Background: Anal fissure is a common complication of the anorectal region and one of the most reported causes of anal pain. Acute anal fissure can be cured by surgery or medical treatment. There is an increase in the use of topical therapy for the treatment of anal fissures. A common topical drug used is Diltiazem (DTZ), a calcium-channel blocker, which relaxes the anal sphincter and thus promotes healing of the anal fissure. Moist exposed burn ointment (MEBO) is an ointment that is effective for the treatment of burns and wound healing and is becoming popular in the treatment of anal fissures. Methods: This is a 1:1:1 randomized, controlled, parallel design, with endpoint measures of change in pain score, wound healing, defecation strain score and patient’s global impression of improvement. The study will be conducted at AUBMC over a 10-week period. Patients will be randomized to three treatment arms: MEBO, Diltiazem, and a combination of MEBO and Diltiazem ointments. Discussion: The results of this study will allow physicians to assess the efficacy and safety of MEBO in the treatment of acute anal fissure, and also in comparison to Diltiazem. This trial will generate evidence-based conclusions regarding the use of a herbal/natural-based product (MEBO ointment) for the treatment of anal fissures. Trial registration: ClinicalTrials.gov Identifier NCT04153032. Clinical Trial Registration Date: 06-NOVEMBER-2019.

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, but their association with thrombosis presents significant clinical challenges. Patients with cancer already exhibit elevated risks for venous thromboembolism and arterial thrombosis, with treatment modalities like chemotherapy further exacerbating this risk. Emerging evidence suggests that ICIs contribute to thrombotic events through multifactorial mechanisms, including immune dysregulation, T cell activation, endothelial dysfunction, elevated tissue factor expression, and impaired fibrinolysis. Additional risk factors such as obesity, smoking, prior thrombotic events, and combination ICI therapy further increase thrombosis susceptibility. The literature reports varying incidence rates of ICI-associated thrombosis, with some studies indicating comparable risks to chemotherapy, while others highlight higher rates, particularly during the initial treatment phase. Management aligns with standard protocols for cancer-associated thrombosis, using low-molecular-weight heparin or direct oral anticoagulants, though optimal treatment duration and the role of prophylactic anticoagulation require further investigation. This review provides a comprehensive overview of the mechanisms, incidence rates, and clinical management strategies of ICI-associated thrombosis, emphasizing the importance of proactive risk assessment to optimize patient outcomes.

Introduction and importance: Desmoid-type fibromatosis (DF) is a rare subtype of soft tissue sarcomas that most commonly occurs in the anterior abdominal wall. When occurring in the retroperitoneum, DF is usually part of familial syndromes while only rarely sporadic. This makes it imperative to report any instance of experience with DF and the oncological outcomes of the different approaches to management. We report two cases of sporadic and severe DF occurring in the retroperitoneum at our institution. Case presentation: The first case is a male that presented with urinary obstruction symptoms and underwent surgical resection of the tumor that extended into the left kidney. The second case is a female with a history of recurrent desmoid tumors of the thigh and was incidentally diagnosed with retroperitoneal DF on imaging. She underwent tumor resection and radiotherapy; however, the tumor recurred with urinary obstruction symptoms that required another surgical resection. Histopathological characteristics and radiological imaging of both cases are described below. Clinical discussion: Desmoid tumors often recur, thus significantly influencing the quality of life which is reflected in one of our cases. Surgery remains a mainstay treatment, and both cases presented in this report required surgical resection of the tumors as symptomatic and curative measures. Conclusion: Retroperitoneal DF is a rare entity, and our cases add to the scarce literature available on the topic, which may well contribute to the formulation of practice-changing recommendations and guidelines focused on this rare variant of DF.

