Early-Onset Colorectal Cancer in Egypt: Pathological Characters, Patterns of Care, and Survival Compared to Average-Age Onset Colorectal Cancer: A Retrospective Multicenter Study

PURPOSE

Early-onset colorectal cancer (EOCRC) is a rising health problem. The incidence of EOCRC has increased over the past 2 decades all over the world. Reports from Egypt since the 1990s have reported a higher incidence among young populations with no identifiable risk factors. The aim of this study was to assess EOCRC in Egypt regarding incidence, characteristics, treatment pattern, and survival compared with average age onset and elderly patients.

MATERIALS AND METHODS

This was a retrospective, record-based, cohort study combining data from four different cancer centers in Egypt. We grouped patients according to age into three categories: the EOCRC group for patients age ≤45 years and the average age onset and elderly cancer group (for patients age ≥65 years).

RESULTS

The study included 1,310 patients with histopathologically proven colorectal cancer, representing four different geographical areas in Egypt. Patients with EOCRC represented 42.4% of the study population. Female patients were 50.6% among the EOCRC group and 52.5% among the average age group. Rectal tumors were significantly higher in EOCRC (54.7% v 40.6%; P < .001). There was no significant difference between both groups regarding the tumor stage at presentation, obstruction, or presence of metastases at presentation. Patients with EOCRC had a significantly higher rate of peritoneum/adnexa metastases than the average age ones (12.3% in EOCRC v 6.9% in the average age group; P < .001). No statistically significant differences between EOCRC and average age groups in both disease-free survival and overall survival were reported.

CONCLUSION

A comprehensive framework for the study of EOCRC is required in Egypt as well as a genomic analysis to identify possible underlying genetic alterations responsible for the high incidence of EOCRC.

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.

The Clinical Significance of Promoter Methylation of Fluoropyrimidine Metabolizing and Cyclooxygenase Genes in Colorectal Cancer

AIMS

This study investigated the impact of promoter methylation of flouropyrimidine (FP) metabolizing and cyclooxygenase 2 (COX2) genes on their mRNA expression and on the clinical outcome of colorectal cancer (CRC) patients.

METHODS

Methylation specific-PCR and real time-PCR of thymidylate synthase (TS), thymidine phosphorylase (TP), dihydropyrimidine dehydrogenase (DPD) and COX2 were performed at baseline and after 3 and 6 months of FP therapy. Pairwise comparisons were conducted between the subgroups of CRC patients. The event free survival (EFS) and the hazard of progression were estimated by univariate and multivariate analyses.

RESULTS

At baseline CRC patients, both TS and TP were overexpressed, in spite of the unmethylation of TS and the full methylation of TP genes. Significant downexpression of DPD and COX2 were associated their promoter's methylation. At the end of FP therapy, TS, DPD and COX2 were overexpressed by 7.52, 2.88 and 3.45 folds, respectively, while TP was downexpressed by 0.54 fold. However, no change was observed in the methylation status of genes with FP therapy. Pairwise comparisons revealed significant difference in the expression and the methylation status of genes according to the clinicopathological characters of CRC patients either at baseline or after FP therapy. The overexpression of DPD and COX2 genes were indicators for a poor EFS of CRC patients. Also, the high level of COX2 expression was found to be significantly correlated with the hazard of progression (HR = 1.73, 95% CI = 1.02-3.03).

CONCLUSION

The promoter methylation of FP metabolizing and COX2 genes has significant impact on the expression and the treatment outcome of CRC patients.

A multi-centre cohort study investigating the outcome of synovial contamination or sepsis of the calcaneal bursae in horses treated by endoscopic lavage and debridement

Background

Previous studies investigating factors associated with survival following endoscopic treatment of contamination/sepsis of the calcaneal bursa are limited.

Objectives

To investigate the factors associated with survival in horses with contamination/sepsis of the calcaneal bursae treated endoscopically and to describe the bacterial isolates involved in the synovial infections.

Study design

Retrospective analysis of clinical records.

Methods

Medical records from 128 horses with contamination/sepsis of the calcaneal bursae treated by endoscopic lavage at seven equine hospitals were reviewed. A follow‐up questionnaire was used to determine survival and return to athletic performance. Descriptive statistics and Cox proportional hazards survival models were used to determine factors associated with survival.

