ISSUE NO. 21 - MAY 2016
Pages Title / Authors / Abstract


Weekly versus Three-Weekly Cisplatin-based Concurrent Chemoradiotherapy as definitive treatment in Head and Neck Cancer- Where do we stand?


S. Rawat, H. Srivastava, P. Ahlawat, M. Pal, G. Gupta, D. Chauhan, S. Tandon, R. Khurana
Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India



Purpose: To compare toxicity, compliance, and early response of weekly and 3-weekly cisplatin administration concurrent with radiotherapy as definitive treatment in locally advanced squamous cell carcinoma head and neck.

Materials and Methods: Patients with histologically proven stage III – IV B head and neck carcinoma presenting from June 2013 to March 2014 were randomly assigned to weekly (35 mg/m2, 6 cycles; arm A) and 3 weekly (100 mg/m2, 3 cycles; arm B) cisplatin with concurrent radiotherapy.

Results: 60 patients were randomly assigned to treatment, 30 in each arm. Median follow-up was 8 months (range 4-13). There was no significant difference in grade 3 mucositis between the two arms (75.9% vs 70%, p = 0.20). Grade 3 neutropenia was more frequent in arm B (55.2% vs 26.7%, p = 0.01). Hypomagnesemia was the commonest electrolyte imbalance and it was significantly higher in arm B (60% vs 20%, p = 0.001). Completion rate of scheduled chemotherapy cycles was higher for patients receiving weekly regimen. Response at 3 months was similar for all the patients {Complete Response (66.7% vs 62.1%), p = 0.200}. Our data suggested that there is a reduced need of hospitalization and supportive care measures for patients receiving weekly cisplatin with RT (p = 0.05).

Conclusions: Weekly cisplatin 35 mg/m2 chemotherapy concurrent with radiotherapy is equally effective and less toxic in terms of neutropenia, hypomagnesemia and need for supportive measures than the conventional 3 weekly cisplatin 100 mg/m2 regimen.

Keywords: Squamous cell carcinoma, Cisplatin, Head and Neck neoplasm, Mucositis, Neutropenia

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Stereotactic Hypofractionated Accurate Radiotherapy of the Prostate (SHARP), 36.25 Gy in Five Fractions for Localized Disease: A Case Series Results from King Faisal Specialist Hospital, Saudi Arabia

M.W. Hegazy1,2, R. Mahmood1
1 Department of Radiation Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
2 Department of Clinical Oncology and Nuclear Medicine, Zagazig Faculty of Medicine, Egypt


Purpose: To evaluate the feasibility, efficacy and toxicity of stereotactic hypofractionated accurate radiotherapy (SHARP) for localized prostate cancer.

Methods and Materials: The current series of SHARP included six patients with localized prostate cancer treated with 36.25 Gy in 5 fractions by Cyber-knife. Non-coplanar conformal fields and daily stereotactic localization of implanted fiducials were used for treatment. Acute and Late Genitourinary (GU) and gastrointestinal (GI) toxicity were evaluated by Common Toxicity Criteria (CTC). Prostate-specific antigen (PSA) values and self-reported sexual function were recorded at 3 months interval at first two years then every 6 months thereafter.

Results: The median follow-up is 32 months. Acute toxicity Grade 1 (GU) noted in four cases and two cases were Grade II; Grade I (GI) was in five cases and one patient in Grade II; also with regards to late toxicity, Grade 1 (GU) and (GI) was present in all cases. No patient has experienced grade 3 or greater acute or late toxicity. Regarding sexual activity, three patients reported impotency before and after therapy and all of them have insulin dependent diabetes mellitus and ischemic heart disease; fourth patient has developed impotence and the other two patients developed no changes as before radiation. The mean basal PSA was 8 ng/ml and became 0.658 ng/ml.

Conclusions: SHARP for localized prostate cancer is feasible with minimal acute or late toxicity. Dose escalation should be possible. MRI guided target volume delineation and intrafraction prostate motion tracking with real-time beam adjustment are critical for safe high dose per fraction prostate SBRT.

