Survival of patients with multiple myeloma has increased significantly during the past two decades. This has been attributed to a better understanding of biology, the introduction of novel agents (immunomodulators, proteasome inhibitors), autologous stem cell transplantation, and maintenance therapy. Supportive care is an important component of overall care for these patients. Most patients have a high burden of symptoms at initial presentation in form of bone pains, fatigue, anemia, renal impairment, and infections, etc. Almost 10–20% of patients may have serious complications in the first 4–6 weeks. A high index of suspicion and timely intervention is important to reduce morbidity and mortality. Therapy-related complications, e.g., neuropathy, thromboembolism, cytopenias, GI symptoms (constipation/diarrhea), and relapse of disease, pose therapeutic challenges. Protocol-based approach, systematic assessment with respect to the quality of life and functioning and coordination with a palliative care team from the beginning may improve overall functioning and outcome.

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All-trans-retinoic acid (ATRA) has shown a significant improvement in the outcome of patients of acute promyelocytic leukemia and is associated with certain unique adverse effects. We report one such case of APL, who developed ATRA syndrome on day 7 of ATRA, which was relieved after ATRA withdrawal and dexamethasone therapy. Subsequently, with the reintroduction of ATRA, patient developed an unexplained fever which was followed by multiple painless ulcers over the scrotum on day 28 of ATRA. ATRA was withdrawn so as not to induce Fournier’s gangrene, and ulcers were closely monitored without the administration of systemic or local corticosteroids. Eventually, ulcers improved and completely healed by 4 weeks. This is a rare case report, wherein the same patient develops ATRA syndrome followed by scrotal ulcers, suggesting that the scrotal ulcer is a rare specific adverse effect of ATRA and its monitoring is required especially in patients having unexplained fever and leucocytosis.

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Background: Radiotherapy to a patient with cervical cancer can be delivered by four-field “box technique” with a benefit of much less dose to intervening tissues along with a better and homogenous dose distribution at the target location. An important ingredient for a good radiotherapy planning is the choice of beam energy. The present study aims to investigate the feasibility of a 4 MV photon beam for the treatment of cervical cancers. Materials and Methods: A population of 20 patients, with carcinoma cervix, was included in the study. All the patients were planned for a prescribed dose of 45 Gy in 25 fractions. Results: Plans were evaluated for planning target volume and found better in terms of coverage and hot spots using 6 MV. The homogeneity index (HI) was 1.1 for both the energies. Similarly, conformity index (CI) was 2.0 depending on the method used for 4 MV and 6 MV photons. Although the HI and CI were comparable for both the plans, yet it seems significantly better for 6 MV. This indicates that spillage in 6 MV plans is lesser as compare to 4 MV. The present study reveals that there is a significant reduction in total monitor units in the plans with 6 MV photon beams, leading to fewer chances of secondary malignancies. Conclusion: A 6 MV photon beam has some proven mileage over 4 MV in terms of target coverage, dose homogeneity, and conformity and remains the best suitable photon energy for the treatment of cervical malignancies.

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Epithelioid hemangioma (EH) of the bone is classified within benign vascular tumors. They are uncommon locally aggressive neoplasms. Tumors usually involve long tubular bones. We report a case of EH of clavicle in a 12-year-old girl treated with tumor resection and fibular grafting.

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Orbital metastasis is rare in breast cancer. We present a case of a 45-year-old premenopausal lady with hormone positive locally advanced breast cancer managed with surgery, chemotherapy, radiation therapy and adjuvant hormone therapy, had systemic failure after 6 years of completion of definitive therapy, in the form of orbital and vertebral metastases. Patient was investigated for other causes, however was found to have 2.6 x 2.0 x 2.9 cm mass encasing the optic nerve, causing early vision loss in one eye, with minimal proptosis. She was not under any adjuvant hormone therapy during the relapse. She was treated with external beam radiotherapy followed by tamoxifen, which showed good partial response radiologically and gradual improvement in her vision and regression of the tumor.

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Renal cell carcinoma (RCC) arising in a renal tissue away from the normal kidney is quite rare with only a few cases reported in the literature. The management of such cases is challenging and requires an individualized treatment approach. We report a case of a young male with a prior history of pyelolithotomy who presented with a right paravertebral mass. CECT chest and abdomen revealed a soft-tissue mass near the right kidney with obvious infiltration into posterior abdominal wall muscles and 12th rib erosion. Image-guided biopsy of the mass demonstrated features of metastatic RCC. The patient underwent surgery with en bloc removal of the tumor with 12th rib, infiltrated paraspinal muscles, a small part of the densely adhered right kidney, and overlying skin. Histopathology with recommended IHC panels showed papillary RCC. Because of the above, the multidisciplinary tumor board considered this as a malignancy arising from a pyelolithotomy scar. The patient was planned for follow-up only without any adjuvant treatment. This case highlights the importance of a multidisciplinary team approach and comprehensive planning in such rare and perplexing cases.

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Background: In Saudi Arabia, colorectal cancer (CRC) accounts for 11.5% of cancer incidence, where nearly one-third is metastatic. Global guidelines recommend accurate pretreatment staging to determine resectability and stage-directed treatment. Computed tomography (CT) scan is among the widely used imaging for staging. However, at times, the characterization of abnormalities detected by CT scan is perplexing. Indeterminate pulmonary nodules (IPNs) are nodules that are neither benign nor malignant, which are incidentally detected on baseline staging chest CT. We aimed to estimate the prevalence of IPN that were identified among CRC patients. Materials and Methods: We conducted a retrospective record review of all newly diagnosed CRC patients between June 2013 and June 2018 from an academic hospital in Jeddah, Kingdom of Saudi Arabia (KSA). Demographics and certain prespecified variables were collected. The presence of IPN on staging chest CT as per consultant radiologist report was documented, and the ability of other modalities to identify the nature of IPN was compared. Data were analyzed using SPSS and a P value < 0.05 was considered significant. Results: Of 283 CRC patients, 208 (73.5%) underwent chest CT, and the mean age was 57.4 years (±SD 13.1). The prevalence of IPN among CRC patients is 17.7%. Thirty IPN patients had a follow-up chest CT for IPN, which identified IPN nature in 18(60%) of them. The likelihood of IPN to be CRC-related metastasis was significantly associated with the presence of synchronous liver metastasis (P = 0.0005), younger age (P = 0.022), and colon cancer (P = 0.011). Conclusion: The prevalence of IPN was 17.7%, which is different in comparison to other studies from different countries. There is a vital need for unified guidelines describing IPN to accurately stage CRC patients, decrease unnecessary follow-ups, and acquire the exact prevalence of IPN.

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Colorectal cancers have been a major burden in our society, with nearly 20,000 deaths in a year. Most of the patients are diagnosed with metastatic disease at presentation and have shorter survival despite the best effective treatment. The detection of novel targets and predictive biomarkers has changed the treatment paradigm, resulting in improved quality of life and prolonged survival in these patients. However, the identification of an ideal biomarker has been a major challenge and a quest for better biomarkers to detect premalignant lesions, early-stage cancers; to identify high-risk subsets who derive maximum benefit from adjuvant chemotherapy and minimize unnecessary chemo-toxicity; to identify newer targeted therapies in advanced stage to improve clinical responses; and to provide personalized treatments that would significantly help in improving survival outcomes. In this review article, we provide an overview of the biomarkers with clinical importance and an update on newer noninvasive, sensitive, and clinically reliable biomarkers in development.

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