Survival from hepatocellular carcinoma at a cancer hospital in Pakistan.

OBJECTIVES: To determine the tumour and general characteristics, especially survival, of patients presenting with hepatocellular carcinoma at our tertiary care cancer hospital. PATIENTS AND METHODS: We retrospectively studied 584 charts of patients consecutively registered between 1995 and 2004 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, in Lahore, Pakistan. Descriptive statistics were obtained for gender, age, tumour size and morphology, alpha fetoprotein level, means of diagnosis, Child-Pugh status, risk factors, treatment given and follow-up. Survival analysis was conducted using the Kaplan-Meier method. RESULTS: Mean age at presentation was 56 years. Four hundred and forty four (76%) were male. Average tumour diameter evaluable in 412 patients was 8 cm. HCC was unifocal in 194 (33%), multifocal in 303 (52%) and unevaluable in 106. Mean AFP was 4,198 u/ml (range 1 - 278,560). Methods of diagnosis were FNA in 71, biopsy in 26, imaging/AFP > 200 in 70, lipiodol angiogram in 42, combinations of two of these in 365 and biphasic CT scans in 10. Initial Child-Pugh available for 400/584 was A in 216, B in 147 and C in 37. Evidence of prior hepatitis B infection was found in 114, and for hepatitis C in 254. Other than the four patients who had TACE followed by surgical resection, treatment was offered to 79/584 patients: among the 48 who had TACE, 26 experienced cancer progression whereas 11 had stable disease ranging from 6 - 20 months; another 11 were lost to follow-up. Of the 14 patients who underwent local resection, 2 were lost to follow-up, 7 developed recurrences but 5 remained disease free for a mean of 33 months. Following ethanol ablation in 17 patients, disease progressed in 5 but remained stable in 2 for a mean of 13 months; 10 were lost to follow-up. At the time of writing, 56 patients are alive (mean follow-up 20 months), 210 are known to have died (mean follow-up 9 months), and 318 were lost to follow-up within 3 months. Median overall survival was 10.5 months, death being the point of interest for survival analysis. Child-Pugh class stratified analysis (400/584) revealed median survival of 12 months for class A, 7.7 months for class B and 4 months for class C (p < 0.001). CONCLUSIONS: Most patients present with large, multifocal tumours, with poor liver function. Sixty one percent had evidence of prior infection with hepatitis B or C. The advanced stage at presentation, poor background liver function in many and the absence of a national liver transplantation program limit treatment options. Only 14% of patients were considered suitable for definitive treatment. Survival correlated with Child-Pugh status at presentation. Overall prognosis remains bleak. There is an urgent need to educate the public about the risks of hepatitis B and C and health professionals about early diagnosis and treatment, including possible development of a sustainable national liver transplant program.

Cervical carcinoma in a Muslim community.

OBJECTIVES: The aim of the research was to review the distributions of age, stage at presentation, and morphology of patients presenting with carcinoma of the cervix in a predominantly Muslim population. STUDY DESIGN: This retrospective study was conducted at a comprehensive cancer diagnostic and treatment facility situated in Lahore, Pakistan, reviewing the medical records of the patients. PATIENTS AND METHODS: Four-hundred and nineteen cervical cancer patients were registered at the hospital during a nine-and a half year time period extending from December 1994 to June 2004. Histology was confirmed by exfoliative cervical cytology typically by means of Papanicolaou smear. The International Federation of Gynecology and Obstetrics classification was used to stage the disease. Univariate analysis on factors as age, stage at presentation, and morphology was conducted. RESULTS: 1) The age distribution of the 419 patient cohort was recorded to be as follows: mean 49.2 years (SD 11.7, range 11-85 years) and mode 50 years (37 patients). Only one patient was less than 18 years. 2) Of these 419 patients, 73.5% (308/419) had squamous cell carcinoma (SCC), 7.9% (33/419) had adenocarcinoma, and 0.7% (3/419) had adenosquamous carcinoma; of the remainder, 1.4% (6/419) had rare types (3 each of sarcoma and small cell carcinoma) and 16.5% (69/419) had unspecified carcinoma. 3) Only two patients (0.5%) were identified as being in stage 0, 49/419 (11.7%) in stage I, 140/419 (33.4%) in stage II, 90/419 (21.5%) in stage III, 52/419 (12.4%) in stage IV, and 86/419 (20.5%) as not being evaluable. CONCLUSIONS: A large proportion of patients (67%) presented in stages II to IV and only 12% presented early at stages 0 or I. This emphasizes the need for early detection of this tumor in our population. Accordingly, the importance of detection of the pre-clinical stage of the disease by considering the possibility of initiating a cost-effective screening measures needs to be emphasized in our setting.

