Capacity building for pediatric neuro-oncology in Pakistan- a project by my child matters program of Foundation S

Introduction

Initiated in June 2019, this collaborative effort involved 15 public and private sector hospitals in Pakistan. The primary objective was to enhance the capacity for pediatric neuro-oncology (PNO) care, supported by a My Child Matters/Foundation S grant.

Methods

We aimed to establish and operate Multidisciplinary Tumor Boards (MTBs) on a national scale, covering 76% of the population (185.7 million people). In response to the COVID-19 pandemic, MTBs transitioned to videoconferencing. Fifteen hospitals with essential infrastructure participated, holding monthly sessions addressing diagnostic and treatment challenges. Patient cases were anonymized for confidentiality. Educational initiatives, originally planned as in-person events, shifted to a virtual format, enabling continued implementation and collaboration despite pandemic constraints.

Results

A total of 124 meetings were conducted, addressing 545 cases. To augment knowledge, awareness, and expertise, over 40 longitudinal lectures were organized for healthcare professionals engaged in PNO care. Additionally, two symposia with international collaborators and keynote speakers were also held to raise national awareness. The project achieved significant milestones, including the development of standardized national treatment protocols for low-grade glioma, medulloblastoma, and high-grade glioma. Further protocols are currently under development. Notably, Pakistan's first pediatric neuro-oncology fellowship program was launched, producing two graduates and increasing the number of trained pediatric neuro-oncologists in the country to three.

Discussion

The initiative exemplifies the potential for capacity building in PNO within low-middle income countries. Success is attributed to intra-national twinning programs, emphasizing collaborative efforts. Efforts are underway to establish a national case registry for PNO, ensuring a comprehensive and organized approach to monitoring and managing cases. This collaborative initiative, supported by the My Child Matters/Foundation S grant, showcases the success of capacity building in pediatric neuro-oncology in low-middle income countries. The establishment of treatment protocols, fellowship programs, and regional tumor boards highlights the potential for sustainable improvements in PNO care.

Propranolol Promotes Bone Formation and Limits Resorption Through Novel Mechanisms During Anabolic Parathyroid Hormone Treatment in Female C57BL/6J Mice

Although the nonselective β-blocker, propranolol, improves bone density with parathyroid hormone (PTH) treatment in mice, the mechanism of this effect is unclear. To address this, we used a combination of in vitro and in vivo approaches to address how propranolol influences bone remodeling in the context of PTH treatment. In female C57BL/6J mice, intermittent PTH and propranolol administration had complementary effects in the trabecular bone of the distal femur and fifth lumbar vertebra (L₅ ), with combination treatment achieving microarchitectural parameters beyond that of PTH alone. Combined treatment improved the serum bone formation marker, procollagen type 1 N propeptide (P1NP), but did not impact other histomorphometric parameters relating to osteoblast function at the L₅ . In vitro, propranolol amplified the acute, PTH-induced, intracellular calcium signal in osteoblast-like cells. The most striking finding, however, was suppression of PTH-induced bone resorption. Despite this, PTH-induced receptor activator of nuclear factor κ-B ligand (RANKL) mRNA and protein levels were unaltered by propranolol, which led us to hypothesize that propranolol could act directly on osteoclasts. Using in situ methods, we found Adrb2 expression in osteoclasts in vivo, suggesting β-blockers may directly impact osteoclasts. Consistent with this, we found propranolol directly suppresses osteoclast differentiation in vitro. Taken together, this work suggests a strong anti-osteoclastic effect of nonselective β-blockers in vivo, indicating that combining propranolol with PTH could be beneficial to patients with extremely low bone density. © 2022 American Society for Bone and Mineral Research (ASBMR).

