Management Practices of Locally Advanced and Metastatic Urothelial Carcinoma: A Questionnaire-Based Survey among Lebanese Oncologists

Background and Objective: The outcome of locally advanced and metastatic urothelial carcinoma LA/mUC has improved over the past years with a plethora of new treatments and the approval of immune checkpoint inhibitors (ICIs), antibody-drug conjugates, and targeted agents, to identify locally advanced metastatic urothelial carcinoma’s current management practices in Lebanon and the implication of the ongoing economic crisis on the medical practice. Methods: An online questionnaire was used to survey ten Lebanese oncologists from six different hospitals, between July 5 and July 11, 2022, requesting information pertaining to their current clinical practice in the pharmacological treatment of locally advanced metastatic urothelial carcinoma. Key Findings: Cisplatin-based chemotherapy was the most frequently reported initial treatment of locally advanced metastatic urothelial carcinoma. Participants reported using immune checkpoint inhibitors in platinum-ineligible patients and those with PDL1 positive tumors. Also, they would not consider the concomitant use of immunotherapy and chemotherapy in the first-line setting. Participants believed that avelumab maintenance is effective in the absence of progression after first-line platinum-based chemotherapy;they would consider initiating it 2 - 10 weeks after completion of chemotherapy. Conclusions and Clinical Implications: After comparing with current international guidelines, this study shows that Lebanese oncologists follow international guidelines and have deep knowledge of recent clinical trials for the management of locally advanced metastatic urothelial carcinoma, regardless of economic crisis challenges.

Myxedema ascites with high CA-125:Case and a review of literature

Ascites appearing in a previously healthy female patient is usually ascribed to a variety of causes,among which,is a cancerous process,especially if it comes with a raised CA-125 level.Although the CA-125 antigen is present on more than 80% of malignant epithelial ovarian tissue of non-mucinous type,it is also found on both healthy and malignant cells of mesothelial and non-mesothelial origin.Myxedema ascites which is caused by hypothyroidism is a rare entity,but on the other hand is easy to treat.It is one of the differential diagnoses when the ascites is refractory to treatment and no other obvious cause can be identified.If the diagnosis is delayed,patients will frequently receive unnecessary procedures,while treatment has very good response rates and ascites resolve with serum CA-125 normalization after adequate hormonal treatment.

Correlation between Fibroscan and laboratory tests in non-alcoholic fatty liver disease/non-alcoholic steatohepatitis patients for assessing liver fibrosis

BACKGROUND Non-alcoholic fatty liver disease(NAFLD) is a spectrum of disease ranging from simple steatosis to non-alcoholic steatohepatitis(NASH), through to advanced fibrosis and cirrhosis. Many patients with NAFLD remain undiagnosed and recognizing those at risk is very crucial. Although liver biopsy is the gold standard method for diagnosing and staging NAFLD, non-invasive imaging and lab modalities are also very promising in diagnosing these diseases.AIM To explore some of these non-invasive modalities in this context and assess how they hold up in terms of making a diagnosis while avoiding an invasive procedure like a liver biopsy.METHODS This study was conducted on NAFLD/NASH patients(n = 73) who underwent Fibroscan examinations at Saint George Hospital University Medical Center over 17 mo in order to assess liver fibrosis. Obtained Fibroscan results were correlated to laboratory tests and calculated aspartate transaminase(AST)/alanine transaminase(ALT) ratio, AST platelet ratio index(APRI) score and Fibrosis-4 score.RESULTS A significant age difference was observed across fibrosis stages of investigated patients. The mean stiffness score was 9.48 ± 11.77 KPa. A significant negative correlation was observed between ALT, AST, Albumin, gamma-glutamyl transferase, cholesterol, LDL, HDL, triglycerides, and ALP when compared across fibrosis stages. On the other hand, a significant positive correlation was found between Bilirubin, PT INR, partial thromboplastin time, glucose, and Platelet count when compared across fibrosis stages, in addition to AST/ALT ratio, APRI, and Fib-4 scores.CONCLUSION This study showed that Ultrasound alone is not efficient in the assessment of advancement of liver disease. Furthermore, the high positive relation between AST/ALT ratio, APRI and Fib-4 scores with fibrosis stages in NAFLD patients suggests that they could be used clinically in combination with Fibroscan to predict significant fibrosis and cirrhosis and to avoid liver biopsy.

Diagnosis and Management of Obesity: A Joint Statement by Practicing Endocrinologists

Obesity is not always recognized as a primary disease, leading to shortage of insurance coverage, clear dispositions about therapeutic strategies, prevention programs and legislation. Worldwide, physicians face the challenge to design affordable and effective treatments against obesity, to improve patient health and wellbeing and reduce the burden on healthcare systems. While international guidelines for obesity management are available, straightforward recommendations applicable in developing countries are needed. In order to develop local consensus recommendations, a panel of endocrinologists with experience in overweight and obesity convened and provided opinions about obesity aetiology, diagnosis, and management, in a structured discussion. Opinions were then developed into recommendations. There was unanimous agreement on recognizing obesity as a disease, which could be diagnosed by any trained physician and best managed by endocrinologists or obesity-trained physicians. The panel reiterated that lifestyle and behaviour changes remain the cornerstone of treatment;underscoring, however, the need for pharmacotherapy or bariatric surgery in some cases. They also identified stakeholders in the fight against obesity (ministries, third-party payers, healthcare providers and others). The establishment of an obesity registry was encouraged, which will pave the way for enhanced obesity research and prevention programs. These recommendations, endorsed by the World Obesity Federation, would be of interest to clinicians worldwide. .

