Issue No. 8 - July 2010

A. Elbasmi¹, A. Al-Asfour¹, Y. Al-Nesf² , A. Al-Awadi^1
1Kuwait Cancer Control Center, Ministry of Health, State of Kuwait, ²Ministry of Health, State of Kuwait

Cancer registry data obtained from the Kuwait Cancer Registry at Kuwait Cancer Control Center (KCCC) of Ministry of Health, State of Kuwait. The data covers the years 1974 to 2007. Aim of this study: was to estimate the magnitude of the cancer problem in Kuwait over the period 1974-2007. Materials and methods: Age-adjusted incidence rates (ASR) with standard error (er) and 95% confidence intervals (95% CI) of age-standardized rates were estimated. Statistical significance was assessed by examining the standardized rate ratio (SRR). Results: It was noted that by following the Cancer registry data there was a trend of increase in adjusted rates among both males and females. Looking into specific cancers it was noticed that comparing the ASR of colorectal cancer among Kuwaiti males, it increased by about 5 folds over the last 33 years and ranked the 1st most frequent site on the years 2003-2007. Prostate cancer incidence increased by 3 folds (14.5 cases /100,000 populations) and ranked the 4th most frequent site among Kuwaiti males. The incidence of Non Hodgkin’s Lymphoma (NHL) and leukemia had increased by 1.5 to 2 folds over the same time period. The rise of lung cancer incidence declined to similar rates compared to that observed in the early 70s and 80s. For Kuwaiti females breast cancer had the highest incidence among Kuwaiti population (15 cases /100,000 populations), it increased by 3 folds (50 cases /100,000 populations) over the last 33 years. The incidence of colorectal cancer increased by about 4 folds; (13 cases /100,000 populations). NHL and leukemia increased by 2-2.5 folds over the same studied duration. Meanwhile Thyroid cancer increased by one fold. Conclusion & Recommendations: Some of the differences in cancer rates over the last 33 years are likely to be attributable to the variation in exposure to specific etiologic factors that are caused by differences in lifestyle and habits, such as dietary, physical activity and obesity. Further research with a view to understanding these changes in cancer incidence is warranted. The need for an interventional prevention programs that vigorously involve, diet, anti-smoking and physical activity among both sexes.

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Early Infections in the Stem Cell Transplant Recipients at AIIMS, New Delhi: A prospective study

G.M. Bhat¹, L. Kumar², A. Sharma², V. Kuchupillai^2
1Dept. of Medical Oncology, SKIMS, Soura, Srinagar, India, ²Dept. of Medical Oncology IRCH, AIIMS, New Delhi, India

The pattern of infections in neutropenic patients including those undergoing stem cell transplant in the west has changed but the same may not be the case in the developing countries as brought out through some earlier observations in some transplant centers in India. The department of medical oncology IRCH, AIIMS has been providing bone marrow transplant facility for over a decade now. It is one of the few bone marrow transplant units in northern India. A prospective study conducted on 70 consecutive bone marrow transplant subjects at this center was carried out with this perspective in view. Objectives: To determine the frequency and pattern of infections in haemopoietic stem cell transplant (HSCT) recipients at this center in India. Keywords: Bone marrow transplant, stem cell transplant, neutropenic sepsis

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IMRT Implementation and Patient Specific Dose Verification with Film and Ion Chamber Array Detectors

S. Sathiyan, M. Ravikumar, C. Varatharaj, S.S. Supe, S.L. Keshava
Department of Radiation Physics, Kidwai Memorial Institute of Oncology, Bangalore, India

