ISSUE NO. 18 - MAY 2015
Pages Title / Authors / Abstract


An Unusual Breast Malignancy 


S. Naqash1, A.H. Sarmast1, H.I. Showkat2, M. Wani1, S. Besina3, M. Banday2, M. Shah1

1Dept. of General Surgery, 2Dept. of Medical Oncology, 3Dept. of Pathology,
SKIMS, Srinagar Jammu and Kashmir 


We describe an extramedullary plasmacytoma of both breasts in a 35-year-old woman. No other involvement was detected in the bone marrow or in any other site . Extramedullary plasmacytomas of the breast are extremely rare, especially those that are not associated with multiple myeloma. 

Keywords: extramedullary plasmacytoma, multiple myeloma, Breast, FNAC

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Nuchal Fibroma : A rare entity of neck masses

N. Alsaleh1, H. Amanguno2
1Department of Surgical Oncology, 2Department of Histopathology
Kuwait Cancer Control Center, Kuwait


A nuchal fibroma is a rare benign mass; it is a fibrolipoma-like soft tissue mass, usually located in the lower back and the neck. Males are affected far more often than females. It can occur extranuchally. It is a slow growing tumor and usually asymptomatic. We present a rare case of a 39-year old female who was diagnosed with nuchal-type fibroma on final pathology. The proper management for this type of tumor is complete excision.

Keywords: nuchal, fibrolipoma, excision

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Epinephrine-secreting large incidental pheochromocytoma in a normotensive male with stormy intraoperative hemodynamics

O. Nazir1, T. Sharma1, M. Maqsood2 A. Khatuja1, R. Misra1
1Department of Anaesthesiology, Artemis Health Institute, Sec-51 Gurgaon Haryana, India.
2Department of Anesthesiology, Government Medical College, Jammu , India


Pheochromocytoma is a rare tumour which is usually suggested by sustained or paroxysmal hypertension however the spectrum of the presentation of pheochromocytoma continues to expand and hypertension may be absent despite excess catecholamine secretion. The normotensive pheochromocytoma is a distinct entity and as in the case we report the presentation was quite unique as well as the intraoperative behaviour was stormy.

Keywords: Incidentaloma , Pheochromocytoma, epinephrine

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Everolimus induced Pneumonitis


Q. Badar1, N. Masood2, A. N. Abbasi1
1Dept of Radiation Oncology, 2Dept of Medical Oncology,
Aga Khan University and Hospital, Karachi, Pakistan


Everolimus (RAD 001) is an orally administered inhibitor of mTOR (mammalian target of rapamycin), a central regulator of intracellular signaling pathways involved in cell growth and proliferation, cellular metabolism and angiogenesis. Drug is currently in use to prevent allograft rejection after solid organ transplantation and in treatment of advanced renal cell carcinoma (RCC). Noninfectious pneumonitis is rare adverse reaction associated with rapamycin and rapamycin analogues. Awareness of this toxicity and appropriate management is important to optimize patient safety. Here we report a case of everolimus induced pneumonitis in a 72 years old male with metastatic renal cell carcinoma (mRCC) after 4 months of commencement of everolimus. Drug was discontinued and patient was treated accordingly and discharged after 10 days of hospital admission.

Keywords: Everolimus, Rad 001, Pneumonitis, Advanced Renal Cell Carcinoma, Metastatic Renal Cell Carcinoma (mRCC)

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Primary Mantle Cell Lymphoma of Appendix


V. L Gaopande1, S. D Deshmukh1, V. C Shinde2
1Department of Pathology, 2Department of Surgery, Smt Kashibai Navale Medical College and Hospital, Pune, Maharashtra, India


We present a case of immunohistochemically proven primary mantle cell lymphoma of appendix that presented as a mass in right iliac fossa. The usual presentation of gastrointestinal mantle cell lymphoma is in the form of multiple lymphomatous polyposis. Mantle cell lymphoma has a unique immunohistochemistry and genetic abnormality.

Keywords: mantle cell lymphoma of appendix, multiple lymphomatous polyposis, immunohistochemistry.

