Carcinoma of cervix, the King Faisal Specialist Hospital & Research Center experience--the need for screening for cervical cancer in developing countries.

The King Faisal Specialist Hospital and Research Center opened in 1975 to provide specialized medical treatment to the citizens of Saudi Arabia and to promote prevention of disease through research and education. It is a national and middle eastern tertiary care hospital for oncology and a principle center for radiation therapy in Saudi Arabia. In this retrospective study, 504 patients with carcinoma of the cervix were analysed. Of the 504 patients, 410 received treatment with curative intent, which comprised radical surgery alone, radical radiation alone or combination surgery and radiation. The overall 3, 5 and 10 years survival of all 504 patients was 64%, 55% and 40%, respectively and for 410 patients treated with curative intent it was 74%, 61% and 51%, respectively. Multivariate analysis, using the Cox regression method, showed that the stage of the disease is the only significant prognostic factor influencing relapse-free survival. Stage for stage, treatment outcomes at King Faisal Specialist Hospital and Research Center match those achieved in the First world, but two-thirds of patients (rather than one-third) present with advanced disease at diagnosis. Therefore, any improvement in overall outcomes will require earlier diagnosis, achievable only through an effective screening program in the Kingdom of Saudi Arabia and similarly in the other Third world countries where patients present with advanced stage disease.

Carcinoma of the uterine cervix in Saudi Arabia: experience in the management of 164 patients with stage-I & -II disease.

BACKGROUND: Earlier stages cervical cancer has been customarily treated with radiation therapy, surgery, or combination thereof. We present our experience in the management of stage-I and -II patients in a major cancer center in the Kingdom of Saudi Arabia. METHODS: Between 1979 and 1991, 164 patients were treated and closely followed at a tertiary care medical center. RESULTS: Patients accounted for 0.78 % of all cancer patient referral. More cases with earlier stages (41.3 %) were referred since 1986, compared to a lower referral (26.1%) during the earlier part of the study (p=0.027). Age ranged from 21 to 80 years with a median of 46.5 years. Clinical stages at presentation included Stage-IA (3.0%), IB (28.7%), IIA (11.6%), and IIB (56.7%). Majority (87.2%) had squamous cell carcinoma, while the rest, had adenocarcinoma (9.1%) or other malignancies (3.6%). Among the 143 patients with squamous cell cancer, eighteen had attempted radical resection, 101 were treated with radiation, and 24 had both modalities. For squamous cancer patients, fifty-one (35.7%) had disease relapse either locally (19 cases), distally (23 patients) or both combined (9 patients). The pattern of failure was unrelated to stage of disease, histological diagnosis or the mode of therapy initially administered. The cumulative five and ten year's survival for squamous cancer patients was 68.3% and 57.9% respectively. Better survival was noted for patients with smaller sized tumors, free parametrium, and Stage-I disease. When all factors were considered in the regression model, only the status of parametrial involvement was found to be of significance. CONCLUSIONS: Cervical cancer is relatively rare in Saudi Arabia. With the improvement in health care delivery, more patients were lately seen at earlier stages of disease. With radiation therapy, two thirds of patients survived five years. The extent of parametrial involvement was the best predictor for long term survival.

Malignant cystosarcoma phyllodes: A review of the clinical experience at King Faisal Specialist Hospital and Research Centre.

Twelve females with cystosarcoma phyllodes of the breast were referred to King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1980 and 1990, representing 0.8% of breast cancer patients seen during this period. Median age was 45 years (range 16 to 65 years). Seven patients (58%) were premenopausal. All patients presented with breast mass, which measured >10 cm in 58% of them. The median duration of symptoms was 15 months (range two to 174). Neither axillary lymph nodes nor distant metastases were seen at presentation. Surgery was the cornerstone of primary treatment (wide local excision in three and mastectomy in nine). Two patients received adjuvant chemotherapy and locoregional irradiation. All patients had malignant tumors histologically. Of the four tumors assayed for hormonal receptors, one was positive for estrogen and progesterone receptors. At a median follow-up of 17 months (range two to 77), four patients had relapsed; one died at 19 months and the projected five year survival is 83%. This limited data supports the observation that malignant cystosarcoma phyllodes is a distinctive clinicopathological entity of female breast cancer with a different natural history from carcinoma of the breast. Our survival results are similar to reported experience from the literature.

Brain metastases of gestational trophoblastic tumor.

