Retrospective review of gynecologic oncology patients with therapy-induced neutropenic fever

Chemotherapy-induced neutropenia and febrile neutropenia in patients with gynecologic malignancy

Chemotherapy-induced neutropenia is a common complication in cancer treatment. In this study, we investigated chemotherapy-induced neutropenia that was recently detected in all patients with gynecologic malignancy. Between January 2009 and December 2011, we examined cases of chemotherapy-induced neutropenia reported in our hospital. We analyzed the incidence and clinical features of chemotherapy-induced neutropenia and febrile neutropenia in patients with gynecologic malignancy. During the study period, we administered over 1614 infusions (29 regimens) to 291 patients. The median age of the patients was 60 years (range 24–84 years). Chemotherapy-induced neutropenia occurred in 147 (50.5%) patients over 378 (23.4%) chemotherapy cycles. Febrile neutropenia occurred in 20 (6.9%) patients over 25 (1.5%) cycles. The mean duration of neutropenia and fever was 3.6 days (range 1–12 days) and 3.4 days (range 1–9 days), respectively. The source of fever was unexplained by examination or cultures in 14 (56.0%) cycles. There were two cases of neutropenia-related death. Chemotherapy-induced neutropenia was associated with older age (over 70 years) (P<0.0001), less than five previous chemotherapy cycles (P=0.02), disseminated disease (P=0.03), platinum-based regimens (P<0.0001), taxane-containing regimens (P<0.0001), and combined therapy (P<0.0001). Febrile neutropenia was associated with poor performance status (P<0.0001), no previous chemotherapy (P<0.05), disseminated disease (P<0.0001), and distant metastatic disease (P=0.03). Neither chemotherapy-induced neutropenia nor febrile neutropenia was associated with bone marrow metastases or previous radiotherapy. By identifying risk factors for febrile neutropenia, such as performance status, no previous chemotherapy, disseminated disease, and distant metastatic disease, the safe management of chemotherapy-induced neutropenia may be possible in patients with gynecologic malignancy.

Etiology and workup of fevers in gynecologic oncology patients

OBJECTIVES

The objectives of this study are to identify the characteristics of febrile gynecologic oncology patients and to evaluate the utility of common diagnostic procedures used to assess the etiologies of their fevers.

METHODS/MATERIALS

Retrospective data were collected for 200 consecutive patients admitted to the gynecologic oncology service at 1 institution between January 2008 and December 2012 for a diagnosis of fever. Data were collected using contingency tables, and the χ test was used as appropriate.

RESULTS

Of the patients admitted for evaluation of fever, 142 (71%) of 200 had a documented fever during hospitalization. The most common etiologies of fever in this population were urinary tract infections (28%) and bloodstream infections (27%), whereas 24% of those admitted for fever did not have a source identified. Abdominal/pelvic computed tomography (CT) scans established the etiology of fever in 53 (60%) of the 89 patients tested, whereas chest x-ray and chest CT were diagnostic for 6% and 21%, respectively. Blood and urine cultures were diagnostic in 29% and 32% of cases, respectively. Patients admitted within 30 days of surgery had a higher percentage of wound infections (38% vs 10%, P < 0.001) as compared with those admitted for more than 30 days after surgery.

CONCLUSIONS

The initial evaluation of the febrile gynecologic oncology patient without obvious source by history and examination should include urinalysis with reflex culture and blood cultures. Abdominopelvic and chest CT may be useful when fever persists and initial assessment is unrevealing. Chest x-ray is commonly done but infrequently diagnostic. Wound exploration may be important in patients with fevers for more than 30 days after surgery.

Inpatient versus outpatient management of neutropenic fever in gynecologic oncology patients: is risk stratification useful?

OBJECTIVE

This study aimed to evaluate the utility of risk stratification of gynecologic oncology patients with neutropenic fever (NF).

METHODS

A retrospective chart review of gynecologic cancer patients admitted with NF from 2007 to 2011 was performed, wherein demographic, oncologic, and NF characteristics (hospitalization length, complications, and death) were collected. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score was calculated; low risk was considered ≥ 21. SAS 9.2 was used for statistical analyses.

