Metastatic pancreatic carcinoma and experience with FOLFIRINOX - a cross sectional analysis from a developing country

Background: Pancreatic cancer is the fourth leading cause of cancer related death with median survival ranging from 3 to 6 months for metastatic disease. Palliative chemotherapy has been the backbone of treatment in advanced stage and has evolved over time. Data pertaining to the disease are scarce from our part of the world where treatment poses a significant challenge due to lack of resources.MATERIALS AND Methods: A retrospective chart review was performed for all patients presenting with stage IV pancreatic carcinoma at a tertiary care hospital in Karachi, Pakistan between January 2008 and December 2012. Data were collected using a pre-designed, coded questionnaire looking at patient characteristics, treatment given and outcome.Results: 101 patients were found to be eligible. Mean age was 56.7 ± 12.8 years, the male to female ratio was 2:1 and most patients had a good performance status. More than half of the tumors were located in the head (57%, n=58) and almost all were adenocarcinomas (95%, n=96). Some 58% (n=59) received first line chemotherapy of which 49% (n=29) received gemcitabine-based regimens and 39% (n=23) received FOLFIRINOX. The median progression free survival for gemcitabine based treatment was 2.9 months (IQR=1.6-5.6) as opposed to 7.3 months (IQR=4.5-9.2) for FOLFIRINOX (P=0.02). Median overall survival was 4.9 months (IQR=2.3-9.5) for first line gemcitabine based treatment and 10.5 months (IQR=7.0-13.2) for first line FOLFIRINOX therapy (P=0.002). Patients on FOLFIRINOX had better survival across all subgroups. Inpatient admissions and dose reductions were more frequent with FOLFIRINOX but the difference between the two regimens was not statistically significant. FOLFIRINOX could be successfully administered as outpatient therapy to a number of patients.CONCLUSIONS: FOLFIRINOX remains a suitable first line option in patients with metastatic pancreatic cancer with good performance status even in a resource-poor country where diagnostic and supportive care facilities may be less than optimal and cost is a limitation

Translation and validation of the Urdu version of the European organization for research and treatment of cancer core quality of life questionnaire (EORTC QLQ-C30) and brain module (QLQ-BN20) in primary brain tumor patients

Introduction: This study translated and validated the Urdu version of the European Organization for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire (EORTC QLQ-C30) and Brain Module (QLQ-BN20) amongst patients with primary brain tumors (PBT) in Pakistan, and assessed the correlation of QoL with resilience, depression, and anxiety.Methods: Translation of the EORTC QLQ-C30 and QLQ-BN20 was performed as per EORTC guidelines. A survey comprising of Urdu translations of EORTC QLQ-C30, QLQ-BN20, Wagnild and Young Resilience Scale (RS-14) and Hospital Anxiety and Depression Scale was administered to patients with PBT at a tertiary care hospital in Pakistan. Reliability (via Cronbach alpha), content validity index (CVI) scores, construct validity, and inter-scale correlations were assessed.Results: Our sample consisted of 250 patients with PBT, most commonly glioma (46.8%) and meningioma (21.2%). All patients were able to understand the Urdu translations. The Cronbach alphas for the QLQ-C30 and the QLQ-BN20 were 0.860 and 0.880, respectively. The CVI scores for clarity and relevance were high for both the EORTC QLQ-C30 (0.98 and 0.96, respectively) and the QLQ-BN20 tool (0.81 and 0.95, respectively). The global QoL domain (EORTC QLQ-C30) showed significant positive correlations with resilience (r = 0.422), and significant negative correlations with depression (r = - 0.541) and anxiety (r = - 0.502). Strong inter-scale correlations were observed between physical functioning and insomnia (r = - 0.690) and role functioning and insomnia (r = - 0.641).Conclusion: Our study confirms the Urdu versions of the EORTC QLQ-C30 and QLQ-BN20 as valid clinical tools for the measurement of QoL in primary brain tumors patients within the cultural and socioeconomic context of Pakistan

A multidisciplinary approach to triage patients with breast disease during the COVID-19 pandemic: Experience from a tertiary care center in the developing world

Background: The COVID-19 pandemic has created a need to prioritize care because of limitation of resources. Owing to the heterogeneity and high prevalence of breast cancers, the need to prioritize care in this vulnerable population is essential. While various medical societies have published recommendations to manage breast disease during the COVID-19 pandemic, most are focused on the Western world and do not necessarily address the challenges of a resource-limited setting.Aim: In this article, we describe our institutional approach for prioritizing care for patients presenting with breast disease.Methods and results: The breast disease management guidelines were developed and approved with the expertise of the Multidisciplinary Breast Program Leadership Committee (BPLC) of the Aga Khan University, Karachi, Pakistan. These guidelines were inspired, adapted, and modified keeping in view the needs of our resource-limited healthcare system. These recommendations are also congruent with the ethical guidelines developed by the Center of Biomedical Ethics and Culture (CBEC) at the Sindh Institute of Urology and Transplantation (SIUT), Karachi. Our institutional recommendations outline a framework to triage patients based on the urgency of care, scheduling conflicts, and tumor board recommendations, optimizing healthcare workers\u27 schedules, operating room reallocation, and protocols. We also describe the Virtual Blended Clinics , a resource-friendly means of conducting virtual clinics and a comprehensive plan for transitioning back into the post-COVID routine.Conclusion: Our institutional experience may be considered as a guide during the COVID-19 pandemic, particularly for triaging care in a resource-limited setting; however, these are not meant to be universally applicable, and individual cases must be tailored based on physicians\u27 clinical judgment to provide the best quality care

