Marzieh Beigom Bigdeli Shamloo¹, Nasrin Elahi², Marziyeh Asadi Zaker², Kourosh Zarea², Armin Zareiyan³

Background : Breast cancer, as the most prevalent cancer among females, exerts physical and mental impacts on both patients and their husbands. The present study aimed at investigating various dimensions of self-concept among husbands of Iranian women with mastectomy.

Methods: This study was conducted on 23 patients with mastectomy and their husbands and therapists using directed content analysis according to Callista-Roy adaptation model. The participants were interviewed regarding how they coped with cancer through video call, and 'physical dimensions' and 'self-concept' subcategories were identified. Content analysis was done using the Elo and Kyngus approach.

Results: The results revealed two main themes, namely 'exposure to physical challenges' and 'weakened to strengthened self-concept'.

Discussion and Conclusion : This research showed the existence of many physical and mental problems of women undergoing mastectomy, and it is recommended to do interventions to reduce these complications.

Keywords: Self-concept, Breast neoplasm, Breast Cancer, Mastectomy, Adaptation, Physiological.

Tumor-Stroma Ratio in ER+/HER2- Breast Cancer: Is it a Tool for Treatment Decision?

Choukri ELMHADI ^1,2, Mohammed Allaoui³, Meryem Zerrik⁴, Mohammed Oukabli³, Rachid Tanz¹, Mohammed Ichou¹,

Purpose : The primary aim of this study is to determine the relationship between tumor-stroma ratio (TSR) and traditional prognostic factors in luminal early breast cancer in women treated at the medical oncology department of the military hospital of Rabat in Morocco.

Methods : A retrospective study was performed on primary invasive ER+/HER2- breast cancer in the period from January 1st, 2019 to December 31st, 2019. Prognostic factors included age, tumour size, lymph nodes status, Scarff-Bloom-Richardson grading, lymphovascular invasion (LVI), Ki67 and the stage of the disease. The type of Adjuvant systemic therapy was also reported .Two independent pathologists have assessed TSR by microscopic evaluation of haematoxylin and eosin tumor slides .Patients with less than 50% stroma were classified as low-stroma, the others are classified as high-stroma.

Results : Of 53 ER+/HER2- operable breast cancer, 41.5% patients had low-stroma and 58.5% patients had high stroma-tumour. High stroma was significantly associated with more stage III (p=0.041), more LVI (0.034), high Ki-67 (p=0.002) and more luminal B disease (p=0.001). Also, high stroma received more adjuvant chemotherapy (p=0.005). The results are maintained in univariate analysis

Conclusions: Data suggest that TSR can be used to guide decisions on adjuvant systemic therapy for ER+/HER2- breast cancer. The integration in routine of this simple and reproducible parameter requires a homogenization of the techniques as well as a prospective validation.

Keywords: breast cancer, luminal, tumor-stroma ratio, decision-support tool

Zain Bukamal¹, Amal AlRayes¹

Objective: The purpose is to study the prevalence of BRCA1 and BRCA2 mutations in high-risk Bahraini patients diagnosed with breast cancer, its relation to family history, and to determine the clinicopathologic features of breast cancer associated with these genetic mutations, over a period of 7 years.

Background : Breast cancer is the most common type of cancer occurring in women and the second most common type generally. Approximately 12% of women worldwide will develop carcinoma of the breast sometime during their life. Additionally, 72% of women with an inherited BRCA1 mutation and 69% of those with a mutated BRCA2 will develop breast cancer by 80 years of age. The incidence of breast cancer in Bahraini women have increased over the last decade. Still, the data on BRCA1 & BRCA2 mutations in relation to breast cancer patients is limited in the Arab region, not omitting Bahrain as a country with deficient BRCA prevalence data.

Methods: This retrospective study was carried out in Salmaniya Medical Complex, Bahrain, to determine the prevalence of BRCA1 and BRCA2 mutations and to observe the breast cancer's histopathologic features that are associated with these mutations.

Results : 271 patients underwent the BRCA gene testing between 2013 and 2019. Out of 271 patients, 35 were excluded. Out of the 236 breast cancer patients, 219 (93%) did not have the mutation. The BRCA gene was carried by a total of 17 (7%) patients; 13 (5%) BRCA1 and 4 (2%) BRCA2. Thirteen BRCA carrier patients had invasive ductal carcinoma (IDC) (76%), 2 had ductal carcinoma in situ (DCIS) (12%), while 2 patients' histopathology was not available. Molecular subtypes showed 4 triple negative basal sub-type (TNBC), 10 positive ER and PR hormonal status, 1 positive HER-2, while 2 patients' hormonal receptor status was not available. Two BRCA1 carriers had both breast and ovarian cancers. A total of 5 (2%) breast cancer male patients were among the tested population, out of which, 1 (0.4% of the total and 20% of the male patients) was a BRCA2 carrier. Out of the 236 patients, 76 (32%) were younger than 40 years of age at the time of diagnosis. Then again, out of the 17 BRCA carrier patients, 7 (41%) were younger than 40 years.

