Knowledge and Perceptions of the End of Life among Tunisian Medical and Paramedical Staff.

Purpose: End-of-life (EOL) care is a vulnerable period in an individual's life. Healthcare professionals (HPs) strive to balance the preservation of human life with respect for the patient's wishes. The aims of our study were to assess HPs' knowledge and perceptions of EOL care and to propose areas of improvement to improve the quality of care. Methods: We conducted a single-center, cross-sectional study involving HPs from a university hospital who encountered EOL care situations. We used a questionnaire divided into four sections knowledge, practice, perception, and training. We calculated the rate of correct answers and the collective competence index. Results: Eighty-six questionnaires were analyzed, with 82.5% (71/86) completed by medical respondents and 17.5% (15/86) by paramedical respondents. Most of the respondents, 71.8% (51/71), were interns and residents. The study focused on palliative care, medical assistance in dying, aggressive medical treatment, and euthanasia, finding adequate knowledge in the first three areas. Respondents assigned to the intensive care unit and those with more than 8 years of experience had significantly higher correct answer rates than their counterparts. Seventy-five percent of respondents (65/86) reported feeling that they had little or no mastery of EOL care, primarily attributing this to insufficient training and the unavailability of trainers. Conclusion: Based on the findings of our study, which we believe to be the first of its kind in Tunisia, we can conclude that HPs possess an acceptable level of knowledge regarding EOL care. However, they require more exposure and training to develop expertise in this area.

Intrahepatic biliary cystadenoma, a challenging diagnosis and management: A case report.

INTRODUCTION AND IMPORTANCE: Biliary cystadenoma (BC) is a benign hepatic cystic tumor with degenerative potential. Hepatic MRI can help guide the diagnosis. Surgical resection is recommended due to the malignant potential of biliary cystadenomas. Only anatomopathological examination of the surgical specimen can establish the definitive diagnosis of BC. The objective of this case report is to enhance our understanding of this disease and contribute to precise diagnosis for optimal management. CASE PRESENTATION: A 55-year-old woman with a history of hypertension and atrial fibrillation presented to the surgery department with paroxysmal right hypochondrial pain. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) revealed a large septated cystic lesion occupying segments II, III, and IV of the liver. The patient underwent left hepatectomy without incident. The postoperative course was marked by a deep collection opposite the sectional area, which was successfully treated with antibiotics and radiological drainage. The pathological diagnosis confirmed BC without signs of malignancy, and no recurrence was detected post-surgery. CLINICAL DISCUSSION: The rarity of BC, the absence of specific clinical signs and its potential for malignant transformation, underline the need for sophisticated imaging techniques. However, preoperative radiological diagnosis does not exceed 50 %. The operative decision requires a multidisciplinary discussion between radiologists and surgeons. This case highlights the unavailability of radical surgical treatment in cases of strong preoperative suspicion of BC. The cooperation of the pathologist in the histological diagnosis is crucial. CONCLUSION: The diagnosis of BC should be considered in cases of multilocular cystic lesions in the liver, particularly in instances of recurrent cysts. Imaging aids in both positive and differential diagnoses. Complete resection is the recommended treatment for any suspected BC.

Synchronous presentation of hepatocellular carcinoma and intrahepatic cholangiocarcinoma: Report of an exceptional case with review of the literature.

