Synovial sarcoma: a rare neoplasm of paranasal sinus.

Synovial Sarcoma (SS) is a rare soft-tissue malignant tumour. Its presentation in the head and neck region is uncommon. Because of the complex anatomy of the head and neck region, surgery with clear margins is not achievable. In such cases, a multi-modality approach is required as there is no established standard of care. In this report, we share the case of a girl who presented with nasal obstruction. Imaging revealed a mass involving the left nasal cavity, paranasal sinuses without intracranial extension. It was diagnosed as synovial sarcoma. She underwent surgical excision and adjuvant radiation therapy (RT) to the tumour bed, followed by an incomplete course of chemotherapy. Later on, she developed systemic disease. Considering the rarity of this case and lack of guidelines for standard treatment, we report on this case to share our experience with management and treatment outcome.

Evaluation of quality of life of gastrointestinal cancer patients presenting to a tertiary care hospital in Pakistan.

Introduction: Quality of life (QOL) appraisal is a meaningful method of outcomes assessment in patients with gastrointestinal (GI) cancer. The aim of our study was to evaluate QOL of patients suffering from GI cancer, who underwent treatment at Aga Khan University Hospital (AKUH), Karachi, Pakistan. Methods: It was a cross-sectional study. A total of 158 adults from December 2020 to May 2021 were included in the study. The EORTC QLQ-C30, validated in Urdu (Pakistan) version, was used to assess the QOL of the participants. Mean QOL scores were calculated and compared with threshold of clinical importance (TCI). Multivariate analysis was done to analyse the correlation between independent factors and QOL scores. A p value of <0.05 was considered as significant. Results: Mean age of the study participants was 54.5 ± 13 years. Majority were male, married and living in combined family system. Most common GI cancer was colorectal (61%) followed by stomach (33.5%); and the most frequent stage at presentation was stage III (40%). Global QOL score was found to be 65.48 ± 1.78. Among functioning scales, role functioning, social functioning, emotional functioning and cognitive functioning were found to be above TCI, whereas physical functioning was found to be below TCI. Among symptom scores, fatigue, pain, dyspnoea, insomnia, appetite loss, constipation and diarrhoea were found to be below TCI, whereas nausea/vomiting and financial impact were found to be above TCI. Multivariate analysis revealed that history of surgery had a positive association (p < 0.001), while being on treatment (p = 0.001) and having a stoma (p = 0.038) had a negative impact on global QOL. Conclusion: This is the first study to evaluate the QOL scores in GI cancer patients in Pakistan. There is a need to identify the reasons for low physical functioning score and explore means to mitigate symptoms scores above TCI in our population.

TKIs beyond immunotherapy predict improved survival in advanced HCC.

PURPOSE: For patients with advanced HCC, predictors of immunotherapy response are scarce, and the benefits of tyrosine kinase inhibitor (TKI) treatment after immunotherapy are unclear. We explored whether clinical features, such as target lesion response, immune-mediated toxicity, or subsequent TKI therapy predict immunotherapy response. METHODS: We retrospectively studied 77 patients with advanced HCC receiving immunotherapy. Patient characteristics and outcomes were assessed using various statistical methods, including the log-rank test and Kaplan-Meier methods. Cox proportional hazard modeling was used for multivariable survival analysis. RESULTS: For all patients, median overall survival (mOS) was 13 months (95% CI 8-19), and median progression-free survival (mPFS) was 6 months (95% CI 4-10). Patients with partial response (PR) and stable disease (SD) compared to progressive disease (PD) had prolonged mPFS (27 vs. 5 vs. 1 month(s), p < 0.0001) and mOS (not met vs. 11 vs. 3 months, p < 0.0001). Patients with vs. without immune-mediated toxicities trended towards longer mPFS (9 vs. 4 months p = 0.133) and mOS (17 vs. 9 months; p = 0.095). Patients who did vs. did not receive a tyrosine kinase inhibitor (TKI) after immunotherapy had a significantly improved mOS (19 vs. 5 months, p = 0.0024)). Based on multivariate modeling, the hazard ratio (HR) of overall survival (OS) of patients receiving TKI vs. no TKI was 0.412 (p = 0.0043). CONCLUSION: We show that disease control predicts prolonged mOS and mPFS. Furthermore, TKI therapy administered after immunotherapy predicts prolonged mOS in patients with advanced HCC.

