Does alternative and traditional WASAM [local cautery] therapy facilitate an early and more extensive locoregional metastasis of breast cancer?

Introduction: A large heterogeneous group of unproven remedies exist to treat cancer in both developed and developing countries. Some of these remedies often do more harm than good to the patients. The traditional medicine is the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures. The traditional medicine in Oman is based on herbal treatment and skin treatment [massage, Cupping and skin burn "cautery" treatment-known as Wasam or Kaiy]. WASAM [local cautery] is widely practiced in Oman for treating cancer. The loco-regional spread of breast cancer depends on numerous factors like tumour size, grade, receptor status, Ki67, Lympho vascular invasion, location of tumour within the breast, multifocal tumour, depth of tumour from skin, and status of local/regional lymphatic drainage

Objective: The objective of study was to analyze the frequency of loco-regional spread in female breast cancer patients who received Wasam therapy

Patients and Methods: It is a retrospective analysis of female breast cancer cases diagnosed between 2008-2014 at the Department of Surgery and National Oncology Center, the Royal hospital who were treated with Wasam therapy. Breast cancer patients' data were retrieved and reviewed from Electronic medical record system [EMR AL-SHIFA]. The tumour [T] stage and Nodal [N] status were analyzed in all patients. The data of patients who received Wasam was compared with those who did not receive it as controls

Results: A total of 532 cases were diagnosed to have breast cancer during the study period, of which 464 were included in this analysis. Out of these 74 have Wasam and 390 were in control group not receiving any Wasam therapy. No Wasam patient had N0 status while more than one third of the control group was N0. About 15.9% [74/464] had Wasam therapy. It was found that 6.7%, 67.6% and 25.7% had one, 2-5 and more than 5 scars of Wasam therapy respectively. These patients underwent surgery [either mastectomy or breast conserving] with pathologic analysis of tumour and axillary lymph nodes [sentinel nodes, sampling or clearance]. Approximately 50% of tumours were less than T2 stage. All 74 patients [100%] who received Wasam therapy showed axillary lymph node metastasis [N1 to N3], irrespective of their T stage [size of tumour]. Further analysis is under way of these cases to look into additional risk factors like tumour grade, ER, PR, Her-2, Ki67, LVI, and location of these tumours within the breast

Discussion: The tumour size [T stage] is an important predictor of locoregional spread. Published data suggest the frequency of axillary nodal metastasis are as: T1a 4.2%, T1b 7.4%, T1c 15.8%, T2 28.7% and T3 26.2%. The Grade I, II, and III have 22.1%, 51.6%, and 26.3% chances of axillary LN metastasis. ER+ve tumours have 38.9% and ER-ve tumours have 8.4% frequency of metastasis to axillary LNs. The data from our study suggest that the Wasam cases have higher and early loco-regional spread of breast cancer [100% vs. 19.2% in T1, 100% vs. 50% in T2, and 100% vs. 90% in T3]. The Wasam therapy can set in local inflammation or infection. This can cause increased local temperature and oedema. This may well facilitate lymph angiogenesis and dilatation of existing channels

External auditory canal as an unusual site for metastasis of breast cancer: a case report

Metastatic breast cancer is one of most common cause of death in women worldwide. The estimated incidence of breast cancer to be metastatic at diagnosis is 6%, with a five year survival rate of about 21%. There are three types of breast cancer recurrence: local, regional and distant metastasis mainly to the lung, liver, bone or brain. Review of literature indicate a relatively few reported cases about metastatic breast cancer to soft tissue. We present a case of metastatic breast cancer to left external auditory canal

Breast cancer molecular subtypes in Oman: correlation with age, histology, and stage distribution - analysis of 542 cases

Breast cancer [BC] is one of the most common malignancies and a foremost health issue throughout world. BC accounted for 23.1% of cancer cases diagnosed in Oman in 2009. BC is a heterogeneous disease, and immuno-histochemical [IHC] markers are used to further classify it into distinct subtypes, which are biologically discrete and display different behaviors. IHC testing of the estrogen receptor [ER], progesterone receptor [PR] and human epidermal growth factor receptor-2 [Her-2]; can sub-classify BC into 4 principal molecular subtypes. These subtypes are luminal A [ER+ and/or PR+, HER2-], luminal B [ER+ and/or PR+, HER2+], basal like [BCL - ER-, PR-, HER2-], and Her2/neu [ER-, PR-, HER2+]. Previous studies have shown preliminary evidence and high probabilities of molecular differences across ethnic and geographic groups which may be responsible for disparities in presentation, biological behavior, treatment response and outcome. BC data from 2006-2010 at the National Oncology Center - The Royal Hospital, Oman were retrospectively retrieved from the electronic patient record system [Al-Shifa]. Data were analyzed with respect to ER, PR, and Her-2 status and tumours were classified on molecular basis. Molecular subtypes were correlated with age, histology and treatment outcome. The results were compared with published regional and international data. There were 542 cases of BC accessible for evaluation. Luminal A subtype was the most common and the BCL subtype was highest among Omani females. Age was a significant factor in basal-like [63.8% younger than 50 years vs. 36.2% older than 50 years] and Her2 +ve tumours [60.9% vs. 39.1%]. High grade tumors were mostly observed [41%] in basal tumors and were lowest in luminal A [19%]. A higher stage at presentation [Stage III and IV] was observed in Her2+ tumours [59%], and a higher [22.4%] mortality was detected in basal like/TN tumours. The molecular classification and sub-typing of BC have revealed ethnic and geographic variation. Luminal A subtype is the most common among Omani female breast cancers but it is less common than in Western females. BCL subtype is highest among Omani females compared with Western females. These differences may have diagnostic, therapeutic and prognostic implications. Large scale and multi-centre studies may confirm these findings and can be translated and incorporated to pertinent management strategies

