Issue No. 1 - Jan 2007
  Sentinel lymph node biopsy in the Sultanate of Oman
  T. Al-Lawati¹, M. Ali Jaffer1, M. Mateen1, H. Nahar1, A. Al-Saadi², S. Thomas3, F. Al-Lawati3 and D. Samarasinghe3
1General Surgery, 2Nuclear Medicine and 3Histopathology, Royal Hospital, Sultanate of Oman
11-16   Twenty five patients with Breast cancer and melanoma, had axillary sentinel lymph nodes (SLN) detection by blue dye alone or with radioisotope, followed by axillary dissection to confirm the histological findings of the SLN. This is the beginning of SLN biopsy in Oman. The histological staging of axillary lymph nodes is the best predictor of survival in patients with breast cancer. Axillary lymph nodes dissection (ALND) is being replaced by SLN biopsy in many centers. In this article we present our experience in the SLN biopsy and announce the start of it in the Sultanate of Oman.

Objective:  To establish the feasibility of newly started sentinel lymph node (SLN) biopsy in our center at the Royal Hospital in the Sultanate of Oman.  Methods:  Twenty five patients with Breast cancer and melanoma were staged with sentinel lymph node (SLN) biopsy, followed by Axillary lymph Node Dissection (ALND). Axillary SLN were detected by injection of blue dye alone or with radioisotope. Intraoperatively, a gamma probe detector identified the isotope-labeled SLN. Two patients underwent pre-operative lymphoscintigraphy. The SLNs were examined histologically by hematoxylin-eosin staining and, if negative by this method an immunohistochemical staining (IHC) was done.

Results: The only failure to detect inguinal SLN was one case after neoadjuvant chemotherapy. Total detection rate of SLN was of 96%. Metastatic spread occurred in 11 patients of these 9 had other lymph node (LN) involved. Nine patients had no SLN involvement and no other LNs involved.

Conclusions: Ethically, according to the international recommendations and looking to the statistics of the Sultanate all clinical N0 should have the choise of SLN biopsy prior to ALND.
    full article
17-21   Anemia in patients with advanced or metastatic non-small cell lung cancer
    S. Abuzallouf1, J. Wright2, O. El Hattab1
1Kuwait Cancer Control Center, Kuwait.  2Hamilton Regional Cancer Center, Canada.
    Objective: To determine the frequency of anemia in patients with advanced or metastatic non-small cell lung cancer (NSCLC) at the time of initial oncologic consultation. Material and Method:  We reviewed 144 consecutive charts of patients with advanced or metastatic NSCLC, who were seen in consultation at the Hamilton Regional Cancer Center (Canada) between January and June of 1998.

Results:  Eighty nine patients had pre-treatment hemoglobin (Hb) levels available and 30 of those patients (33.7%) had levels below 12 gm/dl. The likelihood of anemia increased with advancing stage of underlying disease, found in 25% and 40.8% of stage III and IV patients respectively.

Conclusion: Although only 89/144 patients had Hb results available, 33.7% had hemoglobin level below 12 g/dl. Anemia was more common with an increased burden of disease. Shortness of breath and fatigue were more commonly reported in anemic patients.
    full article
23-28   Evaluation of the prevalence, pattern and management of cancer pain in Oncology Department, The Royal Hospital, Oman

M. Faris, B. Al- Bahrani, A. Emam Khalifa, N. Ahmad
Oncology Department , The Royal Hospital, Muscat

    Introduction: Pain is under-treated in all parts of the world. Moderate to severe pain is experienced by the majority of patients with advanced disease. The aim of this study is to evaluate the prevalence, pattern and pain management in Oman.

Methods:  A prospective study was carried out during a 3 months period. We evaluated all admitted patients and only patients who were complaining of pain were eligible. Assessment of pain intensity and pain relief were done using measuring scales. All patients received pharmacological treatment according to WHO analgesic ladder. 

