Fabrication of eco-friendly graphene-based superhydrophobic coating on steel substrate and its corrosion resistance, chemical and mechanical stability

Superhydrophobic coatings were successfully fabricated on steel substrates using potentiostatic electrodeposition of Ni and Ni-graphene, Ni-G, coatings followed by immersion in an ethanolic solution of stearic acid, SA. Rice straw, an environmentally friendly biomass resource, was used to synthesize high-quality graphene. The Raman spectra proved the high quality of the produced graphene. The Fourier transform infrared spectroscopy, FTIR, results showed that the Ni coating grafted with stearic acid, Ni-SA, and the Ni-G composite grafted with stearic acid, Ni-G-SA, were successfully deposited on the steel substrate. The scanning electron microscope, SEM, results showed that the prepared superhydrophobic coatings exhibit micro-nano structures. The wettability results revealed that the values of contact angles, CAs, for Ni-SA and Ni-G-SA coatings are 155.7° and 161.4°, while the values of sliding angles, SAs, for both coatings are 4.0° and 1.0°, respectively. The corrosion resistance, chemical stability, and mechanical abrasion resistance of the Ni-G-SA coating were found to be greater than those of the Ni-SA coating.

Comparative effectiveness of EDTA and citric acid assisted phytoremediation of Ni contaminated soil by using canola (Brassica napus)

Phytoremediation is an ecofriendly technique to clean heavy metals from contaminated soil by the use of high biomass producing plant species. Chelators can help to improve this biological technique by increasing metal solubility. Therefore, a pot experiment was conducted to determine the effect of the chelators EDTA and citric acid (CA) in phytoremediation of Ni contaminated soil by using Brassica napus (canola). Two cultivars of B. napus, Con-II (tolerant) and Oscar (sensitive), were selected after screening and exposed to NiSO4 at 30 ppm at the time of sowing. CA (10 mM) and EDTA (1.5 mM) were applied either alone or in combination with each other after two weeks of Ni treatments. Different parameters like morpho-physiological and biochemical data were recorded after 15 days of chelate application. The results highlighted the successful use of chelating agents (CA and EDTA) not only to ameliorate Ni stress but also to enhance Ni accumulation which is prerequisite for phytoremediation. The basal application of 10 mMCA and 1.5 mM EDTA concentration proved to be effective for the growth of plants. The combination of chelating agents failed to show any synergistic effects.

Real-world effectiveness and safety profile of teriflunomide in the management of multiple sclerosis in the Gulf Cooperation Council countries: An expert consensus narrative review

Background

The prevalence of multiple sclerosis (MS) is increasing in Gulf Cooperation Council (GCC) countries. Multiple sclerosis contributes to significant burden on patients and caregivers. The pharmacological treatment in MS involves treating acute exacerbations and preventing relapses and disability progression using disease-modifying therapies. Clinical evidence suggests that teriflunomide is one of the therapeutic choices for patients with relapsing–remitting MS (RRMS). However, genetic and cultural differences across different regions may contribute to variations in drug use. Therefore, it is necessary to consider real-world evidence for teriflunomide usage in GCC countries.

Methods

An expert group for MS gathered from GCC countries in December 2020. The consensus highlighting role of teriflunomide in MS management has been developed using clinical experiences and evidence-based approach.

Results

The expert-recommended patient profile for teriflunomide usage includes individuals aged 18 years and above, both men and women (on effective contraceptives) with clinically isolated syndrome or RRMS. The factors considered were cost-effectiveness of the drug, patient preference, adherence, monitoring, established safety profile, and coronavirus disease 2019 status.

Conclusion

Expert recommendations based on their clinical experience will be more helpful to clinicians in clinical settings regarding the usage of teriflunomide and provide valuable insights applicable in day-to-day practice.

Mucopolysaccharidosis Type I Disease Prevalence Among Patients With Idiopathic Short Stature in Saudi Arabia: Protocol for a Multicenter Cross-sectional Study

Background

Since the underlying cause of idiopathic short stature can indeed be undiagnosed mucopolysaccharidosis type I, it is critical to identify patients with mucopolysaccharidosis type I among screened patients with idiopathic short stature.

Objective

The primary objective of this study is to determine the prevalence of mucopolysaccharidosis type I disease in a high-risk group (ie, patients with idiopathic short stature).

Methods

We plan to perform a multicenter, cross-sectional screening study to primarily assess the prevalence of mucopolysaccharidosis type I disease in patients with idiopathic short stature. All eligible patients will be tested after obtaining written informed consent from their parents and guardians. Eligible patients will be recruited over 18 months from specialty care centers for pediatrics and genetics.

Results

This protocol was approved by the Institutional Review Board of King Fahd Medical City and funded by Sanofi Genzyme Saudi Arabia. We expect to collect data from ≥800 patients, as determined by our sample size calculation.

Conclusions

Saudi Arabia is the largest country in the Arabian Peninsula; it has a population of more than 28 million people. To date, there are no reliable data regarding the incidence and prevalence of mucopolysaccharidosis type I in Saudi Arabia; therefore, future multicenter studies will be needed. Further, the prevalence of an attenuated form of mucopolysaccharidosis type I is largely underestimated in Saudi Arabia due to the absence of an effective newborn screening program. Therefore, the implementation of a nationwide newborn screening program is essential for the accurate estimation of the burden of mucopolysaccharidosis and the early diagnosis of patients.