Keywords: Prostate cancer, Stereotactic radiotherapy, Hypofractionation

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FOLFOX as Perioperative Chemotherapy of localized Gastric Cancer: Efficacy and Tolerance

R. Tanz1, C. El Mhadi1, M. Toreis1, M.R. Khmamouch1, T. Mahfoud1, A.A. Ali3, H. Errihani2, M. Ichou1
1Department of Medical Oncology Academic Military Hospital Mohamed V, Rabat, Morocco.
2National Institute of Oncology, Rabat, Morocco.
3Department of Surgery, Academic Military Hospital Mohamed V, Rabat, Morocco


Background: Use of perioperative chemotherapy had significantly improved prognosis of localized gastric cancer. Two studies have validated this approach using cisplatin based chemotherapy despite important toxicities. We conducted this study with the aim to evaluate efficacy and toxicity of FOLFOX regimen in this setting.

Material and Methods: This is a retrospective study including patients followed for gastric cancer in the Oncology Department of the military hospital Mohamed V in Rabat, Morocco over a period of 7 years from 2007 to 2013. Patients received 4 cycles of mFOLFOX as perioperative regimen. Assessment of tumor response after completion of preoperative chemotherapy was granted by comparative CT scan, tumor markers measurements and R0 surgery rate.Adverse events were graded according to classification of the National Cancer Institute Common Toxicity Criteria version 4.0.

Results: Thirty-one patients were included in this study. Use of preoperative chemotherapy showed partial response in fourteen patients (45.1%), stabilization in fifteen patients (48.4%). Tumor markers CEA and CA 19- 9 were significantly decreased. R0 resection rate was 83.87%. Only 2 (6.45%) cases of grade 3/4 hematologic toxicity were reported in our study. Achieving programmed postoperative chemotherapy was possible in 72.41% of patients.

Conclusions: Our study is limited by the retrospective design and small sample size but FOLFOX chemotherapy seems effective and well tolerated in this setting and its place deserves to be studied in a larger study.

Keywords: gastric cancer, perioperative chemotherapy, FOLFOX, efficacy, toxicity

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Evaluation of localization uncertainty of fiducial markers due to length and position variations induced by motion in CT imaging by measurement and modeling


I. Ali1, N. Alsbou2, S. Oyewale1, J. Jaskowiak1, S. Ahmad1, O. Algan1
1Department of Radiation Oncology, Stephenson Oklahoma Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, 73104, USA
2Department of Engineering and Physics, University of Central Oklahoma, Edmond, Oklahoma City, 73034, USA


Purpose: To quantify the variations in the length and position of fiducial markers induced by motion in axial (ACT), helical (HCT) and cone-beam CT (CBCT) imaging and associated uncertainty in image-guided radiotherapy (IGRT) by measurement and modeling.

Methods: A mobile thorax phantom containing markers of various lengths was imaged using ACT, HCT and CBCT imaging. The phantom was imaged while stationary and moving where it was moved sinusoidally with different motion amplitudes and frequency. An analytical motion model was developed that predicts the localization accuracy of IGRT based on fiducial markers in mobile phantom with ACT, HCT and CBCT.

Results: The apparent lengths of the markers varied with the different motion patterns and CT imaging modalities. In CBCT, the apparent length of the markers increased linearly with the motion amplitude for both half-fan and full-fan modes. In HCT and ACT, the apparent length of the markers increased or decreased non-linearly with motion parameters and speed of the imaging couch. When the marker moved opposed to couch motion the apparent lengths decreased, while they increased when the phantom moved along the direction of the imaging couch as predicted by the motion model. The position of marker centers did not shift and distance between makers did not change in CBCT images. However, in HCT and ACT, the position of marker center and distance between markers varied depending on motion parameters during imaging. The marker center could move superiorly or inferiorly and the distance between markers could increase or decrease depending on the phase of motion as predicted by the motion model.

Conclusions: The variations of marker length and position due to phantom motion were quantified by measurement and modeling. These variations may lead to large positioning uncertainties in patient setup and tumor localization based on IGRT with fiducial marker registration.

Keywords: fiducial marker, image-guided radiation therapy, motion artifacts, uncertainty, localization, CT imaging.