Brain involvement by gestational trophoblastic tumor (GTT) was diagnosed by computed tomography in 23 (17%) of 131 patients with metastatic GTT at King Faisal Specialist Hospital and Research Centre between January 1980 and December 1990. All 23 patients had concurrent lung involvement, and 20 presented with neurologic symptoms. There were three treatment groups: Group A--methotrexate, actinomycin-D, chlorambucil and brain irradiation; group B--cisplatin, VP-16, actinomycin-D and intrathecal methotrexate; and group C--palliative therapy and other chemotherapy. While no patients in groups A or C survived, 4 (57%) of 7 patients in group B achieved complete, sustained remission. Serum:cerebrospinal fluid beta-human chorionic gonadotropin ratios were measured in 9 patients and were < 60 in only 4 patients. The clinical features of patients with brain metastases are reviewed in detail.

Vulvar sarcoma: a report of four cases.

The clinical profiles of four patients with primary vulvar sarcomas are presented. Two patients had leiomyosarcoma in association with pregnancy, a third patient had a leiomyosarcoma with epithelioid elements, and a fourth had alveolar rhabdomyosarcoma. The natural history of the disease in the three leiomyosarcomas (including the case with epithelioid elements) was characterized by an indolent protracted course and frequent local recurrence, followed by distant fatal metastases. The patient with alveolar rhabdomyosarcoma is alive-with-disease. Surgery, chemotherapy, and radiotherapy achieved palliation rather than cure. Pregnancy did not seem to influence the prognosis.

Umbilical metastasis (Sister Joseph's nodule) from carcinoma of the vagina.

A case is reported of a squamous cell carcinoma of the vagina with metastasis to the umbilicus (Sister Mary Joseph's nodule). Systemic cisplatinum chemotherapy resulted in partial response, however, the "nodule" was a sign of poor prognosis and indicative of short-term survival. To the best of our knowledge, this is the first report of umbilical metastasis from a primary carcinoma of the vagina.

Neutron therapy for locally advanced head and neck squamous cell carcinoma: optimum dose search.

28 patients with locally advanced primary squamous cell carcinoma of the head and neck received neutron therapy and were randomized between two dose levels: 145 cGy n gamma x twelve fractions, three fractions per week (total 17.4 Gy n gamma). 155 cGy n gamma x twelve fractions, three fractions per week (total 18.6 Gy n gamma). Acute toxicity for skin, mucous membrane, salivary and subcutaneous tissues was graded using the EORTC/RTOG scoring system. Analysis indicates 17.4 Gy n gamma as "safe". A further twelve patients are to be assigned to the higher dose (18.6 Gy n gamma) before making a final dose selection.

Nasopharyngeal carcinoma in Saudi Arabia: a retrospective study of 166 cases treated with curative intent.

A retrospective review was performed of the medical records of 166 adult patients with biopsy-proven carcinomas of the nasopharynx treated with curative intent at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. All patients were treated between June 1975 and December 1985 using megavoltage therapy equipment. Most patients presented with advanced nodal disease: 23 patients (13.9%) were N0, 16 patients (9.6%) were N1, 29 patients (17.5%) were N2, and 98 patients (59%) were N3. The overwhelming majority of patients had nonkeratinizing lesions (158/166). At the time of analysis, mean follow-up time was 24.2 months (range 2-108). Actuarial curves are presented for local/regional control as a function of T-stage and N-stage and for survival and time to development of distant metastases as a function of N-stage. At 4 years local/regional control was 70% for T1 lesions, 59% for T2 lesions, 30% for T3 lesions, and 35% for T4 lesions. There was little correlation between local/regional control and N-stage being about 50% at 4 years for all nodal subgroups. Only six patients exhibited an isolated first failure in the regional nodes alone, whereas 60 patients failed initially at the primary site (either alone or in conjunction with a simultaneous nodal failure). The development of distant metastases correlated to some extent with nodal disease ranging from 20% at 4 years for T1/T2 N0 patients to 70% for patients who initially presented with N3 disease. Survival data was more difficult to obtain due to cultural biases in a medically unsophisticated patient population. True survival curves are bounded by calculating actuarial curves in two ways: death as the failure endpoint and death plus lost-with-active-disease as failure endpoints. In terms of the latter curves, at 4 years "survival" ranged from 39% for patients with T1/T2 N0 lesions to 23% for patients with N3 lesions.

