Radiographic features predictive of recurrence and survival after surgical resection of perihilar cholangiocarcinoma

Objective

To study which radiographic features were associated with recurrence and adverse outcome in patients undergoing surgical resection of perihilar cholangiocarcinoma (PCCA), as well as to evaluate the imaging patterns that signify recurrence after the resection of PCCA.

Materials and methods

This study was conducted in a solitary tertiary center and utilized a retrospective, analytical, case-control design. The study population consisted of patients with pathologically confirmed PCCA who underwent surgical resection and were subsequently followed up from January 2009 to December 2017. A total of 77 patients were enrolled in the study and were categorized into two distinct groups, namely recurrent and non-recurrent. The analysis encompassed the examination of demographic data and recurrence patterns. Additionally, survival and multivariate analyses were employed to assess radiographic imaging data and surgical information.

Results

Seventy-seven patients diagnosed with PCCA based on pathological evidence were included in the study. Among the participants, there were 28 females and 49 males, with ages ranging from 41 to 81 years (mean age of 60.65 ± 7.66). A noteworthy finding was the recurrence rate of 65 % observed following surgical resection. The presence of regional lymph node (LN) metastasis, adjacent organ invasion, and surgical margin emerged as the three independent factors that exhibited a significant association with recurrence after post-operative resection (p = 0.023, p = 0.028, and p = 0.010, respectively). The patients with PCCA who experienced regional LN metastasis had a median overall survival (OS) of 22 months, which was significantly lower than the 46 months observed in those without regional LN metastasis (p < 0.018). Furthermore, the individuals with regional LN metastasis had a death rate that was 2.08 times higher than those without (p = 0.040). In addition, those with adjacent organ invasion had an OS duration of 21 months compared with 52 months in those without (p = 0.008), and the rate of death was 2.39 times higher (p = 0.018). Patients with an R1 resection margin had an OS duration of 36 months compared with 51.56 months in those with an R0 resection margin (p = 0.006), as well as a 2.13 times higher rate of recurrence (p = 0.010) and a 2.43 times higher mortality rate (p = 0.013).

Conclusion

The presence of regional LN metastasis, invasion of adjacent organs, and R1 resection margin were identified as distinct factors that are linked to both disease recurrence and reduced OS. Local recurrence, as well as the spread of cancer to distant organs such as the lungs and liver, were frequently observed patterns of recurrence. To enhance the precision of staging, prognosis, and treatment, the inclusion of periductal fat or invasion of adjacent organs should be considered in the staging system for PCCA.

High XB130 expression in renal cell carcinoma is strongly associated with poor prognosis

The aim of this study was to assess the prognostic value of XB130 expression in three major RCC subtypes, and its association with clinical outcomes and adverse clinicopathologic features. A total of 101 nephrectomy samples at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand, from 2007 to 2017 were included in the study. XB130 immunohistochemistry was performed on slides from a tissue microarray comprised of 71 clear cell RCCs, 23 papillary RCCs, and 7 chromophobe RCCs, and were scored using a Histoscore system on a 0-300 scale. High XB130 expression in clear cell RCC and papillary RCC patients was associated with poor prognosis (log-rank test, P = 0.013, and P = 0.001, respectively). WHO/ISUP grade (P = 0.001) and XB130 high expression (P = 0.019) were found to be independent risk factors for mortality in clear cell RCC using multivariate analysis. The high expression of XB130 in clear cell RCC patients was also associated with high WHO/ISUP grade (P = 0.011), distant metastasis (P = 0.036), TNM stage (P = 0.007), sarcomatoid/rhabdoid differentiation (P = 0.061), and urinary collecting system invasion (P = 0.002). Similarly, high XB130 expression (P = 0.038) was associated with poor prognosis among papillary RCC patients as well as with lymphovascular invasion (P = 0.022), TNM stage (P = 0.030), and sarcomatoid/rhabdoid differentiation (P = 0.044). Overall, our findings showed that high XB130 expression in clear cell RCC and papillary RCC patients are associated with a worse prognosis.

Mismatch Repair Deficiency Is a Prognostic Factor Predicting Good Survival of Opisthorchis viverrini-Associated Cholangiocarcinoma at Early Cancer Stage

BACKGROUND

The mismatch repair (MMR) system prevents DNA mutation; therefore, deficient MMR protein (dMMR) expression causes genetic alterations and microsatellite instability (MSI). dMMR is correlated with a good outcome and treatment response in various cancers; however, the situation remains ambiguous in cholangiocarcinoma (CCA). This study aims to evaluate the prevalence of dMMR and investigate the correlation with clinicopathological features and the survival of CCA patients after resection.

MATERIALS AND METHODS

Serum and tissues were collected from CCA patients who underwent resection from January 2005 to December 2017. Serum OV IgG was examined using ELISA. The expression of MMR proteins MLH1, MSH2, MSH6 and PMS2 was investigated by immunohistochemistry; subsequently, MMR assessment was evaluated as either proficient or as deficient by pathologists. The clinicopathological features and MMR status were compared using the Chi-square test. Univariate and multivariate analyses were conducted to identify prognostic factors.

RESULTS

Among the 102 CCA patients, dMMR was detected in 22.5%. Survival analysis revealed that dMMR patients had better survival than pMMR (HR = 0.50, p = 0.008). In multivariate analysis, dMMR was an independent factor for a good prognosis in CCA patients (HR = 0.58, p = 0.041), especially at an early stage (HR = 0.18, p = 0.027). Moreover, subgroup analysis showed dMMR patients who received adjuvant chemotherapy had better survival than surgery alone (HR = 0.28, p = 0.012).

CONCLUSION

This study showed a high prevalence of dMMR in cholangiocarcinoma with dMMR being the independent prognostic factor for good survival, especially in early-stage CCA and for patients who received adjuvant chemotherapy. dMMR should be the marker for selecting patients to receive a specific adjuvant treatment after resection for CCA.

Preoperative controlling nutritional status (CONUT) score is an independent prognostic factor in cholangiocarcinoma patients treated with hepatectomy

Background

Nutritional status is one of the important factors determining the short- and long-term outcomes of surgery in cancer. This study aimed to assess the prognostic role of preoperative controlling nutritional status (CONUT) score in intrahepatic cholangiocarcinoma (iCCA) patients.

Methods

A total of 101 iCCA patients who underwent hepatectomy between 2015 and 2018 at the Srinagarind Hospital, Khon Kaen University, were included in this retrospective study. Patients were classified according to the CONUT score. Univariate and multivariate analyses were performed to determine the correlation between clinicopathological features and overall survival.

Results

Patients were categorized into normal nutrition (n = 40 or 39.5%), mild (n = 54 or 53.5%), and moderate-severe malnutrition (n = 7). Patients with high CONUT scores had significantly shorter survival (HR 2.55, 95% CI 1.04-6.25, p = 0.04). In multivariable analysis, tumor size (HR = 2.58, p < 0.01), the growth pattern of mass forming combined with periductal (HR = 4, p < 0.01), lymph node metastasis (HR = 7.20, p < 0.01) and high CONUT score (HR = 4.71, p = 0.01) were independent factors for poor survival of iCCA patients.

Conclusion

The preoperative CONUT score is a simple prognostic factor to predict the outcomes of iCCA patients undergoing hepatectomy.

