Primary Prostatic Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review.

Introduction: Primary lymphomas of the prostate are globally rare, representing <0.1% of all prostatic neoplasms. Their rarity and non-specific symptomatology at presentation usually prompt a clinical diagnosis of benign prostatic hyperplasia or chronic prostatitis, leading to significant delay in diagnosis. Case Description: A 32-year-old man presented to our clinic with complaints of difficult urination and perineal pain. An enlarged, hard and nodular prostate was palpable on digital rectal examination. Needle biopsy of the prostate was performed, which revealed diffuse large B-cell non-Hodgkin's lymphoma by immunohistochemical studies. Computed tomography (CT) scan showed a large pelvic mass arising from prostate encasing ureters with bilateral hydronephroureter. No abnormal finding was seen on abdominal CT scan and bone marrow biopsy. Therefore, the disease was classified into the clinical stage IAXE according to the Ann Arbor's criteria. The patient achieved complete response to six cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy with the central nervous system prophylaxis. He remained disease free, until 36 months after the end of chemotherapy. Practical Implications: According to the literature, the treatment and prognosis of primary lymphoma of the prostate are the same as that of other nodal lymphomas. The rituximab-based regimen should be considered in the management of prostatic diffuse large B-cell lymphoma.

Efficacy of Chemotherapy for Locally Advanced and Metastatic Pancreatic Cancer: A Real-life Experience and Outcome from a Tertiary Care Centre.

Introduction: To report response rates, progression-free survival (PFS) and overall survival (OS) in patients with advanced pancreatic cancer treated with different available chemotherapeutic regimens over 10 years. Materials and Methods: This is a retrospective observational study. All patients with locally advanced and metastatic pancreatic cancer (MPC) at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, from January 2008 to December 2017 were studied. Data were collected from the hospital information system. The characteristics and outcomes of all the patients were analysed. PFS and OS were also estimated. Kaplan-Meier curves and log-rank test were applied, and SPSS version 20 was used for data analysis. Results: Eighty-seven subjects with a median age of 56 years (range 21-76) were included. Sixty-two (71%) subjects were male. The most common tumour location was the head of the pancreas in 46 (53%) of all the subjects. Sixty-three (72%) subjects had elevated carbohydrate antigen-19.9 values. About 47 (54%) subjects had locally advanced pancreatic cancer (LAPC), and 40 (46%) subjects had MPC. Chemotherapy regimens used were FOLFIRINOX in 23 (26%), gemcitabine (GEM) based in 66 (65%) and capecitabine (CAP) based in 8 (9%) of the subjects. One (1%) subject had a complete response, 12 (14%) had a partial response, 10 (11%) had stable disease and 59 (68%) of the subjects had progressive disease. The objective response rate (ORR) was 15% and the disease control rate (DCR) was 26%. In MPC, the ORR was 10%, DCR was 18% and tumour progression was seen in 72% of the patients, while in LAPC, the ORR was 19.1, DCR 34% and tumour progression was documented in 64% of the patients, respectively. The FOLFIRINOX chemotherapy regimen had better ORR, DCR and lesser number of progressions as compared to GEM- and CAP-based chemotherapy regimens. The median PFS of the whole group was 32 weeks, and the median OS was 54 weeks. The PFS was significantly higher for LAPC (39 weeks) as compared to the MPC group (25 weeks) (P = 0.028). There was no statistically significant difference between the OS of these two groups (P = 0.451). In addition, PFS was significantly higher with FOLFIRINOX chemotherapy as compared to the other chemotherapy regimens. Regarding OS, there was no statistically significant difference among all chemotherapy regimen groups (P = 0.267). Conclusion: Based on our results, FOLFIRINOX remained the most effective chemotherapy regimen despite the dose modifications and toxicities in all groups, indicating that modified FOLFIRINOX could be considered as a first-line regimen in Southeast Asian population.

Pathologic Complete Response in HER2-Positive Breast Cancer Patients Receiving Trastuzumab in Neoadjuvant Setting.