Results: A total of 335 admissions were recorded during the study period of which 100 patients (30%) were eligible for the study, 52% of cases were males. The mean age was 45 years ± 16.2 years and the most common tumors were GIT and breast cancer. Sixty four patients had pain but did not complain about it. Forty-five patients (45%) had moderate pain but they did not routinely complain about it. The mean hospital stay was 3.5 days and the range 1- 10 days. 

Conclusions: Most cancer patients deny pain for various reasons. Thorough history and repeated pain assessment are very important. Following the WHO analgesic ladder is simple and effective.
    full article
29-33   Comparison of whole body scintigraphy with Tc-99m-methoxyisobutylisonitrile and iodine-131 NA in patients with differentiated thyroid cancer
    K. Al Saleh1, R. Safwat1, I. Al-Shammeri2., M. Abdul Naseer1, H. Hooda1, S. Al-Mohannadi2
Departments of 1Radiation Oncology, 2Nuclear Medicine, Kuwait Cancer Control Centre, Ministry of Public Health, Kuwait
    In this study we compared whole body scintigraphy with Tc-99m-methoxyisobutyli-sonitrile (MIBI) and Iodine-131 NA (131I) for detection of residual and/or metastatic disease in well differentiated thyroid carcinoma.

Methods:  MIBI and I-131 scans were obtained in 60 patients. TSH measurements were done in all the patients prior to scintigraphy.

Results: Out of 60 patients, for whom both I-131 and MIBI scans were done, I-131 scans were positive in 59 (98.3%) patients, whereas MIBI scans were positive in only 17 (27%) patients. There was only one patient in which I-131 scan was negative and MIBI scan was positive.

Conclusion: I-131 scintigraphy still remains the best way to successfully detect residual/metastatic disease in differentiated thyroid carcinoma.
    full article
35-41   Single versus conventional fractionated radiotherapy in the palliation of painful bone metastases

W. E. Hamouda1; W Roshdy2 and M. Teema2
Departments of 1Radiation-Oncology and 2Anaesthesia, Faculty of Medicine, Zagazig University

    Aim: To compare a single 8 Gy fraction with conventional regimen of 40 Gy in 20 fractions as a palliative treatment to patients with bone metastasis and reducing the treatment burden for both the patients and Hospital Staff.

Methods: One hundred and seven patients with painful localized bone metastases requiring palliative radiotherapy were entered into a prospective randomized trial comparing 8 Gy single fraction (SF group) with 40 Gy in 20 fractions, five fractions/week (CF group). The primary tumor was in the breast in (48.1%) of the patients, in the lung in (20.6%) in the prostate in (17.6%), and in other sites in (13.7%). Bone metastases were located in the spine (42.2%), pelvis (29.4%) limbs (21.6%), and other sites (6.8%). Pain relief was measured by visual analogue scale (VAS) and also by analgesic requirement. Evaluation was performed before and at 2 weeks then every 4 weeks for 24 weeks after treatment. A total of 102 patients were evaluable for response; 50 in the SF group and 52 in the CF group.

Results:  There were no significant differences in the frequency or duration of pain relief between the two study groups. In both groups, the maximum benefit was achieved at 8 weeks after treatment; 41 patients (82%) in SF group and (44%) of those in the CF group. The frequency of pain by ≥50% on VAS. Complete pain relief was reported in (44%) of those in the CF group. The frequency of pain relief did not differ between the two groups with respect to the primary tumor, the metastatic sites, and the performance status, but for patients as a whole, there was a significantly lower response rate for lung cancer patients (61.9%) in comparison to patients with breast (91.8%) and prostate (100%) cancer. The median duration of pain relief was 12 weeks in the SF group and 13.5 weeks in CF group. During follow-up, 7 patients (6 in SF group and one in CF group) had their bone metastases re-irradiated. Six of these re-irradiated patients also achieved pain relief.