Programmed death‑ligand 1 expression in tumor cells and tumor‑infiltrating lymphocytes are associated with depth of tumor invasion in penile cancer

The present study aimed to demonstrate the proportion of the programmed death-ligand 1 (PD-L1) expression in penile cancer patients and the association with clinicopathological parameters. Formalin-fixed paraffin-embedded specimens were obtained from 43 patients with primary penile squamous cell carcinoma treated at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, between 2008 and 2018. PD-L1 expression was evaluated by the immunohistochemistry using an SP263 monoclonal antibody. PD-L1 positivity was defined as >25% tumor cell staining or >25% tumor-associated immune cell staining. The correlation between PD-L1 expression and clinicopathological parameters was analyzed. A total of eight of 43 patients (18.6%) were identified as positive for PD-L1 expression in tumor cells and tumor-infiltrating lymphocytes. In the PD-L1 positive group, there was a significant association with pathological T stage (P=0.014) with a higher percentage of PD-L1 positive tumors in T1 stage compared with T2-T4 stage. In this cohort, there was a trend towards longer survival in patients with positive PD-L1 expression (5-year OS: 75% vs. 61.2%, P=0.19). Lymph node involvement and the location of tumor at the shaft of penis were two independent prognostic factors for survival. In conclusion, the PD-L1 expression was detected in 18% of penile cancer patients and high expression of PD-L1 was associated with the early T stage.

Factors Associated with Bone Scintigraphy Positivity in Cholangiocarcinoma

Objective: To examine factors associated with bone scintigraphy (BS) positivity in cases with cholangiocarcinoma (CCA) to help assess appropriate utilization of BS in CCA patients. Material and Methods: This cross-sectional study enrolled CCA patients who underwent BS for detection of bone metastasis between January 2012 and July 2020. The BS images were reviewed by two nuclear medicine physicians to assess BS positivity. Factors including tumor location, T stage, regional lymph node metastasis, other distant metastases, and serum carbohydrate antigen 19-9 (CA19-9) were evaluated. Associations between covariates and positive BS were analyzed using bivariate and multiple logistic regressions. Results: Among 158 CCA patients, 70 (44.3%), 84 (53.2%), and 4 (2.5%) had positive, negative, and equivocal BS, respectively. Of all 70 positive cases, 50 cases (71.4%) had multiple metastatic lesions. The spine was the most common metastatic site (n=55, 78.6%). After exclusion of equivocal cases, 154 were included in the regression models. In bivariate logistic regression, the factors associated with BS positivity were intrahepatic tumor location (OR=2.18, p-value=0.039) and other distant metastasis (OR=2.08, p-value=0.028). Further analysis using multiple logistic regression showed only other distant metastasis was associated with positive BS (OR=2.66, p-value=0.008). Conclusion: There was a significant association between other distant metastasis and BS positivity in CCA patients. This factor should be considered as a clinical indication for requesting BS in this group of patients.

Systemic Treatment for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a diverse group of epithelial cancers that affect the biliary tree. The incidence of CCA is low in Western countries but significantly higher in endemic regions such as China and Thailand. Various risk factors contribute to the development of CCA. Recent studies have revealed molecular alterations in biliary tract cancers, providing insights into cholangiocarcinogenesis and potential targeted therapies. Surgical resection is the primary curative treatment for CCA. Adjuvant chemotherapy has been extensively studied, and some regimens have proven to be beneficial. Neoadjuvant chemotherapy has shown potential benefits in select cases, but its role remains controversial. In advanced stages, chemotherapy is the standard of care, and molecular profiling has identified potential targets such as FGFR, IDH1, HER2, and other tumor-agnostic therapies. Immunotherapy has demonstrated limited benefit in advanced CCA. This chapter provides an overview of the current evidence and ongoing research evaluating various chemotherapy regimens, targeted therapies, and immunotherapies across different stages of CCA.

Are calcium channel blockers related to lung cancer?

Background:

Calcium channel blocker (CCB) is a common antihypertensive agent for the treatment of hypertension. There are inconsistent data of an association of CCB and lung cancer in the literature. This study aimed to evaluate this association by a case-control design.

Methods:

The inclusion criteria were adult patients 18 years or over, diagnosed with hypertension, lung cancer or pulmonary tuberculosis, and presenting with one of the suggestive symptoms of lung cancer. Those who were pregnant or had a diagnosis of lung cancer or pulmonary tuberculosis prior to the diagnosis of hypertension were excluded. Diagnosis of lung cancer was made pathologically, while tuberculosis was made by positive acid-fast bacilli on sputum examination, sputum culture positive for Mycobacterium tuberculosis, or polymerase chain reaction positive for M. tuberculosis with a chest x-ray compatible with tuberculosis. Cases were those diagnosed with lung cancer, while controls were those diagnosed with tuberculosis. Factors associated with lung cancer were calculated by logistic regression analysis.

Results:

There were 178 patients who met the study criteria. Of those, 69 patients (38.8%) were in the case group. The lung cancer group had EGFR gene mutation in 21 patients (52.5%) and adenocarcinoma was the most common cell type of lung cancer (55 patients; 79.7%). There were two factors independently associated with lung cancer including dyslipidemia and family history of lung cancer.

Conclusions:

CCB was not associated with lung cancer in patients with hypertension but dyslipidemia and family history of lung cancer were independently associated with lung cancer in this setting.

Risk factors of left ventricular hypertrophy in obstructive sleep apnea

Obstructive sleep apnea (OSA) and left ventricular hypertrophy (LVH) are both related to major cardiovascular diseases. Previous studies have indicated that, compared with non-OSA, OSA is related to LVH with an odds ratio (OR) of 1.70 (95% CI: 1.44-2.00), particularly in patients with coronary artery disease. Meta-analysis has revealed that the severity of OSA is significantly associated with left ventricular mass compared with non-OSA controls. There is, however, limited data on the risk factors of LVH in patients with OSA. The present study aimed to assess the prevalence and clinical factors that are predictive of LVH in patients with OSA. A retrospective analysis of adult patients diagnosed with OSA who had undergone echocardiography was performed. LVH defined by echocardiography indicated an enlarged LV mass index. Clinical factors predictive of LVH were assessed using multivariate logistic regression analyses. An unadjusted OR and an adjusted OR with 95% confidence intervals (CI) were determined. During the study period, 130 patients met the study criteria, with an LVH prevalence of 27.69% (36 patients). The final predictive model of LVH comprised six factors: Age, sex, unrefreshed sleep, body mass index, systolic blood pressure and apnea-hypopnea index. Only age was independently associated with LVH, with an adjusted OR of 1.048 (95% CI: 1.002-1.096). The prevalence rate of LVH in patients with OSA was 27.69%. Older age was independently related to LVH in patients with OSA.

Artificial intelligence (AI) vs. human in hip fracture detection

Objective

This study aimed to assess the diagnostic accuracy and sensitivity of a YOLOv4-tiny AI model for detecting and classifying hip fractures types.

Materials and methods

In this retrospective study, a dataset of 1000 hip and pelvic radiographs was divided into a training set consisting of 450 fracture and 450 normal images (900 images total) and a testing set consisting of 50 fracture and 50 normal images (100 images total). The training set images were each manually augmented with a bounding box drawn around each hip, and each bounding box was manually labeled either (1) normal, (2) femoral neck fracture, (3) intertrochanteric fracture, or (4) subtrochanteric fracture. Next, a deep convolutional neural network YOLOv4-tiny AI model was trained using the augmented training set images, and then model performance was evaluated with the testing set images. Human doctors then evaluated the same testing set images, and the performances of the model and doctors were compared. The testing set contained no crossover data.

