Issue 43Issue No. 43, September 2023
Electronic ISSN 2521-3881
Issue No. 43 - September 2023
7-11 Outcomes of Breast Intraoperative Electron Beam Radiotherapy (IOeRT) : Case Series of Single Institute Experience in Saudi Arabias

Abdullah Alsuhaibani1, AbdulRahman Alqahtani2, Abdulaziz Alsaif2, AreejBokhari2, Basel AlMefleh3, Yara Aldigi3, Tareq Salah1, 4

1Radiation Oncology department, King Khalid University hospital, King Saud University, Saudi Arabia

2Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia.

3Medical Internship, King Khalid University hospital, King Saud University, Saudi Arabia.

4Clinical oncology and nuclear medicine department, faculty of medicine, Assiut University, Egypt.


Introduction : 85-90% of local recurrences after breastconserving surgery occurs within the index quadrant. Intraoperative radiotherapy may be a good alternative for eligible patients avoiding long course of adjuvant radiation.


Patients and methods: Eligible patients were early stage node negative at least 50 years at time of inclusion, unicentric less than 30mm in diameter any hormone receptor status. 21 Gy was delivered intraoperatively, biologically equivalent to 58 to 60 Gy in standard fractionation using electron beam to 90% isodose line. Cosmetic, Oncological and Patient Satisfaction Evaluation of treated Patients between March 2018 and August 2020 at the King Khalid university hospital, using the IOeRT (Mobetron®). Evaluation done at a combined clinic between surgical and radiation oncology teams at the end of the follow up period before publication.


Results: 15 female patients were evaluable with mean follow up period 33.8 months (19-48 months). Mean Age 56.4 years (50-65 years). Mean tumor size 1.213 cm. Majority of patients were T1. 2 patients showed Sentinel lymph node positive.21 Gy was delivered intraoperatively.4 Patients (26.7%) received adjuvant postoperative external beam radiation therapy (EBRT). 2 patients due to being in Caution group due to positive extensive Ductal carcinoma in situ (DCIS). External beam radiation was 40 Gy/15 fractions/3 weeks using three dimensional radiation therapy (3DCRT). Cosmetically, Apart from one patient score 9 due to presence of keloid scar formation, most patients were in range of 0-3 according to physician evaluation and Modified Hollander's score otherwise, No more than score 3 in any of the patients was detected. Oncologically, Till the time of publication no local or distant relapses was detected. As a patient experience, 100 % of patients were satisfied.


Conclusion : Breast IOERT is a convenient, safe and a valid treatment modality as an option for patients who are otherwise appropriate candidates for APBI. Proper patient selection should focus on clinicopathologic factors predictive of negative nodes and negative margins. Careful assessment of preoperative mammographic and other imaging studies for features, such as extent of calcifications, may be helpful.


Keywords: Intraoperative radiotherapy, Breast cancer, Radiation. IOeRT.


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2 12-18

Comparison of Effectiveness of Moringa Oleifera Leaves Extract Gel (2%) with Retino A (0.1%) Cream for Treatment of Oral Leukoplakia: Double Blinded Randomized Control Trial


Sulem Ansari 1, Shivayogi Charantimath1, Anabelle Fernandes1, Jayraj B. Malik1, Prashanth Panta2,

1 Department of Oral Medicine and Radiology, KLEVK Institute of dental sciences, Belagavi, India
2 Department of Oral Medicine and Radiology, Malla Reddy Institute of Dental Sciences, Hyderabad, India


Aim : The study aims to evaluate and compare the efficacy of Moringa oleifera leaf extract gel (2%) & Retino A cream (0.1%) in reducing the size of lesions in oral leukoplakia.


Objectives : The present study aimed to evaluate the efficacy of two interventions, Moringa oleifera mucoadhesive gel and Retino-A cream, in reducing the size of lesions in patients with oral leukoplakia. Specifically, the objectives were: (1) to assess the efficacy of Moringa oleifera mucoadhesive gel in determining the reduction in lesion size, (2) to assess the efficacy of Retino-A cream in determining the reduction in lesion size, and (3) to compare the efficacy of Moringa oleifera mucoadhesive gel (2%) in determining the change in lesion size in oral leukoplakia patients.


