Mourougan Sinnatamby¹, Saravanan Kandasamy¹, Gunaseelan Karunanidhi¹, Vijayaprabhu Neelakandan¹, Seenisamy Ramapandian¹, Muniyappan Kannan¹, Elakiya Sampath¹,

¹ Department of Radiation Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India

Introduction: Combination of external beam radiotherapy (EBRT) and High Dose Rate (HDR) brachytherapy (BT) with concurrent chemotherapy (Cisplatin 40mg/m2/weekly) is the standard treatment of approach for the carcinoma of uterine cervix. In this study for image based HDR brachytherapy of intracavitary both 192Ir and 60Co sources were used for dosimetry and the dose distribution compared between point doses and volume doses as per the recommendation of ICRU89 and GEC-ESTRO on 3D image based planning. The dosimetry and clinical outcome will decide decisionmaking on choice of radionuclide for HDR brachytherapy of cervix in addition to economic reason.

Materials and Methods: The Study conducted for 27 patients of cancer cervix stage IIB or IIIB with vaginal involvement limited to the upper third of vagina. All patients underwent concurrent chemoradiation Cisplatin 40mg/m2 weekly throughout EBRT by 3D conformal therapy 46Gy in 23# followed by two fractions of HDR brachytherapy with 9Gy/1Fr. Post implants 3mm slice selection of pelvic CT scans performed with ring applicator in place followed by T2 weighted paracorpal or paracoronal section of MRI imaging. The solid ring applicator (AL13017000) from library used for applicator reconstruction. Initially all plan calculated with TG-43 formalism using 192Ir radionuclide (Varian, GammaMed HDR Plus source) and then modelled 60Co radionuclide (Eckert & Ziegler BEBIG GmbH, Co0. A86) used for dose computation. ICRU89 recommended points and volumes of targets and OARs evaluated and compared.

Results: The study concludes that 60Co based point-A, B ICRU and RICRU doses showed a comparable result with that of 192Ir HDR source based dosimetry. The volume based criterion for the target such as GTV, CTVHR, CTVIR for D 90, D98, V150%and V200% are all within 5% dose level comparing two sources.

Conclusion: 60Co a viable alternate to 192Ir by taking into consideration frequency of source exchange and cost reserve with comparable dosimetry.

Keywords: Image-guided , 192Ir, 60Co, Carcinoma cervix, HDR Brachytherapy, Treatment planning

Immunohistochemical Analysis Of Novel Biomarkers Cyclin D1, p53 And Ki67 In Endometrial Carcinoma:Clinicopathological Significance And Prognostic Value.

Manisha A. Atram¹, V B Shivkumar¹, Nitin M. Gangane¹

¹ Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha.442102, Maharashtra, India ORCID ID number 0000-0002-7970-4216

Background: Endometrial carcinoma (EC) is the only gynecologic cancer with increasing incidence and mortality worldwide. This study aimed to determine association of cell proliferation marker CyclinD1, p53 and Ki67 with clinicopathological parameters and survival analysis in patients of EC.

Materials and methods: One hundred twenty-four histological confirmed cases of EC treated at our institute were included in this study. The appropriate tissue blocks of cases which were retrieved from 2010 to 2015. The study period was from Jan 2018 to Jan 2020. Data pertaining to patient's clinical details, histopathological diagnosis, treatment and follow up was retrieved from Hospital information System. Immunohistochemical evaluation of Cyclin D1, p53 and Ki67 was done. Overall survival and Disease-free survival for each category were analyzed by the Kaplan-Meier method.

Results: Of the 124 cases of EC, 108(87.09%) cases were of type I and 16 (12.89%) cases of type II. Overall positive staining of cyclinD1, p53 and Ki67 were noted in 53.22%, 42.22% and 32.3% cases respectively. The clinicopathological parameters affecting disease-free survival were age (p=0.039) histological types (p=0.007), and FIGO stage (p<0.001). Elevated Ki67 index and p53 overexpression was associated with type II morphology (p= 0.001). Whereas Cyclin D1 expression was associated with type I morphology and poorly differentiated tumor.