Covid-19 pneumonia:Timing of pneumomediastinum and pneumothorax in 11 patients

Purpose:As the pandemic continues,many complications,previously recognized as rare,are now being reported as more than frequent complications of Covid-19 pneumonia.Of those,pneumomediastinum and pneumothorax are gaining attention.Their mechanism of occurrence/trigger is not fully understood,but the timing at which they occur is unclear.Methods:This is a case series of 11 Covid-19 patients with pneumomediastinum;retrospectively,we shed light on some of the patients’characteristics,the role of mechanical ventilation,and the timing of pneumomediastinum after initiation of mechanical ventilation.Results:We found that despite following the lung-protective strategy and despite keeping a plateau pressure at an acceptable range,most of our patients had an acute event around the same timing of mechanical ventilation.Conclusions:The similar timing raises questions about other risk factors that remain unknown.Timing and steroids can contribute to the higher incidence of these complications.

Rapid killer:Lung squamous cell cancer

Background:Lung cancer is one of the leading causes of death despite improvement in treatment modalities such as immunotherapy with chemotherapy and precise radiotherapy.NSCLC is a heterogeneous group of diseases that differs in cytology and includes adenocarcinoma,squamous cell carcinoma,bronchioloalveolar carcinoma,and poorly differentiated carcinoma.Usually,NSCLC,in contrast to SCLC,spreads locally,and the doubling time of squamous cell carcinoma is 133 days which classifies it as a relatively slow-growing tumor.Case presentation:We present the case of a 72-year-old male,recently diagnosed with squamous cell carcinoma in the right upper lobe along with secondary deposits.Few days after diagnosis,the patient had severe respiratory distress.This endobronchial tumor has increased significantly in size upon bronchoscopic visualization causing a complete obstruction of his right main bronchus and hypoxemic respiratory failure requiring intubation.Conclusion:To our knowledge,there are few reported cases where lung adenocarcinoma progressed rapidly over days.Squamous cell carcinoma usually takes 3 to 6 months to double in size,but in our case,the progression was very fast.In the last decade,it was confirmed that the doubling time of a tumor is an independent factor in the prognosis of lung cancer patients.On the other hand,further studies are needed to identify genes associated with rapid progression and a worse prognosis for lung squamous cell carcinoma.Hence,this aggressive tumor is a“rapid killer.”

Uterine-ileal perforation post pregnancy related dilatation and curettage managed by laparoscopic small bowel resection and primary anastomosis: A case report

Although rare,small bowel perforation post pregnancy related dilation and curettage presents a serious complication.Herein,we reported a case of 34-year-old female patient presenting for uterine-ileal perforation post pregnancy related dilatation and curettage managed successfully by laparoscopic small bowel resection and primary anastomosis.

Endoscopically managed sunflower bezoar

Rectal bezoar is rare.It is important to admit the patient with huge colorectal phytobezoars to hospital for monitoring,especially if patient needs several endoscopic trials for evacuation.We presented a case of 14-year-old male patient with phytobezoars of sunflower seed extending from the recto sigmoid junction till the anus.The patient was successfully managed with endoscopic evacuation.

Calculus bovis hijacks the tumor microenvironment in liver cancer cells in a multifaceted approach:A falling row of dominoes

Calculus bovis(C.bovis)is widely used in traditional Chinese medicine due to its anti-tumor effects.C.bovis shifts liver cancer tumor microenvironment towards regression by hindering tumor-associated macrophages polarization.Huang et al have demonstrated in their study that C.bovis inhibits M2-tumour-associated macrophages(TAM)polarization by halting the Wnt/β-catenin pathway.The mechanism of action by which C.bovis exerts its anti-tumor effects is multifaceted and includes network pharmacology,transcriptomics and molecular docking.In vitro assays demonstrated that C.bovis-containing serum inhibited M2-TAMs polarization in human hepatocellular carcinomas cells.C.bovis was found to have 22 active components of which 11 were detected in the bloodstream.The anti-neoplastic activity of C.bovis lies in suppressing M2-TAM polarization by modulation of the Wnt/B-catenin pathway.In vitro and in vivo experiments have shown that C.bovis suppresses M2-TAM polarization and halts the Wnt signaling pathway.The inhibitory effect of C.bovis on M2-TAM was reversed by SKL2001,a Wnt agonist,which highlights C.bovis’s selectivity and specificity.C.bovis inhibits M2-TAM polarization by modulating the Wnt/β-catenin pathway,thus impeding liver cancer growth.Owing to the“cross-talk”between transforming growth factor-β(TGF-β)signaling pathways,this paper highlights the potential significance of C.bovis in controlling the tumor microenvironment not only through hindering the polarization of M2-TAMs via the Wnt signaling pathway,but also by downregulating TGF-β.Therefore,C.bovis serves as an igniter to fuel a cascade of signaling events that culminates in the regression of the tumor microenvironment by compromising oncogenesis and angiogenesis.TGF-βis also Core Tip:Calculus bovis(C.bovis)is an herb used in traditional Chinese medicine known for its various anti-inflammatory and anti-tumorigenic effects.C.bovis influences the tumor microenvironment by targeting immune-related pathways.Transcriptome sequencing revealed that C.bovis plays a crucial role in the regulation of M2-tumor-associated macrophages polarization and halting the Wnt/β-catenin pathway.This study provides a solid and promising evidence concerning potential drug therapy in the treatment of liver cancer.In this paper,we shed light on the inevitable“cross talk”between the Wnt and transforming growth factor-βsignaling pathways,thus connecting angiogenesis,oncogenesis and liver fibrosis.C.bovis is deemed a priming molecule that sets the stage for a series of related and inter-connected events,such as angiogenesis,hepatocarcinogenesis and hepatic fibrosis.This process brings about the“domino effect”whereby one event uncovers another related event as a falling row of dominoes.