Table of Contents

Original Articles Outcomes and Impact of a Universal COVID-19 Screening Protocol for Asymptomatic Patients...... 07 Rafal R. Iskanderian, Ahmed Karmstaji, Baraa Kamal Mohamed, Shayma Alahmed, Mohamad H. Masri, Elie Choufani, Humaid Al Shamsi, Naveed Ahmed, Stephen R. Grobmyer Onset of Arterial and Venous Thrombosis and Safety of Antithrombic Therapy in Patients with Gastrointestinal Cancer...... 13 Sayuri Hashimoto, Yoichiro Yoshida, Daisuke Kato, Fumihiro Yoshimura, Suguru Hasegawa Cytoreductive plus Hyperthermic Intraperitoneal in Primary Advanced : The First Reported Pilot Experience from Saudi Arabia...... 19 Ahmed Abu-Zaid, Osama Alomar, Mohammed Abuzaid, Mohannad Alsabban, Hany Salem, Ismail A. Al-Badawi Frequency and Characteristics of Incidental Pulmonary Embolism in Cancer Patients: A Retrospective Study at a Large Oncology Center in Saudi Arabia...... 26 Mohammed W. Althobaiti, Abdullah M. Al Jehani, Mohammed S. Alqarni, Ziad M. Bukhari, Azzam A. Khankan Trends in Thyroid Cancer Incidence in the Gulf Cooperation Council States: a 15-Year Analysis...... 31 Eiman Alawadhi, Amal Al-Madouj, Ali Al-Zahrani An Overview of Medullary Thyroid Cancer Cases Treated at Kuwait Cancer Control Center...... 39 Jitendra Shete, Khaled Al Saleh, Reham Safwat, Ahmed Bedair, Mustafa El Sherify, Amany Hussein, Marwa Nazeeh, Asit Mohanty Lung Cancer in Bahrain: Histological and Molecular Features...... 48 Aalaa Mubarak, Eman Aljufairi, Sayed Ali Almahari Current Status of Cancer-Related Pain and Opioid use in South Lebanon: A Pilot Study...... 52 Fadi S. Farhat, Mohamed Tarabey, Feras Chehade, Tarek Assi, Joseph Kattan Adjuvant Irradiation in Carcinoma Breast Patients: Comparison of 3DCRT and Semi-automated Complex VMAT Hypofractionated Plans...... 58 Akanksha Solanki, Sri Harsha Kombathula, Sumanta Manna, Sanjib Gayen, Sweta Soni, Shekhar Anand, Puneet Pareek, Rakesh Kumar Vyas, Sonal Varshney, Amit Mohan, Sujoy Fernandes Relationships between AML1-ETO and MLL-AF9 fusion gene expressions and hematological parameters in acute myeloid leukemia ...... 65 Abdel Rahim Mahmoud Muddathir, Tarig A. M. Hamid, Elwaleed Mohamed Elamin, Omar F Khabour Review Articles Cancer Risk Factors Among Omanis: A Review...... 70 Abdul Hakeem Alrawahi, Asia Alnaamani, Najla A. Al-Lawati Surgical Management of Bone Sarcomas with an Inappropriate Site: A Case Series and Review of Literature...... 78 Subbiah Shanmugam, Syed Afroze Hussain, Kishore Kumar Reddy Case Reports Basaloid Nasopharyngeal Carcinoma: An Entity That Remains Oblivious...... 83 Satesh Kumaran Ganeson, Jeyasakthy Saniasiaya, Irfan Mohamad, Norhaslinda Abdul Gani : A Case Report...... 87 Turki Alhazmi, Ahmed Abduljabbar, Mohammed Alem, Amr Mansouri, Khaled Bahubaishi Conference Highlights/Scientific Contributions • News Notes...... 91 • Scientific events in the GCC and the Arab World for 2020...... 95 Case Report Pancreatoblastoma: A Case Report Turki Alhazmi1, Ahmed Abduljabbar2, Mohammed Alem3, Amr Mansouri2, Khaled Bahubaishi2 1 Division of Radiology, Umm Al-Qura University, Makkah, Saudi Arabia 2 Division of Radiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia 3 Division of Radiology, King Abdullah Medical City Hospital, Makkah, Saudi Arabia

Abstract and CT scan play a significant role in preoperative diagnosis, which is often quite difficult. The best treatment Pancreatoblastoma (PB), also known as infantile is surgical removal of the . The role of adjuvant pancreatic carcinoma, is an exceedingly rare pancreatic chemotherapy or radiotherapy is still under consideration tumor in childhood, which is considered a malignant due to a minor number of patients treated. Chemotherapy exocrine pancreatic tumor. Some cases have been regimens consisting of cyclophosphamide, etoposide, reported in Saudi Arabia. Although PB primarily presents doxorubicin, and cisplatin have been used in the during childhood, it may occur in adults too. PB tends to neoadjuvant setting with anecdotal benefit. It was found be less hostile in infants and children when compared to that a poorer prognosis was associated with patients who adults. Histologically, PB is characterized by distinguished had metastasis, and patients who could not be operated acinar and squamoid cell differentiation. Most of these on surgically. tumors develop in the head of the pancreas and increase Keywords: Pancreatic - Pancreatoblastoma alpha-fetoprotein in up to 68% of patients. Ultrasound