International Registered Report Identifier (IRRID)

PRR1-10.2196/28619

Splenocystojejunostomy for the treatment of a symptomatic splenic pseudocyst

Pancreatic pseudocyst is a widely recognised local complication following acute pancreatitis. Typically occurring more than four weeks after acute pancreatitis, a pseudocyst is a mature, encapsulated collection found within the peripancreatic tissues manifesting as abdominal pain, structural compression, gastroparesis, sepsis and organ dysfunction. Therapeutic interventions include endoscopic transpapillary or transmural drainage, percutaneous catheter drainage and open surgery. We present our management of idiopathic chronic pancreatitis complicated by a pancreatic pseudocyst extending to the splenic capsule in a 38-year-old man. A trial of conservative management was sought, but later escalated to percutaneous fluoroscopic drainage. Despite a period of volume reduction of the pseudocyst, reaccumulation occurred. We describe successful surgical treatment via means of a splenocystojejunostomy and subsequent pain reduction.

Garlic oil as a fight against histological and oxidative stress abnormalities in Wistar rats after oral inoculation of Anisakis spp. Type II (L3) (Nematoda)

ABSTRACT The consumption of inadequately thermally treated fish is a public health risk due to the possible propagation of Anisakis larvae and their antigenic proteins, the causative agent of the zoonotic disease anisakidosis. The present study demonstrated the physiological and histopathological changes that accompanied an oral inoculation of crude extracts from fresh and thermally treated Anisakis Type II (L3) in Wistar albino rats. Nematode worms were isolated from the marine fish Dicentrarchus labrax. They were examined and taxonomically identified using light and scanning electron microscopy. The study was performed in 6 rat groups: a control group (I), a garlic oil (GO) inoculated group (II), a fresh L3 inoculated group (III), a thermally treated L3 inoculated group (IV), a fresh L3 + GO inoculated group (V), and a thermally treated L3 + GO inoculated group (VI). It was observed that rats inoculated with fresh and thermally treated L3 crude extracts showed abnormal oxidative stress markers associated with the destruction of normal architecture of spleen and thymus. GO produced a protective effect in rat groups inoculated with L3 extracts + GO administration via the amelioration of oxidative stress markers, which was confirmed by the marked normal structure of the organs’ histology. Cooking of L3 infected fish induced severe physiological and histopathological alterations compared to uncooked infected fish. The administration of garlic before and after fish eating is recommended to avoid the dangerous effect of anisakids, even if they are cooked.

Transanal evisceration of small bowel in two patients with chronic rectal prolapse: case presentation and literature review

There are fewer than 100 documented cases of transanal small bowel evisceration in the literature. We report two cases of this rare surgical emergency in an 84-year old man and a 79-year old woman. Both patients required urgent laparotomy, resection of ischaemic bowel and transabdominal resection of the rectal defect with colostomy. Postoperative recovery was uneventful. Rare imaging and clinical photography are shared to highlight the extreme nature of this condition. We identified 38 relevant cases of reported bowel evisceration through our literature review. Most patients were elderly women with untreated rectal prolapse. Gynaecological comorbidity was another risk factor. The aetiological mechanism is suspected to stem from chronic ischaemic insult to the rectal wall, resulting in thinning and subsequent perforation. Surgical management may consist of primary suture repair of the rectal tear, or a Hartmann's procedure. Timely intervention is essential to minimise patient morbidity and mortality.

The use of alemtuzumab in patients with relapsing-remitting multiple sclerosis: the Gulf perspective

Over the past decade, the development of high-efficacy disease-modifying therapies (DMTs) has been responsible for more effective management of relapsing-remitting multiple sclerosis (RRMS). However, the gaps in optimal care for this complex disease remain. Alemtuzumab (Lemtrada®) is a highly efficacious DMT that shows better patient outcomes and therapeutic benefits, but its use is under-recognized in the Gulf region. Experts in the care of multiple sclerosis shared their opinions based on study data and daily clinical experience in identifying the appropriate patient profile suitable for alemtuzumab's therapeutic benefits. Age, disease activity and severity, disability status, physician experience, and economic condition are some of the key indicators for alemtuzumab use.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Cutaneous Metastasis from Breast Carcinoma: a brief report of a rare variant and proposed morphological classification

BACKGROUND

Breast carcinoma is the second commonest cancer in women after non-melanoma skin cancers and, excluding melanoma, the most common tumor to metastasize to the skin in women. Cutaneous metastasis from breast cancer has varied presentations but there is no well-established classification which includes them all.

OBJECTIVE AND CONCLUSION

We report a 69 year-old lady with advanced primary ductal carcinoma of right breast (cT4cN1cM0) who presented five months after radical mastectomy with very extensive cutaneous metastases in absence of distant spread. Skin involvement was in the form of nodules and purpuric papulo-vesicles on a background of erythema which clinically mimicked lymphatic malformation. We also propose a morphological classification of the cutaneous metastasis from breast cancer.

KEYWORDS

Breast Carcinoma, Cutaneous metastasis, lymphatic malformation.