Epithelial ovarian cancer at a cancer hospital in a developing country.

OBJECTIVES: To analyze records of patients seen with malignant epithelial ovarian cancer at a tertiary care cancer hospital in Pakistan and obtain information on factors as laterality, histology, CA-125 levels, and stage of the disease, determine age at presentation and, assess menopausal status of the patients. Also, to review results obtained in light of data published in indexed journals. PATIENTS AND METHODS: We analyzed 544 cases of malignant ovarian epithelial tumors registered at the Shaukat Khanum Memorial Cancer Hospital and Research Center from December 1994-December 2003. RESULTS: Mean age at presentation: 48.1 years (SD 13, range 4-82 years); commonest histological sub-type: serous cystadenocarcinoma (28.6%); most frequently seen stage: 3 (43.5%), followed by stage 4 (22.4%); post-menopausal: 56.8% of the women; bilateral disease: 41.2% of the women; and Cancer Antigen-125 (CA-125) level: elevated in 70% of the females. CONCLUSIONS: Stage at presentation in majority of the cases was advanced as compared to that seen in the west. With only minor variations, our findings seem consistent with those reported in other local studies. However, it is imperative to conduct an extensive population-based study to understand the impact of, and develop strategies for the management of ovarian cancer in Pakistan.

Hodgkin's lymphoma in Pakistan: a clinico-epidemiological study of 658 cases at a cancer center in Lahore.

OBJECTIVES: To study the clinico-epidemiological profile of Hodgkin's lymphoma (HL) in Pakistan. PATIENTS AND METHODS: We retrospectively studied all histopathologically proven cases of HL, who presented between Dec 1995 to June 2003 at Shaukat Khanum Memorial Cancer Hospital and Research Hospital (SKMCH & RC). All the relevant information was obtained through the hospital based cancer registry and medical records of the selected patients. RESULTS: Six hundred and fifty eight histopathologically confirmed cases of HL were identified. There were 505 males and 153 females, with a male to female ratio of 3.3: 1. Patients ranged in age from 1 year - 84 years. The mean age at presentation was 23.8 years. Three hundred and twenty cases (48.6%) belonged to age group <or= 18 years and 338 cases (51.4%) were > 18 years of age. Histopathologically, mixed cellularity (MC) constituted 63.8% of cases, followed by nodular sclerosis (NS) 19.9%, lymphocyte predominant (LP) 7.3% and lymphocyte depleted (LD) 1.2%. Early stage (stage I and II) disease was present in 43.9% of patients at presentation, while 56.1% patients presented with advanced stage (stage III and IV). The majority of patients (81.2%) presented with cervical lymphadenopathy. CONCLUSION: The clinico-epidemiological pattern of Hodgkin's lymphoma in Pakistan manifested is similar to that observed in other developing countries, with male predominance, mixed cellularity as the commonest histological type, advanced stage at presentation and absence of bimodal age distribution.

Characteristics of lung cancer patients--the Shaukat Khanum Memorial experience.

OBJECTIVES: The aims of this descriptive study were to characterize lung cancer patients by age at diagnosis, smoking status, and histology and, also to explore the histologic sub-type according to cigarette smoking, in a tertiary care setting. PATIENTS AND METHODS: A retrospective review of 830 patients for whom smoking status was available in the records was carried out at a comprehensive cancer care facility, the Shaukat Khanum Memorial Cancer Hospital and Research Center, situated in Lahore, Pakistan. RESULTS: The mean age at presentation of the 830 evaluable cases was 59.8 years (standard deviation 11.8, range 18-90). Stratifying by gender, statistically significant differences were found in the average age at diagnosis between males (60.1 years) and females (57.5 years) and, in the distributions of non-smokers, current smokers, and ex-smokers, but none for histology. CONCLUSIONS: Similar to other populations, the age of disease onset amongst females was lower than that seen in males. The proportion of smokers was higher amongst males versus females. The reversal of smoker to non-smoker ratio when stratified by gender, may highlight the importance of exploring alternate pathways implicated in the etiology of lung cancer in our population.