Methods : Clinically diagnosed cases of oral Leukoplakia were included in this study. The sample size is 72. Thirty-six patients had lesion sizes ranging from 2- 4 cm, and 36 patients had lesion sizes ranging from 4.1- 6 cm that were equally distributed in the case and control groups using the chit system. The case and control groups had 36 patients with an equal size range of lesions. The case and control group participants will be advised topical application of the intervention and Retino-A thrice daily using a sterile cotton bud.


Results : M. oleifera gel (2%) was found to be more effective in the reduction in the size of the lesion as compared to Retino-A in the treatment of oral leukoplakia patients.


Conclusions: This study showed that M. oleifera mucoadhesive gel (2%) is an effective and safe treatment option for oral leukoplakia patients. It demonstrated a significant reduction in lesion size compared to Retino-A cream (0.1%) after 3 months of therapy, without any reported adverse effects. However, long-term follow-up studies are needed to evaluate its long-term effectiveness. The potent antioxidant property of M. oleifera makes it a promising candidate for further studies with concentration variations and in other potentially malignant oral disorders, such as lichen planus and OSMF. The development of chemotherapeutic drugs from M. oleifera for cancer treatment should also be considered. Overall, M. oleifera appears to be a promising natural alternative to synthetic drugs for the treatment of oral leukoplakia.

Keywords: Leukoplakia, Oral leukoplakia, premalignant lesion, precancer, potentially malignant disorders.


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3 19-24 Barriers related to Oral Cancer Screening, Diagnosis and Treatment in Karnataka, India

Vijay C R1, Ramesh C1, P Sridhar2, C Ramachandra3, Madhu kumar1

1 Department of Epidemiology and Biostatistics, Kidwai Memorial Institute of Oncology, Bangalore-29
2 Department of Radiation Oncology, Kidwai Memorial Institute of Oncology,Bangalore-29.
3 Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore-29


Background: The most predominant cancer in India is Oral cancer. Annually 130,000 people yield to oral cancer in India, which translates into about 14 deaths per hour and 60-80% of patients present with advanced disease as compared to 40% in developed countries.


Aim: To decide factors associated with primary, secondary and tertiary delays and identify reasons for a lack of follow-up.

Materials and Methods: This study was conducted at the Kidwai Memorial Institute of Oncology, Bengaluru. A hospitalbased cross-sectional study using the direct personal interview method was done. A total of 200 oral cancer patients were included in the study.

Results : 34.5% were men and 65.5% were women. About 97.5% of patients were engaged with either one of the habits like smoking, chewing or alcohol consumption. 84% of patients were not aware of the risk of getting oral cancer. 29% of people agreed that tobacco and alcohol are risk factors for oral cancer and they know about the signs of oral cancer. If detected early, cure rates were higher compared to illiterate people and this difference is statistically significant p< 0.05. 83.5% of patients did not know that oral cancer can be diagnosed early by regular screening of the oral cavity. The cost of staying near a Regional cancer centre, job security, and the social and economic burden on relatives were significant barriers to incomplete treatment and a decreased follow-up rate.


Conclusions:Low awareness is the main barrier to oral cancer detection. Conducting cancer awareness and screening camps frequently will detect oral cancers at an early stage.

Keywords: Oral Cancer, Barriers, Cancer awareness, Oral Screening


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4 25-32

Outcomes of Vacuum-Assisted Beast Biopsy for Management of Benign Breast Masses


Khalil Terro1, Khalid ALhajri1, Mariam ALshammari2

1 Department of General Surgery, Specialized Medical Center, Riyadh, Saudi Arabia.
2 2 Department of General Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.


Introduction : The triple assessment, which combines a clinical examination, radiological imaging, and pathology, is used to assess the breast mass. The open excision of the suspicious lesion is the gold standard for breast biopsy techniques. However, because an excisional biopsy always results in a scar, many surgeons are considering less invasive, alternative methods due to the cost and morbidity of this operation. Image-guided percutaneous core-needle biopsy has recently gained popularity in identifying palpable and non-palpable breast lesions. Vacuum- assisted breast biopsy (VABB) was created to address some of these limitations of core-needle biopsy.

Methodology: We performed a retrospective review of 38 patients who underwent VABB.To Report the recurrence one-year post-VABB for management of benign breast masses and To evaluate patient-reported cosmetic satisfaction using the cosmetic scale.