Results

The resulting output images revealed that the AI model produced bounding boxes around each hip region and classified the fracture and normal hip regions with a sensitivity of 96.2%, specificity of 94.6%, and an accuracy of 95%. The human doctors performed with a sensitivity ranging from 69.2 to 96.2%. Compared with human doctors, the detection rate sensitivity of the model was significantly better than a general practitioner and first-year residents and equivalent to specialist doctors.

Conclusions

This model showed hip fracture detection sensitivity comparable to well-trained radiologists and orthopedists and classified hip fractures highly accurately.

Efficacy, Safety, and Patient-Reported Outcomes of Atezolizumab Plus Bevacizumab for Unresectable Hepatocellular Carcinoma in Thailand: A Multicenter Prospective Study

PURPOSE

Atezolizumab plus bevacizumab treatment is a first-line therapy for unresectable hepatocellular carcinoma (HCC) worldwide. The efficacy, safety, and patient-reported outcomes (PROs) of HCC in Thailand have not yet been reported. This study aimed to evaluate the efficacy, safety, and PROs of atezolizumab plus bevacizumab.

MATERIALS AND METHODS

From September 2020 to August 2021, 30 patients with unresectable HCC who met the inclusion criteria of atezolizumab plus bevacizumab as first-line treatment were enrolled. Analysis was assessed for progression-free survival, overall survival, adverse events (AEs), and quality of life (QoL).

RESULTS

The median progression-free survival and overall survival periods were 6.7 and 10.2 months, respectively. The disease control rate was 63.3%. The frequent AEs were proteinuria, hypertension, and hepatitis. Serious AEs included gastrointestinal bleeding, but none of the patients died from serious AEs. The discontinuation rate was 23.3%, and the median number of treatment cycles was 10.5 cycles. In total, 23.3% of the patients continued treatment after 1 year of therapy. The global health status/QoL and physical function scores showed less deterioration at baseline than at 3 and 6 months (median scores = 76.7, 71.6, and 64.1 in QoL and 84.7, 79.6, and 79.0 in physical function, respectively). The HCC18 symptom score index data showed a slow progression of symptom scores from baseline to 3 and 6 months (12.7, 19.6, and 22.3, respectively).

CONCLUSION

This study demonstrates that atezolizumab plus bevacizumab is effective and has a safety profile comparable with that of previous studies as first-line therapy for unresectable HCC in a real-world setting and in Thai populations. Data on PROs also demonstrate benefits in terms of patients' QoL and symptoms.

Predictive models for Angiostrongylus cantonensis and Gnathostoma spinigerum infection in pathologically or serologically proved eosinophilic meningitis

OBJECTIVE

The two most common causes of eosinophilic meningitis (EOM) are the parasites: Angiostrongylus cantonensis and Gnathostoma spinigerum. This study aimed to evaluate whether clinical factors can predict either neuroangiostrongyliasis or gnathostomiasis in EOM patients.

MATERIALS AND METHODS

We included reports of patients with eosinophils in the CSF and either serological or pathological diagnosis of neuroangiostrongyliasis or gnathostomiasis published in 2014 or earlier and available on PubMed. Predictive clinical models were generated for neuroangiostrongyliasis and gnathostomiasis.

RESULTS

In total, 155 patients were included in the study, 24 in the gnathostomiasis group and 131 in the neuroangiostrongyliasis group. According to the separate models, factors associated with neuroangiostrongyliais were gender of male, Pila/Pomacea snail exposure, and headache, and independent factors for gnathostomiasis were weakness (adjusted odds ratio 50.8) and radicular pain (adjusted odds ratio 35.3). The combined model identified two independent factors for neuroangiostrongyliasis: weakness and radicular pain. The laboratory models revealed that xanthochromic CSF perfectly predicted both neuroangiostrongyliasis and gnathostomiasis. Two other predictive factors were blood eosinophilia and CSF eosinophils, which positively predicted gnathostomiasis (adjusted odds ratios of 1.13 and 1.08, respectively).

CONCLUSION

Clinical factors may be predictive of neuroangiostrongyliasis and gnathostomiasis in EOM.

Hypertensive crisis in patients with obstructive sleep apnea-induced hypertension

Background

Hypertensive crisis is an urgent/emergency condition. Although obstructive sleep apnea (OSA) in resistant hypertension has been thoroughly examined, information regarding the risk factors and prevalence of hypertensive crisis in co-existing OSA and hypertension is limited. This study thus aimed to determine prevalence of and risk factors for hypertensive crisis in patients with hypertension caused by OSA.

Methods

The inclusion criteria were age of 18 years or over and diagnosis of co-existing OSA and hypertension. Those patients with other causes of secondary hypertension were excluded. Patients were categorized by occurrence of hypertensive crisis. Factors associated with hypertensive crisis were calculated using multivariate logistic regression analysis.

Results

There were 121 patients met the study criteria. Of those, 19 patients (15.70%) had history of hypertensive crisis. Those patients in hypertensive crisis group had significant higher systolic and diastolic blood pressure at regular follow-ups than those without hypertensive crisis patients (177 vs. 141 mmHg and 108 vs. 85 mmHg; p value < 0.001 for both factors). After adjusted for age, sex, and Mallampati classification, only systolic blood pressure was independently associated with hypertensive crisis with adjusted odds ratio (95% CI) of 1.046 (1.012, 1.080).

Conclusions

The prevalence of hypertensive crisis in co-existing OSA and hypertension was 15.70% and high systolic blood pressure or uncontrolled blood pressure associated with hypertensive crisis in patients with OSA-associated hypertension.

Diagnostic and Prognostic Value of Circulating Cell-Free DNA for Cholangiocarcinoma

The analysis of cfDNA has been applied as a liquid biopsy in several malignancies. However, its value in the diagnosis and prognosis of cholangiocarcinoma (CCA) have not been well defined. We aimed to investigate the diagnostic and prognostic values of cfDNA level and tumor-specific mutation in circulating DNA (ctDNA) in CCA. The plasma cfDNA levels from 62 CCA patients, 33 benign biliary disease (BBD) patients and 30 normal controls were quantified by fluorescent assay. Targeted probe-based sequencing of 60 genes was applied for mutation profiling in 10 ctDNA samples and their corresponding treatment-naïve tissues. cfDNA levels in CCA were significantly higher than those in BBD and normal controls. We found that cfDNA levels at 0.2175 and 0.3388 ng/µL significantly discriminated CCA from healthy controls and BBD with 88.7 and 82.3% sensitivity and 96.7 and 57.6% specificity, respectively. cfDNA levels showed superior diagnostic efficacy in detecting CCA compared to CEA and CA19-9. ARID1A (30%), PBRM1 (30%), MTOR (30%), and FGFR3 (30%) mutations were the most common. Using nine frequently mutated genes in the ctDNA samples, the diagnostic accuracy of cfDNA sequencing was 90.8%, with 96.7% average sensitivity and 72.4% specificity. This study supports the use of cfDNA as a diagnosis and prognostic biomarker for CCA.

Improvement of allograft kidney biopsy yield by using a handheld smartphone microscope as an on-site evaluation device

Background

Smart lens is a magnifying device that turns the smartphone into a microscopic exploring instrument. It is a convenient and inexpensive tool as an on-site evaluation device for the kidney biopsy specimen. We demonstrate the benefit of using a handheld smartphone microscope compared to the standard procedure in allograft kidney specimens.