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A Rare Variant of Multiple Myeloma; Non-Secretory Myeloma with diffuse osteolytic lesions

S. Sultan, S.M. Irfan
Department of Haematology, Liaquat National Hospital and Medical College, Karachi, Pakistan


Non-secretory myeloma is a very rare entity of plasma cell dyscrasia. It is delineated as symptomatic myeloma without detectable monoclonal immunoglobulin peak on serum or urine electrophoresis with normal immunoquantification. Due to the inability to detect monoclonality often it is difficult to ascertain an early and accurate diagnosis. Misdiagnosing results to undue delay in therapeutic intervention. Consequently extensive imaging studies, serum free light chains detection and morphological confirmation are mandatory. Lytic bone lesions are less frequently seen in this type of myeloma. Here we report the case of a patient with this rare variant having diffuse osteolytic lesions in whom we established the diagnosis by bone marrow examination and document light chain restriction by immunophenotyping. Patient is classified as stage III according to Durie and Salmon criteria in view of anemia and multiple lytic lesions observed.

Keywords: Non-secretory myeloma, Multiple myeloma, Plasma cell dyscrasia, Osteolytic

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Pain and Cancer: A systematic review

F. Elomrani, N. Berrada, S. L’annaz, I .Ouziane , H. Mrabti , H. Errihani
Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco.


Pain is the most common symptoms in patients with cancer, a significant number of cases it is undiagnosed and under treated. It is important to understand the nature of the pain experienced by patients, to distinguish between nociceptive and neuropathic pain. Successful management of cancer pain requires a good knowledge of the causes of pain and various treatment available and information to manage their side effects. Pain has a significant negative impact on the patient and his family, therefore it needs to be managed urgently and appropriately.

Keywords: pain, cancer, treatment, opioids analgesics

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Tumor Thickness: A predictor of nodal disease in early squamous cell carcinomas of buccal mucosa


G. Deshpande, S. Das
Dept. of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat. India


Squamous cell carcinomas of buccal mucosa is one the highest number of malignancies seen in the Southeast Asian region. It is related to chewing a combination of tobacco mixed with betel leaves, areca nut, and lime shell called quid. As it is most commonly due to substance abuse and affects younger population, it has tremendous economical and social consequences. Surgery is the most successful modality of management in these patients. The surgery involves wide excision of the diseased mucosa and neck dissection. Neck dissection is associated with certain morbidities, but is routinely practiced in some centers like ours. We have attempted to evaluate the occurrence of the nodal disease in relation to the thickness of the tumor in cases of early cancers of buccal mucosa (stage I and II). We have used ultrasound of the lesion as our modality to assess the tumor thickness preoperatively. AJCC 7th edition was used to assess the clinical and pathological stage of the disease. We have studied 52 patients of early buccal mucosal squamous cell carcinoma, and we observed that tumors thicker than 7mm (p-0.05) have highest co-relation with nodal metastases. This study also recommends that neck dissection should be prophylactically performed for tumors thicker than 4mm. Tumor characteristics such as grade, perineural invasion, and lymphatic invasion should be considered as predictors for early nodal involvement.

Keywords: Squamous cell carcinoma, tumor thickness, Lymph node, Transcutaneous Ultrasound

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Hypofractionated Simultaneous Integrated Boost (SIB) versus Conventional Fractionation in Localized Prostate: A Randomized Pilot Study


K. El-Ghamrawi1, M. El-Haddad1, S. Hanna2, A. Ali1, M. Kamal3
1Department of Clinical Oncology, Cairo University Hospital, Egypt. 2Department of Radiology,
Cairo University Hospital, Egypt. 3Radiation Physics unit, Cairo University Hospital, Egypt


Purpose: Radical prostatectomy or radiotherapy has comparable results in the treatment of localized prostate cancer. High dose external irradiation entails a prolonged 7-8 weeks of treatment with significant inconvenience to elderly patients. Hypofractionated regimen in prostate cancer depends on the distinctive radiobiological properties of prostate cancer cells; their relative low alpha beta ratio compared to that for late-reacting rectal tissue allows for significant dose escalation per fraction without expected increase in late normal tissue reaction.

Patients and Materials: Between July 2012 and December 2013, twenty patients were blindly randomized into two groups. The planning target volume in the study group received 65Gy to 67.5Gy/25 fractions over 5
weeks. The patients in the control arm received 74Gy to 78Gy in 2Gy/fraction. Cost-benefit was evaluated for both regimens.

