Treating locally advanced disease: an analysis of very large, hilar lymph node positive non-small cell lung cancer using the National Cancer Data Base

BACKGROUND

Very large, locally advanced non-small cell lung cancers (NSCLC) remain a therapeutic challenge. This retrospective study compares the effect of treatment modalities on survival of patients with large NSCLC with hilar lymph node involvement (T3>7 cmN1).

METHODS

The National Cancer Data Base was used to identify adult patients who were diagnosed with T3>7 cmN1 NSCLC from 1999 to 2005 (n=642). Nonsurgical treatments included chemoradiation, chemotherapy, radiation therapy, or no treatment, whereas primary surgical treatments included surgery, chemoradiation or chemotherapy prior to surgery, chemoradiation or chemotherapy after surgery, or postoperative radiotherapy. Five-year overall survival (OS) was estimated by the Kaplan-Meier method and comparisons made using log-rank tests and Cox regression models.

RESULTS

A total of 642 patients were evaluated; 425 nonsurgical (66%) and 217 surgical (34%). Primary surgical therapy was associated with improved 5-year OS; 28% versus 8% and 4% for nonsurgical and no treatment, respectively (p<0.001). The 5-year OS were 11%, 5%, 2%, and 4% for chemoradiation, chemotherapy, radiation therapy, and no treatment, respectively (p<0.001). The 5-year OS were 16% for surgery only, 40% and 44% for neoadjuvant chemoradiation or chemotherapy with surgery, respectively, 40% and 38% for adjuvant chemoradiation or chemotherapy with surgery, respectively, and 18% for postoperative radiotherapy (p<0.001). On multivariate analysis, surgery and chemotherapy in most combinations were associated with significantly improved OS compared with chemoradiation only.

CONCLUSIONS

Surgery with systemic therapy delivered in a neoadjuvant or adjuvant fashion for patients with T3>7 cmN1 NSCLCs is associated with improvements in OS.

Time trends in glioblastoma multiforme survival: the role of temozolomide

BACKGROUND

In 2005, maximum safe surgical resection, followed by radiotherapy with concomitant temozolomide (TMZ), followed by adjuvant TMZ became the standard of care for glioblastoma (GBM). Furthermore, a modest, but meaningful, population-based survival improvement for GBM patients occurred in the US between 1999 (when TMZ was first introduced) and 2008. We hypothesized that TMZ usage explained this GBM survival improvement.

METHODS

We used national Veterans Health Administration (VHA) databases to construct a cohort of GBM patients, with detailed treatment information, diagnosed 1997-2008 (n = 1645). We compared survival across 3 periods of diagnosis (1997-2000, 2001-2004, and 2005-2008) using Kaplan-Meier curves. We used proportional hazards models to calculate period hazard rate ratios (HRs) and 95% confidence intervals (CIs), adjusted for demographic, clinical, and treatment covariates.

RESULTS

Survival increased over calendar time (stratified log-rank P < .0001). After adjusting for age and Charlson comorbidity score, for cases diagnosed in 2005-2008 versus 1997-2000, the HR was 0.72 (95% CI, 0.64-0.82; p-trend < .0001). Sequentially adding non-TMZ treatment variables (ie, surgery, radiotherapy, non-TMZ chemotherapy) to the model did not change this result. However, adding TMZ to the model containing age, Charlson comorbidity score, and all non-TMZ treatments eliminated the period effect entirely (HR = 1.01; 95% CI, 0.86-1.19; p-trend = 0.84).

CONCLUSIONS

The observed survival improvement among GBM patients diagnosed in the VHA system between 1997 and 2008 was completely explained by TMZ. Similar studies in other populations are warranted to test the generalizability of our finding to other patient cohorts and health care settings.

The effect of a lung cancer care coordination program on timeliness of care

BACKGROUND

Timeliness of care improves patient satisfaction and might improve outcomes. The CCCP was established in November 2007 to improve timeliness of care of NSCLC at the Veterans Affairs Connecticut Healthcare System (VACHS).

PATIENTS AND METHODS

We performed a retrospective cohort analysis of patients diagnosed with NSCLC at VACHS between 2005 and 2010. We compared timeliness of care and stage at diagnosis before and after the implementation of the CCCP.