RESULTS

Eighty-three patients met the study criteria. Most (92%) were Caucasian and had advanced stage disease (71%). Primary tumors were 58% ovary, 35% endometrium, and 6% cervix. All patients were receiving chemotherapy on admission (72% for primary, 28% for recurrent disease). Forty-eight percent had a positive culture, and most (58%) positive cultures were urine. Seventy-six percent of patients were considered low risk. High-risk patients were more likely to have a severe complication (10% versus 50%, p=0.0003), multiple severe complications (3% versus 20%, p=0.0278), ICU admission (2% versus 40%, p<0.0001), overall mortality (2% versus 15%, p=0.0417), and death due to neutropenic fever (0% versus 15%, p=0.0124). MASCC had a positive predictive value of 50% and negative predictive value of 90%. The median MASCC score for all patients was 22 (range, 11-26), but the median MASCC score for those with death or a severe complication was 17 (range, 11-24).

CONCLUSION

Based on this pilot data, MASCC score appears promising in determining suitability for outpatient management of NF in gynecologic oncology patients. Prospective study is ongoing to confirm safety and determine impact on cost.

Optimizing intensive care capacity using individual length-of-stay prediction models

Introduction

Effective planning of elective surgical procedures requiring postoperative intensive care is important in preventing cancellations and empty intensive care unit (ICU) beds. To improve planning, we constructed, validated and tested three models designed to predict length of stay (LOS) in the ICU in individual patients.

Methods

Retrospective data were collected from 518 consecutive patients who underwent oesophagectomy with reconstruction for carcinoma between January 1997 and April 2005. Three multivariable linear regression models for LOS, namely preoperative, postoperative and intra-ICU, were constructed using these data. Internal validation was assessed using bootstrap sampling in order to obtain validated estimates of the explained variance (r²). To determine the potential gain of the best performing model in day-to-day clinical practice, prospective data from a second cohort of 65 consecutive patients undergoing oesophagectomy between May 2005 and April 2006 were used in the model, and the predictive performance of the model was compared with prediction based on mean LOS.

Results

The intra-ICU model had an r² of 45% after internal validation. Important prognostic variables for LOS included greater patient age, comorbidity, type of surgical approach, intraoperative respiratory minute volume and complications occurring within 72 hours in the ICU. The potential gain of the best model in day-to-day clinical practice was determined relative to mean LOS. Use of the model reduced the deficit number (underestimation) of ICU days by 65 and increased the excess number (overestimation) of ICU days by 23 for the cohort of 65 patients. A conservative analysis conducted in the second, prospective cohort of patients revealed that 7% more oesophagectomies could have been accommodated, and 15% of cancelled procedures could have been prevented.

Conclusion

Patient characteristics can be used to create models that will help in predicting LOS in the ICU. This will result in more efficient use of ICU beds and fewer cancellations.

Characterization of neutropenic fever in patients receiving first-line adjuvant chemotherapy for epithelial ovarian cancer

OBJECTIVES

Limited information is available on the incidence and characteristics of neutropenic fever (NF) in patients receiving contemporary regimens for epithelial ovarian cancer (EOC). We examined this issue in patients receiving first-line adjuvant chemotherapy with platinum- and paclitaxel-based regimens at a major cancer institute.

METHODS

Charts of patients with EOC at a single institute from 1998 through 2002 were reviewed. Data were collected on the incidence and duration of NF, duration of hospitalization and fever, cultures, antibiotic and chemotherapy regimen, and type of debulking procedure.

RESULTS

140 patients were treated for EOC. 125 patients received first line chemotherapy. 15 episodes of NF were observed. Mean duration of neutropenia and fever was 2.33 and 3.07 days respectively. 9 of 15 (60%) NF episodes occurred after cycle 1. Cultures were positive in 7 of 15 patients (47%). Organisms most frequently recovered were bowel-derived. 8 patients (53%) had bowel resections, and 15 patients (100%) had radical or supraradical procedures. There was a correlation between incidence of NF and type of procedure (P = 0.01) and stage of EOC (P = 0.04). There was no correlation between NF and elderly age, medical comorbidities, and postoperative complications.

CONCLUSIONS

The rate of NF was higher than previously reported. NF occurred most frequently after cycle 1. NF patients were of advanced stage that had undergone more aggressive surgery and had bowel resections. Our data suggest that patients with advanced EOC who undergo more radical procedures should be identified as high risk for developing NF in early cycles.