Cancer Incidence in Saudi Arabia: 2012 Data from the Saudi Cancer Registry

Prevalence of malignancy in thyroid nodules with AUS cytopathology: A retrospective cross-sectional study

Background

Category III (AUS; Atypia of Undetermined Significance) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was established to describe thyroid nodule features that are neither benign nor cancerous.

Objectives

This study aims to evaluate the rate of thyroid malignancy in patients diagnosed with AUS at the Armed Forces Hospital Southern Region (AFHSR), Saudi Arabia.

Method

The patients (508) diagnosed with AUS in their thyroid nodules underwent fine-needle aspiration cytology (FNAC). Data were collected through a chart-based approach, reviewing patients' medical records and relevant information.

Results

Among the cases, the majority were females (84.6%). Among the different age groups, individuals between 40 and 50 years had the highest prevalence of thyroid nodules (32.5%). Approximately 27% of patients exhibited tumor sizes larger than 4 cm. FNAC results revealed 16.5% benign, 26% AUS, and 22.4% follicular neoplasm cases. Histopathology indicated 54.1% of benign and 37.2% of malignant cases. Papillary carcinoma accounts for 80.4% of all malignant cases. A significant correlation was observed between FNAC and postoperative histopathology (P value < 0.05). Hypoechoic nodules exhibited 33.9% of malignant cases, and calcification was observed in 25% of the cases. A significant association was found between malignancy and echogenicity and between malignancy and calcification (P value = 0.003 and 0.001, respectively).

Conclusion

The findings of this study identify malignancy in thyroid nodules with AUS cytopathology, particularly in the Southern region of Saudi Arabia. The correlation between pre-surgery FNAC and postoperative histopathology supports FNAC's diagnostic value. Additionally, echogenicity and calcification can potentially contribute to predicting nodule malignancy.

Screening, awareness and challenges for colorectal cancer treatment in Saudi Arabia: an update

Colorectal cancer (CRC) is the second most common cancer in the world. In Saudi Arabia, CRC is the most common cancer in males and the third most common in females, and its incidence rate is rising as the country continues to develop. However, the country does not have a national CRC screening program for CRC. This review aims to review recent studies that have attempted to address and rectify this issue and discern the most notable and prevalent barriers. Despite these efforts, guidelines are still lacking. Two prospective studies have been conducted in recent years, one of which was a national pilot screening program conducted by the Ministry of Health (MOH). While both had a similar number of participants, the colonoscopy rate for patients with a positive fecal immunochemical test (FIT) in the MOH program was only 20% compared to 75.8% in the Al-Kharj program. Awareness of the Saudi population regarding CRC and its screening appears to be insufficient. The most common barriers to patients' willingness to undergo screening were embarrassment, fear, and pain. Barriers to physicians are mostly related to factors outside their hands, such as lack of equipment and time. We conclude that efforts should be made to establish a national screening program and improve awareness of the population and physicians.

The epidemiological and clinicopathological features of breast cancer in Riyadh, Saudi Arabia

OBJECTIVES

To investigate the epidemiological and clinicopathological features of breast cancer (BC) in Saudi Arabia to improve decisions regarding resource allocation, disease control, and management.

METHODS

We retrieved the records of all patients who presented with histologically proven BC at King Fahad Medical City between 2019 and 2020. The data were analyzed quantitatively, and the results were expressed as percentages and frequencies.

RESULTS

This study comprised 419 patients. The mean age was 50.13 (± 10.96) years. The majority of the patients were obese (56.6%), and approximately a quarter had a history of oral contraceptive pill use, breast biopsy, or an affected family member. Most cases were from the central region (80.1%), followed by the southern provinces (12.7%). Breast lumps were the most common complaint (89%), whereas hypertension and diabetes mellitus were the most common comorbidities. Invasive ductal carcinoma was the most common pathologic type (89.7%). Most patients presented with TNM stages II and III (55.2%), and 27.7% had metastasis. The main therapeutic modalities included radical mastectomy (63.8%), neoadjuvant chemotherapy (60.4%), and adjuvant radiotherapy (82.9%).

CONCLUSION

In Saudi Arabia, a trend of BC incidence migration towards older patients may be ensuing. However, prediction of an advanced and aggressive presentation requires the enhancement of screening programs and standardized protocols for disease management.

Establishment of reference intervals for free light chains and immunoglobulins in Saudi population

OBJECTIVES

Testing of serum-free light chains kappa (κ) and lambda (λ), along with ratio (FLCR) is essential for the diagnosis and management of monoclonal gammopathies. Accurate clinical diagnosis depends upon appropriate local population reference intervals (RIs). This study examined the Saudi population for serum-free light chains and other immunoglobulins to establish RIs and to explore variations in the test results by using the International Federation for Clinical Chemistry and Laboratory Medicine's global protocol for harmonized implementation of RI study.

METHODS

A total of 180 healthy Saudi adults were recruited. All serum samples were assayed using the Freelite reagents from the Binding Site. The variation in reference values attributable to sex, age, BMI, and region was calculated by ANOVA as a standard deviation ratio (SDR). The RIs for the FLCR were derived by the parametric method and validated by using samples from patients with hypo- and hypergammaglobulinemia.

RESULTS

The new RIs for free κ and FLCR were shifted to a higher side from the manufacturer-adapted RIs. Based on the SDR cutoff value (>0.4), between-sex partition RIs were not required for all analytes except IgM. Validation using patients with hypo- or hypergammaglobulinemia and without multiple myeloma, was all within the new RI. BMI, smoking, and exercise were not relevant sources of variation for any analyte.

CONCLUSIONS

Locally derived RIs for free light chains and immunoglobulins analytes specific for Saudis were established after careful consideration of various factors. These RIs were more reliable than those provided as guidance by the manufacturer, or from other countries, for appropriate classification and prediction of disease progression for Saudi patients.

Comprehensive analysis of the role of ubiquitin-specific peptidases in colorectal cancer: A systematic review

BACKGROUND

Colorectal cancer (CRC) is the third most frequent and the second most fatal cancer. The search for more effective drugs to treat this disease is ongoing. A better understanding of the mechanisms of CRC development and progression may reveal new therapeutic strategies. Ubiquitin-specific peptidases (USPs), the largest group of the deubiquitinase protein family, have long been implicated in various cancers. There have been numerous studies on the role of USPs in CRC; however, a comprehensive view of this role is lacking.

AIM

To provide a systematic review of the studies investigating the roles and functions of USPs in CRC.

METHODS

We systematically queried the MEDLINE (via PubMed), Scopus, and Web of Science databases.

RESULTS

Our study highlights the pivotal role of various USPs in several processes implicated in CRC: Regulation of the cell cycle, apoptosis, cancer stemness, epithelial-mesenchymal transition, metastasis, DNA repair, and drug resistance. The findings of this study suggest that USPs have great potential as drug targets and noninvasive biomarkers in CRC. The dysregulation of USPs in CRC contributes to drug resistance through multiple mechanisms.

CONCLUSION

Targeting specific USPs involved in drug resistance pathways could provide a novel therapeutic strategy for overcoming resistance to current treatment regimens in CRC.

Knowledge and Awareness About Risk Factors, Clinical Manifestations, and Prevention of Thyroid Disorders in the Era of COVID-19 and Their Association With Socioeconomic Status Among the General Population in Riyadh, Saudi Arabia

Background Thyroid dysfunction represents the most commonly observed endocrine illness within the population of Saudi Arabia. Thyroid cancer has been recognized as the second most commonly occurring malignant neoplasm among women in Saudi Arabia. Furthermore, there is evidence suggesting that COVID-19 and, to a certain degree, immunization may have an impact on thyroid function. The aim of this study was to evaluate the level of public knowledge, awareness, and attitudes pertaining to the manifestations and risk factors of thyroid disease. Additionally, the study sought to examine the potential role of COVID-19 as a risk factor and explore preventive measures in the context of Riyadh, Saudi Arabia. Methods A cross-sectional online survey was conducted targeting the Saudi population living in Riyadh aged 18 years and older. A self-administered questionnaire constructed on Google Forms was distributed to the general population using an online platform. The questionnaire consisted of five sections: demographic data, risk factors for thyroid disorders, clinical manifestations, prevention, and history of thyroid disease. Binary logistic regression analysis was used to identify predictors of better knowledge of thyroid diseases.  Results Among the 693 participants enrolled, 57.7% were female, and 31.7% were aged between 18 and 25 years. The overall mean knowledge score was 12.2 (SD = 6.57) out of 23 points. Poor knowledge of the risk factors, clinical manifestations, and prevention was observed in 50.4% of the participants. A total of 27.6% had moderate knowledge, and 22.1% had good knowledge levels. Furthermore, only 33.9% of the participants believed that COVID-19 infection was a risk factor. The results of the binary logistic regression analysis revealed that individuals within the age range of 36-45 years, females, and students had a significantly higher level of knowledge compared to other participants (p<0.05). Conclusion This study revealed that the general population of Riyadh, Saudi Arabia, lacked adequate knowledge, awareness, and attitudes regarding the risk factors, clinical symptoms, and prevention of thyroid problems. However, middle-aged individuals, females, and those who were enrolled as students showed a higher level of knowledge. Regarding the pathogenesis of COVID-19, it was observed that all participants had a limited understanding and a lack of awareness. Insufficient public awareness may result in misunderstandings, insufficient identification, and potential oversight of COVID-19-infected patients with thyroid dysfunction. Therefore, it is imperative that healthcare authorities intensify their efforts to broaden the dissemination of information throughout the population.

CD10 expression in urinary bladder urothelial carcinoma is associated with high-tumor grade and stage

Objectives

Primary urinary bladder carcinoma is a common cancer worldwide. There is limited published data about CD10 immunoexpression pattern in urothelial bladder carcinoma (UBC). This study aims to examine CD10 immunoexpression in UBC and evaluate its relationship with clinicopathological parameters.

