Issue No. 15 - JANUARY 2014


Pages Title / Authors / Abstract


Role of taxanes in the treatment of advanced NHL patients: A randomized study of 87 cases

R. Shraddha, P.N. Pandit Radium Institute,
Patna Medical College and Hospital, Patna, India
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NHL is a highly chemo-sensitive as well as radiosensitive disease. From May 2005 to June 2010, 87 patients were randomised into 2 arms. The control arm received the standard CHOP regimen + IFRT, whereas the study arm received Paclitaxel, 135/m2 additionally. The results showed a better Overall Response (87% vs 78%) in the study arm. The 3yr and 5yr overall survival were significantly better in the study arm (89% vs 77%, p- value <0.05; 83% vs 67%, p-value <0.05). However, the incidence and severity of the side effects, haematological and non- haematological were enhanced but manageable in the study arm.

Keywords: Taxanes, Paclitaxel, Non Hodgkin’s Lymphoma



Management of Patients with Recurrent Hepatocellular Carcinoma Following Living Donor Liver Transplantation: A Single Center Experience

Y. Gunay, N. Guler, M. Akyildiz, O. Yaprak, M. Dayangac, Y. Yuzer, Y. Tokat
Liver Transplantation Center, Florence Nightingale Hospital, Abidei Hurriyet cad Istanbul, Turkey
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Objective: Tumor recurrence is the most important predictive factor for the survival of patients following liver transplantation for hepatocellular carcinoma (HCC). The management of recurrent HCC remains controversial. In this study, we presented the clinical outcomes of patients with recurrent HCC following living donor liver transplantation.


Material and Methods: Of the 109 patients who underwent liver transplantation due to hepatocellular carcinoma, sixteen (14.7%) developed tumor recurrence and were included in the study. We analyzed the management of patients with recurrent tumors and their outcomes.


Results: The mean age of patients included in the study was 55.2 ± 7.82 (28–65) years, and 13 patients (81%) were male. The mean follow up and time to recurrence were 25.8 ± 19.2 (5–78) months and 11 ± 9.4 (4–26) months, respectively. Four patients developed recurrence in the liver graft and 12 (75%) developed recurrence in extrahepatic organs. Of these patients, seven had surgical treatment, seven received chemotherapy, and two did not receive any treatment. All four surviving patients received surgical treatment.


Conclusion: Recurrence of HCC following liver transplantation generally occurs in the first two years and in extrahepatic organs. The most effective treatment for patients with single and isolated recurrent tumors is surgery. However, the long term survival differed according to the type of recurrence, depending on which organs recurrence occurred in and whether recurrence was in single or multiple locations. Therefore, the treatment strategy should be individualized for longer survival.


Keywords: The management of HCC, Recurrent HCC, Living donor liver transplantation




Changes in biologic features between primary and recurrent or relapsed breast cancers

  S. Al-Awadi, S. Thuruthel, K. Yamini, P. Muraligopal, I. Maarouf, A. Atta
Department of Medical Oncology, Kuwait Cancer Control Centre, Kuwait
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Objective: Changes in ER, PR and Her2 receptor status between primary and metastatic cancer tissue have been suggested in breast cancer. The frequencies of these changes are still not fully understood. The purpose of this study was to evaluate these changes in breast cancer population of Kuwait.

Subjects and Method: Changes in the biological features between primary and recurrent disease in 70 patients who presented between 2009 and 2012 was studied. Statistical comparisons between groups was done using chi square test while Kaplan Meier method was used to perform analysis of survival after relapse. All analysis was carried out using the IBM-SPSS statistical software.

Results: There was a decrease in ER and PR positivity from 61.4% to 58.6% and 61.4% to 44.3% respectively. The overall change in ER and PR status was 28.5% and 25.7% respectively. There was an increase in the Her2 positivity as the tumor relapsed and overall changes were seen in 5.7% of cases.

 Conclusion: Patients with breast cancer experience change in biological markers through the course of their disease. The changes are more with hormone receptors compared to Her2. Re-biopsy should be considered at relapse if feasible.