Conclusions: The prevalence of BRCA mutation in high risk Bahraini breast cancer patients is 7%. Among those patients, BRCA1 mutation is the most prevalent (5%) and invasive ductal carcinoma (IDC) is the most common histopathological subtype. However, there was not enough data to conclude the most prevalent molecular subtype of breast cancer in BRCA carriers due to deficiency of overseas pathology reports for patients operated outside Bahrain. When developing treatment plans for younger patients with breast cancer, inherited syndromes and precisely BRCA mutations need to be considered. Bahrain is implementing genetic testing for breast cancer patients = 50 years of age since 2018, according to NCCN guidelines. We will continue to build our database to better characterize breast cancer subtypes and determine their hereditary pattern for identification of high risk families in Bahrain and for future development of more specific therapeutic approaches.

Keywords: Breast cancer, BRCA1, BRCA2, BRCA mutation, Bahrain, Arab region

Survival Outcomes of Post-mastectomy Breast Cancer Patients Treated with Hypofractionated Radiation Treatment Compared to Conventional Fractionation -a Retrospective Cohort Study

Ciniraj Raveendran¹, Suma Susan Meloot¹, I Yadev²

Introduction : For post-mastectomy patients, radiation treatment with conventional fractionation with a treatment duration of five weeks was the frequently used regimen, whereas hypofractionated regimens are recently used in the adjuvant treatment, which has a shorter treatment time over three weeks. We determined to estimate the treatment outcome by survival analysis between these two fractionation schedules to determine if any difference exists between these two groups.

Methods: We retrospectively reviewed the data of 348 breast cancer patients who had received adjuvant radiation treatment to the breast from January 2010 to December 2013. After assessing the eligibility criteria, 317 patients had received post-mastectomy radiation treatment to the chest wall and axilla and followed up till December 2018. The conventional fractionation schedule consisted of 50 Gy in 25 fractions, 2 Gy per fraction over five weeks, whereas the hypofractionated schedule was 42.6 Gy in 16 fractions with 2.66 Gy per fraction, over 3.2 weeks. Survival outcomes using 5- year Overall survival and 5-year Disease-free survival between these two fractionations were estimated and compared between the conventional and hypofractionated radiation treatment.

Results: All patients were females with a median age of 50 [IQR 45 to 58] and a median follow-up of 60 months. Of the 317 patients, 194 (61%) received hypofractionated radiation and 123(39%) conventional fractionation. The Kaplan-Meier estimates of the 5- year survival rate were 81% (95% CI = 74.9 to 87.6%) for the hypofractionated group (n = 194) and 87.8% (95% CI = 81.5 to 94.6%) for the conventional fractionation group (n = 123). The log-rank test revealed no evidence of a difference between the survival rates over time (p= 0.1 ). Restricted mean survival time in the hypofractionated group was 54.5 months, and in the conventional fractionation group was 57 months. Further investigation with cox proportional hazards regression analysis, which controlled for age, N stage, and T stage, showed that patients with conventional fractionation radiotherapy were 0.6 times less likely to die than those with hypofractionated radiation (95% CI for the hazard or risk ratio = 0.31 to 1.21; P = 0.2). However, there is no statistical evidence to say the reduction in mortality is different from null. 5-year disease-free survival for the hypofractionated group (n= 194) was 62.6% (55.7-70.2) whereas that for the conventional fractionation group (n=123) was 67.8% (59.8-76.8). However, there was no evidence to say any difference between the disease-free survival rates on the log-rank test (p=0.39). Restricted mean diseasefree survival time in the hypofractionated group was 45.1 months compared to 46.9 months for the conventional fractionation group

Conclusion: In post-mastectomy breast cancer patients receiving radiation treatment, the survival outcome with conventional and hypofractionated radiation therapy is comparable.

Keywords: Post-mastectomy breast cancer, Conventional fractionation radiation therapy, Hypofractionated radiation therapy, 5-Year Disease-Free Survival, 5- Year Overall Survival

Background : There is no reliable prognostic and predictive biomarkers for clear cell renal cell carcinoma (cc-RCC).

