Issue No. 5 - Jan 2009

The diagnosis of presence, location and load of metastatic, bone involvement has important implication on patient management and prognosis. This requires collection of data obtained using different imaging modalities. Bone scintigraphy is a highly sensitive and cost-effective screening modality. However, to overcome its lower specificity and its limitation in evaluation of vertebral metastases, CT, PET or MRI can be utilized to verify the nature of suspicious lesions. Expansion of SPECT/CT may fine tune the highly sensitive bone scintigraphy. PET has an emerging and leading role in many tumors, occasionally obviating the need for bone scintigraphy, particularly in evaluation of response to therapy. PET and whole body MRI offers a potentially important tool to provide the earliest clue of bone marrow metastasis. The value of F-18 PET as a sensitive bone imaging tool needs to be further evaluated on a larger scale in different setting including treated and untreated cancer patients and to evaluate also whether potentially better resolution would lead to more benign lesions detection mimicking metastasis such as fractures, inflammatory, infection, and degenerative involvement of bone. The added value of PET-CT is also to be further examined with this regard.

Background
Epidemiological studies in different parts of the world have revealed controversial results on the association between HCV infection and Non-Hodgkin’s lymphomas. This discrepancy suggests that HCV lymphotropism and its effect on host lymphocytes may be influenced by regional and racial factors as well as by viral genomic variations.

Objectives
To determine the prevalence of HCV infection in Yemeni patients with NHLs diagnosed and treated in our hospital and to evaluate the association between the two diseases.

Methods
All consecutive patients with NHL treated in our Haematology/Oncology Unit between January 2005 and January 2007 were screened for anti- HCV antibodies by enzyme immunoassay. The prevalence of HCV infection in patients with NHLs was compared to that in a non-lymphomatous control group consisted of all patients checked for HCV infection with several acute medical conditions in the same hospital who were coming from different parts of the country.

Results
A total of 192 patients with NHLs were tested for anti-HCV antibodies. One hundred seventeen patients (60.94%) were males and 75 patients (39 .06%) were females. The mean age of the patients was 41.30±19.15 SD and range between 5-80 years. Twenty-nine (15.1%) of the 192 patients were found positive for HCV infection. Twenty-one (17.6%) of 29 positive patients were male and only 8 (10.7%) patients were female. The mostly involved age group was 41-60 representing 24.6%. A total of 20329 patients from different departments were investigated for anti-HCV antibodies and used as a control. Of the 12274 control (60.4%) were males and 8055 (39 .6%) were females. A total of 814 (4%) controls were found positive for HCV antibodies.

Of the positive controls, 529 (4.3%) were males and 285 (3.5%) were females. The association between HCV infection and NHLs was assessed using logistic regression models. There was a significant association of HCV with NHLs, the unadjusted OR [4.27, 95% CI 2.86-6.37] which differ slightly by gender in males the OR [4.86, 95% CI 3.01 - 7.85] and in female the OR [3.26, 95%CI 1.55- 6.84].

For separate NHL subtypes, the numbers of HCV infected cases were limited. Nonetheless, positive associations were noted for indolent type [OR=4.49, 95% CI 1.87-10.78] and for aggressive type as well [OR=4.2195% CI 2.69-6.59].The prevalence of HCV antibodies in cases and controls was more frequent in males and in the age group above 40 years.

Conclusion
In conclusion the results of the present study indicate a higher prevalence of HCV infection among Yemeni patients with NHL than among persons in the control group. Therefore our study demonstrates an association between HCV infection and NHLs. HCV infection may play a role in causing NHLs.

Background
Cisplatin remains a principal chemotherapy agent in the treatment of many solid tumours. However because of its nephrotoxicity, in-patient hydration schedules have been utilized to ensure safe administration.

In May 1995, due to significant load on in-patient bed availability, the Medical Oncology Department of the Cancer Therapy Centre, Liverpool Hospital, developed a short, intravenous fluid hydration protocol to be used on an out-patient setting.

Methods
Following an initial pilot program of the abbreviated hydration regimen, a retrospective study of all adult in-patients and out-patients who received cisplatin (60-100mg/m²) from May 199 5 to August 199 8 was conducted. Biochemistry was performed prior to the start of chemotherapy, and a repeat serum creatinine level was taken immediately prior to each subsequent cycle of chemotherapy, unless clinically indicated at an earlier time. The in-patient hydration protocol was 6000ml of normal saline with 60 mmol/L KCL, and 30 mmol/L MgSO4 over 24 to 28 hours, and the out-patient hydration was 4000ml of normal saline over 6 hours.

Results
A total of 145 patients were included, 57 in-patient (39 %) and 88 out-patients (61%), 95 males, and 50 females. The mean age was 56 years. The maximum mean percentage change in creatinine from baseline for all cycles of chemotherapy for in-patients was 32.5% ranging from –7% to 288% (95% CI=19.9-45.11), and for outpatients 19.9% ranging from –20% to 154% (95% CI=13.47-26.39 ). Although the mean increase was higher in the in-patient group by 12.6%, it was not statistically significant (p=0.079).

Conclusion
In patient’s eligible for cis-platinum therapy on the basis of good performance status and normal renal function, this agent can be safely administered in the out-patient setting with an abbreviated duration, moderate volume intravenous hydration regimen.