INTRODUCTION AND IMPORTANCE: The occurrence of distinct synchronous hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (CC) is extremely rare. Less than 50 cases have been reported in the literature. The aim of our study was to describe the clinicopathological features of this association. CASE PRESENTATION: A 75-year-old female patient with chronic hepatitis C cirrhosis presented with three hepatic nodules affecting segments IV, VIII and V during follow-up of her disease. Only the V-segment nodule was radiologically suspicious of malignancy (classified as LI-RADS5). These nodules were resected after discussion of the case in a multidisciplinary meeting. Histological examination showed that the nodules in segments VIII and V corresponded respectively to an HCC with immunohistochemistry showing HepPar1 (+), CK7(-) and CK19(-), and to an intrahepatic CC with immunohistochemistry showing HepPar1 (-), CK7(+) and CK19(+). The excision was radical. The post-operative course was uncomplicated. After a 6-month follow-up, the patient did not develop any locoregional recurrence or metastases. CLINICAL DISCUSSION: Synchronous association of HCC and CC is very uncommon, and diagnosis is based on pathological and immunohistochemical examination. Infection with the HCV represents a major risk factor for simultaneous association. Synchronous presentation in HCV-infected individuals has been associated with a poorer prognosis compared with cases where only a single type of liver cancer is present. CONCLUSION: The prognosis of this association is generally poor, notably due to the aggressive behavior of CC. Surgical resection remains the first-line treatment option, when possible, but comprehensive management of these complex cases requires a multidisciplinary approach tailored to each patient's specific circumstances.

Obesity and cancer: focus on leptin.

Over the past decades, obesity has grown to epidemic proportions worldwide. It has been associated with an increased risk for different types of cancer. In addition, obesity has been associated with a poor prognosis, an increased risk of metastasis and mortality, and resistance to anti-cancer therapies. The pathophysiological mechanisms underlying the obesity-cancer connection have not yet been fully elucidated. However, this connection could result, at least in part, from the action of adipokines, whose levels are increased in obesity. Among these adipokines, evidence suggests leptin's critical role in linking obesity to cancer. In this review, we first summarize the current state of the literature regarding the implication of leptin in tumorigenic processes. Next, we focus on the effects of leptin on the anti-tumor immune response. Then, we discuss the influence of leptin on the efficiency of antineoplastic treatments and the development of tumor resistance. Finally, we highlight the use of leptin as a potential target for the prevention and treatment of cancer.

Prognostic value of tumor-infiltrating lymphocytes (TILS) and their association with clinicopathological features in breast cancer: A retrospective study involving 53 cases / Valor pronóstico de los linfocitos infiltrantes de tumores (TIL) y su asociación con características clínico-patológicas en el cáncer de mama: un estudio retrospectivo de 53 casos

Objective: Quantitative analysis of tumor-infiltrating lymphocytes (TILs) is currently considered as a prognostic factor in several malignant tumors. The aim of our study was to assess the prognostic value of TILs in breast cancers and its association with other clinicopathological prognostic factors in non-specific type (NST) breast carcinoma in Tunisian population.MethodsRetrospective study included 53 women with NST breast carcinoma. The data were collected over a period of 13 months with a follow-up of 40 months for all the patients. The TILs were evaluated according to the 2014 recommendations of the international working group on TILs.ResultsTILs level was between 3% and 60% with mean of 21%. Ten patients had lymphocyte predominant breast cancer (LPBC). Statistical analysis had shown that the TILs level ≤50% was associated with the presence of vascular emboli and the absence of HER2 amplification. Inflammatory-type carcinoma and HER2 amplification significantly worsened OS. Presence of vascular emboli, lymph node metastases, inflammatory type of carcinoma, TILs ≤50%, and absence of estrogen receptors (ER) were associated with reduced RFS. In multivariate analysis, the presence of vascular emboli was an independent factor for OS. TILs ≤50%, inflammatory type of carcinoma and presence of vascular emboli were independent risk factors for RFS.ConclusionThis Tunisian pilot study showed higher level of TILs in NST breast carcinomas is associated with improved RFS. The therapeutic implications will benefit from multiple research studies including ours on the predictive value of TILs for neoadjuvant or adjuvant treatment. (AU)