Methods

The retrospective study examined 130 samples of UBC tissue and 30 samples of non-neoplastic urothelial bladder tissue, which were obtained from the Anatomic Pathology Department, King Abdulaziz University, Jeddah, Saudi Arabia. The project started in June 2019 and completed in February 2021. Tissue microarrays (TMA) were prepared from paraffin blocks and tissue sections prepared from the recipient blocks were used for immunohistochemistry studies utilizing CD10 antibody. The immunostaining results were recorded and analyzed.

Results

Positive staining of CD10 was observed in 64 (49%) cases of UBC and was not detected in any non-neoplastic urothelium samples. CD10-positive staining was identified in 36.7% and 66.7% of low and high-grade tumors, respectively. There was an association between positive CD10 immunostaining and high tumor grade (p=0.006) and muscularis propria invasion (p=0.007). There was no association between CD10 immunoexpression and age, gender, nodal and distant metastasis, lymphovascular invasion, and tumor recurrence. CD10 immunoexpression was not associated with the probabilities of overall survival (log rank 1.663, p=0.197) or disease-free survival (log rank 1.637, p=0.201).

Conclusions

In UBC, CD10 immunoexpression is associated with higher tumor grade and muscle invasion, but it is not associated with patient survival or other clinicopathological parameters. CD10 immunoexpression cannot be used as a biomarker for poor prognosis in UBC.

Prevalence and Associated Predictors of Hypertension in Adult Patients with Thyroid Nodules at the Royal Commission Hospital, Kingdom of Saudi Arabia

Background

Hypertension and thyroid nodules (TNs) are common medical problems that are increasing in prevalence globally. Hence, we conducted this study to assess the prevalence and associated predictors of hypertension in adult patients with TNs at the Royal Commission Hospital, Kingdom of Saudi Arabia (KSA).

Methods

A retrospective study was conducted between 1 January 2015 and 31 December 2021. Patients with documented TNs based on the Thyroid Imaging Reporting and Data System (TI-RADS) were recruited to assess the prevalence and associated risk factors for hypertension.

Result

Three hundred ninety-one patients with TNs were recruited for this study. The median (interquartile range, IQR) age was 46.00 (20.0) years, and 332 (84.9%) of the patients were females. The median (IQR) body mass index (BMI) was 30.26 (7.71) kg/m². There was a high prevalence of hypertension (22.5%) in adult patients with TNs. In the univariate analysis, there were significant associations between diagnosed hypertension in patients with TNs and age, sex, diabetes mellitus (DM), bronchial asthma, triiodothyronine (FT3), total cholesterol and high-density lipoprotein (HDL). In the multivariate analysis, age (OR = 1.076 [95% CI 1.048 - 1.105]), sex (OR = 2.28 [95% CI 1.132 - 4.591]), DM (OR = 0.316 [95% CI 0.175 - 0.573]) and total cholesterol levels (OR = 0.820 [95% CI 0.694 - 0.969]) were significantly associated with hypertension.

Conclusion

There is a high prevalence of hypertension in patients with TNs. Age, female sex, DM and elevated total cholesterol are significant predictors of hypertension in adult patients with TNs.

The Impact of Data Management on the Achievable Dose and Efficiency of Mammography and Radiography During the COVID-19 Era: A Facility-Based Cohort Study

Purpose

To evaluate the impact of using computational data management resources and analytical software on radiation doses in mammography and radiography during the COVID-19 pandemic, develop departmental diagnostic reference levels (DRLs), and describe achievable doses (ADs) for mammography and radiography based on measured dose parameters.

Patients and Methods

This ambispective cohort study enrolled 795 and 12,115 patients who underwent mammography and radiography, respectively, at the King Fahd Hospital of the University, Al-Khobar City, Saudi Arabia between May 25 and November 4, 2021. Demographic data were acquired from patients' electronic medical charts. Data on mammographic and radiographic dose determinants were acquired from the data management software. Based on the time when the data management software was operational in the institute, the study was divided into the pre-implementation and post-implementation phases. Continuous and categorical variables were compared between the two phases using an unpaired t-test and the chi-square test.

Results

The median accumulated average glandular dose (AGD; a mammographic dose determinant) in the post-implementation phase was three-fold higher than that in the pre-implementation phase. The average mammographic exposure time in the post-implementation phase was 16.3 ms shorter than that in the pre-implementation phase. Furthermore, the median values of the dose area product ([DAP], a radiographic dose determinant) were 9.72 and 19.4 cGycm² in the pre-implementation and post-implementation phases, respectively.

Conclusion

Although the data management software used in this study helped reduce the radiation exposure time by 16.3 ms in mammography, its impact on the mean accumulated AGD was unfavorable. Similarly, radiographic exposure indices, including DAP, tube voltage, tube current, and exposure time, were not significantly different after the data management software was implemented. Close monitoring of patient radiation doses in mammography and radiography, and dose reduction will become possible if imaging facilities use DRLs and ADs via automated systems.

Saudi Arabian Plants: A Powerful Weapon against a Plethora of Diseases

The kingdom of Saudi Arabia (SA) ranks fifth in Asia in terms of area. It features broad biodiversity, including interesting flora, and was the historical origin of Islam. It is endowed with a large variety of plants, including many herbs, shrubs, and trees. Many of these plants have a long history of use in traditional medicine. The aim of this review is to evaluate the present knowledge on the plants growing in SA regarding their pharmacological and biological activities and the identification of their bioactive compounds to determine which plants could be of interest for further studies. A systematic summary of the plants' history, distribution, various pharmacological activities, bioactive compounds, and clinical trials are presented in this paper to facilitate future exploration of their therapeutic potential. The literature was obtained from several scientific search engines, including Sci-Finder, PubMed, Web of Science, Google Scholar, Scopus, MDPI, Wiley publications, and Springer Link. Plant names and their synonyms were validated by 'The Plant List' on 1 October 2021. SA is home to approximately 2247 plant species, including native and introduced plants that belong to 142 families and 837 genera. It shares the flora of three continents, with many unique features due to its extreme climate and geographical and geological conditions. As plants remain the leading supplier of new therapeutic agents to treat various ailments, Saudi Arabian plants may play a significant role in the fight against cancer, inflammation, and antibiotic-resistant bacteria. To date, 102 active compounds have been identified in plants from different sites in SA. Plants from the western and southwestern regions have been evaluated for various biological activities, including antioxidant, anti-cancer, antimicrobial, antimalarial, anti-inflammatory, anti-glycation, and cytotoxic activities. The aerial parts of the plants, especially the leaves, have yielded most of the bioactive compounds. Most bioactivity tests involve in vitro assessments for the inhibition of the growth of tumour cell lines, and several compounds with in vitro antitumour activity have been reported. More in-depth studies to evaluate the mode of action of the compounds are necessary to pave the way for clinical trials. Ecological and taxonomical studies are needed to evaluate the flora of SA, and a plan for the conservation of wild plants should be implemented, including the management of the protection of endemic plants.

Assessment of Pre-existing Type 2 Diabetes Mellitus Prevalence and Risk Factors Among Colorectal Cancer Patients in King Abdulaziz Medical City, Jeddah

BACKGROUND

Diabetes mellitus (DM) and cancer are recognized as non-communicable chronic disorders which are among the top ten causes of death globally. In Saudi Arabia, the prevalence of type 2 DM (T2DM) and colorectal cancer (CRC) is alarmingly high. Both T2DM and CRC share common risk factors. In this study, we aim to assess the prevalence of pre-existing T2DM among CRC Saudi patients.

METHODS

In this cross-sectional study, data were collected from the medical records of 275 Saudi adult patients with CRC from 2009 to 2018 at King Abdulaziz Medical City, Jeddah (KAMC-J).

RESULTS

Participants had a mean age of 57.0 years, standard deviation (SD) of 13.0, and were mostly males (60.00%) and Saudi (100.0%). Participants had a mean BMI of 26.42 (7.35) kg/m². The prevalence of pre-existing T2DM in this study was 40.80%. 15.8% of participants were overweight and obese (BMI>30), respectively. The average age of diabetics and non-diabetics was 63.6 (10.64) and 52.73 (12.43), respectively. Diabetic patients are significantly older than non-diabetic patients (p<0.001). The average BMI for diabetics was 26.96 (7.26) kg/m², whereas the average BMI for non-diabetics was 25.93 (7.48) kg/m². No significant differences were found between the two groups.

CONCLUSION

This study provides new insight into the high prevalence of pre-existing T2DM in CRC patients in Saudi Arabia. In particular, the age of diagnosis of CRC in diabetic patients was significantly higher than in non-diabetics.

Shoulder Metastasis: A Rare Nasopharyngeal Carcinoma Presentation

BACKGROUND Nasopharyngeal carcinoma (NPC) is a rare malignant tumor that arises from the mucosal lining epithelium of the nasopharynx, most commonly at the lateral nasopharyngeal recess or fossa of Rosenmüller. According to global age-standardized incidence rates (ASIRs), in 2018 the incidence rate of nasopharyngeal carcinoma varied from 2.1 to 0.4 per 100 000 in Asia and Europe, respectively. The number of deaths exceeded 50 000. It is one of the few head and neck tumors prone to distant metastasis, most commonly to bones, lung, and liver. CASE REPORT In this case report, we present a rare case in which a 23-year-old male patient presented to our head and neck clinic. The patient presented initially to the orthopedic clinic with a right humeral mass lesion 10 cm with history of pain for the last 7 months. A Tru-Cut biopsy confirmed metastatic NPC. A nasopharyngeal biopsy further revealed his lesion to be an NPC undifferentiated type III. The patient was diagnosed with a T3 N2b M1 stage tumor and he was treated with chemoradiotherapy. CONCLUSIONS NPCs that present with a shoulder/humoral metastasis are very rare clinically. We are presenting this case to increase the awareness of the Otolaryngology - Head & Neck surgery, Orthopedic, and Oncology community of such a rare presentation.