Results: The mean age of the study participants was about 30.34 (+/-10.11) years. The average size of breast masses was 1.23 (+/-0.83) cm. The recurrence rate was 13.16%, confirmed by follow up ultrasound and all these patients underwent excisional biopsy. There were significant differences in breast mass recurrence rate by the side affected. Recurrence was more likely in right-sided breast masses (P=0.048).In our study, no significant relationships between the occurrence of complications following surgery and patient's demographics and mass features and no infection were reported. The hematoma was reported in 2 patients 5.26 %, Mild induration at the site of surgery 2 patients 5.26 %, Small contusion at the site of surgery in one patient 2.63 % and no other complication was reported. The patient's cosmetic satisfaction using the cosmetic scale from 1-5,1: not satisfied,2:low satisfaction,3:mild satisfaction,4:moderate satisfaction,5; completely satisfied, The mean cosmetic score was 4.03.

Conclusion: Our study concluded that VABB is reliable for removing small benign breast masses with a satisfying cosmetic outcome & low recurrence rate, and fewer complications.

Keywords: Benign Breast disease, Breast biopsy and Fibroadenoma.

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5 33-39 Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer in a Lebanese experience: in all aspects

Nizar Ahmadieh1, Toufic Zeidan2, Josselin Abi Chebel1, Fady Gh Haddad2, Elie Nemr1

1Department of Urology, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon.
2Department of Hematology-Oncology, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon.


Background : Bladder cancer (BC) is the most common malignant tumor of the urinary tract and the 11th most frequent cancer worldwide. BC is the 2nd most common cancer in Lebanon in men and women.

Materials and Methods: After searching for patients records in the pathology and oncology database, we identified those who underwent a cystectomy between 2017 and 2019 in our hospital, Hotel Dieu de France - Beirut. We selected for the study the patients who have undergone a cystectomy for MIBC. We excluded patients who initially had a pelvic tumor, or a prostate cancer invading the bladder, and patients with absent medical record from the study. We also noted the gender of the patients, if they are smokers and the number of pack years at the time of diagnosis, as well as their age, the histological type of the tumor, its stage according to the TNM classification and its grade. We also noted whether neoadjuvant chemotherapy was taken by the study's subjects.

Results: The total number of patients who met the inclusion and exclusion criteria was 38. The median age of the population was 66 (+/-10) years and the median number of pack years at diagnosis was 60 (+/- 36). 79% of study's patients were males and 21% were females. Regarding the tumor's histological type, the urothelial type predominated with 92% while the remaining 8% were of the squamous type. Regarding treatment modalities, only 20% of patients in the study received neoadjuvant chemotherapy before cystectomy. 80% of patients underwent a cystectomy directly without neoadjuvant and/or adjuvant chemotherapy. No patient received adjuvant chemotherapy. Among the 7 patients, 2 patients (29%) presented a pathological complete response (pCR; equivalent to pT0N0M0). 14% had a pT3 stage post-neoadjuvant chemotherapy and 43% had a pT4 stage.

Discussion and conclusions: We can note a reluctance of urologists at our institution to prescribe neoadjuvant chemotherapy. It would therefore be interesting to extend the study to the national level with a larger number of patients, as well as to evaluate survival in patients who received neoadjuvant chemotherapy, especially in those presenting a pCR. Our study can serve as a point of change in the practice of urologists in Lebanon regarding BC.

Keywords: Bladder cancer, Lebanese, chemotherapy, neoadjuvant chemotherapy.

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6 40-45 The External Jugular Vein Cut-Down Method for Chemoport Insertion from a Tertiary Cancer Treatment Center in Central India: A Prospective Study

Sandeep Ghosh1, Bonny Joseph1, Amar Jain1, Sanjay M Desai1, Vinod Dhakad1, Soumya Singh2

1 Department of Surgical Oncology, Sri Aurobindo Medical College &P.G Institute, Indore, M.P, India
2Department of Anaesthesiology, Sri Aurobindo Medical College & P.G Institute, Indore, M.P, India


Introduction: In the realm of oncology, the development of TIVAD (chemoport) has been a blessing for cancer patients, freeing them from having to undergo numerous recurrent venepunctures throughout their treatment. The External Jugular Vein cut-down has been the standard procedure for administering chemotherapy to cancer patients at our institution. Here, we discuss our experience with the External Jugular Vein cut-down Chemoport Insertion Technique and the outcomes it produced.

Materials and Methods: We performed a prospective observational study and included all patients who underwent the open External Jugular Vein cut-down technique of Chemoport Insertion from January 2019 to January 2022 in the Department of Surgical Oncology at our hospital.