RESULTS

Data from 352 patients were analyzed: 163 with initial abnormal imaging between January 1, 2005 and October 31, 2007, and 189 with imaging conducted between November 1, 2007 and December 31, 2010. Variables associated with a longer interval between the initial abnormal image and the initiation of therapy were: (1) earlier stage (mean of 130 days for stages I/II vs. 87 days for stages III/IV; P < .0001); (2) lack of cancer-related symptoms (145 vs. 60 days; P < .0001); (3) presence of more than 1 medical comorbidity (123 vs. 82; P = .0002); and (4) depression (126 vs. 98 days; P = .029). The percent of patients diagnosed at stages I/II increased from 32% to 48% (P = .006) after establishment of the CCCP. In a multivariate model adjusting for stage, histology, reason for imaging, and presence of primary care provider, implementation of the CCCP resulted in a mean reduction of 25 days between first abnormal image and the initiation of treatment (126 to 101 days; P = .015).

CONCLUSION

A centralized, multidisciplinary, hospital-based CCCP can improve timeliness of NSCLC care, and help ensure that early stage lung cancers are diagnosed and treated.

EMR-linked cancer tracker facilitates lung and liver cancer care

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Background: VA Connecticut Healthcare System has developed a web-based, EMR-linked Cancer Care Tracking System (CCTS) to facilitate tracking and follow-up of patients with imaging abnormalities concerning for lung or liver cancer. The tracker was developed to facilitate the efforts of a multidisciplinary team at the center of which is a cancer navigator. Methods: CCTS was first envisioned in 2007 when VACT hired a care navigator and implemented a radiology coding system to identify potential cancers. This created the need for a tool to process abnormal images and track the clinical steps required to reach a definitive diagnosis and treatment plan. CCTS was initially used for lung cancers and was expanded to track hepatocellular carcinoma (HCC) in 2009 with additional funding. In addition to case discovery, it offers easy access to patient information with live links to the VA EMR, a surveillance feature, and scheduling, alerting, and reporting functions. In 2011, the system was enhanced with a natural language processing (NLP) program that automatically identifies radiology reports describing potentially malignant lung or liver lesions. Results: CCTS has been in daily operation since February 2010, with 1,778 patients and 2,503 patients tracked in 2010 and 2011, respectively. Addition of NLP technology significantly increases the accuracy of identification of patients with lung or liver nodules. The NLP system identified 21% of all new cases with potential malignancies whose management could have been delayed through coding omissions or errors. Benefits of CCTS and our cancer care coordination program have included a decrease of 25 days in the time from abnormal image to treatment of lung cancer, a significant increase in the diagnosis of stage I/II lung cancers from 32% to 48%, and an increase in the incidence of liver cancer from 1% to 5% of all cancers at VACT. Conclusions: A web-based, EMR-linked cancer care tracking system (CCTS) improves cancer detection, prevents loss to follow-up, provides a safety net for radiology coding omissions or errors, and improves provider efficiency. CCTS is an innovative tool to support multidisciplinary cancer care and has broad applicability to any electronic medical record.

Why does my patient have thrombocytopenia?

Thrombocytopenia, usually defined as a platelet count of less than 150,000/μL, is a common reason for a hematology consult in both the inpatient and outpatient setting. In most patients, the cause of the thrombocytopenia can be identified and treated. This article reviews the clinical approach to the patient with thrombocytopenia, the mechanisms that underlie it, and the laboratory tests available to investigate it. A practical approach to the investigation and management of thrombocytopenia in the clinical settings commonly encountered by the hematology consultant is then described.

