Table of Contents

Original articles

diet, Physical activity, Marital Status and risk of Cancer: a Case Control Study of adults from riyadh, Saudi arabia .......................06Eyad Fawzi AlSaeed and Mutahir A. Tunio

Clinico-hematological Profile of 184 Patients with non-Hodgkin’s lymphoma: an experience from Southern Pakistan ...................11Sadia Sultan, Syed Mohammed Irfan, Anila Rashid, Saira Parveen and Neesha Nawaz

ambiguity of Whole Body PeT CT Scans in diagnosis of Co-existing Tuberculosis and Malignancy: is Histopathological Confirmation Mandatory? .........................................................................................................................................15Prekshi Chaudhary, Sweety Gupta, Nitin Leekha, Ravi S. Rajendra, Shiv S. Mishra, Vandana Arora, Sudarsan De and Sandeep Agarwal

epidemiology and Outcomes with Platinum-Based Chemotherapy in recurrent or Metastatic Carcinoma Cervix in a developing Country: experience from a Tertiary Oncology Centre in Southern india ......................................................................20K.C. Lakshmaiah, Aditi Harsh Thanky, D. Lokanatha, K. Govind Babu, Linu Jacob, Suresh Babu, A.H. Rudresha, K.N. Lokesh, L.K. Rajeev and Aparna Sridharmurthy

disclosure of adverse Cancer news: The Public’s Perspective in a Middle eastern Country .................................................................27Jamal Zekri, Mohamed E. El Sayed and Youssef Nauf

Second Primary Tumors associated with Breast Cancer: Kuwait Cancer Control Center experience ....................................................35Salah Fayaz, Gerges Attia Demian, Heba El-Sayed Eissa and Sadeq Abuzalouf

implications of Observer variation in Gleason Scoring of Prostate Cancer on Clinical Management: a Collaborative audit ...............41A. Harbias, E. Salmo and A. Crump

Squamous Cell Carcinoma of the Buccal Mucosa: a Single institute retrospective analysis of nodal involvement and Survival ...........................................................................................................................................................46Vivek Tiwari and Rakesh Mahawar

Clinical and Pathological Characteristics of Triple Positive Breast Cancer among iraqi Patients ..........................................................51Nada A.S. Alwan, Faisal H. Mualla, Munawar Al Naqash, Saad Kathum, Furat N. Tawfiq and Sana Nadhir

Pre-Treatment nutritional Status and radiotherapy Outcome in Patients with locally advanced Head and neck Cancers ...............61Amit Bahl, Arun Elangovan, Satinder Kaur, Roshan Verma, Arun Singh Oinam,Sushmita Ghoshal, Naresh K Panda

evaluation of BrCa1 large Genomic rearrangements in Group of egyptian female Breast Cancer Patients Using MlPa ...................................................................................................................................................................................64Ola M. Eid, Eman A. El Ghoroury, Maha M. Eid, Rana M. Mahrous, Mohamed I. Abdelhamid, Zahra I. Aboafya, Esmat A. Abdel Ghaffar and Amany H. Abdelrahman

Case reportsBrain Metastasis from Colorectal adenocarcinoma: a Case report ........................................................................................................70Jaroslav Nemec, Abdulsalam Alnajjar, Jasem Albarrak , Shaban A, Mariam Al Otaibi and Asit Mohanty

leiomyosarcoma of Penis: an aggressive and exceptionally rare entity ...............................................................................................73Vinita Trivedi, Muneer A, Rita Rani, Richa Chauhan, Usha Singh and Naveen Kuna

review articlesChemotherapy-induced febrile neutropenia in Solid Tumours ...............................................................................................................77Ayman Rasmy, Mohammed Al Mashiakhi and Amal Ameen

Conference Highlights/Scientific Contributions• NewsNotes ............................................................................................................................................................................................85

• Advertisements .....................................................................................................................................................................................88

• ScientificeventsintheGCCandtheArabWorldfor2017 ..................................................................................................................89

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Corresponding author: Dr. Muneer A, PG Resident, Department of Radiation Oncology, Mahavir Cancer

Sansthan, Patna-801505, India. Phone: +91 9744571234. Email: muneerkhalam@hotmail.com

Case reportA 40-year old male patient presented to our institution

with complaint of a growth over penis, since three months. The growth was progressive in nature and it was associated with pain. There was no history of bleeding, discharge, pruritus or any swelling in the groin area. There was history of partial amputation of penis done10 months back for the similar growth at the glans penis, at some local hospital, Its Histopathology was Moderately differentiated Squamous cell carcinoma, all margins were free and patients was kept on observation. Patient was symptoms-free for six months, there after he noticed a small nodule over a distal end of amputated part of penis which grew in size, and then he was referred to our hospital.