The aim of the study was to assess the appropriateness of pain management in cancer patients by determining the modalities of pain treatment currently provided to cancer patients, comparing this treatment to existing guideline on control of pain in patients with cancer and identifying areas of inappropriate prescribing.

A prospective observational study was carried out in the oncology unit at tertiary-care teaching hospital in Riyadh, Saudi Arabia over a period from May-October 2006 included all adult cancer patients.

Of 160 patients participated in the study, 80 (50%) reported moderate or severe pain. 40% of those with pain were not given any pain medication. Sixty percent of the patients had appropriate pain management. Pain documentation was inappropriate and needs improvement in 57% of the patients. There was under utilization of NSAIDs which were prescribed in 8 (5%) patients only from those on pain medication. Transdermal fentanyl was the most frequently used opioid (21%) for moderate to severe pain.

Therefore, despite published guidelines for pain management, many patients with cancer receive inadequate analgesia.

Intensity modulated radiotherapy (IMRT) is an advanced form of 3D conformal radiotherapy combining several intensity modulated beams to deliver the prescribed dose to the target with precision, sparing the adjacent normal tissue structures. The complex nature of IMRT delivery needs a precise patient specific quality assurance (QA), proper verification of dosimetry and treatment. QA procedures are important measures to ensure that the treatment can be delivered according to the treatment plan. In this report, we are presenting a formulation of a proposed protocol and results of patient specific QA carried on two IMRT plans. The QA consists of an absolute dosimetry, film dosimetry and dynalog files verification of treatment plans. The absolute doses, planar and fluence doses calculated by the TPS are compared with the measured values. The dynalog files recorded during the treatment delivery of two plans were analysed. The measured error in absolute dose is <3% in both the plans. An average of >98% of counts are having <0.1cm errors in dMLC positions. The average RMS value of leaf motions is <0.05cm in both the cases. The errors in film dosimetry are <3%. All the results obtained are comparable to the standard values and well within the acceptable limits. The paper outlines the minimum procedures required for the patient specific QA measurements for the clinical implementation of IMRT. The measurements help to understand and confirm the accuracy of IMRT delivery system.

A soft tissue recurrence associated with pulmonary metastases developed in a 46 year old lady one year after intra-lesional excision and autogenous bone graft of giant cell tumor of bone of the distal end of the right radius. The different imaging modalities and procedures used for staging as well as the management were discussed. Brief review of relevant literatures addressed different factors that influence recurrence, treatment options of primary and recurrent GCT of distal radius, and metaplastic bone formation in such lesions.

Several pathologies have been reported to cause scintigraphic patterns similar to multiple bony metastases. Heterotopic bone formation is known to mimic several inflammatory and neoplastic conditions including recurrent tumors. However, no reports on multi-focal heterotopic bone formation simulating the typical pattern of randomly distributed foci of increased uptake of metastases on bone scan were found in literature. We present a case of a young adult who was repeatedly assaulted by others over a period of one month and on bone scan had a pattern similar to bony metastasis due to multiple foci of heterotopic bone formation and fractures.

Acute myeloid leukemia associated with translocation t(8;21) and the underlying AML1-ETO gene fusion is considered as a distinct type of leukemia with characteristic morphologic features. Variant and masked forms of the classic translocation t(8;21) are uncommon and their clinicopathologic features are less well characterized. We report here a patient with a masked translocation involving chromosomes 6,8 and 21. Chromosomal study at diagnosis initially reported the karyotype as translocation between chromosomes 6 and 8 without visible involvement of chromosome 21. However, fluorescence in situ hybridization studies revealed the involvement of chromosome 21 in the translocation and presence of the AML1-ETO chimeric gene. The complex rearrangement t(6;8;21) observed in our patient was not previously described and could be not detected without combination of techniques. Our case illustrates the challenge of recognizing complex aberrations that occur with variant t(8;21) and further reinforces the utility of fluorescence in situ hybridization applications in more accurate characterization of chromosome abnormalities which can lead to more precise therapeutic stratification.

We report an unusual case of abscess of the abdominal wall as the initial symptom of a perforated right–sided colon cancer in a 62-year old man.

Clinical examination revealed a non-fluctuating, tender, firm mass approximately 7× 5 cm in diameter with overlying cellulitis in the right loin. Abdominal examination showed a fixed mass on the right side of the abdomen. Computed tomography (CT scan) confirmed the presence of a mass arising from the right colon with infiltration of the subcutaneous tissue by this intra-abdominal mass.

Right hemicolectomy with lymph node dissection and en-bloc partial resection of the adherent parietal wall was performed and the final pathology showed a moderately differentiated mucinous adenocarcinoma.
We report a case of ascending colon cancer presenting by an abscess of the abdominal wall.

Primary benign tumours of the heart are rare, with myxomas being the commonest. They are neoplasms of endocardial origin and generally appear to grow rapidly. The presence of connective tissue fibers encrusted with iron and calcium known as Gamna Gandy bodies may indicate a longer duration of tumor.

We present a case of cardiac myxoma with Gamna Gandy bodies, which is an infrequent finding, and briefly review relevant literature.