Issue No. 4 - July 2008

The majority of patients with head and neck cancers (HNC) usually present at diagnosis with locally advanced (stages III or IV) disease. In an effort to improve on the outcome of these patients, chemotherapy (CT) has been integrated as part of the local treatment(s) of surgery and/or defintive radiotherapy (RT). Induction CT was introduced in the middle 1970s because of the poor results obtained with the current treatments in patients with locally advanced HNC. Induction CT is the use of systemic CT before definitive surgery and/or RT. This was coincided at that time with the introduction of cisplatin as an active agent in patients with recurrent/ metastatic HNC. Only patients with unresectable/ inoperable cancers were included in these early trials (1-6). The first trial used only single agent cisplatin. Later most of the phase II studies gave cisplatin and bleomycin with or without a vinca alkaloid of vinblastine or vincristine (1- 4). Without the benefit of randomized trials, it was felt at that time that cisplatin combinations are more effective than single agent cispaltin in patients with locally advanced and previously untreated HNC. All these trials were phase II carried out by single institutions, and CT was given for up to two courses of treatment. In the late 1970s, the National Cancer Institute (NCI) activated the first phase III trial (7). In this trial, patients with resectable locally advanced HNC were randomized to one of three arms: Arm 1 of “standard” treatment of surgery and postoperative RT; arm 2 of one course of induction cisplatin and bleomycin followed by surgery and post-operative RT; and arm 3 of one course of the same induction CT and local treatments and followed by up to six courses of single cisplatin infusion as an adjuvant therapy. As expected from the design of this trial the overall results were negative. Patients on the third arm with additional adjuvant single cisplatin may have border line improved survival.

In 1980, Al-Sarraf (8,9) introduced the combination of two cycles of cisplatin (P) 100mg/ m2 day one followed by 5FU (F) 4,000mg/m2 as 96 hour continuous infusion as induction CT in same group of patients with much promising results, and definitely much less and different side effects. Subsequently, the same group concluded that PF regimen with 5FU infusion for 120 hour, and three courses is the most adequate induction CT. This highly effective regimen gained wide acceptance by most institutions, despite the lack of prospective phase III randomized trial(s) to compare with other cisplatin and bleomycin with or without other agent combinations. Furthermore, PF for three courses was investigated in other settings such as laryngeal preservation, post operative therapy, and as adjuvant treatment. Also, PF was investigated in phase III trials concurrent with single or hyperfractionated RT Vs. the “standard” treatment of total RT alone in patients with unresectable/inoperable HNC. In the late 1990s and early 2000s with the introduction of active Taxane agents (Paclitaxel & Docitaxel), the three drugs combination of Taxane, Platinol, and 5FU (TPF) was studied in phase II trials [Tables 1 and 2]. This combination was also supported by the pre-clinical evidence that demonstrated synergy when taxanes are added to either platinum and or 5FU. Later, the three drugs combination of TPF was compared to PF in at least four phases III randomized studies.

Treatment of acute myeloid leukemia (AML) in the elderly has always been a challenging task. Acute myeloid leukemia in older adults is a biologically and clinically distinct entity. Based on analysis of cytogenetic and molecular data, it is known that leukemic cells in older patients are intrinsically resistant to standard chemotherapy. Due to comorbid disease and impaired bone marrow stem cell reserve, older adults tolerate myelosuppressive chemotherapy poorly, with a treatment-related mortality rate of 25%. In spite of various available targeted therapies, the overall survival has not improved dramatically in the past decade. The ideal post remission regimen in this population has always been a matter of debate. Standard allogeneic bone marrow transplantation is too dangerous to be considered as a mean to eradicate minimal residual disease after remission is obtained and myelointensive chemotherapy is not a beneficial post-remission strategy in this age cohort. These disappointing results call for more effective and less toxic therapeutic options. The advent of non-myeloablative regimens has shown some prospects in select group of patients with good performance status. This review focuses on current therapeutic options available in this group of patients.