Objetivo: El análisis cuantitativo de los linfocitos infiltrantes de tumor (TIL) se considera actualmente como un factor pronóstico en varios tumores malignos. El objetivo de nuestro estudio fue evaluar el valor pronóstico de los TIL en los cánceres de mama y su asociación con otros factores pronósticos clinicopatológicos en el carcinoma de mama de tipo no específico (NST) en la población tunecina.MétodosEn un estudio retrospectivo se incluyó a 53 mujeres con carcinoma de mama NST. Los datos se recogieron durante un período de 13 meses, con un seguimiento de 40 meses para todas las pacientes. Los TIL se evaluaron según las recomendaciones de 2014 del grupo de trabajo internacional sobre TIL.ResultadosEl nivel de TIL estuvo entre el 3% y el 60% con una media del 21%. Tenían cáncer de mama con predominio de linfocitos (LPBC) 10 pacientes. El análisis estadístico mostró que el nivel de TIL ≤ 50% se asociaba a la presencia de émbolos vasculares y a la ausencia de amplificación de HER2. El carcinoma de tipo inflamatorio y la amplificación de HER2 empeoraron significativamente la SG. La presencia de émbolos vasculares, las metástasis en los ganglios linfáticos, el carcinoma de tipo inflamatorio, los TIL ≤ 50% y la ausencia de receptores de estrógeno se asociaron a una menor SSR. En el análisis multivariante, la presencia de émbolos vasculares fue un factor independiente para la SG. Los TIL ≤ 50%, el tipo de carcinoma inflamatorio y la presencia de émbolos vasculares fueron factores de riesgo independientes para la RFS.ConclusiónEste estudio piloto tunecino mostró que un mayor nivel de TIL en los carcinomas de mama NST se asocia a una mejor RFS. Las implicaciones terapéuticas se beneficiarán de múltiples estudios de investigación, incluido el nuestro, sobre el valor predictivo de los TIL para el tratamiento neoadyuvante o adyuvante. (AU)

MUC1 and MUC5AC implication in Tunisian colorectal cancer patients

Background/aim: Mucins, such as MUC1 and MUC5AC, are known for their protective and moisturizing role in intestinal epithelium. Their expression is tightly controlled given their essential role in normal tissue homeostasis, whereas their deregulation leads to chronic inflammation, and even cancer. This study aimed to assess the expression profiles of MUC1 and MUC5AC and their implications in colorectal carcinogenesis. Materials and methods: A retrospective study of 202 patients who underwent colorectal cancer (CRC) surgery was conducted. The expression of MUC1 and MUC5AC was investigated by immunohistochemistry and reverse-transcription polymerase chain reaction (RT-PCR). Statistical analysis of mucin expression pattern, as well as the clinicopathological criteria of the patients, was performed using the chi-square test, survival curves were plotted using the Kaplan­Meier product-limit method, and differences between the survival curves were tested using the log-rank test. Results: The expression of both mucins was abnormally high in the tumor tissues for both mRNA and protein. MUC1 expression was correlated with advanced cancer stages and lymph node metastases for both the mRNA (P < 0.016 and P < 0.002, respectively) and protein level (P < 0.006 and P < 0.001, respectively). However, MUC5AC expression did not pinpoint any significant association between the clinicopathological criteria, but patients who expressed MUC5AC showed an increase in overall survival (P < 0.009). Conclusion: The expression of MUC1 might be a poor prognostic biomarker in CRC and could play a role in tumor transformation and metastasis. However, MUC5AC expression might be a good prognostic in the Tunisian cohort.

[Sclerosing rhabdomyosarcoma of the parotid gland: Unusual location of a rare mesenchymal tumor]. / Rhabdomyosarcome sclérosant de la parotide : localisation inhabituelle d'une tumeur mésenchymateuse rare.