A Review on Nanocarrier Mediated Treatment and Management of Triple Negative Breast Cancer: A Saudi Arabian Scenario

People have continued to be petrified by the devastating effects of cancer for decades and thus a pursuit for developing anticancer agents have seen an ever-increasing trend in the past few decades. Globally, breast cancer is the most common malignancy in women and the second most common cause of cancer-related deaths. In Saudi Arabia, breast cancer is the most common type of cancer among women, constituting almost 14.2% of the total cancer burden. Triple-negative breast cancer (TNBC) is a subtype of breast cancer, which is a pathologically diverse disease of higher grade characterized by the absence of the estrogen receptor (ER), the progesterone receptor (PR), and the human epidermal growth factor receptor 2 (HER2) expressions. Despite the considerable advancements achieved in the therapeutic management of cancer, TNBC remains an unbeatable challenge, which requires immediate attention as it lacks conventional targets for treatment, leading to a poor clinical prognosis. The present research goals are directed toward the development and implementation of treatment regimens with enhanced bioavailability, targetability, minimized systemic toxicity, and improved outcomes of treatment options. The present treatment and management scenario of TNBC continues to provoke oncologists as well as nanomedical scientists to develop novel and efficient nanotherapies. Lately, scientific endeavors have addressed the importance of enhanced availability and targeted cellular uptake with minimal toxicity, which are achieved by the application of nano drug-carriers. This review intends to summarize the incidence rates of TNBC patients, the importance of nanotherapeutic options for patients suffering from TNBC, the identification of promising molecular targets, and challenges associated with the development of targeted nanotherapeutics with special reference to the Saudi Arabian context.

A new extended gumbel distribution: Properties and application

A robust generalisation of the Gumbel distribution is proposed in this article. This family of distributions is based on the T-X paradigm. From a list of special distributions that have evolved as a result of this family, three separate models are also mentioned in this article. A linear combination of generalised exponential distributions can be used to characterise the density of a new family, which is critical in assessing some of the family's properties. The statistical features of this family are determined, including exact formulations for the quantile function, ordinary and incomplete moments, generating function, and order statistics. The model parameters are estimated using the maximum likelihood method. Further, one of the unique models has been systematically studied. Along with conventional skewness measures, MacGillivray skewness is also used to quantify the skewness measure. The new probability distribution also enables us to determine certain critical risk indicators, both numerically and graphically. We use a simulated assessment of the suggested distribution, as well as apply three real-world data sets in modelling the proposed model, in order to ensure its authenticity and superiority.

Trends in the Incidence of Nasopharyngeal Cancer in Saudi Arabia Across One Decade (2007 to 2016)

Background

Cancer is an ongoing global health concern; it is the greatest cause of mortality in the industrialized world and the second-highest cause of death in the developing world. This study aims to assess the incidence and geographic distribution of nasopharyngeal cancer between 2007 and 2016 in Saudi Arabia.

Methods

Data between 2007 and 2016 from Saudi Cancer Registry reports were collected in this study. These reports provide information on all cancer cases, including the age, sex, geographic location, and year of diagnosis for each patient.

Result

Between 2007 and 2016, the Saudi Cancer Registry identified 110,075 cancer cases in total. The mean age-standardized rate of all cancer types for women was 51.7 compared with 48.2 for men. The percentage of cases of nasopharyngeal cancers was 1.2% for women and 2.2% for men in 2007. This percentage decreased to 0.8% for women and increased to 2.7% for men in 2016 in comparison to all cancer cases. The curve for nasopharyngeal cancer of all cancer types for men and women correlated with rises and drops in men over the study period, and a minor decrease in women over time, until another rise in 2016. A positive correlation was observed between nasopharyngeal cancer incidence and age. The age-standardized rate data for nasopharyngeal cancer cases demonstrated a wide variation across Saudi regions. The age-standardized rate per 100,000 people from 2007 to 2016 ranged from 0.39 in Jazan to 1.92 in Qassim, with a national average of 1.06.

Conclusion

From 2007 to 2016, the overall trend of the age-standardized rate for men fluctuated while the female rate slightly dropped before rising again. On the contrary, the incidence of nasopharyngeal cancer varies by region in Saudi Arabia. Further study of this variation would help focus awareness campaigns on the most susceptible regions.

Population-based survival for cancer patients in Saudi Arabia for the years 2005-2009

The Saudi Cancer Registry reported in 2007 the 5-year observed survival for the most common cancer sites for the years 1994-2004. In this report we looked at the cancer survival in the period 2005-2009 and evaluated the trend over the 15 years period from 1994 to 2009. Cases of the top 14 cancer sites reported by the population based Saudi Cancer Registry from 1 January 2005 to December 31, 2009, were submitted for survival analysis. The vital status of those patients was collected. Analysis of survival for the above period was compared with the prior reported 2 periods (1994-1999, 2000-2004). In addition, analysis was done according to age, sex, disease stage and the province. Data of 25,969 patients of the commonest cancer sites were submitted. Of those 14,146 patients (54%) had complete demographic data available and vital status was reported. Thyroid cancer had the highest 5- year observed survival of 94% (95% confidence interval (CI) 93-95%)), followed by Breast (72%, 95% CI 71-74%). In hematological malignancies, Hodgkin's Lymphoma had the highest 5-year survival of 86% (95% CI 84-88%). Survival rates has improved in most of the cancers sites for the studied periods except for lung, uterine and Hodgkin's lymphoma which plateaued. Our study confirms a steady improvement in the 5-year observed survival over time for the majority of cancers. Our survival data were comparable to western countries. This data should be used by policy makers to improve on cancer care in the kingdom.

The prevalence and associated predictors for Bethesda III-VI for reporting thyroid cytopathology in Royal Commission Hospital, Kingdom of Saudi Arabia

BACKGROUND

Thyroid cancer is increasing globally and is currently the most prevalent endocrine malignancy. Recent data show an increase in the incidence of thyroid cancer in the Kingdom of Saudi Arabia (KSA). Thyroid ultrasound and fine-needle aspiration cytology (FNAC) are the cornerstones in managing thyroid nodules. We conducted this study to evaluate the prevalence and the associated predictors for thyroid nodule Bethesda III-VI in eastern KSA.

METHODS

A retrospective study was conducted between January 2015 and 31 August 2021. The participants were recruited patients who received a thyroid ultrasound and ultrasound-guided thyroid FNAC, using the thyroid imaging reporting and data system (TI-RADS) and the Bethesda Classification, respectively.

RESULT

Three hundred and ten patients who underwent thyroid FNAC were enrolled in the study. The median (interquartile, IQR) age was 47.0 (20.0) years, and 266 (85.8%) of them were females. The median (IQR) body mass index was 30.2 (7.6) kg/m². Out of these participants, 64.8% were euthyroid, 27.4% had hypothyroidism and 7.7% had hyperthyroidism. The ACR TI-RADS-3, 4 and 5 were 51.3%, 46.1% and 2.6%, respectively. The Bethesda outcome of thyroid FNAC I-VI was 5.2%, 63.9%, 15.5%, 5.8%, 3.5% and 6.1%, respectively. The risk for malignancy (Bethesda III-VI) was documented in 31.0% and atypia of undetermined significance was most prevalent (15.5%). A higher ACR TI-RADS score was associated with a higher risk of malignancy: ACR TI-RADS-3 (20.8%), ACR TI-RADS-4 (39.2%) and ACR TI-RADS-5 (87.5%). In a multivariate analysis, only the ACR TI-RADS score was significantly associated with the outcome of thyroid FNAC: ACR TI-RADS-4 [OR = 2.59 (95% CI = 1.54-4.36)] and ACR TI-RADS-5 [OR = 29.03 (95% CI = 3.44-245.07)].

CONCLUSION

There was a high prevalence of Bethesda III-VI and atypia of undetermined significance was most prevalent. A thyroid ultrasound report for TI-RADS was significantly associated with the outcome of thyroid FNAC and is a reliable tool in the absence of molecular testing for thyroid cancer.

A Retrospective Cohort Study of Lung Cancer Incidences and Epidemiological Analysis in Saudi Arabian Population from 2006-2016

INTRODUCTION

Lung cancer is one of the leading causes of cancer-related deaths worldwide, including in Saudi Arabia. In the past few decades, the incidence and mortality has increased considerably among the Saudi population. The incidence of lung cancer has increased more than 3% in less than two decades. The current study focuses on analyzing the frequency of diagnosed lung cancer cases, age-standardized incidence rate (ASIR), and crude incidence rate (CIR) classified by year of diagnosis, age group, and different administrative regions of Saudi Arabia, based on the Saudi cancer registry (SCR) for the period of 10 years from 2006-2016.

METHODOLOGY

The present study is a cohort study that focuses on the epidemiological analysis of lung cancer cases. The statistical analysis was performed by t-test, sex ratio, Kruskal-Wallis, and descriptive statistics through SPSS version 20.0.

RESULTS

A total of 4530 lung cancer cases were reported from January 2006 to December 2016. Among males, the ASIR range was reported as 1.2 to 12.3 per 100,000 cases in different regions of Saudi Arabia. Moreover, among females, the ASIR range was reported from 0.2 to 3.1 per 100,000 cases in different regions of Saudi Arabia. Additionally, the overall age-standardized incidence sex ratio was 3.2 per 100,000 cases. The incidence of lung cancer increased with age as 23% was reported in the age group of more than 75 years.