Green marketing orientation impact on business performance: Case of pharmaceutical industry of Pakistan.

This study is based on the natural resource based view, which examines the impact of holistic marketing orientation on business performance (BP) by defining the role of enablers and mediators. The drivers, including corporate social responsibility (CSR) and environmental culture (EC) influence, are tested by analyzing the role of sustainable competitive advantage (SCA) as a mediator. The analysis is based on 298 samples collected from top and middle-level managers working in the pharmaceutical industry. Structural equation modeling was undertaken using Smart PLS 3.2.8. The research outcomes reveal that corporate social responsibility and environmental culture have a substantial impact on green marketing orientation (GMO). The results show that GMO has a significant direct and indirect impact on business performance while a full mediation of sustainable competitive advantage exists between the green marketing orientation and business performance. The outcomes will facilitate managers in green marketing strategy and decision making in the long-term, with 3-fold benefits in addition to strengthening their competitiveness.

Acute dermatitis in adult female patients receiving hypofractionated radiotherapy for breast cancer: experience from a low- and middle-income country.

Radiotherapy (RT) is an important component of treatment in the management of breast cancer patients. The radiation treatment paradigm has been shifted towards hypofractionated RT. This study aims to determine the severity of acute dermatitis in patients receiving hypofractionated RT for breast cancer at a tertiary care university hospital in Pakistan. Patients with biopsy-proven invasive breast carcinoma or DCIS who were referred for radical radiotherapy after discussion in the breast tumour board were retrospectively reviewed. Physical assessment of the patients for evaluation of the severity of radiation dermatitis will be carried out in the first week, last week and on the first follow-up after 1 month of completion of RT, according to the Radiation Therapy Oncology Group/European Organisation For Research And Treatment Of Cancer (RTOG/EORTC) criteria. We identified 92 female patients in 6 months at Aga Khan University Hospital, with a mean age of 53.1 years. Most of the treated patients had clinical stage 3 (64%) cancer, while others were stage 2 (42%), stage 1 (2%) and stage 0 (2%). The surgeries performed were mastectomy in 59 patients and breast-conserving surgery in 33 patients. Histology was Intra Ductal Carcinoma (IDC) (95%), DCIS (3%) and Invasive Lobular Carcinoma (ILC) (2%). Most of the patients received chemotherapy (96%). Radiotherapy dose was 4256 cGy in 16 fractions, followed by a boost of 10 Gy. The radiation techniques used were intensity-modulated radiotherapy (47.8%) and three-dimensional conformal radiotherapy (52.2%). Most of the patients experienced no toxicity (59%), while grade I toxicity was observed in 29% of the patients and grade II toxicity was observed in 11%. Only 1% of the patients experienced grade III skin toxicity. Hypofractionated radiation therapy is beneficial because of the shorter overall treatment time which reduces the socio-economic burden, not only for patients but also for radiotherapeutic institutions. However, extended follow-up is to be reported for long-term toxicity and other consequences.

Ceftriaxone-Induced Reversible Agranulocytosis: A Case Report and Review of Drug-Induced Agranulocytosis.

In the modern era of medicine, agranulocytosis is a rare occurrence. Despite significant improvement in patient survival, it still carries significant mortality. Agranulocytosis is most commonly caused by chemotherapeutic agents and numerous non-chemo drugs. As it can develop anytime during treatment and patients can remain asymptomatic, frequent cell count monitoring is an essential tool to make a timely diagnosis. An appropriate drug switch, work up to rule out infection and granulocyte colony-stimulating factor (G-CSF) injection in high-risk cases is the management. The patient should be kept under observation till the resolution of agranulocytosis. We present a case of ceftriaxone-induced agranulocytosis which was completely reversible upon stoppage of drug and granulocyte colony-stimulating factor administration. The pathogenesis of ceftriaxone-induced agranulocytosis is unknown. It is suggested to occur either by an immunologic mechanism or because of direct drug toxicity.

Male Breast Cancer: The Three Decades' Experience of a Tertiary Care Hospital in a Lower-Middle Income Country.

