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The precise population of the Palestinian territories is disputed, but a 2017 estimate was 4 543 126 people, including 2 155 743 people in the West Bank and 1 795 183 in Gaza. The Palestinian territories rank 121st out of 233 countries and dependencies by population (its people comprise 0·07% of the world population). Palestinian health care has been a major concern since the 1994 Oslo agreement when the Palestinian Authority took over the administration of health care for the region. This effort has been supported by WHO and foreign donors, especially the US Government. Despite major political, economic and social challenges for the region, health care in Palestine is one of the best among Arab countries in terms of life expectancy and maternal, infant, and child mortality rates. Cancer is the second leading cause of death in Palestine at 14%, exceeded only by heart disease at 30%. The cancer burden in Palestine is expected to increase, reaching levels that further challenge the financial and infrastructural resources of the current health-care system, of which financial and political uncertainty exacerbate the problem. In this Review, we discuss the current state of cancer care in the Palestinian territories including epidemiology, screening, and prevention efforts, and infrastructural and workforce issues for the region. We also discuss examples of some encouraging progress that has been made for health in the region and the enormous challenges that the Palestinian health-care system still faces.

Background: One of the most frequently used methods for quantifying PD-L1 (programmed cell death-ligand 1) expression in tumor tissue is IHC (immunohistochemistry). This may predict the patient's response to anti-PD1/PD-L1 therapy in cancer. Methods: ImageJ software was used to score IHC-stained sections for PD-L1 and compare the results with the conventional manual method. Results: In diffuse large B cell lymphoma, no significant difference between the scores obtained by the conventional method and ImageJ scores obtained using the option “RGB” or “Brightness/Contrast.” On the other hand, a significant difference was found between the conventional and HSB scoring methods. ImageJ faced some challenges in analyzing head and neck squamous cell carcinoma tissues because of tissue heterogenicity. A significant difference was found between the conventional and ImageJ scores using HSB or RGB but not with the “Brightness/Contrast” option. Scores obtained by ImageJ analysis after taking images using 20 × objective lens gave significantly higher readings compared to 40 × magnification. A significant difference between camera-captured images’ scores and scanner whole slide images’ scores was observed. Conclusion: ImageJ can be used to score homogeneous tissues. In the case of highly heterogeneous tissues, it is advised to use the conventional method rather than ImageJ scoring.

Autologous hematopoietic stem cell transplantation (auto-HCT) remains a cornerstone in relapsed Hodgkin lymphoma (HL), especially where access to novel agents is limited. We evaluated trends in outcomes after auto-HCT at King Hussein Cancer Center (KHCC) over two decades. We retrospectively analyzed adult HL patients who underwent auto-HCT between 2003 and 2020, divided into two eras: group A (2003–2015) and group B (2016–2020). Survival was estimated by Kaplan–Meier and compared by log-rank; prognostic factors were assessed with Cox regression. We identified 265 patients (group A: N  = 149, 56%; group B: N  = 116, 44%). The median age at transplant was 30.2 years (range 18.7–64). 109 (43%) had primary refractory disease.) With a median follow-up of 44 months (range 0.1-233.7), the 5-year OS and PFS were 64.4% and 46.7%, respectively. Compared to group A, patients in group B were more likely to receive ≥ 1 salvage regimen (54% vs. 40%, p  = 0.027), receive GDP (gemcitabine, dexamethasone, cisplatin) (48% vs. 2.2%, p  < 0.001), receive TEAM (thiotepa, etoposide, ara-C, melphalan) conditioning (20% vs. 6.5%, p  < 0.001), and receive pembrolizumab at relapse (23% vs. 4.3%, p  < 0.001), they were less likely to relapse post auto-HCT (35% vs. 55%, p  = 0.003). Multivariate analysis identified younger age, CR at transplant, later transplant era, and longer remission duration after frontline therapy as independent predictors of improved survival ( p  = 0.01). Auto-HCT outcomes for HL at KHCC have improved significantly in the modern era. This reflects advances in salvage regimens, supportive care, reduced non-relapse mortality, and integration of immunotherapy for post-autoHCT relapses.