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Effect of Fractionated Dose of Radiotherapy on Oral Mucosa in Head and Neck Cancer Patients: A Cytological Assessment


S. Khan1, SMA Feroz2, M. Jain3, V. Mathur4, Sameera Khan5
1Dept. of Oral and Maxillofacial Pathology and Microbiology, College of Dentistry, Jazan University, Jazan, Saudi Arabia.
2Dept. of Prosthodontics, College of Dentistry, Jazan University, Saudi Arabia.
3Dept. of Oral Pathology and Microbiology, People’s Dental Academy, Bhopal (MP), India
4Department of Oral Pathology and Microbiology, People’s College of Dental Sciences & Research Centre, Bhopal (MP), India.
5Consulting Clinical Psychologist


Background: Cancer therapy couples with it a plethora of complications of short and long term effects which can be so distressing that patient may tolerate only lower less-effective doses of therapy, may postpone treatments or will discontinue treatment entirely. Fractionated dose of radiotherapy coupled with therapy induce local or systemic infections due to high cellular turnover rates of the oral mucosa, diverse and complex microflora and trauma to oral tissues. Several mucosal abnormalities often results in epithelial and glandular destruction and inflammation, which can be so devastating that it may cause atypical changes on the area exposed to radiation. Thus, the aim of this study was to investigate the feasibility of using cytological evaluation to detect oral epithelial atypia among Head and Neck cancer patients receiving fractionated dose of radiotherapy.

Methods: Study was conducted on 125 head and neck cancer patients receiving radiotherapy. Subjects were divided into 5 study groups on the basis of fractionated dose of radiotherapy from 10th-50th fractions respectively. Mucosal changes were evaluated by exfoliative cytology and atypical changes and inflammatory cell infiltration were assessed.

Results: Without prior knowledge of the subjects’ group, oral epithelial atypia was detected with increase fractionated dose of radiation. Dense inflammatory nfiltrate were identified in nearly all study groups irrespective of dose of radiotherapy.

Conclusion: Cytological atypia and inflammatory infiltrates were detected after exposure to radiotherapy.

Keywords: Atypia, cytology, oral mucosa, radiotherapy, inflammatory infiltrate

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Change in the Quality of Life in Oropharyngeal, Laryngeal and Hypopharyngeal Cancer Patients treated with Volumetric Modulated Arc-Based Concomitant Boost Radiotherapy 

P. Kannan1, A. Mukherji1, K. Saravanan1, K.S. Reddy2, S. Vivekanandam1, C. Shamsudheen3, V. Santhosh4
1Department of Radiotherapy, JIPMER, Puducherry, India.
2Department of Oncology, Mahatma Gandhi Medical College and Research Centre, Puducherry, India.
3Malabar Institute of Medical Sciences, Kozhikode, Kerala, India.
4Kailash Cancer Hospital and Research Institute, Vadodara, Gujarat, India


Objective: To assess the change in the quality of life (QOL) in Oropharyngeal, Laryngeal and Hypopharyngeal cancer patients treated with concomitant boost radiotherapy by Volumetric Intensity Modulated Arc Therapy (VMAT) technique.

Methods: Thirty patients with oropharynx, larynx or hypopharynx cancers of stage II to IVA were treated with an Accelerated fractionation schedule using Concomitant boost. The dose given was 1.8Gy/fraction daily, 5 days a week to the large field for 28 fractions and a daily concomitant boost of 1.5Gy/fraction to the boost field over the last 12 treatment days for a total dose of 68.4Gy/40 fractions/5½weeks by VMAT technique with concurrent chemotherapy (in stage III and IV patients) using Cisplatin 100mg/m2 IV three weekly during week 1 and week 4 of irradiation. QOL was assessed using the European Organization of Research and Treatment of Cancer Quality of Life Core Questionnaire, version 3.0 (EORTC QLQC30) and EORTC head and neck module (EORTC QLQ-HN35) before treatment, at the end of treatment, 1 month, 3 months and 6 months post treatment. The QOL scores and their evolution over the five measurements were calculated.

Results: The change in the QOL scores was acceptable in general. There was a significant reduction in quality of life scores at the end of treatment. The QOL improved in the followup period; and by 3 months post irradiation, there was a return of QOL scores to the baseline value.

Conclusion: The QOL scores indicate that concomitant boost radiotherapy by VMAT is well tolerated and helps in rapid return to baseline quality of life scores. We believe that this is one of the first papers which have combined concomitant boost radiotherapy with VMAT technique in head and neck cancers. VMAT based concomitant boost radiotherapy helps in rapid return to baseline quality of life.

Keywords: Head and neck cancers, volumetric arc therapy in head and cancers, concomitant boost radiotherapy, IMRT, altered fractionation, quality of life, head and neck cancers.