Rhabdomyosarcoma is a malignant mesenchymal tumour with skeletal muscle differentiation. Its sclerosing variant is a rare entity, which is described in the latest WHO edition of soft tissues in association with the spindle cell subtype, with which it shares clinical, morphological and cytogenetic features. Cytogenetic advances have allowed a prognostic approach to fusiform/sclerosing cell rhabdomyosarcoma by individualizing 3 different genomic prognostic groups. The parotid location of sclerosing rhabdomyosarcoma is exceptional with only two reported cases in the literature. It can pose a diagnostic challenge because of its rarity and histological similarities with other malignancies. We report the third case of sclerosing rhabdomyosarcoma of the parotid gland, which occurred in a 7-year old girl, who had consulted for a painless swelling of the parotid region of 4 months duration. Gross examination of the partial parotidectomy demonstrated an ill-circumscribed 35×30mm, firm and white glistening tumor. Histologically, it was composed of cords and trabeculae of small round cells, with ovoid and often irregular nuclei. Mitoses were numerous. The cytoplasm was scanty and cell margins were unclear. Tumor cells were set in a prominent hyalinized matrix. Scattered rhabdomyoblastic-like tumor cells were noted. The diagnosis of sclerosing rhabdomyosarcoma was performed after the positive immunostaining with desmin, myogenin and smooth muscle actin. No cytogenetic or molecular studies were performed. The patient underwent adjuvant chemo and radiotherapy, without recurrences or distant metastases during the 8-year follow-up.

[CD10 expression in stromal cells of patients with breast cancer: a poor prognostic marker]. / Expression stromale de CD10 dans les cancers du sein: marqueur de mauvais pronostic.

INTRODUCTION: markers in breast cancer stem cells, such as cluster of differentiation 10 (CD10), would be correlated with invasive and metastatic potential of several types of cancer, contributing to tumor growth and metastases. In patients with breast cancer, its prognostic value is still controversial, given the discrepancy of results. The purpose of the study was to study CD10 expression in stromal cells of patients with breast cancer as well as to evaluate the prognostic value of this expression. METHOD: we conducted a retrospective, descriptive and prognostic study. It involved 57 patients with invasive cancer of no special type, whose data were collected in the Department of Pathological Anatomy at the Mongi Slim Hospital over a 38-month period. CD10 expression was studied immunohistochemically and interpreted by semi-quantitative scoring system based on three categories with thresholds of 10 and 30%. RESULTS: the average age of patients was 56.4 years. Twenty-eight patients (49%) had labeled CD10 stromal, half of patients had a score of 1 (low) and the other half had 2 (high). This labeling significantly reduced recurrence-free survival (p=0.001). However, it had no influence on overall survival (p=0.84). The correlation study showed that CD10 expression in stromal cells was significantly correlated with 12 poor prognostic factors in patients with breast cancer. CONCLUSION: CD10 expression in stromal cells of invasive breast cancer is a poor prognostic factor, predictive of poor survival without recurrence and associated with a high invasive and metastatic potential.

Primary neuroendocrine tumour of the common hepatic duct: An unexpected Klatskin-like lesion.

The biliary system is an uncommon location for neuroendocrine tumours (NETs), and within this system, the common hepatic duct is an even more rare site for NETs. Clinical and radiological presentations are challenging because these tumours may be preoperatively confused with Klatskin-like lesions. Here we report a well-differentiated grade 2 NET arising from the common hepatic duct in a 64-year-old female. Curative surgery was performed, and no evidence of recurrent disease was observed at the 2-months follow-up.

Prognostic value of CD44s expression in urothelial bladder tumors.

Urothelial bladder carcinoma (UBC) includes a large group of malignancies with a variable clinical behavior. Despite remarkable developments in recognition of bladder carcinogenesis and prognostic factors, the recurrence rate is still high. Thus, identification of novel biomarkers involved in tumor cell invasion and metastatic dissemination is a constant challenge. AIM: To assess the prognostic impact of CD44 standard (CD44s) expression in UBT. METHODS: We assessed the immunohistochemical expression of CD44 in 38 samples of endoscopically resected UBT. Only membranous staining was considered positive. We analyzed topographic distribution of CD44s staining. Correlation of CD44s expression, clinicopathological features and disease progression was analyzed by Chi2 and Fisher tests. Kaplan-Meier analysis was used to investigate CD44s prognostic value. RESULTS: The mean age of patients was 61,24 years with male to female ratio of 18/1. CD44s expression was positive in 33 cases (87%). There was no significant correlation between CD44 expression and the parameters:  age, gender, tumor size, focality, tumor site, stage, recurrence and tumor progression. CD44s loss of expression is, nevertheless, correlated with a high tumor grade. Topographic distribution of CD44s staining was associated with focality, grade and stage. Basal/parabasal staining expanded to the tumor layers in homogeneous "laminate" pattern used to be of better prognosis, compared to the heterogeneous "islets" or "dispersed" pattern. CONCLUSIONS: Our results highlighted the prognostic value of CD44 expression in UBT. Focusing especially on staining pattern offers a better understanding of bladder carcinogenesis mechanisms.