Ewing's Sarcoma of the Head and Neck: A Retrospective Analysis of 24 Cases

Introduction and purpose. Primary Ewing's sarcoma arising from the bones of the head and neck region is extremely rare representing only 1– 4% of all Ewing's sarcoma cases. Previous reports suggest a better prognosis for that particular anatomic site. The purpose of this study was to analyze the clinico-epidemiologic characteristics of that rare clinical presentation, as well as its patterns of failure and prognosis following treatment.

Materials and methods. This study included a retrospective review of the medical records of patients with the diagnosis of Ewing's sarcoma of the head and neck region treated at King Faisal Specialist Hospital and Research Center between 1975 and 1996.

Results. Out of a total number of 24 cases analyzed, there were 17 males and 7 females with a ratio of 2.4:1. The median age at diagnosis was 16.5 years. A painful swelling was the most common clinical presentation.The maxilla was the most common site of presentation (9/24 cases). There were 3/24 cases who presented with metastatic disease at diagnosis.The majority of patients (16/24 cases) had a tumor size >10 cm. Most patients were treated with systemic chemotherapy plus localized irradiation following an initial biopsy.With a mean follow up of 3.4 years, the 5-year actual overall survival (OS) for the whole group was 53%, while the 5-year actuarial disease-free survival (DFS) was 30%. These figures were higher than those repor ted from our institution for young patients (≤ 14 years treated for Ewing' s sarcoma in other anatomic locations (30% v 15%). The response to chemotherapy was the only prognostic factor that affected both the OS and DFS.

Conclusion. The prognosis of Ewing's sarcoma of the head and neck region is slightly better than that of other anatomic sites.The response to systemic chemotherapy is one of the most important prognostic factors affecting both DFS and OS of Ewing's sarcoma of the head and neck. Multimodality therapy consisting of an initial biopsy, aggressive combination chemotherapy and localized radiotherapy is the treatment of choice for Ewing's sarcoma of the head and neck region and may result in long-term survival.

Fentanyl Transdermal Therapy System (TTS-Patch) for Post-Traumatic Blunt Chest Injury

Proper post-extubation pain control in traumatic blunt chest injury represents a challenge to provide adequate analgesia for proper lung inflation and to prevent re-intubation. In this case, the average opioid (Remifentanil) infusion drip in a traumatic blunt chest injury patient in the 48 hours prior to extubation was calculated and converted to the equivalent analgesic one of the Fentanyl Transdermal Therapeutic System (Fentanyl TTS Patch). The analgesic gap before the onset of action for the applied fentanyl patch was covered by frequent injections of tramadol. Evaluation of the Fentanyl TTS effect through the post-extubation period was carried out by measuring the analgesic effect on a visual analogue scale, the alertness status by simple sedation score, while the respiratory performance was followed by the negative inspiratory force. The outcome in this case showed that Fentanyl Patch is a reliable, favorable, safe and non-invasive method that produces a good analgesic effect and positive impaction on the post-extubation course of respiratory performance with a satisfactory outcome and no side effects.

Experienced Airway Management in Laryngotracheal Injuries: Series of Cases, Survey and Review of Literature

Definitive airway control of penetrating laryngotracheal injury can be an extremely difficult challenge for the emergency physician. We report three serious cases of penetrating neck trauma with laryngeal injury that were managed successfully using different techniques of airway control in the Emergency Department (ED) of Hamad General Hospital during the three years from January 2006 through December 2008. Individualized assessment, identification of type of injury and familiarity with airway control techniques and the available options assure timely, safe and proper airway control in such injuries. Choice of technique in penetrating laryngotracheal injury is multifactorial and depends upon case presentation, physician preference, skill, and clinical constraints. The incidence of neck injury during this period was lower than in other reports; being 0.07 % of total trauma cases, while the incidence of penetrating neck injuries represented 17.6% of total neck injuries with no deaths. Implications Statement: Familiarity and availability of variant airway management techniques and variant surgical interventions in penetrating laryngotracheal injuries, improve outcome and reduce mortality.

Prospective phase II study of neo-adjuvant doxorubicin followed by cisplatin /docetaxel in locally advanced breast cancer—5 years of follow up

10574

Background: Neoadjuvant (primary) chemotherapy as part of multimodality treatment is increasingly used as standard of care for patients (pts) with locally advanced breast cancer and firmly established. We conducted a prospective study using doxorubicin 75 mg/m2 q 3 weeks × 3 cycles followed sequentially by docetaxel 75 mg /m2 and cisplatin 75 mg/m2 q 3 weeks × 3cycles. All pts had definitive surgery followed by radiation therapy, ± tamoxifen. Primary end points were pathologic complete response (pCR), secondary endpoints were, safety, rate of conservative surgery and overall survival. Material: Eligible pts included biopsy proven invasive breast cancer, T2-T4 (primary = 4–10 cm) N0-N2, M0. 59 of 60 enrolled pts completed treatment one patient refused surgery after the completion of 6 cycles of chemotherapy were excluded from the analysis, median age:41yrs (24- 60), Premenopausal: 68%, median tumor size: 6.0cm (4 - 10), Stage IIB:32% and IIIA / IIIB: 68%, both ER / PR positive: 53%, Her2/neu (3+) by IHC staining and /or Fish positive: 29%. All patients had negative metastatic workup. Results: 59 pts are evaluable for analysis: clinical complete response was seen in: 44%, clinical partial response in: 56 %. Breast conserving surgery was performed in: 44 %, and MRM in: 56%. Pathological complete response (pCR) in the breast was: 31 %, in axilla were: 37 %. Grade3–4 Toxicities: Febrile Neutropenia: (13%), Nausea vomiting: (12%), Mucositis: (10%), weakness/asthenia/weight loss: 12%. Overall at follow up of 60 months the DFS & OS (67% and 74%).Patients who achieved complete pathologic response in breast and/or axilla the DFS and OS were (91%), 13 patients relapsed 46% were Her2 positive. Conclusion: Sequential combination of doxorubicin followed by docetaxel/cisplatin is a safe, feasible and active combination, that offer the possibility of conservative surgery and associated with high clinical and pathologic response, further investigation of this combinations are warranted.