The fluorescence properties of biological tissues have been considered as intrinsic parameters to discriminate diseased from normal conditions. In vivo fluorescence diagnosis of cancer is based on special fluorescent dyes and their properties of tumour selective retention. The experimental in vivo model of the chorioallantoic membrane (CAM) of chicken embryos was used for cultivating a murine tumourous system consisting of the SSK II fibrosarcoma. Proto porphyrine (PpIX) synthesis in CAM inoculated tissues as well as in native CAM was induced by 5-ALA. The modulation effects of several biochemicals on the 5-ALA induced PpIX production were tested. The fibrosarcoma cells have not revealed autofluorescence with distinctively higher signal intensities than the substrate tissue. Fibrosarcoma cells are clearly distinguished by higher xenofluorescence intensities compared to the CAM tissue in the background. 5-ALA induced xenofluorescence intensity in fibrosarcoma was significantly enhanced by glucose and inhibited by ethanol. It can be concluded that some chemical agents can modulate the intensity of 5-ALA induced xenofluorescence through their modulation the enzymatic cell activity and these can be used for improvement by varying both the diagnostic and the therapeutic effectiveness of the photosensitizers in its application in the photo therapy process.

Background
Abnormal cytology report ( C3 – C5 ) is routinely used as part of the triple assessment in diagnosis of malignant breast lesions. Its value has been questioned in recent years in view of an equivocal ( C3, C4 ) results when compared with core biopsy. The aim of this study was to find the significance of abnormal report of cytology alone and in combination with clinical and image findings; and how accurately it helps in clinical decision making.

Material and methods
We analysed 255 consecutive cases of abnormal cytology which had follow-up histopathology in our hospital from June 2002 to May 2007. The positive predictive value (PPV) was calculated alone and in combination with clinical and image findings. The PPV was also done in subsets according to patient age ( < and ≥ 50 years ). In addition, sensitivity, specificity, predictive values, and likelihood ratios ( LRs ) were determined for each broad category of triple test. Results The PPV of C3, C4, C5 report alone was 20%, 87.2%, and 100% respectively. C5 report is unequivocal proof of malignancy irrespective of age, clinical, and radiologic findings. Higher levels of PPV can be attained when C4 cytology is combined with suspicious clinical and radiological findings ( 93.8% ). Patients with ≥ 50 years age with C4 cytology proved mostly malignant on histology ( 18/19 ) suggesting that an intra-operative frozen section may be more relevant in older age patients with C4 report since an additional core biopsy in these patients may still be inconclusive. C3 is the least useful and even when combined with suspicious clinical and radiological findings its PPV reached 54.6%, thus prompting a preoperative biopsy.

Conclusion
Our study indicates that FNAC is still a valid and useful test in diagnosis of breast lesions and is critical to the surgeons in decision making. Moreover it gives outstanding results when combined with clinical and radiological findings in diagnosis and management of breast cancer.

Objective
The purpose of this study was to evaluate the role of US guided hand held vacuum-assisted breast core biopsy (VACB) in the surgical management of breast nodules.

Materials And Methods
Twenty five breast nodules in twenty five women were subjected to US guided 11-gauge vacuum-assisted breast core biopsy over a period 22 months. Biopsies were performed using handheld 11-g VACB needle under US guidance using high-resolution US equipment with a 7.5–10 MHz linear transducer. A median of 12 specimens were obtained per lesion with insertion of a clip marker in place. Pre and post procedure imaging findings, complications, histologic outcome, and medical records were reviewed.

Results
The patient median age was 50.16 years (range, 36- 72 years). Lesion median size was 1.7 cm (range 0.8-3.0 cm). Lesions were categorized using BI-RAD system as follow: 12 (48%) category 3, 11 (44%) category 4 and 2 (8%) as category 5. Six out of 25 (24%) lesions were palpable. The median time required to perform the biopsy was 25 min (range, 20-40 min). Complete removal of the lesion seen at sonography was achieved in 22/25 lesions (88%) and was significantly more frequent in lesions measuring < 1.5 cm than in larger lesions. Accuracy was 100 %. No repeat was asked. Surgical biopsy was spared in 24/25 (96%) patients. One case was referred for surgical excision upon pathologist advice.

Conclusion
In our small series, US guided vacuumassisted beast core biopsy was a fast, less invasive, accurate method in diagnosing breast nodules. It is a cost effective procedure, accepted by the patient and led to sparing surgical procedure in 96 % of women. VACB has become an integral part in the management of breast nodules and further work.

Aim of the Work
To asses the profile, pattern of failure and survival for patients with uterine sarcoma seen in KCCC.

Material and Methods
A total of 23 records for patients with uterine sarcoma attending KCCC between July 1993 to May 2007 were available for review. The medical records were assessed for the profile of the disease, histological types, types of treatment, pattern of failure and survival. All cases were proven histologically. The majority of cases 15/23 (65.2%) were endometrial stromal sarcoma, 4/23 (17.4%) had leiomyosarcoma and 4/23 (17.4%) had carcinosarcoma. Twenty two out of 23 patients (95.6%) had surgery and 8/22 (36.4%) were given adjuvant post-operative pelvic radiotherapy. Three patients were treated with palliative intent by radiation. Five patients received palliative chemotherapy.