Conclusion: This study indicates that a single fraction of 8 Gy is as effective as 40 Gy in 20 fractions for the palliation of painful bone metastases. Single fraction schedule may be preferred for patient convenience and an option for re-treatment in the case of recurrent pain.
    full article
43-49   Patterns of failure in cervical carcinoma and outcome of salvage therapy: a retrospective study

S. Vasishta, A. Varghese, A. Ragheb
Department Of Radiation Oncology, Kuwait Cancer Control Centre, Kuwait

    Objective:  The objective of this study was to study the patterns of failure after definitive therapy in cervical cancer, the treatment given to patients after recurrence and the final outcome in these patients.  Materials and

Methods: Case records of 105 patients of cervical cancer of clinical Stages I to IV treated with definitive radiation or surgery with or without post-operative radiotherapy at Kuwait Cancer Control Centre (KCCC), Kuwait from 1995 to 1999 were retrospectively analyzed. Patients who developed recurrence were studied for the pattern of their recurrences, the type of treatment received by them after their recurrence and the results of their salvage therapy.

Results: The sites of failure were classified as pelvic only (P), pelvic+ distant metastasis (P+DM), or distant metastasis only (DM). Out of the thirty patients in stage Ib, the sites of first failure were, P = 5 (16.6%), P+DM = 1 ( 3.2%), DM = 1 ( 3.2%); of the fourteen patients in stage IIa , P = 2 (14%), P+DM = 1 ( 7%), DM = 2 (14%); of the 36 patients in stage IIb, P = 3 (8%), P+DM = 6 (16.5%), DM = 5 (14%); of the 14 patients in stage IIIb, P = 5 ( 35.5%), P+DM = 1 (7%), DM =0 (0%); of the 5 patients in stage IVa, 3 patients absconded after treatment and the failure rate was, P =0 ( 0%), P+DM = 0 ( 0%), DM = 1 (50%). The therapy after failure was surgery, irradiation, chemotherapy or supportive care. The median survival was evaluated as a function of time to failure after initial treatment and was 6, 6, 9, and 30 months for those failing less than 6, 6-12, 13-24 & 25-36 months after initial treatment respectively. The cohort treated initially with surgery had a better outcome of salvage therapy at relapse.

Conclusions: Long term survival can be achieved in a small percentage of selected patients who fail treatment with definitive radiation or surgery for invasive carcinoma of the uterine cervix. The probability of survival is greater for those who fail more than 24 months after initial treatment than for those who fail before 24 months. The chance of survival is also related to the initial type of treatment, site of recurrence & type of salvage therapy. The complications of salvage treatment of recurrent disease should be minimized.
    full article
51-57   Metastasis to the thyroid gland: unusual site of metastasis
    A. Saber1, S. Ramzy2, I. Gouda3
1 Department of Clinical Oncology, Minia Medical School, Egypt
2 Department of Surgery, National Cancer Institute, Egypt
3 Department of Pathology , National Cancer Institute, Egypt
    The incidence of metastasis to the thyroid gland in autopsy series varies from 1.25 % to 24%. Metastasis to the thyroid gland is usually considered as a terminal event, and the effectiveness of conventional treatment has been questioned.

Methods: Seven patients with metastasis to the thyroid gland were studied retrospectively. Primary tumor origin was identified in all of them. Metastasis to the thyroid gland was confirmed by fine needle aspiration cytology or histology. Data were analyzed for the type of malignant lesions, the clinical course of the disease, and the prognosis after thyroid involvement.

Results: Two patients had lung as a primary tumor site. Breast, iris, kidney, parotid and soft tissue sarcoma were the involved primary sites in the other cases. The time from the diagnosis of primary tumor to metastasis to the thyroid gland was considerable (ranged from 13- 135 months, median 60 months). Fine needle aspiration cytology detected metastasis in five of seven patients. Treatment was surgery alone or surgery with adjuvant therapy. One patient didn’t receive any treatment.

Conclusions: In any patient with a previous history of malignancy, no matter how old that history is, a new thyroid mass should be considered as recurrence until proved otherwise. Although detection of metastasis to the thyroid gland often indicates poor prognosis, aggressive surgical and medical therapy may be effective in a small percentage of patients.
    full article
59-70   Combined modality management approaches in primary gastric lymphoma

I. Al-Sheneber, H. R. Shibata
Surgical Departments, K.S.A. Saudi Cancer Foundation

    Background: Gastric lymphoma is a common presentation of non-Hodgkin’s lymphoma. Controversy about many aspects of its classification and management, especially regarding the role for surgical resection.

