1 +/- 2.58 days. The recurrence rate was 22.5%. Median diseasefree survival was 27 months. There was no difference in short-term outcomes between the two arms except for operating time which was longer in SLS arm (p < 0.0005).

Conclusion: Laparoscopy is feasible in combined surgery in selected patients. Minor liver resection may be associated with laparoscopic colorectal surgery without increasing morbidity.

Keywords: Laparoscopy, synchronous liver metastases, simultaneous resection, liver resection, portal vein ligation, colorectal cancer.

Yaser M. Dahlan^1,2,3, Bader H. Shirah^2,3, Abdullah S. Alghamdi^2,3, Abdulkader A. Al Kenawi^1,2,3, Faisal M. Sanai^1,2,3

¹ King Abdulaziz Medical City, Jeddah, Saudi Arabia.
² King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
³ King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.

Background: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. Most patients with HCC are unsuitable for surgical therapies. Therefore, nonsurgical therapies play a central role in the management of this disease. Several percutaneous treatment modalities are available for HCC including radiofrequency ablation (RFA), transarterial chemoembolization (TACE), and transarterial radioembolization (TARE). In this study, we aim to evaluate the clinical outcomes, morbidity and mortality rates, and survival rates of four treatment modalities for HCC (RFA, TACE, TARE, and Sorafenib) and compare the success rate of each modality.

Methods: A retrospective observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria were composed of patients diagnosed with HCC who received RFA, TACE, TARE, or Sorafenib treatments between 2008 and 2017. The primary outcome of this study was recurrence-free patients at the last follow-up.

Results: A total of 108 patients were included in this study. The mean age of the patients was 68.01+/-9.98 years. Eighty-Two patients (75.9%) underwent interventions with the intention to cure or stabilize HCC, while twentysix patients (24.1%) were started on Sorafenib as a palliative treatment. The five years recurrence-free rates were 41.2% with RFA, 40% with the combination of TACE and RFA, 23.3% with TACE, and 0% with TARE. All patients on Sorafenib died from advanced-stage HCC.

Conclusion: This study provides further evidence for the efficacy of several treatment modalities for the management of HCC. RFA and the combination of TACE and RFA showed better outcomes with a recurrence-free rate reaching up to 40%. TACE had a moderate survival benefit up to 23.3%. TARE showed negative survival benefits. Sorafenib continues to be an important palliative treatment but does not offer curative potential.

Keywords: Hepatocellular Carcinoma; Radiofrequency Ablation; Transarterial Chemoembolization; Transarterial Radio embolization; Sorafenib; Saudi Arabia.

Nada Ayoub¹, Anthony Nozhy¹, Ashraf shawki¹, Ashraf Hassouna², Dalia Ibraheem³, Mohamed Elmahdy⁴, Ayman Amin¹

¹ Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt.
² Department of Radiation Therapy, National Cancer Institute, Cairo University, Egypt.
³ Department of Medical Oncology, National Cancer Institute, Cairo University, Egypt.
4Department of Surgical Oncology, Nasser Institute Hospital for Research and Treatment, Egypt.

Purpose: This study presents the experience of the National Cancer Institute, Cairo University, in diagnosis and management of ACC of the head and neck.

Methods: This is a retrospective review of 57 patients with ACC managed during the period from January 2011 to January 2016. Data about the characteristics and management of the disease were recorded. All patients were followed up to detect the development of local recurrence and distant metastasis and their management.

Results: The mean age was 45.5+/-15.1, with a femaleto-male ratio of 1.5:1. The minor salivary glands were affected in 61.4% of cases. Four patients (7%) were metastatic at presentation. The main presenting symptom was swelling, followed by pain. Surgical resection was performed in 48 patients (84.2%) followed by adjuvant radiotherapy in 36 of them. Four patients received radical radiotherapy. Treatment failed in 3 patients. Recurrences were recorded in 21 out of the 50 cured patients; 9 had locoregional recurrence, 9 had distant metastases, and 3 had both. The overall survival (OS) and disease-free survival (DFS) at three years were 79% and 57.1%, respectively. Surgical resection improved OS (p< 0.001). Advanced T-stage, lymph node invasion, solid tumors, close or positive margins worsened OS. Adjuvant radiotherapy was associated with better DFS (p = 0.003), while solid tumors were associated with worse DFS.

Conclusion: Despite aggressive management with radical surgery and adjuvant radiotherapy, recurrence affects 42% of the patients within three years. Patients with unresectable tumors have a poor prognosis. Adjuvant radiotherapy improves DFS but not OS.

Keywords: adenoid cystic - radiotherapy - surgerycarcinoma - neck dissection

Deepak Roshan VG¹, Sangeetha K Nayanar², VipinGopinath³, K J Philip², NoushadAryadan², Vivek Nair², VaradharajaPerumal²

¹ Division of Genetics &Cytogenetics , Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
² Division of Pathology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
³ Division of Molecular Oncology , Malabar Cancer Centre, Thalassery, Kannur, Kerala, India.

Introduction: The majority of colorectal cancers (CRC) develop through the chromosomal instability pathway and approximately 15% display microsatellite instability (MSI) as a carcinogenic event. CRCs with microsatellite instability status have a characteristic phenotype. We aimed to assess the clinico-pathological and MSI profiles of sixty-one cases of CRC through immunohistochemical (IHC) staining for the mismatch repair(MMR) proteins and DNA based Polymerase Chain Reaction (PCR) assay for microsatellite markers.