No significant financial relationships to disclose.

Redo transanal endorectal pull-through: a preliminary study

The aim of this study is to evaluate the safety and efficacy of the redo transanal endorectal pull-through (TEPT) for patients with persistent symptoms after pull-through for Hirschsprung's disease (HD). Seven children were included in the study, their ages ranged from 2.5 to 6 years (four males and three females). They presented with persistent obstructive symptoms after pull-through for HD, which was remediated with redo TEPT. Indications were persistent constipation, anastomotic stricture unresponsive to dilatation with or without attacks of enterocolitis. Mean follow-up period was 12 months (ranged from 8 to 16 months). Obstructive symptoms were relieved in all patients with no soiling throughout the period of follow-up. Enterocolitis developed once in two patients who responded to conservative management after hospitalization. There were no deaths and anastomotic leakage, persistent stricture and cuff abscess did not develop in our series. EMG mapping of the external anal sphincter showed a good resting and powerful squeezing pressure curve. Redo TEPT is a useful alternative procedure for persistent symptoms of HD, and it appears to be safe and effective.

Report of an International Network of Cancer Treatment and Research workshop on non-Hodgkin's lymphoma in developing countries

The International Network of Cancer Treatment and Research (INCTR) recently organized a workshop on non-Hodgkin lymphomas (NHLs) in selected developing countries with the purpose of examining existing information relating to the pathology and management of these neoplasms, and identifying potential areas for research. This report provides a summary of the information presented and is focused primarily on the pathology of NHLs in children and adults. In most countries, the WHO classification of lymphomas was used and most participating centers included immunohistochemistry using a wide array of lymphoid antibodies as part of routine diagnosis. Some of the series had been reviewed by an external panel of experts. B-cell lymphomas accounted for 82-88% of all NHLs. The proportions of chronic lymphatic leukemia (4-6%), mantle cell lymphoma (MCL, 3-5%), and plasmacytoma (2-4%) were similar in the series presented. However, there was a significant variation in the proportion of follicular lymphoma (FL), which accounted for 15% and 11% in India and Kuwait, but less than 5% in Pakistan and Egypt. All of these frequencies are significantly lower than those reported in Western series. Diffuse large B-cell lymphoma accounted for about 35% of cases in India but for more 50% in other countries, but this difference was not accounted for by an increased incidence in a single lymphoma subtype in India, but rather an apparent paucity of several subtypes (such as mantle cell and marginal zone lymphomas (MZL)) in other series. There were relatively high frequencies of Burkitt lymphoma in Egypt (7%) and precursor T-cell lymphoblastic lymphoma in India (6-7%). Peripheral T-cell lymphomas (PTCLs) (not otherwise specified and angioimmunoblastic subtypes) accounted for 3-5% of NHLs, and extranodal lymphoma of T/NK cell type was rare (<1%). These differences in the relative proportions of NHL subtypes among developing countries and between developing countries and the rest of the world presumably arise from differences in environmental and genetic factors that influence lymphomagenesis and strongly suggest that more research in developing countries would provide valuable insights into the pathogenesis of lymphoid neoplasms.

Dietary fat and breast cancer in Saudi Arabia: a case-control study

A case-control study investigated the association between dietary fat and breast cancer in Saudi Arabian women attending a specialist hospital in Riyadh. Women with breast carcinoma (n= 499) newly diagnosed between 1996-2002, and control women (n = 498) randomly selected from patients' attendants and relatives, completed a food frequency questionnaire. Serum levels of triglycerides and total cholesterol were measured. A significant positive association was found between risk of breast cancer and intake of fats, protein and calories. Adjusted odds ratios for the highest quartile of intake versus the lowest were 2.43 for saturated fat, 2.25 for animal protein, 2.12 for polyunsaturated fat, 1.88 for cholesterol and 2.69 for total energy from dietary intake. For serum triglycerides the adjusted odds ratio was 2.16 for the highest quartile.