Conclusion: Cyclin D1 positive staining, p53overexpression and an elevated Ki-67index all had an independent prognostic significance in endometrial cancer. This panel of biomarkers may help to differentiate tumor behavior, and necessity for more radical surgery and post- operative chemotherapy.

Keywords: Endometrial carcinoma, cyclin D1, p53, Ki67, Survival analysis

Rathee Ravish¹, Punatar Chirag B¹, Agrawal Gaurav¹, Nagaonkar Santoshi¹, Joshi Vinod S¹, Late Sagade Sharad N¹, Srinivas V¹

Objectives: To evaluate the role of alkaline phosphatase (ALP) as marker of bone metastases in patients of genitourinary cancers compared to bone scan, and to correlate with NCCN guidelines.

Methods: This retro-prospective, observational study included all newly diagnosed patients of renal, bladder (muscle invasive) and prostate cancers who presented from July 2014 to March 2017. For diagnosis of bone metastases, ALP groups (raised/normal) were compared with bone scan (positive/negative). Sub-group analysis was done on patients with normal ALP levels and positive bone scan.

Results: 150 patients were included and stratified depending on bone scan findings. Hemoglobin values were significantly different between two groups in renal and prostate cancers (p=0.015 and 0.002 respectively). ALP values were significantly different between two groups in prostate cancers (p=0.0008), but not for others. Three out of seven patients with bone metastases for renal cancers (42.9%) and all three for bladder cancers had normal ALP values, no bone symptoms, and would have been missed. For prostate cancers, out of 23 who had bone metastases, ALP was normal in ten. All these ten had Gleason score of >8 and all except one had S. PSA >20ng/ml. All cases would have been detected irrespective of ALP values.

Conclusions: ALP has limited sensitivity but reasonable negative predictive value for bone metastases in genitourinary cancers. Current guidelines may miss significant number of cases with bone metastases for renal and bladder cancers. Current guidelines have good accuracy for prostate cancers, since PSA and Gleason score are independent predictors of bone metastases.

Keywords: Alkaline Phosphatase, Bone scan, Genitourinary cancer

Post-Menopausal Status and Risk for Cervical Dysplasia

Kenia Edwards¹, Mary Fatehi¹, Joshua Fogel^1,2,

Introduction: The study aim is to determine the association of post-menopausal status with abnormal Pap smear cytology and cervical dysplasia detected by colposcopically-directed biopsy. We also study the association of biopsy-confirmed dysplasia with Pap smear results.

Patients and Methods: This retrospective study included 480 women with abnormal Pap smear results who were referred for colposcopy. Covariates considered included demographic (age, race/ethnicity, smoking status), sexual activity (age first sexual intercourse, number lifetime partners, duration current partner), and disease (HIV, high-risk HPV, immunosuppression).

Results: Post-menopausal status was not significantly associated with abnormal Pap smear cytology or cervical dysplasia. We found a statistically significant association of high-grade dysplasia with high-grade Pap smear results: ASC-H (B=3.43, SE=0.84, p<0.001); HSIL (B=3.50, SE=0.84, p<0.001) and AGC (B=3.47, SE=1.02, p<0.01).

Discussion and Conclusion: Although clinicians may want to consider not requiring colposcopically-directed biopsy for certain post-menopausal patients, we recommend continuing with current cervical cancer guidelines of screening for all women regardless of menopausal status.

Keywords: uterine cervical dysplasia, cervical intraepithelial neoplasia, postmenopause, menopause, papanicolaou test

Introduction: Breast cancer (BC) is the leading malignancy globally with consequent morbidity, mortality and burden on health care resources when diagnosed at an advance stage. Early-stage diagnosis is crucial to the better outcome. Screening is pivotal to early detection at an early stage. It is understood to reduce mortality, improve outcome, and is cost effective.