Material and methods

This was a cohort study of allograft kidney biopsies performed between June 2015 and November 2017 in Srinagarind Hospital, Khon Kaen University, Thailand. The clinical utility of the “Chula smart lens” applied to the smartphone as an on-site evaluation device was studied. Clinical data, diagnostic quality, and complications were retrospectively reviewed and compared between the smart lens group and the standard group.

Results

The study cohort consisted of 93 allograft kidney biopsies (standard:47, smart lens:46). The mean age was 40.6 (18–48) years, and 63 patients (67.7%) were male. By using the smart lens device, the number of obtained tissue cores was higher (3.5 vs 2.9, p = 0.019) and the inadequacy rate for diagnosis was significantly lower (7% vs 21.3%, p = 0.05).

Conclusion

Using a handheld smartphone microscope as an on-site evaluation device resulted in more positive glomeruli and diagnostic yield compared to the standard procedure.

Efficacy of Combination Docetaxel and Nintedanib in Advanced Non-Small Cell Lung Cancer in Thailand: A Multicenter Study

Introduction

The mainstay systemic treatment for non-oncogenic addictive advanced stage non-small cell lung cancer is chemotherapy. Anti-angiogenic agents are additive compounds that enhance disease control and lead to improvement of overall survival benefit. Recently PD-(L)1 blockage, a checkpoint inhibitor, has been adopted as another line of treatment. A sequential strategy to enhance the efficacy of combination docetaxel and nintedanib after immunotherapy, correlated with genomic mutation, has been explored.

Method

A retrospective cohort study of 56 patients from 8 centers in Thailand who received combination docetaxel and nintedanib via the Thai nintedanib Named Patient Use program was conducted. Demographic characteristics, treatment details, and treatment responses were retrieved from medical records.

Results

The majority of patients were male (62.5%) with adenocarcinoma subtype (88%). Thirty-five percent had sensitizing EGFR mutation. Combination docetaxel and nintedanib was given as second to fourth line of treatment. Median PFS of docetaxel/nintedanib was 5.6 months [95% CI 4.8-6.9]. Median OS of the entire cohort was 22.5 months [95% CI 20.2-31.1]. Among them, only four patients received this combination after immunotherapy which limited the validity of efficacy analysis. Median PFS of those four patients was 7.9 months [range 5.2-9.1] which was slightly higher than the remaining cohort (median PFS 4.5 months, 95% CI: 4.0-6.0, p-value 0.09). Among the adenocarcinoma subtype, a relapse-time of platinum-doublet chemotherapy of more than 6 months was solely indicated as a benefit of combination docetaxel/nintedanib treatment compared to the relapse-time of platinum-doublet chemotherapy of less than 6 months by multivariate HR of PFS 0.32 [95% CI: 0.14-0.68, p-value 0.003].

Conclusion

Combination docetaxel and nintedanib provided more benefit in relapse-time of platinum-doublet chemotherapy of more than 6 months in advanced stage adenocarcinoma lung cancer. Neither EGFR nor ALK alteration influenced the outcome of treatment.

Prevalence and Risk Factors of Obstructive Sleep Apnea in Hypertensive Emergency

Introduction:

Obstructive sleep apnea (OSA) is a common factor associated with hypertensive crises. There is limited evidence of prevalence and risk factors of OSA in hypertensive emergency.

Methods:

This study recruited adult patients who diagnosed as hypertensive emergency and tested for OSA. The study period was between July 2019 and January 2020. The patients were categorized as OSA and non-OSA groups by the evidence from polysomnography. Prevalence and risk factors for OSA were executed.

Results:

During the study, there were 52 eligible patients. Of those, 30 patients (57.69%) were diagnosed with OSA. The stepwise logistic regression analysis for predicting OSA had two remaining factors: body mass index and diastolic blood pressure. Only body mass index was independently associated with OSA with an adjusted odds ratio of 1.166 (95% confidence interval of 1.033, 1.316). The body mass index of 25.02 kg/m² gave sensitivity and specificity of 80.00% and 59.09%, respectively. The area under the receiver operating characteristic curve was 70.98%.

Conclusion:

OSA had high incidence rate in patients with hypertensive emergency. High body mass index was a predictor for OSA associated with hypertensive emergency.

Prevalence and factors correlated with hypertension secondary from obstructive sleep apnea

Background

In 2003, the JNC 7 reported obstructive sleep apnea (OSA) as a cause of secondary hypertension. The prevalence of OSA in hypertension ranges from 30-80%. There are limited data on the prevalence and risk factors of OSA in hypertensive patients. This study thus aimed to evaluate prevalence and clinical predictors of obstructive sleep apnea (OSA) in these patients.

Methods

This was a cross-sectional study and conducted at the hypertension clinic at Khon Kaen University’s Srinagarind Hospital, Thailand. We enrolled patients with hypertension treated at the clinic. OSA was defined as apnea-hypopnea index of 5 events/hour or over according to cardiopulmonary monitoring. Patients whose hypertension was due to any other causes were excluded. The prevalence of OSA was calculated and risk factors for OSA were analyzed using multivariate logistic regression.

Results

There were 726 hypertensive patients treated at the clinic. Out of those, 253 (34.8%) were randomly studied and categorized as either non-OSA (147 patients, 58.1%) or OSA (106 patients, 41.9%). There were four independent factors associated with OSA-induced hypertension: age, sex, history of snoring, and history of headache. Headache had an adjusted odds ratio (95% confidence interval) of 3.564 (95% confidence interval of 1.510, 8.411).

Conclusion

Age, male sex, history of snoring, and headache were independent predictors of hypertension caused by OSA.

Obstructive sleep apnea in patients with diabetes less than 40 years of age

BACKGROUND AND AIM

Obstructive sleep apnea (OSA) is known to be associated with diabetes mellitus (DM). Age is factor associated with different clinical features of OSA. There is limited data on clinical differences of young DM patients with OSA versus older DM patients with OSA. This study aimed to find clinical differences of DM coexisting with OSA between young age group and older.

METHODS

This is a retrospective, analytical study conducted at Srinagarind Hospital, Thailand. The inclusion criteria were adult patients diagnosed as DM with OSA. The study period was between January 2008 and December 2019. The diagnosis of OSA was made by presence of apnea hypopnea index (AHI) of ≥5 times/hour by polysomnography. Clinical predictors of OSA in young DM patients with age under 40 years were executed.

RESULTS

There were 56 patients in the young diabetes mellitus group, while there were 137 patients in the older diabetes mellitus group. The mean (SD) age of diagnosis for diabetes mellitus of both groups were 31.61 (6.53) and 54.68 (7.62) years, respectively. There were three independent predictors for DM in the young: atrial fibrillation (AF), body mass index (BMI) and glomerular filtration rate (GFR). Presence of AF perfectly predicted DM with OSA in age over 40 years. The adjusted odds ratio for BMI and GFR were 1.29 (95% CI 1.05, 1.58) and 1.06 (1.01, 1.13). The BMI over 32 kg/m² and GFR over 77 ml/min/m² gave sensitivity of 80.00%.

CONCLUSIONS

Young DM patients with OSA had more severe OSA, were more obese, had better renal function, and had fewer AF than the older ones.

How common is obstructive sleep apnea in young hypertensive patients?

