Issue No. 9 - January 2011

Pages Title / Authors / Abstract

Late Presentation of Breast Cancer in Aden, Yemen

  W. Al-Kahiry1, H.H. Omer2, N. M. Saeed3, G. Abdul-Hamid1
1Al-Amal Oncology Unit, Aden
 2University of Aden
 3University of Sana’a, National Oncology Center, Sana’a, Yemen
Correspondence: Dr. Waiel Al-Kahiry, Al-Amal Oncology Unit - Aden, Yemen, Email:

The aim of this study is to determine the frequency and characteristics of patients who presented with late stage breast cancer at Al-Amal Oncology Unit in Aden. It was conducted retrospectively in Aden, at Al-Amal Oncology Unit of Al-Gamhouria Modern General Hospital, by reviewing all records of breast cancer patients at any stage and attended with histopathologically documented breast cancer from the time of establishment of the unit on December 1, 2007 to December 31, 2009. The total number of documented breast cancer patients was 197 and classified according to the stage at presentation and after the exclusion of 21 patients who were not staged. 118 patients with late inoperable stages were selected and carefully evaluated of their demographic characteristics and was found that they represented 67.0% of the total staged breast cancer patients. Most of these patients are in the reproductive age and residents of Aden governorate and neighboring governorates. Metastasis was mainly evident at the lymph nodes, bones, liver and lungs. The case fatality rate for late stage breast cancer is 8.5 per 100 patients. This study concludes that a high percentage of Yemeni patients in Aden presented with late stage breast cancer which led to the failure of possible curative surgical intervention and resulted to high metastatic disease and fatality rate. Keywords: Late Presentation, Aden, Yemen, Breast Cancer, Stages


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Hyperfractionated Radiation Theraphy and Concurrent Chemotheraphy for advanced Head and Neck Cancer

  K. Al Saleh1, R. Safwat1, H.S. Hooda1, A. Bedair1, A. Al-Basmy2, H. Al-Wikeel1, M. Naseer1, Z. Thotathil1
1Radiation Oncology Department, 2Epidemiology Department,
Kuwait Cancer Control Center (KCCC), Ministry of Health, Kuwait
Correspondence: Dr. Khaled Al Saleh, Consultant, Radiation Oncology Dept, KCCC, Min. of Health, Kuwait, Email:

Purpose: To investigate the feasibility of combining hyperfractionated radiotherapy regimen with concomitant chemotherapy and to assess its toxicity in patients with advanced head and neck carcinoma (HNC). Progression free survival (PFS) and overall survival (OS) were set as secondary end points.

Patients and Methods: Between November 2003 and November 2007, 48 patients with stage III and IV HNC who met the eligibility criteria were enrolled in the study. Hyperfractionated Radiation consisted of 120 Gys twice daily, 6 hours apart, for a total of 69.6 Gys in 58 fractions over 6 weeks and boost of 6 Gys in 3 fractions in case of residual disease. Three cycles of concurrent chemotherapy in the form of Cisplatin 75 mg/ m² on day 1 and Fluorouracil 750 mg/m² 24 hour infusion on day 1-4 during weeks 1, 4 and 6 of irradiation.

Results: 48 patients have completed the treatment to date. The median radiation dose was 72 Gys including the boost to residual lymph node or primary site. The treatment was delivered in a median overall period of 54 days, with a recorded median delay of 7 days. Grade 4 skin toxicity was experienced by 4.1% of patients only. Therapy was well tolerated (grade 3 mucositis in 21%, grade 4 in 26%, grade 3 leukopenia in 10%). Weight loss of more than 10 kg was reported in 10 (16.7%) of the cases. The most common late toxicity was mild to moderate xerostomia which was encountered in 34 (70.8%) cases and improved thereafter. Hypothyroidism was encountered in 7 (14.6%) of the cases. Complete response (CR) was observed in 40 patients (83.3%). Partial response (PR) was achieved in the remaining 8 patients (16.7%). Disease relapse occurred in 9 patients (18.8%) after complete response and 2 patients developed progressive disease after partial response. 3 patients relapsed locally, 5 patients developed distant metastasis and 1 patient developed both local and distant metastasis. 2 patients (4.1%) died of treatment complications, 8 patients (16.7%) died with progressive locoregional, and metastatic disease. The 2- year disease free survival was 77% and the 2- year overall survival was 79%.

