Myoepithelioma-like hyalinizing epithelioid tumor of the foot with OGT-FOX03 fusion gene: Imaging findings, surgical implications, and pathological correlates

Myoepithelioma-like hyalinizing epithelioid tumors are rare neoplasms that share morphological characteristics of myoepitheliomas but lack traditional immunophenotypic findings. Though little is known about these tumors at present, a handful of recent studies have confirmed that they harbor a novel fusion gene known as "OGT-FOXO." Though closely resembling myoeptheliomas, Myoepithelioma-like hyalinizing epithelioid tumors are considered a distinct tumor entity, and few studies have explored their clinical characteristics or their potential for malignancy. Furthermore, literature describing imaging findings of these tumors is virtually non-existent. Understanding the radiological and pathological differences between Myoepithelioma-like hyalinizing epithelioid tumors and myoepitheliomas is helpful in developing a comprehensive differential for soft tissue neoplasms of the foot. We describe a case of MHET of the foot and correlate MRI findings with pathology in addition to describing surgical technique and implications to care.

Managing life-threatening 5-fluorouracil cardiotoxicity

5-Fluorouracil (5-FU), a known cardiotoxin, is the backbone for the treatment of colorectal cancer. It is associated with arrhythmias, myocardial infarction and sudden cardiac death. Most commonly, it is associated with coronary vasospasm secondary to direct toxic effects on vascular endothelium.A woman with metastatic colon cancer, originally treated with a 5-FU infusion as part of the FOLFIRI (Folinic acid, 5-Fluorouracil, Irinotecan) regimen, was unable to tolerate the chemotherapy due to chest pain. She was transitioned from infusional 5-FU to inferior 1-hour bolus 5-FU, in an attempt to minimise cardiotoxicity, but had disease progression. A multidisciplinary decision was made to again trial 5-FU infusion and pretreat with diltiazem. She tolerated chemotherapy without adverse events. A multidisciplinary discussion is recommended for co-management of reversible 5-FU-associated cardiotoxicity. After coronary artery disease (CAD) risk stratification and treatment, empiric treatment with calcium channel blockers and/or nitrates may allow patients with suspected coronary vasospasm, from 5-FU, to continue this vital chemotherapy.

Real-world uptake and concordance of actionable genetic mutations between tissue NGS and liquid biopsy in oncology patients in a safety-net hospital: A single center analysis

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Background: Advances in genomic mutation profiling have helped strengthen the management of cancer, however access to these advances can be challenging in hospitals serving majorly low-income neighborhoods due to socioeconomic factors. In a retrospective cohort study at our safety net hospital, serving lower socioeconomic populations, we identified the real-world uptake of tissue based next-generation sequencing (NGS) and liquid biopsy (ctDNA) in treated oncology patients. Methods: Records from 85 solid tumor patients treated at UF Health were evaluated for specific demographics and for completion of liquid biopsies and also NGS of patients’ tumors. 25 of those patients had completed liquid biopsies and were included. Genomic mutation profiles were stratified by liquid biopsies and whether or not NGS was completed. Concordance of multiple variant mutations between NGS and liquid biopsy were analyzed to determine if both tests were actionable. Results: Of these 85 patients, 25 obtained genomic mutation profiles from liquid biopsies with 10 also obtaining profiles from NGS. Of the profiled tumors, 64% contained actionable variant mutations for a specific therapy. Comparative analysis between patients with liquid biopsies and NGS revealed a concordance rate of 70% in variant mutation identification and 20% concordance rate in actionable variant mutations. Additionally, of the patients who received only liquid biopsies, 52% contained variant mutations that were actionable. Conclusions: Our data shows that 64% of patients with liquid biopsy and 70% with NGS had actionable mutations. The low concordance in actionable mutations between NGS and liquid biopsy suggests that both tests should be done to inform cancer management. Our data demonstrates that hospitals that serve low-income populations have limited access in obtaining genomic mutation profiling through liquid biopsies or NGS due to the socioeconomic challenges our patients face. Cancer centers in safety-net hospitals should address challenges to obtaining actionable data provided by genetic mutation profiling to inform treatment options for those patients.[Table: see text]

Consequences of the COVID-19 pandemic on new cancer visits to a comprehensive cancer center in New York

