Shaukat Khanum Memorial Cancer Hospital Research Articles

INCIDENCE OF ACCIDENTAL AWARENESS DURING GENERAL ANESTHESIA – A TERTIARY CANCER CARE HOSPITAL EXPERIENCE

Objective: To find out the incidence of accidental awareness during general anesthesia in a cohort of cancer patients in a tertiary care center in Pakistan. Methodology: This was an observational study conducted on cancer patients undergoing surgery under general anesthesia in Shaukat Khanum Memorial Cancer Hospital and Reserach Center. A total of 1000 patients were interviewed by a registered nurse in the Post-Anesthesia Care Unit (PACU) using the modified Brice questionnaire. The outcome measured was the incidence of awareness and/or dreaming intra-operatively. Results: Among the total 1000 patients, 516 patients were male and 484 were females. There were 356 patients under the age of 40, 462 between the ages of 41 and 60, and 182 above 60 years. Most of the patients were American Society of Anesthesiologists (ASA) Grade 2 (n = 834), while 14 were ASA Grade 1 and 152 were ASA Grade 3. The total intravenous anesthetic was used on 83 patients, whereas balanced anesthesia was used on 917. Elective surgery was performed on 968 individuals, while emergency surgery was performed on 32 others. Two patients had definitive awareness (n = 2) and two patients described dreaming during surgery (n = 2). Conclusion: Our study found the incidence of awareness during general anesthesia in the adult cancer population to be at par, if not more than that reported worldwide.

Prevalence and Risk Factors of Low Anterior Resection Syndrome in Epithelial Ovarian Cancer Surgery.

BackgroundIn this study, we aimed to determine the prevalence and risk factors of low anterior resection syndrome (LARS) in epithelial ovarian cancer (EOC) surgery.MethodologyA descriptive cross-sectional study was conducted at the Gynecologic Oncology Section of the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan. Using non-probability consecutive sampling technique, all patients who underwent cytoreductive surgery involving low anterior resection for EOC between January 2016 and January 2021 were included. Patients were assessed for LARS symptoms using the LARS score, along with its risk factors. Descriptive statistics, that is, continuous variables were expressed as the median and interquartile range, while categorical variables were expressed as frequencies and percentages. The LARS score was categorized according to a two-tier model with “no or minor LARS” and “major LARS.” Univariate analyses were performed by the chi-square tests providing odds ratios and 95% confidence intervals to identify risk factors for major LARS.ResultsOverall, 95% of cases had LARS scores that fell in “no or minor LARS,” while only 5% of cases had “major LARS.” Univariate analyses relieved no statistically significant association between the occurrence of major LARS and any of the risk factors.ConclusionsThe prevalence of LARS was 5%, and no risk factors were associated with major LARS in our study population.

Outcomes of Uretero-ileal Anastomosis in Bladder Cancer Cystectomies: Bricker vs. Wallace 1.

BackgroundThe two commonly used methods for uretero-ileal anastomosis (UIA) during radical cystectomy for muscle-invasive bladder cancer (MIBC) are the Bricker and Wallace 1 techniques. Published data on the incidence of strictures at anastomotic sites is limited. This study compares both anastomotic techniques in terms of uretero-ileal stricture (UIS) rates and the factors that govern it in the patient group.Material and methodsRecords of all patients presenting with bladder cancer who underwent radical cystectomy at the department of uro-oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) Lahore, Pakistan, from January 1, 2009, to December 31, 2018, were reviewed retrospectively, and all adult patients aged >18 years out of them were selected for the study.ResultsWith a total of 116 patients, the mean age was 54.37 ± 11.16 and a male majority (83.6%). Urinary diversion using ileal conduit was performed in 70 (60.3%) patients and the rest of them i.e. 46 (39.7%) had neobladder formation. Amongst them, uretero-ileal anastomosis was constructed via Bricker and Wallace 1 in 73 (62.9%) patients and 43 (37.1%) patients respectively. Pelvic radiotherapy was received by 13 (11.2%) patients. Anastomotic stricture developed in 19 (16.4%) cases. A relatively similar proportion of stricture rate was found in Bricker and Wallace 1 technique (10% vs 13%). Body mass index (BMI) was found to be significantly higher in patients who developed UIS. Incidence of stricture formation was more on the left than right side i.e. 12 (63.2%) vs five (26.3%) while two (10.5%) patients developed bilateral strictures.ConclusionNo significant difference in stricture formation was noted between Bricker and Wallace 1 technique. High BMI and anastomotic leaks were the contributory factors for this complication during our experience.