Conclusion: Hyperfractionated radiotherapy and concurrent chemotherapy is tolerable. Results regarding LC and OS are encouraging as compared to conventional radiotherapy and concurrent chemotherapy. Keywords: Locally advanced H&N cancer, Hyperfractionated radiotherapy, concurrent chemotherapy


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Population-based study of Hodgkin's lymphoma in Kuwait

  S. H. Alshemmari1, K. P. Sajnani2, S. Refaat2, A. A.Ellbasmi3
1Department of Medicine, Kuwait University, Kuwait,
Department of Medical Oncology, HMJ Cancer Center, Kuwait,
Kuwait Cancer Registry, HMJ Cancer Center, Kuwait
Correspondence: Dr. Salem Alshemmari, Department of Medicine, Faculty of Medicine, Kuwait University, State of Kuwait, P.O.BOX 24923-13110 Safat, Tel:965-25319596. Fax: 965-25338907. Email:

Introduction: Hodgkin lymphoma (HL) comprises about 25% of all malignant nodal lymphomas worldwide. Incidence of HL has been increasing in many countries around the world, in the western countries in particular. Cancer incidence variations in different ethnic groups in the same country can lead to some important information about the search of etiological factors. Some researchers found an association between ethnicity and increased risk of HL. In this study, we evaluated the epidemiologic and clinical characteristics of patients with HL and the HL subtypes in Kuwait who were diagnosed between 1998 and 2006 and we analyzed the changes in the incidence of HL over time based on age, sex, and ethnicity.

Material and Method: The Kuwait Cancer Control Center is a tertiary referral hospital and the only cancer hospital in the entire state of Kuwait. We identified 293 patients who were newly diagnosed with HL by histopathology between January 1, 1998, and December 31, 2006, at the Kuwait Cancer Control Center. Incidence data were crossvalidated with the population-based Cancer Registry of Kuwait. Clinical data were obtained by reviewing the patients’ medical records.

Results: The median age at diagnosis was 39 years (range, 10–85 years) for patients with cHL and 36 years (range, 14–51 years) for patients with NLPHL. The age-adjusted incidence rate was 2.1 cases (range, 1.2–2.9) per 100,000 people per year in the period between 1998 and 2006. NLPHL and cHL were predominant in men with a male to female ratio of 2:1. However, the mean annual percentage change in HL incidence among Kuwaiti patients and non-Kuwaiti patients per year showed unexplained higher percentage in females both Kuwaiti and non-Kuwaiti. cHL comprised 92.5% of all HL cases and NLPHL comprised 7.5%. Nodular sclerosis was the predominant histologic subtype of cHL (58.9%), whereas mixed cellularity was the second most frequent histologic subtype of cHL, (25.9%).

Conclusion: Although the incidence of HL was slightly lower in Kuwait than the worldwide incidence; it was similar to Asian descent population. Incidence of HL varied in the same country among different ethnic subgroups. The mean annual percentage change increased in Kuwaiti and non-Kuwaiti females. Keywords: Hodgkin lymphoma, population-based study, Kuwait.


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Peripheral dose from a dual energy linear accelerator equipped with tertiary multileaf collimators and enhanced dynamic wedge

  C. Varatharaj, M. Ravikumar, S. Sathiyan, S. S. Supe
Department of Radiation Physics, Kidwai Memorial Institute of Oncology, Bangalore, India
Correspondence: Dr. C. Varatharaj, Department of Radiation Physics, Kidwai Memorial Institute of Oncology, Hosur Road, Bangalore, 560 029, Karnataka, India, Phone : +91 80 26094043, Fax : +91 80 26560723, E-mail:

Peripheral dose (PD) or the dose outside the geometrical boundaries of the radiation field is of clinical importance when anatomical structures with low dose tolerances might be involved(1). It is the aim of this study is to estimate the PD on linear accelerators on different wedge systems without multileaf collimator (MLC). Measurements were performed on a dual energy linear accelerator equipped with tertiary MLC and enhanced dynamic wedge (EDW). Measurements were made using an ionization chamber embedded in a Radiation Field Analyser (RFA-300) with the secondary collimator and MLC setting of 5x5, 10x10, 15x15, and 20x20 cm2, and with the MLC fully retracted. The effects of SSD on PD were measured at three SSDs of 90, 100, and 110 cm for the irradiation fields of 5x5, 10x10, 15x15, and 20x20 cm2 and the effects of the three different wedges (Upper wedge, Lower Wedge and Enhanced Dynamic Wedge) on PD were measured for 45° wedges with field size of 15x15 cm2. Data were taken from 3 cm to 24 cm away from the field edge.

