Background Nodal disease is prognostic in pancreatic ductal adenocarcinoma (PDAC); however, optimal number of examined lymph nodes (ELNs) required to accurately stage nodal disease in the current era of neoadjuvant therapy remains unknown. The aim of the study was to evaluate the optimal number of ELNs in patients with neoadjuvantly treated PDAC. Methods A retrospective study was performed on patients with PDAC undergoing resection following neoadjuvant treatment between 2011 and 2018. Clinicopathological data were extracted and analyzed. Results Of 546 patients included, 232 (42.5%) had lymph node metastases. The median recurrence free survival (RFS) was 10.6 months (95% confidence interval: 9.7–11.7) and nodal disease was independently associated with shorter RFS (9.1 vs 11.9 months; p < 0.001). A cutoff of 22 ELNs was identified that stratified patients by RFS. Patients with N1 and N2 disease had similar median RFS (9.1 vs 8.9 months; p = 0.410). On multivariable analysis, ELN of ≥ 22 was found to be significantly associated with longer RFS among patients with N0 disease (14.2 vs. 10.9 months, p = 0.046). However, ELN has no impact on RFS for patients with N1/N2 disease (9.5 vs. 8.4 months, p = 0.190). Adjuvant therapy was associated with RFS only in patients with residual nodal disease. Conclusions Lymph node metastases remain prognostic in PDAC patients after neoadjuvant treatment. Among N0 patients, a cutoff of 22 ELN was associated with improved RFS and resulted in optimal nodal staging.

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BackgroundThe coronavirus disease 2019 , declared a pandemic in March 2020, has affected the entire healthcare system, including the surgical practice. Guidelines for the management of surgical patients during this COVID-19 era need to be established to provide timely yet safe surgical care. In this study, we aimed to evaluate the outcomes of the COVID-19 testing algorithm established for surgery patients presenting to a tertiary care hospital in Karachi, Pakistan, and to compare the outcomes among patients who underwent elective versus emergency surgery. MethodologyThis is a cross-sectional study conducted at a tertiary care hospital in Pakistan to apply and assess the outcomes of the COVID-19 testing algorithm established for patients presenting for surgery. We included all patients who underwent any surgery from May to October 2020. The total sample size was 6,846. The data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA). The categorical variables were assessed using the chi-square or Fisher's exact test. A p-value of <0.05 was considered significant. ResultsA total of 6,846 surgeries were performed from May 1 to October 31, 2020. In total, 74% of the surgeries were elective procedures. We observed that a significantly higher proportion of emergency surgery patients tested positive for COVID-19 (4.2%) compared to elective surgery patients (25/5,063, 0.5%). A higher proportion of surgeries were performed in September (1,437, 21%) and October (1,445, 21%) while the lowest number of surgeries were performed in May (625, 9.1%). From week one to week five, a higher proportion of emergency surgeries were performed (32%) compared to elective surgeries (25%). Only 1.9% of the patients who were undergoing surgery were COVID-19 positive, with the highest number of COVID-19 cases presenting in June. Overall, 74.7% of the COVID-19-positive patients underwent emergency surgeries. ConclusionsThe timely establishment of well-defined guidelines for surgical management during the pandemic allowed us to provide timely and effective surgical care to patients with the priority of minimizing the spread of COVID-19 and preventing unnecessary deferral of surgeries.

Objective: To combat the lack of brain tumour registries, the Pakistan Brain Tumour Epidemiology Study (PBTES) was conducted without any funding from an external source. Methods: A retrospective analysis of patient data, including patients of all age groups diagnosed with all histopathological types of brain tumours from all over Pakistan, was performed. For this, Pakistan Brain Tumour Consortium (PBTC) was established, including 32 neurosurgical centres from around the country. Data was collected online through a proforma that included variables such as patient demographics, clinical characteristics, operative details, postoperative complications, survival indices, and current functional status. The data collection and analysis team included principal investigators, core leads, regional leads, regional associates, and student facilitators. Despite logistical concerns and lack of resources, the PBTES was conducted successfully, and a formal brain tumour surveillance database was formed without any external funding, which remains unheard of. Conclusion: The methods applied in this study are reproducible and can be employed not just to develop more robust brain tumour and other cancer registries but also to study the epidemiology of communicable and non-communicable diseases in resource-limited settings, both locally and globally.  Keywords: brain neoplasms, retrospective study, epidemiology, noncommunicable diseases. Continue...