Methods: The authors reviewed the clinical features, staging, pathology, prognosis, and management issues with an emphasis on the role of surgical resection.

Results: Staging usually can be completed using noninvasive techniques. Those with a low-grade B-cell MALT type lymphoma with Helicobacter pylori infection may be treated with antibiotics and close follow-up. Patients with stage I or II disease may be treated with chemotherapy and radiation. Surgery is indicated for those with perforation or uncontrolled bleeding.

Conclusions: Gastric lymphoma, primarily a B-cell tumor, can be diagnosed and managed effectively with various approaches. Few prospective, randomized trials of alternative approaches have been performed.
    full article
71-76   Secondary hypertrophic osteoarthropathy: new insights on pathogenesis and management
    I. Nahar1, M. Al-Shemmeri2 and M. Hussain3
Department of Medicine, 1Mubarak Al-Kabir, 2Farwania Hospital, 3Amiri Hospital, Kuwait
    Hypertrophic osteoarthropathy is a syndrome that includes finger clubbing, periostitis with new subperiosteal bone formation of long bones and arthritis. It is often related to an intrathoracic neoplasms or chronic infections; hence called hypertrophic pulmonary osteoarthropathy. A primary or idiopathic form, also known as Pachydermoperiostosis, also exist. It is commonly seen in children and young adults and has not been found associated with underlying disease. Platelet derived growth factors has been recently recognized to have a key role in the pathogenesis of this disorder. Hypertrophic osteoarthropathy may cause disabling symptoms. Cure of neoplasia may result in regression of the hypertrophic osteoarthropathy.
    full article
77-92   Intra arterial hepatic chemotherapy for unresectable colorectal metastases: A review
    Y. Abdulaal, P. Ross, N. Heaton
The Liver Transplant Unit, Institute of Liver Studies, King’s College Hospital, Saudi Arabia
    Background: Hepatic arterial infusion (HAI) chemotherapy is based on the idea that liver metastases are perfused almost exclusively by the hepatic artery. This approach has been extensively investigated in 1970s and 1980s. Currently, there is a worldwide growing interest in intra-arterial therapeutic approaches for hepatic metastases. The principal aim of this review was to define current role of HAI in the management of metastatic colorectal cancer.

Methods: Data for this review were identified by searches of MEDLINE using the search terms “hepatic arterial infusion”, “colorectal cancer” and “chemotherapy”. Abstracts and reports from meetings were included only when they related directly to previously published work. Only papers published in English between 1966 and 2005 were included.

Results and Conclusion: There are 10 published randomized clinical trials comparing fluoropyrimidine-based HAI with systemic route. Two meta-analyses of the earlier 7 trials confirmed a statistically significant response rate and improved disease-free survival with HAI. However, the cost and complication rates were of primary concern. The last decade witnessed the introduction of new chemotherapeutic regimens including biologically targeted agents for the management of metastatic colorectal cancer patients and advancement in radiological and surgical techniques. These led to reconsideration of HAI-based therapeutic modalities with many running trials addressing its value in this new era. The results of these trials may help to clarify the role of HAI in the near future.
    full article
93-98   Incidental finding of a large chest wall osteosarcoma--a case report
    K. Moghazy, Y. Al-Jehani, A. El-Baz2, Y. El- Ghoneimy1
Department of 1Radiology and 2Surgery. King Faisal University, Dammam, Saudi Arabia
    Primary chest wall tumors are rare and primary osteosarcoma of the chest wall is considered as an even rare among the primary chest wall malignant tumors. The main presentation is rapidly expanding painful mass with elevation of alkaline phosphatase. We present a case of a 34 years old male who was found to have an incidental asymptomatic large chest wall mass with normal alkaline phosphatase level. He underwent several radiological diagnostic modalities which showed the extent and delineation of the mass. Complete excision of the mass was achieved and the chest wall defect was reconstructed with Prolene mesh. The histopathology confirmed the diagnosis of osteosarcoma of the chest wall.
    full article