Results show that due to tertiary MLC, PD can be reduced by means of a factor of two to three at certain distance from the edge of the field compared with TG-36 data. In between the wedges, the PD was less for the EDW when compared with the upper and lower physical wedges. We conclude that the reduction in PD is significant in reducing or eliminating the need for external peripheral shielding to reduce the dose on affected critical organs.

Keywords: peripheral dose, multileaf collimator, enhanced dynamic wedge, linac, MLC

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Proteomics approaches: New Technologies and Clinical Applications in Breast Carcinomas

  B. Hamrita1, H. B. Nasr1, K. Chahed1, L. Chouchane1,2
1Laboratoire d’Immuno-Oncologie Moléculaire, Faculté de Médecine de Monastir, Tunisia
2Department of Genetic Medicine, Weill Cornell Medical College in Qatar and Qatar Foundation, Doha, Qatar
Correspondence: Dr. Bechr Hamrita, Laboratoire d’Immuno-Oncologie Moléculaire, Faculté de Médecine de Monastir, Tunisia, Email:

Breast cancer is the most diagnosed cancer in women, accounting for approximately 40,000 deaths annually in the USA. In Tunisia, the incidence of breast cancer is approximately 19 new cases per 100,000 women per year. Significant advances have been made in the areas of detection and treatment, but a significant number of breast cancers are detected late. The advent of proteomics provides the hope of discovering novel biological markers that can be used for early detection, prognosis, diagnosis, and therapy. Several proteomics technologies have been used to uncover molecular mechanisms associated with breast. Introduction: Breast cancer is a major health problem and one of the leading causes of death among women worldwide. Its incidence is steadily rising in developing countries. In Tunisia, the incidence of breast cancer is approximately 19 new cases per 100,000 women per year. Invasive carcinomas represent 70-80% of all breast cancer and among these, infiltrating ductal carcinomas (IDCA) are the most aggressive forms and have a poor prognosis. Histopathologically identical breast cancers show a different biological behavior in terms of aggressiveness, progression, and response to therapy. Thus, there is a great need for new breast cancer biomarkers that might help detect this cancer at an earlier stage, to uncover prognostically distinct subclasses, and to provide best individual treatment. Currently, the search for specific cancer-related alterations are largely carcinoma at the global level to discover protein patterns that distinguish disease and disease-free states with high sensitivity and specificity. Two dimensional gel electrophoresis coupled with mass spectrometry constitute a new proteomicsbased paradigm for detecting disease in pathology specimens and monitoring disease response to therapy. This review describes these proteomics technologies and their application in the analysis of breast carcinoma.

Keywords: Breast cancer, Proteomics, Markers, 2-DE, MALDI-TOF


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Breast Conservative Surgery For Operable Invasive Ductal Carcinoma After Neoadjuvant Chemotherapy Or Hormonal Therapy- A Challenge For Breast Surgeon: A Review Based On Literature and Experience

  J.Y. Bobin, K. Al-Khaledi, J. Ahmad
Surgical Oncology Department, Kuwait Cancer Control Centre, Kuwait
Correspondence: Dr. Jean-Yves Bobin, Surgical Oncology Department, Kuwait Cancer Control Centre, Kuwait, Email:

Neoadjuvant chemotherapy or hormonal therapy is based on biological data and enables more patients to be treated with breast conserving surgery for locally advanced T2 and T3 without significantly increasing the rates of ipsilateral breast recurrence. Careful consideration of an optimal preoperative planning aims at accurately determining the patterns of primary tumour down staging and at the amount and location of any residual tumour in the breast, besides converting patients from mutilating surgery candidates to candidates for breast conservative procedure. The use of induction chemotherapy has the potential to improve the cosmetic results but free margins must be achieved and surgery must be planned in onco-plastic surgery. Axillary lymph node clearance is still the gold standard surgery in the treatment of the axilla. Sentinel lymph node biopsy can be done for clinically N0 patients but only in control trials.

Keywords: Neoadjuvant systemic therapy, breast cancer surgery


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Laryngeal synovial sarcoma: Case report and Literature review

  A.M. Al-Nemer, M. El-Shawarby
Pathology Department, College of Medicine, University of Dammam, Saudi Arabia
Correspondence: Dr. Areej Al-Nemer, Pathology Department, College of Medicine, University of Dammam, Saudi Arabia, Email:

Synovial sarcoma is a rare malignant mesenchymal neoplasm of youth with no benign counterpart. This cancer typically occurs about the knee and ankle joints. The involvement of the head and neck region is rare, and the laryngeal location is exceptional, which make the correct diagnosis challenging for the surgical pathologist and unanticipated for the clinician. Up to our knowledge, only 14 cases have been reported so far within this site. Here we add a new case in a 26-year-old Saudi man who presented with voice change and dysphagia, which are common symptoms of a more common benign condition in this site. The patient was operated and the histopathological diagnosis of synovial sarcoma was made, after which he received radiotherapy with no recurrence after 20 months. The correct diagnosis is crucial in such a case for proper management.