On physical examination, all his vitals were found to be within normal limits. Local examination showed an 8×9 cm ulcer of proliferative growth at the shaft of penis. Bilateral inguinal lymph node was palpable, which was less than 2 cm, mobile, firm, and non-tender. Routine laboratory work-up showed a normal picture. Chest X-ray, Ultrasound examination revealed no evidence of metastatic disease.

The patient underwent total penectomy with perineal urethrostomy. Bilateral inguinal lymph node dissection was done in view of N+ status. Post-operative period was uneventful. Gross examination of specimen revealed a Cauliflower like fungative growth, white, firm lesion measuring 14x12x9 cm, arising from smooth muscle of corpora cavernosum. The distance of the lesion from closest surgical margin was 3 cm. The cut surface of the lesion was solid and firm, with focal necrosis and

abstract

Penile leiomyosarcoma is a very rare disease of penile mesenchymal tissue, most of them are of vascular origin and pathologically classified into the superficial and deep type. Because of the small number of cases reported so far, the conclusions about treatment and prognosis are

equivocal. Here we report a case of 40-year old patient who presented with leiomyosracoma of penis; despite adequate surgery patient developed local recurrence and distant metastasis indicating aggressive nature of leiomyosarcoma entity of penis.

Keywords: leiomyosarcoma, penis, recurrence

Case Report

leiomyosarcoma of Penis: an aggressive and exceptionally rare entity

Vinita Trivedi, Muneer A, Rita Rani, Richa Chauhan, Usha Singh, Naveen Kuna

Department of Radiatin Oncology, Mahavir Cancer Sansthan, Patna, India

hemorrhagic areas. Microscopic findings gave differential diagnosis of sarcoma or sarcomatoid carcinoma with a Mitotic rate of 8-9/10 HPF.All inguinal lymphnodes were negative for metastasis. Immunohistochemistry was strongly positive for S100, Calponin, Caldesmon, smooth muscle actin (SMA). The tumour cells were negative for CK and P63. A diagnosis of high grade leiomyosarcoma of the penis was rendered.

The patient was discharged, with an advice to come for regular follow up. After 3 months patient turned up with complaints of growth of 4x3 cm around the urethrostomy site, with profuse bleeding along with multiple small nodular ulcerations all over the growth. Patient was given hemostatic radiotherapy to a total dose of 20 Gy/5# /one week. Bleeding got controlled, but growth increased further in size. Complete metastatic work up was done again; Chest x-ray was suggestive of multiple lung metastases. Hence the patient was put on palliative chemotherapy.

discussionSquamous cell carcinoma is the most common

primary malignant neoplasm of the penis. Primary mesenchymal malignancies of the penis are very rare entities, representing less than 5% of penile tumors(1, 2). These soft tissue tumors comprise vascular sarcomas (Kaposi’s sarcoma epithelioid hemangioendothelioma, angiosarcoma) and less frequently leiomyosarcomas

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Leiomyosarcoma of penis a rare entity, Vinita Trivedi, et. al.

and rhabdomyosarcomas(2). Leiomyosarcoma represents approximately5-6% of penile sarcomas (3). This type of malignant tumor has a very low incidence and varies demographically with a rate of 0.1 to 0.9/100 000 men, and in the developed countries of Europe and the United States, up to 19/100 000 men. In the poorer countries of Africa and South America, there is a 10% incidence of malignant tumors in men (4).

The age range at diagnosis for penile leiomyosarcoma is from 6 to 84 years with the highest incidence in fourth and fifth decade; only 3 cases were reported in children (5).Our patient was also in his fifth decade of life.

Leiomyosarcomas of the penis can arise in two clinico-pathological settings. Superficial lesions, originating from the smooth muscle of the glans or the dermis of the shaft, usually present as small, painless noduleslocated on the dorsum of the shaft, rarely invade deeper structures and are not accompanied by urinary symptoms. Deep-seated tumors, arising from the smooth muscle of the corpus spongiosum or the corpus cavernosum, show a tendency to invade and obstruct the urethra, thus causing urinary symptom (5). In contrast to the superficial tumors, the deep lesions show greater propensity to metastasize and have therefore poorer prognosis (6), as seen in our case.

Sarcomas usually spread by hematogenous route. Lymph node disease is very rare, as was seen in this case.

figure 1. (a).iHC positive for Caldesmon, (b) iHC positive for SMa, (c) iHC positive for calponin, (d) Higher power view of the tumor showing fasicles of malignant smooth muscle cells with mitotic figures H & e

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G. J. O. Issue 25, 2017

Hence lymphadenectomy is not recommended routinely, but if it is present it indicates a high rate of distant spread particularly in the lungs, liver and brain (7).