Results

Horses underwent one (n = 107), two (n = 19), or three (n = 2) surgeries. Survival to hospital discharge was 84.4%. Univariable survival analysis revealed that administration of systemic antimicrobials prior to referral was associated with reduced mortality (hazard ratio, [HR] 0.41, 95% CI 0.18–0.91, P = 0.03). Increased mortality was associated with bone fracture/osteomyelitis (HR 2.43, 95% CI 1.12–5.26, P = 0.03), tendon involvement (≥30% cross sectional area) (HR 3.78 95% CI 1.78–8.04, P = 0.001), duration of general anaesthesia (HR 1.01, 95% CI 1.00–1.02, P = 0.04), post‐operative synoviocentesis (HR 3.18, 95% CI 1.36–7.43, P = 0.006) and post‐operative wound dehiscence (HR 2.5, 95% CI 1.08–5.65, P = 0.04). Multivariable Cox proportional hazards model revealed reduced mortality after systemic antimicrobial administration prior to referral (HR 0.25, 95% CI 0.11–0.60, P = 0.002) and increased mortality with tendinous involvement (≥30% cross‐sectional area) (HR 7.92, 95% CI 3.31–19.92, P<0.001). At follow‐up (median 30 months, range 0.25–13 years, n = 70) 87.1% horses were alive, 7.1% had been euthanised due to the calcaneal injury and 5.7% had been euthanised for unrelated reasons. From 57 horses with athletic performance follow‐up, 91.2% returned to the same/higher level of exercise, 5.3% to a lower level and 3.5% were retired due to persistent lameness of the affected limb.

Main limitations

Retrospective study and incomplete follow‐up.

Conclusion

Endoscopic treatment of contamination/sepsis of the calcaneal bursae has an 84% survival rate to hospital discharge. Tendinous involvement reduced survival whilst systemic antimicrobials administration prior to referral improved survival.

Prognostic Impact of WT-1 and Survivin Gene Expression in Acute Myeloid Leukemia Patients

BACKGROUND

Wilms Tumor 1 (WT1) and Survivin genes are important leukemia-associated antigens (LAAs) in AML with potential prognostic impact.

METHODS

We investigated WT1 and Survivin expression levels by RT-PCR in 61 AML patients in correlation with clinical characteristics and outcomes.

RESULTS

WT1 was overexpressed in 45 patients (73.8%), associated with higher BM blasts (p = 0.017), lower incidence of favorable-prognosis cytogenetics (p = 0.035), and higher incidence of Flt3-ITD mutations (p = 0.026). Survivin was overexpressed in 17 patients (27.9%) with higher mean WBC count (p = 0.049). Patients with overexpression of either gene showed inferior complete remission (CR) rates and survival rates, patients with overexpression of both genes showed higher mean WBCs (p = 0.035) and higher BM blasts (p = 0.029) while the double negative group showed higher incidence of favorable cytogenetic events (p = 0.021), better CR rates and survival rates.

CONCLUSIONS

Our findings support the introduced prognostic impact of WT1 and Survivin genes in AML patients and its potential use in MRD monitoring and immunotherapy.

Sequential bacterial sampling of the midline incision in horses undergoing exploratory laparotomy

BACKGROUND

There is limited information about bacterial isolates that are present on the equine midline incision during and following exploratory laparotomy.

OBJECTIVES

To investigate the bacterial species cultured from the ventral midline pre-, intra- and post- laparotomy, whether particular bacterial isolates are associated with the development of surgical site infections (SSIs) and to report the antimicrobial resistance phenotypes of these isolates.

STUDY DESIGN

Prospective cohort study.

METHODS

The ventral midline of 31 horses undergoing exploratory laparotomy was sampled for bacterial culture at set time-points pre, intra and post-operatively. Inclusion criteria were that horses must have undergone exploratory laparotomy within 90 min of the initial colic examination upon hospital admission and must not have been placed in a stable prior to surgery. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration.

RESULTS

Seven horses (22.6%) developed a SSI. None of the variables tested were associated with the altered risk of SSI. The prevalence of a positive bacterial culture from the incision increased progressively over time and a variety of bacteria were isolated. A positive intra-operative culture was not a predictor of SSI; and when a SSI did occur, it was due to a different bacterial isolate. MRSA and ESBL-producers were identified in the post-operative period in one and four different horses respectively, but none of these developed a SSI.