Keywords: synovial sarcoma, larynx


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Gastrointestinal Stromal Tumours (GISTs): Case Report and Review of the literature

  A. M. Al-Amri1, M.A. Shawarbi2, A. Y. El-Hassan3, K. S. Al-Johi2
1Department of Internal Medicine, 2Department of Pathology, 3Department of Radiology
King Fahd Hospital of the University, Eastern Province, Al-Khobar, Saudi Arabia
Correspondence: Dr. Ali Al-Amri, P.O. Box 40182, Al-Khobar 31952, Saudi Arabia. Email:

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, the majority of which is KIT (CD117) positive. In this case report, we describe a case of recurrent and metastatic GIST who presented with hepatic and brain metastases. Despite the patient's GISTs was negative for c-Kit (CD 117), he responded to imatinib mesylate (Glivec) treatment with complete resolution of his liver and brain lesions. The patient has been and still in complete remission for 18 months of follow-up.

Keywords: GIST, Gastrointestinal stromal tumors


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Extensive Visceral Calcification Demonstrated on Tc-99m MDP Bone Scan in Patient with Sphenoidal Sinus Carcinoma and Hypercalcaemia of Malignancy: A Bad Prognostic Sign

  S. Usmani, H. A. Khan, F. A. Huda, N. Al Nafisi, S. Al Mohannadi
Hussain Makki Al Jumma Centre for Specialized Surgery (HMJCSS), Kuwait
Correspondence: Dr. Sharjeel Usmani, Department of Nuclear Medicine, Hussain Makki Al Jumma Centre for Specialized Surgery, PO Box: 1488, 83001 Khaitan Kuwait, Tel: 0096597613437, Email:

Sphenoidal sinus carcinoma is a rare cause of hypercalcemia of malignancy. We report on a 37-year-old male with sphenoidal sinus carcinoma with intracranial extension who developed hypercalcemia of malignancy with progressing disease and demonstrated diffuse metastatic visceral calcifications of lungs, myocardium, stomach, kidneys and thyroid on follow-up 99mTc-methylene diphosphonate bone scan. In the absence of extensive skeletal metastases, bone scan help confirm humoral nature of hypercalcaeimia.

Keywords: Bone scan, visceral calcification, Humoral hypercalcemia, Sheniodal Sinus carcinoma.


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Trichoadenoma in a mature Cystic Teratoma: A Rare Finding

  P. Kaur, R. Bansal, M. Madan, A. Nutan
Pathology Department, Giansagar Medical College and Hospital, Banur, Dist Patiala, Punjab, India
Correspondence: Dr. P. Kaur, Pathology Department, Giansagar Medical College and Hospital, Banur, Dist Patiala, Punjab, India. Email:

Skin adnexal tumors arising in dermoid cysts of the ovary are exceedingly rare. We report a trichoadenoma arising in a dermoid cyst in a 42-year-old female. The histopathology of trichoadenoma has also been described briefly. Mature teratomas, which are almost all cystic (dermoid cysts), account for approximately 25% of all ovarian tumors, and 30% of benign ovarian tumors. They usually develop in children or women of the reproductive age group. Histologically, they are composed of variable proportions of tissue originating from the ectoderm, mesoderm, and endoderm. Cystic cavities are lined by mature epidermis. Although skin appendages and neural tissue are extremely common, there are only few case reports of skin adnexal tumors arising in a mature teratoma. We report a case of ovarian teratoma with a trichoadenoma. To the best of the authors’ knowledge, this is the first report describing this rare benign skin adnexal tumor, in a mature cystic teratoma of the ovary. Keywords: trichoadenoma, mature cystic teratoma

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Bilateral ductal carcinoma in situ (DCIS) in a male breast: A case report

  N Al-Saleh
Department of Surgical Oncology, Kuwait Cancer Control Center, Ministry of Health, Kuwait
Correspondence: Dr. Noha Al Saleh, Specialist in Surgical Oncology, Kuwait Cancer Control Center, Department of Surgical Oncology, Email: or, Fax: 25359229