Keywords: breast cancer, hormone receptors, Her2 neu, receptors, biological features, changes



Pattern of Diffuse Large B cell Lymphoma (DLBCL) in Aden, Yemen

A.A. Abdulla1, S.M. Bakhubaira1, W. M. Al-Kahiry1,2, G.H.Moshar’a2
1Faculty of Medicine and Health Sciences, University of Aden, Yemen,
2Al-Amal Oncology Unit, Al-Gamhouria Modern General Hospital, Aden, Yemen
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Background: DLBCL is part of aggressive lymphomas with limited survival in the absence of effective treatment. Aim: The aim of this study was to determine the frequency and the pattern of presentation of DLBCL in patients diagnosed in Aden.


Methods and Material: It was conducted prospectively in Aden, at Al-Amal Oncology Unit of Al-Gamhouria Modern General Hospital. All patients confirmed to have NHL by histopathology were selected from Jan. 1st to Dec. 31st, 2009. They were clinically examined and investigated for clinical staging and classification.


Data analysis:  Data analysis was conducted by the SPSS 18 program, using the Chi square, Fisher Exact, hypothesis test (Z-test) and student t-tests.


Results: The frequency of DLBCL was 35%. In DLBCL, the median age was 51.5 years, with male to female ratio of 3.67:1. Clinically, most patients were nodal and B symptoms were present in 64.3% of them; weight loss and sweating were reported more than in the other subtypes of NHL. Investigations showed that 64.3% were anemic, 35.7% with high ESR and high β2 microglobulin, 21.4% with low albumin and high uric acid. Half of them presented in stage III and IV disease and according to the IPI scoring, 64.3% presented with intermediate to high risk disease. Comparison with other NHL subtypes was performed and showed that DLBCL is associated with aggressive pattern of presentation.


Conclusion: This study concluded that DLBCL is an aggressive NHL at presentation and needs immediate diagnosis and intervention to improve the outcome.


Keywords: DLBCL, NHL, Lymphoma, Pattern, Aden, Aggressive



Anaplastic Thyroid Cancer: a Retrospective analysis of 120 cases

  M. Aldehaim, R. Mahmood, F. Hussain, A. Memon, A. Al-Hebshi, N. Al-rajhi, M. El-sebaie, E. Khalil, M. Ahmad
Research Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

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Introduction: Anaplastic Thyroid Cancer (ATC) is one of the most lethal malignancies with very short survival and extremely poor treatment outcome. ATC accounts for 2-5% of all thyroid cancers worldwide with an annual incidence of about 2/million.


Objective: To review the natural history and treatment outcome of ATC patients treated at King Faisal Specialist Hospital and Research Centre (KFSH and RC) located at Riyadh, Saudi Arabia.


Material and Methods: Retrospective review of 120 Saudi cancer patients collected from registry data at KFSH & RC from 1976-2008. Search key words included: thyroid cancer, anaplastic, undifferentiated and not otherwise specified. Search was not restricted to particular age, gender, treatment or tumor size. Demographic information, baseline patient characteristics including date of diagnosis, type of treatment and date of death were obtained from KFSH & RC registry data and Saudi death registry.


Results: A total of 120 cases were identified at our cancer centre from 1976 to 2008. Of these total, 73 were females (60.8%) and 47 were males (39.2%). The average age at diagnosis was 63.34 +/- 12.8 years. Thirty-four patients underwent surgery (28.3%), 52 had a palliative radiation treatment (43.3%) and only 5 had chemotherapy (4.2%). The median survival was 53 days (0-457).


Conclusion: Our review proves that ATC is rapidly fatal cancer and is unresponsive to currently available therapeutic options. More research is needed to understand the tumor biology and novel treatment options.


Keywords: thyroid cancer, anaplastic, undifferentiated, radiation treatment, chemotherapy, median survival, Riyadh and Saudi Arabia.