OBJECTIVE: To compare the pathological complete response in human epidermal growth factor receptor type 2 (HER-2) positive breast cancer patients getting neoadjuvant chemotherapy with or without trastuzumab. STUDY DESIGN: Retrospective randomised double-arm observational study. PLACE AND DURATION OF STUDY: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from 2008 to 2016. METHODOLOGY: HER2-positive, lymph node positive, breast cancer patients receiving neoadjuvant chemotherapy (NACT) were retrospectively observed. Patients getting neoadjuvant trastuzumab, fulfilling the inclusion criteria were studied. The comparison group included randomly selected equal number of HER2-positive breast cancer patients having similar tumor characteristics, getting NACT only. Pathological complete response (pCR) was defined as no residual invasive or in situ residual tumor in breast tissue, or in the lymph nodes. One hundred and fifty-six patients were studied. Eighty-nine patients with HER2-positive disease received trastuzumab preoperatively. Sixty-four (n=64) patients received the complete standard dose of neoadjuvant trastuzumab along with chemotherapy. Almost equal number of patients (n=67) with HER2- positive disease were selected by random assortment for the reference group who did not receive trastuzumab before surgery. RESULTS: The pathological complete response of study group was (n=32) 50%, which was 26.1% higher than the reference group (n=16) 23.9%; and this difference was statistically significant with a p-value of 0.002 (<0.05). The overall pCR was 36.6% (n=48). CONCLUSION: Addition of trastuzumab to neoadjuvant chemotherapy doubled the pCR in HER2-positive breast cancer. Targeted therapy should be offered to all eligible patients with HER2-overexpressing breast cancer.

Germ cell tumor and Takotsubo Cardiomyopathy: A treatment dilemma.

Germ cell tumors (GCT) are uncommon malignancies in adult males and comprise less than 1% of male cancers. Due to highly curative nature and productive life years gained after treatment; reduction of chemotherapy related toxicities becomes vital. Cisplatin is the backbone of GCT chemotherapy, & is related to myocardial injury, thromboembolism & vasculitis. Though it should not be replaced with Carboplatin, however in certain circumstances, its use maybe unsafe; especially in cases when patient have prior myocardial infarction. We report a case of Takotsubo cardiomyopathy (TCM)secondary to GCT diagnosis in a young male. This patient presented with symptoms of myocardial infarction however, coronary angiography was normal and a diagnosis of TCM was made. Though, it is rare but a unique challenge, as whether Cisplatin use would be safe in this particular scenario? On one hand patient had stress related myocardial injury while he was also at risk of further Cisplatin induced complications. There are no clear cut guidelines, so after informed consent his treatment regimen was modified to EC (Etoposide/Carboplatin) instead of EP (Etoposide/Cisplatin). Patient has completed 4.6 years of follow-up without any evidence of relapse. We suggest informed decisions and to weigh the pros and cons of using an inferior regimen, in order to achieve same long term prognosis while preventing any acute complications, in younger patients with curable cancers.

Hepatosplenic mucormycosis post autologous stem cell transplant.

Mucormycosis is a life threatening fungal infection and remains an important cause of morbidity and mortality in immunocompromised patients after hematopoietic stem cell transplant. We report here a case of hepatosplenic mucormycosis in a patient after autologous stem cell transplant. A young man with anaplastic large cell lymphoma underwent autologous hematopoietic stem cell transplant after achieving complete remission with standard chemotherapy and consolidative radiotherapy. He was found to have incidental hepatosplenic hypodensities on follow up imaging, that were proved to be mucormycosis on histopathology after getting CT-guided biopsy of splenic lesions. He was treated with intravenous amphotericin-B followed by complete radiological resolution of hepatosplenic lesions. Although these infections are often life threatening but limited disease may have better outcome if diagnosed and treated early and aggressively.

Borderline tumors of the ovary: A clinicopathological study.

OBJECTIVE: To report experience with borderline ovarian tumors (BOTs) in a developing country like Pakistan with limited resources and weak database of health system. METHODS: Patients with BOTs managed at Shaukat Khanum Cancer hospital, Lahore, Pakistan from 2004 to 2014 were included and reviewed retrospectively. Data was recorded on histopathological types, age, CA-125, stage of disease, treatment modalities and outcomes. RESULTS: Eighty-six patients with BOT were included with a median age of 35 years. Forty-two (49%) patients had serous BOTs and 43 (50%) had mucinous BOTs, while one (1%) had mixed type. Using FIGO staging, 80 patients had stage I; two patients had IIA, IIB and stage III each. Median follow-up time was 31.5 months. All patients had primary surgery. Seventy (81%) patients underwent complete surgical resection of tumor. Forty-three (50%) patients had fertility preserving surgery. Seventy-three (85%) patients remained in remission. Recurrent disease was observed in 13 (15%) patients. Median time to recurrence was 22 months. On further analysis, age above forty years, late stage at diagnosis and incomplete surgery were significantly associated with invasive recurrence. CONCLUSION: Despite a low malignant potential, relapses may occur in patients above forty years of age, incomplete surgery and staging information and advanced stage at presentation. Fertility sparing surgery should be considered in young patients. Complete excision of tumor and prolonged follow-up are advised because recurrence and transformation to invasive carcinoma may occur.