Response Evaluation with Dynamic FDG PET/CT during the Primary Systemic Therapy of Breast Cancer - A Case Report

18-fluorine-fluorodeoxyglucose (FDG) positron emission tomography (PET) and mainly combined with computed tomography (CT), abbreviated as FDG PET/CT is a useful and accurate tool for staging and restaging in locally advanced breast cancer. In daily practice static images are prepared during the PET/CT examinations. However, despite the success of static PET and PET/CT imaging, the role of precise quantification of FDG-uptake – measured by dynamic acquisition – is ambiguous in the staging and management of different malignancies. In this case report, we described our experience with staging, interim and restaging dynamic PET/CT examinations of a woman suffering from breast cancer. Based on the described case we concluded that dynamic PET/CT is suitable for accurate quantification of FDG-uptake in primary breast tumors. However, performing dynamic PET/CT examinations is time-consuming, therefore, it is important to define the group of patients where their use is with the most favourable benefit/risk ratio. Furthermore, using of interim PET/CT scan is recommended in cases with clinically controversial baseline tests. Based on literature in vivo biomarkers of the dynamic PET/CT are predictive of more favourable tumor response and longer disease-free survival, as confirmed by our own results.

Appearance of 4 Degree Rash While Treating Advanced Lung Cancer with Icotinib – Whether to Stop the Drug: A Case Report

Skin and skin adnexa toxicities are the most common side effects associated with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs). Previous research showed that the rash appeared, and the severity of EGFR-TKIs may be a marker of clinical benefit. In this context, we report a 75-year-old man with advanced lung cancer who on receiving icotinib developed severe adverse reactions, 4 degree rash (NCI-CTC AE version 4.0 common toxicity grading standards grade), and refused to stop taking the drug; but with the anti-infection and symptomatic nursing, the patient recovered, the rash disappeared, and the patient received a better prognosis. Thus, we would like to emphasize the importance of deciding whether to stop the drug when patients developed adverse reactions of 3-4 degree rash.

Daclatasvir Plus Sofosbuvir With and Without Ribavirin for Previously Treated or Untreated Chronic HCV Infection Genotype 1, 2 and 4 in Togo

Background: Daclatasvir (DCV) is a potent, pangenotypic nonstructural protein 5A inhibitor with demonstrated antiviral efficacy when combined with sofosbuvir (SOF) with or without ribavirin (RBV) in patients with chronic hepatitis C virus (HCV) infection. We are using SOF-DCV combination for large scale treatment. Objectives: The aim of the current study was designed to investigate the efficacy and safety of sofosbuvir/daclatasvir, with or without ribavirin for previously treated or untreated in treatment of HCV genotype 1, 2 and 4, as well as their effect on the liver fibrosis. Methods: One hundred twenty-seven patients with chronic HCV infection were categorized into 2 groups. The group 1 comprised treatment naïve patients, with total serum bilirubin ≤ 1.2mg/10-1L, serum albumin ≥ 3,5g/10-1L, ALAT ≥ 3N, ASAT≤ 2N and platelets count 150 x 109 /L. The group 2 included Peg-INF-alpha or sofosbuvir treatment-experienced patients or patients having at least 2 of the following characteristics: total bilirubin ≤ 1.2mg/10-1L, serum albumin ≥ 3,5g/10-1L, ALAT ≥ 3N, ASAT ≤ 2N and platelets count 150 x 109 /L. The first group was treated with sofosbuvir/daclatasvir for 12 weeks except sofosbuvir treatment experienced patients, who were treated with sofosbuvir/daclatasvir + ribavirin for 24 weeks, with generic medications: DCV 60 mg plus SOF 400 mg ± ribavirin (RBV) within the treatment of hepatitis C virus infection. Efficacy and safety were assessed, and baseline factors associated with sustained virological response at post-treatment week 12 (SVR12) were explored. Results: Sustained virological response (SVR12), was 95,8% in group 1 and 93,8% in group 2. Such high efficacy was accompanied with tolerable adverse effects as well as with significant improvement in liver fibrosis. Conclusion: SOF plus DCV with or without ribavirin achieved high efficacy and safety in HCV genotypes 1,2 and 4 patients. Their effect was accompanied with attenuation of liver fibrosis. Further wider-scale studies are needed to evaluate the actual role of IL 18 polymorphism in treatment response with Sofosbuvir/Daclatasvir.

Induction Chemotherapy with Docetaxel, Cisplatin and 5-Fluorouracil (TPF) Followed by Chemoradiotherapy for Locally Advanced Head and Neck Cancer: Can It Achieve Its Potential?

