University Hospital Waterford: 5-year experience of cutaneous melanoma

INTRODUCTION

The incidence of cutaneous melanoma (CM) continues to rise in Ireland. Despite significant advances in melanoma molecular therapy, surgery remains the mainstay of treatment for CM. The University Hospital Waterford (UHW) prospectively maintained CM registry was established in 2010.

AIM

To summarize 5-year experience (2010-2015) of primary CM presenting to UHW.

METHODS

Data were retrospectively obtained from a central electronic pathology and radiology repository augmented by HIPE data and theatre logs. Data collected included patient demographics and clinico-pathological characteristics, specimen number, size, anatomical location, melanoma subtype, Breslow thickness, Clark's level, ulceration, and mitosis.

RESULTS

592 CMs were managed in UHW during the study period. Overall, females comprised the majority of cases with mean age at presentation 60.78 ± 18.29 years. The most commonly affected anatomical location was the lower limb (26.7%) followed by the back (15.1%), upper limb (15.07%), and face (14.40%). Superficial spreading and lentigo maligna were the most common histological subtype accounting for 19.8 and 20%, respectively. Overall, the mean Breslow depth was 2.4 ± 3.7 mm with corresponding Clark's Level III. Sentinel lymph node positivity was 39/103 (37.89%) most commonly located in the axilla (53.8%) and groin (30.7%).

CONCLUSION

There has been a steady increase in the number of cutaneous melanoma presentations over the past 5-years to the South East Cancer Centre. Patients are managed best by prompt surgical excision and multidisciplinary management. Our results are in keeping with international standards and work continues in determining overall 5-year survival and recurrence rates.

Free living amoebae in water sources of critical units in a tertiary care hospital in India

BACKGROUND

Isolation of free-living amoebae (FLA) is reported sparsely from water taps, ventilators, air conditioners, haemodialysis units and dental irrigation systems of hospitals worldwide. Their prevalence in hospital environment especially in wards having immunocompromised patients may pose a risk to this group of susceptible population as they may cause disease themselves or may carry pathogens inside them. No study from India has performed such surveillance.

OBJECTIVE

To evaluate extent of FLA contamination in water sources of bone marrow transplant (BMT) intensive care unit (ICU), transplant ICU, haemodialysis unit and high dependency unit in a tertiary care hospital in India.

MATERIALS AND METHODS

A total of hundred samples including fifty each of tap water samples and swabs from mouth of taps used for drinking, bathing and hand washing purposes in these units were collected according to standard procedure. Samples were inoculated onto non-nutrient agar plates at room temperature followed by morphological confirmation. Molecular identification including polymerase chain reaction (PCR) and sequencing was performed in culture positive samples.

RESULTS

Four tap water samples and ten swab samples showed growth of trophozoites and cyst formation. Morphologically, four amoebae resembled Acanthamoeba spp. which was further confirmed by PCR and sequencing showed them to be of T3 and T4 genotypes.

CONCLUSION

The presence of these FLA in hospital water sources emphasises the urgent need of implementing effective preventive measures. Further studies are required to estimate the true prevalence of FLA in Indian hospitals by taking larger number of samples.

Development of touch down-multiplex PCR for the diagnosis of toxoplasmosis

PURPOSE

The diagnosis of toxoplasmosis is challenging since conventional methods like culture and immunofluorescence are not universally available. Serology, which is used regularly might be negative during early phase of infection and in immunosuppressed patients or may remain positive for a long time. Several molecular tests have been used for the diagnosis of toxoplasmosis, but none of them have an internal control which would inform us regarding the presence of polymerase chain reaction (PCR) inhibitors thus, undermining the confidence of a laboratory physician.

MATERIALS AND METHODS

We designed a multiplex PCR containing primers targeting human beta globin gene which would act as internal control and two primers against the B1 gene and 5s gene which aid in sensitive detection of T. gondii.

RESULTS

Multiplex PCR had a sensitivity of 83.3% and specificity of 100%.

CONCLUSION

Multiplex PCR may provide a sensitive and specific tool for diagnosis of human toxoplasmosis.