Objective: The objective of the study was to see the impact of screening program on Breast cancer stage in Oman. In this study we looked into the trends in stagespecific breast cancer incidence during two pre-specified time periods 2006-2010 and 2015-2017, before and after the introduction of a national screening programme in Oman.

Patients and Methods: It is a retrospective analysis, where breast cancer patient's data was retrieved from Oman national cancer Registry ministry of health Sultanate of Oman, for two pre-specified time periods 2006-2010 before the introduction of cancer screening programs and 2015-2017. The cases included were those who had confirmed histopathology diagnosis and where a composite stage, based on TNM stage, was available to be analysed and compared in these two pre-specified time periods to find out the difference between these two time periods. The statistical analysis was carried out and p values were determined. Ethical approval obtained from Royal Hospital medical ethics and scientific research committee.

Results: There was a 41% reduction in stage IV breast cancer from 23.01% to 13.58 %, and 86.15% increase in stage 0-1 from 6.86 % to 16.98%. (p Value <001). The stage 0 cases increased from 0% to 4.26 %. With regard to tumour size, T0-1 tumours increased from 14.16% to 26.03%, while T4 tumours decreased from 16.59% to 7.69%. There was increase in node negative breast cancer cases in Oman. The N0 increased from 28.43% to 37.64%. The diagnosis as Non-metastatic M0 disease increased from 39.77% to 60.23%, while diagnosis as metastatic M1 disease decreased from 55.32% to 44.68%.

Discussion and Conclusions: The introduction of national screening programme in Oman resulted in a continued increase in localized cancers and a decline in advanced disease. Screening programmes should be evaluated continuously and systematically to ensure their targeted objectives. The causal link between stage distribution and mortality needs to be investigated further in the context of screening. Health planners, policymakers, and other stakeholders; including clinicians, educators, community members, and advocates, should be aware of the health system requirements, as well as overall costs of these approaches to breast cancer early detection, to make effective investments, plans, and policies.

Keywords: Breast Cancer, Screening, Oman, Royal hospital, early detection, early stage, OCA

Nikhila Radhakrishna¹, B. K. Yamini², Amrut Sadashiv Kadam³, N. Shivashankar⁴, Chendil Vishwanathan³, Rajesh Javarappa³,

Background: Laryngeal toxicity (LT) following concurrent chemo-radiotherapy (CCRT) for non-laryngeal head & neck cancers(NLHNC) has been inadequately studied. Electroglottography (EGG), a non-invasive technique for objective quantification of LT, measures the change in electrical impedance generated by glottic closure.

Aim: Objective and subjective assessment of acute LT post-CCRT in NLHNC.

Materials and Methods: A prospective study on 30 NLHNC patients, treated with CCRT; 66-70Gy/33- 35fractions with weekly Cisplatin. Flexible laryngoscopic examination and EGG were performed at baseline, 6weeks, and 3months post-CCRT; Grades of LT and contact quotients(CQ) were documented. Patientreported outcomes of voice-related quality of life(QoL) performed at the same intervals, using a 30-item Voice Symptom Scale (VoiSS) questionnaire.

Statistical analysis: Results of continuous measurements were studied by mean +/- standard deviation. Analysis of variance (ANOVA) was used for comparison of pretreatment and post-treatment results in more than two groups. Significance was assessed at 5% level of significance. Post- hoc analysis has been done using Tukey – Krammer method for multiple comparisons. Correlation analysis was performed using Pearson correlation test.

Results: 26/30 patients completed CCRT; 14 were available at 6weeks; 10 at 3months post-CCRT for analysis. At 6 weeks, 3/14(21.5%) patients had Grade II LT; 11/14(78.57%) had grade III. At 3months, 2/10(20%) had Grade I, 6/10(60%) had grade II but 2/10(20%) had worsened to grade IV. Mean CQ at baseline was 50.77 + 5.55; which decreased at 6 weeks to 48.56 + 4.66 and further at 3months to 45.56 + 4.66 ( p>0.05) suggestive of glottic hypo-adduction. VoiSS responses showed a significant impact on QoL in all three domains at six weeks and three months post-CCRT, compared to baseline (P < 0.0001).