Rapid rituximab infusion: local center experience

Rituximab, a chimeric monoclonal antibody [MoAb] targeting CD20 has been widely used in the management of B-cell lympho-proliferative disorders.[1-3] The usual recommended schedule of regular administration over 3 to 4 hours requires considerable healthcare resources and oftentimes inconvenient for patients. Literature shows the availability of published reports proving the safety and feasibility of rapid infusion of rituximab. This study explored the safety and tolerability of rituximab infusion over a shorter total infusion time. A total of 24 patients diagnosed with CD20+ Non-Hodgkin's lymphoma and planned to receive rituximab at a dose of 375mg/m2 in combination with standard chemotherapy regimens were included in the study from January 2009 to December 2009. The administration of first rituximab dose was unaltered and given as per standard practice of 3-4 hours infusion. The second and subsequent doses were delivered over a total infusion time of only 90 minutes [20% of dose in the first 30 minutes, remaining 80% over the next 60 minutes]. These patients, aged between 15 and 79 years, received a total of 152 rituximab infusions with an average of 6.33 [ +/- 2.37] infusions per patient. Grade 1 infusion related toxicity was reported in 5 infusions [3.2%], and there were no acute reactions or G3/4 toxicity in any infusion episode. A rapid infusion of rituximab is well tolerated, feasible and safe when administered as second and subsequent infusions in the course of therapy for those who tolerate the first dose without significant infusion related toxicity. This shortened infusion method results in a substantial reduction in resource utilization. Our institution has now adopted this as a routine practice

Diagnostic efficacy of stool antigen test [HPSA], CLO test and serology for the detection of helicobacter pylori infection

The diagnosis of Helicobacter pylori infection was initially being made through invasive methods but now non invasive methods have been developed to make the diagnosis easier. The present study was done to evaluate the diagnostic efficacy of a two non invasive tests i.e. Helicobacter pylori Stool antigen test [HpSA] and Helicobacter pylori IgG serology with an invasive method i.e. Campylobacter like organism [CLO] gel test. Methods. The study was conducted in the gastroenterology unit of Pakistan Medical Research Council Research Centre Karachi. Adult patients with gastroduodenal disease were selected for study and their medical history was recorded. Endoscopy was done on all patients and the antral biopsy sample was tested for H.pylori using CLO test. Serology [IgG] was done elsewhere using ELISA and titers of over 50 units were recorded as positive. HpSA was done to determine the presence of H.pylori antigen in stool. Results. Out of 43 patients 34 [79%] were males and 9 [21%] females. The main presenting symptom was epigastric pain in 74% cases. Although H.pylori IgG antibody titers of over 50 were taken as positive but for this study titres of over 100 were taken as significant for comparison with other tests. CLO test was positive in 26 [60.5%] cases, H. Pylori antibody titers of over 100 IU were present in 33 [76.7%] cases and HpSA in 21 [48.8%]. Using CLO test as the gold standard the sensitivity of serology was 81% and that of HpSA 65% with a 29% and 76% specificity respectively. Conclusion. In our setting CLO test is still the best diagnostic test for H. Pylori detection. Both non invasive tests i.e. serology and stool HpSA are less sensitive than CLO but amongst each other both are equally sensitive

Superficial bladder cancer PT1G3: management controversies

To evaluate and identify high risk patients having superficial bladder cancer and to assess the role of radical cystectomy as primary treatment modality. An eight-year retrospective analysis of bladder cancer patients presenting to SlUT was undertaken. After clinical evaluation and routine laboratory investigations, IVU, sonography, CT Scan/MRI, cystoscopy, histopathology, were performed when indicated. A follow-up cystoscopy was carried out at regular intervals [3-6 months] up to a maximum of 8years. Of the 550 [59.7%] patients diagnosed as urothelial tumours, 61/330 [18.4%] had pT1G3 disease, with a male to female ratio of 14:1. Most of the cases [81.7%] were between 41-70 years of age. Haematuria was the presenting symptom in every case, followed by frequency 82.4%, dysuria 32.7% and clot retention 32.7%. There was no significant occupational association, however 25 [40.9%] were smokers for over 25 years. Filling defect on IVU was seen in 52 [85.2%] cases whereas Sonogram revealed echogenic masses in 44 [72.4%]. The morphological site, as per CT scan and cystoscopy was 72.1% lateral wall, 6.6% dome, 3.3% base and 18% were multicentric disease. Growth less than 1 cm was seen in 27%, 1.5 cm in 41% while greater than 5 cm in 32% of cases, All patients underwent endoscopic resection. Intravesical Mitomycin C was given to 27 and BCG to 15 cases. Of the high risk patients, 12 were primarily treated by radiation therapy whereas 22 underwent primary radical cystectomy and 16 had a salvage cystectomy and ileal conduit. Recurrence of the carcinoma was seen in 12 patients who had received intravesical chemo/immunotherapy, in 8 treated initially with radiotherapy and 8 subjected to radical cystectomy. The management of pT1G3 is still a controversial area of carcinoma bladder treatment. In view of the high cost of therapy, fast progression, high recurrence rate and metastasis, we in our setup recommend an early radical surgery in pT1G3 disease. This not only eliminates the lesion but is also cost effective