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Background: Studies on cancer patients during the COVID-19 pandemic have shown a decrease in new diagnoses, delays in care, and a shift to later stage disease presentations. Considering that NY has been an epicenter for COVID-19 in the U.S., we investigated its impact on new cancer diagnoses at the two campuses of NYU’s Perlmutter Cancer Center and hypothesized that there would be a decrease in presentations during the peak outbreaks in NY. Methods: We conducted a single center, retrospective analysis of new cancer diagnoses before, during, and after the peak of the pandemic between Dec 1, 2019, and Aug 31, 2020. Following IRB approval, subjects were identified using our cancer center database, which includes both inpatient and outpatient visits. Subjects were included regardless of their treatment plan. New diagnoses before COVID-19 (Dec to Feb), at first peak (March to May), and during the initial recovery phase (June-Aug) were assessed. No COVID-19 vaccines were available during this time. Results: As summarized in Table, during the initial COVID-19 peak, there was a substantial decrease in new patient visits with statistically significant differences seen by age and certain cancer types including breast, skin, and hematologic malignancies. In all cancers, there was a decrease in the proportion of new patient visits among those over age 75 during the peak. When confining analyses to breast, skin, and hematologic cancers, we saw a significant increase in the proportion of younger new patients at the peak period. We also observed an association between age and stage, with an increase in new stage I diagnoses in the younger (age 18-54) population at peak. Telemedicine was most utilized by the younger population during both peak and recovery periods. Conclusions: In this retrospective analysis, we found that during the initial COVID-19 peak, prior to vaccine availability, outpatient visits for hematologic and solid malignancies decreased at our cancer center in NY. The decrease in the proportion of all cancer types in elderly patients during the peak was likely related to hesitancy among this vulnerable population to seek care. The widespread use of telemedicine also likely contributed to the increased incidence in new patient visits in younger patients. Lessons learned from this experience can help guide outreach to vulnerable populations during future outbreaks, particularly by fostering telemedicine use among the elderly.[Table: see text]

Abstract P2-15-03: Neoadjuvant endocrine therapy (NET) as bridge therapy for early stage breast cancer during COVID-19: A single institution experience

Background: Neoadjuvant endocrine therapy (NET) has long been limited to patients who were deemed medically unfit for immediate surgery or on clinical trials. Coronavirus disease 2019 (COVID-19) resulted in a global pandemic, which led to deferral of elective surgeries including breast surgeries for early stage breast cancer patients during March - June 2020. Institutional guidelines were developed based on societal recommendations, including NCCN, to use NET as a bridge to surgery. Objective: Primary objective was to establish a database of early stage HR+ Her2/neu- breast cancer patients diagnosed during COVID-19 who were treated with NET as a bridge to surgery. Secondary endpoints include correlation between duration of NET and changes in pathological variables. Method: This was a single institution, retrospective observational study from Perlmutter Cancer Center at NYU Langone Hospital and NYU Langone Hospital - Long Island of DCIS and early stage breast cancer patients diagnosed from March 15, 2020 - June 1, 2020 during COVID-19 pandemic. Inclusion criteria were males and females older than 18 years of age and initial diagnosis of DCIS or early stage HR+ Her2/neu- breast cancer who did not require neoadjuvant chemotherapy by established guidelines. Descriptive statistics were calculated separately by DCIS and invasive breast cancer using SAS version 9.4. Results: From March 15 - June 1, 2020, 13 patients who were diagnosed with DCIS and 41 patients with early stage HR+ Her2/neu- invasive breast cancer received NET (Table 1). Of the 41 patients with invasive breast cancer, 19 (46%) had Oncotype DX assay on biopsy specimens; 12/19 (63%) had scores 10-14 and 7/19 (37%) had scores 15-25. 38/41 (92.7%) had post-surgery Ki-67% and 16/38 (42.1%) demonstrated maturation arrest (Ki-67 <2.7%). 26/41 (63%) invasive breast cancer patients had pre and post Ki-67% checked while on aromatase inhibitors (AI); 21/26 (81%) had a decrease in Ki-67%, 2/26 (7.7%) patients had no change, and 3/26 (11.5%) had an increase. Of those 21 patients, the percent change of Ki-67% from baseline was mean 69.15% ± 22.58 and median 71.83%. No significant associations with changes (pre to post) in Ki-67%, T stage, ER% and PR% in NET for ≤4 weeks and >4 weeks (Table 2). Median duration of NET in invasive breast cancer was 6.85 weeks. 1 patient had a complete pathological response after NET and 2 patients were upstaged from DCIS to invasive carcinoma at the time of surgery. Conclusion: While the sample sizes are small, this is a unique cohort of early stage surgically resectable breast cancer patients who were treated with NET during the COVID-19 pandemic. This real-world data confirms pathological changes, especially decrease in Ki-67% even with short duration use of NET that has been reported in trials of neoadjuvant AI. Long term follow-up for survival outcome is planned.

Table 1.Demographics of early stage breast cancer patients diagnosed during COVID-19.DCIS (n=13)Invasive Breast Cancer (n=41)Total (n=54)Menopause status (n, %)Pre-menopause7 (53.8)6 (14.6)13 (24.1)Post-menopause6 (46.2)35 (85.4)41 (75.9)Diagnosis (n, %)Self-Palpated08 (19.5)8 (14.8)Screening13 (100)33 (80.5)46 (85.2)Age (n, %)≤503 (23.1)5 (12.2)8 (14.8)50+10 (76.9)36 (87.8)46 (85.2)Clinical Stage (n, %)Tis13 (100)013 (24.1)I037 (90.2)37 (68.5)II04 (9.8)4 (7.4)NET in weeks (n, %)≤43 (23.1)11 (26.8)14 (25.9)4+10 (76.9)30 (73.2)40 (74.1)Genomic Testing (n, %)Oncotype DX019 (86.4)19 (86.4)ProSigna03 (13.6)3 (13.6)Mammaprint000