Introduction a large mass occupying most of the left side of the . CT scan of the abdomen was performed, which Pancreatoblastoma is an extremely rare pancreatic showed an exophytic mass probably arising from the left tumor in childhood. It was reported for the first time in liver lobe. The CT report offered the following differential [1] 1957 . Pancreatoblastoma usually affects children diagnoses: primary liver lesions such as , ranging from one to eight years old and also may be seen HCC, and less likely mesenchymal tumor; Secondary liver [2, 3, 4] in elderly individuals . It is usually misdiagnosed as lesions such as metastasis and lymphoma. Furthermore, neuroblastoma or hepatoblastoma in children under the pancreatic origin of the mass could not be entirely age of 7 years. Partially differentiated acini of fetal origin excluded due to the absence of fat planes between the will be noticed in pathology analysis of pancreatoblastoma mass and the pancreas. MRI of the liver was advised [5,6] . The presenting symptoms are palpable mass with and pediatric surgery consultation was sent. MRI of the [7] anorexia, vomiting, and abdominal pain . abdomen was done {Figures 1, 2, 3, and 4} and it showed The tumor is clinically silent and large in size at the time a large upper abdominal mass exerting mass effect on of presentation. The symptoms are mostly due to the adjacent structures namely the liver, pancreas, and mass effect and include abdominal pain, vomiting and with no clear invasion to the adjacent vessels. [7] constipation . This mass, according to the MRI, was likely originating from the pancreas, however hepatic origin could not Case Presentation be totally excluded. Further clinical evaluation, surgical A 9-year-old girl presented with abdominal pain consultation, and histopathological correlation was and abdominal mass. The abdominal pain started three advised. Her laboratory work-up including chemistry was years ago, it was mild and nonspecific. The patient was admitted many times as a case of abdominal pain for investigation that was treated as urinary tract infections. Corresponding author: Amr Mansouri, MBBS - Later on, the pain increased in severity with associated Radiology resident at King Abdulaziz University weight loss. Upon examination, she looked sick, in pain Hospital, Jeddah, Saudi Arabia. Contact email: and cachectic. Cardiothoracic and CNS examinations were [email protected] unremarkable. Abdominal examination demonstrated

87 Pancreatoblastoma: A Case Report, Turki Alhazmi, et. al. unremarkable except for an elevated alpha-fetoprotein. A are exceptionally rare, causing less than 0.2% of pediatric pediatric surgeon assessed the patient and took a tissue deaths due to [2,8,9,10]. The congenital form is biopsy. The biopsy histopathology report confirmed the associated with Beckwith-Wiedemann syndrome and diagnosis of pancreatoblastoma - stage III. has been characterized as a cystic form [9,11]. Patients with PB have been reported with an elevated Alpha- The patient received chemotherapy as per PLADO fetoprotein that could reach up to 68%. About 4% of the protocol as tolerated. After seven months, CT scan was patients were reported to have the risk of malignancy repeated for the patient {Figures 5, 6, and 7} and showed (nephroblastoma, hepatoblastoma, rhabdomyosarcoma significant reduction in mass size that was followed by and pancreatoblastoma) that is associated with surgical resection. The surgery showed that the tumor was Beckwith-Wiedemann syndrome. Usually in ultrasound arising from the proximal part of the body of the pancreas, it demonstrates a large, well-defined, heterogeneous emerging through the lesser omentum, involving the lesser mass with solid and multilocular cystic areas that contain curvature of the stomach, and infiltrating the lower part of hyperechoic septae. Dilatation of the biliary duct is not the hepatic segment 4 without lymphadenopathy {Figure 8}. common as the tumors themselves are soft. Discussion Although they are frequently large at presentation, CT findings usually show well defined, heterogeneous Pancreatoblastoma is an extremely rare primary masses of solid and multilocular cystic components neoplasm of childhood that has been seen in both young with enhancing septa, which may demonstrate fine and elderly populations, but usually affects children calcifications similar to those seen in neuroblastoma. ranging from 2–8 years old. Pancreatic tumors in children Generally, it occurs in the head of the pancreas, which

Figure1A and 1BAxial and coronal T2WI demonstrates an exophytic mass arising from the pancreatic body and tail. It displacing the left hepatic lobe anteriorly with definite invasion. It shows predominantly low signal intensity lesion with multiple areas of cystic degeneration.