CONCLUSIONS

The study concludes a rise in crude incidence rates and ASIR for lung cancer among Saudi population. Among males, the Eastern region had the highest overall ASIR followed by Tabuk region, and, among females, the highest overall ASIR was reported in the Eastern region followed by Riyadh and the Northern region.

Screening Practices, Knowledge and Adherence Among Health Care Professionals at a Tertiary Care Hospital

Introduction

Screening, a routine procedure done on individuals with or without disease, results in the early detection of disease. The aim of this study was to assess healthcare professionals’ (HCPs) level of knowledge related to and the adherence to screening.

Methods

A survey was conducted in HCPs, using a self-administered questionnaire. Knowledge was defined based on the correct or incorrect responses to the questions. Adherence to screening was considered if a test was done at least once in the past one year.

Results

Of the 379 participants, 61% were nurses, 34% physicians, and 5% pharmacists. The majority 68.78% were female. The average age of pharmacists was 29.17±7.09, physicians 35.57±10.08, and nurses 35.46±8.63 years. The knowledge related to breast cancer screening ranged between 50% and 57% and of a Pap smear, 41–54%. 94% nurses and 90% pharmacists had recorded an incorrect response to the required age of colon cancer screening. The overall screening adherence to diabetes was 46%, hypertension 68%, liver profile 43%, lipid profile 50%, breast cancer 10.38%, Pap smear 26%, prostate cancer 33%, and colon cancer 2.37%. HCPs aged ≥45 years had good adherence to diabetes screening. Pharmacists (88%) had the highest level of adherence to hypertension screening. Female HCPs poorly adhered to breast 38% and cervical cancer 26% screening. Only a third 33% of males, aged > 50 years, were screened for prostate cancer. Among HCPs aged ≥50 years (n=32), only three were screened for colon cancer.

Conclusion

Despite the increased incidence of diabetes, breast and colon cancer in Saudi Arabia, HCPs displayed poor knowledge related to screening. The adherence to diabetes screening was good. However, HCPs in a high-risk group displayed poor adherence to screening, specifically for breast, cervical and colon cancer. The medical and cancer screening guidelines should be made available to all HCPs regardless of their specialty.

Patient Perceptions and Determinants of Choice for Breast Reconstruction after Mastectomy among Saudi Patients

Background:

Undergoing mastectomy is often associated with a negative impact on the mental well-being of patients. Patients who undergo postmastectomy breast reconstruction (BR) have a better self-image and higher self-esteem. Many patients with breast cancer (BC) are unaware of the availability of BR options. This study aimed to assess BC patient perceptions and identify the determinants of patient choices to undergo BR after mastectomy.

Methods:

This study was conducted between May 10, 2019 and February 29, 2020 via an interview-based questionnaire, among BC patients at King Abdul Aziz University Hospital, Jeddah, Saudi Arabia. Ethical approval was obtained from the research ethics committee before the data collection.

Results:

Altogether, 400 patients (an overall 82% response rate) were included, of whom 155 (38.75%) were group 1 (willing to undergo BR). The mean age for group 1 was 46.04 ± 8.79, which was younger than for group 2 (unwilling to undergo BR) (P < 0.001). Furthermore, 117 (75.5%) of group 1 had no history of any chronic illness compared with 145 (59.2%) of group 2 (P < 0.001). Group 1 had more knowledge about BR (69.7%, P < 0.001), and the main reason to undergo BR was to regain femininity (26.8%). The remaining patients (31.3%) were unwilling to undergo BR in order to avoid additional surgery.

Conclusions:

The lack of knowledge and misconception about BR is one factor preventing BC patients from undergoing BR. Spreading awareness and providing accurate information regarding the procedure will allow women with BC to overcome postmastectomy fear.

Colorectal cancer survival among Ministry of National Guard-Health Affairs (MNG-HA) population 2009-2017: retrospective study

Background

Colorectal cancer (CRC) is the most diagnosed cancer among males and third among females in Saudi Arabia, with up to two-third diagnosed at advanced stage. The objective of our study was to estimate CRC survival and determine prognostic factors.

Methods

Ministry of National Guard- Health Affairs (MNG-HA) registry data was utilized to identify patients diagnosed with CRC between 2009 and 2017. Cases were followed until December 30th, 2017 to assess their one-, three-, and five-year CRC-specific survivals. Kaplan-Meier method and Cox proportional hazard models were used to assess survival from CRC.

Results

A total of 1012 CRC patients were diagnosed during 2009–2017. Nearly, one-fourth of the patients presented with rectal tumor, 42.89% with left colon and 33.41% of the cases were diagnosed at distant metastasis stage. The overall one-, three-, and five-year survival were 83, 65 and 52.0%, respectively. The five-year survival was 79.85% for localized stage, 63.25% for regional stage and 20.31% for distant metastasis. Multivariate analyses showed that age, diagnosis period, stage, nationality, basis of diagnosis, morphology and location of tumor were associated with survival.

Conclusions

Findings reveal poor survival compared to Surveillance, Epidemiology, and End Results (SEER) population. Diagnoses at late stage and no surgical and/or perioperative chemotherapy were associated with increased risk of death. Population-based screening in this population should be considered.

Knowledge and intentions regarding the Pap smear test among Saudi Arabian women

Background

The knowledge of Pap smear and uptake of preventive behaviors to prevent cervical cancer are the most important contributors to the advanced stage of the disease. Knowledge is one of the most leading factors to predict the health behaviors and a helpful factor in performing screening procedures. This study aimed to investigate Saudi Arabian women knowledge of Pap testing in relation to their intention to undergo the test.

Methods

An online survey including demographic characteristics (3 questions), knowledge (13 questions), and intentions (3 questions) towards Pap smear was completed by 467 Saudi Arabian women. Data were analyzed through SPSS version 22, using descriptive statistics and correlation to measure the relationship between knowledge, demographic factors, and intention.

Results

The study found that average level of knowledge was 1.3 which is between high and moderate knowledge, and the average score for the intention was 2.88, to indicate that the intentions to uptake Pap smear among the participants were above the average. The study revealed a significant correlation between demographic factors and intention (p<0.01).

Conclusion

Findings from the current study can inform health care providers about Saudi Arabian women knowledge of Pap smear and the intention to uptake the test. Strategies to motivate women to undergo Pap screening should be introduced.

Clinical and Therapeutic Characteristics of Cancer Patients in the Southern Region of Saudi Arabia: A Cross-Sectional Study

Aims: Due to the continuous changes in modern lifestyle and the need to explore the effect of these changes on the risk of developing cancer, ongoing research on the epidemiology and characteristics of cancer patients is requested. This study explored the epidemiology of cancer, its characteristics, treatment patterns, and risk factors in the southern region of Saudi Arabia. Methods: A retrospective cross-sectional study was conducted using cancer patients’ medical records at Asir Central Hospital in the southern region of Saudi Arabia. Active patients’ records were extracted between January 2013 and December 2019. Results: A total of 2038 patients were identified during the study period, with a mean age of 60.9 (SD: 19.0) years. The patients had survived with their cancer for a median duration of 4 years (IQR: 2–6). Around 4.6% of the patients required ICU admission with a median period of 9 days (IQR: 5–14.75). The death rate during the study period was 10.9%. Around 20.8% of the cases were metastatic, of which 77.8% were at stage four of metastasis, and 19.7% of the patients were receiving chemotherapy for their disease. The most common types of cancer were malignant neoplasms of digestive organs, comprising 40.8% of the sample. Older age (60 years and above) and using specific chronic disease medications were predictors associated with a higher risk of death due to cancer (p < 0.05). Smoking history, using specific chronic disease medications, and having previous surgery were predictors associated with a higher risk of ICU admission (p < 0.05). Conclusion: Breast, colon, and liver cancers were the most prevalent in the southern region of Saudi Arabia. Several modifiable cancer risk factors were identified. The results of this study should support decision-makers in the initiation of programs for key modifiable risk factors that enhance lifestyle changes and reduce cancer risks.

Prevalence of colorectal cancer biomarkers and their impact on clinical outcomes in Riyadh, Saudi Arabia

Objectives

KRAS, NRAS, and BRAF mutations are commonly present in colorectal cancer (CRC). We estimated the frequency of KRAS, NRAS, and BRAF mutations and assessed their impact on survival and other clinical variables among Saudi patients.

Design

Retrospective cohort study design.

Settings

Oncology department of a tertiary hospital in Riyadh, Saudi Arabia. We gathered information from 2016 to 2018.

Participants

Cohort of 248 CRC patients to assess the demographic data, pathological tumour features, response to treatment modalities, disease progression, and metastasis.

Statistical analysis used

Correlation analysis using the chi-square test. Survival analysis using a Kaplan Meier method. Cox regression analysis to calculate the hazard ratios.

Results

Demographic data revealed that 84% of patients were diagnosed with CRC above the age of 50 years. Only 27% of patients presented with distant metastasis. KRAS mutations were the most prevalent (49.6%), followed by NRAS mutations (2%) and BRAF mutations (0.4%). Wild type tumours were found among 44.4% of patients. KRAS mutation showed no significant correlation with the site, type, pathological grade, and stage of the tumour.

The mean survival time was shorter among patients with KRAS mutations than among patients with wild type KRAS tumours (54.46 vs. 58.02 months). Adjusted analysis showed that the survival time was significantly affected by patients’ age at diagnosis (P = 0.04). Male patients had an increased risk of mortality by 77% (hazard ratio: 1.77).

Conclusions

Saudi CRC patients had a high frequency of KRAS mutations and a low frequency of BRAF mutations. The KRAS mutation status did not affect the patients’ survival.

Utility of Stimulated Thyroglobulin in Reclassifying Low Risk Thyroid Cancer Patients' Following Thyroidectomy and Radioactive Iodine Ablation: A 7-Year Prospective Trial

Context

Following total thyroidectomy and radioactive iodine (RAI) ablation, serum thyroglobulin levels should be undetectable to assure that patients are excellent responders and at very low risk of recurrence.