Table 2.No significant associations with changes in pre to post in T stage, ER%, PR% or Ki-67% in patients treated with NET for ≤4 weeks and >4 weeks.≤4 weeks>4 weeksp-valueChange in T stage0.5810Decrease2 (27.27%)8 (26.67%)No change7 (63.64%)15 (50%)Increase1 (9.09%)7 (23.33%)Change in ER%0.2444Decrease4 (36.36%)9 (30%)No change4 (36.36%)5 (16.67%)Increase3 (27.27%)16 (53.33%)Change in PR%1.0000Decrease7 (70%)21 (70%)No change2 (20%)5 (16.67%)Increase1 (10%)4 (13.33%)Change in Ki-67%0.3224Decrease4 (66.67%)17 (85%)No Change1 (16.67%)1 (5%)Increase1 (16.67%)2 (10%)

Citation Format: Julie Huang, Joshua Feinberg, Bahram Dabiri, Jordan Baum, Meredith Akerman, Anthony Pasquarella, Abhinav Rohatgi, Shubhada Dhage, Amber Guth, Nina D'Abreo. Neoadjuvant endocrine therapy (NET) as bridge therapy for early stage breast cancer during COVID-19: A single institution experience [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-15-03.

Abstract P5-14-20: Neoadjuvant endocrine therapy (NET) during COVID-19: Single institution survey of patients’ perspectives

Background: Coronavirus disease 2019 (COVID-19) resulted in a global pandemic, which led to deferral of surgeries for early stage breast cancer during March - June 2020. Institutional guidelines were developed to use neoadjuvant endocrine therapy (NET) as a bridge to surgery. As a follow up to initial data presented at SABCS 2020 demonstrating patient acceptance of NET, the present study provides results from a survey which explored psychosocial factors associated with medication compliance. Objective: Primary objective was to identify any barriers to compliance with NET. Method: This was a single institution, prospective study that surveyed patients diagnosed with DCIS and early stage breast cancer at Perlmutter Cancer Center at NYU Langone Hospital and NYU Langone Hospital - Long Island from March 15, 2020 - June 1, 2020. Questions were based on the Beliefs about Medicines Questionnaire specific for endocrine therapy (BMQ-AET) and the Medication Adherence Report Scale. Responses were recorded on a Likert scale and included 7 questions regarding perceptions about breast cancer treatment, 10 questions addressing experience with NET, and 5 questions gauging at adherence to NET. Inclusion criteria were males and females older than 18 years old, with an initial diagnosis of DCIS or early stage HR+ Her2/neu- breast cancer, who were prescribed NET. Descriptive statistics were calculated and subgroups were compared using Fisher’s exact tests. Analyses were performed using SAS version 9.4. Results: From March 15 - June 1, 2020, 13 patients were diagnosed with DCIS and 29 patients with HR+ Her2/neu- breast cancer for whom NET was recommended. Demographics are shown in Table 1. All 42 patients were female with an average age of 60.9 years. Majority of patients were post-menopause (74%) and predominantly white (64%), with an income of less than $60,000 (52.4%). Average NET duration was 6.7 weeks. Survey responses displayed in Table 2 indicate statistically significant p values in bold. Patients >50 years old, post-menopause and invasive breast cancer had a stronger belief that NET would be helpful, resulting in greater perception to breast cancer treatment and higher adherence to NET. Patients treated with NET for greater than 4 weeks also felt that NET would make them feel well compared to ≤4 weeks. Interestingly, no significant differences in responses based on education or income level were observed. Conclusion: COVID-19 pandemic presented a unique opportunity to use NET, which is often underutilized outside of clinical trials. In this single institution prospective study, we found that post-menopause patients greater than 50 years old with invasive breast cancer perceived hormonal therapy as beneficial to their health, resulting in increased medication compliance. These findings can be used when counseling patients currently treated with NET as well as those patients may be appropriate for NET in the post-COVID era.

Table 1.Demographics of early stage breast cancer patients diagnosed during COVID-19.DCIS (n=13)Invasive Breast Cancer (n=29)Total (n=42)Menopause Status (n, %)Pre-menopause7 (53.8)4 (13.8)11 (26.2)Post-menopause6 (46.2)25 (86.2)31 (73.8)Diagnosis (n, %)Self-Palpated06 (20.7)6 (14.3)Screening13 (100)23 (79.3)36 (85.7)Age (n, %)≤504 (30.8)4 (13.8)8 (19)50+9 (69.2)25 (86.2)34 (80.9)Average Age (range)54.9 (40 – 72)63.6 (32 – 85)60.9 (32 – 85)Race (n, %)White7 (53.8)20 (69%)27 (64.3)Non-White6 (46.2)9 (31%)15 (35.7)Education (n, %)K-121 (7.7)6 (20.7)7 (16.7)College and Graduate12 (92.3)23 (79.3)35 (83.3)Income (n, %)$0 – $60,0005 (38.5)17 (58.6)22 (52.4)$>60,0017 (53.8)12 (41.3)19 (45.2)No response1 (7.7)01 (2.4)NET in Weeks (n, %)≤45 (38.5)7 (24.1)12 (28.6)4+8 (61.5)22 (75.9)30 (71.4)