Obstructive sleep apnea (OSA) has been reported to be a cause of hypertension in 40-80% of hypertensive patients. However, there are limited data available on the prevalence and predictors of OSA in young hypertensive patients. This study was conducted between October 2017 and October 2018. The inclusion criteria were (1) age over 18 and under 35 years (2) diagnosis with hypertension and (3) available respiratory polysomnography results. Patients with other causes of secondary hypertension were excluded. Predictors for OSA were analyzed using multivariate logistic regression analysis. There were 593 consecutive young patients who were diagnosed with hypertension during the study period. Of those, 475 (80.10%) were excluded due to their hypertension having renal causes (429; 90.32%), endocrine-related causes (40; 8.42%), or cardiovascular causes (6; 1.26%). Of the remaining patients (118 patients) who were eligible for the study, 105 (88.98%) of whom were diagnosed with OSA. The median age of the patients with OSA did not differ from those without OSA (29 vs 23 years; p value 0.065). There were two independent predictors for OSA: age and body mass index with adjusted odds ratios (95% confidence interval) of 1.280 (1.049, 1.562) and 1.258 (1.083, 1.462), respectively. In conclusion, after excluding other possible causes of hypertension, we found OSA to be highly prevalent in hypertensive patients younger than 35 years old. Increasing age and high body mass index were predictors for OSA in young hypertensive patients.

Are full-face helmets the most effective in preventing head and neck injury in motorcycle accidents? A meta-analysis

Motorcycles are the most common type of vehicle involved in traffic deaths in developing countries. Although helmets can provide protection against injury, there is limited evidence available regarding which type of helmet best protects against head and neck injuries in this setting. This review was conducted based on articles in the PubMed, Scopus, and Web of Science databases. We compared full-face helmets with other types of helmet with regard to head and neck injury prevention in road accidents involving motorcyclists. Of 702 studies, six were eligible with a total of 6,529 participants. When compared with partial and open helmets, the odds ratio of full-face helmets was 0.356 (95% CI of 0.280, 0.453) and 0.636 (95% CI of 0.453, 0.894), respectively, for reduction of head and neck injuries. In conclusion, full-face helmets reduced head and neck injuries in motorcycle accidents to a greater extent than other types of helmet. Policy makers should recommend that motorcyclists use full-face helmets.

Role of Inhaled Corticosteroids for Asthma Exacerbation in Children: An Updated Meta-Analysis

Background:

Several studies showed that inhaled corticosteroids (ICS) may be a potential treatment in acute asthma exacerbation in children. This study was an update meta-analysis on the roles of ICS in the management of acute asthma exacerbation in children presenting to the hospital.

Materials and Methods:

Published articles with key words of ICS for asthma exacerbation, asthma attacks, and acute asthma in children aged under 18 years in the hospital setting with outcome of hospital admission between 2009 and 2018 were enrolled. The databases used in this study were Medline, Scopus, and Web of Science. Odds ratio of comparison between ICS and other treatments on hospital admissions was calculated.

Results:

There were 311 eligible studies met the searching criteria; seven eligible studies for the analysis; comprised of three meta-analysis and four added studies. The ICS had a significant reduction in hospital admission compared with placebo in overall with odds ratio of 0.63 (95% confidence interval [CI]: 0.41–0.96) and in moderate-to-severe group with odds ratio of 0.17 (95% CI: 0.05–0.51). Comparing with systemic corticosteroid (SC), ICS had significantly lower hospital admissions overall and in mild-to-moderate group with odds ratios of 0.63 and 0.26, respectively. The combination of ICS and SC had odds ratio of 0.75 (95% CI: 0.57–0.99) over SC in moderate-to-severe asthma exacerbation.

Conclusions:

ICS significantly reduced hospital admission in asthma exacerbation in children. It may be used alone for mild-to-moderate asthma exacerbation and combination with SC for moderate-to-severe asthma exacerbation.

Prognostic Factors for Penile Cancer and Survival in Response to Multimodality Therapy

Purpose

To report treatment outcomes of penile cancer in a single institution in Thailand and to identify prognostic factors for survival, highlighting the crucial role of multi-modality treatment (MMT).

Patients and Methods

Squamous cell carcinoma of penis patients who were treated at Srinagarind hospital between 2007–2015 were retrospectively analyzed. Clinical and pathological data were retrospectively reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method and data were compared using the Log rank test. Cox regression analysis of factors affecting survival was conducted.

Results

A total of 70 patients were identified with a median follow-up of 69.4 months. Twenty-eight patients (40%) presented with early-stage (stage I or II), whereas 42 patients (60%) were stage III or IV disease. The median OS was 29.3 months (Interquartile range 10.5 months - not reached) for the entire cohort. Nodal involvement was the only factor identified from the multivariate model with the adjusted HR or 5.74 (95% CI 2.52–13.04). For patients with stage IIIB/IV, multi-modality treatment (MMT) resulted in longer survival when compared with surgery alone (HR 0.37; 95% CI 0.16–0.90).

Conclusion

Patients with penile cancer in Thailand presented with younger age and more locally advanced stage. Nodal involvement is the single poor prognostic factor for OS and MMT was associated with longer survival in stage IIIB/IV disease.

Predictors of chronic kidney disease in obstructive sleep apnea patients

Introduction

Obstructive sleep apnea (OSA) is a common condition in patients with chronic kidney disease (CKD). It may worsen renal function in CKD patients and is associated with uncontrolled blood pressure. Although OSA is found in up to 80% of CKD patients, there are limited data available on its clinical features in patients with and without CKD.

Objective

This study aimed to identifying the differences in the clinical characteristics of OSA between CKD and non-CKD OSA patients and determine the clinical predictors for CKD in OSA patients.

Methods

This was a retrospective study conducted at Khon Kaen University's Srinagarind Hospital in Thailand between July and December 2018. The inclusion criteria were diagnosis with OSA via polysomnography and having undergone laboratory tests for CKD. Obstructive sleep apnea is diagnosed according to the apnea-hypopnea index (AHI) as experiencing ≥5 events/hour, while CKD diagnosed based on the KDOQI guidelines. Eligible patients were divided into two groups: OSA with CKD and OSA without CKD. Predictors of CKD in OSA patients were analyzed using multivariate logistic regression analysis.

Results

During the study period, there were 178 OSA patients who met the study criteria, 88 (49.44%) of whom were in the OSA with CKD group. Both age and body mass index were comparable between OSA patients with CKD and those without (age: 59 and 57 years, respectively; body mass index: 30 and 29 kg/m², respectively. There were three significant factors that differed between those with and without CKD group including systolic blood pressure (147 vs 135 mmHg), proportion of patients with diabetes (55% vs 34%), and proportion of patients with Mallampati scores of 3-4 (73% vs 39%). There were three independent predictors for OSA in patients with CKD: female sex, high systolic blood pressure, and Mallampati score of 3 or 4, with adjusted odds ratios (95% confidence interval) of 4.624 (1.554, 13.750), 1.060 (1.020, 1.101), and 2.816 (1.356, 5.849), respectively. The Hosmer-Lemeshow chi-square statistic of the predictive model was 6.06 (p 0.640). Systolic blood pressure of more than 130 and 150 mmHg resulted in sensitivity of 84.21% and specificity of 81.40%, respectively.