Relation of External Beam Radiotherapy Dose with Subclinical Hypothyroidism in Patients undergoing Adjuvant Neck Radiation after Surgery for Squamous Cell Carcinoma of Head and Neck

The objective of this study was to find out the radiation dose relationship with subclinical hypothyroidism in the postoperative head and neck squamous cell carcinoma patients, who underwent adjuvant neck external beam radiotherapy. It was a prospective cohort study done between June 2018 and January 2020. One hundred patients, who were fulfilling the criteria of histological proven postoperative head and neck squamous cell carcinoma (SCC) of AJCC 2018 stage I to III, were enrolled. Patients were irradiated for 50 Gy to the bilateral lower neck on a linear accelerator. A CT scan face and neck with contrast along with T3, T4, and TSH was done before and after 4 weeks of chemoradiotherapy. All the patients were kept on surveillance for every three months for one year with the above-mentioned CT scan and thyroid function test. Ten patients (10%) had received radiation dose less than 30 Gy to the thyroid gland, while 90 patients (90%) had received radiation dose >30 Gy to thyroid gland. After one year of completion of treatment, 27.8% patients (n = 25) developed subclinical hypothyroidism among those patients (n = 90), who received radiation dose more than 30 Gy to thyroid gland. None of the patients had subclinical hypothyroidism among those patients (n =10), who received radiation dose below 30 Gy to thyroid gland (p= 0.062). Key Words: Head and neck cancer, Neck radiotherapy, Subclinical hypothyroidism.

Concurrent Cisplatin-Based Chemoradiation in Squamous Cell Carcinoma of Cervix

OBJECTIVE

To evaluate the efficacy of cisplatin-based concurrent chemoradiation in squamous cell carcinoma of cervix and the frequency of acute toxicity.

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Department of Clinical Oncology, Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN), Karachi, from September 2010 to September 2011.

METHODOLOGY

Eighty patients with histologically proven squamous cell carcinoma of cervix were included. Patients were treated with concurrent chemoradiation. External beam radiation was delivered with 50 Gy whole pelvis along with 40 mg/m2 weekly cisplatin followed by brachytherapy three insertions of 6.5 Gy each, one week apart. Response to treatment was assessed using response evaluation criteria in solid tumours (RECIST) criteria at 4 weeks after treatment. Acute toxicity of chemoradiation was assessed using common toxicity criteria.

RESULTS

Out of the 80 patients, 8 patients were lost to follow-up. Remaining 72 patients aged 28 - 65 years with mean age of 48.03 ±8.9 years. Forty-eight patients (66%) were in stage II-B, 5 (7%) were in stage III-A, 7 (10%) were in stage III-B, and 12 (17%) were in stage IV-A. Overall response to treatment was 92%, in which 39 (54%) had complete response, and 27 (38%) had partial response while 6 (8%) show progressive disease. About 70% patients had diarrhea, 61.2% patients developed vomiting, 45.8% patients had dermatitis, 43% patients had vaginal mucositis, 40.3% had anemia, 13.9% patients had neutropenia, 27.8% patients had dysuria, and 22.2% patients had proctitis.

CONCLUSION

Cisplatin-based concurrent chemoradiation is an effective treatment in locally advanced stage of cervical cancer with manageable toxicity.

Diagnostic accuracy of Tc-99m-MIBI for breast carcinoma in correlation with mammography and sonography

OBJECTIVE

To evaluate the accuracy of 99mTc-MIBI scintimammography (SMM) in differentiating malignant breast cancer from benign breast mass and in detecting axillary lymph node metastasis in comparison with mammography and ultrasonography.

STUDY DESIGN

Comparative cross-sectional study.

PLACE AND DURATION OF STUDY

At the Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN), Karachi, from December 2006 to May 2007.

METHODOLOGY

A total of 28 patients (both with breast lumps or/and axillary masses) included were in the study. They underwent clinical examination, mammography and ultrasound imaging followed by planar SMM using a single head detector. All subjects received a 740-1110 MBq bolus injection of 99mTc-Sestamibi. 5-10 minutes and 1 hour delayed images were acquired after the injection. SMM scans were considered positive when there was focal area of increased radiotracer uptake. Qualitative (visual) as well as quantitative evaluation of scans was done and compared with ultrasound and mammography, taking histopathology as Gold standard. Sensitivity, specificity, negative and positive predictive values (NPV and PPV respectively) were determined.