Survival outcomes of unilateral retinoblastoma based on pathological risk stratification-experience at a tertiary care centre in Pakistan.

Retinoblastoma (RB) is the most common childhood intraocular malignancy. In high-income countries over the past decade, upfront enucleation for unilateral RB is least favoured due to other alternatives that can help in globe preservation, but in low-middle income countries it is still the preferred option due to lack of resources and expertise. The treatment of RB after enucleation is tailored based on the histopathological risk features, as adjuvant chemotherapy with high-risk features reduces the risk of metastasis. The aim of our study was to analyse the survival outcomes of adjuvant therapy based on histopathological risk stratification in patients who underwent upfront enucleation for unilateral RB with advanced disease. A retrospective study was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan. A total 113 patients (aged 3 months till 16 years) diagnosed with unilateral RB who had upfront enucleation from July 2009 till January 2019 were included in this study. The mean age of diagnosis was 37.4 months (±24.5) and male-to-female ratio of 1.3:1. The most common clinical presentation was leukocoria (74.3%). Patients who underwent enucleation had advanced disease; group D present in 62.8% followed by group E (32.7%). Histopathology revealed high-risk features in 29 patients (25.7%) and intermediate risk in 54 patients (47.8%). Disease progression and relapse was seen in patients with high-risk histopathological features. The 4-year over-all survival and EFS observed for this cohort was 74% and 71%. Awareness about the early symptoms among the general population and health care personnel at a nationwide level is needed to facilitate early detection and lessen disease related morbidity and mortality.

Breast conservation surgery (BCS) for breast cancer in a resource limited country - Are we upto the challenge!

To analyse outcomes of breast conservation surgery and to identify the factors that could have affected the outcomes. The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of breast conservation surgery cases done between January 2011 and October 2014 in order to cover up for the 5-year follow-up of the last enrolled patient. Data, obtained through the institutional information and database system, included disease-recurrence, 5-year disease-free survival and overall survival. Data was statistically analysed using SPSS 20. Of the 553 cases, 417(75%) had no loco-regional recurrence or distant metastasis, while 136(25%) had some form of loco-regional, distant or contralateral metastasis at 5-year follow-up. In patients who had recurrence or metastasis, only progesterone receptor status, nodal status and mode of treatment showed significant association (p<0.05). Mortality at 5-year follow-up was 77(14%). Amongst the patients who died, only progesterone receptor status and nodal status had significant association (p<0.05). Five-year overall survival for the cohort was 476(86%), whereas 5-year disease-free survival was 409(74%). Breast conservation surgery was found to have favourable outcomes, while progesterone status, nodal involvement and mode of treatment significantly affected the outcome.

Efficacy of Paediatric Preinduction Anxiety Distraction Techniques During Oncologic Procedures

Introduction: Children undergoing oncologic procedures as part of their treatment may suffer from anxiety. It could be related to parental separation, pain/ bodily harm or a previous bad experience of procedure. Pre-procedure anxiety may result in adverse clinical outcomes such as emergence delirium, pulmonary complications and behavioral issues. Preoperative anxiety must be assessed to deal with using appropriate preinduction distraction techniques.&#x0D; Aims &amp; Objectives: The objective of audit is to determine efficacy of preinduction distraction techniques used in our clinical set up (to meet RCoA standards) in reducing anxiety and need of restrain for children at time of induction.&#x0D; Place and duration of study: Shaukat Khanum Memorial Cancer Hospital &amp; Research Centre, Lahore Pakistan. 14th of January 2020 to 15th of March 2020 (8 Weeks).&#x0D; Material &amp; Methods: It is a prospective outcome-based audit study of 101 children (2-8 years) undergoing intrathecal chemotherapy and bone marrow biopsy at Shaukat Khanum Cancer Hospital, Lahore. All children had non- pharmacological preinduction distraction techniques (Parental/legal guardian presence and/or play car) to reduce anxiety, cry and need for restraint. Anxiety levels as assessed by modified Yale Preoperative Anxiety Scale (mYPAS), cry and restrain were benchmarked with Royal College of Anesthetists (RCoA) standards.&#x0D; Results: A total of 101 children with a median age of 4 years (2-8 years), had 100% parental/legal guardian presence at induction. In our audit, 52% of children cried and 43% were found to be anxious. However, only 21% children required use of restraint (holding still in laps) by accompanying parent/legal guardian. This is acceptable for restraint but not for cry/ anxiety as per RCoA benchmark.&#x0D; Conclusion: Preinduction distraction technique of parental presence and/or toy car, showed only limited benefit in terms of cry, restraint and anxiety levels. Our audited results met benchmark set by RCoA only in terms of restraint but not for anxiety/cry.