Loss to follow-up of patients with malignant lymphoma

Loss to follow-up (LTFU) in cancer patients is a serious problem, yet there is little data on this and on the underlying reasons. Of 144 paediatric and 431 adult patients with lymphoma diagnosed in 1997/1998 at King Faisal Specialist Hospital and Research Center, Riyadh (KFSHRC), 30% and 48.5%, respectively, were LTFU after 4 years (excluding patients known to have died). In 2001-2002, 196 paediatric and adult lymphoma patients at KFSHRC were enrolled in a prospective study in which explanations were obtained in detail for non-attendance at follow-up appointments (No Show). Sixteen months after commencement of the study, 49 patients were No Show, because of patient-based communication problems (20), transportation problems (8), patient not contactable (18), and personal reasons (3). In addition, patients were recorded incorrectly as No Show through hospital/patient communication problems. The No Show patients, especially the 23 who failed to keep a second appointment, are identifiable as potential LTFU during the 3 years in which this cohort will be followed. This study and, we suggest, other studies on LTFU should stimulate interest in this issue, in the predisposing factors, and in strategies to address them.

Dietary fat and breast cancer in Saudi Arabia: a case-control study

A case-control study investigated the association between dietary fat and breast cancer in Saudi Arabian women attending a specialist hospital in Riyadh. Women with breast carcinoma [n= 499] newly diagnosed between 1996-2002, and control women [n = 498] randomly selected from patients’ attendants and relatives, completed a food frequency questionnaire. Serum levels of triglycerides and total cholesterol were measured. A significant positive association was found between risk of breast cancer and intake of fats, protein and calories. Adjusted odds ratios for the highest quartile of intake versus the lowest were 2.43 for saturated fat, 2.25 for animal protein, 2.12 for polyunsaturated fat, 1.88 for cholesterol and 2.69 for total energy from dietary intake. For serum triglycerides the adjusted odds ratio was 2.16 for the highest quartile

Prognostic factors and treatment modalities in uterine sarcoma

The aim of this study was to identify the impact of various prognostic factors in the management of uterine sarcoma. Fifty-nine patients with uterine sarcoma were treated at King Faisal Specialist Hospital and Research Center between 1980 and 1997. Forty-three patients (73%) were treated by total abdominal hysterectomy and bilateral salpingo-oophorectomy, 7 (12%) total abdominal hysterectomy and bilateral salpingo-oophorectomy with sampling of pelvic lymph nodes, and 9 (15%) had biopsy only. Nine patients received adjuvant treatment; five had radiation therapy (XRT), two had chemotherapy, one had combined XRT and chemotherapy, and one received hormonal treatment. Leiomyosarcoma cases accounted for 42% of all the uterine sarcomas, carcinosarcoma cases for 34%, and endometrial stromal sarcoma (ESS) for 24%. Fifty (85%) patients had pathologic grade II and III tumor, with only 9 patients grade I. Twenty-seven patients (46%) were classified surgically as stage I, 7 (12%) as stage II, 17 (29%) as stage III, and 8 (13%) had stage IV tumor. Recurrences developed in 34 patients (71%). The 5- and 10-year overall actuarial survival for all patients was 42%, and the corresponding relapse-free survivals for those who achieved complete response after primary treatment (48 patients) were 27% and 20%. On the univariate analysis, grade I tumors (p = 0.04), ESS (p = 0.02), nonmetastatic stage (p = 0.05), and negative peritoneal cytology (p = 0.04) were associated with better overall survival. Factors associated

Pulmonary metastatectomy for soft tissue sarcomas: is it valuable?

BACKGROUND

A retrospective study and analysis was performed to determine the value and benefit of pulmonary metastatectomy for soft tissue sarcomas, and which factors predict prognosis following resection.

METHODS

Twenty-three patients underwent resections for pulmonary metastases from a soft tissue sarcoma (STS) at King Faisal Specialist Hospital and Research Center (KFSH&RC), between January 1985 and December 1998. There were 11 male and 12 female patients. Thirteen of 23 patients (57%) had one to three metastases, and 10 (43%) had four or more metastases. A total of 41 thoracic explorations was performed for the 23 evaluable patients. Median sternotomy was used only for three patients and lateral thoracotomy was used for 20 patients as an initial surgical approach. Pulmonary resections performed included one or more wedge resections (n=16), segmentectomy (n=5), and lobectomy (n=2). No one in this series underwent pneumonectomy. The number of resected metastatic nodules ranged from one-six with average three. Eight patients (35%) received various kinds of postoperative adjuvant chemotherapy.

RESULTS

The overall and disease-free survival rate post-metastatectomy at five years was 24% and 21%, respectively. Various prognostic indicators were examined to evaluate their association with improved survival. Age, sex localization of the primary site and histologic type, tumor grade, size of the resected nodules, laterality (unilateral or bilateral), types of resection, adjuvant chemotherapy, and local recurrence did not significantly affect survival. However, patient with disease free interval >6 months, and those with three or fewer metastases showed a trend toward a higher five-year overall survival (p=0.06, 0.07, respectively).

CONCLUSIONS

Surgical excision of lung metastases from soft tissue sarcomas is well accepted and should be considered as a first line of treatment if preoperative evaluation indicated that complete resection of the metastases is possible. Further investigation is needed before chemotherapy can be recommended as additional therapy.