Emergence of Balamuthia mandrillaris meningoencephalitis in India

We report two cases of fatal chronic meningoencephalitis caused by Balamuthia mandrillaris in immunocompetent men. Diagnosis of amoebic meningoencephalitis was made ante-mortem in one case and postmortem in another by histopathological examination and confirmed by demonstration of B. mandrillaris deoxyribonucleic acid (DNA) by polymerase chain reaction (PCR).

Impaired monocyte-macrophage functions and defective Toll-like receptor signaling in hepatitis E virus-infected pregnant women with acute liver failure

Acute viral hepatitis resulting due to hepatitis E viral infection (AVH-E) is often serious in pregnancy and could result in acute liver failure (ALF). The role of monocytes and macrophages (mono-macs) in the pathogenesis of AVH-E and development of ALF-E in pregnancy is unclear. We investigated the functions of mono-macs in pregnant (P), AVH-E (n = 44), ALF-E (n = 12), healthy controls (HC; n = 20) and compared with nonpregnant (NP) AVH-E (n = 10), ALF-E (n = 5), and HC (n = 10). We also recruited non-hepatitis E virus-related pregnant (P), ALF-NE (n = 5) and non-pregnant (NP), ALF-NE (n = 12) patients with ALF. Mono-macs, dendritic cell (DC) phenotypes, and Toll-like receptor (TLR) expressions were studied by flow cytometry and reverse-transcriptase polymerase chain reaction. Mono-macs functionality was determined by analyzing their phagocytic activity and reactive oxygen species (ROS) generation by using flow cytometry. Frequency of mono-macs and DCs was increased during HEV infection compared to HC (P < 0.001). Macrophages were increased (P < 0.002) in ALF-E(P) compared to ALF-NE(P). The macrophage phagocytic activity and Escherichia coli-induced ROS production was significantly impaired in ALF-E(P) compared to AVH-E(P) (P < 0.001), ALF-E(NP), and ALF-NE(P) patients (P < 0.02). TLR3 and TLR9 expression and downstream MYD88 signalling molecules IRF3 and IRF7 were significantly down-regulated in ALF-E(P) (P < 0.00) compared to AVH-E(P) and ALF-NE(P).

CONCLUSION

Functionality of mono-macs is impaired in pregnant ALF-E patients compared to AVH-E(P). Reduced TLR3 and TLR7 expression and TLR downstream-signaling molecules in pregnant ALF-E patients suggests inadequate triggers for the innate immune responses contributing to development and severity of ALF-E. Studies using TLR agonists to activate mono-macs may be of use and in vitro studies should be undertaken using patient samples.

Comparison of haematological and biochemical changes between non-anaemic and anaemic primigravid women in a north Indian population to establish normative values

Pregnancy is accompanied by several haemodynamic, biochemical and haematological changes, which may lead to severe problems, if they are not suitably addressed. The current study highlights the haematological and biochemical differences observed in anaemic (AP) and non-anaemic primigravida (NAP), in the 2nd trimester, in a north Indian population. There were significant differences (p < 0.05) in the body weight and body temperature of NAP compared with AP. A significant decrease (p < 0.001) in haematological parameters including haemoglobin, haematocrit, erythrocyte count, MCH and MCHC, was observed in AP; however, MCV was found to be significantly higher (p = 0.038). Many biochemical parameters viz. potassium, albumin, total protein and calcium levels were significantly reduced (p < 0.01) in AP, except alkaline phosphatase whose level was found significantly increased (p < 0.01). The findings of the study suggest that haematological and biochemical changes take place in anaemia during pregnancy. Further, the results obtained should be used for establishing normative values for similar populations.

Single port laparoscopic colorectal surgery in debilitated patients and in the urgent setting

Single port laparoscopy is a relatively new niche in the expanding spectrum of minimal access surgery for colorectal disease. To date the published experience has predominantly focused on planned operations for neoplasia in the elective setting. It seems probable however that the benefits of minimal abdominal wounding will be greatest among those patients with the highest risk of impaired wound healing. Combining this with the impression of improved cosmesis suggests that (the mostly young) patients with inflammatory bowel disease needing urgent operation are the most likely to appreciate and benefit from the extraoperative effort. The extension of single port surgery to the acute setting and for debilitated individuals is therefore a likely next step advance in broadening the category of patients for whom it represents a real benefit and ultimately aid in focusing by selection the subgroups for whom this technique is best suited and most appropriate. We describe here our approach (including routine use of a surgical glove port) to patients presenting for urgent colorectal operation for benign disease. As provision of specialized approaches regardless of timing or mode of presentation is a defining component of any specialty service, this concept will soon be more fully elucidated and established.