Design and analysis of 300MW solar configuration and its comparison with Quaid-e-Azam solar park

Pakistan's recent energy crisis demands efficient utilization of renewable energy resources. The country, being richest with respect to solar potential, is experiencing a remarkable progress in power generation from Photovoltaic sources. Quaid-e-Azam Solar Park (QASP) is an example to improve the efficiency in term of Performance Ratio (PR) and energy injected into grid. In an attempt to further elevate the efficiency, the present work proposes configuration consisting of modules and inverters with low temperature coefficient. Based on meteorological data obtained from Meteonorm/NASA, performance of the proposed configuration is simulated in PVsyst and is then compared with that of QASP. Comparative results indicate that the proposed configuration annually improves PR by a factor of 3-4% while increasing the energy injected into the grid by 4.5 MW. It is anticipated that physical realization of the proposed configuration will improve energy yield

Recurrence free survival and patterns of recurrence in pancreatic ductal adenocarcinoma: An institutional perspective

Objective: To determine recurrence-free survival, patterns of loco-regional and systemic recurrence in patients with pancreatic adenocarcinoma.Methods: We conducted a retrospective Study at the Department of Oncology in a tertiary care Hospital, Karachi Pakistan from January 2013 to December 2019. We studied the sample size of 67 adults of 18 to 70 years of age, diagnosed with adenocarcinoma of the pancreas and treated primarily with curative intent. All patients received complete treatment for the primary disease in our institution and data was extracted retrospectively from the hospital\u27s medical record. Records were reviewed for recurrence of disease and patterns of loco regional and systemic recurrence. SPSS version 23 was used to analyze the data.Results: Out of 67 patients with pancreatic adenocarcinoma, 65 patients (97%) had a complete clinical and radiological response on the follow up scans performed at three months after the completion of curative treatment. However 2 (3%) patients had disease recurrence/residual disease on first follow up scan. Subsequent follow ups showed cancer recurrence was observed in 60 (89.5%) patients, out of which 10 (14.9%) had loco regional while 7 (10.5 %) had systemic only recurrence. Most of the patients (n= 43; 64.1%) had systemic as well loco regional recurrences. The most frequent site of distant metastasis was the liver (66 %). The median recurrence free survival was 09 months (IQR= 8, 15).Conclusion: This retrospective analysis highlights the patterns of recurrence after curative treatment of pancreatic ductal adenocarcinoma and indicates high recurrence rates which is expected for an aggressive disease like pancreatic carcinoma. By better understanding the patterns of recurrence, it can help in identifying subsets of patients with high risk of recurrence as well as in managing such patients more effectively

No difference in treatment outcome between patients with nodal versus extranodal diffuse large B-cell lymphoma

Background and aim: Diffuse large B-cell lymphoma (DLBCL) has been classified using various parameters, including the site of origin. Studies have reported conflicting outcomes when DLBLC patients were stratified according to the site of origin. This study aimed to investigate the response rate and survival outcomes in nodal versus extranodal DLBCL and compare the results to a region-matched study covering the 1988 - 2005 period. Methods: A single-center retrospective cohort study was conducted on all patients diagnosed with DLBCL and treated in a tertiary care hospital in Pakistan during 2014 - 2019. We calculated the mean and median for continuous variables and frequency and percentages for all categorical variables. Progression-free survival (PFS) and overall survival (OS) were calculated using Kaplan-Meier survival curves. A Cox proportional hazards model was used to determine the hazard ratio (HR) for OS. Results: Of the 118 patients, 49 patients (41.5%) had nodal disease and 69 patients (58.5%) were diagnosed with extranodal DLBCL. The majority of patients in the nodal and extranodal cohorts presented with Stages III and IV disease (73.4% and 62.3%, respectively). A complete response to (immuno) chemotherapy was achieved in 71.4% of nodal DLBCL patients and 65.2% of extranodal DLBCL patients. The 5-year PFS and median PFS in the entire cohort were 0.8% and 17 m, respectively. The PFS and median PFS in the nodal and extranodal DLBCL cohort were 0% and 1.4%, respectively, and 15 m and 19 m, respectively. The 5-year OS and median OS in the entire cohort were 16.1% and 19 m, respectively. The OS and median OS in the nodal and extranodal DLBCL cohort were 8.2% and 21.7%, respectively, and 19 m and 21 m, respectively. Multivariable linear regression revealed that the ABC phenotype (nodal, HR = 1.37, 95% CI = 1.37 - 3.20; extranodal, HR = 1.65, 95% CI = 1.46 - 3.17; GBC as reference) and double and triple hit DLBCL (nodal, HR = 1.29, 95% CI = 1.19 - 2.81; extranodal, HR = 1.87, 95% CI = 1.28 - 2.43; and non-expressors as reference) are independent negative predictors of OS. Conclusions: DLBCL incidence in the Karachi region has remained comparable but patient composition in the extranodal DLBCL cohort has shifted to predominantly advanced stage. Nodal and extranodal DLBCL were associated with similar PFS and OS profiles and first- and second-line treatment responses. Cell of origin and antigen expression status was independent negative predictors of OS, disfavoring the ABC phenotype and lesions with c-MYC and BCL2 and/or BCL6 overexpression. Relevance for patients: DLBCL is an aggressive type of non-Hodgkin\u27s lymphoma, however; patients respond well to standard systemic chemotherapy. Extranodal type of DLBCL patients tend to have more residual disease after first-line systemic chemotherapy, but physicians should keep in mind that the subsequent line treatment mitigates its negative impact on surviva