PATTERNS OF MYOINVASION IN ENDOMETRIOID ADENOCARCINOMA OF ENDOMETRIUM

Objective: To assess the patterns of myoinvasion of endometrial endometrioid adenocarcinoma, their frequencies in our hospital and to correlate these patterns with survival.&#x0D; Study Design: Retrospective observational study.&#x0D; Place and Duration of Study: Department of Pathology, Shaukat Khanum Memorial Cancer Hospital &amp; Research Centre, Lahore, from Aug 2019 to Apr 2020.&#x0D; Methodology: All cases of endometrial endometrioid adenocarcinoma between 2015 and 2017 were retrieved from the archives, independently reviewed by two researchers, all key reporting parameters recorded in addition to the pattern of myoinvasion as per their operational definitions described by Cole and Quick. The follow-up of 3-5 years was obtained from archives and through telephonic contact for outside hospital patients. Disease free survival and relapse-associated mortality were represented through Kaplan-Meier curves.&#x0D; Results: Eighty cases of myoinvasive endometrial endometrioid adenocarcinoma were reviewed. We found that infiltrating irregular gland pattern was the most frequent in all the age groups. Thirty-five (43.75%) cases showed this type of invasion, followed by broad front pattern 23 (28.75%), Microcystic Elongated and Fragmented (MELF) pattern 15 (18.75%) and adenomyotic pattern 6 (7.5%). One case showed a combination of the last two patterns, whereas adenoma malignum pattern was not seen. Follow-up of these patients showed 8 (10%) patients with relapse related mortality including 5 (62.5%) infiltrating irregular glands, 2 (25%) adenomyosis-like and 1 (12.5%) broad front pattern of myoinvasion. Seventy-two (90%) patients had recurrence free survival.&#x0D; Conclusion: Frequency of infiltrating irregular pattern of myoinvasion in endometrial endometrioid adenocarcinoma is high and associated with recurrence related mortality. Recognition....................

Hemophagocytic lymphohistiocytosis/macrophage activation syndrome: a case series

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hematologic disorder occurring more commonly in children, but there are reported cases in adults as well. It is classified as a primary HLH or secondary HLH, which can occur due to autoimmune diseases, infections, and malignancies. Secondary HLH is a challenge for physicians concerning diagnosis and management. In this case series, we report two patients of HLH diagnosed between August 2018 and August 2019 at Shaukat Khanum Memorial Cancer Hospital &amp; Research Centre Lahore Pakistan, which were triggered by different underlying conditions like autoimmune diseases and malignancies or a combination of both.

THE ROLE OF DIAGNOSTIC OESOPHAGO-GASTRODUODENOSCOPY (OGD) AND COLONOSCOPY IN CANCER OF UNKNOWN PRIMARY

Objective: To study the role of gastrointestinal procedures, namely oesophago-gastroduodenoscopy (OGD) and colonoscopy, in helping to establish a definitive primary tumour site in cancer of unknown primary.&#x0D; Study Design: Prospective observational study.&#x0D; Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital &amp; Research Centre, Lahore Pakistan, from Jan 2018 to Jan 2019.&#x0D; Methodology: A total of 115 patients included in the study were those, who underwent OGD and a colonoscopy for the diagnosis of a cancer of unknown primary. Data collected included demographics, baseline clinical characteristics, definitive diagnosis, tissue diagnosis and immune-histochemical stains. Primary outcome was the attainment of a definitive diagnosis via OGD and/or colonoscopy.&#x0D; Results: A total of 115 patients underwent a diagnostic gastrointestinal procedure. Of these 70 (61%) were males. Mean age was 63 ± 12.6 years (range 22-88 years). Abdominal pain comprised the most common presenting complaint, found in 61 (53%). The most common tissue diagnosis of the metastatic sites was adenocarcinoma 81 (70.45%). Tumour markers including carcinoembryonic antigen, alpha-fetoprotein and carbohydrate antigen 19-9 were checked in 90 (78.2%), 46 (40%) and 69 (60%) patients respectively. No patient reached a definitive diagnosis by means of OGD and/or colonoscopy.&#x0D; Conclusion: OGD and colonoscopy when done collectively as diagnostic procedures to look for a primary tumour, have no value in the evaluation of patients with cancer of unknown primary.