On gross section they are usually rubbery in consistency, well circumscribed and with white, yellow, or grey appearance. Microscopically they are composed of spindle shaped smooth muscle fibers arranged into interlacing fascicles. The importance of mitotic rate andother nuclear differentiation variables have not been analyzed in the literature, but the data show that the degree of differentiation is reliable in order to predictthe tumor propensity to infiltrate the adjacent structures or to metastasize(8). The metastatic potential also varies according to the size of lesions, 29% for <5 cm and 50% for >5 cm. The most frequent sites of distant metastases are the lungs, liver and brain. Large tumors especially those located at the root of the penis or deep seated lesions, often have a poor prognosis despite aggressive surgical intervention as seen in our patient. Histological prognostic parameters include tumor growth pattern (circumscribed or infiltrative), high mitotic count (> 10 mitoses/10 HPF) and Grade 3 histology (9). So tumor depth, grade and size seem to be the best predictors of clinical outcome.

Because of rarity and poor patient prognosis, there has been no standard adjuvant treatment protocol (10). Treatment of this rare malignancy is predominantly surgical, either wide excision or amputation; however,

figure 2: (a) appearance of growth just before hemostatic radiotherapy (b) appearance of growth - 2 days after starting of hemostatic radiotherapy (c) appearance of growth- 2 days after completion of hemostatic radiotherapy (d) Chest x-ray of the patient showing metastasis.

the approach should be individualized. Complete resection with negative surgical margins associated with better survival (9).

Adjuvant chemotherapy and radiotherapy have no clear role in the management of penile leiomyosarcoma. However, since the deep seated tumour is associated with high incidence of local recurrence and distant metastases, combination of local pelvic radiotherapy and systemic chemotherapy might be effective as an adjuvant therapy. Extrapolating the benefit of adjuvant radiation therapy in all high-grade and recurrent soft tissue sarcoma (10), adjuvant radiotherapy should be considered in all large sized, high grade, deep seated leiomyosarcoma penis; to decrease the chance of local recurrence and probability of distant metastasis.

ConclusionLeiomyosarcoma of the penis is a very rare disease

and have a poor prognosis in large deep-seated lesions. The analysis of prognostic factors can help to identify patients at higher risk for disease progression. Surgical treatment with negative surgical margins provides the best chance of cure. The effectiveness of radiation therapy and chemotherapy is debatable in adjuvant setting. However high rates of both local recurrences and distant metastasis obviates the need of adjuvant therapy, hence the limited role of adjuvant treatment in localized leiomyosarcoma needs to be further explored.

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Leiomyosarcoma of penis a rare entity, Vinita Trivedi, et. al.

references1. Cibull TL, Thomas AB, Badve S, Billings SD. Leiomyosarcoma

of the penis presenting as a cutaneous lesion. Journal of cutaneous pathology. 2008; 35(6):585-7.

2. Dominici A, Rose AD, Stomaci N, et al. A rare case of leiomyosarcoma of the penis with a reappraisal of the literature.International journal of urology. 2004; 11(6):440-444.

3. Dehner LP, Smith BH. Soft tissue tumors of the penis.Aclinicopathologicstudy of 46 cases. Cancer 1970; 25:1431-47.

4. Centeno-Flores Marianela, A,* García-Rodríguez Francisco, Gil Rebeca, Padrón-Rivera, Luis Héctor. Primary leiomyosarcoma of the penis. Rev MexUrol 2013;73(1):46-49

5. Isa SS, Almaraz R, Magovern J. Leiomyosarcoma of the penis: case report and review of the literature. Cancer 1984; 54: 939–42.

6. Nkposong EO, Osunkoya BO. Leiomyosarcoma of the penis.West Africa Med J 1972; 21: 32.

7. Srinivas V, Morse MJ, Herr HW, et al. Penile cancer: relation of extent of nodal metastasis to survival. J Urol. 1987; 137: 880.

8. Katsikas VS, Kalyvas KD, Ioannidis SS, et al. Leiomyosarcoma of the penis. Sarcoma 2002; 6(2):75-77.

9. Fetsch JF, Davis Jr CJ, Miettinen M, Sesterhenn IA. Leiomyosarcoma of the penis: A clinicopathologic study of 14 cases with review of theliterature and discussion of the differential diagnosis. Am J Surg Patholgy2004; 28:115-25.

10. Nanri M, Kondo T, Okuda H, Tanabe K, Toma H. A case of leiomyosarcoma of the penis. Int J Urol 2006;13:655-8