Breast Cancer Molecular Subtypes in Oman: Correlation with Age, Histology, and Stage Distribution – Analysis of 542 Cases

  I. Mehdi , A. A. Monem, B. Al Bahrani, F. A. Ramadhan
National Oncology Center, The Royal Hospital, Muscat, Oman


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Background: Breast cancer (BC) is one of the most common malignancies and a foremost health issue throughout world. BC accounted for 23.1% of cancer cases diagnosed in Oman in 2009. BC is a heterogeneous disease, and immuno-histochemical (IHC) markers are used to further classify it into distinct subtypes, which are biologically discrete and display different behaviors. IHC testing of the estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor-2 (Her-2) can sub-classify BC into 4 principal molecular subtypes. These subtypes are luminal A (ER+ and/or PR+, HER2−), luminal B (ER+ and/or PR+, HER2+), basal like (BCL - ER−, PR−, HER2−), and Her2/neu (ER−, PR−, HER2+). Previous studies have shown preliminary evidence and high probabilities of molecular differences across ethnic and geographic groups which may be responsible for disparities in presentation, biological behavior, treatment response and outcome.

Patients and Methods: BC data from 2006-2010 at the National Oncology Center – The Royal Hospital, Oman were retrospectively retrieved from the electronic patient record system (Al-Shifa). Data were analyzed with respect to ER, PR, and Her-2 status and tumours were classified on molecular basis. Molecular subtypes were correlated with age, histology and treatment outcome. The results were compared with published regional and international data.

Results: There were 542 cases of BC accessible for evaluation. Luminal A subtype was the most common and the BCL subtype was highest among Omani females. Age was a significant factor in basal-like (63.8% younger than 50 years vs. 36.2% older than 50 years) and Her2 +ve tumours (60.9% vs. 39.1%). High grade tumors were mostly observed (41%) in basal tumors and were lowest in luminal A (19%). A higher stage at presentation (Stage III and IV) was observed in Her2+ tumours (59%), and a higher (22.4%) mortality was detected in basal like/TN tumours.

Conclusions: The molecular classification and sub-typing of BC have revealed ethnic and geographic variation. Luminal A subtype is the most common among Omani female breast cancers but it is less common than in Western females. BCL subtype is highest among Omani females compared with Western females. These differences may have diagnostic, therapeutic and prognostic implications. Large scale and multi-centre studies may confirm these findings and can be translated and incorporated to pertinent management strategies.

Key Words: Molecular subtypes, breast cancer, Oman, Royal Hospital



Cardiac toxicity in breast cancer patients

  N.Y. Ibrahim, E.S. Saad
Clinical Oncology Department, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Egypt
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Aim: To asses cardiac toxicity post radiotherapy in left cancer breast patients with different fractionations.


Methods: This is a prospective randomized study conducted at Kasr El-Ainy Center of Clinical Oncology and Nuclear Medicine (NEMROCK). Cardiological assessment using RTOG toxicity criteria was done for left sided breast cancer patients after at least five years of conformal radiation therapy. There were two arms of radiation, conventional (50Gy/25sttt/5 Ws) and hypofractionation (42.5 Gy /16 fractions /3 1/5 weeks).


Results Thirty patients were included in each arm. After a median follow up of 62 months (range 60 to 72), cardiac dysfunction developed more in the conventional arm but was insignificant (P value =0.36). Grade I & II toxicity was 83.3 vs 70% and grade III was 3.3% in the hypofractionated arm only. The rate of localregional tumor relapse at 5 years was similar (3.3%).


Conclusion: Hypofractionated radiotherapy decreased cardiac toxicity though not statistically significant, however it is more cost effective and time consuming.


Keywords: breast cancer, cardiac toxicity, hypofractionation, Egypt



Superior vena cava obstruction (SVCO) in patients with advanced non small cell lung cancer (NSCLC)


H.N. Lee1, M.S. Tiwana1, S. Saini2 , S.K. Verma3, M. Saini4, N. Jain 2 , M. Gupta1 , N. Chauhan5
1Radiation Oncology, 2Surgical Oncology, 3Medical Oncology, 4Radiodiagnosis, 5Pathology, STM Cancer Research Institute, Himalayan Institute Hospital Trust, Swami Ram Nagar, Jolly Grant, Dehradun, India

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Introduction: To report on prognostic and treatment factors influencing the response of SVCO and related survival outcomes in advanced non small cell lung cancer.


Material and Methods: From November 2008 through December 2011, 18 consecutively diagnosed NSCLC patients with SVCO were included in this study. The patient, tumor and treatment related factors were analyzed. Median overall survival (OS), Kaplan -Meier survival plots, T-test, Cox Proportional Hazards models were generated by multiple covariates (MVA) and analyzed on SPSS software (version 19.0; SPSS, Inc., Chicago, IL).