Objective

To assess the utility of stimulated (sTg) and non-stimulated (nsTg) thyroglobulin levels in prediction of patients outcomes with differentiated thyroid cancer (DTC) following total thyroidectomy and RAI ablation.

Method

A prospective observational study conducted at a University Hospital in Saudi Arabia. Patients diagnosed with differentiated thyroid cancer and were post total thyroidectomy and RAI ablation. Thyroglobulin levels (nsTg and sTg) were estimated 3-6 months post-RAI. Patients with nsTg <2 ng/ml were stratified based on their levels and were followed-up for 5 years and clinical responses were measured.

Results

Of 196 patients, nsTg levels were <0.1 ng/ml in 122 (62%) patients and 0.1-2.0 ng/ml in 74 (38%). Of 122 patients with nsTg <0.1 ng/ml, 120 (98%) had sTg levels <1 ng/ml, with no structural or functional disease. sTg levels >1 occurred in 26 (35%) of patients with nsTg 0.1-2.0 ng/ml, 11 (15%) had structural incomplete response. None of the patients with sTg levels <1 ng/ml developed structural or functional disease over the follow-up period.

Conclusion

Suppressed thyroglobulin (nsTg < 0.1 ng/ml) indicates a very low risk of recurrence that does not require stimulation. Stimulated thyroglobulin is beneficial with nsTg 0.1-2 ng/ml for re-classifying patients and estimating their risk for incomplete responses over a 7 years follow-up period.

CHD4 Predicts Aggressiveness in PTC Patients and Promotes Cancer Stemness and EMT in PTC Cells

Chromodomain-helicase-DNA-binding protein 4 (CHD4), a core subunit of the nucleosome remodeling and deacetylation (NuRD) complex is highly expressed in several cancers. However, its role in the pathogenesis and progression of papillary thyroid carcinoma (PTC) has not been investigated. We investigated the prognostic significance of CHD4 in a large cohort of Middle Eastern PTC patients and explored the functional role of CHD4 in regulating cancer stemness and EMT in PTC cells. CHD4 overexpression was observed in 45.3% (650/1436) of PTCs, and was associated with aggressive clinico-pathological parameters and worse outcome. Functional analysis using PTC cell lines showed that forced expression of CHD4 promoted cell proliferation, spheroid growth, migration, invasion and progression of epithelial to mesenchymal transition (EMT) in PTC cells whereas its knockdown reversed the effect. Methylation of E-cadherin was associated with loss of expression in CHD4 expressing cells, while CHD4 depletion reactivated E-cadherin expression. Most importantly, knockdown of mesenchymal transcriptional factors, Snail1 or Zeb1, attenuated the spheroid growth in CHD4 expressing PTC cells, showing a potential link between EMT activation and stemness maintenance in PTC. These findings suggest that CHD4 might be a promising therapeutic target in the treatment of patients with an aggressive subtype of PTC.

Cancer Trends in Iraq 2000-2016

OBJECTIVES

Precise and quantitative assessment of the trend of cancer burden enables policymakers and health managers to prioritize diseases and allocate resources better. This infers what caused a decrease or increase in the rate of cancer occurrence, and if it denotes timing of implementation of a control measure, it presents the impact on the disease rate. This study's objective was to evaluate trends in child and adult cancer in Iraq from 2000 onwards.

METHODS

We used the registries of the Iraqi Ministry of Health that were gathered from all governorates from 2000-2016. Data were presented as incidence rates to depict the trends of different types of cancers distributed by age, gender, and governorates.

RESULTS

Breast cancer witnessed a significant increase with predominance in females. Lung cancer rate increased significantly from 4.08 to 5.60/100 000 (p = 0.038), affecting males more than females. The brain cancer trend showed a bimodal pattern (two peaks in 2004 and 2011) with no significant trend change (p = 0.788). Both genders were similarly affected. The trend of stomach and colorectal cancer showed an accelerated increase after 2007.

CONCLUSIONS

Almost all cancers (particularly lung and gastrointestinal) showed constantly raising trends, especially after 2007. Only cervical and laryngeal cancer had a decreasing trend. Most cancers were predominant in males.

Loss of expression of Syndecan-1 is associated with Tumor Recurrence, Metastatic Potential, and Poor Survival in patients with Colorectal carcinoma

OBJECTIVE

The loss of expression of syndecansyndecan-1 is associated with poor prognosis in many types of human cancer. The objective of this study was to evaluate the relation between syndecan-1 immunoexpression and several clinicopathological parameters in a subset of colorectal carcinoma (CRC) patients.

METHODS

Pathology tissue blocks of 202 primary tumors, 41 adenomas, and 37 normal colonic mucosae were used in this study. The cases diagnosed in the period 1995-2015 was included in the study. Immunohistochemistry analysis was performed using anti-CD138/syndecan-1 (B-A38) mouse monoclonal antibody. A semiquantitative method was used to score the syndecan-1 expression based on an evaluation of the percentage and intensity of the membranous and cytoplasmic expression. The data collected from Pathology Department at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. This is a retrospective cohort study that was conducted from July 2018 until August 2019.

RESULTS

Loss of syndecan-1 immunoexpression was observed in 72 (42.6%), 5 (12.2%), and 3 (8.1%) cases of CRC, adenomas, and normal mucosae, respectively. Low expression of syndecan-1 showed an association with nodal (p=0.003) and distant (p=0.001) metastasis, lymphovascular invasion (p=0.001), and tumor recurrence (p=0.006). Low syndecan-1 expression were associated with short overall survival (OS) (log rank 4.019, p=0.045) and disease-free survival (DFS) probabilities (log rank 4.748, p=0.029).

CONCLUSION

Loss of syndecan-1 immunoexpression is associated with metastatic potential, tumor recurrence and shorter survival in CRC and is considered a potential biomarker of poor prognosis in CRC patients.

Risk of Colorectal Carcinoma May Predispose to the Genetic Variants of the GST, CYP450, and TP53 Genes Among Nonsmokers in the Saudi Community

PURPOSE

Colorectal carcinoma (CRC) represents a considerable public health burden in Saudi Arabia. Several candidate genes and genetic variants have been associated with morbidity and mortality among patients with CRC. We explored whether allelic variants of the GSTM1, GSTT1, CYP450 (rs4646903 and rs1048943), and TP53 (rs1042522) genes predisposed nonsmoking Saudi individuals to increased risk for CRC.

PATIENTS AND METHODS

DNA from buccal cells of 158 participants (80 with CRC and 78 healthy controls) were analyzed for five SNPs using conventional PCR and TaqMan genotyping assays. The SNPStats software was utilized to choose the best interactive inheritance mode for selected SNPs (https://www.snpstats.net).

RESULTS

The mean age of diagnosis was 62.4±13.5 years (range, 40-83 years), with those aged 71-80 years and those aged 40-50 years accounting for the most diagnoses (35.7% and 28.6% of diagnosis, respectively). The GSTM1 and TP53 rs1042522 SNPs were associated with CRC (OR= 3.7; P< 0.0001, and OR= 1.6; P= 0.033, respectively). A plausible contribution to CRC was observed for the GSTM1 and TP53 rs1042522 SNPs (x ² _Yates= 14.7; P= 0.00013, and x ² _Yates= 11.2; P= 0.0008, respectively), while the GSTT1 null variant did not affect risk. Heterozygosity in the CYP450 (rs4646903 and rs1048943 SNPs) was associated with a significant risk for CRC. The GSTM1/GSTT1 and CYP450 rs4646903/rs1048943 SNP pairs were in linkage disequilibrium, and the associations were statistically significant (P= 0.01 and P= 4.6x10^‒7, respectively).

CONCLUSION

The GSTM1 and TP53 rs1042522 variants can increase the development of CRC in Saudi nonsmokers. Even the presence of one copy of a variant allele in the CYP1A1 gene can predispose CRC risk. Additional studies should also examine other SNP combinations with lifestyle factors that may help prevent, rather than facilitate, colorectal tumorigenesis.

Thirty-Day Mortality After Curative and Palliative Anti-Cancer Treatment: Data Interpretation and Lessons for Clinical Implementation

Purpose

Despite advancements in cancer therapeutics, mortality and morbidity due to anti-cancer treatments still occur but are not frequently reported. We aimed to report the 30-day mortality and morbidity of all curative and palliative anti-cancer treatments.

Patients and Methods

Adults with solid and hematological malignancies from two large cancer centers in Saudi Arabia, irrespective of the cancer stage and treatment type, were included in this retrospective observational study.

Results

Between December 1, 2019 and February 29, 2020, 1694 patients from King Abdullah Medical City in Makkah and King Fahad Medical City in Riyadh were included in the study. Among them, 77.5% were younger than 65 years of age; 72.8% were female; the prevalence of obesity, diabetes, and hypertension was 35%, 34%, and 28%, respectively; and 66.5% of patients had breast and gastrointestinal cancers. Fifty-nine (3.5%) patients died within 30 days of receiving anti-cancer treatment. Of them, 9 (0.3%) were treated with curative intent, and 50 (3%) were treated with palliative intent.

Conclusion

Our results emphasize the need to address preventable metabolic changes and implement innovative, predictive, preventive, and personalized medicine (PPPM) approaches focusing on patient profiles. Reporting the 30-day outcomes of all anti-cancer treatments will also allow the identification of factors underlying mortality and morbidity and lead to an improvement in oncological outcomes via innovative programs designed to improve clinical decision-making.