RESULTS

There were 22 patients presenting with breast lesions (20 palpable, 2 non-palpable) and 6 patients with axillary lump. Scintimammography accurately predicted malignant lesions in the breast (sensitivity 93.3%, specificity. 71.4%, PPV 87.5%, NPV 83.3%, overall accuracy 86.4%) as well as in patients with axillary metastasis (sensitivity 100%, specificity 66%, PPV 75%, NPV 100%, accuracy 83%). A combination of scintimammography with any other imaging modality provides better results than a single test to detect breast cancer.

CONCLUSION

SMM has good diagnostic accuracy in the detection of breast cancer as well as in axillary metastasis in association with mammography and ultrasound.

Dual phase qualitative and quantitative 99mTc-MIBI scintimammography for predicting response to neoadjuvant chemotherapy in breast cancer

OBJECTIVE

To determine the role of dual phase 99mTc-MIBI scintimammography in predicting chemotherapeutic response in breast cancer.

STUDY DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

Karachi Institute of Radiology and Nuclear Medicine (KIRAN), from September 2004 to March 2005.

METHODOLOGY

Female patients with locally advanced breast cancer being planned for the anthracycline-based neoadjuvant chemotherapy were included in this study. All subjects received a 740 MBq bolus intravenous injection of 99mTc-MIBI. Ten minutes and 3 hours post-injection planar images were obtained in prone, lateral and supine positions using double head gamma camera. MIBI washout was scored as follows: >30% as a positive prognostic test (predicting a poor response to chemotherapy) and <30% as negative prognostic test (predicting a good response to chemotherapy). Qualitative analysis of MIBI scans was also performed and categorized as visual wash-out or no visual washout as apparent on the early and delayed images. The criterion for the good and bad response was the reduction of >50% and <50% in the tumour burden respectively. Accuracy analysis, Chi-square test and Wilcoxan sign rank test were applied.

RESULTS

There were 32 females (mean age: 46.3 years; median age 46 years; age range 33-65 years). Quantitative dual phase 99mTc-MIBI scintimammography was found to be a good predictor of chemotherapeutic response in breast cancer. These were true positive in 8 patients and true negative in 19 patients with sensitivity (Sens.) 72%, specificity (Spec.) 90%, Positive Predictive Value (PPV) 80%, Negative Predictive Value (NPV) 86.5%, p <0.03. Receiver Operating Characteristics (ROC) curve analysis demonstrates 30% as a cut-off value for the wash-out in quantitative dual phase MIBI for the prediction of the chemotherapeutic response. In comparison, qualitative scintimammography had Sens. 82%, Spec. 53%, PPV 29%, NPV 93% and p <0.38. Statistical difference was found between early and delayed uptake ratios in the responders and non-responders.

CONCLUSION

Quantitative dual phase 99mTc-MIBI scintimammography is a simple, reliable, non-invasive and effective tool for predicting the response to neoadjuvant chemotherapy. Furthermore, quantitative assessment is more precise than qualitative (visual wash-out) approach.

Papillary thyroid carcinoma formation in a thyroglossal cyst. A case report

Thyroglossal cyst rarely presents with carcinoma formation in the remnants of the thyroid gland. We report a 40 year old male with papillary thyroid carcinoma formation in a thyroglossal cyst. The patient underwent surgical intervention for the cyst. His pathology was positive for thyroid carcinoma and he underwent complete thyroidectomy with postoperative radioactive iodine treatment. His follow up revealed no evidence of recurrence.

Role of 99mTc-MIBI scintimammography and X-ray mammography in the diagnosis of locoregional recurrence of breast cancer

OBJECTIVE

To evaluate the utility of Tc- MIBI scintimammography in the loco-regional recurrence of breast cancer and its comparison with mammography.

