Ductal carcinoma in situ (DCIS) in Karachi

Objective: To study the frequency of ductal carcinoma in situ (DCIS) in a large pathology series. DCIS is a proliferation of non-invasive, malignant epithelial cells within the ductolobular system of the breast. It is a heterogeneous entity with several morphologic variants that differ in gross appearance, growth pattern, cytologic features, mammography, and malignant potential. Methods: The data of The Aga Khan University\u27 Pathology Department, diagnosed on the basis of histopathology, during a 6-year period (1st January 1998 to 31st December 2003) was reviewed, all cases of DCIS studied, and data was analyzed with the help of analytical software SPSS. Results: Thirty-eight cases of DCIS were reported to the Aga Khan University Pathology Department, during a 6-year period (1998 to 2003), comprising approximately 1% of all breast cancers reported to the unit in the same period. The mean age of the patients at diagnosis was 48.95 years (CI 95% 44.6; 53.3). Approximately half the cases occurred in the 45-54 year age group (figure 1). Two cases (5.3%) were recurrences with previous lumpectomy scars. Comedo necrosis was observed in five (13.2%) cases, whereas 33 (86.8%) cases were non-comedo type. The clinical presentation was a palpable mass (92.1%), nipple discharge (5.3%) or clinically occult lesions diagnosed on mammography (2.6%). Approximately half the patients presented with a grade 2 disease. Atypical ductal hyperplasia was observed in a third of the cases, predominantly associated with a grade 1 and 2 disease. The estrogen and, progesterone receptor status was studied in 12 (31.6%) cases. Estrogen positivity was observed in 11 (91.7%) cases and progesterone positivity in 7 (58.3%) cases. Microcalcification was observed in four (10.6%) cases. Conclusion: The cases reported in this study are the indolent grade 1 or 2 cases with a non-comedo pattern, and a positive estrogen and progesterone receptor status. If untreated, only 40% of these innocuous forms of DCIS become invasive over a time span of approximately 25-30 years. In Pakistan we are missing the more aggressive forms of DCIS which have a shorter transition to invasive carcinoma

Small B Cell Non-Hodgkins Lymphoma in Pakistan

Objective: To study the pattern of small B cell lymphomas in Pakistan. Methods: This descriptive study was carried out at the Aga Khan University Hospital pathology department including 1721 cases of Non-Hodgkins Lymphoma (NHL) diagnosed during a period of five years (1998-2002) and classified according to REAL/WHO classification. The antibodies used included Leukocyte Common Antigen (LCA), Pan B (CD20, CD79a), Pan T (UCHL-1), Bcl 2, Mib 1(Ki 67) and Cyclin D1 (Dako, Denmark). Results: Out of the 1721 NHL cases, only 140 (8.1%) could be categorized as small B-cell NHL. The study group comprised small lymphocytic lymphoma/chronic lymphocytic leukemia (58 cases; 41.4%) followed by follicular lymphoma (46 cases; 32.9%), mantle cell lymphoma (15 cases; 10.7%), extra nodal marginal zone B cell lymphoma of MALT type (15 cases; 10.7%), lymphoplasmacytic lymphoma (5 cases; 3.6%) and splenic marginal zone B-cell lymphoma (1 case; 0.7%). No case of nodal marginal zone lymphoma was diagnosed. The age ranged from 18 to 98 years with a mean and median of 54.64 and 58.50 years respectively. Small B-cell NHL was more common in males; with male to female ratio of 2.1. Majority of the small B-cell NHL were nodal at presentation with a nodal to extranodal ratio of 3.4. Conclusion: It is concluded that the frequency of these small B-cell NHL is very low in our population in contrast to the western literature. Further studies based on epidemiologic and etiological factors are required to look into this marked difference of occurrence of these indolent lymphomas

Metaplastic carcinoma of the breast, an intriguing rarity.