Are there differences in chemotherapy (CT) administration and outcomes in elderly patients (pts) diagnosed with colorectal cancer (CRC)?

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Background: CRC is the third most common cancer in men and women in the United States. The median age at diagnosis is 70 years (yrs). Controversy exists in the literature regarding benefit from CT in elderly pts with CRC. We performed a retrospective study to evaluate CT rate and its benefit in different age groups of pts with CRC.

Methods: Data on pts diagnosed with CRC from 1993-2008 were collected from the Cancer Information Resource File. Complete data on age, gender, stage, tumor characteristics, treatment, and overall survival (OS) were available on 32,177 pts and were analyzed by age in four categories: < 50, 50-69, 70-79, and ≥ 80 yrs.

Results: Of 32,177 pts, 7% were < 50, 35% were 50-69, 32% were 70-78, and 26% were ≥ 80 yrs. The table reports pt demographics, median OS (MOS) by age and stage, and rates of CT by age and stage. As reported in the table, use of CT declined with advancing age, regardless of stage. Multivariate Cox regression analysis simultaneously adjusted for age at diagnosis, gender, race, stage, and grade revealed that CT was associated with reduced mortality in all age categories: < 50 yrs, HR 0.75; 50-69, HR 0.61; 70-79, HR 0.53; and ≥ 80, HR 0.55 (all p < 0.01).

Conclusions: Older pts receive CT less frequently than younger pts. The use of CT in the elderly was associated with a reduced mortality, similar to that seen in younger pts. Younger pts were more likely to present with stage IV disease when compared to the elderly. Randomized, prospective trials are required to explore the differences noted.

[Table: see text]

No significant financial relationships to disclose.

Abstract P1-09-03: A Pharmaco-Economic Analysis of Tamoxifen (T) vs. Aromatase Inhibitors (AI) in Adjuvant Treatment of Postmenopausal (PoM) Women (W) with Hormone Receptor Positive (HRP) Breast Cancer (BC)

Background: Endocrine Therapy (ET) is an important component of adjuvant therapy in PoM W with HRP BC.AI are the preferred modality of ET despite higher cost. We performed an analysis to determine the cost of the difference in BC specific survival benefit when using AI compared to T in the adjuvant treatment of HRP BC in PoM W. Methods: Prices of medications were obtained through First Data Bank Blue Book. Annual incidence of BC globally was taken as reported in GLOBOCAN 2008. Incidence of non-metastatic, HRP BC in PoM W was calculated using data on incidence of metastatic BC (6%), HRP BC (80%) and W with PoM status (75%) from Cancer Statistics 2009 and Anderson WF et al, 2002 respectively. Meta-analysis of ATAC and BIG-98 trials comparing 5 years (yrs) of T and AI (T and anastrozole/letrozole), in the adjuvant setting presented by Dowsett et al, JCO, Vol 28, No 3 (January 20), 2010: 509-518 was used for calculating BC specific survival benefit of AI over T.

Results: Annually, 780,307 W globally would be eligible for 5 yrs of adjuvant ET. The cost of 5 yrs treatment for these W with T vs. AI is $5.4 billion (B) United States dollars (USD) vs. $22.5 B USD, respectively. The absolute BC specific survival benefit of treating W with AI over T for 5 yrs was 1.1%. Therefore, treating 780,307 women with AI rather than T for 5 yrs would benefit about 8583 W from BC specific mortality. The cost for saving one woman from BC related mortality, if treated with AI rather than T would be $1,992310.38 USD [(22.5 B USD — 5.4 B USD/8583]. AI use was associated with fewer endometrial cancers and thromboembolic events than T but with more arthralgias and fractures. Conclusion: AIs have shown benefit over T, but applying those results en-mass to all patients with HRP BC might be a substantial economic burden on society with relatively small benefits. Target markers for subset of patients who might preferentially benefit from AIs more than T need to be identified to best optimize the benefit from these drugs. Each class of drugs have different side effect profiles which should help individualize treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-09-03.