Table 2.Perceptions of breast cancer and hormonal therapy.Perceptions About Hormonal TherapyPerceptions About Breast Cancer TreatmentAdherence To Hormonal TherapyMy health at present depends on me taking hormone treatment (p-value)Hormone treatment is a mystery to me (p-value)My health in the future will depend on me taking hormone treatment (p-value)Taking hormone treatment makes me feel I am taking positive steps to remain well (p-value)How much do you feel that your current hormone therapy can help? (p-value)How much do you feel that you need your current hormone therapy? (p-value)I miss out on a dose (p-value)I stop taking medication for a while (p-value)Age >50 vs. ≤500.04020.56510.00580.08330.04770.87370.04831.0000Post-Menopause vs. Pre-Menopause0.00330.02720.00530.13380.00060.24520.01661.0000Invasive vs. DCIS0.00381.00000.00450.16480.01810.00011.00000.0133Non-White vs. White0.47420.04340.76400.05220.91430.77730.61280.1369Duration of NET: ≤4 vs. >4 weeks0.43190.49971.00000.02840.11390.75430.05220.8833Screening vs. Self-Palpated0.51100.02560.62571.00000.44230.05930.47760.6353K-12 vs. College/Graduate0.43660.65400.16151.00000.41450.67531.00000.8321Income: ≤$60,000 vs. >$60,0000.54590.27860.59900.85690.09530.07000.78980.0581

Citation Format: Julie Huang, Joshua Feinberg, Meredith Akerman, Anthony Pasquarella, Abhinav Rohatgi, Bahram Dabiri, Jordan Baum, Shubhada Dhage, Amber Guth, Nina D'Abreo. Neoadjuvant endocrine therapy (NET) during COVID-19: Single institution survey of patients’ perspectives [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-20.

Efficacy and Safety of COVID-19 Convalescent Plasma in Hospitalized Patients: A Randomized Clinical Trial

IMPORTANCE

There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19.

OBJECTIVE

To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen.

DESIGN, SETTING, AND PARTICIPANTS

CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation.

INTERVENTIONS

A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline).

MAIN OUTCOMES AND MEASURES

The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8.

RESULTS

Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR<1] = 72%); the cOR for the secondary adjusted outcome was 0.92 (95% CrI, 0.74-1.16; P[cOR<1] = 76%). Exploratory subgroup analyses suggested heterogeneity of treatment effect: at day 28, cORs were 0.72 (95% CrI, 0.46-1.13; P[cOR<1] = 93%) for participants enrolled in April-June 2020 and 0.65 (95% CrI, 0.41 to 1.02; P[cOR<1] = 97%) for those not receiving remdesivir and not receiving corticosteroids at randomization. Median CCP SARS-CoV-2 neutralizing titer used in April to June 2020 was 1:175 (IQR, 76-379). Any adverse events (excluding transfusion reactions) were reported for 39 (8.2%) placebo recipients and 44 (9.4%) CCP recipients (P = .57). Transfusion reactions occurred in 2 (0.4) placebo recipients and 8 (1.7) CCP recipients (P = .06).

CONCLUSIONS AND RELEVANCE

In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04364737.

A Stress and Pain Self-management m-Health App for Adult Outpatients with Sickle Cell Disease (RADIANCE Study): Protocol for a Randomized Controlled Study (Preprint)

Background

This paper describes the research protocol for a randomized controlled trial of a self-management intervention for adults diagnosed with sickle cell disease (SCD). People living with SCD experience lifelong recurrent episodes of acute and chronic pain, which are exacerbated by stress.

Objective

This study aims to decrease stress and improve SCD pain control with reduced opioid use through an intervention with self-management relaxation exercises, named You Cope, We Support (YCWS). Building on our previous findings from formative studies, this study is designed to test the efficacy of YCWS on stress intensity, pain intensity, and opioid use in adults with SCD.

Methods

A randomized controlled trial of the short-term (8 weeks) and long-term (6 months) effects of YCWS on stress, pain, and opioid use will be conducted with 170 adults with SCD. Patients will be randomized based on 1:1 ratio (stratified on pain intensity [≤5 or >5]) to be either in the experimental (self-monitoring of outcomes, alerts or reminders, and use of YCWS [relaxation and distraction exercises and support]) or control (self-monitoring of outcomes and alerts or reminders) group. Patients will be asked to report outcomes daily. During weeks 1 to 8, patients in both groups will receive system-generated alerts or reminders via phone call, text, or email to facilitate data entry (both groups) and intervention use support (experimental). If the participant does not enter data after 24 hours, the study support staff will contact them for data entry troubleshooting (both groups) and YCWS use (experimental). We will time stamp and track patients’ web-based activities to understand the study context and conduct exit interviews on the acceptability of system-generated and staff support. This study was approved by our institutional review board.

