Journal of Cancer & Allied Specialties

Mitigating Cardiotoxicity Associated with Anticancer Drugs: An Updated Systematic Review

Zobia Farooq — 2024-06-08

Introduction: This systematic review investigated strategies to mitigate cardiotoxicity induced by anticancer medications, emphasizing exercise and pharmacological interventions. Methods: We systematically reviewed three randomized controlled trials (RCTs), one ATOPE trial, and one retrospective cohort study. Results: Among 448 patients, exercise interventions, particularly in breast cancer patients, demonstrated significant improvements in left ventricular ejection fraction (LVEF) and cardiotoxicity prevention. Pharmacological interventions, including candesartan and carvedilol, have shown potential in reducing early DOX-induced subclinical cardiotoxicity (DISC). The protective efficacy of candesartan in alleviating DISC was greater than carvedilol and the control group. Combination therapy with lisinopril and bisoprolol effectively preserved the LVEF. A retrospective cohort study demonstrated the cardioprotective potential of SGLT-2 inhibitors in reducing cardiovascular events. Conclusion: This systematic review underscores the promise of exercise and pharmacological interventions for preserving cardiac function in cancer patients receiving chemotherapy. These findings have significant implications for enhancing the quality of care for cancer patients.

Using Hybrid Telemedicine Model to Care for Patients with Breast Cancer: a Natural Quasi-Experimental Study

Khawaja Shehryar Nasir — 2024-05-30

Introduction: This investigation assessed the clinical characteristics of patients who received care through telemedicine and the clinical impact telemedicine service had on breast cancer patients in a low-income country. Materials and Methods: This natural experimental study assessed the impact of telemedicine service on cancer outcomes among breast cancer patients at Shaukat Khanum Memorial Trust (SKMT), Pakistan, between January 1st, 2018, to December 31st, 2022. The study group (hybrid group) consisted of patients that had both face-to-face and telemedicine appointments, and the control group (physical group) included patients with only face-to-face encounters. Results: A total of 3,205 patients were included in the analysis. Among those included in the analysis, 3,188 (99.5 %) were females, and the mean age of the cohort was 48.10 ± 11.94 years. Statistically significant differences were observed between the two groups in age, demographic distribution, disease stage, average number of emergency room visits, mean length of stay in the Intensive care unit, and the final patient status (alive at the end of observation period). However, the binary logistic regression model (forward-LR) suggested that the final patient outcome was related to disease relapse, COVID-19 infection, and age. Conclusion: Telemedicine clinics, when conducted in parallel with physical clinics (hybrid setup), are safe and have a clinical impact similar to having just physical encounters among breast cancer patients in a low-income country.

The Oncological Safety of Submental Flap Reconstruction in Head and Neck Cancers: An Extended Follow-up Study

Muhammad Umar Qayyum — 2024-06-07

Introduction: The oncological safety of a submental flap is thought to be controversial. The objective of our study was to validate our previous study regarding the oncological safety of submental flaps in oral cavity reconstruction. Materials and Methods: An electronic database was searched from 2015 to 2021 for all head and neck tumour patients, where reconstruction was performed using a submental flap. Results: Eighty-eight oral cavity squamous cell carcinoma patients, amongst whom 71 were males (81.8%), with a mean age of 55.3 years (range: 25-79 years), were retrieved from the database. The sites of involvement were 37 buccal mucosa, 27 lower alveolus and 24 tongue. The mean follow-up was 33.5 months. The submental flap reconstruction was done for 88 patients; 3 had complete loss of flap, 17 had incomplete loss/partial necrosis, and 68 patients had uneventful recovery of the flap. We had 16 patients with local recurrence. Of these, 4 (4.5%) patients had clear margins and no lymphadenopathy at the level I at the final histopathology report. Conclusion: This study provides validation of the oncological safety of the submental flap and establishes that nodal positivity at level 1 alone does not contribute to recurrence at the primary site.

