Life threatening bleeding from an osteonecrosis of the jaw: Are bisphosphonates safe in irradiated head and neck cancer patients?

Osteonecrosis of the jaw is a significant complication secondary to radiation therapy or drug therapy, most commonly bisphosphonates. Safety data regarding the administration of bisphosphonates in bone metastatic head and neck cancer patients with history of jaw irradiation are almost non-existent. In this paper, we report the case of a Head and Neck (HNC) patient, with history of radiation therapy to the mandible region, treated with intravenous bisphosphonates for bone metastases that resulted in gross, life threatening mouth hemorrhage secondary to advanced, locally invasive ONJ.

Efficacy and safety of everolimus in hormone receptor positive breast cancer in a developing country: Real-life single institutional experience.

INTRODUCTION: Breast cancer is the second leading cause of cancer-related mortality despite the staggering improvement in cancer therapeutics. So far, published data illustrate endocrine therapy as the cornerstone treatment for patients with hormone receptor-positive metastatic breast cancer. Unfortunately, most patients eventually develop resistance to this treatment. METHODS: The purpose of this study is to evaluate the efficacy of mammalian target of rapamycin inhibition in reversing hormone resistance in the Lebanese breast cancer patients. Efficacy of the intervention according to the independent factors and notable side effects encountered were the primary points of the evaluation. RESULTS: In total, fifty patients received the combination of everolimus and exemestane. The mean age of the study population was 61 ± 11 years. Sensitivity to hormonal therapy before the start of the combination treatment was estimated at 64%. Response rate was 14%, and all patients were partial responders. After regular interval evaluation, the median progression-free survival was 5.2 months since the initiation of therapy. The main toxicities associated with the combination were stomatitis (22%), myalgia (22%), skin toxicity (8%), and hyperglycemia (4%), all Grades 1 and 2. CONCLUSION: Everolimus has been shown to be effective in overcoming hormonal resistance in Lebanese breast cancer patients with results inferior to those reported in the BOLERO-2 population. The particular differences in molecular and pathological aspects of breast cancer in our region should stimulate the extensive research for a better understanding of the particular pattern of the disease.

Angiogenesis inhibition in the second-line treatment of metastatic colorectal cancer: A systematic review and pooled analysis.

The last two decades have seen intensive efforts devoted to the development of compounds that target angiogenesis for the treatment of metastatic colorectal cancer (mCRC). In this review, we describe supporting evidence and ongoing development of angiogenesis inhibitors in the second-line treatment of mCRC, and summarize relevant randomized trials to help therapeutic decision-making in daily practice.

Unusual Destruction of the Nasal Septum.

Extranodal Natural Killer/T-cell lymphoma (ENKTL) is the most common cause of nasal cell lymphoma. It manifests by progressive destruction of the facial midline features with nasal obstruction and local destruction of soft tissue. Therefore, establishing the diagnosis of this disease tends to be difficult. This is attributed to an extensive differential diagnosis of infectious, autoimmune, neoplastic and inflammatory etiologies. We herein report the case of a 63-year-old female who presented to our department for persistent nasal congestion resistant to symptomatic treatment that was found to have an ENKTL. In this paper, we discuss the pathogenesis, clinical and imaging findings, differential diagnosis, prognosis and treatment.

Treatment of cancer patients in their last month of life: aimless chemotherapy.

PURPOSE: The use of chemotherapy in the last month of life (CLML) of cancer patients is considered an aggressive approach to be avoided. We examined the practice of CLML in Lebanese cancer patients, and we investigated patient and tumor characteristics that justify this practice. To our knowledge, this is the first study describing CLML of Middle Eastern patients with advanced cancer. METHODS: We conducted this study at Hotel-Dieu de France University Hospital (HDF), Lebanon. Cases eligible for this study were all individuals diagnosed with cancer who died at HDF between the 1st of January and the 31st of December 2014. Demographic and clinical characteristics of the patients were obtained from the hospital registration records. Data concerning the management plan, primary malignancy and stage, chemo-sensitivity, line, type, and timing of chemotherapy in the last month of life were also obtained. RESULTS: Among the 130 cancer patients who were enrolled, CLML was administered to a total of 55 patients (42.3 %), of whom 26 patients (50 %) received more than one cytotoxic drug. Oral drug was only given to 9 patients (16.4 %). Interestingly, CLML increased the risk of death in the last month of life (p = 0.02), yet progression of disease constituted the major cause of death in this subgroup (54.6 %). The only variable to have statistical significant correlation with CLML was performance status (p = 0.03). The type of tumor and recent diagnosis of less than 2 months were also correlated to CLML (p = 0.03 and 0.024, respectively). CONCLUSION: The high percentage of patients receiving CLML underlines the difficulty of end-of-life discussions in patients from Middle Eastern societies. This is true in the context of a country with little availability of palliative care resources, where health policies should be more focused on incorporating palliative medicine in all medical strategies.

