Lung cancer screening in Lebanon: Joint statement from the Lebanese Pulmonary Society and the Lebanese Society of Medical Oncology

Lung cancer is the leading cause of cancer mortality worldwide. The 5-year survival rate of patients is ~15%, since the majority of patients present with the disease at an advanced stage. The resulting burden from this disease entails solid efforts towards early detection and smoking cessation. In Lebanon, the triad of high incidence and mortality from lung cancer, extensive tobacco consumption and delayed diagnosis calls for urgent actions. Furthermore, lung cancer screening with a low-dose computed tomog- raphy (CT) scan allows for the early detection and reduces mortality rates, as documented in several randomized trials and meta-analyses and recommended by international relevant societies. A panel of Lebanese lung cancer experts, members of the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society, have convened and discussed all aspects and challenges related to lung cancer screening implementation in Lebanon. Accordingly, national guidelines were proposed in this joint statement, which defines the particular high-risk population that would most benefit from screening. Pillars to success involve a solid, evidence-based national program, efficient smoking cessation programs and proper referral and follow-up. In parallel, the quality and logistical basic requirements must be optimized with well-equipped centers, trained personnel and expert radiologists; in addition to promoting awareness, adherence and sustainability. Physicians need to be trained to ensure accurate risk stratification for the screening and proper referrals from different specialties. Awareness should also be raised in the general population on the safety and benefits of low-dose CT, and to encourage smoking cessation via dedicated programs. In a country where the economic situation is challenging, and where third-party payers are resistant to cover screening initiatives, support from the Lebanese Ministry of Public Health is warranted, along with a cost-effectiveness analysis to uncover the elevated cost of treating advanced stage lung cancer. © 2023 The authors

Role of 18F-FDG PET/CT in the staging of non small cell lung cancer: Lebanese experience regarding 72 cases

Staging of non-small cell lung cancer (NSCLC) plays a key role in the therapeutic choice and directly affects the prognosis. The role of PET/CT (positron emission tomography) using 18-Fluorodeoxyglucose (FDG) for the staging of NSCLC was studied in the Lebanese population. We compared the results of PET/CT with those of the conventional CT scan in T and N staging for 72 patients; we correlated PET/CT outcome with tumor grade and determined the impact of the difference between staging NSCLC using PET/CT and CT on the therapeutic options. A positive correlation between the results of PET/CT and CT scan was found in 85[%] of cases. PET/CT has correctly classified pleural effusion as benign in three cases and as malignant in one case and increased the N stage by one point in three cases compared to injected CT scan. PET/CT improves the accuracy of staging of NSCLC allowing a good delineation of the primary tumor, a better evaluation of locoregional lymph node involvement and metastases and identification of the nature of pleural effusion

A Non-Interventional Multicenter Study of First-Line Bevacizumab in Combination with Chemotherapy in Patients with Metastatic Colorectal Cancer in Lebanon

Purpose: When combined with chemotherapy, bevacizumab improves progression-free survival (PFS) in metastatic colorectal cancer (mCRC). This observational trial was designed to assess the safety and efficacy of bevacizumab plus first-line chemotherapy in a real-world setting in Lebanon. Patients and Methods: A non-interventionaL multicenter study of first-LIne AVastin® (bevacizumab) in combination with chEmotherapy in patients with metastatic colorectal cancer (LLIVE) is a multicenter, prospective, Lebanon-based, observational study that enrolled mCRC patients who received first-line bevacizumab plus chemotherapy combination. The primary end point of the study was PFS. Secondary endpoints comprised the overall response rate (ORR) and the safety and tolerability of bevacizumab. Results: A total of 196 patients were enrolled between July 2010 and August 2013. The median duration of follow-up was 11 months. Median duration of bevacizumab treatment was 4 months with FOLFOX being the chiefly chemotherapy regimen used in the first-line setting (26%). Median PFS was 8.22 months (95% confidence interval (CI): 7.005–9.443). The ORR was 50.3% (complete response 7.5%, partial response 42.8%). The most common adverse event encountered was hypertension (28%) followed by epistaxis (4.8%), diarrhea (4%), anemia (4%) and headache (4%). Grade 3/4 adverse events occurred in 15.2% of patients. Conclusion: The trial further substantiated the efficacy and safety of bevacizumab and chemotherapy in the first-line treatment of mCRC patients in Lebanon. © 2022 Temraz et al. T

Genetic markers of chronic lymphocytic leukemia: a retrospective study of 312 patients from a reference center in Lebanon

Aim: Chronic lymphocytic leukemia (CLL) is a highly heterogenous hemopathy. Genetic stratification of CLL patients has important prognostic and therapeutic values - mainly immunoglobulin heavy chain variable region gene (IGHV) mutational status and the presence of cytogenetic abnormalities. The genetics of CLL in Lebanon is scarcely described in the literature. Patients & methods: In this work, we studied the genetic biomarkers of 312 Lebanese CLL patients. Results: Prominent IGHV genes were IGHV4-34, IGHV1-69 and IGHV3-30; and CLL #1 and #5 presented major subsets. Some similarities as well as major differences were highlighted when comparing our data with previously published data. Conclusion: The distribution of IGHV alleles in our series differed from previously described distributions, suggesting involvement of antigenic selection and regional variables in CLL pathogenesis. © 2023 Future Medicine Ltd

Placenta accreta: Elective versus emergent delivery as a major predictor of blood loss