Conclusions

Female sex, high systolic blood pressure, and Mallampati score of 3-4 were suggestive of OSA with CKD. Obstructive sleep apnea patients with one or more of these predictors may have a high risk of CKD.

Crizotinib-Associated Renal Cysts in Anaplastic Lymphoma Kinase-Positive Lung Cancer Patients: A Single-Center Experience

Crizotinib is an anaplastic lymphoma kinase (ALK) inhibitor that was approved for ALK-harboring lung cancer. There have been reports about the development and progression of renal cysts from crizotinib. We report a series of 3 cases of crizotinib-associated renal cysts in patients admitted to our institution, with different kinds of presentation. A monitor for complex renal cysts is warranted in patients receiving crizotinib.

Perioperative outcomes in elderly patients undergoing nephrectomy for renal cell carcinoma

Purpose

To determine if age should be considered a relative contraindication to surgery for safety reasons.

Methods

Renal cell carcinoma (RCC) patients who underwent nephrectomy from January 2007 to December 2017 were analyzed retrospectively. Patients were grouped into age<65 and age≥65 years. The demographic data, surgical outcomes, complication, hospital stay, blood loss, and survival were compared between the two groups.

Results

A total of 101 patients were included; 74 in the younger group, and 27 in the older group. Compared to the young group, lower BMI, higher anemia, higher ASA grade, and comorbidities were frequent in the elderly. The operative time, blood loss, and renal function decline were comparable between two age groups. The complication rates in the older and younger group were 22% and 12%, respectively. The survival time was shorter in older patients compared to the younger ones; hazard ratio 2.25; 95%CI 1.08–4.69, p-value=0.031.

Conclusion

Nephrectomy in elderly patients is safe and feasible and preoperative assessment along with diligent postoperative care may further increase survival. Age alone cannot be regarded as a contraindication for nephrectomy in RCC.

Perception of a "good death" in Thai patients with cancer and their relatives

Background

Understanding the perceptions regarding what constitutes a "good death" among cancer patients and their families could help healthcare teams to ensure proper palliative and supportive care.

Objectives

To demonstrate and compare the wishes cancer patients and the perceptions of their relatives regarding end-of-life care, and to identify factors associated with patients' preferences regarding place of death.

Methods

A sample of cancer patients and their relatives who attended the Srinagarind Hospital (Thailand) oncology clinic or day chemotherapy from September 2017 to August 2018 were enrolled. Questionnaires were given to the participants, in which the patients were asked to respond based on their own end-of-life preferences, and relatives were asked to imagine how the patients would respond to the questions.

Results

One hundred eighty pairs of patients and relatives were recruited. Respondents in both groups placed importance on place of death, relationship with family, physical and psychological comfort, and relationship with the medical staff. Both groups generally agreed with the statements on the questionnaire (10/13 statements). Relatives underestimated the preferences of the patients in 3 areas: "not being a burden to others," "preparation for death," and "physical and psychological comfort." Being married (adjusted odds ratio (AOD) 6.4, 95%confidence interval (CI) 1.1,36.5), having had more than 6 years of education (AOD 6.5, 95%CI 1.8,23.7), having lung cancer compared to colon cancer (AOD 12, 95%CI 1.2,118.7), duration after cancer diagnosis (AOD 0.9, 95%CI 0.93,0.99), previous hospital admission (AOD 5.7, 95%CI 1.5,21.2), and life satisfaction (AOD 17.6, 95%CI 2.9,104.9) were factors associated with preference for home death.

Conclusion

Thai cancer patients and their relatives indicated similar preferences with regard to what constitutes a good death and patients' wishes for their end-of-life period. However, the patients' relatives underestimated the importance patients placed on statements in three domains. Factors that influenced a preference for a home death were identified.

An ecological study of eosinophilic meningitis caused by the nematode, Angiostrongylus cantonensis (Chen, 1935) (Nematoda: Metastrongylidae)

Climate change and other weather factors are associated with several infectious diseases, but are rarely reported as being associated with nematode infection. Eosinophilic meningitis (EOM) is an emerging disease worldwide caused by the nematode, Angiostrongylus cantonensis. It is transmitted through various agents such as snails and slugs. Temperature and rainfall are associated with snail population. There have been no previous studies on the relationship between weather and EOM. This was an ecological study. Numbers of EOM patients and weather data in Thailand's Loei province from 2006 to 2017 were obtained using a national database. A Spearman correlation was used to explore the relationship between EOM and weather variables. We developed a Poisson time series model combined with a distributed lag model (DLM) for estimating the effects of weather on EOM. We also created an autoregressive integrated moving average with exogeneous variable (ARIMAX) model for predicting future EOM cases over the following 12 months. There were 1126 EOM patients in the study. Among several weather factors, wind was significantly negatively correlated with the number of EOM patients (r_s: -0.204, 95% CI: -0.361 to -0.058; p value: 0.014). The ARIMAX(3, 0, 0) model with wind speed as a variable was appropriate for predicting the number of EOM patients. The predicted and actual numbers of EOM patients in 2018 were highly concordant. In conclusion, wind speed is significantly negatively correlated with the number of EOM patients.

Health Insurance and Colorectal Cancer Survival in Khon Kaen, Thailand

Background: Evidence from healthcare studies demonstrates that patients’ health insurance affects service accessibility and the outcome of treatment. However, assessment on how colorectal cancer survival relates to health insurance is limited. Objective: The study examined the association between health insurance and colorectal cancer survival in Khon Kaen, Thailand. Methods: The retrospective cohort study was conducted with 1,931 colorectal cancer patients from Khon Kaen cancer registry between January 1, 2003 and December 31, 2012, and was followed-up until December 31, 2015. Relative survival was used to estimate the survival rate. Cox proportional hazard regression was used to estimate the relationship between health insurance and colorectal cancer survival, represented with the hazard ratio. Result: Most of the participants were males, and the median age was 62 years. The median survival time was 2.25 years (95% CI: 2.00-2.51). The five-year observed survival rate and relative survival rate were 36.87 (95% CI: 34.66-39.08) and, 42.28 (95% CI: 39.75-44.81), respectively. The factors that showed significant associations with poorer survival after adjustment for gender and age were non-surgical treatments (HRadj=1.88;95%CI=1.45-2.45), advanced stage (III+IV) (HRadj=2.50; 95%CI=2.00-3.12), histological grading in poorly differentiated (HRadj=1.84; 95%CI=1.32-2.56), and Universal Coverage Scheme (HRadj=1.37;95%CI=1.09-1.72). Conclusion: The survival of colorectal cancer patients in the Universal Coverage Scheme was likely to be poorer than in the Civil Servant Medical Benefit Scheme. This indicates an urgent need for a national program for colorectal cancer screening in the general population and access to health insurance.

Frailty Syndrome in Biliary Tract Cancer Patients: Prevalence and Associated Factors

Background:

Frailty, a risk of unfavorable outcomes from disability to adapt to stressors, is common in the elderly but could occur in younger patients with cancer. This study focused on the prevalence of frailty in biliary tract cancer (BTC) and associated factors.

Methods:

A total of 75 BTC patients receiving chemotherapy from January 2016 to September 2017 were enrolled. Frailty was diagnosed by the FRAIL (Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight) scale. Univariate and multivariate regression analyses were used to analyze factors associated with frailty.