Results: Both groups were comparable regarding risk factors, with no significant statistical differences. Four patients in the study group developed grade 2 urinary toxicity and one patient had grade 3 during treatment. At six months no patient had urinary symptoms. In the control arm 4 patients have grade 2 toxicity during treatment which disappeared at six months. The two groups showed no statistical difference in the mean quality of life. Serum PSA reached a nadir value of 0.02 and 0.04 in the study and control groups respectively at 3 month post-treatment. The cost of treatment for the study group was 25000 L.E. per patient compared to 40000 L.E. in the control group. The hypofractionated group consumed 31138 MU compared to 45611 MU for the control group with a p-value of 0.015.

Conclusion: Hypofractionated IMRT with concomitant boost for localized cancer prostate is a feasible option with lesser cost and comparable toxicities. Longer followup is required to assess the late effects before recommending it as a standard of care.

Keywords: IMRT, prostate cancer, hypofractionation, local tumour control

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Quantitative evaluation of the dosimetric effects of balloon deformation and source position in high-dose rate mammosite breast brachytherapy


I. Ali1, S. Negusse2, S. Ahmad1, O. Algan1
1Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA.
2Muskogee Regional Cancer Center, 300 Rockefeller Dr, Muskogee, OK, USA


Purpose: To investigate quantitatively the deformation of the mammosite balloon, eccentricity of the source position and their effects on the dose delivered to the tumor lumpectomy site and critical structures.

Materials and Methods: The distances of the brachytherapy source to the surface of the mammosite balloon were measured in using radiographic images for fractions 1 to 10 for twelve patients. The dose at the balloon surface (nearly 680cGy) and prescription dose of 340cGy at 1cm from the balloon surface were calculated for the different fractions and their dependence on the balloon volume and source position were

Results: The position of the source can be offset from the center of the mammosite balloon by up to 6mm.
Deformation of the balloon led to variations in its dimensions by up to 8mm. The dose at 1cm from the balloon surface that covers the lumpectomy site varied by up to 19% from 340cGy along the elongated diameter of the balloon and by up to 40% along the short diameter. Maximal doses to the skin, ribs and lung were 420cGy, 630cGy and 500cGy per fraction, respectively, which depended mostly on their distance
from the balloon surface.

Conclusion: The geometric variations in the shape of the balloon and position of the source can cause lack
of dose coverage to the lumpectomy site or create hot dose spots in the surrounding normal tissue that might compromise intended clinical goals. Users as well as vendors should consider correction measures for the deformation of the balloons and the eccentricity of the position of the high dose source.

Keywords: breast cancer, lumpectomy site, mammosite, highdose-rate brachytherpay, balloon deformation, source centricity

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Spectrum of ovarian tumors: Histopathological study of 218 cases

N.A. Mansoor1, H.S. Jezan1, 2
1Faculty of Medicine and Health sciences. University of Aden Yemen.
2 Ibin Sina Laboratory Aden, Yemen


Background: Ovarian tumors are a group of neoplasms that have diverse spectrum of features according to
the particular tumor entity. Ovarian cancer is the leading cause of death in females. The aim of this study is to determine the frequency of ovarian tumors and its distribution according to cell of origin and age group.

Material and method: This is a retrospective study of all cases of ovarian tumors collected during a period of 9 years from the Histopathology Department of Al-Gamhuria Teaching Hospital from 1993-1996 and Ibn Sina laboratory in Aden Governorate from 2009- 2013.

Results: The tumors are grouped according to the nature of tumor whether benign, borderline or malignant,  and according to cell of origin and age group. Benign tumors are the most frequent (86.7%), and malignant are less (13.3%). The total surface epithelial tumors are 63.7%, benign serous tumors are the most common (44%), followed by mucinous t mors (9.6%), serous tadenocarcinoma (2.8%), mucinous cystadenocarcinoma (1.8%), serous cystadenoma borderline (1.4%), and endometrioid adenocarcinoma (1.4%). The least frequent tumors are mucinous cystadenoma borderline and poorly differentiated carcinoma at 0.9% each. Tumors derived from sex cord stromal tissue as benign fibroma and thecoma comprise 5%, while malignant tumors are granulosa cell tumor (1.4%) and androblast ma moderately differentiated (0.5%). Tumors derived from germ cell as benign cystic teratoma are 26.6% while malignant tumors were dysgerminoma (0.9%) and malignant teratoma (0.5%).