Implementation of Intensity Modulation Radiotherapy (IMRT) and patient dose verification was carried out with film and I’mariXX using linear accelerator with 120-leaf Millennium dynamic multileaf collimator (dMLC). The basic mechanical and electrical commissioning and quality assurance tests of linear accelerator were carried out. The leaf position accuracy and leaf position repeatability checks were performed for static MLC positions. Picket fence test and garden fence test were performed to check the stability of the dMLC and the reproducibility of the gap between leaves. The radiation checks were performed to verify the position accuracy of MLCs in the collimator system. The dMLC dosimetric checks like output stability, average leaf transmission and dosimetric leaf separation were also investigated. The variation of output with gravitation at different gantry angles was found to be within 0.9 %. The measured average leaf transmission for 6 MV was 1.6 % and 1.8% for 18 MV beam. The dosimetric leaf separation was found to be 2.2 mm and 2.3 mm for 6 MV and 18 MV beams. In order to check the consistency of the stability and the precision of the dMLC, it is necessary to carryout regular weekly and monthly checks. The dynalog files analysis for Garden fence, leaf gap width and step wedge test patterns carried out weekly were in good agreement. Pretreatment verification was performed for 50 patients with ion chamber and I’mariXX device. The variations of calculated absolute dose for all treatment fields with the ion chamber measurement were within the acceptable criterion. Treatment Planning System (TPS) calculated dose distribution pattern was comparable with the I’mariXX measured dose distribution pattern. Out of 50 patients for which the comparison was made, 36 patients were agreed with the gamma pixel match of >95% and 14 patients were with the gamma pixel match of 90-95% with the criteria
of 3% delta dose (DD) and 3 mm distance-to-agreement (DTA). Commissioning and quality assurance of dMLC for IMRT application requires considerable time and effort. Many dosimetric characteristics need to be assessed carefully failing which the delivered dose will be significantly different from the planned dose. In addition to the issues discussed above we feel that individual MU check is necessary before the treatment is delivered. Keywords: IMRT, dMLC, Quality Assurance, I’mariXX, DTA, Delta dose

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Quantitative Tumor Volume VS TNM Staging: The Impact on Prognosis in Head and Neck Cancer

R. Hadi¹, S. Kumar², M. Srivastava², M.C. Pant², P.K. Srivastava², N. Jamal^2
1Department of Radiation Oncology, IRCS Cancer Hospital, India; ²Department of Radiotherapy, Chhatrapati Shahuji Maharaj Medical University, India

Objectives: To evaluate the prognostic value of tumor volume (TV) by clinical method (CM) and Computerized Tomography (CT) scan in head and neck (H&N) cancer. Materials and Methods: Total 25 patients’ (pts) pretreatment tumor volume (PT TV) was assessed clinically by cuboid volume method. Afterwards contrast enhanced computerized tomography (CECT) images of the pts were transferred to workstation by DICOM software. The computerized tomography tumor volume (CT TV) was obtained on Radworks 6.0, using mouse control cursor. After assessment, the patients were given 3 cycles of neoadjuvant chemotherapy followed by radiotherapy by conventional method on Co-60 Theratron 780 C. After 1 month of treatment, TV was again measured. Statistical method: Statistical analysis was done on MSTAT statistical analysis software. Two-tailed student t test, chi square test and test for two proportions for significance had been used. Results: Large variations in tumor volume were found both in intra as well as inter T-stages. As the tumor size increases with T stages, the difference in measurement of TV by both methods decreases. CT TV results pre as well as post-treatment were more consistent than clinical method. Conclusion: The use of TV as a prognostic factor by CT scan seems to be more useful parameter than the CM. TV should be included in the TNM (tumor, node, and metastasis) classification after setting the strict guidelines for tumor delineation, to solve the discrepancy of treatment outcome in the same clinical stage. Keywords: Head and neck cancer, tumor volume, CT scan

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Angiomyofibroblastoma of the vulva: Report of a rare distinct entity

R. Arora, A.A. Abou-Bakr, M.S. Ahmad
Department of Pathology, Farwaniya Hospital, Kuwait

Angiomyofibroblastoma is a rare benign mesenchymal tumor of lower female genital tract. It has characteristic histomorphology and shows myofibroblastic differentiation. Clinically it is imperative to differentiate angiomyofibroblastoma from other mesenchymal tumors of this region especially aggressive angiomyxoma which is locally infiltrative and needs long term followup. We report clinical, histological, and immunohistochemical features of a case of angiomyofibroblastoma and discuss relevant points regarding histogenesis and biological behaviour. We stress the need to recognize this tumor on clinicopathologic basis to avoid any potential therapeutic implications. Keywords: Angiomyof ibroblastoma, vulva, mesenchymal tumor

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One Patient, Two lymphomas, Three primaries

A.W. Eshra¹, A. Al-Hendal¹, M. Al Enzi¹, M. Al-Mishaan¹, W. Abo Dief^2
1Department of Surgery, ²Department of Histopathology, Sabah Hospital, Kuwait