Results:

The prevalence rates of frailty and pre-frailty were 12% (9 cases) and 60% (45 cases). According to multivariate logistic analysis, three factors were associated with frailty, including old age, high body mass index (BMI), and history of liver surgery. The adjusted odds ratios of the factors were 1.12 (95% CI: 1.01, 1.24), 1.28 (95% CI: 1.01, 1.64), and 6.16 (95% CI: 1.11, 34.16), respectively.

Conclusion:

Frailty is not uncommon in BTC patients. Old age, high BMI, and history of liver surgery are important risk factors for frailty.

Thai medical students' attitudes regarding what constitutes a "good death": a multi-center study

BACKGROUND

Few studies exist regarding the perception of medical students toward older adults' wishes during their end-of-life period. Better understanding of students' perceptions regarding this topic could help improve palliative education. The purposes of this study were to examine the perceptions of medical students regarding what constitutes a "good death" and to demonstrate the factors associated with the necessary care decisions in older patients.

METHODS

This is a cross-sectional study. A questionnaire was developed and given to all of the medical students at two medical schools in Thailand (Siriraj and Srinagarind Hospital) from September 2017 to February 2018. They were asked to response to the questions by imagining how older people would think, and their preferences regarding care at the end-of-life period. The anonymous questionnaires were collected and analyzed.

RESULTS

A total of 1029 out of 2990 surveys were returned (34.4%). A minority of the sixth-year medical students rated themselves as being knowledgeable about palliative care (11.3%). According to the survey, desire to have spiritual needs met and have their loved ones present were the most important conditions that contributed to a "good death". Factors associated with reluctance to receive prolonged treatment were female sex (adjusted odds ratio (AOR 1.39), being in the clinical years of training (AOR 1.92), self-rated good health (AOR 1.45), and prior experience of watching someone dying (AOR 1.61). Enrollment in Srinagarind medical school (AOR 2.05), being a clinical student (AOR1.91), and being dissatisfied with life (AOR 1.78) were independent factors related to preference for home death.

CONCLUSIONS

Most medical students signified understanding of concepts of geriatric palliative care but felt that they had insufficient knowledge in this area. Multiple factors related to decision regarding the care that was required were identified. Medical schools should consider this information to improve geriatric palliative medical education in undergraduate training.

Comparison of Thai older patients' wishes and nurses' perceptions regarding end-of-life care

BACKGROUND

Achieving a "good death" is a major goal of palliative care. Nurses play a key role in the end-of-life care of older patients. Understanding the perceptions of both older patients and nurses in this area could help improve care during this period.

OBJECTIVES

To examine and compare the preferences and perceptions of older patients and nurses with regard to what they feel constitutes a "good death."

RESEARCH DESIGN

A cross-sectional study.

PARTICIPANTS AND RESEARCH CONTEXT

This study employed a self-report questionnaire that asked about various options for end-of-life care. It was distributed to older patients who attended the outpatient clinic of internal medicine and nurses who worked at two medical schools in Thailand from September 2017 to February 2018. Patients were asked to respond to the questions as if they were terminally ill, and nurses were asked to imagine how older patients would answer the questions.

ETHICAL CONSIDERATION

Approval from Institutional Review Board was obtained.

FINDINGS

A total of 608 patients and 665 nurses responded to the survey. Nurses agreed with concepts of palliative care, but they rated themselves as having poor knowledge. The patient respondents felt that it was most important that they receive the full truth about their illnesses (29.2%). The nurses thought the most important issue was relief of uncomfortable symptoms (25.2%). On seven out of the 13 questions, nurses overestimated the importance of the relevant issue to patients and underestimated the importance on one question (p < 0.05).

DISCUSSION

Both nurses and older patients signified concepts of palliative care, but nurses felt that they lacked adequate knowledge. Nurses estimated that patients would have positive attitudes toward autonomy and the closure of life affairs to a significantly greater degree than the patient respondents.

CONCLUSIONS

We recommend that palliative care education be improved and that steps be taken to allow for more effective nurse-patient communication with regard to the patients' end-of-life wishes.

Bone metastasis from cholangiocarcinoma mimicking osteosarcoma: A case report and review literature

Cholangiocarcinoma is an aggressive tumor of the hepatic biliary system and it commonly spreads to the regional lymph nodes, liver and lungs. However, bone metastasis from cholangiocarcinoma is rare compared with other tumors. We herein present the case of a 61-year-old Asian woman who presented with pain in the right scapular area. Magnetic resonance imaging revealed bone destruction and an adjacent soft tissue mass at the right scapula. The findings on computed tomography imaging were compatible with cholangiocarcinoma. Bone biopsy was performed and the diagnosis of cholangiocarcinoma with bone metastasis was confirmed. The survival time was 10 months, despite administration of palliative radiotherapy and chemotherapy. Therefore, bone metastasis from cholangiocarcinoma should be considered as a differential diagnosis in patients who present with an osteolytic bone lesion and a liver mass.

The impact of skeletal muscle mass on survival outcome in biliary tract cancer patients

Low skeletal muscle mass is frequently observed in cancer patients and is known to be a poor prognostic factor for survival outcomes. The purposes of our study were to determine the prevalence of sarcopenia and its relation to mortality in biliary tract cancer. Body composition measurements (skeletal muscle index, total fat mass, bone mineral content) were evaluated by using dual-energy x-ray absorptiometry in 75 biliary tract cancer patients before chemotherapy. Muscle strength was measured by handgrip strength and gait speed. Overall survival and its associated factors were determined. The mean appendicular muscle mass was 17.8±2.7 kg in men and 14.0±2.1 kg in women (p < 0.05). Sarcopenia was diagnosed in 46 patients (61.3%) and higher proportion of men was classified as sarcopenia than women (69.0% vs 35.3%, p < 0.05). Multivariable analysis adjusted for chemotherapy regimen and age revealed that high appendicular muscle mass independently predicted better survival outcomes (HR 0.40; 95% CI, 0.18 to 0.88; p = 0.023). Sarcopenia is common in biliary tract cancer patients and low appendicular muscle mass was associated with poor survival outcome.

Breast Cancer Incidence Trends and Projections in Northeastern Thailand

BACKGROUND

The northeast has the lowest incidence of breast cancer of all regions in Thailand, although national rates are increasing. The heterogeneity in subnational trends necessitates a comprehensive evaluation of breast cancer incidence trends and projections to provide evidence for future region-specific strategies that may be employed to attenuate this growing burden.

METHODS

Joinpoint regression and age-period-cohort modeling were used to describe trends from 1988-2012. Data was projected from three separate models to provide a range of estimates of incidence to the year 2030 by age group.

RESULTS

Age-standardized rates (ASRs) increased significantly for all women from 1995-2012 by 4.5% per year. Rates for women below age 50 increased by 5.1% per year, while women age 50 years and older increased by 6% per year from 1988-2012. Projected rates show that women age 50 years and older have the largest projected increase in ASRs by 2030 compared to younger women and all women combined.

CONCLUSIONS

Breast cancer trends in Khon Kaen are presently lower than other regions but are expected to increase and become comparable to other regions by 2030, particularly for women ages 50 years and older.