A randomised phase II study on neo-adjuvant chemotherapy for 'high-risk' adult soft-tissue sarcoma

The aim of this study was to examine the strategy, feasibility and outcome of neo-adjuvant chemotherapy, with doxorubicin and ifosfamide, in adult patients with 'high-risk' soft-tissue sarcomas. Patients with 'high-risk' soft-tissue sarcomas, defined as tumours > or =8 cm of any grade, or grade II/III tumours <8 cm, or grade II/III locally recurrent tumours, or grade II/III tumours with inadequate surgery performed in the previous 6 weeks and therefore requiring further surgery, were randomised between either surgery alone or three cycles of 3-weekly doxorubicin 50 mg/m(2) intravenous (i.v.) bolus and ifosfamide 5 g/m(2) (24 h infusion) before surgery. The type of surgery had to be planned at randomisation. Tumours were to be amenable to surgery by amputation, compartmental resection, wide or marginal excision. If chemotherapy was given, surgery had to be performed within 21 days after the last chemotherapy. Patients received postoperative radiotherapy in cases of marginal surgery, microscopically incomplete resection and no further possibility for surgery, and in cases of surgery because of local recurrence. 150 patients were entered into the study and 134 were eligible, 67 in each arm. The most frequent side-effects of chemotherapy were alopecia, nausea and vomiting (95%), and leucocytopenia (32%). One patient died of neutropenic fever after the first cycle of chemotherapy. Chemotherapy did not interfere with planned surgery and did not affect postoperative wound healing. Limb-salvage was achieved in 88%, amputation was necessary in 12% (all according to the plan at randomisation). The trial was closed after completion of phase II, since accrual was too slow to justify expanding the study into the scheduled phase III study. At a median follow-up of 7.3 years, the 5 year disease-free survival is estimated at 52% for the no chemotherapy and 56% for the chemotherapy arm (standard error: 7%) (P=0.3548). The 5 year overall survival for both arms is 64 and 65%, respectively (standard error 7%) (P=0.2204). Neo-adjuvant-chemotherapy with doxorubicin and ifosfamide at these doses and with this schedule was feasible and did not compromise subsequent treatment, surgery with or without radiotherapy. Although not powered to draw definitive conclusions on benefit, but with an at least 7 year median follow-up, the results render it less likely that major survival benefits will be achieved with this type of chemotherapy.

Primary thyroid lymphoma: a retrospective analysis of prognostic factors and treatment outcome for localized intermediate and high grade lymphoma

Non-Hodgkin's lymphoma presenting in the thyroid gland is uncommon. A review of the King Faisal Specialist Hospital and Research Centre (KFSH & RC) experience was performed to assess treatment outcome and prognostic factors in this rare extranodal presentation of localized lymphoma. Sixty patients treated at KFSH & RC between 1975 and 1995 were identified, and their records were reviewed retrospectively. Eight patients who had stage III or IV disease, low grade, or did not complete their prescribed treatment were excluded from the study. There were 38 female and 14 male patients with a median age of 59.5 years at the time of diagnosis (range: 10-87 years). Thirty-five of the 52 patients underwent diagnostic partial or total thyroidectomy at other institutions based on a preoperative assumption of thyroid carcinoma. All 52 patients had non-Hodgkin's lymphoma of intermediate (94%) or high (6%) grade. Detailed staging was carried out in all patients; 16 patients (31%) had disease confined to the thyroid gland (stage IE), whereas 36 (69%) had associated disease in cervical lymph nodes and/or the mediastinum (stage IIE) disease. All patients were treated with curative intent. A total of 18 patients (35%) were treated with a single-modality treatment--radiotherapy alone in 2, chemotherapy alone in 13, and surgery alone in the remaining 3 patients. The majority of patients (34/52; 65%) were treated with a combined-modality approach. The overall relapse-free survival (RFS) and overall survival (OS) at 5 years were 72% and 88%, respectively. There were no significant differences in outcome between those treated with single-modality and those with combined-modality therapy. A univariate analysis showed that the presence of mediastinal lymph node involvement was the most important prognostic factor affecting both RFS and OS. Patients with Hashimoto thyroiditis and without "B" symptoms were found to have a significantly higher RFS without influence on the OS. However, patients who had a good performance status (PS) of 0, 1, and 2 were found to have a significantly higher overall survival in comparison to those with poor performance status. Age, sex, stage, histology, lactic acid dehydrogenase level, tumor bulk, and the treatment modality were not found to correlate with RFS or OS. Mediastinal involvement and PS were found to be the most important independent prognostic factors influencing RFS and OS.

F-18 FDG positron emission tomography in primary breast non-Hodgkin's lymphoma

A 50-year-old woman had an irregular, mobile, firm right breast mass that became progressively larger in the past 3 months that measured 18 x 15 cm at the time of examination. She had no nipple discharge or skin changes. A 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) showed a ring-shaped breast uptake consisting of high peripheral glycolytic activity and a cold center most likely representing necrosis or hemorrhage despite the absence of a history of trauma, surgical intervention, chemotherapy, or radiation to the breast. Whole-body images did not show any evidence of lymph node involvement or distant metastases. These results were confirmed by computed tomography of the chest, abdomen, and pelvis. Cytologic examination of a fine-needle aspiration of the breast mass showed diffuse large B-cell, intermediate grade, non-Hodgkin's lymphoma. Although it occurs infrequently, primary breast lymphoma should be considered in patients with a breast mass that shows a ring-shaped FDG uptake. A PET scan, in contrast to other imagining techniques, offers the advantage of screening the entire body, excluding the presence of metastases, and confirming the primary origin of the breast lymphoma.