Figure 2: Axial T1WI demonstrates an exophytic mass aris- Figure 3: Axial T1WI with fat saturation and post gadolini- ing from the pancreatic body and tail. It displacing the left um administration. It demonstrates a heterogeneously en- hepatic lobe anteriorly with definite invasion. It shows pre- hancing exophytic mass arising from the pancreatic body dominantly low signal intensity. and tail. 88 G. J. O. Issue 34, 2020 tend to be large and solitary with uncommon dilatation of the . Invasion of adjacent structures may happen Summary less frequently and the biliary tree could be noted. MRI Pancreatoblastoma is an extremely rare pancreatic findings would show low‐intermediate signal intensity tumor in childhood. It usually presents late with upper on T1, heterogeneous hyperintense signal on T2 [12]. abdominal pain, and many have a palpable mass in the Histologically, pancreatoblastoma is characterized by epigastrium. Alpha-fetoprotein may be elevated in up to the presence of squamous corpuscles and aggregates or 68% of patients. [1] large epithelioid cells with formation of acini . Radiological findings are not specific. However, Surgical resection is the primary treatment of the location, the age and the imaging appearance are pancreatoblastoma. The role of adjuvant chemotherapy all helpful to reach the diagnosis. Histologically, PB is for the surgically resectable tumor is uncertain, although characterized by the presence of squamous corpuscles chemotherapy is commonly used on an empiric basis [13]. and aggregates or large epithelioid cells with formation of Radiotherapy and chemotherapy are added for metastatic acini. Surgical resection is the optimal treatment method. or recurrent disease [14]. The prognosis is good for patients Chemotherapy and radiotherapy are commonly used in with a resectable mass [15]. the setting of metastasis or recurrence. References 1. Becker WF. Pancreatoduodenectomy for carcinoma of the pancreas in an infant; report of a case. Ann Surg. 1957;145(6):864‐872. doi:10.1097/00000658- 195706000-00008 2. Shorter NA, Glick RD, Klimstra DS, Brennan MF, Laquaglia MP. Malignant pancreatic tumors in childhood and adolescence: The Memorial Sloan-Kettering experience, 1967 to present. J Pediatr Surg. 2002;37(6):887‐892. doi:10.1053/jpsu.2002.32897 Figure 4: DWI image demonstrating a restricted diffusion predominantly peripherally within the mass.

Figures 5, 6 and 7: Axial CT post contrast images at the level of the tumor demonstrating heterogeneous enhancement and interval regression of the tumor post chemotherapy.

3. Klöppel G, Maillet B. Classification and staging of pancreatic nonendocrine tumors. Radiol Clin North Am. 1989;27(1):105‐119. 4. Friedman AC, Edmonds PR. Rare pancreatic . Radiol Clin North Am. 1989;27(1):177‐190. 5. Horie A, Yano Y, Kotoo Y, Miwa A. Morphogenesis of pancreatoblastoma, infantile carcinoma of the pancreas: report of two cases. Cancer. 1977;39(1):247‐254. doi:10.1002/1097-0142(197701)39:1<247: aid- cncr2820390138>3.0.co;2-f Figure 8: Axial CT post contrast image showing complete 6. Cubilla AL, Fitzgerald PJ. Classification of resolution of the tumor post- surgical resection with no (nonendocrine). Mayo Clin Proc. 1979;54(7):449‐458. radiological evidence of recurrence 89 Pancreatoblastoma: A Case Report, Turki Alhazmi, et. al.

7. Passmore SJ, Berry PJ, Oakhill A. Recurrent pancreatoblastoma with inappropriate adrenocorticotrophic hormone secretion. Arch Dis Child. 1988;63(12):1494‐1496. doi:10.1136/adc.63.12.1494 8. Chang CH, Perrin EV, Hertzler J, Brough AJ. Cystadenoma of the pancreas with cytomegalovirus infection in a female infant. Arch Pathol Lab Med. 1980;104(1):7‐8. 9. Klimstra DS, Wenig BM, Adair CF, Heffess CS. Pancreatoblastoma. A clinicopathologic study and review of the literature. Am J Surg Pathol. 1995;19(12):1371‐1389. doi:10.1097/00000478-199512000-00005 10. Levey JM, Banner BF. Adult pancreatoblastoma: a case report and review of the literature. Am J Gastroenterol. 1996;91(9):1841‐1844. 11. Drut R, Jones MC. Congenital pancreatoblastoma in Beckwith-Wiedemann syndrome: an emerging association. Pediatr Pathol. 1988;8(3):331‐339. doi:10.3109/15513818809042976 12. Radiopaedia.org/articles/pancreatoblastoma. 13. Chung EM, Travis MD, Conran RM. Pancreatic tumors in children: radiologic-pathologic correlation. Radiographics. 2006;26(4):1211‐1238. doi:10.1148/rg.264065012 14. Willnow U, Willberg B, Schwamborn D, Körholz D, Göbel U. Pancreatoblastoma in children. Case report and review of the literature. Eur J Pediatr Surg. 1996;6(6):369‐372. doi:10.1055/s-2008-1071019 15. Chun Y, Kim W, Park K, Lee S, Jung S. Pancreatoblastoma. J Pediatr Surg. 1997;32(11):1612‐1615. doi:10.1016/ s0022-3468(97)90465-6

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