Background: Extra-gastrointestinal stromal tumor is a rare subtype of soft tissue sarcomas with significantly variable presentation, management, and prognosis. This makes it crucial to report the different institutional experiences of encountering extra-gastrointestinal stromal tumors (EGIST). Case presentation: We report 3 cases of EGIST diagnosis at American University of Beirut Medical Center for 2 males and 1 female in the 5th, 6th, and 7th decades of life, respectively. For the first case, the tumor was initially suspected to be ovarian cancer, but biopsy revealed a diagnosis of EGIST, and the patient was started on neoadjuvant therapy. In the second case, the tumor was retro-gastric and prelim diagnosis was gastric cancer but again biopsy revealed an EGIST histopathology, and the patient underwent surgery and adjuvant treatment. For the third case, a previous history of testicular cancer prompted an initial suspicion of recurrence with metastasis but biopsy and immunohistochemistry staining revealed EGIST with related markers. The patient underwent treatment at a different institution in his home country. Conclusion: This report sheds light on the importance of keeping EGIST amongst any differential list for abdominal and pelvic tumors. It also shows that EGIST-focused studies are needed to assess the effectiveness of the different treatment modalities available when utilized specifically for EGIST. This would allow for better oncological outcomes and improved quality of life.

Background: Breast cancer is the most prevalent malignancy among women and the leading cause of cancer-related mortality. Sentinel lymph node biopsy (SLNB) has emerged as an alternative to axillary lymph node dissection (ALND), with the ACOSOG Z0011 trial demonstrating that SLNB alone yields equivalent oncologic outcomes to ALND for patients with 1–2 positive sentinel lymph nodes (SLNs). Objective: This study evaluates the adoption of Z0011 recommendations at the American University of Beirut Medical Center (AUBMC) and their impact on oncologic outcomes. Methods: This retrospective cohort study includes female patients with early-stage breast cancer (T1–T2, N0, M0) who underwent breast-conserving surgery with SLNB at AUBMC, between January 2011 and December 2016. Data were extracted from the institutional breast cancer database, including demographics, tumor characteristics, surgical management, and follow-up outcomes. Results: SLNB alone was adopted, following publication of the Z0011 trial, in 93.4% of patients, with 6.6% undergoing ALND. Among patients with 1–2 positive SLNs, 27.1% underwent completion ALND. The median number of lymph nodes retrieved increased from two to four over the study period. The most common molecular subtypes observed were luminal A (54.1%), characterized by a predominant stage T1 presentation and small tumor sizes (median tumor size, 1.4 cm). Among patients with 1–2 positive SLNs who underwent ALND, no recurrences or metastatic events were reported. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 95.9% and 93.4%, respectively. No notable differences in OS and DFS were observed between the SLNB alone and ALND groups. Conclusions: Our study demonstrates that SLNB alone provides comparable oncologic outcomes to ALND, supporting its safety and effectiveness as an alternative for early-stage breast cancer patients with 1–2 positive SLNs. These findings extend the Z0011 trial’s applicability to diverse populations, reinforcing SLNB as a less invasive, safe alternative to ALND.

Purpose The ACOSOG-Z0011 clinical trial introduced drastic changes to the traditional surgical practice for early breast cancer with positive sentinel lymph nodes. This study evaluates how these changes have affected the surgical management of early breast cancer at our institution. Methods A retrospective chart review was conducted for Lebanese women with a diagnosis of invasive breast cancer and who were ≥18 years of age, had undergone upfront breast-conserving surgery, and SLNB without any prior chemotherapy had no distant metastasis and had one or more positive SLNs, between 2011 and 2016. Results Data from our cohort shows that 78% of patients out of the 233 with clinically negative nodes go on to have negative nodes on surgical sentinel pathology as well. However, the incidence of micromets is 5.5% amongst positive SLNs versus 94% of positive SLNs having macromets. Survival data analysis showed a 5-year and 10-year locoregional recurrence rates of 1.72% and 2.15%, respectively. At 3-years follow-up, distant metastasis occurred in 3.4% of cases. Additionally, the 10-year overall survival is 98.7% and disease-free survival is 95.3%. The rates of ALND decreased from 46.7% to 18.2% in patients with 2 or less positive sentinel nodes between the two time periods 2011-2013 and 2014-2016. Conclusion With a follow-up period extending more than five years, our study shows that ALND offers no superiority to SLNB alone in terms of overall survival and disease-free survival. This does not only conform with the findings of Z0011 but adds to its generalizability to populations of different ethnicities.