Abstract Metaplastic carcinoma breast is categorized as a rare heterogenous neoplasm generally characterized by a mixtureof adenocarcinoma with dominant areas of spindle cell, squamous and/or other mesenchymal differentiation. Todetermine the epidemio-demographic and histopathologic characteristics of this rare entity a retrospective studywas conducted to review all cases at the Aga Khan University Hospital (AKUH) Karachi, received during 1st January2000 to 31st August 2005. Twenty-four patients were identified with a mean age at diagnosis of 46.4 (±SD 3.8) years,and an age range of 28-68 years. The mean tumor size was 7.9 cm, range 2.0–17.0 cms (±SD 4.77). The specimenswere mostly obtained by modified radical mastectomy(54.2%) followed by biopsy (29.2%), lumpectomy (8.3%),and total mastectomy (4.2%). Skin ulceration was found in 37.5% cases. Component sub-categorization showed 13(54.2%) cases of infiltrating ductal carcinoma with squamous metaplasia, followed by 2 (8.3 %) cases with heterologouselements, 4 (16.7%) cases with spindle cell component, 2 cases of matrix producing carcinoma and one case ofsquamous cell carcinoma. The malignancy was high grade, modified Bloom Richardson’s grade III (54.2 %) andgrade II (12.5%). Such grading was not applicable to 4 cases of spindle cell component and 1 case with extensivechondroid areas. Twelve patients had information available on the nodal status. Five (41.6%) were node-negative,four (33.33%) had 1-3 lymph node involvement positive, and three (12.5%) had more than 3 lymph nodes positive.The median 3 year Event Free Survival (EFS) was 10% and overall survival was 30%. MCB is an aggressive diseasewith a poor prognosis. This aspect appears bleaker in our population either due to the biological characteristic of themalignancy in a high risk group or the lack of availability and accessibility of health coverage, resulting in a delayedpresentation. MCB is an uncommon breast malignancy and due to the lack of sufficiently large studies there islimited knowledge as to the pathogenesis, progress, best treatment protocols and prognosis. Collaborative studiesare therefore recommended to allow for better understanding of this intriguing neoplasm

Phylloides tumors in adolescent girls and young women in Pakistan.

Abstract The objective of this study was to determine the frequency of phylloides tumor (PT) in adolescent girls and youngwomen (less than and equal to 25 years of age) and to define the clinico-pathological features of PT in this unusualclinical setting. This descriptive study was carried out at the Aga Khan University Hospital (AKUH) pathologydepartment. All consecutive cases of PT diagnosed during the last sixteen years in the section of histopathology from1st January 1990 to 31st June 2005 were included. Selection of cases was restricted to patients up to 25 years of age.A total of 42 cases of PT in up to 25 years of age were diagnosed. This comprised 11% of the total PT cases (totaln=363). The number of benign (BPT), borderline (BLPT) and malignant (MPT) was identical i.e. 14 (33.3%) each.Clinically all cases presented with a solid, mobile, palpable mass. The mean age was 19.1 years (95% CI, 16.7-21.6),21.9 years (95% CI, 20.7-21.9) and 19.7 years (95% CI, 17.2-22.3) in BPT, BLPT and MPT respectively. In majorityof cases the surgical procedure performed was lumpectomy (50% of BPT, 78% of BLPT and 64% of MPT). Highgrade PT (BLPT and MPT) is an uncommon mammary tumor in adolescent girls and young women but seems to beoccurring with increased frequency in the study population. This observation may indicate the biological behavior ofPT in a high risk population, though chances of referral bias are also present. In view of the rarity of the disease,larger population studies are suggested to confirm our findings

Orbital Embryonal Rhabdomyosarcomain Karachi (1998-2002)