Clonal seborrheic keratosis: a rare skin tumor.

Seborrheic keratosis is a benign epidermal neoplasm, representing one of the most common skin tumors. Clonal seborrheic keratosis is one of the histological subtypes of this entity. It is an uncommon lesion which may resemble other benign or malignant lesion. We report a case of a 60-year-old woman presented with a 7 year history of a gradually growing, cutaneous lesion on her left arm. On physical examination, the lesion was elevated, well-circumscribed, measuring 5 cm in maximum diameter. The tumor was biopsied. Histopathological examination revealed the presence of well-defined nests of clear-looking or basaloid keratinocytes within an acanthotic epidermis, corresponding to the Borst-Jadassohn phenomenon. The tumor cells were small and monomorphic. We diagnosed this tumor as clonal seborrheic keratosis. Although surgical excision was recommended, our patient refused an operation. This case of clonal seborrheic keratosis is presented for its rarity and for differential diagnosis.

[Unexpected discovery of isolated osteochondroma in the pubic symphysis]. / Ostéochondrome solitaire de la symphyse pubienne de découverte fortuite.

Osteochondroma is the most common benign bone tumor. It usually affects the metaphyses of the long bones, in particular around the knee and the proximal humerus. It very rarely affects the pubic symphysis, usually with an atypical symptomatology. We here report the case of a 35-year old man in whom osteochondroma in the pubic symphysis encroaching on the iliopubic branch was fortuitously discovered. Radiological examinations as well as macroscopic and histological examination confirmed the diagnosis and the absence of signs of malignancy.

A disconcerting false gastric diverticulum mimicking malignancy.

Gastric diverticula are the most uncommon form of gastrointestinal diverticula. They can either be of true or false type with different pathogenesis. They may be very challenging to diagnose as symptoms are nonspecific and imaging can simulate a malignant lesion. We report an unusual case of pre-pyloric diverticulum in a 69-year-old man, leading to severe gastric obstruction with a poor general condition. As subsequent endoscopy and imaging were alarming and couldn't exclude malignancy, the patient underwent an antrectomy. The final diagnosis was made on pathological examination. We discuss, through this case, the clinical and pathological features of gastric diverticula with an emphasis on the pathogenesis of this rare entity and the risk of a malignant transformation.

Metatypical Basal Cell Carcinoma: A 6-Year Retrospective Study.

Metatypical basal cell carcinoma (MBCC) represents a high-risk type of cutaneous tumor and has characteristics similar to basal cell carcinoma and squamous cell carcinoma. We report a retrospective study of 13 patients who presented with cervicofacial MBCC. Our study found an increased prevalence of aggressive clinicohistologic features and showed disease recurrences in more than one-third of the patients; therefore, we conclude that MBCC is an aggressive variant that requires a complex surgical approach for achieving a stable and complete remission. (SKINmed. 2019;17:24-28).

Predictive factors for histological response to neo-adjuvant treatment in rectal cancers.