Results

This study was funded by the National Institute of Nursing Research of the National Institutes of Health in 2020. The study began in March 2021 and will be completed in June 2025. As of April 2022, we have enrolled 45.9% (78/170) of patients. We will analyze the data using mixed effects regression models (short term and long term) to account for the repeated measurements over time and use machine learning to construct and evaluate prediction models. Owing to the COVID-19 pandemic, the study was modified to allow for mail-in consent process, internet-based consent process via email or Zoom videoconference, devices delivered by FedEx, and training via Zoom videoconference.

Conclusions

We expect the intervention group to report reductions in pain intensity (primary outcome; 0-10 scale) and in stress intensity (0-10 scale) and opioid use (Wisepill event medication monitoring system), which are secondary outcomes. Our study will contribute to advancing the use of nonopioid therapy such as guided relaxation and distraction techniques for managing SCD pain.

Trial Registration

ClinicalTrials.gov NCT04484272; https://clinicaltrials.gov/ct2/show/NCT04484272

International Registered Report Identifier (IRRID)

PRR1-10.2196/33818

Efficient passivation of n-type and p-type silicon surface defects by hydrogen sulfide gas reaction

An efficient surface defect passivation is observed by reacting clean Si in a dilute hydrogen sulfide-argon gas mixture (<5% H₂S in Ar) for both n-type and p-type Si wafers with planar and textured surfaces. Surface recombination velocities of 1.5 and 8 cm s^-1are achieved on n-type and p-type Si wafers, respectively, at an optimum reaction temperature of 550 °C that are comparable to the best surface passivation quality used in high efficiency Si solar cells. Surface chemical analysis using x-ray photoelectron spectroscopy shows that sulfur is primarily bonded in a sulfide environment, and synchrotron-based soft x-ray emission spectroscopy of the adsorbed sulfur atoms suggests the formation of S-Si bonds. The sulfur surface passivation layer is unstable in air, attributed to surface oxide formation and a simultaneous decrease of sulfide bonds. However, the passivation can be stabilized by a low-temperature (300 °C) deposited amorphous silicon nitride (a-Si:N_X:H) capping layer.

COVID-19 outcomes in hospitalized patients with active cancer: Experiences from a major New York City health care system

Background

The authors sought to study the risk factors associated with severe outcomes in hospitalized coronavirus disease 2019 (COVID‐19) patients with cancer.

Methods

The authors queried the New York University Langone Medical Center's records for hospitalized patients who were polymerase chain reaction–positive for severe acute respiratory syndrome coronavirus 2 (SARS CoV‐2) and performed chart reviews on patients with cancer diagnoses to identify patients with active cancer and patients with a history of cancer. Descriptive statistics were calculated and multivariable logistic regression was used to determine associations between clinical, demographic, and laboratory characteristics with outcomes, including death and admission to the intensive care unit.

Results

A total of 4184 hospitalized SARS CoV‐2+ patients, including 233 with active cancer, were identified. Patients with active cancer were more likely to die than those with a history of cancer and those without any cancer history (34.3% vs 27.6% vs 20%, respectively; P < .01). In multivariable regression among all patients, active cancer (odds ratio [OR], 1.89; CI, 1.34‐2.67; P < .01), older age (OR, 1.06; CI, 1.05‐1.06; P < .01), male sex (OR for female vs male, 0.70; CI, 0.58‐0.84; P < .01), diabetes (OR, 1.26; CI, 1.04‐1.53; P = .02), morbidly obese body mass index (OR, 1.87; CI, 1.24‐2.81; P < .01), and elevated D‐dimer (OR, 6.41 for value >2300; CI, 4.75‐8.66; P < .01) were associated with increased mortality. Recent cancer‐directed medical therapy was not associated with death in multivariable analysis. Among patients with active cancer, those with a hematologic malignancy had the highest mortality rate in comparison with other cancer types (47.83% vs 28.66%; P < .01).

Conclusions

The authors found that patients with an active cancer diagnosis were more likely to die from COVID‐19. Those with hematologic malignancies were at the highest risk of death. Patients receiving cancer‐directed therapy within 3 months before hospitalization had no overall increased risk of death.

Lay Summary

Our investigators found that hospitalized patients with active cancer were more likely to die from coronavirus disease 2019 (COVID‐19) than those with a history of cancer and those without any cancer history.

Patients with hematologic cancers were the most likely among patients with cancer to die from COVID‐19.

Patients who received cancer therapy within 3 months before hospitalization did not have an increased risk of death.

Investigators have found that hospitalized patients with active cancer are more likely to die from coronavirus disease 2019 than those with a history of cancer and those without any cancer history. Patients who receive antineoplastic medications at least 3 months before hospitalization have no overall increased risk of death.