Objective: To study the epidemiology of ocular Rhabdomyosarcoma (ORMS) in Karachi. Methods: Incident ORMS cases resident of Karachi, registered at Karachi Cancer Registry (KCR) during 1st January 1998 to 31st December 2002 were included in the study. The data were classified using ICD-O2; computerized with Canreg-3, and analyzed using SPSS 10.0. Results: Ten cases of ORMS were reported to KCR during 1998-2002. RMS originated in the orbit in eight cases, conjunctiva in one and eyelid in one. Nine cases presented with proptosis, associated with conjunctivitis in four cases. One case presented with eyelid swelling. The crude annual incidence rate was 0.13/100,000, the age standardized rate was 0.3/100,000. The mean age of childhood cases was 10.4 years (95% CI 4.0; 16.7); and adult cases was 24.8 years (95% CI 12.8; 36.7). At presentation, eight patients were older than 10 years and three were older than 20 years. Five cases were categorized as childhood malignancies. Tumors were a TNM stage III disease at presentation in eight cases; survival at the end of one year was 70%, and at the end of two years 20%. There were no survivors at the end of three years. Conclusion: ORMS in Karachi is a disease with a dismal survival. It may reflect a late presentation, or shorter adult ORMS survival or a manifestation of a different genetic pattern, associated with rapid evolution and poor prognosis. Health education for the population, especially parents and health providers is essential for early ORMS diagnosis. Pediatricians, ophthalmologists and health professionals, can play a vital role. Healthcare planning should focus on capacity building for ophthalmologic screening. Cytogenetic studies are advised to determine the genetic pattern

Awareness of cancer risk factors among patients and attendants presenting to a tertiary care hospital in Karachi, Pakistan

OBJECTIVE: To determine awareness of cancer risk factors in the patients and attendants of Out-patient Clinics at a University Hospital in Karachi, Pakistan. METHODS: A cross-sectional survey was conducted on 315 respondents reporting to a tertiary care hospital in Karachi, Pakistan, to assess their level of awareness regarding risk factors of cancer. RESULTS: The respondents belonged to an urban population with the mean time spent in Karachi of 29.1 years (SD +/- 13.94). There were 213 (67%) males and 102 (33%) females. All respondents had heard of the word \u27cancer\u27, while only 57.5% were aware of cancer risk factors. However, only 42.8% could identify age, 33% diet, 35% drugs and 31% obesity as risk factors for cancer. Even those who were aware of the risk factors were not able to appreciate personal risk of cancer. CONCLUSION: Despite awareness regarding some of the risk factors, the surveyed population was not aware of intrinsic risk factors for cancers like increasing age and obesity. It is important to create awareness through educational programs on cancer prevention, dissemination of knowledge pertaining to the preventable and avoidable cancer risk factors, the benefits of early diagnosis, and availability of screening tests

Cancer Patterns in Quetta (1998-1999)

Introduction: Quetta, the capital of Baluchistan, is located at latitude 30,25; longitude 67.00. It has a population of 759,245; 425,474 males (56%) and 333,771 females (44%); Census 1998. The majority of residents are Persian or Baluchi speaking Baluchs. Methodology: The cancer cases from Quetta reported to the Karachi Cancer Registry were reviewed. The data included cases from the Aga Khan University Hospital (AKUH), Pathology Department (Quetta collection point) and health care facilities in Karachi. The residents of Baluchistan were ascertained and cancer cases residents of Quetta identified with the help of recorded addresses and retraceable telephone numbers. Results: During a 2-year period, 1st January 1998 to 31st December 1999 the Karachi Cancer Registry received 1077 cancer notifications from Quetta. Approximately half the cases were registered from the AKUH Quetta collection point. Others were the referral patterns in Karachi. The age-standardized incidence rate (ASR) of cancer, all sites (1998-99) was 137.0 for males and 92.8/100,000 for females. The commonest cancer in the males and females was cancer of the esophagus (lCD­10 categories C15; males- ASR 25.5, 17.2 %; females- ASR 23.4, 23.1%). One of the highest in the world, for both genders. Incidence of cancer breast in the females (lCD-10 categories C50; ASR 11.8, 13.3%) was low, Conclusion: The cancer data from Quetta is quite distinct from the cancer pattern of Karachi. It represents only a part of the cancer burden of Quetta; nonetheless it gives a glimpse into the cancer profile of Baluchistan. The high incidence of esophageal cancer indicates an extension of the geographical limits of the esophageal cancer belt