Outcomes of multidisciplinary treatment in penile cancer: Experience from Thailand

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Background: Penile cancer is relatively more common in Thailand compared to western countries. We report multidisciplinary treatment outcomes of penile squamous cell carcinoma at a regional center in northeast of Thailand. Methods: Using an institutional database, a total of 68 patients with squamous cell carcinoma of penis treated during 2009-2015 were identified. Patient demographics, pathological data, and treatment modality were reviewed. Survival data was calculated using the Kaplan-Meier method. Results: Median age was 53 years (25-89 years) and the median follow-time was 2.7 years. At presentation, 39 patients (57.4%) were node positive, and 9 (13.2%) had metastatic disease. Management was penile preserving surgery in 13 patients, partial penectomy in 36 patients, total penectomy in 15 patients, and palliative with radiation and/or chemotherapy in 4 patients. The 3-year overall survival for patients with N0-1 and N2-3 was 86% and 35% respectively. For those with high risk (N2/N3) non-metastatic disease, multimodality treatment improved overall survival significantly compared with surgery alone (13.7 mo vs 8.6 mo; HR 0.32, p-value = 0.04) Conclusions: Patients present with locally advanced disease had a poor prognosis. Multidisciplinary management improved overall survival N2/N3 patients.

Programmed Death-Ligand 1 (PD-L1) Expression Associated with a High Neutrophil/Lymphocyte Ratio in Cholangiocarcinoma

Background: Effective treatments for cholangiocarcinoma (CCA) are still lacking. There are promising results of checkpoint inhibitor programmed cell death ligand-1 (PD-L1) activities in early phase trials. This study aimed to investigate the expression of PD-L1 and its relation to possible treatments for CCA. Methods: Formalin-fixed paraffin-embedded tumor samples from 46 patients with cholangiocarcinoma were retrieved. PD-L1 expression was evaluated by immunohistochemistry using anti-PD-L1 antibody, clone 5H1. A PD-L1 positive response on tumor cells was defined as >1% of tumor cell membranes stained. The association between PD-L1, clinico-pathological characteristics was analyzed using Fisher’s exact test, and survival analysis was done with the Cox regression model. Results: Out of 46 samples, 32 (70%) had positive PD-L1 expression in tumor cell membranes. The median level of PD-L1 expression was 1.75% (0-34.7). PD-L1 expression was significantly associated with stage IV disease (OR 3.98, p=0.046) and a high neutrophil/lymphocyte ratio (OR 5.36, p=0.018). PD-L1 positivity was associated with worse overall survival compared with those with a PD-L1 negative tumor but did not reach a level of significance (7.2 vs. 7.9 months, p=0.32). Conclusion: PD-L1 is widely expressed in CCA but was not predictive for overall survival. PD-L1 positivity was (7.2 and 7.9 months, p=0.32). Significantly associated with stage IV disease and a high neutrophil/lymphocyte ratio.

Frailty syndrome in ambulatory patients with COPD

Frailty is a state of increased risk of unfavorable outcomes when exposed to stressors, and COPD is one of the several chronic illnesses associated with the condition. However, few studies have been conducted regarding the prevalence of COPD and its related factors in Southeast Asia. The objectives of this study were to determine the prevalence of frailty in COPD patients and to identify the associated factors in these populations. A cross-sectional study of COPD patients who attended a COPD clinic was conducted from May 2015 to December 2016. Baseline characteristics were collected, and the diagnosis of frailty was based on the FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) scale. Descriptive statistics were used to analyze baseline data. Factors associated with frailty were analyzed using univariate and multivariate regression analyses. The results showed that the prevalence rates of frailty and pre-frailty were 6.6% (eight out of 121 cases) and 41.3% (50 out of 121 cases), respectively, among COPD patients. Fatigue was the most common component of the FRAIL scale that was found more frequently in frail patients than in non-frail patients (odds ratio [OR] 91.9). Factors associated with frailty according to multivariate analyses were comorbid cancer (adjusted OR [AOR] 45.8), at least two instances of nonelective admission over the past 12 months (AOR 112.5), high waist circumference (WC) (AOR 1.3), and presence of sarcopenia (AOR 29.5). In conclusion, frailty affected 6.6% of stable COPD patients. Cancer, two or more instances of nonelective hospitalization over the past 12 months, high WC, and presence of sarcopenia were associated with frailty. Early identification and intervention in high-risk patients is recommended to prevent or delay the adverse outcomes of frailty.

Acquired factor VII deficiency associated with synovial sarcoma

Background: Acquired factor VII (FVII) deficiency mostly results from liver disease or vitamin K antagonists. Isolated acquired FVII deficiency is a rare event, and only a few cases have been reported. To our knowledge, this is the first reported case of synovial sarcoma associated with FVII deficiency.

Objective: To describe our findings in a 20-year-old man, who presented with hemoptysis, weight loss, and later developed a suprascapular mass.

Methods: A review of the medical record of the patient plus a comparison with the literature was conducted.

Results: A biopsy from a suprascapular mass was made and the histopathological diagnosis of the tumor was confirmed as synovial sarcoma. Initial studies indicated a normal activated partial thromboplastin time and a prolonged prothrombin time. The FVII level was 31%. No evidence of a FVII inhibitor or inactivator was demonstrated. Prothrombin time normalized during tumor regression and FVII level was elevated to 103%.

Conclusion: Clinicians should be alert to the possible association of acquired FVII deficiency in cancer patients.

Hospital-based Population of Elderly Cancer Cases in Northeastern Thailand

BACKGROUND

The proportion of aged Thais (≥65 years old) is expected to be 30% by 2030, leading to an increased number of elderly cancer cases. Older individuals have distinct patterns of cancer and treatment needs. We therefore conducted the present study of new cancer cases and trends to get a perspective on the elderly cancer situation in Northeast Thailand.

MATERIALS AND METHODS

All new elderly cancer cases (≥65 years) registered in the hospital-based cancer registry at the Faculty of Medicine, Srinagarind Hospital, Khon Kaen University during 1993-2012 were included in the study.

RESULTS

Elderly patients accounted for 31.6% of all cancer patients and new cancer cases in the older age group increased 46% from the first to second decades. The absolute number of oldest old (80+ years) doubled. The top three cancers in males were liver and bile duct, lung, and colorectal. In females, the three most common cancers were liver and bile duct, oral cavity, and cervix. Cancers with the highest percentages of increase were thyroid, prostate, and colorectal.

CONCLUSIONS

Elderly cancer cases are increasing. Treatment modalities and palliative care for older populations are urgently needed.

Treatment Outcome and Predictors of Survival in Thai Adult Rhabdomyosarcoma Cases

BACKGROUND

Adult rhabdomyosarcoma (RMS) is a rare and aggressive disease with limited data compared with pediatric RMS. The goal of this study was to determine the treatment outcome and identify factors related to survival outcome in Thailand.

MATERIALS AND METHODS

Adult patients (≥15 years old) with the pathological diagnosis of RMS between 1985 and 2010 were reviewed. The data were retrospectively reviewed from the pathological results and medical records from Srinagarind Hospital, Khon Kaen University.

RESULTS

A total of 34 patients were identified in the study. The median age at diagnosis was 35.5 years and the most common primary sites were extremity and the head and neck region. The incidence of pleomorphic RMS increased with age and none was found in those aged younger than 20 years old. The median survival time was 9.33 months (95%CI: 5.6-13.1). The 1- and 5- year survival rates were 38.2% (22.3-54.0) and 20.6% (9.1-35.3). On multivariate analysis, age and size of tumor did not predict better outcome while chemotherapy and surgery were significantly associated with longer survival.

CONCLUSIONS

Outcome of adult RMS was poor. Surgery and chemotherapy are s trongly associated with better prognosis and multimodality treatment should be incorporated in the clinic.