The Impact of Body Mass Index on the Clinicopathological and Prognostic Factors of Colorectal Cancer in Saudi Arabia

Background Obesity is a known risk factor of colorectal cancer (CRC); however, the relationship between obesity and clinicopathologic characteristics and prognosis of CRC remains unclear. This study aimed to investigate the relationship between body mass index (BMI) and clinicopathological and prognostic factors of CRC in Saudi Arabia. Method This was a retrospective cross-sectional study of patients with CRC diagnosed between 2014 and 2018 at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. BMI was calculated by dividing the patient's weight in kilograms by height in meter squared and was classified according to the World Health Organization criteria. Statistical tests, including analysis of variance and chi-square tests, were used to investigate the relationship of each BMI category with clinicopathologic (histological type, degree of differentiation, tumor location, and medical comorbidities) and prognostic variables (TNM stage, lymph nodes involvement, and lymph nodes yield). Results Of 233 patients who were included, 60.1% were male and 39.9% were female patients, with a mean age (standard deviation) of 58.8 ± 13.7 (range: 26-99) years. The median BMI was 26.5 kg/m². Overall, 3%, 34.3%, 33.0%, and 29.6% patients were classified as underweight, normal weight, overweight, and obese, respectively. Furthermore, 57.1% (4/7), 39.2% (31/80), 38.7% (29/77), and 25.8% (17/69) of underweight, normal, overweight, and obese patients had Stage IV disease (p = 0.20). Of 16 patients with transverse colon cancer, 8 (50%) were obese (p = 0.38), and 1 (6%), 5 (31%), and 2 (13%) were underweight, normal weight, and overweight, respectively. Conclusion Underweight patients are more likely to present with metastatic CRC, while obese patients are more likely to present at earlier stages, although the difference was not statistically significant. BMI is not related to lymph node yield, histological type, or the degree of differentiation.

The Increasing Trends in Cases of the Most Common Cancers in Saudi Arabia

BACKGROUND

Cancer epidemiology in Saudi Arabia (SA) differs from that of the USA with respect to types of common malignancies. Hematologic malignancies are among the top five cancers prevalent in SA, including lymphoma and leukemia. Most common malignancies in SA also include breast, thyroid, and colorectal cancer. We sought to evaluate the current trends of these most common cancers in SA.

METHODS

Electronic search analysis pertaining to Hodgkin's lymphoma, leukemia, breast, colorectal, and thyroid cancer were carried out from two databases: The Saudi Cancer Registry (SCR) and the Surveillance, Epidemiology, and End Results (SEER). Data on prevalence and incident frequency were collected. Trends from 2001 to 2014 were calculated and compared between SCR and SEER.

FINDINGS

Leukemia is the most common cancer type among males in SA, followed by colorectal cancer. Hodgkin's lymphoma has become the third most common malignancy among Saudi males. Percentage of women's breast cancer and thyroid cancer among total cancer cases have increased by 10.5% and 1.7% respectively from 2001 to 2014, making them the first and second most common cancers in women respectively. Trends of thyroid cancer among males has been stable. Colorectal cancer stands as third most common among Saudi females.

INTERPRETATIONS

There have been significant changes in trends of incidence rate of the most common cancers in SA among both males and females over the past decade. Breast cancer rates have risen at an alarming pace. More epidemiological studies need to be conducted to evaluate etiological factors at environmental, molecular, and genetic levels.

Nasopharyngeal Cancer: Prevalence, Outcome, and Impact on Health-Related Quality of Life at Princess Norah Oncology Center, Jeddah, Saudi Arabia

Introduction

Head and neck malignancies are considered among the most common cancers that arise from different anatomical sites in the region. The number of new cases diagnosed worldwide each year is estimated to be more than 550,000 resulting in about 380,000 deaths. One of these head and neck cancers that may affect patient quality of life is the nasopharyngeal carcinoma (NPC). The purpose of our study is to assess the outcome, and the quality of life of these patients. Our study reviews NPC patients treated at Princess Norah Oncology Center, Jeddah, retrospectively over the past 15 years to provide additional information on this disease in Saudi Arabia.

Methods

We included all histologically confirmed cases of NPC seen at National Guard Hospital in Jeddah between 2002 and 2017. The data was collected retrospectively from the BestCare system, hospital information system, and the medical records. The created table included demographics, comorbidities, and first symptoms. The research table also contained stage at presentation and treatment modalities. Moreover, 25 patients were asked to complete the Arabic versions of European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC HN-35) module questionnaire to assess the quality of life. All results were computed using IBM SPSS version 23 (IBM Corp., Armonk, NY), which was provided by College of Medicine at KSAU.

Results

A total of 107 patients with adequate documentation were identified. There were 72.9% males and 27.1% females; 81.3% of patients were alive and in remission and 18.7% were dead. Neck mass was the most common clinical manifestation present in 84.1% of patients. Radiotherapy and chemotherapy were the most used modality by 96.3%. The five-year survival rate year was 81.3%. Moreover, the H&N-35 questionnaire showed that the NPC survivors suffered mostly poor social contact.

Conclusion

A large proportion of the identified patients were in remission. Quality of life assessment shows that the main impact of the disease and treatment was on social contact.

Integration of Transcriptome and Metabolome Provides Unique Insights to Pathways Associated With Obese Breast Cancer Patients

Information regarding transcriptome and metabolome has significantly contributed to identifying potential therapeutic targets for the management of a variety of cancers. Obesity has profound effects on both cancer cell transcriptome and metabolome that can affect the outcome of cancer therapy. The information regarding the potential effects of obesity on breast cancer (BC) transcriptome, metabolome, and its integration to identify novel pathways related to disease progression are still elusive. We assessed the whole blood transcriptome and serum metabolome, as circulating metabolites, of obese BC patients compared them with non-obese BC patients. In these patients' samples, 186 significant differentially expressed genes (DEGs) were identified, comprising 156 upregulated and 30 downregulated. The expressions of these gene were confirmed by qRT-PCR. Furthermore, 96 deregulated metabolites were identified as untargeted metabolomics in the same group of patients. These detected DEGs and deregulated metabolites enriched in many cellular pathways. Further investigation, by integration analysis between transcriptomics and metabolomics data at the pathway levels, revealed seven unique enriched pathways in obese BC patients when compared with non-obese BC patients, which may provide resistance for BC cells to dodge the circulating immune cells in the blood. In conclusion, this study provides information on the unique pathways altered at transcriptome and metabolome levels in obese BC patients that could provide an important tool for researchers and contribute further to knowledge on the molecular interaction between obesity and BC. Further studies are needed to confirm this and to elucidate the exact underlying mechanism for the effects of obesity on the BC initiation or/and progression.

Vimentin immunoexpression is associated with higher tumor grade, metastasis, and shorter survival in colorectal cancer

BACKGROUND/AIM

The association between vimentin immunoexpression and poor prognosis has been described in many human cancers. The objective of this study was to evaluate the relationship between vimentin immunostaining and colorectal carcinoma (CRC) clinicopathologic parameters.

MATERIALS AND METHODS

Samples included 202 primary CRC tissues, 41 adenomas and 37 normal colonic mucosae. Anti-Vimentin (V9) monoclonal antibody was used for immunohistochemical staining. Vimentin expression was evaluated based on the percentage of cytoplasmic expression in epithelial cells.

RESULTS

Vimentin expression was identified in 35 (17.3%) of CRC samples. All normal mucosa and adenoma samples were vimentin negative. There was an association between positive vimentin immunostaining and high tumor grade, distant metastasis, and short overall (Log rank 5.112, P=0.024), as well as disease-free survival probabilities (Log rank 6.173, P=0.013). There was no association between vimentin expression and age, gender, tumor location, tumor size, tumor stage, nodal involvement, lymphovascular invasion, margin status, or tumor recurrence.

CONCLUSION

Vimentin immunoexpression is associated with worse prognosis in CRC patients. Vimentin can be considered a potentially important disease biomarker and could be a target for CRC therapy.

Predictors of Survival Among Colorectal Cancer Patients in a Low Incidence Area

Background

Colorectal cancer is the third most common malignancy in Saudi Arabia. The best therapeutic regimen for colorectal cancer is a matter of ongoing debate and data on its treatment in Saudi Arabia are limited.

Purpose

The objective of this study was to explore the predictors of survival and to compare the risk of mortality among colorectal cancer patients treated with different therapeutic modalities.

Patients and Methods

The study utilized data from the electronic colorectal cancer registry of a university-affiliated tertiary care hospital. The Kaplan-Meier survival analysis was used to estimate the survival rates over 36 months of follow-up across rectal and colon cancer patients as well as different sociodemographic and medical characteristics. Bivariate and multiple Cox proportional-hazards regressions were conducted to estimate the risk of mortality among rectal and colon cancer patients undergoing different treatments.

Results

The number of patients in the registry who were followed up for 36 months was 143 patients. The majority of patients had colon cancer (74.13%). Rectal cancer patients had generally better survival estimates compared to their colon cancer counterparts. Colon cancer patients treated with chemotherapy had a significantly lower risk of mortality controlling for the use of surgery, radiotherapy, and other variables including age, gender, stage of cancer, and family history of colorectal cancer (HR=0.33; P=0.03). Additionally, colon cancer patients with a family history of colorectal cancer had significantly higher risk of mortality (HR=3.40; P=0.02).

Conclusion

The findings of this study highlight the value of chemotherapy in managing colon cancer patients.

Incidence Rates of Breast Cancer by Age and Tumor Characteristics Among Saudi Women: Recent Trends

Introduction and objectives

With such a huge country as Saudi Arabia, it would be expected to have variations in the pattern and incidence of breast diseases. This study aims to determine the recent trends in breast cancer incidence rates by age and tumor characteristics among female patients treated in the Armed Forces Hospital Southern Region (AFHSR) from the period of January 2010 to December 2017.

Methods

This study is a retrospective chart review where all breast biopsy reports of female patients were seen between January 2010 and December 2017 at the AFHSR, Saudi Arabia, to observe the pattern of breast cancer as well as to calculate the incidence rates by age and tumor characteristics among the study subjects.