Conclusion: Electroglottography is a potential tool to quantify acute LT post CCRT. Patient-reported outcomes may not correlate to the objective measures of laryngeal toxicity and require separate recording and reporting. A larger sample size would be required to draw further significant correlations.

Keywords: Electroglottography, laryngeal toxicity, head neck cancer, voice, chemo-radiotherapy

Amrallah A. Mohammed^1,2,, Fifi Mostafa Elsayed³, Mohammed Algazar⁴ Hayam E Rashed⁵

¹ Medical Oncology Department, Faculty of Medicine, Zagazig University, Egypt.
² Oncology Center, King Salman Armed Forces Hospital, Tabuk City, Saudi Arabia.
³ Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Suez Canal University, Egypt.
⁴ Department of General Surgery, Faculty of Medicine, Zagazig University, Egypt.
⁵ Department of Pathology, Faculty of Medicine, Zagazig University, Egypt.

Background: Tumor-infiltrating lymphocytes (TILs) reflect the antitumor response of the host. This study aimed to assess the value of TILs in predicting pathological response after neoadjuvant chemotherapy (NAC) and survival outcomes in patients with triple-negative breast cancer (TNBC).

Methods: A retrospective analysis conducted between February 2012 and December 2015. Patients with stage I, II, and III TNBC patients were enrolled. TILs were assessed in haematoxylin and eosin-stained sections from true cut needle biopsies before NAC. According to international TILs working group, we had three groups; low (0-10%), intermediate (11-59%), and high TILs (= 60%).

Results: A total of 159 patients was included, 56% were premenopausal and 76.1% were less than 60 years. The main bulk of patients had histological grade III, high Ki 67, and high TILs (74.2%, 84.3%, and 72.3%), respectively. The pre-treatment high TILs was significantly correlated with high Ki-67 (p = 0.001), pCR (p <0.001), and late relapse (p <0.001). Other clinico-pathological features such as age, menopausal status, tumor size, histological grade, lymph node involvement and lympho-vascular invasion weren't significantly correlated with TILs levels. 71.3% of enrolled patients having high TILs achieved pCR, vs 27.8% in the intermediate group and 30.8% in low group. After a median follow-up of 45.3 months, patients with high TILs were significantly associated with longer DFS and OS as compared to intermediate and low TILs (27.2 vs 15.9 vs11.4 months for DFS and 70.2 vs 34.3 vs 27.6 months for OS) p<0.001).

Conclusion: Pre-treatment level of TILs had a predictive and prognostic value in TNBC patients receiving NAC. TILs may be integrated into the basic laboratory for TNBC prognostication as a credible biomarker.

Keywords: triple negative breast cancer - neoadjuvant chemotherapy - pathological response- tumorinfiltrating lymphocytes.

Sujal Parkar¹, Abhishek Sharma², Mihir Shah³

¹ Department of Public Health Dentistry, Siddhpur Dental College and Hospital, Patan, Gujarat, India.
² Department of Public Health Dentistry, Rajasthan University of Health Science College of Dental Sciences Dental College), Jaipur, Rajasthan, India.
³ Department of Periodontology, Ahmedabad Dental College and Hospital, Gandhinagar, Gujarat, India.

Introduction : Head and neck cancer and its treatment play a significant role in a patient's quality of life. The evaluation of the quality of life is important for the better survival of the patients. The study aims to determine how the different treatment modalities impact the quality of life in head and neck cancer patients.

Methods: A prospective cross-sectional study was conducted among the 400 HNC patients. Patients who were newly diagnosed with cancer (treatment not yet started) and those who received cancer-directed treatment were enrolled. The quality of life was assessed by using European Organization for Research and Treatment of Cancer: Core (QLQ-C30) and Head and Neck specific module (QLQ-H&N35).