Initial Experience of Pancreaticoduodenectomy in a Newly Developed Hepato-pancreato-Biliary Unit Serving in a Lower-Middle Income Country

Neelma — 2024-06-08

Introduction: Pancreaticoduodenectomy (PD) is the only potentially curative treatment for pancreatic head adenocarcinoma. This study aimed to determine short-term outcomes of PD performed over one year at a newly established Hepato-Pancreatico-Biliary (HPB) unit in Khyber Pakhtun Khwa (KPK) Province of Pakistan. Material and methods: A retrospective analysis of a prospectively maintained Hospital Information System (HIS) was undertaken of all patients referred to the unit between May 2021 to August 2022. Data were collected from the medical records of patients in the hospital information system. Data were analyzed for primary location, age, complications, and operative parameters. Results: The primary site of disease were ampulla (n=18, 52.9%), pancreas (n=11, 32.4%), and duodenum (n=5, 14.7%). The median duration of surgery was 7 hours. 16 (47.1%) patients required blood transfusion either intraoperatively or in the peri-operative period. Patients with preoperative biliary drainage (PBD) were more likely to have multidrug-resistant positive bile cultures with a p-value of 0.2 [n=12(35.3%) vs n=5(14.7%)]. Overall morbidity was 38.2%. The most common complications were wound infection (n=12, 35.3%), delayed gastric emptying (n=6, 17.6%), and type B pancreatic fistula (n=3, 8.8%). The complication rate was higher in patients with biliary stenting [n=11(32.4%) vs n=2 (5.9%); p-value 0.06]. The median length of hospital stay for patients without complications was less (6 vs 12 days; P<.001). The complication rate was lower in Total Laparoscopic PD (TLPD) with p=0.4 (TLPD;2.9%, open; 23.5%, laparoscopic-assisted;11.8%). 90-day mortality was zero. Conclusion: Short-term outcomes for PD in our facility are comparable to high-volume centers. Preoperative biliary drainage can significantly increase operative time, hospital stay, and morbidity.

Cancer Statistics from the Shaukat Khanum Memorial Trust’s Hospital-based Cancer Registry, Pakistan, 1994–2022: An Observational Study

Farhana Badar — 2024-06-08

Introduction: The Shaukat Khanum Memorial Trust (SKMT) has been operational since February 1990. The first Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC) started functioning in Lahore on December 29, 1994. SKMCH&RC, Peshawar, started its operation in December 2015. The study aimed to give an overview of the cancer cases registered at SKMCH&RC over a 28-year period. Material and Methods: This study comprised patient data entered into the hospital information system after registration at the centers affiliated with the Trust. The malignancies were stratified according to sex and age category (children (</= 18 years) and adults (> 18 years)). Results: Neoplasms of the breast, lower gastrointestinal (GI) tract, and lip and oral cavity were prevalent in all ages and both sexes combined; in adult females, neoplasms of the breast, ovary and uterine adnexa, and lip and oral cavity; in adult males, lower GI system, prostate, and lip and oral cavity; and in children, Hodgkin lymphoma, acute lymphoblastic leukemia (ALL), and non-Hodgkin lymphoma (NHL) were predominant. Conclusion: Cases registered in a hospital-based registry are important. When combined with information from other facilities, they can estimate population-level statistics. This can improve cancer surveillance in the country for effective disease prevention, control, and management.

Survival Outcomes in Malignancy-related Hypercalcemia: A Tertiary care Single Center Experience