Methods: DNA from 47 cc-RCC tissue samples were sequenced using next generation sequencing and a customized gene panel testing for tumor-driver genes including 19 Mucin genes.

Results: Distinctive variants in 12 Mucin genes were present in all samples. These genes are: MUC2, MUC3A, MUC4, MUC5AC, MUC5B, MUC6, MUC7, MUC12, MUC16, MUC17, MUC19, and MUC22. The numbers of distinctive and non-distinctive variants were counted for each sample. The median number of variants was 455. High variant number (HVN) (>455) was associated with shorter overall survival compared to low variant number (=455) [Median 50 months vs. not reached; P=0.041]. In the 11 patients who received anti-angiogenic tyrosine kinase inhibitors (TKIs), HVN was associated with a trend of shorter progression free survival.

Conclusion: Alterations in Mucin family genes are common in ccRCC. HVN is associated with worse prognosis and may predict decreased benefit from anti-angiogenic TKIs.

Keywords: Mucin; Variants; Renal cell carcinoma; Biomarker; Tyrosine kinase inhibitors

Udip Maheshwari¹, Pankaj Goyal¹, Varun Goel¹, Nivedita Patnaik², Venkata Pradeep babu koyyala¹, Krushna Chaudhari¹, DC Doval¹, Vineet Talwar¹

Background: Advanced gastric cancer is associated with poor survival despite chemotherapy. Maintenance chemotherapy has been successfully tried in lung cancer and colorectal cancers however there is scarce literature on maintenance therapy in advanced gastric cancer. We report a prospective non-randomized single-arm trial of capecitabine maintenance after response to docetaxel, cisplatin, and 5-Flurouracil-based chemotherapy.

Method: 50 patients with advanced gastric cancer, who had achieved response or had stable disease after 6 cycles of Docetaxel, Cisplatin, and 5-Flurouracil (D 75 mg/m2, C 75 mg/m2, FU 750 mg/m2/d d1-d5, q3 weeks) chemotherapy were prospectively selected to receive maintenance chemotherapy with capecitabine (1000mg/ m2 bid d1-d14 q21 days) until progression.

Results: During the median follow-up period of 18 months all patients had progressed, however, there was no treatment-related death, the median time to tumor progression was 10.3 months, with grade 3 and 4 toxicities in 10-15% of patients, and treatment delays in 75% of patients.

Conclusions: Our study has shown that maintenance chemotherapy with capecitabine post-first-line docetaxel, cisplatin, and 5-FU-based chemotherapy is effective and delays tumor progression. However, toxicity was a concern in our study which led to treatment-related delays but without any treatment-related death. Most patients continued therapy till progression.

Keywords: Capecitabine, maintenance, carcinoma stomach, Time to tumor progression

Vikash¹, Vikas Kailashiya¹, Mohan Kumar¹, Puneet²

¹ Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
² Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.

Objective : Gallbladder carcinoma is the most frequent biliary tract carcinoma with over all very poor prognosis. Epidermal growth factor receptor (EGFR) is known to be involved in carcinogenesis and overexpressed in various malignancies including head and neck, breast, lung and colon carcinomas. This study was done to explore the expression of EGFR in gallbladder carcinoma cases in the north Indian population so that it may be used as a therapeutic target in these patients.

Materials and Methods : 59 cases of gallbladder carcinoma diagnosed by histopathological examination were included in study. Expression of EGFR was seen by immunohistochemistry method on histopathology slides.

Results: Out of 59 gallbladder carcinoma cases 46 (78%) were female and 13 (22%) were male with female to male ratio of 3.54:1. Mean age was 51.71+/-11.32 years. On histopathological examination 51 (86.4%) cases were conventional adenocarcinoma, 2 (3.4%) adenosquamous carcinoma, 2 (3.4%) mucinous adenocarcinoma, 2 (3.4%) papillary adenocarcinoma, 1 (1.7%) signet ring cell carcinoma and 1 (1.7%) squamous cell carcinoma histological subtypes. EGFR expression was present in 31 (52.5%) of gallbladder carcinoma cases and strong EGFR expression was significantly associated with poor differentiation of tumour.

Conclusion: In our study EGFR was positive in the majority of gallbladder carcinoma cases. There was inverse correlation between differentiation of tumor and EGFR expression. Strong EGFR expression was significantly higher in poorly differentiated tumors compared to well differentiated tumors suggesting its role in prognosis. This also suggest that EGFR might have a role in tumor progression and aggressiveness. Therefore, EGFR have potential to be used as therapeutic target in significant number of patients. More larger sample studies are required to confirm our findings. EGFR may be further studied as therapeutic target in clinical trials in the Indian population to improve morbidity and mortality of gallbladder carcinoma patients.