Objective: In view of concerns about toxicity and deliverability of induction chemotherapy and its impact on subsequent chemoradiotherapy, a retrospective review was carried out with patients treated for locally advanced head and neck cancer (LAHNC) in a single centre between 2007-2017. Patients and Interventions: Patients with LAHNC and good performance status receiving induction chemotherapy with docetaxel, cisplatin and 5-fluorouracil (TPF) followed by chemoradiotherapy to 70Gy in 35 daily fractions with platinum-based chemotherapy. Main Outcome Measures: Overall and cause-specific survival, rates of locoregional recurrence or distant metastasis, treatment-related toxicity. Results: One hundred and eight patients with LAHNC were treated with 1-4 cycles of TPF (95 receiving two cycles) followed by chemoradiotherapy. The mean delivered dose intensity was 97.6% for all TPF cycles. Median interval from the start of the final cycle of TPF to the start of radiotherapy was 24 days, with 92/103 (89%) starting radiotherapy within 28 days. Median radiation treatment time was 47 days. The mean delivered dose intensity for chemotherapy delivered concurrently with radiotherapy was 97%. There were significantly fewer dose reductions in those receiving platinum/5FU combinations than platinum only regimes (P < 0.0001). For those receiving two cycles of TPF, 90% of patients completed the whole course of treatment within 14 weeks (median overall treatment time 13.1 weeks). There were four treatment-related deaths during induction chemotherapy and none during radiotherapy. Twenty-five developed locoregional failure and 13 distant metastases (both in eight). Actuarial overall survival was 60.7% at five years, with progression-free survival of 77.9% at two years and 74.1% at five years. For oropharynx cancers, overall survival was 70.4% and progression-free survival 80.8% at five years. Conclusion: Although significant toxicity from TPF was observed, with appropriate support, it is possible to complete treatment without undue compromise of subsequent treatment.

Hand and Foot Syndrome Associated with Capecitabine

Having cancer impacts the patient both psychologically and physically. However, if cancer is accompanied with HFS, the patient’s condition gets even worse. Capecitabine is a prodrug approved to treat several types of cancer such as breast and colorectal cancer. It is associated with several adverse effects such as hand and foot syndrome (HFS) which mostly affects the palms and legs. The provoked mechanisms of HFS are not clear yet. They require further validation of HFS pathogenesis. Up to now, prevention and treatment of HFS are not clearly solidified. Evidence supports the use of celecoxib, urea-based creams, and vitamin E to reduce the severity and the incidence of HFS. This review aims to provide the gaps and ways to further clinical evaluations.

Pathology and Diagnosis of Mantle Cell Lymphoma

Mantle Cell Lymphoma (MCL) is a rare type of B-cell non-Hodgkin lymphoma (NHL), characterised by an aggressive clinical course and a poor prognosis that remains incurable for the majority of patients. Cyclin D1 overexpression, which results from t(11; 14)(q13; q32), is the pathogenic hallmark in MCL disease and causing cell cycle disruption. MCL has been categorized based on lymphoid malignancies in the WHO update into two significant subgroups, nodal and leukemic non-nodal MCL; each type has a particular clinical presentation and distinct molecular features. SOX11 is overexpressed in nodal MCL subtype, while the leukemic non-nodal sub-type is associated with SOX11 negativity. MCL has a wide range of differential diagnoses, including other types of low-grade lymphoma, most notably chronic lymphocytic leukaemia (CLL), follicular lymphoma (FL), marginal zone lymphoma (MZL), and lymphoblastic lymphoma (LBL). Therefore, accurate histological biopsy diagnosis is paramount in this rare subtype of NHL. MCL has a distinctive clinical presentation and particular morphological and immunophenotypic features with specific cytogenetic abnormalities. The recent advances in molecular and cytogenetic analysis have improved the accuracy of MCL diagnosis and enhanced disease prognosis. Furthermore, B cell receptor inhibitors have revolutionized MCL treatment. Therefore, an accurate diagnosis of MCL is very important since this may require an aggressive and novel targeted therapy.