Gene expression associated with lymphovascular invasion and genomic risk in early-stage breast cancer

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Background: Lymphovascular invasion (LVI), the passage of carcinoma cells through lymphatic and blood vessels, is an important early step in metastasis; however, LVI is excluded from most breast cancer (BC) clinical risk assessments. Previous studies assessed the prognostic value of LVI to estimate clinical outcomes. To gain understanding of the molecular basis of LVI, we evaluated differentially expressed genes (DEGs) between tumors with LVI versus those without LVI, stratified by the 70-gene signature (MammaPrint/MP) and 80-gene molecular subtyping signature (BluePrint/BP). Methods: The prospective, observational FLEX Study (NCT03053193) includes stage I-III BC patients who receive MP/BP testing and consent to full transcriptome and clinical data collection. Patients with LVI (n=581) and without LVI (n=600, randomly selected), enrolled from 2017 to present, were included. LVI was assessed by local pathology laboratories. Differential gene expression analysis of 44k Agilent microarray data was performed with R limma package. DEGs were compared within all samples, BP Luminal subtype, MP risk groups (Low Risk [LR]/Luminal A and High Risk [HR]/Luminal B), and by lymph node (LN) status. DEGs with FDR<0.05 were considered significant. Results: Of tumors with LVI (LVI+), 66% were MP HR; notably, 51% of tumors without LVI (LVI-) were MP HR. LVI was associated with larger T stage, LN involvement, high grade, negative ER status by IHC, and younger patient age (LVI+ vs. LVI-, p<0.05 for all comparisons). Patient ethnicity, obesity, and tumor type did not differ by LVI status; however, prevalence of type 2 diabetes trended higher in patients with LVI+ HR tumors (21%), compared with LVI- HR (15%, p=0.09) and LVI+ LR (11%, p=0.004). There were significant transcriptomic differences between LVI+ and LVI, with most DEGs evident in the Luminal B subset. DEGs in LVI+, LN-negative (LN-) tumors overlapped substantially with the overall Luminal group analysis. Functional enrichment analysis showed dysregulation of cell cycle, extracellular matrix (ECM) organization, cell adhesion, and cytokine receptor pathways. Gene sets related to insulin growth factor pathways were also enriched in LVI+ tumors. Conclusions: DEGs associated with LVI were primarily found in MP HR Luminal, LN-negative tumors; enrichment analysis suggested dysregulation of ECM organization and cell adhesion pathways, consistent with previous reports. DEGs were not associated with LVI presence in LN+ tumors, suggesting that LVI assessment may be less relevant in LN+ breast cancer. Future studies will assess clinical outcomes, as well as LVI-associated gene expression in BP Basal- and HER2-type tumors. However, the current analysis indicates few DEGs in LVI+ MP LR tumors; thus, the potential prognostic information gained from LVI-associated gene expression is likely already captured by the MP and BP signatures. Clinical trial information: NCT03053193.

Mutational profile analysis and related outcomes in primary and metastatic pancreatic cancer (PC)

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Background: PC has not been well molecularly characterized and there is an unmet need in our understanding of the biological properties of PC. One previous study has found that the presence of CDKN2A mutations is an independent negative prognostic OS indicator. We evaluated molecular analysis on tumor specimens to determine whether increased mutational burden affects survival. Methods: PDAC samples from patients seen at the NYU Perlmutter Cancer Center at Winthrop Oncology Hematology Associates between 2015-2020 were profiled using next generation sequencing through Foundation Cdx. Genomic data was correlated with mined clinical data. Pt outcomes were correlated with the presence of mutations defined in 3 categories: 3 or less mutations, 4 mutations, 5 or more mutations. Results: Our cohort (N = 81) included 42% men and 58% women. 55% percent had primary (localized and locally advanced) disease and 44% had stage IV disease. Genetic mutations were most commonly found in KRAS, CDKN2A, TP53, NOTCH, SMAD4. Mutations seen less frequently were BRAF, HER2, RB1, ARID1A, MTAP, MLL, BRCA2. 43% of pts had 3 or less mutations, 15% 4 mutations, 42% had 5 or more mutations. There was no difference in number of mutations present between primary vs metastatic cancers. Median PFS was 13.5 months and overall survival (OS) for all pts was 20.0 months. The OS in primary group was 26.1 mos while it was 12.4 mos in the metastatic group. Patients with 5+ mutations had a 1.5 mos decreased OS and a 10% decreased 24-mos OS%. When stratified by primary (localized) disease, there was an 8.3 mos decrease in the 5+ mutation group vs 3 mutation group. When stratified by metastatic disease at diagnosis, there was no appreciable difference in OS between mutational groups. Conclusions: In the primary PC cohort, increasing burden of gene alteration patterns from 3 to 5+ mutations is correlated with decreased overall survival. The effect did not extend to the metastatic group likely due to disease burden driving survival whereas in primary PC group, survival reflected the tumor biology. This suggests that as additional carcinogenic pathways (DNA repair, growth, apoptosis) are mutated, tumor biology becomes more aggressive. This study provides an impetus for mutational profiling in early stage pancreatic cancer. These findings can contribute to the use of molecular profiles for prognostication and further development of targeted therapies. [Table: see text]

Considerations for the Management of Oncology Patients During the COVID-19 Pandemic