METHODS

The study population comprised of 33 subjects (mean age, 44.9 +/- 14.1 years); evaluated for suspected loco-regional recurrence of breast cancer on clinical examination. All subjects received a 740-1000 MBq bolus IV injection of 99mTc-MIBI preferably in pedal vein. At 5-10 min and 60-90 min post injection planar images were obtained in prone lateral and supine anterior position using double head gamma camera. MIBI uptake was scored as follows: 1: as normal uptake (compared with contralateral side); 2: focal low intense uptake (equivocal); 3: focal high intense uptake (positive). Mammography was performed by two standard views of cranio-caudal and mediolateral oblique in 26 patients. All patients had either excision biopsy or fine needle aspiration cytology (FNAC) for tissue diagnosis.

RESULTS

Out of 33 patients, 21 had confirmed as recurrence on hiostopathology/cytology. Scintimammography was found true positive in 18 and true negative in 11 patients. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 85.7%, 91.7%, 94.7%, 78.6% and 87.8% respectively. In comparison, mammography was true positive in 9 and true negative in 6 patients with sensitivity of 52.9%, specificity, 66.7%, PPV 75%, NPV 42.9% and accuracy 57.7%.

CONCLUSION

Scintimammography has better diagnostic accuracy than mammography in the detection of loco-regional recurrence of breast cancer.

Assessment of viable myocardium by nitrate augmented 99mTc MIBI myocardial perfusion imaging

OBJECTIVE

To determine the efficacy of 99mTcMIBI with nitrate administration for the detection of viable myocardium in patients with MI.

METHODS

Thirty-five patients (31 men, 4 women; mean age 51.91 +/- 8.86 years, median = 50) with previous history of myocardial infarction (with mean duration of 11.50 +/- 11.4, median =4 months after MI) were included in the study. All patients underwent baseline rest and Nitroglycerine 99mTcMIBI myocardial perfusion imaging (2 day protocol). Fifteen out of 34 patients were also submitted for rest and redistribution TI-201 imaging (3 day protocol). The data were reconstructed in transaxial slices and then reoriented into short, vertical long and horizontal long axis slices. The images were divided into seven different segments for qualitative as well as semi quantitative analysis. The images were interpreted by two independent observers. The segments with tracer activity of more than 55% as compared to maximum, were considered as viable.

RESULTS

In the baseline study with 99mTcMIBI, 168/245 (68.57%) were viable segments and these were increased to 197 (80.40%) in the Nitrate MIBI study (p = 0.001 vs. baseline). Total 21 (60%) out of 35 patients demonstrated viable myocardium. The concordance for viable segments detection between Nitroglycerine MIBI and redistribution TI-201 imaging was found in 100 out of 105 segments (95.24%) for 15 patients, with significant kappa = 0.746 +/- 0.079 SE.

CONCLUSION

The data suggest that use of nitrate augmented 99mTcMIBI protocol in Cardiac SPECT imaging results in improved detection of viable but hypoperfused segments and achieves results similar to those from standard TI-201 rest and redistribution protocol.

Aggressive axillary evaluation and adjuvant therapy for nonpalpable carcinoma of the breast

While quadrantectomy or lumpectomy with axillary node sampling and dissection, or both, has been shown to be an equivalent alternative to modified radical mastectomy, some surgeons have begun to omit axillary dissection altogether in patients with extremely small tumors, believing that the axilla is unlikely to be involved. In reviewing the incidence of axillary involvement with 69 nonpalpable primary tumors in one community for nine years, 20 per cent of patients with invasive carcinoma had axillary involvement. In a four year review of the Connecticut Tumor Registry, we identified 137 instances of quite small invasive carcinoma of the breast that were 1 millimeter or less. Sixteen per cent of these patients had axillary involvement. The survival of patients with nonpalpable primary tumors and axillary involvement was no different than patients with palpable primary tumors and axillary involvement. Regardless of how small the primary tumor, the incidence of axillary disease is significant and failure to evaluate the axilla will result in understaging and inappropriate decisions about adjuvant therapy.