Sara Ashfaq — 2024-06-09

Introduction: Malignancy-related hypercalcemia is commonly observed in patients with advanced stages of cancer. It is intricately linked with an unfavourable prognosis among oncology patients. This study aimed to evaluate survival outcomes among individuals diagnosed with hypercalcemia associated with malignancy. Materials and Methods: This retrospective analysis of 173 cancer patients with hypercalcemia who sought treatment at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, between July 2019 and June 2020. This cohort of patients underwent a longitudinal follow-up for 2.5 years. To assess survival outcomes, the Kaplan-Meier tool was used to construct survival curves and estimate the survival probability over time. The significance of potential survival factors was evaluated using the log-rank test. Results: All patients exhibited elevated levels of calcium. At admission, the cohort demonstrated varying degrees of hypercalcemia severity attributable to malignancy: mild hypercalcemia was observed in approximately 61.3% of patients, moderate hypercalcemia in 23.7%, and severe hypercalcemia in 15% of cases. Among the total sample, most patients were female (54.9%), with a median age of 54. The primary tumour site most frequently observed was in cases of breast cancer (35.3%), wherein the prevalent histological subtype was lobular/ductal invasive carcinoma (34.1%). Most of the patients (93.6%) had an Eastern Cooperative Oncology Group (ECOG) performance status (ECOG) > 1. Additionally, the median overall survival for patients diagnosed with hypercalcemia was 51 days. Notably, there was a significant association between survival factors, including the primary site of malignancy (P=0.001), bone metastasis (P=0.04), severity and symptoms of hypercalcemia (P=0.001), altered mental state (P=0.001), albumin levels (P=0.001), and ECOG (P=0.001). Conclusion: Malignancy-related hypercalcemia in patients with cancer is a significant predictor of an unfavourable prognosis. The aforementioned survival factors may have the potential to influence patient survival outcomes. Further studies on larger cohorts are warranted.

Marginal Contribution of Pathogenic RAD51D Germline Variants to Pakistani Early-Onset and Familial Breast/Ovarian Cancer Patients

Noor Muhammad — 2024-06-21

Introduction: RAD51D has been reported as a breast cancer (BC) and ovarian cancer (OC) predisposition gene, particularly among Caucasian populations. We studied the prevalence of RAD51D variants in Pakistani BC/OC patients. Materials and methods: In total, 371 young or familial BC/OC patients were thoroughly analyzed for RAD51D sequence variants using denaturing high-performance liquid chromatography pursued by DNA sequencing of differentially eluted amplicons. We also assessed the pathogenic effects of novel variants using in-silicoalgorithms. All detected RAD51D variants were investigated in 400 unaffected controls. Results: No pathogenic RAD51D variant was detected. However, we identified nine unique heterozygous variants. Of these, two missense variants (p.Pro10Leu and p.Ile311Asn) and one intronic variant (c.481-26_23delGTTC) were classified as in silico-predicted variants of uncertain significance (VUS), with a frequency of 0.8% (3/371). The p.Pro10Leu variant was detected in a 28-year-old female BC patient of Punjabi ethnic background, whose mother and maternal cousin had BCs at ages 53 and 40, respectively. This variant was also detected in 1/400 (0.25%) healthy controls, where the control subject’s daughter had acute lymphoblastic leukemia. The p.Ile311Asn variant was identified in a female BC patient at age 29 of Punjabi ethnicity and in 1/400 (0.25%) healthy controls, where the control subject’s daughter had Hodgkin’s disease at age 14. A novel intronic variant, c.481-26_-23delGTTC, was found in a 30-year-old Punjabi female BC patient but not in 400 healthy controls. Conclusion: No pathogenic RAD51D variant was identified in the current study. Our study data suggested a negligible association of RAD51D variants with BC/OC risk in Pakistani women.

Clinical Outcome of Patients Receiving Rituximab in Combination with Bendamustine in Indolent B-cell Lymphomas: A Single-center Institutional Study