Worldwide incidence and mortality due to the coronavirus disease 2019 (COVID-19) pandemic is greatest in the United States, with the initial epicenter in New York. In Nassau County, New York, where we practice, our institution has had more than 2500 cases and has discharged from the hospital more than 1000 patients. As many academic and private institutions have swiftly shifted their clinical and research priorities to address the pandemic, data are emerging regarding both the impact of malignancy on COVID-19 outcomes as well as the challenges faced in assuring that cancer care remains unimpeded. Of concern, recent studies of cancer patients primarily in China and Italy have suggested that advanced malignancy is associated with increased susceptibility to severe COVID-19 infection. At present, more than 500 clinical trials are underway investigating the pathogenesis and treatment of COVID-19, including expanded use of oncology drugs, such as small molecular inhibitors of cytokine pathways. Here, we begin by reviewing the latest understanding of COVID-19 pathophysiology and then focus our attention on the impact of this virus on hematologic and oncologic practice. Finally, we highlight ongoing investigational treatment approaches that are so relevant to the care of oncology patients during this extraordinary pandemic.

Refractory hypercalcaemia secondary to localised gastrointestinal stromal tumour

Gastrointestinal stromal tumours are a rare form of intra-abdominal neoplasm derived from mesenchymal tissue, typically presenting with abdominal pain, anaemia or bleeding into the bowel or abdominal cavity. Hypercalcaemia is an unusual complication, having been documented in only seven previous patients, all of whom had advanced metastatic disease. We present a case of treatment-resistant hypercalcaemia in a patient with non-metastatic gastrointestinal stromal tumour, which resolved following excision of the tumour.

Optimization Of Porous Silicon Reflectance For Solar Cell Applications

The potential use of porous silicon as an antireflective coating on solar cells has recently been recognized. This study investigates the effect of current density, anodization time, and surface conditions on the reflectance of porous silicon which was fabricated by anodizing (100) float zone single crystal Si wafers. The wafers were coated on one side with Al prior to anodization, and a HFbased solution was used as the electrolyte. Current densities of 5 – 100 mA/cm2 were used to anodize both polished and unpolished wafers over time intervals ranging from 2sec - 30 minutes. Reflectance properties were tested over the 400 - 1100 nm range, and minimum reflectances of 3 – 5% were achieved. The reflectance of the best porous Si sample normalized with respect to the sun's spectrum compares favorably with the reflectance of a double layer ZnS/ MgF2 with prior texturing.

Acute superior vena cava obstruction following Ivor-Lewis oesophagectomy

A 53 year old man developed upper body swelling, hypotension, anuria and a metabolic acidosis within 24 h following an Ivor-Lewis oesophagectomy. His co-morbidities included hypertension, hypercholesterolaemia, ischaemic heart disease and he was a smoker. He did not have radiotherapy but had received neo-adjuvant chemotherapy through an in-dwelling right subclavian central venous catheter. Azygous vein ligation during oesophagectomy resulted in acute upper body venous hypertension and signs of hypovolaemic shock which were attributed to undiagnosed thrombotic occlusion of the superior vena cava. The patient was anticoagulated and made a full recovery after a period of stay in intensive care.

Effect of understaging of early oesophageal tumors on treatment

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Background: Early and node negative oesophageal cancers do not undergo chemotherapy as it is felt that as the risk of lymph node metastasis is small, early operative intervention is considered the best option. We analysed a prospective database in a tertiary referral centre to see, with current preoperative staging modalities, if a significant number of patients were under staged and hence under treated preoperatively. Methods: Four hundred and fifteen patients underwent esophagectomies for cancer in our unit between March 2000 and December 2006. 117 were preoperatively staged as either T1/T2 N0. Pre-operative staging was by gastroscopy, endoscopic ultrasound (EUS), CT scan and PET-CT. These were discussed in a multi-disciplinary meeting and as per current evidence did not undergo preoperative chemotherapy. Results: 115 patients were analysed as two were excluded. Preoperatively there were 35 T0N0, 30 T1N0, and 50 T2N0. There were 42 (36.5%) patients who were under staged utilising the standard preoperative staging protocol. These were preoperatively staged as T0N0 –2, T1N0 –6, T2N0 –34. 6 did not have EUS, only 4 had a PET- CT and 1 had a staging laparoscopy. Gastroscopy, CT scan and EUS was the staging protocol in 87%. Post op staging was T1N1–7, T2N1–12, T2N2–1, T3N0–10, T3N1–11, T3N2–1. Conclusions: Utilising current preoperative staging methods one third of patients were under staged. Looking specifically at T2N0 68% were under staged. We feel that early oesophageal cancer especially T2N0 disease may benefit from neoadjuvant chemotherapy based on the current staging protocols.

No significant financial relationships to disclose.

Transhiatal oesophagectomy: techniques, tips and outcomes

AIM

To demonstrate our technique and valuable tips for transhiatal oesophagectomies.

METHOD

215 patients underwent transhiatal oesophagectomies in our unit between 2000 and 2006.

RESULTS

In-hospital mortality was 0.9%. Anastomotic leak in 12 patients (5.6%). Chyle leak was seen in five patients and recurrent nerve neuropraxia in six patients. Iatrogenic splenectomy rate was 6%. The median operative time was 151 minutes (range 93-276 minutes). Overall median length of hospital stay was 15 days (range 8-95 days). The median survival for all patients undergoing transhiatal oesophagectomy for invasive malignancy was 42.9 months and the one-year and five-year survival were 81% and 48% respectively.