INTRODUCTION: The complete histological response represents the goal of neo-adjuvant treatment of locally advanced rectal cancer. This objective is a real challenge requiring the research of predictive factors for this response, from the perspective of targeted therapeutic strategies. The results of the various studies focused on these predictive factors are discordant. AIM: To seek a correlation between 7 prognostic factors tested in pre-therapy and the histological response to neo-adjuvant treatment. METHODS: A retrospective study involving 44 patients with locally advanced rectal adenocarcinoma who received neo-adjuvant radiotherapy or radiochemotherapy. The 7 prognostic factors studied were clinical (age and sex), radiological (tumor size and parietal invasion) and histological (histological grade, vascular and nerve invasion) features. The complete histological response was defined by Bateman's tumor grade m-RCRG 1 and the absence of lymph node metastases. RESULTS: A complete histological response was observed in 25% of cases (n = 11). In multivariate analysis, age> 60 years (OR: 1.14 and p = 0.028), male sex (OR: 21 and p = 0.045) and radiological wall invasion exceeding the subserosa (OR: 11 , 5 and p = 0.008) were significantly associated with the histological response. In contrast, none of the 3 histological factors tested were correlated with this response's intensity. CONCLUSION: Age, gender, and pre-therapeutic parietal invasion could be used to select "good" and "poor" responders to neo-adjuvant treatment in locally advanced rectal cancers.

Chronic gastritis classifications.

Chronic gastritis are inflammatory diseases of the gastric mucosa whose diagnosis depends on  pathological examination. They are frequent and cover a significant part of the daily activity of pathologists. Their origin is often infectious, particularly by Helicobacter Pylori. Several classifications of chronic gastritis were proposed but in order to achieve standardization in the drafting of pathological reports of gastric biopsies, pathologists currently following the recommendations of the revisted Sydney System. OLGA (Operative Link for Gastritis Assessment) and OLGIM (Operative Link for Gastritis Intestinal metaplasia Assessment) stages are increasingly used since they allow the clinicians to select patients with « high risk ¼ chronic gastritis, which require special monitoring. The aim of this paper was to perform a review of the different classifications of chronic gastritis currently available to pathologists.

[Colon adenocarcinoma and synchronous type 1 papillary renal cell carcinoma: a unique association]. / Adénocarcinome colique et carcinome à cellules rénales papillaire de type 1 synchrones: une association exceptionnelle.

The detection of primary tumors synchronous with colorectal cancer has been the subject of multiple publications. This association can occur sporadically or fall under the framework of well defined clinical syndromes such as Lynch syndrome. Synchronous association of colorectal cancer (CRC) and renal cell carcinoma is rare. It is even more rare when renal cell carcinoma is of papillary origin, with only 2 cases reported in the literature. The association between CRC and renal cell carcinoma does not seem to be related to mismatch repair proteins (MMR) abnormality and does not include, up to now, any clinical syndrome. We report the case of a 69-year old woman with colorectal cancer associated with synchronous type 1 papillary renal cell carcinoma unexpectedly detected during screening for CRC. We here discuss the pathogenesis as well as the prognosis of this rarely described entity.

HHV8/EBV Coinfection Lymphoproliferative Disorder: Rare Entity with a Favorable Outcome.

HHV8/EBV-associated germinotropic lymphoproliferative disorder (GLD) is a challenging diagnosis given its rarity, the particular clinical presentation, and the lack of expression of markers usually used in establishing hematopoietic lineage. We report a new case of HHV8/EBV GLD in an immunocompetent 78-year-old woman. The diagnosis was made in an incidentally discovered lymphadenopathy. Histological examination showed a nodular lymphoid proliferation centered by aggregates of atypical plasmablastic cells admixed with small lymphoid cells. Tumor cells were strongly positive with EMA, HHV8, LMP1, CD38, CD138, and kappa light chains. They were negative with common lymphoma-associated markers (CD20, CD3, CD15, CD30, CD10, and bcl2). In situ hybridization confirmed the monotypic kappa light chains and the EBV infection (EBER+). A polyclonal pattern of Ig gene rearrangement was detected by PCR analysis. In the adjacent lymph node parenchyma, some germinal centers mimicked Castleman disease. In this case, the differential diagnosis was discussed with an early stage of large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease. The clinical presentation, the immunophenotype, and the molecular results helped to make the accurate diagnosis. Through the review of the nine previously reported cases in literature, we discuss the clinical and pathologic features and the differential diagnosis of HHV8/EBV GLD.