Pancreatic small cell cancer.

Small cell carcinoma (SCC) is most commonly associated with lung cancer. Extra-pulmonary SCC can originate in virtually any organ system, with the gastrointestinal tract being the most common site of involvement. We review the clinical presentation, pathogenesis, histology, imaging modalities and optimal therapeutic management of PSCC in light of available evidence.

Acquired factor inhibitor in a patient with monoclonal gammopathy of undetermined significance responding to rituximab.

Bleeding diathesis is a rare manifestation of monoclonal gammopathies that is often attributed to a dysfunction of the coagulation pathway. Patients usually present with a severe bleeding disorder attributed to an acquired factor inhibitor, most commonly factor VIII inhibitor. Data are sparse concerning this disease, and subsequently the best course of action is not yet defined in such clinical instances. In this article, we report the case of a patient, known to have a monoclonal gammopathy of unknown significance, who was followed for over two decades for a bleeding disorder attributed to an acquired thrombin inhibitor. We describe also the different modalities used as maintenance and event treatments as the patient presented repetitive cataclysmic bleedings.

Validation of the EORTC QLQ-INFO 25 questionnaire in Lebanese cancer patients: Is ignorance a Bliss?

INTRODUCTION: Despite worldwide trends toward optimizing full disclosure of information (DOI), the prevailing belief that cancer diagnosis should be concealed from patients, for their own good, has endured for a substantial period of time in Middle Eastern communities. OBJECTIVES: This study would assess the reliability of the Arabic translated version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-INFO 25). The study was also designed to quantify DOI to Lebanese cancer patients and determine patient satisfaction with this DOI. Moreover, we compared the differences in the level of information among groups based on clinical and biographical variables. METHODS: A sample of patients, being treated for a variety of malignancies, was prospectively evaluated. A physician interviewed patients using the Arabic version of the EORTC QLQ-INFO 25, on the day of hospitalization for chemotherapy, before treatment was administered. RESULTS: In total 201 patients were interviewed. The translated version of the EORTC QLQ-INFO 25 showed high reliability when assessed using Cronbach's alpha coefficients for internal consistency with values scoring higher than 0.7 for all scales and the full questionnaire. There was a considerable lack of information provided to the participants with 38.8 % being unaware of their diagnosis and more than half being uninformed about the extent of their disease. Paradoxically, 86.5 % of patients expressed their satisfaction about the amount of information they received and 89.5 % believe the information provided was helpful. Further analysis showed no significant association between gender, marital status, cancer site and stage and the amount of information received. However, age and level of education were associated with DOI such as younger and more educated patients received more information. Older patients were also found to be the most satisfied with the information they received, despite having less access to information. CONCLUSIONS: Although a high proportion of patients were not properly informed about their diagnosis, the overwhelming majority were satisfied with the amount of information they received and believed it was useful, reflecting the complexity of Middle Eastern cultural influences on cancer patients' perspectives.

Safety of rituximab in a patient with chronic renal failure and low-grade non-Hodgkin lymphoma.

An 82-year-old man, with known chronic renal failure and a creatinine clearance (CrCl) of 18 mL/min, was diagnosed with low-grade marginal zone non-Hodgkinlymphoma (NHL) of his right orbit. He received rituximab as single treatment (375 mg/m 2 every 3 weeks). After eight cycles, almost complete response was obtained, rituximab was extremely well-tolerated, and his creatinine levels remained stable throughout the whole treatment.

BRAFV600 mutant non-small-cell lung cancer resistant to Vemurafenib.

Vemurafenib has shown significant activity in V600 mutant melanoma; however the role of this agent in Lung adenocarcinoma with an activating BRAF mutation is still evolving. One of our patients had a rare activating BRAF mutation detected through tumor exome sequencing, which led to a switch from her successful therapy to Vemurafenib and ultimately tumor progression. The lack of adequate response was disappointing both in terms of lost disease free survival and heavy financial burden to the patient who had to cover the charges of her unsuccessful off-label therapy. This experience, despite its highlight of treatment failure, puts into question the use of next generation sequencing and the trend for using off-label agents in pursuit of an optimal response without the support of strong clinical evidence.

Optimum chemotherapy for the management of advanced biliary tract cancer.

Biliary tract cancers (BTCs) are highly fatal malignancies, which are often diagnosed at an advanced stage and have relatively poor prognosis. The treatment of patients with advanced BTC is systemic, based on chemotherapy or best supportive care, depending on their performance status. Despite clinical trials studying many chemotherapeutic regimens and targeted therapies for the treatment of BTC, the standard of care for advanced BTC remains the combination of gemcitabine with cisplatin. Many new molecules targeting proliferation and survival pathways, the immune response and angiogenesis are currently undergoing phase I and II trials for the treatment of advanced BTC with promising results.