Skull Base Osteomyelitis: A Single-Center Experience.

BackgroundSkull base osteomyelitis (SBO) is an uncommon entity and carries a high mortality rate. It can be be odontogenic, sinogenic, or otogenic in origin, in addition to being a complication of skull surgery/trauma. Pseudomonas is one of the most commonly identified pathogen. The goal of the study is to describe the clinical spectrum, microbiologic characteristics, treatment, and its response among different patients with SBO. In addition, we compared the outcomes of bacterial and fungal osteomyelitis.MethodologyThis is a single-center retrospective analysis of patients with SBO who presented to Shaukat Khanum Memorial Cancer Hospital & Research Centre Lahore, Pakistan between January 1998 and September 2019. A total of 15 patients with SBO were identified.ResultsSBO was common in males (79.9%) with a high body mass index. Diabetes mellitus was the most common co-morbid condition (46.62%). Bacterial etiology was seen in 46.62% and fungal isolate was detected in 6.66% of the patients; 26.64% were culture-negative and the remaining had a mixed culture. The mean duration of treatment was 17.58 ± 10.85 weeks. Overall, five (33.3%) patients were cured and did not have a recurrence of symptoms at six months, while three (19.98%) had a recurrence of symptoms at six months from the end of the treatment; six (39.96%) patients were lost to follow-up.ConclusionsPatients with SBO can present with various conditions, and early identification of the condition and a positive culture growth can guide optimal treatment.

Achieving Complete Radiological and Bio-Chemical Response as a Predictor of Long-Term Survival in Stage IV Epithelial Ovarian Cancer.

ObjectiveEpithelial ovarian cancer (EOC) is common among ovarian cancers. The majority of existing literature shows combined data of stage III and stage IV. Therefore, we aimed to look for whether achieving complete radiological and biochemical response after initial treatment of stage IV epithelial ovarian cancer as a predictor of long-term survival in the Pakistani population.MethodsA cross-sectional study was conducted of patients with stage IV epithelial ovarian cancer diagnosed and treated from 2006-2013 at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Overall survival was defined as the number of months between patients’ diagnosis at the hospital and any cause of death or last follow-up date. Kaplan Meier curve was used to report the overall survival. The log-rank test was used to distinguish the survival difference in complete and no complete response. P-value <0.05 was considered statistically significant.ResultA total of fifty patients of stage IV epithelial ovarian carcinoma, with a mean age of 53 ± 2 received neoadjuvant chemotherapy and suitable patients underwent interval-debulking surgery. Among these fifty patients, twenty-one (42%) patients who achieved complete radiological and biochemical response had a median survival of greater than five years. Patients without co-morbidities (46%) and having good performance status (52%) showed better results of the treatment. Patients’ tolerance to chemotherapy with good response and fit enough to undergo interval-debulking surgery, achieving complete radiological and biochemical response after initial induction therapy were significantly associated with long-term survival (P<0.05).ConclusionOutcomes of patients who present with stage IV EOC remains dismal. Patients who achieved complete radiological and biochemical response after neoadjuvant chemotherapy and interval-debulking surgery was significantly associated with long-term survival.

Assessment of Informed Consent and the Impact of Simulation on Anesthesia Trainees.