Results: Tumor involving pharynx and larynx had significantly worst score as compared to cancer of oral cavity. The quality of life deteriorated in the advanced stage of cancer as compared to the initial stage. Problems related to social contact were significantly more in patients treated with surgical treatment. The symptoms scores were high in patients receiving chemoradiation therapy. Patients treated with single treatment had a significantly better score on most scales than patients receiving combined treatment modality. Performance status was a strong predictor of quality of life.

Conclusion: The result of the study concludes that the many domains of quality of life were significantly affected in patients receiving cancer-directed treatment. Assessment of quality of life will help reduce the impact of therapeutic complications and thus improve patient's quality of life.

Keywords: Head and neck cancer, quality of life, surgery, chemo-radiati

Gustavo H. Marin¹, Hector Trebucq¹, Carlos Prego¹, Luis Mosquera¹, Gustavo Zanelli¹, Daniela Pena¹, Gustavo Sanchez¹, Marcela Mayet¹, Julieta Spina¹, Andrea Lallee`¹, Florencia Scigliano¹, Adrian Fernandez¹

¹ National University of Buenos Aires Centre, Faculty of Health Science, Olavarria, Buenos Aires, Argentina. (Zip Code 7400) Phone: +54 2284 426382.

: Health systems provides care only to those people who spontaneous demand for attention; excluding those who don't perceive illness or are not aware enough to consult. Alternative healthcare models based on the nominal-personalized care like "University Center for Integrated Care of Referred Health Care" (CUIDARAS) may have better results. In order to demonstrate benefits of this model, it was performed an experience based in colorectal cancer (CRC) detection and care that focused the entire population of the town.

Methods: It is an intervention study for early detection of CRC. A survey and a physical examination were performed in each adult from "CH" town. Two visits were made. Blood in stool test (BIST) was self-collected, analyzed and results delivered with appointment for a programmed video-colonoscopy (VCC) when test was positive.

Results: people enrolled (n546) had 59.9+_­­­6.4 yrs. Adherence was 93.8% of the target population; 99.2% performed BIST; while 95.3% a positive BIST had access to VCC and treatment. Overall cost of the experience (stool test, VCC, biopsy, local treatment) was 7685 USD, while costs associated to an advanced CRC classic treatment was USD 9577/patient (USD 26098 if treatment included bevacizumab).

Conclusion: The present study based on preventive actions like blood in stool test, applied as a screening to all inhabitants in town, had 93.8% of adherence and high level of CRC early detection. A health model based on personalized care (CUIDARAS), achieved more effective results in terms health care and disease prevention, with a favorable benefit/cost ratio compared with classical health care provide by current system.

Keywords: Model of care; colorectal cancer, CUIDARAS, personalized care.

Nik Mohd Syahrul Hafizzi Awang¹, Rosli Mohd Noor¹, Rosdi Ramli¹, Baharudin Abdullah²

¹ Department of ORL, Hospital Raja Perempuan Zainab (II), Kota Bharu, Kelantan, Malaysia
² Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.

Background: The infratemporal fossa poses a great challenge to surgeons due to its complex anatomy and communications to many surrounding areas. The disorders that arise from this area can be infections and neoplasms. They can cause varieties of complications due to the extension of the pathologies and compression effect to the other adjacent structures. Inflammatory pseudotumor of the infratemporal fossa is one of the rare disorders of the head and neck.

Case Presentation: We report a patient with a pseudotumor of infratemporal fossa that extends to the orbital area and cavernous sinus, causing orbital apex syndromes. The diagnostic imaging, different surgical approaches of the biopsy and methods of treatment of this case are discussed.

Discussion and Conclusion: Radiological imaging and immunohistopathology are essential in establishing the diagnosis and determine the complications. The surgeons must well understand the characteristics and the impact of the disorders on the adjacent structure and give prompt decision to provide definitive treatments.