Results

Overall, the incidence rates of breast cancer among female patients ranged between three to eight confirmed cases of breast cancer for every 1000 patients for the period of 2010 to 2017, where the highest incidence rate was reported in the year of 2017. Additionally, two distinct patterns are observed in breast cancer trends, i.e., the most common type of cancer was ductal carcinoma with an incidence percentage of 81.80%, followed by lobular carcinoma (3.40%). There was no statistical evidence that the associated population means of age are significantly different from the type of tumor characteristics.

Conclusions

In this study, the average age for diagnosed women with invasive breast cancer is about 56 years of age while in situ is 51 years. Among women of all age groups, ductal carcinoma is the most common. There is also an increase in the incidence of breast cancer between 2016 to 2017, where the highest incidence rate was reported in the year 2017. Continued vigilance, mammographic screening, and patient education are needed to establish an early diagnosis and perform the optimal treatment.

Differential prolactin levels among male and female patients with thyroid related complains in the Hail regions of Saudi Arabia

Thyroid diseases are caused by autoimmunity due to hormone imbalance both in male and female patients. Therefore, it is of acute importance to measure, analyze and compare thyroid hormone levels among populations with thyroid-related complications. Hence, we examined 202 male and female thyroid patients in the Hail regions of Saudi Arabia and estimated their hormone levels. Blood samples were collected from patients and processed for the hormonal profiling such as prolactin, luteinizing hormone (LH), FSH, free T3 (FT3), free T4 (FT4) and TSH3. Further, measurement of thyroid gland size in the Hail population was also completed. Results of our study showed a significant difference in the level of prolactin between male and female patients. Other hormones are namely luteinizing hormone (LH), FSH, free T3 (FT3), free T4 (FT4), TSH3 did not show any significant difference between male and female patients with thyroid disorder. Thus, the levels of the majority of hormones, namely luteinizing hormone (LH), FSH, free T3 (FT3), free T4 (FT4), and TSH3, except prolactin, did not differ significantly between male and female thyroid patients. Validation of the observation using large scale population size is warranted in future investigations.

Fascin expression in urinary bladder urothelial carcinoma correlates with unfavourable prognosis

BACKGROUND

Urinary bladder crothelial carcinoma (UCB) is the most common urinary bladder neoplasm. The present study aims at investigating immunostaining of fascin in UCB in relation to clinicopathologiccriteria in Saudi Arabia.

METHODS

This study utilised 122 UCB and 25 apparently normal urothelium archival pathologic samples prior to local or systemic therapy. Tissue microarrays were constructed and the generated TMA blocks were used for Immunohistochemical staining. The mouse anti-fascin monoclonal antibody was used. A 25% was used to specify low and high fascin immunostaining.

RESULTS

Fascin immunostaining was detected in UCB and apparently normal urothelium. High immunostaining was statistically less frequent than low fascin immunostaining (P≤0.001). In UCB, high fascin immunostaining was associated with older patients (P=0.005) and local disease recurrence (P=0.002). High fascin immunostaining was an independent predictor of local disease recurrence (P=0.002) and associated with poor overall survival (P=0.027).

CONCLUSION

High fascin immunostaining in UCB was associated with adverse prognostic factors and may be used as an independent prognostic marker. Fascin was detected in apparently normal urothelium and may contribute to UCB carcinogenesis. Further investigations (molecular and clinical) are required to understand the molecular interaction of fascin with UCB and its possible therapeutic applications.

Estimation of cancer risks during mammography procedure in Saudi Arabia

The aims of the present work were to quantify radiation doses arises from patients' exposure in mammographic X-ray imaging procedures and to estimate the radiation induced cancer risk. Sixty patients were evaluated using a calibrated digital mammography unit at King Khaled Hospital and Prince Sultan Center, Alkharj, Saudi Arabia. The average patient age (years) was 44.4 ± 10 (26-69). The average and range of exposure parameters were 29.1 ± 1.9 (24.0-33.0) and 78.4 ± 17.5 (28.0-173.0) for X-ray tube potential (kVp) and current multiplied by the exposure time (s) (mAs), respectively. The MGD (mGy) per single projection for craniocaudal (CC), Medio lateral oblique (MLO) and lateromedial (LM) was 1.02 ± 0.2 (0.4-1.8), 1.1 ± 0.3 (0.5-1.8), 1.1 ± 0.3 (0.5-1.9) per procedure, in that order. The average cancer risk per projection is 177 per million procedures. The cancer risk is significant during multiple image acquisition. The study revealed that 80% of the procedures with normal findings. However, precise justification is required especially for young patients.

Colorectal cancer in Saudi Arabia as the proof-of-principle model for implementing strategies of predictive, preventive, and personalized medicine in healthcare

Colorectal cancer (CRC) is the most commonly diagnosed cancer among Saudi males and ranks third in females with up to 73% of cases diagnosed at late stage. This review provides an analysis of CRC situation in the Kingdom of Saudi Arabia (KSA) from healthcare perspective. A PUBMED (1986-2018) search was done to identify publications focusing on CRC in KSA. Due to reports of increased CRC incidence among young age group (< 50), and given the young population of KSA, the disease may burden the national healthcare system in the next decades. Environmental factors attributed to increasing incidence rates of CRC include red meat consumption, sedentary lifestyle, and increased calorie intake. Despite substantial investment in healthcare, attention to predictive diagnostics and targeted prevention is lacking. There is a need to develop national screening guidelines based on evidence that supports a reduction in incidence and mortality of CRC when screening is implemented. Future approaches are discussed based on multi-level diagnostics, risk assessment, and population screening programs focused on the needs of young populations that among others present the contents of the advanced approach by predictive, preventive, and personalized medicine. Recommendations are provided that could help to develop policies at regional and national levels. Countries with demographics and lifestyle similar to KSA may gain insights from this review to shape their policies and procedures.

Effects of Hexane Root Extract of Ferula hermonis Boiss. on Human Breast and Colon Cancer Cells: An In Vitro and In Vivo Study

Breast and colon cancers are leading causes of cancer-related deaths globally. Plants are a potential source of natural products that may be used for the treatment of cancer. Ferula hermonis (FH) is reported to have diverse therapeutic effects. However, there are few reports on the in vitro anticancer potential of FH extract. Our results showed that the Ferula hermonis root hexane extract (FHRH) can induce dose-dependent cytotoxic effects in breast and colon cancer cells with MTT IC₅₀ values of 18.2 and 25 μg/ml, respectively. The FHRH extract induced apoptosis in both breast and colon cancer cells; this was confirmed by light and nuclear staining, q-PCR, and caspase 3/7 activation. This study also demonstrated the antitumor activity of FHRH in 9,10-dimethylbenz[α]anthracene DMBA-induced rodent mammary tumor model. The GC/MS analysis revealed the presence of 3,5-Dimethylbenzenemethanol, Alpha-Bisabolol, Alpha-pinene, Beta-pinene, and Baccatin III that have various pharmacological potentials. Overall, the present study suggests that FHRH extract possesses anticancer potential which is mediated through apoptotic effects in MDA-MB-231 and LoVo cells. The present study also considered a basis for further investigations into the potential use of FHRH extract as an anticancer therapy for breast and colon cancers.

Overexpression of SIRT1 in urothelial carcinoma of the urinary bladder is associated with local recurrence and poor survival

Objectives:

To investigate the relationship of Silent mating type information regulation 2 homolog-1 (SIRT1) immunostaining to urothelial carcinoma of the urinary bladder (UCB) clinicopathological parameters.

Methods:

The study includes a total of 147 specimens composed of 122 urothelial carcinoma and 25 of non-neoplastic normal mucosae. The clinical information and the corresponding paraffin blocks of the cases were collected from the Pathology Department at King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. Tissue microarrays were prepared and unstained slides were cut from the recipient blocks. Immunohistochemistry study was performed using anti-human SIRT1 antibody. The study was conducted from July 2016 until May 2018.

Results:

In UCB, high SIRT1 immunostaining (59.8%) was greater than low SIRT1 immunostaining (40.2%). High SIRT1 immunostaining was associated with local disease recurrence (p=0.017). However, there was no relation with other clinicopathological parameters. Regression analysis demonstrated that SIRT1 overexpression is an independent predictor of local disease recurrence (p=0.002). High SIRT1 immunostaining was associated with lower overall survival (log rank [Mantel-Cox]=6.478, and p=0.011) and disease-free survival (log rank [Mantel-Cox])=4.281, and p=0.039).

Conclusion:

The results revealed that SIRT1 is an important prognostic factor for UBC patients and is a potential target for therapeutic intervention. Further immunohistochemical and molecular evaluations are required to explore the mechanism of action of SIRT1 and to investigate molecular downstream of this potential biomarker in UCB.

Increased COX-2 Immunostaining in Urothelial Carcinoma of the Urinary Bladder Is Associated with Invasiveness and Poor Prognosis

BACKGROUND

Urothelial carcinoma of the urinary bladder (UCB) is the commonest bladder tumor. Cyclooxygenase-2 (COX-2) mediates angiogenesis, cell survival/proliferation, and apoptosis. This study investigates the relation of COX-2 immunostaining in UCB to clinicopathological parameters in Saudi Arabia.

METHODS

The study population includes 123 UCB and 25 urothelial mucosae adjacent to UCB. UCB samples were collected before any local or systemic therapy. Tissue microarrays were designed and constructed, and TMA blocks were sliced for further immunohistochemical staining. Immunohistochemical staining was done using a mouse anti-human COX-2 monoclonal antibody. A cutoff point of 10% was chosen as the threshold to determine low and high COX-2 immunostaining.