IntroductionOver the years, the process of obtaining informed consent has evolved and now places an emphasis on the concept that patients should play a major role in medical decision making. Failure to adequately involve patients in making decisions regarding their health can lead to medicolegal consequences.Therefore, taking informed consent is a fundamental component of anaesthesia training. Simulation, for training, is an excellent tool that is being utilised widely in the training of medical professionals. The use of simulated training for teaching the process of informed consent is an innovative initiative that can provide improved results.Material and methodsAfter approval from the institutional review board, a prospective clinical study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from August 2019 to September 2020. Sixteen anaesthesia trainees were randomly selected for the study. The study was divided into pre-interventional, interventional and post interventional phases. For data collection, a predesigned checklist was used. Data collected was analysed using SPSS version 23 (IBM Inc., Armonk, New York). The McNemar test was deployed to assess the difference between the baseline assessment and post-simulated training assessment; p-value < 0.05 was taken to be significant.ResultsOf the 16 participants, the majority were males (n= 13). A positive impact was observed in terms of improvement of the outcome of the following study components i.e., description of benefits of the procedure (p=0.01), disclosure of associated minor risks (p=0.005), disclosure of major risks (p=0.01), discussion of alternatives (p=0.001), teach back (p=0.001), documentation of patients’ verbal agreement (p=0.01), and communication skills involving utilising the process of connecting, introduction, communication, permission, response, and exit (p = 0.01).ConclusionSimulated training had a positive impact in improving outcomes in the following study components: description of benefits of the procedure, disclosure of associated risks, discussion of alternatives, teach back, documentation of patients’ verbal agreement, and utilisation of the process of connecting, introduction, communication, permission, responding, and exiting.

Impact of COVID-19 Pandemic on Treatment of Pediatric Oncology Patients: Report from Resource-limited Setting.

The aim of this study was to determine how the COVID-19 pandemic impacted on the effective management; and the outcome of pediatric oncology patients in Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore. Data was retrospectively reviewed from 15 March to 15 June 2020 after the approval of Institutional Review Board Committee. A total of 258 patients on active oncology treatment between the study period were included. The total number of patients whose treatment was affected were 118 (45.7%), while 140 (54.3%) patients received treatment in time. There was total 34 (13.2%) patients relapsed, 23 (67.6%) patients in which treatment delayed, and 11 (32.4%) patients in which their treatment not delayed; while, n=218 (84.5%) were in remission, and 6 (2.3%) patients absconded. COVID-19 pandemic caused a sudden impediment in the treatment of pediatric oncology patients, and is likely to affect the long-term survival outcome of pediatric oncology patients. Key Words: Chemotherapy, Radiotherapy, Surgery, Long term outcome.

EVALUATION OF PROGNOSTIC FACTORS IN PATIENTS WITH RELAPSED HODGKIN’S LYMPHOMA UNDERGOING AUTOLOGOUS STEM CELL TRANSPLANT

Objective: To identify the prognostic factors in relapsed Hodgkin’s Lymphoma patients with regards to their impact on the outcome of autologous hematopoietic stem cell transplant.&#x0D; Study Design: Retrospective observational study.&#x0D; Place and Duration of Study: Department of Medical Oncology, Shaukat Khanum Memorial Cancer Hospital &amp; Research Center, Lahore, Jun 1999 to Jun 2019.&#x0D; Methodology: Out of a total of 2061 Hodgkin’s Lymphoma patients, 37 (1.8%) patients with relapsed disease underwent autotransplant and were studied using the Hospital Information System. We obtained details of clinicopathological factors, treatment, and outcome. In our study, the outcome variable was event after transplant (relapse/disease progression/death).&#x0D; Results: Among the 37 relapsed Hodgkin’s Lymphoma patients undergoing auto-transplant, 24 (64.9%) patients had an early relapse after first-line chemotherapy. In this early relapse group of 24 patients, 9 (37.5%) remained well after auto-transplant but 15 (62.5%) patients had an event. Out of 37 relapsed Hodgkin’s Lymphoma patients undergoing auto-transplant, a complete response on pre-transplant imaging was observed in 24 (64.9%) patients. In those 24 patients with a complete response on pre-transplant imaging, 16 (66.7%) patients remained well after transplant while 8 (33.3%) patients had a worse event. Twoyear progression-free and overall survival proportions were 56% and 77% respectively.&#x0D; Conclusion: Complete metabolic response on pre-transplant imaging was associated with better overall survival. Adverse factors observed were initial short duration of complete response, bulky disease at relapse, variables comprising international prognostic score, B symptoms, and raised erythrocyte sedimentation rate at relapse.

Risk factors for blood loss in liver resection surgery: An Institutional Review.