Results: Out of 136 patients, 3 (2.2%) had failed external jugular vein (EJV) cannulation, and alternative access (Internal Jugular Vein) was chosen for cannulation. The most common indication for chemoport insertion in our study was carcinoma of the breast, around 72.93% (97/133), and hence the majority of patients were females, about 84.21% (112/133). Only 18.04% (24/133) were male patients. The age distribution ranged from 2 years to 84 years. Out of 133 patients, complications were observed in 14 patients (10.52%). Around 6 patients (4.5%) had problems with catheter blockage after one cycle of chemotherapy. 4 patients (3%) had port infections at the chamber region (pectoral region). 3 patients (2.2%) had catheter tip displacement into the brachiocephalic vein. 1 patient (0.75%) had extravasation of chemotherapy.

Conclusion: In conclusion, our study demonstrates that the External Jugular Vein cut-down technique offers several advantages in the realm of oncology, as it is a safe, efficient, and straightforward technique for chemoport insertion. With its minimal learning curve and simplicity, this technique represents a favorable initial option for successfully implanting chemoports in cancer patients. Further research and comparative studies are needed to validate and further explore the benefits of this technique in diverse patient populations and healthcare settings.

Keywords: Chemoport, TIVAD, External Jugular Vein, Chemotherapy access port, cut-down technique

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7 46-50 Beam Focal Spot Offset Determination for Linear Accelerators: A Phantom less Method

Silpa AjayKumar1,2, Arathi.C1, Resmi KB1, Suja C A1, Lisha Jose1, Vinin.N.V1, Geetha Muttath1, M.M Musthafa2

1 Radiation Oncology Department, Malabar Cancer Centre, Kerala, India
2 Dept. of Physics,University of Calicut, Calicut UniversityP.O, Kerala. India


Abstract: The effectiveness of radiotherapy treatment is influenced by the position of beam focal spot; therefore, it is important to verify the beam focal spot periodically. In this study the beam focal spot offset is measured using an electronic portal imaging (EPID) based technique and co- rotational penumbra modulation technique(CPM).

Materials and Methods : This method utilizes one set of jaws and the multileaf collimator (MLC) to form a symmetric field and then a 180o collimator rotation was utilized to determine the radiation isocenter defined by the jaws and the MLC, respectively. The difference between these two isocentres is then directly correlated with the beam focal spot offset of the linear accelerator. In the current study, the method has been used for Varian ClinaciX and Elekta Versa HD linear accelerators. Since an Elektalinac with the AgilityŽ head does not have two set of jaws, a modified method that making use of one set of diaphragms, the MLC and a full 360o collimator rotation is implemented.

Results: The method is validated against CPM and found to be in agreement within 0.00923+/- 0.009360 mm ( SD) also the method has been found to be reproducible to within 0.0365 mm (SD).

Conclusion: The method could be used for routine quality assurance (QA) to ensure that the beam focal spot offset is in tolerance.

Keywords: QA,focal spot. EPID, ClinaciX, Versa HD

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8 51-60 Early Development of Cancer Treatments

Zainab H. Almansour1

1 Biological Sciences Department, College of Science, King Faisal University, Hofuf 31982, Saudi Arabia.


Abstract: The treatment of cancer has evolved as our understanding of the underlying biological processes has improved. Yet, the efficient delivery of cancer therapeutics remains a major challenge in the filed necessitating a multidisciplinary approach that integrates knowledge obtained from diverse fields, such as chemistry, biology, engineering, and medicine. Cancer treatment aims to remove all or most of the tumor as possible and to prevent the recurrence or spread of the primary tumor. Cancer treatment involves a careful examination of the available options, which may include a combination of the major treatment methods, such as surgery with chemotherapy and/or radiation therapy. The type of therapy chosen depends on several factors, such as the location, grade, and stage of the tumor, as well as the patient's performance status. As new knowledge about cancer biology becomes available, treatments will be developed and modified in the pursuit of cancer cures to improve efficacy, precision, survivability, and quality of life. The main objective of this review is to expand our understanding of the early development of commonly applied cancer treatment strategies: surgery, chemotherapy, and radiotherapy.

Keywords: Chemotherapy; Radiotherapy; Surgery; Therapy; Tumor.