Timeliness of care and stage at diagnosis of non-small cell lung cancer (NSCLC) with the implementation of a cancer care coordination program (CCCP) at a VA medical center

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Background: Timeliness of care improves patient satisfaction and may improve outcomes. A CCCP was established in Nov 2007 to improve timeliness of care of NSCLC patients at the Veterans Affairs Connecticut (VACT) Healthcare System. Methods: We performed a retrospective cohort analysis of patients diagnosed with NSCLC at VACT between 2005-2010. We compared timeliness of care and stage at diagnosis before and after the implementation of the CCCP. Results: Data from 352 patients was analyzed: 163 with initial abnormal imaging between 1/1/2005 and 10/31/2007, and 189 with imaging between 11/1/2007 and 12/31/2010. Variables associated with a longer interval between the initial abnormal image and the initiation of therapy were: (1) earlier stage (mean of 130 days for stages I/II vs. 87 days for stages III/IV, p<0.001),(2) lack of cancer-related symptoms (145 vs 60 days, p<0.001), (3) presence of medical co-morbidities (111 vs 76 days, p=0.01), and (4) depression (127 vs 98 days, p=0.029). Substance abuse increased the interval from initial abnormal image to tissue diagnosis by 29 days (p=0.032) but did not affect the interval from image to treatment. The mean interval between diagnosis and initiation of treatment was 19 days longer in blacks vs. non-blacks (55 vs 36 days, p=0.0118) although the overall time from abnormal image to diagnosis and to treatment was not statistically different. In a multivariate model adjusting for stage, histology, reason for initial imaging, and presence of a primary care provider, implementation of a CCCP resulted in a mean reduction of 25 days in the time between the first abnormal image and initiation of cancer treatment (126 to 101 days, p=0.0154). The percent of patients diagnosed at stages I and II increased from 32% to 48% (p=0.0065) after the implementation of a CCCP. Conclusions: A centralized, multidisciplinary, hospital-based CCCP can improve timeliness of NSCLC care, and may also help ensure that incidental, early stage lung cancers are treated.

Utility of peripheral blood flow cytometry in differentiating low grade versus high grade myelodysplastic syndromes (MDS) and in the evaluation of cytopenias

The diagnostic utility of flow cytometry in the evaluation of cytopenias and in the differential diagnosis of low-grade versus high-grade myelodysplastic syndrome (MDS) is not widely appreciated. In this report, we measured granulocyte CD10/control fluorescence ratio in 29 patients with MDS & chronic myelomonocytic leukemia (CMML) using peripheral blood (PB) flow cytometry (FC). We found a lower ratio in high-grade MDS and CMML (mean ratio of 2.2 ± 0.7) vs. low-grade MDS (3.65 ± 0.9) and 16 cytopenic controls without MDS (3.67 ± 0.65; p<0.001). The sensitivity and specificity of CD10 ratio <3 for the group that included the high risk MDS and CMML patients were 87.5% and 100%, respectively. Our data suggests that FC of PB may be helpful in the work-up of patients with cytopenias and in the differential diagnosis of low-grade vs. high-grade MDS.

Prostate cancer, comorbidity, and participation in randomized controlled trials of therapy

BACKGROUND

Randomized controlled trials (RCTs) evaluate the potential benefits of chemotherapy regimens and guide clinical care for patients with cancer. Inclusion criteria for RCTs are usually stringent and may exclude many patients seen in clinical practice. Our objective was to determine the proportion of men with castrate-resistant prostate cancer (CRPC) in a clinical setting that would have been excluded from major phase 3 RCTs.

METHODS

We reviewed eligibility criteria from 24 phase 3 clinical trials evaluating chemotherapy for CRPC active from January, 2004, through April, 2008. We created a common list of criteria used in at least 3 studies and separately considered the criteria from a prominent RCT (TAX 327). We applied these criteria to a population of patients with CRPC treated during 2004 to 2006 at the Veterans Affairs Connecticut Healthcare System.

RESULTS

Among 106 patients with CRPC, 99 (93%) had complete medical records, and 45 (45%) of the 99 would have been excluded from RCTs. Common reasons for exclusion were abnormal laboratory values, other malignancies, and other serious medical conditions including cardiac disease.

CONCLUSIONS

Almost half of the CRPC patients examined in a clinical setting would have been ineligible for phase 3 RCTs, highlighting that such trials may not be applicable to general oncology practice.

Locally recurrent and metastatic apocrine-gland carcinoma in an elderly man

BACKGROUND

A 78-year-old man with a history of untreated hypertension and dementia presented with a rapidly growing, painful mass in the left axilla. He was a nonsmoker and did not consume alcohol. There was no family history of malignancy. The patient had not experienced any constitutional symptoms, such as fever, weight loss, night sweats, or loss of appetite.