Objectives: This case is presented to emphasize the importance of recognizing nipple discharge as a clinical sign of male ductal carcinoma in situ and an opportunity for early diagnosis. Clinical presentation and intervention: A 68-years old gentleman presented with bilateral bloody nipple discharge. Clinical examination of breasts showed no masses in either breasts and no axillary lymphadenopathy. He was investigated with bilateral mammogram, ultrasound scan and magnetic resonance imaging of the breasts. All were leading to a diagnosis of intraductal papilloma on the left retroareolar region and suspicious microcalcifications on the right retroareolar area. Retroareolar excision under general anesthesia confirmed the presence of DCIS in both specimens. Completion mastectomy was performed which showed no residual disease in either breasts.

Conclusion: DCIS in male breast is very rare and hard to diagnose due to male breast morphology. It is best treated with mastectomy without axillary dissection.

Keywords: Ductal carcinoma in situ, DCIS, male breast cancer


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Soft tissue high grade myoepithelial carcinoma with round cell morphology: Report of a newly described entity with EWSR1 gene rearrangement

  M. El-Kabany, R. Al-Abdulghani, A. E. Ali, I. M. Francis, S. A. Hussein
Department of Pathology, Hussain Makki Al-Juma Center for Specialized Surgery, Kuwait City, Kuwait
Correspondence: Dr. Moustafa El-Kabany, Consultant Histopathology, Pathology Department, KCCC, Ministry of Health, Kuwait, e.mail:

The case of soft tissue malignant myoepithelioma is presented including clinicopathological, immunohistochemical and cytogenetic findings. A 36-year-old Saudi male patient suffered from large mass involving right scapula and right shoulder joint measuring 14x13x11 mm. Core biopsy revealed sheets and lobules of poorly differentiated small malignant cells with marked atypia and frequent mitosis. Initially, immunohistochemistry was reactive for vimentin, pan-cytokeratin, EMA and CD99. The case was negative for desmin, SMA, CD34, S-100 protein and GFAP. FISH analysis exhibited negativity for SS18 (18q11.2) gene rearrangement and positivity for EWSR1 (22q12) gene rearrangement and a diagnosis of Ewing/PNET was considered. Clinical behavior and therapeutic response did not match the diagnosis with re-evaluation. Wedge biopsy demonstrated aggregates of epithelioid cells besides calponin and P63 positivity. Final diagnosis of malignant myoepithelioma with EWSR1 gene rearrangement was issued; a new entity with aggressive course. Myoepithelial carcinoma of soft tissue exhibits a wide spectrum of cytomorphology with overlapping phenotype similar to other soft tissue sarcoma like synovial sarcoma, mesenchymal chondrosarcoma, epithelioid sarcoma as well as Ewing/PNET. Moreover, a new finding of EWSR1 gene rearrangement is recognized in malignant myoepithelioma with different fusion partners. Hence, myoepithelial carcinoma should be kept in mind in diagnosis of soft tissue tumors even with unusual phenotype and gene rearrangement.

Keywords: Soft tissue myoepithelioma, soft tissue myoepithelial carcinoma, CD99, P63, EWSR1 (22q12)

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Hepatoid Adenocarcinoma of the Stomach – A rare pathological entity

  M. Muralee1, I. Ahamed1, T. Somanathan2, K.S. Anila2
1Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
2Division of Pathology, Regional Cancer Centre, Trivandrum, India
Correspondence: Dr. Madhu Muralee, Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
Phone: - 04712522285,

Hepatoid adenocarcinoma is a rare cancer with an extremely poor prognosis. Here, we describe two cases referred to our hospital with suspected gastric cancer. Gastrointestinal endoscopy revealed lesions in the stomach. Biopsy from the lesions was reported as adenocarcinoma. Both the patients underwent exploratory laparotomy. One was an operable lesion and the other was an inoperable lesion. Total gastrectomy was done in the operable lesion and feeding jejunostomy was done in the inoperable case. Histologically, both turned out to be hepatoid adenocarcinomas. Retrospective analysis showed the serum levels of alphafetoprotein (AFP) are markedly elevated in both cases. We describe this rare entity of hepatoid adenocarcinoma of the stomach, and review the literature concerning the clinicopathological aspects of the cases.

Keywords: Gastric cancer, Hepatoid adenocarcinoma, Alpha Feto Protein, Stomach


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UAE Cancer Congress 2010 Abstracts, Dubai, UAE, October 28-30, 2010

  Complete Abstracts