Background: Surgical resection of the primary or metastatic liver lesions is the treatment of choice for patients with resectable tumors. Identifying and managing preoperative and intraoperative risk factors responsible for increased blood loss during liver resection is extremely important. Therefore, the present study aims to identify preoperative and intraoperative risk factors associated with blood loss during liver resection.&#x0D; Methodology: A retrospective cross-sectional study was conducted on 72 patients who underwent liver resection for resectable primary and metastatic liver lesions at the Department of Surgical Oncology Hepatobiliary Unit, Shaukat Khanum Memorial Cancer Hospital, and Research Center Lahore. The study continued from October 2014 to July 2017, and data were collected from hospital records, including demographic, biochemical, and perioperative variables.&#x0D; Results: Out of the total 38 patients, 52.8% were female, with a mean age of 40.59 ± 21.66 years at the time of surgery. The results after multivariate analysis conclude two independent risk factors responsible for significant blood loss of more than 1000 milliliters during liver resection. These factors include liver cirrhosis, where the odds ratio is 7.96 with 95% CI (1.00-63.31) and P-value of 0.05 and operative time of 390 minutes where odds ratio is 8.94 with 95% CI (2.28-36.48) and P-value of 0.02.&#x0D; Conclusion: The risk factors associated with increased intraoperative blood loss during liver resections in our population are mainly associated with preoperative parameters, including positive viral serology and radiologically proven liver cirrhosis. In contrast, intraoperative factors were intravenous fluid administration and operative time.

Early outcomes of limb salvage surgery with mega-prosthesis

Objective: To determine the early outcomes of limb salvage surgery with mega prosthesis. Methods: This retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&amp;RC) from 1st January 2017 till 31st January 2020. Data like demographics, histopathology, functional and survival outcomes were retrieved from the Hospital Information System. Musculoskeletal Tumor Society (MSTS) score was used to evaluate the functional outcomes after the surgery. For survival analyses, Kaplan-Meier curve was applied. Prosthesis joint infection, amputation rate, metastasis, mortality rate, and recurrence were also recorded. Results: This study included 43 patients who underwent limb salvage surgery with endoprosthesis reconstruction at SKMCH&amp;RC. The mean age at the time of diagnosis was (26.5±15.8) years. Patients with distal femoral replacement had the highest MSTS scores (81.45±9.70) while those with proximal humerus replacement has the lowest MSTS scores (56.8±11.2). There was a strong association between site of tumor and MSTS (F=3.30, P=0.017). We also found a correlation between surgical site infection and MSTS scores (r=0.484, P=0.001). Patients with recurrence also had significantly lower MSTS scores (P&lt;0.05). The cumulative survival rate at the end of two-year follow-up was (71.4±17.1)% in proximal femur tumor patients, (88.0±7.8)% in distal femur tumor patients, and (50.0±3.5)% in proximal humerus tumor patients. Besides, patients with Ewing sarcoma had the highest survival rate (97.5±11.0)% while patients with chondrosarcoma had the lowest survival rate (77.8±13.9)%. Conclusions: Limb salvage surgery with mega-prosthesis can be performed with satisfactory functional and survival outcomes, but further studies are needed to compare it with other limb salvage methods. This study can be used as a reference for future studies.

Establishment of biobanking facility at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan.

Establishment of biobanking facility at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan.

Outcome of Postchemotherapy Residual Disease in Extracranial Germ Cell Tumor in Children: Experience of a Tertiary Care Center.

The aim was to review outcome with residual disease at the end of first line chemotherapy in patients with extracranial germ cell tumor (GCT) in our resource limited setting. A retrospective analysis of 196 patients with GCT recruited at Shaukat Khanum Memorial Cancer Hospital (SKMCH) from January 2008 to December 2016. Data fields included site, histopathology, stage, risk groups, baseline alpha fetoprotein, beta human chorionic gonadotropin levels, residuum after primary treatment, completeness of surgical excision and outcomes. Data analysis involved quantitative analysis, mean and median calculations, event free survival (EFS) and overall survival (OS) calculations using Kaplan-Meier curves. In 196 included patients, M:F ratio was 1. There were 81 (41.3%) adolescents. Alpha fetoprotein was >10,000 IU/L in 56 (28.6%) patients. Sixty-two (31.6%) patients had extragonadal disease. Most patients (n=137, 69.9%) presented with advanced stage (III/IV). Seventy-six patients had postchemotherapy residual disease (n=59 [78%] with partial response (PR) and 17 [22%] with no response [NR]). Five-year OS was 83% and EFS was 67%. Five-year EFS of patients with complete remission after primary chemotherapy was 85% versus 70% in patients with PR and 6% in those with NR (P=0.001). OS in patients with complete remission, PR and NR was 94%, 87%, and 46%, respectively. All patients with NR progressed or relapsed and 8/17 died. Four patients with normalized tumor marker response were found to have active tumor on resection of postchemotherapy residuum. Patients with postchemotherapy residual disease in pediatric extracranial GCTs, fare better if their residuum is resected compared with those who do not undergo resection.