Results
The mean age of all patients was 53.17±11.06 (range 34-80 years). The majority of patients 15/23 (65.2%) had stage I disease. High tumor grade was seen in 12/23 (52.2%) of patients. The pattern of failure was local in only 2 patients, systemic in 4 patients and both local and systemic in 5 patients. The overall DFS- 5 years was 59.6%.The 5 y-DFS for patients treated by surgery & RT was 87.5% compared to 36.4% for those treated by surgery alone. Patients with early disease (stage I) had a 5 year DFS of 74% compared to 33.3% for those with advanced disease (stages III&IV). Patients with high grade tumors had a 5 year- DFS of 27% versus 100% for those with low grade tumors.

Conclusion
Stage and grade are important predictors of survival. Post-operative adjuvant pelvic irradiation is associated with improved 5-years DFS.

Breast cancer is the most common cancer among women and the second leading cause of death in women after lung cancer. The principle aim is to study the utility of Tc- MIBI scintimammography in evaluation of breast cancer and lymph node metastases.

Materials and Methods
A total of 36 patients both with breast lumps or/and axillary masses suspected breast cancer on clinical examination and/or at conventional imaging procedures (CIP’s) were included in this study. The mean age was 47.13 years, median age 47 and age range 22-77 years. All patients received a 740-1000 MBq bolus IV injection of 99mTc-MIBI preferably in a pedal vein. At 5-10 min post injection planar images were obtained in prone lateral and supine anterior position using dual head gamma camera. MIBI uptake was scored as follows: 1 for normal uptake (compared with contralateral side), 2 for focal low intense uptake (equivocal), 3 for focal high intense uptake (positive). All patients had histopathology for tissue diagnosis.

Results
There were 36 patients who presented with breast lesions (30 palpable, 6 non-palpable) and 8 patients with axillary lump. Scan was found true positive in 24 patients and was true negative in 7 patients with breast lesion. In case of axillary lump, it was true positive in 4 and true negative in 2 patients. Planar scintimammography showed sensitivity of 86%, specificity 88%, PPV 96%, NPV 64% and accuracy of 86% (p< 0.01). However sensitivity, specificity, PPV, NPV and accuracy for axially metastasis were 86%, 67%, 80%, 67% and 75% respectively. (P-value <0.01).

Conclusion
It is concluded from the study that SMM has good diagnostic accuracy in the detection of breast cancer specially in palpable lesion and lymph node metastases.

Osteosarcoma of the talus is extremely rare and only few cases have been reported in the literature. We present a case of a 33 years old male who presented with painful swelling of his left ankle joint. He underwent several radiological diagnostic modalities which showed osteolytic lesion in the posterior aspect of the left talus associated with new bone formation projecting from the posterior-medial aspect of that bone. His chest X-Ray showed multiple rounded lung metastases some of them showed calcifications. Open biopsy was performed. The histopathology confirmed the diagnosis of osteoblastic osteosarcoma of the talus.

Proliferating trichilemmal tumor (PTT) is an uncommon, usually benign lesion that usually arises on the scalp of elderly women. The lesion bears close morphologic resemblance to squamous cell carcinoma at the microscopic level, making a correct histologic diagnosis extremely important. We present a case of PTT occurring on the chest wall of a 75-years-old man to highlight the significance of recognizing this unusual tumor at an uncommon location and discuss points of differentiation from squamous cell carcinoma.

We report here a case of primary colorectal T-cell lymphoma of the cecum in a 30-yearold man. Patient presented with a history of abdominal pain, fever, vomiting and hematochezia. Clinical examination was unremarkable and colonoscopy showed an ulcerating mass in the colon. A right hemicolectomy with dissection of the paracolic lymph nodes was performed. The final histopathological examination showed a primary T-cell lymphoma of the cecum. Staging didn’t show any involvement in any other sites of the body. Primary colon lymphoma is a rare gastrointestinal tumor that represents less than 1% of the gastrointestinal lymphomas. Peripheral T-cell lymphoma represents a relatively small proportion of lymphomas and has a lower prevalence in Western countries. The risk factors, clinical presentation, staging, prognostic factors and treatment modalities of extra-nodal lymphoma are discussed.