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Prostate biopsy handling: special tissue embedding technique with sponges affects the yield of prostatic tissue available for microscopic examination

K. Sitpura, E. Salmo
Department of Histopathology, Bolton NHS Foundation Trust, United Kingdom


Prostate cancer is considered as the second most frequently diagnosed malignancy and the sixth leading cause of cancer death in males. The quality of the prostate biopsy and its processing techniques may influence the outcome of the histopathological assessment which is the gold standard for cancer diagnosis. An audit of 240 prostate biopsies from 20 patients was conducted to compare the quality and length of tissue before and after the implementation of sponge embedding technique. The average length of prostatic biopsy before the procedure was 5.8 mm (range 1-15 mm) and the average length after implementation of the procedure was 9.5 mm (range 2-17 mm). This equates to a total of 60% increase in tissue volume after implementation of sponge embedding. A simple modification in the embedding of prostate biopsy in the laboratory resulted in higher quality biopsies available for histopathological examination.

Keywords: Prostate, biopsy, cancer, sponge, technique

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Expression of VEGF-A in Epithelial Ovarian Cancer: Correlation with Morphologic Types, Grade and Clinical Stage


C.S. Premalata1, K. Umadevi2, K. Shobha2, M. Anurekha1, L. Krishnamoorthy3
1Department of Pathology, 2Department of Gynaecologic Oncology, 3Department of Biochemistry,
Kidwai Memorial Institute of Oncology, M.H. Marigowda Road, Bengaluru, India


Aim: The objective of this study was to evaluate the expression pattern of vascular endothelial growth factor A (VEGF A) in epithelial ovarian cancers (EOC) and to correlate the intensity of expression with morphologic types, histologic grade and clinical stage of the disease.

Methods: Tissue microarrays were constructed from paraffin blocks of 78 cases of EOC in duplicate. Immunohistochemical staining for VEGF A was carried out with mouse monoclonal antibody and the intensity was scored independently by two pathologists (CSP and MA).

Results: Twenty six of 78 (33.3%) cases of primary malignant epithelial ovarian neoplasm showed high VEGF A expression. Among high expressors, 23 were seen in serous carcinomas, two in undifferentiated carcinomas and one in mixed carcinoma. High expression was not seen in other types like, endometrioid, mucinous and clear cell carcinomas. High VEGF-A expression was also associated high grade and advanced stage of the disease.

Conclusion: High VEGF-A expression in epithelial ovarian cancer was found to be associated with serous morphology, high grade and advanced stage of the disease. Though some degree of VEGF A expression was seen in most ovarian carcinomas, high expression was seen in only one third of cases and this may help in selecting the patients for targeted therapy with antiangiogenic agents.

Keywords: ovarian cancer; tissue microarray; VEGF, VEGF-A expression

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Efficacy of Different Protocols in Treatment of Nephroblastoma: A revisit


O.M. Zakaria1,2, M.Y.I. Daoud1 , S.H. Farrag2, AS Al Mulhim1
1Department of Surgery, College of Medicine, King Faisal University, Al Ahsa, KSA.
2Department of Surgery, Faculty of Medicine, Suez Canal University. Egypt


Background: Management of Nephroblastoma (NB) remains a subject of debate despite the fact that it ranked first among primary childhood’s renal neoplasm. We have previously discussed this issue 13, 14, yet, the sample size was limited.

Aim: The aim of this study was to further evaluate the efficacy of initial surgery in the treatment of stage II & III pediatric NB as a part of the short administration schedule as in National Wilms’ Tumor Study (NWTS)-4 and to evaluate its effectiveness compared to the long administration schedule.

Patients and Methods: The study included 50 children who were primarily diagnosed as stage II & III NB. They were divided into 2 equal groups. Group I (n = 25) included children who have undergone neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy, while group II (n = 25) included children who have undergone primary surgery as an initial management followed by chemotherapy. After a mean postoperative follow-up period of 20±6 months, clinical and radiological evaluation was performed to all patients.

Results: In group I, 15 patients were preoperatively diagnosed as stage II and 10 patients as stage III while in group II, 16 patients were proved to be stage II and 9 patients were stage III. After a follow up period, clinical and radiological evaluation using CT was performed to all patients. In patients with stage II, evidence of recurrence was noted in 5 patients of group I whereas no patient showed any evidence of recurrence in group II. In patients with stage III, rebound increase in size was seen in 3 patients in group I and only one patient in group II.

