Journal of Cancer & Allied Specialties

Reduction in Average Length of Stay in Emergency Department of a Low-Income Country's Cancer Hospital.

2024-01-23T16:15:08-08:00

Introduction: Prolonged length of stay (LOS) in emergency departments (ED) is a widespread problem in every hospital around the globe. Multiple factors cause it and can have a negative impact on the quality of care provided to the patients and the patient satisfaction rates. This project aimed to ensure that the average LOS of patients in a tertiary care cancer hospital stays below 3 hours. Materials and Methods: The Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) approach was followed. Results: The average LOS was 166 minutes before implementing interventions. The two primary reasons for the increased length of stay were delays secondary to physician assessment and diagnostic lab reports. Strategies were defined to control these factors, which helped reduce the average length of stay to 142 minutes, a 30% reduction. Conclusion: A process improvement model similar to this project is recommended to enhance the quality of hospital services. It will provide valuable insights into the process flow and assist in gathering precise data on the various steps involved. The data collected can then be analyzed to identify potential causes and make informed decisions that can significantly improve hospital processes.

Complications and Outcome of Bone Sarcoma Patients with Limb Salvage using Liquid Nitrogen-treated Bone for Reconstruction

2024-01-23T16:15:07-08:00

Introduction: The recommended treatment method for bone sarcoma is wide local excision and reconstruction to preserve limb function. Established methods of reconstruction are mega prosthesis or biological reconstruction. This study aimed to determine the complications and functional outcomes associated with limb salvage surgery using liquid nitrogen-treated bone. Materials and methods: We retrospectively observed the short-term outcome of limb salvage surgeries where liquid nitrogen bone was used for reconstruction. A total of 15 patients underwent reconstruction with liquid nitrogen auto graft from January 2018 to December 2020. We used the free freezing method of liquid nitrogen treatment after wide local excision of sarcoma. We observed short-term outcomes after liquid nitrogen-treated bone reconstruction in limb salvage surgery. Survival of the auto grafts was recorded using the Kaplan–Meier method with a 95% confidence interval. Results: The mean follow-up was 19.83 ± 4.5 months. The mean Musculoskeletal Tumor Society (MSTS) score was 62.4 ± 7.9 %, while the average Toronto extremity score was 59.6 ± 5.7 %. Three patients died during the study duration due to visceral metastasis. Skin necrosis and wound breakdown were major complications in 9(60%) patients. Deep infection was observed in 4 (26.7%). Similarly, 4(26.7%) patients had non-union at either the proximal or distal osteotomy site, while the average time of bone union in the rest of the patients was 6.3 +/- 1.7 months. A total of 6 (40%) patients underwent re-operation after liquid nitrogen treatment, either due to infection or non-union at the osteotomy site. Recurrence was observed in 3 (20%) of patients. Conclusion: We observed a high complication rate with liquid nitrogen-treated autograft reconstruction. Vascularized fibula with liquid nitrogen-treated autograft or endoprosthesis should be encouraged.

Impact of SSO-ASTRO margin guidelines on re-excision rate in breast-conserving surgery: A single-center experience

2024-01-23T16:15:06-08:00

Introduction: Breast-conserving surgery (BCS) has been historically linked with a high rate of re-excision. To address this issue, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) developed consensus guidelines in 2014 to standardise practices and improve clinical outcomes for BCS patients. In our tertiary cancer care hospital, we assessed the impact of these guidelines on the re-excision rate following BCS. Materials and Methods: We conducted a retrospective study on breast cancer patients who underwent BCS at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan. The study compared the re-excision rate before the implementation of the SSO-ASTRO consensus guidelines (November 2015 to July 2017) and after the implementation (January 2018 to August 2019). Margins were considered positive if "ink on tumour" was present and negative if "no ink on tumour" was present. Fisher's exact test or chi-square test was used to compare the re-excision rates between the pre- and post-guideline periods. Results: A total of 919 patients were identified, with 533 from the pre-guideline period and 386 from the post-guideline period. Of the 919 patients, 31 with ductal carcinoma in situ (DCIS) were excluded from the re-excision analysis because the guidelines were not implemented on the DCIS. Furthermore, the overall rate of re-excision in our data was 4.3%. The re-excision rate decreased from 71.1% to 28.9% (P ≤0.05) following the adoption of the guidelines. We observed a statistically significant decrease in the re-excision rate after implementing the SSO-ASTRO guidelines. Conclusion: Implementation of the SSO-ASTRO margin guidelines led to a notable decrease in the overall re-excision rate in our data set. These findings suggest that continued adherence to the guidelines may lead to a further reduction in the re-excision rate in the future.