Results: Thirteen patients (72%) had presented with SVCO before the pathological diagnosis of underlying lung malignancy, while 5 (28%) progressed to SVCO after initiating treatment with chemotherapy. Twelve (68%) patients achieved subjective relief from the obstruction at the completion of palliative radiation therapy. Treating oncologists preferred 4 Gy per fraction in 11 (62%), while the median biologically equivalent dose delivered was 28 Gy. Six (33%) patients received chemotherapy during the course of treatment. Median OS of the entire cohort was 3±1.85mths and 1-year survival rate of 7%. Univariate analysis confirmed that SVCO patients with good performance score (p=0.02), and partial response to chemotherapy (p= 0.001) have superior OS. However, Cox regression modeling for MVA demonstrated only good performance SVCO patients (p = 0.05) have a better OS.


Conclusion: RT effectively relieves SVCO but overall poor survival associated in our clinical scenario needs to be improved with multimodality approach. Adjuvant chemotherapy is to be considered after initial radiation therapy in good performance patients.


Key words: superior vena cava obstruction (SVCO), radiation therapy, chemotherapy, non small cell lung cancer (NSCLC), BED (biologically equivalent dose)



The Dilemma of Serum Tumor Marker (STM) Flares

  A. Venniyoor, B. Al Bahrani, B. Rajan
Division of Oncology, National Oncology Centre, The Royal Hospital, Muscat, Sultanate of Oman
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Serum tumor marker (STM) estimation is often used in clinical practice in monitoring response to treatment and as a predictor of treatment failure and relapse. However, there are pitfalls in interpretation, particularly in the immediate post treatment period, when a rise in titre could be observed, the phenomenon being termed as “flare”. A literature search was done to examine this phenomenon for some of the commonly used serum tumor markers in malignancies. This phenomenon has been documented with respect to AFP, beta HCG, CEA, AC 15.3, PSA, CA 19.9 and CA 125 with or without other evidence of progression. Based on this review, a practical approach is suggested so that the clinician is not misled into changing a potentially effective treatment regime. A practical approach would be to correlate serum tumor marker values with other clinical and radiological parameters, and not to rely exclusively on serum marker values to guide therapy.


Keywords serum, tumor markers, flares, STM pseudoprogression


Detection of cytogenetics abnormalities in chronic lymphocytic leukemia using FISH technique and their prognostic impact

  O.M. Eid1, M.M. Eid1, H.F. Kayed1, W.M. Mahmoud1, S.S. Mousafa2, M.M. Ismail2 and D.M. Abdeen1
1Human Cytogenetics Department, National Research Center, Cairo, Egypt,
2Clinical and Chemical Pathology Department, Faculty of Medicine, Ain Shams University, Egypt
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Introduction: Chronic lymphocytic leukemia (CLL) is a clonal lymphoproliferative disorder characterized by progressive accumulation of morphologically and immunophenotypically mature lymphocytes. Characterization of genomic aberrations may help to understand the pathogenesis of CLL and may give prognostic information independent from conventional clinical markers for a risk-adapted management of CLL patients.


Aim: The aim of the present study is to determine the most common cytogenetics abnormalities between patients with CLL and its prognostic impact.


Patients and Methods: The present study was carried out on 20 adult patients presented with chronic lymphocytic leukemia. The patients were diagnosed on the basis of standard clinical (lymph node involvement and/or hepatosplenomegaly), hematological and immunophenotypic criteria for diagnosis of B-CLL. All cases were studied at the time of their diagnosis. FISH technique was successfully performed on PB samples using CLL LSI probes for ATM (11q22) / GLI (12q13) and 13q14/ p53 (17p13).


Results: For comparative statistical studies, the patients were divided into group I (patients with favorable outcome) and group II (patients with unfavorable outcome). All patients showed one or more cytogenetic abnormality with the prevalence of p53 in 16 patients out of 20 that perfectly correlated with the poor outcome of the patients. This is followed by deletion in the 13q14 and to a lesser extent deletion in ATM gene, but no one has exhibited amplification in the 12q13 locus.