Survival analyses of breast cancer patients--the Shaukat Khanum Memorial experience.

Seven hundred subjects with breast cancer malignancies were followed up in time from December 1994 to December 2002 to determine survival distributions between sub-groups of breast cancer patients who had undergone surgical resection of the tumor followed by adjuvant treatment. Tumor size, nodal status, and Estrogen Receptor (ER) status at the time of presentation were ascertained. Tumors were classified according to the TNM system of the American Joint Committee on Cancer (AJCC), sixth edition, and grouped into T1/T2 and T3/T4; lymph nodes were categorized as N0 (node-negative) and N1, N2, and N3 combined (node-positive). The endpoint of interest for disease-free survival was relapse, and for overall survival, it was death. The Wilcoxon statistics for testing the equality of disease-free survival distributions between groups of patients with tumor size greater than 5 versus less than or equal to 5 cm, node-positive versus node-negative, and ER-positive versus ER-negative were found to be statistically significant (p < 0.05). For overall survival, substantial differences were found between groups of patients stratified according to tumor diameter and nodal involvement, but none for ER status.

Geographical variation in the epidemiology of esophageal cancer in Pakistan.

STUDY OBJECTIVES: To evaluate whether factors such as the geographic area of residence, sex, and anatomic subsite of esophagus can prognosticate the histologic subtype of esophagus cancer. DESIGN: To study the major histologic subtypes of esophagus cancer stratified by various factors through multivariate analyses using morphology as the dependent factor and gender, province, and subsite of esophagus as independent factors. SETTING: A tertiary care cancer hospital situated in the city of Lahore in Pakistan. PATIENTS: Three hundred and thirty five patients diagnosed either with esophageal squamous cell carcinoma or adenocarcinoma, from December 1994 to April 2004, were included. Subjects were residents of either Punjab or the Northwest Frontier Province in Pakistan. MAIN RESULTS: An excessive likelihood of development of squamous cell carcinoma versus adenocarcinoma was established for the Northwest Frontier Province as compared to Punjab (odds ratio 2.7, 95 percent confidence interval: 1.2, 6.2, p = 0.02), and in the upper-third of the esophagus relative to the lower-third of the organ (odds ratio 8.8, 95 percent confidence interval: 2.8, 28.3, p < 0.001). CONCLUSIONS: This histologic variation may be explained by environmental and lifestyle factors peculiar to geographical regions.

Variables associated with recurrence in breast cancer patients-the Shaukat Khanum Memorial experience.

From a cohort of female breast cancer patients registered at the Shaukat Khanum Memorial Cancer Hospital and Research Center, in Lahore, Pakistan, during the time period extending from December 1994 to December 2002, 700 subjects who were followed up in time, were selected. Those who presented with benign tumors, carcinoma in situ, or metastases were excluded from the analyses. Age, tumor size, nodal status, menopause, estrogen receptor (ER), and progesterone receptor (PR) status, at the time of presentation, were determined. Tumors were classified according to the TNM classification (American Joint Commission on Cancer (AJCC)-sixth edition), and subsequently, grouped into T1/T2 and T3/T4. Lymph nodes were categorized as N0 (node-negative) and N1, N2, and N3 combined (node-positive). The odds ratio (OR) for developing recurrence in T3/T4 versus T1/T2 was determined to be 2.06 (95% confidence interval (CI) 1.39-3.05, p < 0.001); the OR for node-positive relative to node-negative was found to be 2.54 (95 % CI 1.61-4.0, p < 0.001). Furthermore, the association between the odds of developing recurrence in ER-positive compared to ER-negative was represented by an OR of 0.61, (95 % CI 0.40-0.94 (p= 0.02)). These findings are consistent with the observations that ER-positive, node-negative, and T1/T2 lesions have a decreased risk of recurrence. Also, ER-positive patients may have a better response to hormonal treatment than those who are ER-negative.