A Longitudinal Metagenomic Comparative Analysis of Oral Microbiome Shifts in Patients Receiving Proton Radiation Versus Photon Radiation for Head and Neck Cancer

2024-01-23T16:15:04-08:00

Introduction: Due to the radiation-sparing effects on salivary gland acini, changes in the composition of the oral microbiome may be a driver for improved outcomes in patients receiving proton radiation with potentially worse outcomes in patients exposed to photon radiation therapy. To date, a head-to-head comparison of oral microbiome changes at a metagenomic level with longitudinal sampling has yet to be performed in these patient cohorts. Methods and Materials: To comparatively analyze oral microbiome shifts during head and neck radiation therapy, a prospective pilot cohort study was performed at the Maryland Proton Treatment Center (MPTC) and the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center. A longitudinal metagenomic comparative analysis of oral microbiome shifts was performed at three-time points (pre-radiation, during radiation, and immediately post-radiation). Head and neck cancer patients receiving proton radiation (n=4) were compared to photon radiation (n=4). Additional control groups included healthy age- and sex-matched controls (n=5), head and neck cancer patients who never received radiation therapy (n=8), and patients with oral inflammatory disease (n=3). Results: Photon therapy patients presented with a lower microbial alpha diversity at all timepoints and there was a trend towards reduced species richness as compared with proton therapy. Healthy controls and proton patients exhibited overall higher and similar diversity. A more dysbiotic state was observed in patients receiving photon therapy as compared to proton therapy in which oral microbial homeostasis was maintained. Mucositis was observed in 3/4 photon patients and was not observed in any proton patients during radiation therapy. Bacterial de novo pyrimidine biosynthesis pathway and nitrate reduction V pathway were comparatively higher following photon exposure. These functional changes in bacterial metabolism may suggest that photon exposure produces a more permissive environment for proliferation of pathogenic bacteria. Conclusion: Oral microbiome dysbiosis in patients receiving photon radiation may be associated with increased mucositis occurrence. Proton radiation therapy for head and neck cancer demonstrates a safer side effect profile in terms of oral complications, oral microbiome dysbiosis, and functional metabolic status.

Survival Analysis and Correlates with Molecular Epidemiology: 10-year Retrospective Series of High-Grade Glioma in Pakistan

2024-01-23T16:15:03-08:00

Introduction: High-grade gliomas are malignant, recurring primary CNS tumors requiring extensive postoperative chemotherapy and radiation treatment. Isocitrate dehydrogenase (IDH), 1p19q, and ATRX mutations significantly influence survival and response to chemotherapy, as seen in many extensive studies from the Global North. This study aims to report data from the local region regarding progression-free survival and overall survival in light of molecular characteristics. Materials and Methods: A 10-year retrospective series was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, with 285 patients presenting from 2008 to 2018. Prospective follow-up data was collected, and complete molecular profiles were available for patients presenting from 2010 onwards. Survival analysis was conducted through the Kaplan-Meier method, with log-rank reported. Results: 70.53% (201) of patients were male, with a mean age at diagnosis of 43.33 ± 15.1 years. 265 patients within the cohort completed postoperative radiotherapy, while 141 patients underwent chemotherapy (PCV [Procarbazine, lomustine and vincristine] or Temozolomide). Mean survival, in months, within the cohort was as follows: glioblastoma (14.1), anaplastic astrocytoma (27.5), and anaplastic oligodendroglioma (39.8). Survival curves showed a lower survival for IDH wild-type (p<0.0001), ATRX mutated (p=0.029), and 1p19q non-deleted (p=0.008) tumors from Pakistan. Discussion: Our findings quantified long-term survival outcomes for high-grade glioma from Pakistan, analysing the various treatment patterns. Of particular importance, molecular sub-classification significantly predicted survival outcomes by IDH, ATRX, and 1p19 co-deletion mutations. Expanding brain tumour epidemiology will benefit assessing the efficacy of regional oncological centres and establishing standards of care.

Mutation Analysis of Epidermal Growth Factor Receptor Gene in Non-Small Cell Lung Cancer for Selection of Patients Eligible for Tyrosine Kinase Inhibitor Therapy

2024-01-23T16:15:03-08:00

Introduction: Epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor therapy is effective as a first-line treatment of advanced non-small-cell lung cancer (NSCLC). This research study investigated the distribution of EGFR mutations in patients diagnosed with NSCLC to assist in selecting patients who could benefit from tyrosine kinase inhibitor therapy. Materials and Methods: This cross-sectional study was conducted between July 2017 and November 2022. A real-time multiplex Polymerase Chain Reaction (PCR) assay supplied by Roche Diagnostics was used to examine DNA obtained from 682 tumor biopsies collected from NSCLC patients. DNA amplification was performed in a Cobas z 480 instrument for mutation analysis. The PCR assay was designed using specific primers and probes to detect 43 different mutations targeting exons 18-21. Results: Among the 682 samples, 466 (68.3%) were males, and 216 were females. The male-to-female ratio was 2.1. Twenty per cent of the male and 37% of the female samples were positive for EGFR mutations. The most common mutations were the in-frame deletion of exon 19, followed by L858R in exon 21, exon 20 insertion and S769I, exon 18 G719X. In addition, three mutations, namely del exon 19, T790M and exon 20 insertions were also detected in a patient, suggesting an actively progressive disease. Conclusions: This study showed that EGFR mutations are more common in Pakistani female patients than males. Secondly, in-frame deletion of exon 19 and exon 21 mutation L858R are prevalent in most of the NSCLC patients. The prevalence of common and rare EGFR mutations in Pakistani patients provides an opportunity for a subset of patients' chance of therapy.