RESULTS

COX-2 immunostaining is higher in UCB than in the adjacent urothelium (p = 0.033). High COX-2 immunostaining is associated with high-grade UCB (p = 0.013), distant metastasis (p = 0.031), lymphovascular invasion (p = 0.008), positive muscle invasion (p = 0.017), pT2 and above (p = 0.003), and high anatomical stages (stage II and above). High COX-2 immunostaining is an independent predictor of higher tumor grade (p < 0.001), muscle invasion (p = 0.015), advanced pathological T (p = 0.014), lymphovascular invasion (p = 0.011), and distant metastasis (p = 0.039). High COX-2 immunostaining is associated with lower overall survival rate (p = 0.019).

CONCLUSION

COX-2 immunostaining is associated with the invasiveness of UCB which may be used as an independent prognostic marker. COX-2 may be a significant molecule in the initiation and progression of UCB. Molecular and clinical investigations are required to explore the molecular downstream of COX-2 in UCB and effectiveness of COX-2 inhibitors as adjuvant therapy along with traditional chemotherapy.

β1 Integrin is essential for fascin-mediated breast cancer stem cell function and disease progression

Breast cancer remains the second cause of tumor‐related mortality in women worldwide mainly due to chemoresistance and metastasis. The chemoresistance and metastasis are attributed to a rare subpopulation with enriched stem‐like characteristics, thus called Cancer Stem Cells (CSCs). We have previously reported aberrant expression of the actin‐bundling protein (fascin) in breast cancer cells, which enhances their chemoresistance, metastasis and enriches CSC population. The intracellular mechanisms that link fascin with its downstream effectors are not fully elucidated. Here, loss and gain of function approaches in two different breast cancer models were used to understand how fascin promotes disease progression. Importantly, findings were aligned with expression data from actual breast cancer patients. Expression profiling of a large breast cancer dataset (TCGA, 530 patients) showed statistically significant correlation between fascin expression and a key adherence molecule, β1 integrin (ITGB1). In vitro manipulation of fascin expression in breast cancer cells exhibited its direct effect on ITGB1 expression. Fascin‐mediated regulation of ITGB1 was critical for several breast cancer cell functions including adhesion to different extracellular matrix, self‐renewability and chemoresistance. Importantly, there was a significant relationship between fascin and ITGB1 co‐expression and short disease‐free as well as overall survival in chemo‐treated breast cancer patients. This novel role of fascin effect on ITGB1 expression and its outcome on cell self‐renewability and chemoresistance strongly encourages for dual targeting of fascin‐ITGB1 axis as a therapeutic approach to halt breast cancer progression and eradicate it from the root.

What's new?

Residual cancer stem cells (CSCs) have the ability to regrow tumors and to metastasize to distant organs, resulting in disease relapse and increased cancer mortality. In breast cancer, CSC populations are enriched by aberrant expression of the actin‐bundling protein fascin, induction of which is also associated with chemoresistance and metastasis. In this study, fascin was found to upregulate β1 integrin (ITGB1) expression, an effect that proved critical to breast cancer cell adhesion and self‐renewal. Coexpression of fascin and ITGB1 was associated with decreased survival in chemotherapy‐treated breast cancer patients. The findings identify the fascin‐ITGB1 axis as a potential therapeutic target.

Specific Cytotoxic Effects of Parasporal Crystal Proteins Isolated from Native Saudi Arabian Bacillus thuringiensis Strains against Cervical Cancer Cells

Currently, global efforts are being intensified towards the discovery of local Bacillus thuringiensis (Bt) isolates with unique anticancer properties. Parasporins (PS) are a group of Bt non-insecticidal crystal proteins with potential and specific in vitro anticancer activity. However, despite the significant therapeutic potential of PS-producing Bt strains, our current knowledge on the effects of these proteins is limited. Hence, the main objective of this study was to screen Bt-derived parasporal toxins for cytotoxic activities against colon (HT-29) and cervical (HeLa) cancerous cell lines. Nine non-larvicidal and non-hemolytic Bt strains, native to Saudi Arabia, were employed for the isolation of their parasporal toxins. 16S rDNA sequencing revealed a 99.5% similarity with a reference Bt strain. While PCR screening results indicated the absence of selected Cry (Cry4A, Cry4B, Cry10 and Cry11), Cyt (Cyt1 and Cyt2) and PS (PS2, PS3 and PS4) genes, it concluded presence of the PS1 gene. SDS-PAGE analysis revealed that proteolytically-cleavaged PS protein profiles exhibit patterns resembling those observed with PS1Aa1, with major bands at 56 kDa and 17 kDa (Bt7), and 41 kDa and 16 kDa (Bt5). Solubilized and trypsinized PS proteins from all Bt strains exhibited a marked and dose-dependent cytotoxicity against HeLa cancerous cells but not against HT-29 cells. IC₅₀ values ranged from 3.2 (Bt1) to 14.2 (Bt6) with an average of 6.8 µg/mL. The observed cytotoxicity of PS proteins against HeLa cells was specific as it was not evident against normal uterus smooth muscle cells. RT-qPCR analysis revealed the overexpression of caspase 3 and caspase 9 by 3.7, and 4.2 folds, respectively, indicative of the engagement of intrinsic pathway of apoptosis. To the best of our knowledge, this is the first report exploring and exploiting the versatile repertoire of Saudi Arabian environmental niches for the isolation of native and possibly novel Saudi Bt strains with unique and specific anticancer activity. In conclusion, native Saudi Bt-derived PS proteins might have a potential to join the arsenal of natural anticancer drugs.

Efficacy of Regorafenib in Metastatic Colorectal Cancer: A Multi-institutional Retrospective Study

BACKGROUND

Regorafenib is a multi-kinase inhibitor approved for treatment of refractory advanced colorectal cancer. It was found in the clinical trials to have a modest benefit and significant toxicity. Our aim was to assess the outcome in our local clinic practice.

PATIENTS AND METHODS

Records of patients with confirmed colorectal cancer treated with regorafenib were reviewed. Clinical, pathological, and molecular data were collected. Efficacy and factors of possible prognostic significance were analyzed.

RESULTS

A total of 78 patients with metastatic colorectal cancer were treated with regorafenib from February 2014 to February 2016 in 4 different institutions (median age: 50.5 years; male: 40 [51.3%]; KRAS mutant: 41 [52%]; right colonic primary: 18 [23%]). A total of 52 patients (66.7%) had Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 to 1, whereas in 25 patients (32.1%) it was >1. In total, 58 patients (74%) had dose reduction. No patient achieved objective response, 15 patients (19%) achieved stable disease, and 56 patients (72%) had progressive disease. With a median follow-up of 6.5 months, the median progression-free survival was 2.8 months (95% confidence interval [CI], 2.5-3.3) and overall survival was 8.0 months (95% CI, 6.2-9.7). Only performance status of ⩽1 had a statistically significant impact on progression-free survival and overall survival in both univariate and multivariate analyses.

CONCLUSIONS

Regorafenib in our clinical practice has equal efficacy to reported data from pivotal registration trials. Our data suggest that performance status is the most important prognostic factor in patients treated with regorafenib, suggesting a careful selection of patients.

Anticancer Activity of Camel Milk via Induction of Autophagic Death in Human Colorectal and Breast Cancer Cells

Background/Objective:

Camel milk is traditionally known for its human health benefits and believed to be a remedy for various human ailments including cancer. The study was aimed to evaluate the inhibitory effects of commercially available camel milk on cancer cells and its underlying mechanism(s).

Materials and Methods:

Two cell lines: colorectal cancer HCT 116 and breast cancer MCF-7 were cultured with different doses of camel milk. The effects of camel milk on cell death were determined by MTT assay, viability by trypan blue exclusion assay and migration by in vitro scratch assay. The mechanism was elucidated by western blotting and confocal microscopy was used to confirm autophagy.

Results:

Camel milk significantly reduced proliferation, viability as well as migration of both the cells. The accumulation of LC3-II protein along with reduction in expression of p62 and Atg 5-12, the autophagy proteins implied induction of autophagy. The (GFP)-LC3 puncta detected by confocal microscopy confirmed the autophagosome formation in response to camel milk treatment.

Conclusion:

Camel milk exerted antiproliferative effects on human colorectal HCT 116 and breast MCF-7 cancer cells by inducing autophagy.

Overexpression of PARP is an independent prognostic marker for poor survival in Middle Eastern breast cancer and its inhibition can be enhanced with embelin co-treatment

Patients with aggressive breast cancer (BC) subtypes usually don’t have favorable prognosis despite the improvement in treatment modalities. These cancers still remain a major cause of morbidity and mortality in females. This has fostered a major effort to discover actionable molecular targets to treat these patients. Poly ADP ribose polymerase (PARP) is one of these molecular targets that are under comprehensive investigation for treatment of such tumors. However, its role in the pathogenesis of BC from Middle Eastern ethnicity has not yet been explored. Therefore, we examined the expression of PARP protein in a large cohort of over 1000 Middle Eastern BC cases by immunohistochemistry. Correlation with clinico-pathological parameters were performed. Nuclear PARP overexpression was observed in 44.7% of all BC cases and was significantly associated with aggressive clinico-pathological markers. Interestingly, nuclear PARP overexpression was an independent predictor of poor prognosis. PARP overexpression was also directly associated with XIAP overexpression, with PARP and XIAP co-expression in 15.8% (159/1008) of our cases. We showed that combined inhibition of PARP by olaparib and XIAP by embelin significantly and synergistically inhibited cell growth and induced apoptosis in BC cell lines. Finally, co-treatment of olaparib and embelin regressed BC xenograft tumor growth in nude mice. Our results revealed the role of PARP in Middle Eastern BC pathogenesis and prognosis. Furthermore, our data support the potential clinical development of combined inhibition of PARP and XIAP, which eventually could extend the utility of olaparib beyond BRCA deficient cancer.