Keywords: infratemporal fossa, inflammatory pseudotumor, immunohistopathology, orbital apex syndromes, cavernous sinus

Aashita¹, Vikas Yadav¹, Rajiv Sharma¹, Pragyat Thakur¹, Hemendra Mishra¹, Sanchit Jain²

¹ Department of Radiotherapy, VMMC and Safdarjung Hospital, New Delhi, India
² Department of Pathology, VMMC and Safdarjung Hospital, New Delhi, India

Abstract: Incidence of multiple primary malignancies is reportedly increasing globally. Limited cases of triple metachronous cancers are available in the literature. Here, we report a case of a female with an unusual combination of triple metachronous malignancy over a span of 15 years involving endometrium, nasal cavity and rectosigmoid that has not been reported before in the literature.

Keywords: multiple primary malignancy, triple metachronous cancer, nasal squamous cell cancer, endometrial cancer, recto-sigmoid cancer, Lynch Syndrome

Ala Aljehani¹, Ahmed Abu-Zaid^2,3, Mohamed Ismail Albadawi⁴, Osama Alomar^2,5, Abdulmohsen Alkushi⁶

Abstract: Perivascular epithelioid cell tumors (PEComas) are infrequent mesenchymal neoplasms. Primary uterine PEComas are extremely uncommon. To the best of knowledge, around 110 cases of uterine PEComas have been documented in the English-language literature thus far. Herein, we present the case of primary uterine PEComa in a 56-year-old Saudi woman who presented to clinical attention with a six-month history of left-sided abdominal pain. Gynecological examination showed a 5-cm solid mass involving the left adnexa. Tumor markers were normal. Computed tomography scan demonstrated a 4.2 x 4.4 x 3.4 cm superior left fundal exophytic mass.Patient underwent total abdominal hysterectomy plus bilateral salpingo-oophorectomy. Final histopathological examination demonstrated benign/uncertain malignant potential PEComa. No further adjuvant therapy was administered. At six-month follow up, the patient was asymptomatic without recurrence. In conclusion, uterine PEComas are rare. Histopathological assessment establishes the definitive diagnosis. Surgery remains the gold standard in the treatment of uterine PEComas and adjuvant therapy should be guided based on clinical and histopathological risk factors.

Keywords: Uterine perivascular epithelioid cell tumor, PEComa, Uterine sarcoma, hysterectomy

Ashwag Alqurashi¹, Saleh Baeesa¹, Maher Kurdi², Deema Hussein³, Hans-Juergen Schulten⁴

¹ Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia..
² Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
³ King Fahd Medical Research Center, Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.
⁴Center of Excellence in Genomic Medicine Research, Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.

Background: Human skin cautery, a traditional thermal therapy, is traced back to Hippocrates beyond the 5th century. Those ancient healers used this method to control bleeding and infection and remove cancerous tumors. Such traditional procedure is still in practice in several regions of Asia and Africa to treat certain conditions. There is a lack of reports in the literature regarding the long-term complication and the possible tumorigenesis following traditional treatment with thermal cauterization. Here, we report two patients with intracranial meningiomas and investigate the gene expression profile for a patient.

Cases presentations: We report two adult patients who presented with a headache and hemiparesis over six months. Brain magnetic resonance imaging (MRI) scans of both patients revealed intracranial meningiomas. During preoperative preparation of the patients, cautery marks were noticed over the scalp region above the intracranial tumors site, which was performed during childhood. The patients underwent uneventful resection of meningiomas with no local recurrence over a 5-year follow up. In addition, we performed a biofunctional genetic microarray expression analysis on the affected meningioma.

Conclusion: There is a lack of evidence-based scientific reports in the literature regarding the long-term complications and tumorigenesis following aggressive treatment with thermal cauterization. Herein, we report the first possible association between previous scalp traditional cautery and the development meningioma in two patients and discuss a proposed causal relationship. However, further advanced studies and research should be done to support, or reject, our hypothesis.

Keywords: Traditional medicine. Cautery. Meningioma. Pathogenesis. Gene expression.