MAIN LIMITATIONS

Sampling was limited to hospitalisation and no culture results were available for horses developing SSI following hospital discharge.

CONCLUSIONS

A variety of bacterial species may be isolated from equine laparotomy incisions peri-operatively without development of SSI. SSI does not appear to be solely related to bacterial contamination of the incision peri-operatively and other mechanisms such as bacteraemia merit further investigation.

ERCC1 and ERCC2 as predictive biomarkers to oxaliplatin-based chemotherapy in colorectal cancer patients from Egypt

BACKGROUND

The impact of Excision repair cross-complementation group 1 (ERCC1) and group 2 (ERCC2) expression levels on the efficacy of oxaliplatin-based chemotherapy is still controversial. The present study was conducted to determine the predictive value of these molecular biomarkers in stage III and IV colorectal cancer (CRC) patients receiving oxaliplatin (OX)-based chemotherapy as first-line treatment.

METHODS

The study included 80 CRC patients who received first line oxaliplatin based chemotherapy The expression levels of ERCC1 and ERCC2-mRNA and proteins were determined in the primary tumors by quantitative real time reverse transcription polymerase chain reaction(RT-qPCR) and immunohistochemistry (IHC); respectively. The results of mRNA expression were correlated with patients' characteristics, response to treatment, overall- and event free survival (OS & EFS).

RESULTS

Sixty four out of the 80 patients were legible for assessment of ERCC1 and ERCC2 expression. The cut-off levels of ERCC1and ERCC2-RNA were 3.8×10^-3& 4.6×10^-3; respectively. Reduced ERCC1 and ERCC2 RNA expressions were detected in 50 (78.1%) and 48 (75%) cases, respectively whereas reduced proteins were detected in 48 cases (75%) for ERCC1 and ERCC2. After The median follow up period was 30.5months (range: 7-104months), Patients with low mRNAERCC1levels showed significantly longer OS (p=0.011) and EFS (p˂0.001). However, no significant relation was found between ERCC2 levels and OS or EFS. In multivariate analysis performance status (PS), stage of the disease and ERCC1-mRNA expression were independent prognostic factors for EFS whereas tumor histology and stage of the disease were independent factors for OS.

CONCLUSIONS

ERCC1 expression levels may help in selecting patients who benefit from oxaliplatin chemotherapy in stage III & IV CRC. Further large trials are needed to validate these data.

Colic in a working horse population in Egypt: Prevalence and risk factors

REASONS FOR PERFORMING STUDY

Colic is an important health problem in managed horse populations. Currently, there is limited information about colic prevalence and risk factors for colic in working horse populations.

OBJECTIVES

To determine the prevalence of, and risk factors for, colic in a working horse population in Egypt and to describe management practices in this working horse population.

STUDY DESIGN

Cross-sectional survey.

METHODS

Owners of 350 working horses were interviewed. Data about their horses, management and colic episodes in the preceding 12 months were collected. Dental examination was conducted on 342 horses and blood samples (n = 100) were collected for immunodiagnosis of tapeworm (Anoplocephala perfoliata) infection. Multivariable logistic regression analysis was used to identify risk factors for a history of colic in the preceding 12 months.

RESULTS

The 12-month prevalence of colic was 54.6%. Severe and moderate tapeworm infection intensity was identified in 3% and 26% of horses tested, respectively. Horses that had severe dental disease (odds ratio [OR] 6.8, 95% confidence interval [CI] 1.9-24.3, P<0.001), that displayed stereotypic behaviour (OR 2.0, 95% CI 1.15-3.5, P = 0.013), were fed ground corn during the 'dry season' (OR 1.65, 95% CI 1.03-2.6, P = 0.035) or that had received an anthelmintic in the previous 6 months (OR 2.1, 95% CI 1.3-3.3, P = 0.003) were more likely to have a history of colic in the preceding 12 months. Horses fed on rice bran during the 'green season' (OR 0.47, 95% CI 0.26-0.9, P = 0.015) and that displayed geophagia/coprophagia (OR 0.19, 95% CI 0.05-0.73, P = 0.001) were less likely to have a history of colic.

CONCLUSIONS

Colic is common in this working horse population and this study has identified factors associated with altered likelihood of colic. The study provides important information that may be used to inform future prospective studies investigating colic in working horse populations and to assist development of preventive healthcare strategies. The Summary is available in Chinese - see Supporting information.

