Resource Oriented Decision Making for Treatment of Metastatic Colorectal Cancer (mCRC) in a Lower-Middle Income Country: Egyptian Foundation of Medical Sciences (EFMS) Consensus Recommendations 2020

Purpose

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide and the second cause of cancer related mortality. Treatment options for patients with metastatic CRC (mCRC) expanded during the last two decades, with introduction of new chemotherapeutic and targeted agents. Egypt is a lower middle-income country; Egyptian health care system is fragmented with wide diversity in drug availability and reimbursement policies across different health care providing facilities. We report the results of consensus recommendations for treatment of patients with metastatic colorectal cancer developed by Egyptian Foundation of Medical Sciences (EFMS), aiming to harmonize clinical practice through structured expert consensus-based recommendations consistent with the national status. EFMS recommendations could be utilized in other countries with similar economic status.

Methods

EFMS recommendations were developed using a modified Delphi process, with three rounds of voting till the final recommendations were approved. A non-systematic review of literature was conducted before generating the provisional statements. Content experts were asked to vote on some recommendations in two different resource groups (restricted resources and non-restricted resources). External review board of experts from a low income and lower-middle countries voted on the applicability of EFMS recommendations in their countries.

Results

The current recommendations highlighted the discrepancy in health care between restricted and non-restricted resources with expected survival loss and quality of life deterioration. Access to targeted agents in first line is very limited in governmental institutions, and no access to agents approved for third line in patients who failed oxaliplatin and irinotecan containing regimens for patients treated in restricted resource settings.

Conclusion

Management of mCRC in developing countries is a challenge. The currently available resource-stratified guidelines developed by international cancer societies represent a valuable decision-making tool, adaptation to national status in each country based on healthcare system status is required.

Laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer: initial Egyptian experience at the National Cancer Institute

BACKGROUND

Laparoscopic gastrectomy has been used as a superior alternative to open gastrectomy for the treatment of early gastric cancer. However, the application of laparoscopic D2 lymphadenectomy remains controversial. This study aimed to evaluate the feasibility and outcomes of laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer.

RESULTS

Between May 2016 and May 2018, twenty-five consecutive patients with gastric cancer underwent laparoscopic D2 gastrectomy: eighteen patients (72%) underwent distal gastrectomy, four patients (16%) underwent total gastrectomy, and three patients (12%) underwent proximal gastrectomy. The median number of lymph nodes retrieved was 18 (5-35). A positive proximal margin was detected in 2 patients (8%). The median operative time and amount of blood loss were 240 min (200-330) and 250 ml (200-450), respectively. Conversion to an open procedure was performed in seven patients (28%). The median hospital stay period was 8 days (6-30), and the median time to start oral fluids was 4 days (3-30). Postoperative complications were detected in 4 patients (16%). There were two cases of mortality (8%) in the postoperative period, and two patients required reoperation (8%).

CONCLUSIONS

Laparoscopic gastrectomy with D2 lymphadenectomy can be carried out safely and in accordance with oncologic principles.

Clinicopathologic and prognostic significance of overexpression of her-2/neu and p53 oncoproteins in gastric carcinoma using tissue microarray

BACKGROUND

The aim of the study was to verify the frequency of the immunohistochemical overexpression of her-2/neu and p53 in gastric carcinoma and their relation to the other clinico-pathological features and the impact on survival rates.

PATIENTS AND METHODS

A total of 93 patients of gastric carcinoma, who had a potential curative surgery in the period from 2001-2007 and with representative paraffin blocks, and sufficient follow-up data were included in this study. They were arrayed and evaluated for protein marker overexpression using tissue microarray (TMA). Patients, tumor and treatment characteristics were collected from the patients' files. The possible prognostic significance of p53 and her-2/neu over expression and different clinico-pathological features on survival rates were explored.

RESULTS

Twenty four (25.8%) cases were her-2/neu and p53 positive. None of the examined clinico-pathologic factors had a significant relation to her-2/neu overexpression. p53 was overexpressed in intestinal type, 14/34 (41.2%), more than in diffuse type, 10/59 (16.9%), (p= 0.01). There was no relation between the overexpression of p53 and her-2/neu. The median survival period was 17.7 months. The survival rates at 12 months were 64.2%, 52.2%, 55.6% and 45.0% for overall (OS), local control (LC), metastasis free survival (MFS) and disease free survival (DFS) rates, respectively. Patients with advanced stages had a significantly lower OS and MFS. Age above 57 years was associated with significantly lower OS, LC, MFS and DFS. Patients who received radiotherapy had significantly higher OS, LC, MFS and DFS. None of the survival rates had been affected by the overexpression of p53, or her-2/neu.

CONCLUSION

Although, this study failed to show any prognostic effect of p53 and her-2/neu on survival rates, we may suggest that p53 overexpression may play a role in the pathogenesis of intestinal gastric adenocarcinoma. It could also demonstrate the significantly improved survival rates with adjuvant chemoradiation. Also, TMA is a useful technique for rapid identification of protein expression profiles using minimal samples from archived tissues.

Clinico-Pathological and Prognostic Significance of p53, Bcl-2 and Her-2/neu Protein Markers in Colorectal Cancer Using Tissue Microarray

BACKGROUND

The prognostic role of her-2/neu has been established in breast cancer but remains controversial in colorectal cancer (CRC). Widespread genetic mutations in colorectal carcinogenesis exist on chromosome 17. Her- 2/neu gene and the tumor suppressor gene p53 are both located on this chromosome. Bcl-2 protein prolongs survival of a variety of cells by blocking apoptosis. The aim of this study is to evaluate the relationship between the overexpression of p53, bcl-2 and her-2/neu protein markers and the clinico-pathologic characteristics of CRC, and their influence on survival rates.

PATIENTS AND METHODS

One hundred and four cases of CRC had paraffin blocks with representative tissue, and sufficient follow-up data. They were arrayed and evaluated for protein marker expression using tissue microarray (TMA).

RESULTS

Ten (9.6%), 35 (33.7%) and 27 (26%) of the patients were her-2/neu, p53 and bcl-2 positive, respectively. None of the examined clinico-pathologic factors had a significant relation with her-2/neu overexpression. Patients with +ve bcl-2 had a significantly higher mean age (52.4-/+13.3years) compared to 45.4-/+14.4 years for bcl-2 negative patients, p=0.03. Positive p53 was overexpressed in 20/44 (45.5%), 6/17 (35%), 9/43 (21%) cases of the colon, recto-sigmoid, and rectal sites, respectively, p=0.05. For the whole population, p53 overexpression had a significantly lower disease-free survival (DFS). For patients with Dukes' stage B, overexpression of p53 protein had a significant reduced overall survival (OS) p=0.04, metastasis free survival (MFS) p=0.004, and DFS p=0.01 rates. Expression of bcl-2 had a significantly better MFS p=0.001, while her-2/neu overexpression worsened the OS rate significantly, p=0.04.

CONCLUSION

This study recommends the application of TMA technique for its economic importance and reliable quick throughput. The results from this study also suggest that overexpression of p53, bcl-2, and her-2/neu protein markers appear to be useful in selecting a group of CRC patients with a worse prognosis and constitute potential candidates for adjuvant therapy. Key Words: Her-2/neu , p53 , Bcl-2 , Colorectal cancer , Tissue microarray , Prognostic factors.