OBJECTIVE: To compare blood loss and the use for blood transfusion between elective (planned) and emergent cesarean hysterectomy performed for placenta accreta by a single, multidisciplinary team and to present the team's pre-operative evaluation and the surgical technique. STUDY DESIGN: Prospective cohort study at a single tertiary care center. Maternal and neonatal outcomes were compared between elective and emergent delivery of pregnancies complicated by placenta accreta. The primary outcomes were the need for blood transfusion and the number of units transfused. RESULTS: A total of 28 cases of confirmed placenta accreta underwent peripartum hysterectomy, including 22 as elective and 6 as emergent. Eleven out of 22 (50%) subjects in the elective group received blood transfusion, while all subjects in the emergency group required transfusion (p=0.03). More importantly, the number of units of packed red blood cells transfused was only 1.90 (±2.20) units in the elective cases compared to 7.83 (±4.90) units in cases performed emergently (p=0.03). CONCLUSION: Elective cesarean hysterectomy for this indication using a clearly outlined surgical approach is associated with significantly lower blood loss and hence less need for transfusion, compared to its emergent counterpart. © 2017-IOS Press and the authors

Management of Multiple Myeloma in the Middle East: Unmet Needs, Challenges and Perspective

Multiple myeloma (MM) is a prevalent hematological malignancy. Resource-constrained settings such as the Middle East are particularly burdened by the increasing trends in MM morbidity and mortality in addition to challenges in the management of MM. It thus becomes necessary to identify and address debatable areas of current practice and gaps in the management of MM in the Middle East. With a special focus on the Lebanese situation, the first-line treatment of the very elderly (> 80 years old) is discussed, in addition to the impact of relapse type (biochemical or clinical relapse) on maintenance therapy, the choice of first relapse therapy in relation to maintenance therapy, and the role of MRD in the MM treatment landscape. The need for realistic management guidelines accounting for local resources and expertise, in addition to the reflection of drug accessibility and cost on clinical practice are recognized. © 2022, The Author(s)

Diagnosis and management of patients with stage III non‑small cell lung cancer: A joint statement by the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society (Review)

Proper management of stage III non‑small cell lung cancer (NSCLC) might result in a cure or patient long‑term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncolo‑ gists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scan‑ ning remains a cornerstone in the discovery of a lung lesion, a positron‑emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case‑by‑case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncolo‑ gist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unre‑ sectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physi‑ cian panel, available literature and evidence governing the treatment, management and follow‑up of patients with stage III NSCLC. © 2023 Spandidos Publications. All rights reserved

A Phase 1/2 Study of Mini-Hyper-Cvd Plus Venetoclax in Patients With Relapsed/Refractory Acute Lymphoblastic Leukemia

Preclinical studies suggest that Bcl-2 inhibition with venetoclax has antileukemic activity in acute lymphoblastic leukemia (ALL) and may synergize with conventional chemotherapy. We designed a phase 1/2 clinical trial to evaluate the safety and efficacy of low-intensity chemotherapy in combination with venetoclax in adults with relapsed or refractory ALL. Patients received the mini-hyper-CVD regimen (dose-attenuated hyperfractionated cyclophosphamide, vincristine, and dexamethasone alternating with methotrexate and cytarabine) in combination with venetoclax (200 mg or 400 mg daily) on days 1 to 14 in cycle 1 and on days 1 to 7 in consolidation cycles. Twenty-two patients were treated. The median number of prior therapies was 2 (range, 1-6). Thirteen patients (59%) had undergone prior allogeneic stem cell transplant (allo-SCT), and 7 of 18 patients (39%) with B-cell ALL had previously received both inotuzumab ozogamicin and blinatumomab. The recommended phase 2 dose of venetoclax in the combination regimen was 400 mg daily. The composite complete remission (CR) and CR with incomplete hematologic recovery (CRi) rate was 57% (CR, 43%; CRi, 14%), and 45% of responders achieved measurable residual disease negativity by multiparameter flow cytometry. Four patients proceeded to allo-SCT. The median duration of response was 6.3 months. The median overall survival was 7.1 months, and the 1-year overall survival rate was 29%. The most common grade ≥3 nonhematologic adverse events were infection in 17 patients (77%) and febrile neutropenia in 4 patients (18%). Overall, the combination of mini-hyper-CVD plus venetoclax was active in heavily pretreated relapsed/refractory ALL. Further development of venetoclax-based combinations in ALL is warranted. This trial is registered at www.clinicaltrials.gov as #NCT03808610

Crohn's disease: A retrospective analysis between computed tomography enterography, colonoscopy, and histopathology

Introduction: To investigate the spectrum of computed tomography enterography (CTE) findings of active Crohn's disease (CD) in comparison to endoscopic, histopathologic and inflammatory markers. Methods: Hospital records of 197 patients with known or suspected CD who underwent CTE over a period of 5 years were reviewed. Eighty-nine patients fulfilled the inclusion criteria. Three-point severity scores for endoscopy, pathology, and haematologic inflammatory markers were recorded. The findings on CTE were identified by three readers and correlated with endoscopic, pathologic, and haematologic severity scores. Statistical analysis was carried out employing a Pearson Chi square test and Fisher exact test. Receiver operating characteristic (ROC), visual grading characteristic (VGC) and Cohens’ kappa analyses were performed. Results: The CTE findings which were significantly correlated with the severity of active disease on endoscopy include bowel wall thickening, mucosal hyperenhancement, bilaminar stratified wall enhancement, transmural wall enhancement, and mesenteric fluid adjacent to diseased bowel (p < 0.05). Only bowel wall thickening and bilaminar stratified wall enhancement correlated with the pathological severity of active CD. ROC and VGC analysis demonstrated significantly higher areas under the curve (p < 0.0001) together with excellent inter-reader agreement (k = 0.86). Conclusion: CTE is a reliable tool for evaluating the severity of active disease and helps in the clinical decision pathway. © 2019 The College of Radiographer