Risk factors for surgical site infection following laparotomy: Effect of season and perioperative variables and reporting of bacterial isolates in 287 horses

REASONS FOR PERFORMING STUDY

Surgical site infection (SSI) is an important cause of post operative morbidity following laparotomy.

OBJECTIVES

To investigate risk factors for SSI, including effect of season and surgery performed outside normal working hours, and to report bacterial isolates and antimicrobial resistance patterns.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data were obtained from horses that had undergone exploratory laparotomy over a 3-year period (2010-2013) in a UK hospital population. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration that developed during hospitalisation. Multivariable logistic regression was used to identify associations between pre-, intra- and post operative variables and altered likelihood of SSI.

RESULTS

Surgical site infection developed in 73/287 (25.4%) horses during hospitalisation. Horses of greater bodyweight (odds ratio [OR] 1.002, 95% confidence interval [CI] 1.0002-1.005, P = 0.03), increased packed cell volume (≥48%) on admission (OR 3.03, 95% CI 1.32-6.94, P = 0.01), small intestinal resection (OR 2.27, 95% CI 1.15-4.46, P = 0.02) and post operative colic (OR 2.86, 95% CI 1.41-5.79, P = 0.003) were significantly associated with increased likelihood of SSI in a multivariable model. SSI was also significantly more likely to occur during winter (OR 3.84, 95% CI 1.38-10.70, P = 0.01) and summer (OR 5.63, 95% CI 2.07-15.3, P = 0.001) months in the model. Three-layer closure of the incision was protective (OR 0.31, 95% CI 0.16-0.58, P<0.001) compared to 2-layer closure. There was no effect of surgery being performed outside normal working hours (P = 0.5). The most common bacterial isolates were Escherichia coli (59.5%), Enterococcus spp. (42.4%) and Staphylococcus spp. (25.4%). Penicillin resistant isolates accounted for 92% (96/104) of isolates while 18% (21/119) of isolates were gentamicin resistant.

CONCLUSIONS

Laparotomy during winter and summer months was associated with increased likelihood of SSI but there was no effect of surgery performed outside normal working hours. This information assists in identifying horses at high risk of SSI and informing development of preventive strategies.

Prevention of post operative complications following surgical treatment of equine colic: Current evidence

Changes in management of the surgical colic patient over the last 30 years have resulted in considerable improvement in post operative survival rates. However, post operative complications remain common and these impact negatively on horse welfare, probability of survival, return to previous use and the costs of treatment. Multiple studies have investigated risk factors for post operative complications following surgical management of colic and interventions that might be effective in reducing the likelihood of these occurring. The findings from these studies are frequently contradictory and the evidence for many interventions is lacking or inconclusive. This review discusses the current available evidence and identifies areas where further studies are necessary and factors that should be taken into consideration in study design.

Untreated hepatocellular carcinoma in Egypt: outcome and prognostic factors

Background

Hepatocellular carcinoma (HCC) is a common cancer worldwide as well as in Egypt with hepatitis C and B, alcohol and aflatoxins being the commonest risk factors.

Aim

The objective of this study was to assess the prognostic factors affecting overall survival (OS) of untreated HCC in Egypt.

Methods

This retrospective study was conducted at Tanta Cancer Center, Egypt where 288 HCC cases who received no specific therapy and were followed-up until death were identified. The impact of possible prognostic factors on OS was assessed using the log-rank test (univariate analyses) and Cox regression method (multivariate analysis).

Results

The median OS of untreated HCC was 2.3 months (95% confidence interval: 1.9–2.6). The 1, 3, 6, 12, 24 months OS rates were 84%, 42%, 21%, 9%, and 3%, respectively. All cases had died by 46 months. Male sex, advanced Child-Pugh class, the clinical presentation of ascites, cough, fatigue, and the presence of metastases were associated with poor survival (P<0.05 for all). In multivariate analysis; cough, presence of ascites, and Child-Pugh class were independent predictors of poor survival.

Conclusion

OS in untreated HCC in Egypt is very short. Many factors interact to produce this dismal survival.

Age at diagnosis in women with non-metastatic breast cancer: Is it related to prognosis?

OBJECTIVE

Primary objective was to verify whether breast cancer patients aged less than 40 years at diagnosis have poorer prognosis than older patients. Secondary to assess prognostic factors influencing disease free survival.