The aim of the study was to assess the predictive value of interim FDG-PET/CT (iPET) in patients with Hodgkin’s lymphoma (HL) treated with Adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy. A total of 245 consecutive patients with de novo HL between 12/2013 and 12/2017 were evaluated retrospectively. All patients were treated with upfront ABVD, performed PET/CT scans at baseline, after 2 cycles (interim PET, iPET2) or 4 cycles (iPET4) and at the end of therapy, and followed up for at least 6 months after therapy. The response status on iPET was defined according to the standard five-point Deauville scores (DS) as follows: complete metabolic response (CMR, DS 1–3) and non-complete metabolic response (nCMR) (DS 4 and 5). End-of-treatment (EoT) response was assessed by FDG-PET/CT and if needed biopsy confirmation of PET-positive findings. The association between iPET and EoT response was investigated using logistic regression analysis. Survival analysis was performed using the Cox regression hazard model and Kaplan–Meier methods. Sixty-nine patients underwent iPET-2 and 176 iPET-4. No association was found between the timing of iPET and iPET response status ( P -value = 0.71). Two hundred and one patients (82%) had iPET-CMR and 44 (18%) iPET -nCMR. iPET was strongly associated with EoT response status: 194/201 (96 .5%) of iPET-CMR had a complete response at the EoT while only 21/44 (47.7%) of patients with iPET-nCMR presented a complete response at EoT ( P -value < 0.0001). The median follow-up was 32 months (range 6–81). Patients with iPET-CMR presented a better outcome with 91% 3 y event-free-survival (EFS) and 95% 3 y overall survival (OS) than those with iPET-nCMR (41 and 86%, respectively, P -value < 0.0001). In multivariable analyses, iPET retained an independent prognostic factor of EFS and OS ( P -value < 0.0001 and P -value = 0.002, respectively). iPET is highly predictive of outcome of HL patients treated with ABVD and allows to tailor therapy to the individual patient.

Background Patients with aggressive lymphomas are at higher risk for venous thromboembolism (VTE). ThroLy is a risk assessment model (RAM) derived to predict the occurrence of VTE in various types of lymphomas. In this study, we assess the clinical application of ThroLy RAM in a unified group of patients with diffuse large B-cell lymphoma (DLBCL). Methods Hospital databases were searched for patients with DLBCL and radiologically-confirmed VTE. Items in the ThroLy RAM, including prior VTE, reduced mobility, obesity, extranodal disease, mediastinal involvement, neutropenia and hemoglobin < 10.0 g/dL, were retrospectively reviewed. Results A total of 524 patients, median age 49 (range: 18-90) years were included. Patients had high disease burden; 57.3% with stage III/IV and 34.0% with bulky disease. All were treated on unified guidelines; 63 (12.0%) had primary refractory disease. Venous thromboembolic events were reported in 71 (13.5%) patients. Among 121 patients with high (> 3) ThroLy score, 22.3% developed VTE compared to 8.4% and 12.4% in those with low and intermediate risk scores, respectively (P = .014). Simplifying the ThroLy model into two risk groups; high-risk (score ≥ 3) and low risk (score < 3) can still segregate patients; VTE developed in 44 (17.2%) high-risk patients (n = 256) compared to 27 (10.1%) in the low-risk group (n = 268), P = .038. Neutropenia, a component of the ThroLy, was encountered in only 14 (2.7%) patients. Conclusions ThroLy RAM can identify patients with DLBCL at high risk for VTE. Model can be modified by dividing patients into two, rather than three risk groups, and further simplified by omitting neutropenia.

Primary mediastinal large B-cell Lymphoma (PMLBCL) is a rare aggressive lymphoma with unique clinical, pathological, and molecular features. The optimal frontline therapy is subject of ongoing debate. Our study aims to evaluate the outcomes of PMLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) at King Hussein Cancer Center. Adult patients >18 years of age with PMLBCL treated with RCHOP from January 2011 to July 2020 were identified. All demographics, disease and treatment related variables were retrospectively collected. Correlations of clinical and laboratory variables with progression-free survival (PFS) and overall survival (OS) were determined by univariate and multivariate analyses using backward stepwise Cox regression models. The PFS and OS were plotted using Kaplan‒Meier curves. 49 patients were included with a median age of 29 years. 14 (28.6%) had stage III or IV, 31 (63.3%) had mediastinal bulky disease. International prognostic index (IPI) was 0-1 in 35 (71.4%). Radiotherapy was given to 32 (65.3%) patients. End of treatment (EOT) response was complete (CR) in 32 (65.3%), partial response (PR) in 8 (16.3%) and progressive disease (PD) in 9 (18.4%). Patients who achieved CR at EOT, compared favorably with those who did not in regard to 4-year OS (92.5% vs 26.9%, p=<0.001). Overall objective response to salvage chemotherapies was 26.7%. At a median follow-up of 46 months, 4-year PFS and OS were 60% and 71% respectively. In multivariate analysis, IPI > one correlated with the EOT response (p=0.009), PFS (p=0.004) and OS (p= 0.019). In PMLBCL, RCHOP chemotherapy backbone in the frontline therapy is suboptimal but can be used in patients with low IPI. Adapting more intensive chemoimmunotherapy regimens may be considered for patients with high IPI. Salvage chemotherapy has limited activity in patients with relapsed or refractory disease.