Conclusion: p53 deletion as a sole abnormality has a higher prognostic power than other cytogenetics abnormalities. The cytogenetics study using FISH panel for CLL patients in a complementary fashion to the other clinical and laboratory findings may overcome the pitfalls in the diagnosis and may also assess the assignment of therapeutic protocols for CLL patients according to the results of their cytogenetic analysis at the time of diagnosis.


Keywords: FISH, chronic lymphocytic leukemia, CLL, p53, cytogenetics, Egypt



Outcome of young age at diagnosis of breast cancer in South Egypt

A. Ibrahim1, M.A. Salem2, R. Hassan1
1Medical Oncology Department, 2Surgical Oncology Department, South Egypt Cancer, Institute, Assiut University, Egypt
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Background: Incidence of breast cancer in patients <40 years old accounts for 20% of the total breast cancer patients in Egypt which is quite higher than the incidence reported worldwide. This study was conducted to evaluate the differences in survival between age groups below and above the age of 40.


Method: 170 patients <40 years and 500 patients ≥40 years were evaluated retrospectively to assess the differences in disease free survival (DFS) and overall survival (OS) between age groups after adjustment of other risk factors like stage, lymph node status, tumor size, and hormonal positivity.


Results: After median follow up of 49 months, there was no significant difference between the 2 age groups with regards to DFS p= 0.6 and OS P=0.7 and there was no significant difference between the 2 groups when we stratified the patients according to stages, hormonal status and number of metastatic lymph nodes. However, we found significant increase in local recurrence after breast conserving surgery in patients <40 years compared to patients ≥40 years.


Conclusion: Patients <40 years exhibited more often at advanced stage and large tumors size compared to patients ≥ 40 years; However, there was no significant difference in DFS and OS when we adjusted other risk factors. Furthermore, our analysis revealed that age <40 years can be considered as an adverse prognostic factor for the locoregional failure after breast conserving surgery.


Keywords: breast cancer, young age, <40 years old, locoregional failure, DFS


Spontaneous remission in acute myeloid leukemia: A Case Report


M. Adam and A. Eltayeb

National Cancer Institute, University of Gezira, Wadmedani, Sudan

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Spontaneous remission of Acute Myeloid leukaemia (AML) is an uncommon event, temporary and its mechanism is yet to be determined. We report here a case of spontaneous remission of AML in a 35 years old male who was diagnosed with AML (M4) in Jan 2011. He presented very ill with fever, bleeding tendency and oral candidacies. He received supportive care only and chemotherapy was withheld. His general condition improved and fever subsided. White blood cell (WBC) count started to drop spontaneously and gradually until he became leukopenic and developed febrile neutropenia. After the second recovery, his full blood count (FBC) and bone marrow examination showed haematological remission. He was followed up for six weeks after which relapse occurred. Chemotherapy was started immediately, but unfortunately was not continued because of sepsis. The patient died four weeks after relapse. Other reports on the spontaneous remission of AML showed a similar temporary period of remission with different duration, and then followed by relapse. Possible mechanisms of spontaneous remission in AML are discussed with a review of the literature.


Keywords: Acute myeloid leukemia, spontaneous remission


Mammary hamartoma- a clinical dilemma

  K.F. Magdalene, G. Robin, M. Sapna
Sree Narayana Institute of Medical Sciences, Chalaka, Kerala, India
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Mammary hamartoma is an uncommon benign lesion. The frequency of the tumor is reported between 0.04 -1.15% and it accounts for 4.8% of all benign breast tumors. The lesion may be under-diagnosed by the clinician because of the varied clinical presentation or by the pathologist, as the microscopic appearance is not distinctive. A case of left sided mammary hamartoma in a 46-year-old female who presented with a freely mobile mass is reported. A clinical diagnosis of fibroadenoma was made and lumpectomy performed. Histopathology and gross diagnosis confirmed it to be a case of mammary hamartoma. Extensive area of adenosis, focal cystic change, apocrine metaplasia and columnar cell change was noted. Identification of hamartoma is important because there are the problems of recurrence, co-existent carcinomas and association with Cowden syndrome.

 Keywords: Hamartoma, fibroadenoma, apocrine metaplasia, ductal carcinomas