Concomitant adenocarcinoma and non-Hodgkin’s lymphoma, both located in the intestinal tract, are unusual. Collision tumors of the colon on the other hand are extremely rare neoplasms. A case of true collision tumor of a marginal zone lymphoma and a moderately differentiated adenocarcinoma of the ascending colon (hepatic flexure) is reported. Simultaneously, a third primary is identified as follicular lymphoma involving the terminal ileum. Correlation with clinical history, radiology investigations, endoscopic findings and histological examination of the resected specimen as well as the use of ancillary techniques such as immunohistochemistry are the most useful in making the correct diagnosis of a synchronous three primaries involving the small bowel and colon. Therefore, we present these three primary synchronous neoplasms involving two different parts of the gastrointestinal tract, with two of these three primaries colliding at one organ. Keywords: Lymphoma, adenocarcinoma, collision tumor, concomitant tumors, immunohistochemistry

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Upper gastrointestinal tract bleeding caused by a gastrointestinal stromal tumor of the stomach

A. Al-Hendal¹, A.J. Al-Sabbagh¹, M. Al-Mishaan¹, W. Abo Dief^2
1Department of Surgery, ²Department of Pathology Sabah Hospital, Ministry of Health, Kuwait

We report a case of upper gastrointestinal bleeding caused by a gastrointestinal stromal tumor in a 50-year old man. The patient was having melena for two months, and on admission he was hemodynamically stable. Upper G.I endoscopy showed diffuse gastritis and an extrinsic compressing mass in the upper part of the stomach. CT scan of the abdomen showed exophytic mass in the fundus of the stomach, with central necrosis. The patient was submitted to operative management. There were no features of dissemination but there was invasion of the hilum of the spleen. Wide local resection and splenectomy performed. Post operative course was complicated by a bleeding from the anastomotic site that required re-exploration and suturing of the bleeding vessel. Histologic examination revealed that it was composed of spindle-shaped cells with elongated nuclei. Post operatively the patient received adjuvant treatment with Imatinib [Gleevec]. The patient has an uneventful follow-up period so far. Keywords: Upper gastrointestinal bleeding, Gastrointestinal stromal tumors (GIST, Spindle cells, Imatinib mesylate

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Avascular Necrosis of Bone in Children with Leukemia: Experience of Pediatric Hematology Unit in Kuwait

M.J. Bourisly, Z. Al-Mazidi, H. Saleh, M. Bourhama, E. Al-Matter
NBK 1, Department of Pediatrics, Al-Sabah Hospital, Ministry of Health, State of Kuwait

Avascular necrosis of the bone (AVNB) is an uncommon serious complication of acute leukemia. Between the years 1997-2007, seven children with acute leukemia of different risk groups presented with symptoms, signs and investigational evidence of avascular necrosis of bone. They were all diagnosed during their maintenance chemotherapy except one patient who had AVNB post-transplant following hematological relapse. Six patients had avascular necrosis of the hip (AVNH), and one patient had avascular necrosis of the foot. Other complications for steroids, such as hyperglycemia were observed in some of the patients. The steroids were omitted in almost all patients immediately. Two patients had surgical intervention and the rest received conservative management. Two patients recovered fully and the rest are still under follow-up at orthopedic clinic pending further management. Key words: Avascular necrosis of the bone, avascular necrosis of the hip, leukemia, BMT, steroid therapy

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Fibrous Hamartoma of Infancy in an unusual location- A case report

L. Agrawal, R. Bansal, J. Singh, S. Sharma
Pathology Department, Giansagar Medical College and Hospital, Banur, Punjab, India

Fibrous hamartoma of infancy is an uncommon fibroproliferative lesion that occurs only in infancy and childhood. It predominantly affects healthy boys and can be found in almost any subcutaneous tissue. The tumor is most frequently found in the axilla, followed by shoulder, inguinal area, and chest wall. This tumor can cause much concern about malignancy because it is firm and may be fixed to underlying tissues. Despite the occasional local recurrence, the clinical course is benign and the prognosis is excellent. Treatment is by local excision. The diagnosis is made by the characteristic histologic features. In order to avoid the misdiagnosis of malignancy and unnecessary radical therapy, both surgeon and pathologist must be familiar with this entity. We report a case of fibrous hamartoma of infancy in a 4-year-old boy in gluteal region. Keywords: Fibrous hamartoma of infancy, myofibroblast, organoid