EVALUATION OF IMPROVEMENT IN RENAL FUNCTION AFTER FIRST-LINE CHEMOTHERAPY IN MULTIPLE MYELOMA PATIENTS PRESENTING WITH RENAL IMPAIRMENT

Objective: To evaluate the effect of response to first-line chemotherapy on renal functions in multiple myeloma (MM) patients.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital, Lahore, from Jan 2013 to Dec 2017.&#x0D; Methodology: Multiple myeloma patients with renal impairment (RI) at baseline were included. Data was collected from the hospital registry.The variables assessed pre and post first-line chemotherapywere age, gender, initial estimated glomerular filteration rate and serum creatinine levels. Progression-free survivaland overall survival (OS) was calculated for both groups of patients i.e those who had improvement in renal funtions and those who did not show improvement. Kaplan-Meier curves were drawn, and SPSS-20 was used for data analysis.&#x0D; Results: Mean age was 48 ± 7 years. Out of 139 myeloma patients, 35 (25.1%) had RI at baseline. Males were 23 (65.7%), while females were 12 (34.3%). Cyclophosphamide, thalidomide and deamethsone (CTD)were used in the majority 30 (85.7%) followed by boretzomib, thalidomide and dexamethasone (VTD) in 2 (5.7%) patients. Boretezomib and dexamethasone (BorDex), lenalidomide and dexamethasone (Len Dex), lenalidomde, cyclophosphamide and dexamethasone (LCD) were given to 1 (2.8%) patient each. Serum creatinine levels normalized in 19 (54.3%). Dialysis was required in 11 (31.4%) patients out of which 3 (8.6%) got dialysis-independent while 8 (22.9%) patients remained dialysis-dependent. The medianoverall survival in whomcreatinine levels normalized was 35 months while it was 15 months in those in whom it did not normalize.&#x0D; Conclusion: Prompt administration of chemotherapy regimens can lead to an improvement in renal function....................

Role of Diffusion-Weighted Imaging in the Evaluation of Post-Treatment Tumor Response in Rectal Carcinoma.

IntroductionRectal cancer has become a major cause of mortality worldwide. Imaging has a primary role in staging and assessing the response to therapy. MRI is superior to all other modalities in local staging of the rectal tumor and in predicting tumor response. Pelvic MRI has an undeniable role in the therapeutic management of rectal cancer, particularly for the determination of the circumferential resection margin (CRM), evaluation of sphincter invasion, and assessment of the extramural vascular invasion. Post-chemoradiotherapy (CRT) staging aims at assessing treatment response and choosing methods for further treatment such as surgical resection or extended CRT. MRI with diffusion restriction is a non-invasive and useful tool for assessing the treatment response of locally advanced lower rectal cancer. It will reduce the burden of extensive abdominoperineal resection (APR) surgery in patients.ObjectiveThe purpose of this study was to determine the role of diffusion-weighted imaging (DWI) in the evaluation of post-treatment tumor response in rectal carcinoma.Materials and methodsThe study was approved by our institutional review board, which waived the requirement for informed consent. The clinical data of all the patients treated for rectal carcinoma at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore between February 1, 2014, and February 28, 2019, were retrospectively evaluated. The inclusion criteria were as follows: (1) patients with histopathologically proven rectal adenocarcinoma, (2) those who underwent APR before February 2019 at our hospital, and (3) those who underwent MRI including DWI/apparent diffusion coefficient (ADC) imaging before and after CRT. Those patients who had upfront surgery without neoadjuvant CRT and those who did not have MRI imaging with DWI/ADC were excluded from the study.ResultsA total of 200 patients who fulfilled the inclusion criteria were included in this study. Among those, 141 were males and 59 were females. On histology, 110 had moderately differentiated adenocarcinoma, 25 had well-differentiated adenocarcinoma, and 65 had poorly differentiated adenocarcinomas. Overall diagnostic accuracy of DWI MRI sequence was calculated to be 91%, while the sensitivity was 98.09%, specificity was 65.12%, positive predictive value was 91.12%, and negative predictive value was 90.32%.ConclusionDWI was proven to be very useful in the post-treatment evaluation of tumor response with very high diagnostic accuracy.