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9 61-66 An Unusual Cause of Recurrent Visible Hematuria; Posterior Urethral Hemangioma: A Case Report and Review of Literature

Moath K. Alfentoukh, Abdullah H. Alghamdi, Ahmed Allohidan, Ahmed Alzahrani, Saeed Abdullah Alzahrani, Rami M. Hasan

Department of Urology and Nephrology, King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia


Abstract: Urinary tract hemangiomas are uncommon entity to urologists, despite their benign nature and course; they can cause significant patient's hemodynamic instability or distress if not recognized and managed properly. Here, we present a case of urethral hemangioma with its treatment, follow-up course and review of literature of similar cases.

Introduction: Bloody urine or urethral bleeding can be the initial presentation of a number of different medical and surgical conditions, some of which are benign and others are malignant, when encountered, they are alarming and must be evaluated thoroughly. As a cause, urethral hematomas are faced rarely, among all urinary tract sites; they are the second least common(1). Due to their paucity in clinical practice, there is no agreed approach on their management and each case has to be individualized. In the literature, different assessment and treatment methods were tried with satisfactory outcomes in each one. Here we report a case with detailed, concise explanation of such pathology and a comprehensive comparison in light of previous literature.

Keywords: Urethral hemangioma, urethral bleeding, benign urinary tract tumors

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10 67-73 Scrotal Wall Metastasis from Adenocarcinoma of Unknown Origin, with Concurrent Extramammary Paget's Disease - a Case Report

Liang Meng Loy1, Kiat Yee Elise Vong2, Szu Lyn Cristine Ding3,4, Zhan Peng Daniel Yong5, Justin Kwan1, Bien Peng Tan 1

1 Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
2 Department of Medical Oncology, Tan Tock Seng Hospital, Singapore
3 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
4 Department of Pathology, Tan Tock Seng Hospital, Singapore
5 Department of Urology, Tan Tock Seng Hospital, Singapore


Introduction: Scrotal cancer is a very rare disease, with the most common subtype being squamous cell carcinoma. Metastatic carcinoma to the scrotal wall is very rare. A histological finding of adenocarcinoma in a scrotal malignancy invariably suggests a metastasis from another primary cancer. We describe an enigmatic case of metastatic adenocarcinoma to the scrotum managed as metastatic adenocarcinoma of unknown origin. Attempts to identify a primary cancer were complicated by ambiguous diagnostic results. This is the first case in literature of metastatic cancer to the scrotum from an adenocarcinoma of unknown origin, and this was complicated by concurrent extramammary Paget's disease.

Case Presentation: A 70-year-old male presented with painless progressive scrotal skin swelling, which was shown on histology to be adenocarcinoma. Immunohistochemistry showed prostatic lineage markers. However, the argument for a prostatic primary was weakened by negative prostate transrectal ultrasound biopsy findings and negative radiological findings. The scrotal metastatic adenocarcinoma was managed as metastatic adenocarcinoma of unknown origin. A differential of occult poorly differentiated prostatic primary was considered in view of the clinical phenotype of an elderly male patient with extensive sclerotic bony metastases, immunohistochemistry results and relatively low PSA level in relation to systemic burden of disease. The patient was managed with palliative systemic chemotherapy (carboplatin/paclitaxel) with initial disease response, but eventually developed progressive disease.

Discussion and Conclusion: Finding of adenocarcinoma in scrotal skin malignancy indicates a metastasis and should prompt further work-up to identify a primary cancer, particularly of other genitourinary or lower gastrointestinal origin, so that treatment can be targeted at the underlying primary malignancy. However, attempts to identify a primary cancer might be complicated by ambiguous diagnostic results.

Keywords: Scrotal cancer, adenocarcinoma of unknown origin, prostatic metastases, extramammary Paget's disease, case report

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11 74-77 Glioblastoma with Primitive Neuroectodermal Tumor like Component: Rare and Enigmatic.

Sameer Ahmed AH. Ansari1, Mahera Roohi1, Khalifa A. Al doseri1, Khalid Ahmed Alsindi1, Talal A. Almayman2

1 Department of Pathology, King Hamad University Hospital, Bahrain
2 Department of Neurosurgery, King Hamad University Hospital, Bahrain


Abstract: Glioblastoma (GBM) with Primitive Neuroectodermal tumor (PNET) like features is an extremely rare tumor showing dual features of malignant glioma and primitive neuroectodermal tumour occurring mostly in adults. It poses diagnostics dilemma to the neuropathologist and treating oncologist team because of its rarity, tendency to spread to cerebrospinal fluid and dismal prognosis. We have described this tumor in a 11 years old male child in this case report.

Keywords: glioma,glioblastoma,primitive neuroectodermal tumor, variant, pediatric

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