Time trends in the incidence of cancer cervix in Karachi South, 1995-2002

Introduction:The objective of the study was to determine the trends of cancer cervix in Karachi South during an eight (1995-2002) year period. Methododology: Cancer cervix cases recorded at Karachi Cancer Registry during 1st January 1995 to 31st December 2002 were analyzed. Trends were studied by analyzing the age standardized incidence rates (ASR)s in 2 time periods, 1995-97 and 1998-2002. Results: Cancer cervix ranked sixth in the 1995-97 period the age standardized incidence rate (ASR) world and crude incidence rate (CIR) per 100,000 were 6.81 and 3.22. It reached the fifth ranking in the 1998-2002 period with an ASR and CIR of 7.5 and 4.0 per 100,000. Thus between 1995 and 2002, the incidence of cervical cancer registered an approximate 10% increase. The mean age of the cancer cases was 53.3 years (SD 11.6, 95% CI 50.58, 55.96, range 32-85 years) and 50.7 years (SD 11.7, 95% CI 48.8, 52.5, range 51 years) in period 1 and 2 respectively. The morphological components of squamous cell carcinoma and adenocarcinoma remained stable during this period, though a marginally higher component and increasing incidence of adenocarcinoma was observed throughout. A negligible down staging was observed in the 1998-2002 period. Localized malignancy was observed in 30.8% in period 2 as compared to 25.7% in period 1 and the component of carcinoma in situ increased from 0% percent in period 1 to 1.3% in the second period. Despite this two thirds of the cases still presented with a regional or distant spread of disease. Conclusion: Pakistan at present falls into a low risk cancer cervix region. The cause of concern is the steadily increasing incidence especially in the younger birth cohorts, the advanced disease at presentation, insignificant in-situ cancers and no preventive intervention or awareness practices in place

Factors influencing in-hospital length of stay and mortality in cancer patients suffering from febrile neutropenia

Introduction: Febrile neutropenia (FN) is a major complication of chemotherapy, costly in terms of morbidity, mortality and associated financial expenditure. The present study was conducted with the goal of highlighting FN as a serious problem in Pakistan, with the longer term objective of improved cancer survival, reduction in length of stay (LOS) in hospital, morbidity, mortality and costs in our existing developing country scenario. Methods: A cross-sectional descriptive study was conducted on Patients, \u3e or =18 years, admitted with FN as a consequence of chemotherapy at a referral hospital in Karachi from 1st September 2006 to 30th April 2007. Results: A total of 80 Patients [43 (53.8%) males and 37 (46.2%) females] were selected. The mean age was 47.4 (SD +/-16.6, range 18-79) years. Sixty eight Patients (86%) were \u3c or = 65 years, 50% were \u3c or = 50 years. Overall, inhospital mortality was 11%, 4% for Patients on granulocyte colony stimulating factor (G-CSF) prophylaxis as against 20% for those without. The cause of death was either pneumonia or septic shock. Mean LOS was 7.53 (SD +/-3.8, range 2-17) days. Hematological malignancies, older age, severity of dehydration, pneumonia and culture positivity were significantly associated with LOS and death. Those above 50 years of age were 1.5 times as likely to be hospitalized longer and \u3e three times as likely to die. Bacteremia conferred a 5-fold and pneumonia an 8-fold increase in the risk of death. Conclusion: The results of this study indicate that age, vital instability, dehydration, high creatinine, culture positivity and hematological malignancies are high risk factors in chemotherapy induced FN. Identification of FN risk factors with poor outcomes may help in devising protocols for modified dosage or including GCFs initially. This may help reduce the cost of cancer care as well as mortality and morbidity. Prospective studies of FN in multiple centers in Pakistan may be beneficial in evaluating these risk factors further