Dose-intensive epirubicin-based chemotherapy is superior to an intensive intravenous cyclophosphamide, methotrexate, and fluorouracil regimen in metastatic breast cancer: a randomized multinational study

PURPOSE

To determine the relative efficacy of a cyclophosphamide epirubicin and fluorouracil (CEF) regimen compared with an intravenous (IV) cyclophosphamide, methotrexate, and fluorouracil (CMF) combination in metastatic breast cancer.

PATIENTS AND METHODS

Patients were randomized to receive either CEF (cyclophosphamide 400 mg/m(2) IV, epirubicin 50 mg/m(2) IV, and fluorouracil 500 mg/m(2) IV on days 1 and 8), or CMF (cyclophosphamide 500 mg/m(2) IV, methotrexate 40 mg/m(2) IV, and fluorouracil 600 mg/m(2) IV on days 1 and 8). Treatment was given in 3- to 4-week cycles for a total of six to nine cycles.

RESULTS

A total of 460 patients (223 CEF and 237 CMF) were randomized. Overall response rate was superior for CEF than CMF in all randomized patients (57% v 46%, respectively; P =.01) and in the assessable subset (66% v 52%, respectively; P =.005). With a median follow-up of more than 20 months, time to progression (TTP) was significantly longer with CEF than CMF (median 8.9 v 6.3 months, respectively; P =.0064), as was time to treatment failure (TTF) (median 6.2 v 5.0 months, respectively; P =.01). Significant survival differences were not observed between CEF and CMF (median 20.1 v 18.2 months, respectively; P =.23). Granulocytopenia and infections were similar in both arms. Grade 3/4 nausea/vomiting and alopecia were more frequent with CEF, whereas diarrhea was more frequent with CMF. Cardiac toxicity, primarily asymptomatic, required withdrawal from study of 15 patients on CEF (7%) and one patient on CMF.

CONCLUSION

This CEF regimen safely provides significantly better tumor control than CMF, manifest as a higher response rate, and longer TTP and TTF, but not survival, when used as first-line chemotherapy for metastatic breast cancer.

Prospective phase II trial of alternating intravesical Bacillus Calmette-Guérin (BCG) and interferon alpha IIB in the treatment and prevention of superficial transitional cell carcinoma of the urinary bladder: preliminary results

BACKGROUND AND OBJECTIVE

Evaluate the efficacy and toxicity of alternating intravesical instillation of Bacillus Calmette-Guerin(BCG) and Interferon alpha2-b (IFN) in the treatment and prevention of recurrence of superficial transitional cell carcinoma (TCC) of the urinary bladder.

METHODS

Patients with Ta, T1 tumors and carcinoma in situ, either recurrent (TaG1, T1G1) or primary/recurrent TaG2 TaG3, T1G2, T1G3 and Tis (T: Tumor stage, G: grade) are eligible. All patients received intravesical BCG 81 mg on Weeks 1, 3, 5 and 7 and IFN 100 million units on Weeks 2, 4, 6 and 8. Cystoscopy performed 4 weeks after completion of therapy, and every 3 months thereafter.

RESULTS

There was a total of 37 patients. Thirteen had TaG2, 13 T1G2, 1 T1G1, 4 TaG1, 1 TaG3, 3 T1G3 and 7 Tis (5 concurrent with other above tumors). Index lesion cleared in 7/10 patients. With a median follow-up of 26.2 month, 22 patients (59%) failed above therapy. Median time to treatment failure was 7 months. Seven, 6 and 9 patients recurred at a higher, lower and same stage or grade respectively. No grade 3 or 4 toxicity was encountered.

CONCLUSIONS

Alternating intravesical BCG and IFN is effective and well tolerated therapy for superficial TCC of urinary bladder.

Malignant germ cell tumors of the ovary. Pregnancy considerations

OBJECTIVE

To study the pregnancy association and malignant germ cell tumors of the ovary with regard to its effects on tumor prognosis.

STUDY DESIGN

: Seventy-five patients with malignant germ cell tumors of the ovary treated at the King Faisal Specialist Hospital-Research Center (KFSH-RC) Riyadh, Kingdom of Saudi Arabia between January 1976 and December 1992, were reviewed. Data was retrieved from the medical records and the database of ovarian tumor pathology. Patients with tumor/pregnancy association were identified and correlation with obstetrical outcome and tumor prognosis analyzed. Patients who conceived after treatment were identified and their reproductive outcome described.

RESULTS

Malignant germ cell tumor was associated with pregnancy in a group of ten patients. Possible tumor effects upon pregnancy in this group included operative delivery by caesarean section (n=3), mid-trimester termination (n=2), spontaneous abortion (n=1). Four patients had normal vaginal birth with no apparent tumor effects upon pregnancy. Pregnancy did not seem to influence the tumor prognosis of pure dysgerminoma (n=6), however, two patients with non-dysgerminomatous germ cell tumor (one endodermal sinus tumor and one immature teratoma) died of rapidly progressive disease during the second trimester. Two patients with advanced (stage IIIC) disease concurrent with pregnancy (one pure dysgerminoma and one mixed germ cell tumor), had normal fetal outcomes and achieved long-term survival. Amongst the 22 patients who planned to conceive after conservative surgery, with or without post-operative adjuvant chemotherapy, 12 conceived (12/22) and achieved a total of 20 pregnancies. Their outcomes included normal births (n=18) including one set of twins and hydatidiform moles (n=2).