BRCA Tumor Analysis as Molecular Screening for Germline Testing

Background: In patients with advanced high-grade serous ovarian cancer (HGSOC) and prostate adenocarcinoma, the identification of somatic/germline BRCA1/2 mutations allows new therapeutic opportunities. To estimate the prevalence of somatic and germline BRCA1/2 mutations in non-mucinous high grade ovarian/fallopian tube/peritoneal extraovarian cancer (NMHGOC) and prostate adenocarcinoma. Methods: Prevalence was established by analyzing patients with NMHGOC or prostate adenocarcinoma, with a BRCA1/2 study in the tumor between 2017 and 2018. Whether a germline study had been carried out was subsequently reviewed. Results: 10 patients out of 43 (23.3%) with NMHGOC had a BRCA1/2 mutation in the tumor. 9 patients (20.9%) presented a BRCA1/2 mutation in the germline setting (2 without tumor result due to limited tissue sample). 3 patients (6.9%) had only somatic mutations. 30% of the mutations in the tumor were, therefore, somatic mutations. Of the 9 patients with prostate adenocarcinoma, 2 (22.2%) had a BRCA2 mutation in the tumor. While 1 (11.1%) had the mutation in the germline setting, 1 patient (11.1%) had only somatic mutations. Conclusion: In our series, the prevalence of somatic and germline BRCA1/2 mutations in NMHGOC is similar to that reported in the literature. Whereas somatic mutations are only present at the neoplastic tissue, the rate of mutations in the tumor is higher than in the germline setting. A more effective diagnostic and predictive strategy could be achieved with tumor BRCA analysis as the first attempt. Initial results in prostate adenocarcinoma point to the same conclusion for this tumor.

Management of the Procedural Pain Induced by Bone Marrow Biopsies: An Observational Study

Introduction: Bone marrow biopsy is an investigation procedure in hematology which might lead to procedural pain. Therefore, our study aimed to assess procedural pain intensity and to identify factors associated with pain experience. Methods: We performed an observational study of consecutive patients who underwent a bone marrow biopsy in a tertiary hospital hematology ward. The pain was assessed using a visual analogue scale (0-100 mm) before, during and after the procedure. We also collected data as premedication strategy, anxiety, physician’s experience and the experience of a previous biopsy. Results: Forty consecutive patients were recruited. The biopsies were mostly performed for diagnostic purposes (45%). Thirty percent had local anesthesia alone and 70% had local anesthesia plus any other medication. The mean pain before the procedure was 9mm (SD=1.7), during 36mm (SD=2.7) and after 9.5mm (SD=1.0). No statistical difference has been shown between the different pain prophylaxis (p=0.622). The level of anxiety before the procedure was significantly correlated with the procedural pain experienced (r2=0.323, p=0.042), while the length of the procedure and previous experience of the procedure were not. Conclusion: This study suggests that bone marrow procedural pain can be improved and highlights several promising mitigation-strategies to address this issue.

Efficacy of Single Pre-Operative Dose of Glucocorticoid (125mg of Solumedrol Intravenous) in Terms of Seroma Formation in Patients Undergoing Mastectomy with Axillary Clearance For Breast Cancer: A Randomized Control Trial

Objective: The study aimed to determine the efficacy of single dose of glucocorticoid (125 mg of Solumedrol intravenous) in terms of seroma formation after mastectomy in patient with carcinoma of breast. Study Design: Randomized control trial. Place and Duration of Study: Study was conducted in the Department of General Surgery, Liaquat National Hospital Karachi, Pakistan from july 1 to dec 31, 2010. Patients and Methods: Patients were randomly divided in two groups (study and control) each group consisting of 30 patients. Randomization was done by opening of a sealed envelope which had a slip bearing the name of study medication (solumederol or saline as placebo) to be administered. The study group received a single dose of inj 125mg solumedrol IV half an hour prior to surgery by resident scrub in surgery. A similar procedure was applied to the control group and patients in controlled group were administered an equal volume of saline intravenously. After drain removal patients in both groups were observed for a duration of 2 weeks for sermoa formation. Detection of seroma formation was based on clinical grounds by absence of any fluid collection at mastectomy bed as detected by manual palpation. SPSS 10 was used for analysis. Results: Seroma formation was observed in 66.7% (40/60) women 2 weeks post drain removal. Rate of seroma formation was significantly low in study groups than control groups (33.3% vs. 100%; p=0.0001). Conclusion: Single dose of steroid is efficacious in reducing the post mastectomy seroma formation.

A Rare Presentation of Warthin’s Tumour in the Submandibular Gland of a 7- Year-Old Boy

A seven-year-old boy presented with a painless swelling of the right submandibular salivary gland for 1 year. The submandibular swelling was not associated with any calculus. Right submandibular sialo adenectomy done. Surprisingly the histopathology came as Warthin’s tumour. Warthin’s tumour mostly occurs in parotid gland in older age group. Because of the rare occurrence of this tumour in a young boy in extra parotid location, the case is reported.