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Anaplastic Variant of Clear Cell Sarcoma of the Kidney - A rare Case Report

M. Kukreja¹, M. Kamal², V.K. Iyer¹, A.A.S.R. Mannan³, S. Agarwal^4
1Department of Pathology, AIIMS, New Delhi, INDIA; ²Government College Rohtak, India; ³Department of Pathology, Al Jahra Hospital, Kuwait; ⁴Department of Pediatric Surgery, AIIMS, New Delhi, India

Clear cell sarcoma (CCSK) of the kidney is an uncommon but distinctive pediatric renal tumor with a characteristic histological pattern and marked propensity for bone metastasis. The rare anaplastic variant constitutes about 3% of cases of CCSK and carries an unfavorable prognosis, with increased tumor recurrence and resistant to chemotherapy. This variant show high frequency of p53 gene mutation and p53 over expression in comparison to the usual CCSK. We present a case of anaplastic variant of CCSK in an 10-year-old boy with both cytologic and histologic features, highlighting the importance of recognizing this rare entity. Keywords: Bone metastasis; clear cell sarcoma of the kidney; Wilms tumor.

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Assessment of Metabolic Response to Pre-operative Treatment of Rectal Cancer

S. Abu Zallouf, M. El-Sherify, S. Fayaz
Radiation Oncology Department, Kuwait Cancer Control Center, Al-Shuwaikh, Kuwait.

In the era of targeted therapy and high precision radiotherapy for patients with cancer, tailoring and individualization of treatment is needed more and more. In part to avoid ineffective administration of a toxic treatment to a patient that unlikely to get any benefit of it. And also to decrease the expenses of treatment and saving the drugs and resources to patients that deserve. Many predictive factors and markers are searched and well-known in many malignancies, but still rectal cancer lacks such predictors. As the pre-operative chemoradiotherapy is becoming the standard of care of treating patients with locally advanced rectal carcinoma, a predictive factor, or at least an early indicator, of patient’s response to treatment is needed. First, it may help to modulate the pre-operative treatment by employing another chemotherapeutic or targeted agent e.g. oxaloplatin or cetuximab instead of the standard fluorouracil compounds. It may also help to avoid continuation of unnecessary protracted course of radiotherapy for 5—6 weeks for a patient who is unlikely to achieve a satisfactory response. This will help to avoid the definite toxicity of pelvic irradiation and avoid wasting time before going to surgery. Here comes the role of imaging techniques in predicting the metabolic response such as functional computerized tomography (CT) and magnetic resonance imaging (MRI) or positron-emission tomography (PET) scan. In this review we will go through the principles, indications and benefits of employing such techniques in the assessment of response to pre-operative chemoradiotherapy of rectal cancer. Keywords: Rectal cancer, chemoradiotherapy, metabolic response, predictor

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Oncology Centre, Salmaniya Medical Complex (SMC), Bahrain

Cancer is one of the major health problems in the Kingdom of Bahrain. It is the third leading cause of death, after cardiovascular and endocrine diseases, accounting for 10.6% (1 out of 10) of annually reported deaths. The department of Oncology (SMC) is a specialized cancer care centre in the kingdom of Bahrain and Middle East. Salmaniya Medical Complex is accredited by Canadian Board. SMC has collaboration with Princess Margret Hospital, Canada in cancer management. The centre was founded in 1996 and it is managed by the Ministry of Health, Kingdom of Bahrain. The Oncology department offers comprehensive treatment options for cancer in the form of Radiation Oncology, Medical Oncology, Surgical Oncology, Hematology Oncology, Pediatric Oncology and Palliative Care. SMC Oncology treats over 500 new cancer patients each year from the Kingdom of Bahrain and neighboring countries. It is equipped with state-of-the-art medical equipments and services including 38 in-patient beds and 15 day care beds. Currently, the Centre has 21 highly qualified Consultants, 25 Residents, 4 Physicists, 7 Radiation Therapists and 50 paramedical staff.