Introduction Male breast cancer is uncommon and managed on the guidelines of female breast cancer due to tumor rarity. We sought to identify the incidence, clinicopathological features, and survival of all male breast cancer patients managed in our hospital. Methods A retrospective cross-sectional study was conducted at Aga Khan University Hospital (AKUH), Karachi, Pakistan, from January 1986 to December 2018. Demographic data, treatment records, and follow-up data of all male breast cancer patients who were treated at AKUH was reviewed. Results Thirty-eight out of 42 patients who presented over a period of 32 years were included. The mean age was 63 years. The most common tumor type and subtype were invasive ductal carcinoma (89.5%) and luminal A (73.7%), respectively. The majority (36.8%) of the patients presented at stage III. Among 30 (78.9%) patients who underwent surgery, mastectomy was performed in 30 (78.9%), upfront axillary clearance in 24 (63.2%), axillary sampling in five (15.1%) cases, and sentinel lymph node biopsy in one (2.6%) case. Neoadjuvant chemotherapy was given to 10 (26.3%) patients, and adjuvant chemotherapy to eight (21.1%) patients. Adjuvant hormonal treatment was administered to 22 (57.9%) patients, and 13 (34%) patients received adjuvant radiation to the chest wall. The five-year overall survival was 38.2% and the median survival was 36 months. The five-year disease-free survival (DFS) was found to be 33.7%. Conclusion Breast cancer in males presents at an advanced stage with poor survival. Multicenter studies are required to accurately identify incidence, prognostic factors, and outcomes in order to have a better understanding of its management.

Fertility preservation is an imperative goal in the clinical practice of radiation oncology: a narrative review.

With reduced cancer mortality in recent years, increased efforts must be put into safeguarding cancer survivors' long-term quality of life (QOL). Fertility preservation is recognised as a key component of QOL in survivorship. Concerns about fertility have been seen to significantly impact cancer patients' emotional and mental health as, generally, both malignancy and its treatment may cause a temporary or permanent reduction in infertility. This article reviews the primary effects of radiation therapy on male and female gonads and has further highlighted procedures through which the functioning of these organs can be protected before or during radiation treatment. We have also emphasised the importance of the establishment of multidisciplinary tumour boards and patient education regarding future reproductive function which is an important component of the care of individuals with cancer. This article highlights that infertility is a persistent and major concern that can add to long-term stress in cancer survivors, and education about fertility preservation before the initiation of any treatment is especially important.

Gastro-intestinal stromal tumor (GIST): Experience from a tertiary care center in a low resource country.

Objectives: The aim of this retrospective study was to review the overall survival (OS) and disease-free survival (DFS) of GISTs treated surgically at our center over the past decade. Material and Methods: We undertook a 12-year retrospective review of our experience in treating this condition with a focus on long-term outcomes of treated patients in a resource-constrained environment. Incomplete follow-up information continues to be a major problem with studies conducted in low resource settings, and in order to overcome this, we undertook telephonic contact with patients or their relatives to get the necessary information about their clinical status. Results: Fifty-seven patients with GIST underwent surgical resection during this period of time. The stomach was the most common organ involved in the disease, with 74% of the patients. Surgical resection was the main treatment approach, with R0 resection possible in 88%. Nine percent of the patients were given Imatinib as neoadjuvant treatment and 61% were offered the same, as adjuvant therapy. The duration of adjuvant treatment changed from one year to three years over the study period. Pathological risk assessment categorized the patients as Stage I, 33%; Stage II, 19%; Stage III, 39%; and Stage IV, 9%. Of the 40 patients who were at least three years from surgery, 35 were traceable giving an 87.5%, overall three-year survival. Thirty-one patients (77.5%) were confirmed to be disease-free at three years. Conclusion: This is the first report of mid-long-term outcomes of the multimodality treatment of GIST from Pakistan. Upfront surgery continues to be the main modality. OS & DFS in resource-poor environments can be similar to those seen in a better-structured healthcare setting.

Abscopal Effect: An Old Concept with a New Horizon.