INVESTIGATIONS

Physical examination, blood tests, excisional biopsy, studies of tumor morphology and immunohistochemistry, CT of the chest and abdomen, and PET scan.

DIAGNOSIS

Carcinoma of the axillary apocrine gland.

MANAGEMENT

Surgical excision, and radiation therapy.

Plasmablastic lymphoma presenting as an arm mass in an individual negative for human immunodeficiency virus: a case report

Plasmablastic lymphoma is an aggressive diffuse large B-cell lymphoma classically arising in the oral cavities and jaws of individuals infected with the human immunodeficiency virus (HIV). More recently, cases of plasmablastic lymphoma have been identified in individuals negative for HIV. We report a case of plasmablastic lymphoma presenting as a rapidly expanding upper extremity mass in a 66-year-old individual negative for HIV. Aggressive multiple-agent chemotherapy resulted in a dramatic improvement of all symptoms. Increasing awareness of plasmablastic lymphoma in individuals who are HIV negative can allow for a better understanding of its clinical course and for specific chemotherapeutic regimens to be developed.

Gastrointestinal endoscopic findings in men with unexplained anemia and low normal ferritin values

BACKGROUND

Most practice guidelines recommend endoscopic evaluation of the gastrointestinal (GI) tract in men and postmenopausal women with anemia and a serum ferritin less than 20-40 ng/ml. The diagnostic yield of endoscopy in patients with anemia, no GI symptoms or signs, and low normal ferritin is not known.

OBJECTIVE

The aim of this study was to investigate the yield of upper and lower GI endoscopic evaluations in anemic patients with ferritin levels between 40 and 100 ng/ml.

DESIGN

A retrospective review of patients' charts was conducted.

SUBJECTS AND METHODS

Patients at the Veterans Affairs Connecticut Healthcare System who underwent GI endoscopic evaluation for the sole indication of anemia and ferritin in the low normal range (40-100 ng/ml) were included in this study.

MEASUREMENTS

Incidence of pathology of the upper and lower GI tract was determined.

RESULTS

We identified 54 male patients who had a ferritin level of 40-100 ng/ml and no GI symptoms or known GI bleeding. Upper GI findings (malignancy, peptic ulcers, Helicobacter pylori gastritis, arteriovenous malformations) were found in 14/47 cases (30%). Lower gastrointestinal findings, including large tubular adenomas and arteriovenous malformation, were identified in 3/53 cases (6.7%).

CONCLUSION

Our study supports GI endoscopy in anemic patients with ferritin between 40 and 100 ng/ml, even in the absence of GI symptoms or documented bleeding.

Hemophagocytosis exacerbated by G-CSF/GM-CSF treatment in a patient with myelodysplasia

We describe a 75-year-old man with neutropenia in whom bone marrow aspirate and biopsy demonstrated hemophagocytosis associated with myelodysplasia (MDS). Therapy with granulocyte-colony stimulating factor (G-CSF) and granulocyte-monocyte-colony stimulating factor (GM-CSF) caused splenomegaly and severe thrombocytopenia, which recurred upon rechallenge. We propose that myeloid growth factors may be detrimental in patients with MDS-associated hemophagocytosis.

Molecular diagnostics of malignant disorders

Expansion of our understanding of the molecular basis of cancer has enabled us to apply molecular techniques to categorize malignancies into more uniform, informative groups. In this review we describe the basic molecular techniques used for this purpose, including Southern blotting, polymerase chain reaction (PCR) and quantitative PCR, fluorescence in situ hybridization, DNA microarrays, and proteomics. The main applications of these techniques in the modern management of acute leukemia, chronic myeloid leukemia, lymphomas, and breast cancer are summarized.