Epidemiology and clinical characteristics of testicular tumors in Saudi Arabia: King Faisal Specialist Hospital and Research Centre experience.

The data on 62 patients with germinal testicular tumors seen at King Faisal Specialist Hospital and Research Centre between January 1977 and June 1983 were analyzed to determine the epidemiologic and clinical characteristics of the disease in Saudi Arabia. Fifty-seven patients were Saudis. The geographic distribution of Saudi patients seemed to coincide with population concentrations. Testicular seminomas (TS) and non-seminomatous testicular tumors (NSTT) comprised 50% each. The mean age was 41 and 27.8 years for TS and NSTT, respectively. Fifteen patients had cryptorchidism of the involved testicle. Three patients with NSTT had a history of trauma to the involved testicle. The most common presentations were painless testicular swelling (51.6%), painful swelling (16%), and abdominal or inguinal swelling (21%). The delay between the onset of symptoms and referral (mean 15 months) was considerable. Eighty percent of patients with NSTT and 45% of those with TS had advanced disease at referral.

Puberty due to a mixed germ cell tumour of the hypothalamus secreting BhCG and alpha-fetoprotein.

A 14 year-old boy presented with visual impairment due to a large suprasellar tumour secreting beta-human chorionic gonadotrophin (BhCG) and alpha-fetoprotein (alpha FP). He was sexually mature with an advanced bone age of 17 years, and suffering from partial hypopituitarism. Treatment with external radiotherapy resulted in a reduction of tumour size and fall of the serum testosterone BhCG and alpha FP levels. We conclude that pubertal development had been initiated and maintained by ectopic hCG production from his intracerebral mixed germ cell tumour. Patients with tumours in the pineal and suprasellar regions should be screened for elevated levels of BhCG and alpha FP. We suspect that many of these tumours cause precocious puberty by secreting BhCG.

Kaposi's sarcoma and its management by radiotherapy.

Thirteen patients with Kaposi's sarcoma were treated by radiotherapy between 1975 and 1984. Five patients were kidney transplant recipients receiving immunosuppressive drugs, while eight patients had spontaneous Kaposi's sarcoma. Eleven patients were followed up for periods from two to 63 months (mean, 27 months). All patients had complete response throughout the period of follow-up except one patient who developed recurrence one year after completion of radiotherapy. There was no difference in the response between transplant recipients and patients with spontaneous disease. This response was also unrelated to the dose or type of radiation used. Radiotherapy has been found effective in the local control of Kaposi's sarcoma with complete relief of symptoms and minimal morbidity.

Testicular seminomas in Saudi Arabia: clinical characteristics, prognostic indicators, and recommendations for management.

Thirty Saudi patients with pure testicular seminoma were treated at King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, between January 1977 and June 1983. Disease characteristics in Saudi Arabia including clinical findings, response to therapy, and prognosis are described and compared to those in other populations reported in the literature. Symptom durations were 3 to 42 months. Many of the patients presented with an extensive tumor burden and a poor performance status. There was a higher incidence of anaplastic seminoma and of cryptorchidism than in other series and a relatively high incidence of elevated betahuman chorionic gonadotropin (B-HCG). Patients initially underwent funiculo-orchiectomy. Twenty-two patients received radiation therapy and four received chemotherapy. Patients with limited disease responded well to orchiectomy and radiation therapy. However, those with extensive tumor burden had an unsatisfactory response to radiation therapy. Preradiation chemotherapy is recommended for patients with massive retroperitoneal metastases, nodal disease above the diaphragm, or extranodal disease and patients with minimal or moderate sized retroperitoneal nodal disease associated with an elevated B-HCG.

Post-circumcision carcinoma of the penis. I. Clinical aspects.

Fifteen patients with post-circumcision squamous cell carcinoma of the penis are discussed (13 were referred from the southwestern region of Saudi Arabia). Carcinoma developed in circumcision scars on the penile shaft. Excision was the only effective treatment and resulted in disease control in approximately 64 per cent of those treated surgically. Radiation therapy and chemotherapy did not seem to be effective in these patients.

Medulloblastomas: a review of modern management with a report on 75 cases.

The authors summarize the 8-year experience of a tertiary medical center with 75 cases of medulloblastoma in Saudi Arabia. A discussion of the evolution of modern management of this difficult problem ensues. As 5-year survival statistics approach 80% in some institutions, attention is being focused on the long-term effects of modern therapy and the quality of life led by these children.