CONCLUSIONS

Our findings suggest that, (1) The association of pure dysgerminoma and pregnancy did not adversely affect the tumor prognosis or fetal outcome. However, the question remains as to whether pregnancy worsened the prognosis of non-dysgerminomatous germ cell tumors. (2) Recent platinum-based regimens of multiagent chemotherapy for germ cell tumors did not seem to affect fertility potential.

Optimization of oral etoposide dosage in elderly patients with non-Hodgkin's lymphoma using the fraction of dose absorbed measured for each patient

This study was undertaken to investigate the pharmacokinetics of etoposide for optimizing its oral dosage in elderly patients with non-Hodgkin's lymphoma (NHL) using the fraction of dose absorbed calculated from the data generated from first oral and intravenous doses in the same patient. Twenty-three NHL patients (ages 61-95 years) entered this study. Each received 50 mg/m2 of etoposide by 1-hour i.v. infusion, which was repeated every 24 hours for 5 days. The second cycle commenced on day 21, with etoposide being administered by mouth at a dose as close to 50 mg/m2 as possible. Serial blood samples were collected and analyzed for etoposide by HPLC. The fraction of dose absorbed (F) was calculated as F = (AUCor/AUCi.v.) (Di.v./Dor), and etoposide was then given orally for the following 20 days at a daily dose equivalent to Dor/F. After 1 week free of etoposide administration, a second cycle of oral etoposide at the adjusted dose was given for 21 days. The mean +/- SD values for t1/2 beta, tmax, Cmax, CLTor, and MRT observed following the first oral dose were 8.98 +/- 4.84 h, 1.39 +/- 0.96 h, 0.083 +/- 0.046 mg.L-1/mg.m-2, 1.89 +/- 1.2 L.h-1/m2, and 10.37 +/- 2.76 h, respectively, and those observed following the first intravenous dose were 8.05 +/- 5.11 h, 1.57 +/- 0.17 h, 0.142 +/- 0.043 mg.L-1/mg.m-2, 1.25 +/- 0.44 L.h-1/m2, and 7.69 +/- 1.53 h, respectively. The mean +/- SD of F was 0.80 +/- 0.34. The data obtained indicate that optimization of etoposide oral dosage using F yielded good clinical results while keeping the morbidity at a level that is similar to that of the i.v. administration.

F-18 FDG uptake in breast infection and inflammation

PURPOSE

Whole-body fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography (PET) scanning has been useful in the management of breast cancer. However, F-18 FDG uptake sometimes has been associated with benign breast disease. Four cases are reported of F-18 FDG breast uptake caused by infectious or inflammatory mastitis that mimics malignant disease.

METHODS AND RESULTS

Two women had F-18 FDG whole-body scans for the evaluation of a large breast mass after inconclusive results of ultrasonography. In both cases, intense focal F-18 FDG breast uptake was noted that mimicked breast cancer. Histologic examination showed, in one patient, chronic granulomatous infiltration that likely represented tuberculous mastitis, because she showed a good clinical response to empirical anti-tuberculous treatment. The second patient had lactational changes associated with acute inflammation, and the culture grew Staphylococcus aureus. The breast mass completely disappeared 3 weeks after a course of antibiotic treatment. The other two patients had staging F-18 FDG PET scans 1 and 12 months after lumpectomy for breast carcinoma to detect residual, recurrent, or metastatic disease. Both scans showed a ring-like uptake in the involved breast, with superimposed intense focal uptake suggesting tumor necrosis centrally and malignant foci peripherally. In both cases, histologic examination revealed hemorrhagic inflammation secondary to postsurgical hematomas and no evidence of malignancy.

CONCLUSION

Acute or chronic infectious mastitis and postsurgical hemorrhagic inflammatory mastitis should be considered in patients who have a breast mass, especially those with a history of tenderness or surgery.

Carcinoma of cervix, the King Faisal Specialist Hospital & Research Center experience--the need for screening for cervical cancer in developing countries

The King Faisal Specialist Hospital and Research Center opened in 1975 to provide specialized medical treatment to the citizens of Saudi Arabia and to promote prevention of disease through research and education. It is a national and middle eastern tertiary care hospital for oncology and a principle center for radiation therapy in Saudi Arabia. In this retrospective study, 504 patients with carcinoma of the cervix were analysed. Of the 504 patients, 410 received treatment with curative intent, which comprised radical surgery alone, radical radiation alone or combination surgery and radiation. The overall 3, 5 and 10 years survival of all 504 patients was 64%, 55% and 40%, respectively and for 410 patients treated with curative intent it was 74%, 61% and 51%, respectively. Multivariate analysis, using the Cox regression method, showed that the stage of the disease is the only significant prognostic factor influencing relapse-free survival. Stage for stage, treatment outcomes at King Faisal Specialist Hospital and Research Center match those achieved in the First world, but two-thirds of patients (rather than one-third) present with advanced disease at diagnosis. Therefore, any improvement in overall outcomes will require earlier diagnosis, achievable only through an effective screening program in the Kingdom of Saudi Arabia and similarly in the other Third world countries where patients present with advanced stage disease.