Keywords: EGFR Expression, Gallbladder Carcinoma, Immunohistochemistry, Targeted Therapy

M D Ray¹, J R Jeena Josephin¹, Premanand N¹

¹ Department of Surgical Oncology, Dr. BRA IRCH, All India Institute of Medical Sciences, New Delhi, India.

Objective: Groin dissection has been a nightmare for many surgeons due to its higher morbidity especially flap necrosis. Various modifications in incisions have been described in the literature to reduce the complications but with variable outcomes. By our novel "River Flow" incision technique, we have significantly reduced the procedure related complications without compromising onco surgical principles

Methods: A prospective longitudinal clinical observational study was designed after Institutional Ethical Committee clearance, aiming to minimize the rate of complications, especially flap necrosis. All patients who underwent unilateral/bilateral ilio-inguinal block dissection (IIBD) from January 2014 to December 2021 were included in the study. The "River Flow" incision was made and standard ilio-inguinal block dissection was performed. Flap viability, seroma formation, lymphedema, infection, etc. were observed and noted during hospitalization and on followup. Clavien- Dindo classification was used to grade the postoperative complications. We have taken our historical data of 235 groin dissections as a control and compared them with the results of the present study. It is one of the largest studies on groin dissection so far.

Results: A total of 138 patients underwent 240 groin dissections. The most common diagnosis was carcinoma penis (44.9%) followed by carcinoma vulva (22.4%). Overall, the outcome of all groin dissections showed no postoperative mortality. None of the patients had complete flap necrosis. But in our historical data, the flap necrosis rate was 38%. The most common complication observed was seroma formation in 13.7% of cases followed by surgical site infection (6.52%). All the complications were managed conservatively. The postoperative stay of the patients was also significantly less. The median hospital stay was 3 days.

conclusion: "River Flow" incision technique is a simple but effective novel surgical technique for therapeutic ILND for any surgical setup without the learning curve. It can avoid flap necrosis, and decrease morbidity significantly without compromising the onco surgical principle of standard groin dissection.

Keywords: Groin dissection, skin necrosis, river flow incision

Nasser Alkhushaym¹, Goot Albuainain², Tuqa A AbuShaheen³, Mohammed Y. Alshami⁴, Ali S Almutairi³, Ayman Ahmed Sakr⁵, Ayat S Almuhayshi³

¹ Pharmaceutical Care Department, Royal Commission Health Services Program, Jubail, Saudi Arabia
² Pharmaceutical Care Department, King Abdulaziz Naval Base, Armed Forces Hospital, Jubail, Saudi Arabia
³Pharmaceutical Services Department, Mouwasat Medical Services, Eastern Province, Saudi Arabia
⁴ Pharmaceutical Care Services, King Abdulaziz Hospital, Ministry of National Guard Health Affairs, Al-Ahsa, Saudi Arabia
⁵ Assistant professor of Tropical Medicine-Faculty of Medicine-Menoufia University-Egypt

Background and objective : Pancreatic cancer (PC) is the seventh leading cause of death among cancers mortality. Pancreatic carcinogenesis remains poorly understood. There is still an urge to allocate other related risk factors that may help in better recognition of this pathogenesis. There is increasing evidence suggested that peptic ulcer disease (PUD), and its treatment might affect the development of PC however, studies findings reported conflicting results. Our meta-analysis aimed to study the association between PUD and its treatments (proton pump inhibitors [PPIs] and histamine-2 receptor antagonists [H2RAs]) and risk of PC.

Methods: We searched PubMed/MEDLINE, Embase, and Cochrane library databases from inception through January 2022. We included case-control studies, cohort, and randomized control trials which reported the association between PUD, PPIs, and H2RAs and the risk of PC. Odds ratio (OR) were used to calculate pooled estimates for PC risk. The association were evaluated using random-effects models, in two sided statistical tests.

Results: A total of 22 publications were retained for the meta-analysis. PUD was associated with a significant increase in PC risk (OR 1.26, 95% CI= 1.01-1.57, P= 0.038, I2= 92%). The risk of developing PC were significant in patients receiving PPIs (OR 1.76, 95% CI= 1.26-2.46, P=0.001, I2= 98%) and H2RAs (OR 1.25, 95% CI = 1.042- 1.49, P= 0.016, I2= 80%).