Objective: To observe the patient characteristics and centres providing neuro-oncological care in public and private health hospitals in Pakistan. Methods: The Pakistan Association of Neuro-oncology carried out a retrospective, cross-sectional study in 2019 on patients admitted to 32 hospitals in Pakistan, with dedicated neurosurgical facilities. Patients with a histopathological diagnosis of an intracranial tumour were included. Results: Public health care facilities catered for 84% patients with ages between 20 and 60 years and children having intracranial tumours. Private centres were utilised by 66.7% patients from the upper socioeconomic sector. More patients were lost to follow-up in the public sector (n = 784) versus in the private sector (n = 356). Mortality was also higher in the public sector hospitals, (13.9%) as compared to 9.6% in the private sector. Conclusion: Public and private sector health services for neuro-oncological care in Pakistan still have a long way to go to cover the gaps for unmet needs. Strengthening health systems for brain tumour care is imperative to increase both the access to care and the quality of care to fulfil this need. Keywords: Retrospective study, Health systems, Brain neoplasms, Health care, Epidemiology, Chemoradiotherapy.

INTRODUCTION Gliomas are the most common malignant brain tumors of the central nervous system in adults. Specialized treatment modalities have improved morbidity and mortality within high-income countries. In lower- and middle-income countries (LMICs), the overall mortality rate is still seen to be alarmingly high. As there is a shortage of statistical data available regarding the epidemiology of these tumors and their management within the country, the objective of this study is to define the landscape of treatment patterns and current epidemiological data regarding gliomas in Pakistan. METHODS As part of the Pakistan Brain Tumor Epidemiology Study (PBTES), data was collected from major neurosurgical centers across the country, consisting of 35 hospitals in all 4 provinces. Our retrospective study looked at patients who underwent surgical procedures for gliomas in 2019, where a surgical pathology was available. The data was collated and analyzed using appropriate statistical methods. RESULTS 791 patients with gliomas were identified (61.8 % in public sector hospitals, 39.1% in private sector). The most common histopathological subtypes were glioblastoma (33.5%), followed by astrocytoma (18.8%) and oligodendroglioma (11.9%). Gender distribution was skewed towards men (65%). The most commonly performed initial surgical procedure was gross total resection (50% in public hospitals, 41% in private hospitals). Private institution hospitals performed surgical biopsies as the first surgical procedure (23%) more often than public hospitals (9%). Regarding adjuvant treatments, only 26% of patients were given chemotherapy, and there was no data regarding 53% of patients. Similarly, only 15% of patients received radiation therapy, and there was no data for 60% of patients. CONCLUSIONS Our study was able to identify the gaps in glioma management within Pakistan, particularly with regards to chemoradiotherapy. Identifying these unmet needs is the first step in developing comprehensive care for glioma patients.

INTRODUCTION Global oncology development within LMICs (low- and middle-income countries) requires bridging gaps in healthcare systems. Brain tumor care in Pakistan is currently sparse and concentrated in urban centers. Distance traveled to a hospital dictates a patient’s access to care, neurosurgical access, and continuity of care through adjuvant chemoradiotherapy and primary care providers can be disrupted if patients cannot overcome the barriers due to extensive distances traveled. METHODS Data was collected as part of the Pakistan Brain Tumor Epidemiology Study (PBTES) regarding patients with brain tumors who underwent surgical procedures in 2019 at private and public major neurosurgical centers across Pakistan. Using patient addresses, we used a mapping software to calculate the distance traveled by each patient to the primary hospital. Analysis was done using appropriate statistical methods. RESULTS Out of 2403 patients, the mean distance traveled across the country was 240 km. The longest distance traveled within Pakistan was from Skardu to Karachi (2002 km) for resection of a pituitary adenoma (28 hours via car). Only 48% of patients were able to reach their primary hospital within 50 km. 52% of patients had to travel more than 50 km, and 18% had to travel upwards of 500 km to reach their primary hospital. Additionally, 101 patients traveled to Pakistan from other countries for brain tumor surgery (98 patients from Afghanistan [mean distance traveled: 723.6 km], 3 patients from Syria, Oman, and Sudan). CONCLUSION Prior studies have described a cut-off of 50 km as an acceptable limit for distance from the primary hospital in cancer patients for optimal follow-up and outcomes, which is achieved by only 48% of brain tumor patients in Pakistan. Most patients have poor access to surgical care for brain tumors, further compounded by repeat traveling for follow-ups and chemoradiotherapy.

Very little research has been conducted on brain tumor epidemiology in Pakistan and a few studies that do exist provide regional data only. Conducting population based epidemiological studies in low-and-middle income countries (LMICs) like Pakistan can be particularly challenging due to limited resources, poor clinical and research infrastructure, unreliable or incomplete hospital records and a lack of standardization across the health care system. Population-wide studies and registries play an important role in cancer epidemiology and can help identify the current magnitude of cancer burden and its likely future evolution, allowing for better planning of prevention, diagnosis, management, and rehabilitation. This paper describes our experience in designing and conducting Pakistan Brain Tumor Epidemiology Study (PBTES), a first-ever nationwide study carried out to assess the distribution of brain tumors in Pakistan. In addition to the aforementioned obstacles, we were also faced with the global health crisis caused by the COVID-19 pandemic and had to promptly adjust our study accordingly. Other investigators conducting epidemiological studies in LMICs with similarly challenging and constricting settings could benefit from our experiences.