Conclusion: Benign tumors outnumber the malignant tumors. Surface epithelial tumors are the most common class of tumors. Bilateral tumors are not frequent. The high death rates are due to advanced malignancy during the time of diagnosis from the majority of cases.

Keywords: ovarian tumors, cell of origin, age

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Rare Chromosome Structural Aberration Characterizing Oncology Malignancy


A. Movafagh1, A. Sayad1, M. Hashemi2, H. Darvish1, D. Zare-Abdollahi1, B. Emamalizadeh1, F. Shahvaisizadeh1, N. Mansouri1, S. A. Mortazavi-Tabatabaei3
1Department of Medical Genetics, Pediatric Neurology Research Center, Mofid Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Department of Molecular Genetics, Islamic Azad University, Tehran Medical Sciences Branch, Tehran, Iran.
3Proteomics Research Center, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.


Ring chromosome aberration are rare abnormality potentially involving any chromosome in patients diagnosing in Oncology. The present review and case study has focused on the ring chromosome associated with oncology malignancies.

Material and Methods: An electronic peer review article search was performed systematically to obtain relevant literature with the CINAHL, Google scholar, and Pub Med databases. The keywords included marker, abnormalities, structural, Ring chromosome. The inclusion criteria for the review were that the documents were original quantitative research and published in English. This was also initiated using Medline, Mitelman database (, Danish cytogenetic register and other pertinent web references on ring chromosomes in Oncology malignancies. Articles that were not directly relevant to the present objective were excluded. Also the un-stimulated bone marrow specimen of present case manipulated with Methotrexate cells culture synchronization and finally was treated by GTG banding technique.

Results: Ring chromosome was observed in 10% of the total cells. Cytogenetic analysis demonstrated apparently ring (15) 46, XY, r(15) karyotype. The clinical findings revealed history of nausea, loss of  appetite, diarrhea, night sweats, and a weight loss, anemia and diagnosed as accelerated CML.

Conclusion: Our finding adds to the spectrum of both morphology and genetic rearrangements in oncology
malignancies. Additional future analyses in similar subject will be necessary to draw firm conclusions.

Keywords: Ring chromosome; Marker; Malignancy; Mechanisms; Abnormality

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Infectious complications after allogeneic bone marrow transplantation: Sheikha Badryia Center, Kuwait


S. AlShemmari1, S. Refaat2, A. A. Abdullah3, M.A. Abul4
1Department of Medicine, Kuwait University Faculty of Medicine, Kuwait.
2Department of Medical Oncology, Shaikha Badryia Stem Cell Transplant Center; Kuwait Cancer Center, Kuwait .
Microbiology Department, Ibn Sina Hospital, Kuwait.
4Virology Department, Mubarak AlKabeer Hospital, Kuwait


Objective: To present our experience of post-transplant infections in allogeneic stem cell transplants at Sheikha Badryia Stem Cell Transplant Centre, Kuwait.

Methods: Retrospective analysis of 21 consecutive patients with malignant and non-malignant hematological disorders who received a transplant of an unmanipulated bone marrow graft from an HLAidentical sibling donor from November 2011 to December 2013. Pre-transplant infection surveillance was carried out, and strict prophylaxis against infection was observed. Bone marrow stem cells were used as the stem cell source. Cyclosporin and methotrexate with or without mycophenolate mofetil / methylprednisolone were used as graftversus-host disease (GVHD) prophylaxis. The engraftment was monitored with molecular analysis. Survival was calculated from the date of transplant to death or last follow-up.

Results: Twenty-one patients received allogeneic stem cell transplants from HLA- matched siblings for various hematological disorders. Twelve patients were female. The median age of the patient cohort was 34 years (range 3-41 years). All patients and donors were cytomegalovirus (CMV) IgG-positive. Seventeen patients (80.95%) developed febrile episodes in different phases of post-transplant recovery. Posttransplant infections were confirmed in 20 patients (90.2%) on the basis of clinical assessment and microbiological, virological, and histopathological examination. Mortality related to infections and chronic graft versus host disease was one patient (4.8%).

Conclusion: 90% of our patients developed febrile episodes with relatively low culture yield. The majority of infections were treated effectively.

Allogeneic stem cell transplants, Infections, Kuwait

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