Conclusion: There is a 1.26-fold increase risk of PC in patients with PUD. The elevated PC is also attributable to 1.76-fold greater risk in PPIs group compared to 1.25-fold in H2RAs group.

Keywords: Peptic ulcer; proton pump inhibitors; histamin-2 receptor antagonist; pancreatic cancer

Denis Cetin¹, Mustafa Murat Midik¹, Mustafa Mustafayev¹, Burcak Karaca ²

¹ Department of Internal Medicine, School of Medicine, Ege University, 35100, Bornova, Izmir, Turkey..
² Division of Medical Oncology, Tulay Aktas Oncology Hospital, School of Medicine, Ege University, 35100, Bornova, Izmir, Turkey.

Abstract: Prostate sarcoma is an extremely rare malignancy that accounts for only %0.1 of all neoplasms of the prostate gland. Primary prostate leiomyosarcoma (PLSOP) is the most common subtype in adults. Due to the fact that it is an extremely rare malignancy, case reports have been reported frequently and several publications in the form of case series. The number of case reports in the world is less than 200. Our opinion is that publishing such rare diseases and bringing them to the literature will have positive benefits both scientifically and for the patients. We present a patient with PLSOP and discuss the clinical, diagnostic and therapeutic aspects of this rare malignancy.

Keywords: Prostate, Leiomyosarcoma, Cancer, Prognosis.

Nadin Shawar Al Tamimi¹, Yousra Bennouna¹, Mohammed El Fadli¹, Rhizlane Belbaraka¹

¹ Department of medical oncology, University Hospital center Mohammed VI, University Cady Ayyad, Marrakech, Morocco

Abstract: Neuroendocrine breast cancers are rare tumors that were recognized as a distinct entity by WHO classification in 2003. It is much rarer in male breast cancer. Diagnosis is based on immunochemical analysis in which the expression of at least one neuroendocrine marker is required, associated with the exclusion of another primary site of the tumor. These tumors have a worse long-term outcome compared to other breast cancers. Small cell carcinoma of the breast is a high-grade subtype, presents with more advanced disease, and has a poorer prognosis compared with other neuroendocrine breast subtypes. A proper therapeutic strategy is still not well established. In the herein reported case, a 62-year-old male patient was diagnosed with small cell neuroendocrine carcinoma of the breast, metastatic to the liver, lung, bone and lymph node, and was treated with a first-line Platinum-Etoposide chemotherapy combination with a good clinical and radiological response. Only four previous cases of male small cell breast carcinoma were reported.

Keywords: Neuroendocrine Breast Carcinoma, Small Cell Carcinoma, Diagnosis, Prognosis, Treatment.

Ugur Topal¹, BegÜm Calim GÜrbÜz², Hasan Bektas¹

Pancreatoblastoma is a rare malignant epithelial neoplasm of the pancreas. It primarily occurs in the pediatric population and is extremely uncommon in adults. A 64-year-old male patient with no known systemic disease presented to our clinic with abdominal pain and dyspeptic complaints. On physical examination, a tender epigastric mass was palpated. The patient was operated on with a preliminary diagnosis of gastrointestinal stromal tumor. Enbloc resection of the mass was performed. The transverse colon was segmentally resected with wedge resection of the gastric corpus. A stapled side-to-side anastomosis was performed. The macroscopic examination of the case revealed a tumoral lesion of approximately 16x13.5x10m, located in the submucosal area between the gastric corpus and the transverse colon. The microscopic examination showed acini, which have a highly cellular appearance, contain areas of necrosis, and form nested structures in places, stratification in places. The immunohistochemical examination demonstrated positive Trypsin expression, while focal positive expression of neuroendocrine markers such as Synaptophysin, Chromogranin, and Insulinomaassociated protein 1 (INSM-1) was observed. In betacatenin staining, aberrant nuclear and cytoplasmic positive expression was observed, and this staining pattern and morphology confirmed the diagnosis of pancreatoblastoma. Pathological Stage:pT3,N0,Mx the patient had an uneventful postoperative period and was referred to the oncology department for adjuvant chemotherapy. Pancreatoblastoma is an extremely rare type of pancreatic cancer and there are no established guidelines for the treatment of this aggressive disease. Surgical resection is recommended if anatomically possible. Pancreatoblastoma should be considered in the differential diagnosis of asymptomatic masses containing cystic-solid components and reaching very large sizes.

Keywords: Pancreas,Rare tumor, Pancreatoblastoma