Zurrya Khan — 2024-06-22

Introduction: Indolent non-Hodgkin lymphomas (NHL) are a diverse category of malignancies characterized by a chronic relapsing-remitting disease course. In the modern era, patients usually receive a combination of Bendamustine plus rituximab as the initial therapy, otherwise known as an R-Benda regimen. While clinical trials have demonstrated R-Benda to be superior to other regimens, our study aims to provide insight into real-world outcomes of R-Benda therapy. Materials and Methods: We conducted a retrospective study for the period of January 2015 to July 2022 among patients receiving R-Benda for indolent NHLs at the Aga Khan University Hospital, Karachi, Pakistan. All patients underwent pre- and post-treatment assessment via positron emission tomography (PET) scan and computed tomography (CT) imaging. The response to treatment was assessed, and the overall survival (OS) and progression-free survival (PFS) were assessed using a Kaplan-Meier survival analysis. Results: We enrolled 118 patients, out of which the majority were elderly males (64%). The 2-year follow-up rate was 76.3% (n=90), and the median follow-up time was 29 months. The most common histopathology encountered was Follicular lymphoma (52%) presenting with stage IV disease (56%). Approximately 73% experienced a complete metabolic response to the treatment. Of these, 31.4% subsequently experienced a relapse. Additionally, 17.7% of patients underwent a partial response, while 7% had refractory disease. The mean OS was 140 months (95% CI: 120-160), while the lower quartile value was 50 months. On the other hand, the median PFS was 80 months (95% CI: 43-N/A). Conclusion: Our study demonstrated that patients on R-Benda had good clinical outcomes, with the vast majority living beyond 50 months. Moreover, 76.1% had no disease progression for the first two years. It adds to the existing body of literature that demonstrates that in real-world experience, the outcomes of R-Benda treatment are better than those reported by earlier randomized-control trials.

Living Donor Liver Transplantation for Adult Hepatic Undifferentiated Embryonal Sarcoma: A Case Report

Usman Shafique — 2024-06-08

Introduction: Undifferentiated embryonal sarcoma of the liver (UESL) is an aggressive tumor. There is no established treatment, and it is an uncommon tumor in adults. Treatment usually includes a combination of surgery, chemotherapy, and occasionally liver transplantation. The role of liver transplantation in patients with irresectable UESL merits exploration. Case Description: A 20-year-old boy with a large palpable abdominal mass, shortness of breath, and weight loss presented to our clinic. His CT showed a large cystic lesion measuring 11.5 x 22.7 x 23 cm, predominantly involving the left lobe and right anterior sector, with a biopsy consistent with UESL. The tumor was closely applied to the right hepatic vein, with bland main portal vein thrombosis. Due to an irresectable tumor and deteriorating clinical condition, living donor liver transplantation was performed. The patient remains in good health at 16 months follow-up. Practical Implication: In carefully selected patients with UESL, when other options are not feasible, liver transplantation might prolong survival and improve quality of life.

Synchronous Invasive Ductal Carcinoma of Breast and Diffuse Large B-cell Lymphoma: A Case Report

Tahira Yasmeen — 2024-06-08

Introduction: It is uncommon for breast cancer and non-Hodgkin lymphoma (NHL) to present simultaneously. An increase in the rate of simultaneous malignancy identification has resulted from adopting more sensitive staging imaging techniques. Case Description: Here, we describe a patient who was diagnosed with axillary diffuse large B cell lymphoma (DLBCL) in a cancer hospital during a staging work-up for suspected breast cancer. Breast cancer was staged as Stage IIA and DLBCL as Stage IE. She was given three cycles of R-CHOP protocol. Interim Positron emission tomography scan showed a complete metabolic response (Deauville score 2). She was given one more cycle of R-CHOP. Then, she had right breast-conserving surgery with axillary lymph node dissection in August 2023. Histopathology report showed residual disease with Ductal carcinoma in Situ (DCIS). She was recommended weekly Paclitaxel for twelve cycles and Trastuzumab and Pertuzumab for one year. She is currently having her adjuvant systemic therapy, after which she will be planned for local radiation. Endocrine treatment will be started once chemotherapy is completed. Practical Implications: Complete baseline work-up per standard protocols/ guidelines should be done in each malignancy. Biopsy of metastatic sites should be done wherever possible. All histopathologies should be reviewed thoroughly before treatment initiation, as they may significantly alter patient management.