Abscopal effect is defined as a phenomenon where radiation delivery at one site induces shrinkage of disease at a distant site, outside the radiation field. Although it is an old concept but with recent advancements in the fields of diagnostic and therapeutic oncology, this effect has gained popularity and nowadays has become an area of interest for the researchers.With the current success of immunotherapy, there is robust and interesting data looming to evaluate potential synergistic effect of radiation coupled with immunotherapy to attain abscopal effect. Our article highlights background, mechanism and a brief literature review for abscopal response in conjunction with immunotherapy. Keywords: Abscopal Effect, Radiation, Immunotherapy, Personalized Medicine.

Association Between Perioperative Hypothermia and Surgical Site Infection After Elective Abdominal Surgery: A Prospective Cohort Study.

Introduction Surgical site infections (SSIs) account for 14-16% of nosocomial infections and are one of the major causes of increased morbidity, hospital stay, cost of care, and even mortality. Hypothermia as a risk factor for SSI is debated but there is lack of conclusive evidence. The present study explores the association of hypothermia with SSI. Methodology This is a prospective cohort study conducted on adult patients who underwent elective laparotomy. Patients were divided into two cohorts, the Hypothermia Cohort and the Normothermia Cohort, based upon episodes of hypothermia of <360C in the perioperative period. SSI was diagnosed based upon criteria defined by the Center for Disease Control and Prevention (CDC). Postoperative follow-up to detect SSI was done until 30 days after the operation. Results A total of 183 patients met the selection criteria and were included in the study. Ninety patients (49%) had perioperative hypothermia and were followed in the Hypothermia Cohort, while 93 patients (51%) who remained normothermic in the perioperative period were followed in the Normothermia Cohort. Mean age of the patients was 49.77 +/- 14.82 years. Almost two-thirds of the participants were females (63.9%). Patients who developed hypothermia were significantly older and had lower BMI. Also the proportion of female patients was significantly higher in the Normothermic Cohort. Rate of SSI was similar in both groups (10% versus 10.8%) with p-value of 0.867. Multivariable regression analysis also failed to show any significant association between hypothermia and SSI. Conclusion Our study failed to show any statistically significant association between hypothermia and surgical site infection.

Impact of Peer Review in the Radiation Treatment Planning Process: Experience of a Tertiary Care University Hospital in Pakistan.

PURPOSE: To evaluate and report the frequency of changes in radiation therapy treatment plans after peer review in a simulation review meeting once a week. MATERIALS AND METHODS: Between July 1 and August 31, 2016, the radiation plans of 116 patients were discussed in departmental simulation review meetings. All plans were finalized by the primary radiation oncologist before presenting them in the meeting. A team of radiation oncologists reviewed each plan, and their suggestions were documented as no change, major change, minor change, or missing contour. Changes were further classified as changes in clinical target volume, treatment field, or dose. All recommendations were stratified on the basis of treatment intent, site, and technique. Data were analyzed by Statistical Package for the Social Sciences and are presented descriptively. RESULTS: Out of 116 plans, 26 (22.4%) were recommended for changes. Minor changes were suggested in 15 treatment plans (12.9%) and a major change in 10 (8.6%), and only one plan was suggested for missing contour. The frequency of change recommendations was greater in radical radiation plans than in palliative plans (92.3% v 7.7%). The head and neck was the most common treatment site recommended for any changes (42.3%). Most of the changes were recommended in the technique planned with three-dimensional conformal radiation therapy (50%). Clinical target volume (73.1%) was identified as the most frequent parameter suggested for any change, followed by treatment field (19.2%) and dose (0.08%). CONCLUSION: Peer review is an important tool that can be used to overcome deficiencies in radiation treatment plans, with a goal of improved and individualized patient care. Our study reports changes in up to a quarter of radiotherapy plans.

Incidental Renal Cell Carcinoma in Pelvic Malignancies.

Simultaneous diagnosis of renal cell carcinoma with pelvic malignancies is rare but a well-documented phenomenon. It is not uncommon to have incidental renal masses on imaging done for investigating other tumors. There are no established guidelines for the treatment of patients with dual malignancies. The management of such patients is challenging and requires a multidisciplinary approach. We present a series of three cases with a diagnosed pelvic malignancy but further workup revealed a kidney tumor. Both the malignancies were evaluated individually and diagnosed as two different primary neoplastic lesions. This case series examines each distinct patient's presentation, discusses the diagnosis, and compares and contrasts the findings while discussing the literature on this topic.