Cancer patients are at higher risk of serious complications of COVID-19. Few studies evaluated the impact of COVID-19 on cancer patients in low- and middle-income countries. Our study aims to evaluate the outcomes of COVID-19 infection in cancer patients treated at our institution.  Methods: Medical records of patients with a positive COVID-19 polymerase chain reaction (PCR) between April 2020 and October 2020 were reviewed. Fisher's exact test and logistic regression analysis were employed to correlate various variables with mortality. Survival estimates were generated using the Kaplan-Meier method. A total of 317 patients were included, with a median age was 55 years (range: 19-88). 82 (25.9%) had hematological neoplasms while the remainder had solid cancers. At the time of infection, 220 (69.4%) had active cancer, and 99 (31.2%) had received systemic anticancer treatment (SACT) within four weeks. Hospitalization was required for 101 (31.8%), 17 (5.3%) were admitted to the ICU and 50 (15.8%) died. Among patients with active cancer, SACT was delayed or discontinued in 140 (63.6%) patients.  In the entire patient cohort, low albumin (p=<0.001) and leucocytosis (p=<0.001) correlated with mortality within six months of COVID-19 infection. The six-month mortality rate in patients with active cancer was significantly higher in patients with hypertension (p=0.024), no recent SACT (0.017), hematological cancer (p=0.029), low albumin (p=<0.001), leucocytosis (p=0.002) and lymphocyte count of less than 500/µL (p=0.004). Recent chemotherapy was associated with better 6-month survival rates (78.8% vs 89.9%, p=0.012) in patients with active cancer, patients with solid cancers (95.9% vs 82.2%, p=0.006) and was non-inferior in patient with hematological neoplasms (72% vs 65.4%, p=0.519).  Conclusion: COVID-19 infection in our cancer patients was associated with significant morbidity and mortality and adversely affected their treatment. The decision to delay or discontinue SACT should be individualized, considering other risk factors for mortality.

Natural killer (NK)/T‐cell lymphomas (NKTCLs) are rare, aggressive lymphomas prevalent in East Asia and South America. Despite improvements, largely due to asparaginase‐based therapies, outcomes for advanced disease remain poor, and the role of autologous stem cell transplantation (auto‐HCT) remains controversial. This study evaluated real‐world outcomes of auto‐HCT in NKTCL patients across Asia and Europe. We included 130 adult NKTCL patients undergoing auto‐HCT between 2011 and 2022 using data from the European Society for Blood and Marrow Transplantation (EBMT) registry and South Korean registry data. Median age was 51.3 years; 66.9% were male. Most patients (95.1%) had an Eastern Cooperative Oncology Group (ECOG) score 0–1; 65.3% had Stage III–IV disease. One prior therapy line was reported in 53.1%, and ≥2 lines in 46.9%. Asparaginase‐based regimens were used in 79.5% pretransplant. Responses at auto‐HCT included complete (59.7%), partial (27.9%) remission, and stable/progressive disease (12.4%). Epstein–Barr virus (EBV)‐DNA in the peripheral blood was reported in 37.3%. With a median follow‐up of 4.6 years, 3‐year overall survival (OS) and progression‐free survival (PFS) were 63.8% and 47.6%. Relapse and NRM rates at 3 years were 46.7% and 5.7%. Patients in complete remission had improved 3‐year OS (75.2%) compared to PR (52.8%) and stable/progressive disease (32.0%) (P = 0.007). Detectable EBV‐DNA in the blood at auto‐HCT was associated with poor outcomes (3‐year OS: 26.7% vs. 78.1% in patients with undetectable EBV‐DNA; P < 0.0001). Patients achieving complete remission and undetectable EBV‐DNA in the blood before auto‐HCT had a favorable survival, suggesting auto‐HCT may be a treatment option in selected high‐risk patients. This is the largest multinational cohort evaluating prognostic factors for auto‐HCT for NKTCL.