Conclusions: This study confirmed our previous conclusions that initial surgical intervention with appropriate adjuvant therapy has a better outcome than the neoadjuvant chemotherapy and delayed surgery for children primarily diagnosed as stage II & III NB. Moreover, it may also act as a short administration schedule for the treatment as it is not less effective than the long administration schedule and can be administered at a substantially lower total treatment cost.

Key words: Nephroblastoma, SIOP, NWTSG4, Children, Chemotherapy and Surgery.

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Ectopic Intrathymic Parathyroid adenoma demonstrated on Tc-99m Sestamibi SPECT-CT

S. Usmani1, M. Oteifa2, F. Abu Huda1, A. Javaid1, H.G. Amanguno3,  F. Al Kandari1
1Department of Nuclear Medicine, 2Department of Surgery, 3Department of Pathology,
Kuwait Cancer Control Center (KCCC), Kuwait


Intrathymic parathyroid adenoma is a rare cause of primary hyperparathyroidism. In this case, Tc-99m Sestamibi SPECT-CT successfully localized abnormal tracer uptake in the mediastinum with corresponding low density lesion on CT images suggestive of mediastinal parathyroid adenoma which late on confirmed on histopathology. After the median sternotomy a large intrathymic parathyroid adenoma was identified and excised. With the help of gamma probe the surgeons detect the lesion early and with more confidence as well as reducing the total operation time. Tc-99m Sestamibi SPECT-CT scintigraphy and gamma probe localization is recommended for preoperative and intra operative localization of ectopic parathyroid adenomas.

Keywords: Tc-99m Sestamibi SPECT-CT parathyroid scintigraphy, parathyroid adenoma

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Is cutaneous leishmaniasis a risk factor for basal cell carcinoma?


M. Chisti, R. Almasri, I. Hamadah
Department of Dermatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia


Background: Basal cell carcinoma (BCC) is the most common epithelial neoplasm of skin. Risk factors for the development of BCC include intermittent intense sun exposure, radiation therapy, family history of BCC, immune suppression and fair complexion, especially red hair. It can originate in scars like small pox, vaccination, chicken pox or surgical scars.

Objective and Conclusion: We present a case of basal cell carcinoma arising in a leishmania scar on the nose, sixty years after the primary lesion. Although rare, BCC’s have arisen in leishmania scars. Thus the possibility of basal cell carcinoma should be considered while dealing with such patients. Even though a causal relationship, if any, cannot be ascertained at present.

Keywords: basal cell carcinoma, cutaneous leishmaniasis, scar

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Bilateral Choroidal Metastases from Prostate Cancer revealed in a patient under Abiraterone - Fourteen years after diagnosis


H.R. Kourie1, J. Antoun2, F. Bteich1, A.Jalkh2, M. Ghosn1
1Hematology-Oncology Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.
2Ophthalmology Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon


Choroidal metastasis from prostate cancer is very rare and usually presents late during the disease. Since 2010, many new drugs were approved in the treatment of castrationresistant prostate cancer, including Abiraterone acetate. We report a case of bilateral choroidal metastases from prostate cancer 3 months after the initiation of Abiraterone. Abiraterone was not efficient in controlling the progression of the disease in this case, especially the choroidal metastasis. More case reports are essential in order to evaluate the role of Abiraterone in controlling choroidal metastases from prostate adenocarcinoma.

Keywords: prostate cancer, abiraterone, metastases

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Spectrum of Presentation of Anorectal Malignant Melanoma: Experience of a Tertiary Care Centre of North India


A. Gupta1, P. Prakash2, A. Rattan2, N. Wadhwa3, S. Kumar2, V. Rathi4
1 Department of Surgery, Dr. Baba Saheb Ambedkar Medical College Hospital, Delhi, India
2 Department of Surgery, 3 Department of Pathology, 4 Department of Radiology, UCMS & GTB Hospital, New Delhi, India


Malignant melanoma of the anorectum is a rare but highly aggressive tumor. We report our experience of anorectal melanoma in five patients. Of these, two have advanced disease, two had localized disease and one patient had florid systemic metastases with a history of hemorrhoidectomy one year prior. One patient whose metastatic workup was negative, expired on post-op day 15 of abdominoperineal resection due to unsuspected but florid cerebral metastases. Another patient with localized disease underwent an APR with curative resection and post-op whole body PET scan negative for occult or residual disease. Advanced stage patients were referred for chemotherapy. To improve prognosis, it is important to detect anorectal melanoma at an early stage.