A Rare Case of Primary Malignant Melanoma of Cervical Spine having Extramedullary Intradural Origin: A Single Case Report and Literature Review

2024-01-23T16:15:07-08:00

Introduction: Primary spinal malignant melanoma (PSMM) of extra medullary intradural origin is a rare malignant condition with limited current literature regarding its clinical course, magnetic resonance imaging (MRI) findings, treatment strategies and outcomes. Case discussion: This is a case report of a patient with PSMM who was treated with surgery followed by radiotherapy for his residual disease in Shaukat Khanum Memorial Trust, Pakistan. The clinical and radiological findings of this case were retrospectively analyzed using the Hospital Information System. Practical implementations: PSMM of extra medullary intradural origin is a rare malignant tumor that shows characteristic findings on MRI. Surgical resection is the preferred treatment, and radiotherapy is useful for residual disease.

Pediatric Ewing Sarcoma of Kidney: A Case Series and Review of Literature

2024-01-23T16:15:05-08:00

Introduction: Renal Ewing sarcoma is an aggressive and rare malignancy affecting children and adolescents. Limited data on its management contributes to uncertainties in treatment Case description: We present two pediatric cases of Renal Ewing Sarcoma. Both cases emphasize the significance of accurate diagnosis, multimodal treatment, and long-term follow-up in achieving favourable outcomes. Accurate diagnosis of renal Ewing sarcoma is crucial for effective management. Multimodal treatment involving neoadjuvant chemotherapy, surgical resection and staging with lymph node sampling, and chemotherapy continuation has shown promising results in our cases. Long-term follow-up is essential for monitoring disease progression and ensuring optimal outcomes. Practical Implications: There is limited data published about these renal tumors, especially in the pediatric population, and most studies lack long-term follow-up (6,7,20), with uncertain management due to limited data. This data will add to the newer and multimodal approach and form the basis for future meta-analysis to help formulate guidelines in upcoming international meetings. Continued research efforts are necessary to optimize strategies and improve the prognosis for pediatric patients with renal Ewing sarcoma.

Association of Wilms Tumor with Crossed Fused Renal Ectopia in Children: A Case Report

2024-01-23T16:15:04-08:00

Introduction: Wilms tumor is the most common renal malignancy in children. The occurrence of Wilms tumor with various congenital genitourinary anomalies has been reported, particularly in horseshoe kidneys, hypospadias, disorder of sexual development, and double collecting system. However, Wilms tumor with crossed renal ectopia is a rare finding.

Case Description: We are reporting a case report of Wilms tumor in a 3-year-old girl who presented with a huge left flank mass with cross-fused renal ectopia. After the initial workup and triphasic computed tomography (CT) scan of the chest, abdomen, and pelvis for confirmation of diagnosis and metastasis, the patient underwent image-guided tissue biopsy followed by neo-adjuvant chemotherapy, left radical nephrectomy with separation of fused right ectopic renal moiety and adjuvant chemoradiation.

Practical Implication: This report shows an association of Wilms tumor with cross-fused renal ectopia, a rare combination. Unusual findings on imaging with unilateral flank mass should be considered as part of the differential diagnosis for this rare finding. Adjuvant chemotherapy and modern imaging helped delineate the anatomy and ease the surgery for safe resection, improving the overall outcome.

Emergency Angioembolization for Life-Threatening Haemorrhage in Wilms Tumour

2024-01-23T16:15:02-08:00

Introduction: Renal artery embolization has been used in a palliative fashion for symptomatic relief of hematuria or flank pain in unresectable renal cell carcinoma in adults. There is limited data on using embolization for actively bleeding and unresectable tumours in the oncological pediatric population. Case description: A previously healthy, five-year-old boy with no significant past medical or surgical history presented to the clinic with gradually worsening abdominal distension associated with occasional abdominal pain, gross hematuria, and lethargy for four months. Diagnostic investigations showed an 18 cm left-sided metastatic (pulmonary) renal tumour (Wilms), which was deemed unresectable on imaging. Treatment was planned on SIOP-RTSG protocol. However, he became hemodynamically and vitally unstable with acute sudden distension of the abdomen on the left side after the first cycle of chemotherapy. Imaging showed active bleeding from an inferior branch of the left renal artery. Selective angioembolization was done, and chemotherapy was reinitiated with a patent left main renal artery. Following the fourth cycle of chemotherapy, he developed hemodynamic instability and abdominal pain; imaging revealed the resolution of pulmonary nodules and bleeding from the left renal artery (main); this was again embolized, and the patient was stabilized. The patient was operated on after optimization and complete resection of the mass was done with negative margins. On six months follow up, he is well. Practical implications: To the best of our knowledge, this is the first case where angioembolization has been done in conjunction with neoadjuvant chemotherapy to downsize a Wilms Tumor to achieve favourable outcomes. Continued research efforts are necessary to optimize strategies and improve the prognosis for pediatric patients, and this case is one of the prime examples.