Patients & Methods: Haematoxylin & Eosin stained sections of the tumor were evaluated for various histopathologic features. Immunohistochemistry was performed for the four MMR proteins, MLH1, MSH2, MSH6 and PMS2. NCI recommended panel of five nucleotide repeat markers was amplified from tumor DNA.

Results: The majority of the patients were males above fifty years of age. Around 61% of tumors were in the leftsided colon. Adenocarcinoma NOS (55, 90%) was the most common histological type. A total of 18 (29.5 %) cases showed dMMR by immunohistochemistry. Loss of PMS2 protein and combined loss of MSH2 & MSH6 were the most common findings in low and high MSI respectively. Of the 13 cases selected for PCR analysis, nine cases had high MSI (at least two markers unstable) and four cases had low MSI (one marker unstable) Results of PCR based DNA assay showed good concordance with IHC. No significant statistical association could be identified between the status of MSI by either methods and sociodemographic or clinical features.

Discussion: MSI constitutes 12%-20% and 6%-13% of CRCs in Western and Eastern countries respectively. In our series IHC staining revealed that 29.5% of cases showed dMMR. This was similar to other Indian studies which reported a prevalence of 22-27%. The combined loss of MSH2 & MSH6 (78%) was the most common type of dMMR. There was good concordance between IHC and PCR results. The issue of heterogenous or weak staining is a limiting factor in IHC interpretation and few cases of dMMR may be missed.

Conclusion: To conclude, IHC can be a very useful screening tool to detect microsatellite instability and triage cases of dMMR for MSI biomarker testing. The MSI status also serves as a prognostic and predictive tool.

Keywords: Colorectal cancer, microsatellite instability, immunohistochemistry, Polymerase chain reaction

Pooja Sethi¹, Akanksha Singh¹, Bheemanathi Hanuman Srinivas², Rajesh Nachiappa Ganesh², Smita Kayal³

¹ Department of Radiation Oncology, RCC JIPMER, Puducherry, India
² Department of Pathology, JIPMER, Puducherry, India
³ Department of Medical Oncology, RCC JIPMER, Puducherry, India

Abstract: Extraosseous Ewing's Sarcoma (EES) is a high grade rare malignancy from Ewing's family tumors (EFTs) occurring in soft tissues. Diagnosis of EES relies on a constellation of features, including round cell morphology, characteristic immunohistochemistry (such as CD99, FLI-1 and NKX2.2 positivity), and pathognomic molecular abnormalities of t(11;22)(q24;q12). Multimodality treatment has improved the prognosis and clinical outcome in EFTs. Due to its rarity, the current recommendation to treat EES is based on Skeletal Ewing's Sarcoma (SES) guidelines. However, achieving clear surgical margins in the Head and Neck region is often challenging due to complex anatomy and close proximity to critical structures, placing patients at risk of loco-regional recurrence in the absence of adjuvant therapy. The literature on head and neck EES is scarce, consisting of a few retrospective case series and case reports. Herein, we describe the characteristic clinico-pathological features and treatment of three EES patients with primaries from Parotid, Nasal cavity/ Nasopharynx and Oropharynx, with a comprehensive review of the literature.

Keywords: Ewing's Family of tumors, Extraosseous Ewing's sarcoma of head and neck.

Aysel Sunnetcioglu¹, Buket Mermit Cilingir¹, Aysegul Demirbas¹, Irfan Bayram², Mesut Ozgokce³

Abstract: Pancreatic neuroendocrine tumors (PNETs) are rare malignancies characterized by insidious onset and mostly present with metastasis at the diagnosis. Lung metastasis manifesting diffuse ground-glass opacity is a very rare pattern that is difficult to distinguish from nonmalignant pulmonary diseases. Recognition of this atypical metastases pattern and avoidance of this potential pitfall are crucial. We report a unique case of the Metastatic Pancreatic Neuroendocrine Tumor Mimicking Interstitial Lung Disease diagnosed by transbronchial lung biopsie.

Keywords: Neuroendocrine Tumor, Metastasis, Groundglass opacity, interstitial lung disease

Amman Yousaf¹, Ahmad Tayyab², Ahmad L.F Yasin³, Muhammad Junaid Ahsan⁴, Ali Toffaha⁵, Fariha Ghaffar⁶, Shoaib Muhammad⁷

¹ Internal Medicine, McLaren Flint-Michigan State University, MI, USA.
² University of Oklahoma, Med/Peds Resident. USA.
³ Department of Radiology, Hamad Medical Corporation, Qatar.
⁴ Department of Internal Medicine, Creighton University, USA.
⁵ Department of General Surgery, Hamad Medical Corporation, Qatar.
⁶ Allama Iqbal Medical College, Pakistan.
⁷Gulab Devi Hospital, Al-Aleem Medical College, Pakistan.

Abstract: Primary adrenal lymphoma (PAL) often occurs bilaterally and is a rare malignancy of old age. Workup for primary adrenal insufficiency often unmasks this underlying grave pathology. In this article, we present a case of a 73-yearold patient who presented with features of primary adrenal insufficiency and renal colic. Diagnostic abdominal imaging revealed bilateral suprarenal masses as the cause of adrenal gland destruction and the patient's symptoms. FDG PET-CT scan and histopathology confirmed the diagnosis of mature bilateral B-cell primary adrenal lymphomas. Though the patient showed an excellent initial response to the first four chemotherapy cycles, a relapse resulted in metastatic disease. This article highlights the PAL's disease course, imaging features, and management dilemma due to Chemotherapy's side effects and a higher recurrence rate.

Keywords: Primary adrenal lymphoma, Primary adrenal insufficiency, R-CHOP, Role of imaging.