Keywords: anorectum, melanoma, malignant

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Metaplastic carcinoma of breast: A case series of seven patients from a tertiary care center and review of literature


R. Benson1, R. Madan1,2, P.K. Julka1, G.K. Rath1
1Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
2Department of Radiation Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh-160012


Purpose: Metaplastic carcinoma of breast (MCB) is a rare histological subtype of breast carcinoma and accounts for less than 1 percent of the total breast cancer cases. Here we are reporting a series of seven patients of MCB from single institute along with review of literature.

Material and Methods: Patients records from January 2008 to August 2014 were retrieved to search for MCB patients. A retrospective review was conducted to document the clinicopathological features, treatment and outcomes of these patients. The data was entered in a predesigned proforma document.

Results: Seven patients were diagnosed to have MCB during this period. Most common symptom at presentation was lump in the breast with associated discharge per nipple in one patient. On histology, there was no definite differentiation in four patients while one patient had spindle cell neoplasia, one had osteoid and chondroid neoplasia respectively. Five patients underwent modified radical mastectomy while other two patients underwent simple mastectomy. All the patients were pathologically node negative and triple negative breast cancer. Adjuvant chemo-radiotherapy was given to all patients. Median follow up was 4 years (Range 3-6 years). Three out of seven patients completed 5 years of follow up. One patient developed isolated liver metastasis six years after completion of the treatment and she lost to follow up for further treatment.

Conclusion: Metaplastic carcinoma of breast is a rare disease entity and there are no specific treatment guidelines. The prognosis of patients in this rare sub group remains poor and multi institutional studies evaluating role of new therapies may be required to improve outcome.

Keywords: Metaplastic breast cancer, treatment, outcome

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DNA methylation and Cancer: Identifying and targeting epigenetic modifications may be the future of cancer therapy?


G. Maresca1, P.S. Wismayer2
1University of Malta Medical School, Mater Dei Hospital Msida, Malta, Europe.
2Department of Anatomy, Faculty of Medicine and Surgery, Biomedical Sciences Building, University of Malta, Msida, Malta, Europe


DNA methylation has been recognized as one of the most important epigenetic mechanisms regulating the expression and inhibition of genes giving rise to an organism’s phenotype. It is hence of no surprise that when DNA methylation mechanisms are disrupted by intrinsic or extrinsic causes, the likelihood of tumourigenesis increases. Both hypermethylation and hypomethylation may predispose to cancer formation through aberrant inhibition or expression of particular genes and this is seen in different types of cancers, such as laryngeal squamous cell carcinoma and acute myeloid leukaemia. By increasing our knowledge and understanding of these epigenetic mechanisms, we will be able to develop diagnostic techniques such as methylation profiling, to screen for and detect aberrant methylation patterns which may predispose to cancer formation in our patients. This would enable early diagnosis and treatment which may also involve the use of drugs developed to provide directed epigenetic therapy, shifting away from the current trend which involves the use of radical anti-cancer therapy. These diagnostic and treatment options may be the future of cancer management.

Keywords: Epigenetics, DNA Methylation, Cancer, Epigenetic therapy, methylation profiling

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Novel agents in second-line therapy for EGFR wild-type Advanced Non-Small-Cell Lung Cancer


L. El Amarti1,2, I. Elghissassi1,2, M. Layachi1,2, H. Mrabti1,2, H. Errihani1,2
1Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco.
2Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco


Lung cancer is the leading cause of cancer-related mortality worldwide owing to its advanced-stage at the time of diagnosis. The majority of patients will require a second-line therapy after progression during first-line treatment. While treatment for NSCLC with EGFR mutation or EML4/ALK fusion, target therapy is the favored second-line therapy if not already used in first-line therapy, NSCLC with EGFR wild-type remains an unmet need and many oncologists favor cytotoxic therapy. Recently, a better understanding of lung cancer biology, with a better selection of patients based on histology, molecular biology and the identification of potential target antigens in the immune system have significantly improved patient outcome. This article will provide an update on different treatment options available for patients with EGFR wild-type advanced NSCLC who relapse after first-line therapy, which includes essentially ramucirumab, vandetanib, nivolumab, and pembrolizumab and considerations that may allow clinicians to a better choice of agent for second-line therapy.

Keywords: EGFR wild type, non-smal

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