T-cell large granular lymphocyte leukemia and related disorders

T-cell large granular lymphocyte (LGL) leukemia is a clonal proliferation of cytotoxic T cells, which causes neutropenia, anemia, and/or thrombocytopenia. This condition is often associated with autoimmune disorders, especially rheumatoid arthritis, and other lymphoproliferative disorders. The diagnosis is suggested by flow cytometry demonstrating an expansion of CD8(+)CD57(+) T cells and is confirmed by T-cell receptor gene rearrangement studies. Mounting evidence suggests that LGL leukemia is a disorder of dysregulation of apoptosis through abnormalities in the Fas/Fas ligand pathway. In most patients, this is an indolent disorder, and significant improvement of cytopenias can be achieved with immunosuppressive agents such as steroids, methotrexate, cyclophosphamide, and cyclosporin A. This review provides a concise, up-to-date summary of LGL leukemia and the related, more aggressive, malignancies of cytotoxic T cells and natural killer cells.

Thymidylate synthase: a critical target for cancer chemotherapy

Thymidylate synthase (TS) is a key enzyme in the synthesis of 2'-deoxythymidine-5'-monophosphate, an essential precursor for DNA biosynthesis. For this reason, this enzyme is a critical target in cancer chemotherapy. As the first TS inhibitor in clinical use, 5-fluorouracil (5-FU) remains widely used for the treatment of colorectal, pancreatic, breast, head and neck, gastric, and ovarian cancers. The reduced folate, leucovorin, has been shown to enhance the activity of 5-FU in colorectal cancer. However, response rates of the combination remain in the 25%-30% range, and much effort has been focused on designing new, more potent TS inhibitors. Raltitrexed is a folate analogue that is approved as first-line therapy for advanced colorectal cancer in Europe, Australia, Canada, and Japan, although it remains an investigational agent in the United States. Pemetrexed is an antifolate analogue that has shown promising activity in several solid tumor types, including mesothelioma. ZD9331, a highly specific TS inhibitor that dose not require polyglutamation for its activation, has shown activity in patients with refractory ovarian and colorectal cancer. Capecitabine is an oral fluoropyrimidine carbamate that was designed to generate 5-FU preferentially in tumor cells; this agent was recently approved by the US Food and Drug Administration as first-line therapy for patients with advanced colorectal cancer. As the number of TS inhibitors available for general clinical use increases, further research is needed to elucidate the critical molecular and biochemical elements that determine the efficacy and tumor specificity of each compound.

Malignant hypoglycemia associated with a large mesenchymal tumor: case report and review of the literature

PURPOSE

To examine hypoglycemia associated with a non-islet-cell tumor caused by the secretion of abnormal insulinlike growth factors.

PATIENT AND METHODS

We describe a 54-year-old woman with a massive solitary fibrous tumor who experienced worsening hypoglycemia with suppressed levels of insulin and insulinlike growth factor I but abnormally "normal" levels of insulinlike growth factor II.

RESULTS

Efforts to control her symptoms with frequent meals, prednisone, and intravenous dextrose infusions were only partially successful. Attempts at reducing the tumor size by embolizing its arterial supply and percutaneous alcohol injections were unsuccessful, and the patient died 24 hours after surgical debulking.

DISCUSSION

Patients with non-islet-cell tumor hypoglycemia usually have abnormally high levels of an incompletely processed precursor of insulinlike growth factor II, which is more bioavailable than the normal molecule. In some patients, treatment with corticosteroids and growth hormone increases blood sugar levels, but the most effective therapeutic approach is to resect or debulk the tumor.

Can hospital relocations and closures be stopped through the legal system?

The recent history of litigation to stop hospital closings in or relocations from minority communities is reviewed. Legal arguments and facts raised by plaintiffs and defendants in seven cases are summarized in the context of civil rights and health planning legislation. The results of the litigation are mixed. One hospital was denied permission to close, but this was decided principally on procedural grounds. A planning agency's recommendation against closing another hospital may prove difficult to implement for financial reasons. Several cases have resulted in modifications of relocation plans and have established guarantees of certain rights to plaintiffs. These, however, may be difficult to enforce if hospitals lack the desire or resources to sustain needed levels of service. Generally, the courts have been reluctant to undertake socioeconomic decision making. They have tended to excuse relocations with racially discriminatory impacts when it has been argued that the relocations were necessary for hospital financial survival, and they have been unwilling to test the credibility of those arguments. Legal avenues to contesting with success the closing of most hospitals also appear to be blocked by similar untested contentions.