METHODS

941 women were diagnosed with non-metastatic breast cancer at NCI, Cairo in 2003. Epidemiologic, clinico-pathological characteristics, treatment modalities and disease free survival were compared among the two age groups. Prognostic factors were evaluated for association with disease-free survival.

RESULTS

One hundred-eighty-one patients (19.2%) were younger than 40 years and 760 (80.8%) were older. Older women presented with higher rates of comorbidities and younger women presented with more hormone non-responsive tumors. Young women presented with larger tumors pT4=13.8% compared to 8.6% in older women, yet not significant. Young women were treated with more conservative surgery, more adjuvant chemotherapy and radiotherapy while older women with more radical mastectomies and more hormonal treatment. Recurrence rates were significantly higher among young women 44.2% compared to 34.5% in older women. Five year disease free survival in young women was 38.9% ± 4.6% compared to 48.6% ± 2.5% with adjusted hazard ratio of 1.22 95% CI (0.91-1.64), p=0.19. Multivariate analyses identified positive axillary lymph nodes (pN2-pN3), larger tumor size (pT3-pT4), hypertension, lobular carcinoma type and lack of adjuvant systemic treatment as independent factors associated with poor DFS.

CONCLUSION

Young women were not found to have poorer prognosis, yet they presented with more ER negative tumors. Most of women presented with advanced stage and young women had higher recurrence rates.

Transarterial chemoembolization for the treatment of hepatocellular carcinoma: a single center experience including 221 patients

BACKGROUND

Hepatocelluar carcinoma (HCC) is a major health problem in Egypt as well as in many countries. Transarterial chemoemoblization (TACE) is a treatment modality applicable to locally advanced HCC beyond surgery or ablative therapies and is associated with survival improvements. The aim of this study was to assess the outcomes of TACE in our center over the past four years.

METHODS

This is a retrospective cohort study that included 221 patients with locally advanced HCC treated with TACE in a single center between the years 2007 and 2010. The median age was 57 years with male predominance. Liver cirrhosis, viral hepatitis and Bilharziasis were encountered in 64%, 31% and 8% of patients, respectively. Abdominal pain was the most common presenting symptom (67%). Most cases were diagnosed based on radiology (57%) with a TNM stage I or II (73%) and a median AFP value of 150 ng/mL.

RESULTS

221 patients received 440 cycles of TACE with a median of 2 cycles per patient. Cisplatin and doxorubicin (50mg per cycle, each) were the most commonly used drugs. Impaired liver function was the most common toxicity. Liver cell failure occurred in 17% of patients. An objective tumor response was achieved in 44% of cases. The median overall survival (OS) was 16 months (95% CI, 13-19 months) and the median progression free survival (PFS) was 6 months (95% CI, 4.3-7.8 months). Responding patients, Child-Pugh class A and patients receiving standard doses of chemotherapy had a significantly better OS than their counterparts. Only Child-Pugh class A was associated with significantly longer PFS (p < 0.001).

CONCLUSION

TACE produces reasonable responses and fair survival rates in locally advanced HCC but with noticeable toxicities. Proper patients' selection and prompt liver support are mandates for improving TACE outcomes.

A case of synchronous double primary breast carcinoma and osteosarcoma: Mismatch repair genes mutations as a possible cause for multiple early onset malignant tumors

Background:

Simultaneous or consequent development of multiple solid tumors might be faced in some patients, especially the young. These tumors might be related to certain hereditary cancer syndromes or certain genetic predispositions.

Case Report:

We present the case of a 19-year-old woman with metastatic breast cancer to the contralateral axillary lymph node, associated with simultaneous osteosarcoma of the left lower femur. As she did not fit into any of the familial cancer syndromes, genetic predisposition was suspected. We detected MLH1 and MSH2 promotor methylation (PM), microsatellite instability (MSI), and different mutational events in both tumors. BRCA1 gene mutations were detected in the breast tumor, with reduced mRNA expression of BRCA1&2. ERCC1, MLH1 and MSH2, especially in OS, and RRM1 was overexpressed in both tumors.

Conclusions:

Aberrations in MMR genes could explain simultaneous or consequent development of multiple solid tumors, especially in a young patient. We recommend detecting these defects, close follow-up for those patients, and genetic counseling for their family members. Further studies in a larger population are essential to support our results.