CONCLUSION

This is a safe and oncologically sound procedure. We feel that the tips can be helpful for anyone performing this procedure.

Anastomotic strictures and delayed gastric emptying after esophagectomy: incidence, risk factors and management

The aim of this study was to report the incidence, risk factors, and management of gastric conduit dysfunction after esophagectomy in 177 patients over a 3-year period in a single center. Patients with anastomotic strictures or delayed gastric emptying (DGE) were identified from a prospective database. Anastomotic strictures occurred in 48 patients (27%). Eighty-three percent of early anastomotic strictures (<1 year) were benign, and all late strictures (>1 year) were malignant. Dilatation was effective in 98% of benign and 64% of malignant strictures. DGE occurred in 21 patients (12%), and was associated with both anastomotic leak (P = 0.001) and anastomotic stricture (P = 0.001). 4/8 patients with late DGE (>3 months postesophagectomy) were tumor-related. Pyloric dilatation was effective in 92% of early and 63% of late DGE. Pyloric stents were inserted in 3 patients with tumor-related DGE. After esophagectomy, early anastomotic strictures (within 1 year) and early delayed gastric emptying (within 3 months) are usually benign and respond to dilatation. However, patients presenting later with tumor-related obstruction are unlikely to respond to anastomotic or pyloric dilatation and should be stented.

Training in oesophageal surgery--the gold standard: a prospective study

INTRODUCTION

Competency in complex oesophagogastric surgery, within the current climate of changes to medical training and reduced hours, requires repeated, focused, hands-on training. We describe the training methods for oesophagectomy in our institution.

METHODS

All oesophageal resections under the care of one consultant surgeon are regarded as training cases. When trainees start they are shown the first resection; subsequently, the trainees then perform every case with the consultant scrubbed. Consultant input consists of retraction and tips in difficult situations. All data were collected on a prospective database.

RESULTS

Two hundred and seventy patients (215 males, median age=64 years) underwent primary oesophagectomy under the consultant, between January 2000 and May 2007. Fifteen resections (6%) were performed solely by the consultant. ASA grading was: I=15, II=154, III=95, IV=5, and unrecorded=1. In-hospital mortality and clinically apparent leak rate was 1.9% (5 deaths) and 6.2% (n=17), respectively. Reoperation was required in 15 patients (5.5%). The median length of hospital stay was 14 days (range=8-95 days). Median lymph node yield was 13 (range=0-64).

CONCLUSIONS

Trainees under supervision can competently perform an oesophagectomy without compromising patient care. An early hands-on approach leads to a rapid ascent of the learning curve and is essential in today's climate of limited training opportunity.

Laparoscopic gastrectomy for gastric cancer: early experience among the elderly

BACKGROUND

The data are scarce on the outcome for elderly patients presenting with resectable gastric cancer in the West who have been treated with minimally invasive surgery. This report presents the authors' early experience with totally laparoscopic gastric resections for cancer in elderly patients.

METHODS

A total of 20 patients underwent laparoscopic gastrectomy procedures: 14 distal, 5 subtotal, and 1 total gastrectomy. The male-to-female ratio was 15 to 5. The ages ranged from 75 to 88 years (mean, 80 years).

RESULTS

All cases were managed laparoscopically with R0 resection. Four patients needed high-dependency unit care postoperatively. There were no perioperative deaths. The median time required for the procedure was 212 min, and time to diet was 4 days. The hospital stay was 8 days. Four patients experienced significant complications, with two patients requiring reoperation. The pathology was adenocarcinoma for 17 patients and high-grade dysplasia for 3 patients.

CONCLUSION

Among elderly patients for whom conventional gastric surgery carries a high morbidity and mortality risk, minimal access surgery may offer equivalent oncologic integrity but with superior safety and economy. The primary aim is to remove the tumor with at least a D1 lymphadenectomy.

Does rectus sheath infusion of bupivacaine reduce postoperative opioid requirement?

INTRODUCTION

The aim of this work was to assess the effect of intermittent bupivacaine infusion into rectus sheath space on postoperative opioid requirement, postoperative pain score and peak expiratory flow rate.

PATIENTS AND METHODS

A prospective, randomised study involving patients undergoing midline laparotomy. Patients were randomised to receive either intermittent infusion of bupivacaine 0.25% or normal saline via catheters placed in the rectus sheath for 48 h after operation. All patients received intravenous morphine infusion on demand with a patient-controlled analgesic device (PCAD).

RESULTS

Forty ASA I-III patients were studied. Nineteen were randomised to receive bupivacaine and 21 patients received normal saline. Patient characteristics and surgical variables were comparable in the two groups. The mean wound lengths were similar. There was no statistically significant difference in postoperative opioid requirement, postoperative pain score and peak expiratory flow rate between the two groups.

CONCLUSIONS

Intermittent bupivacaine infusion into the rectus sheath space after midline laparotomy does not reduce postoperative opioid requirement nor does it affect postoperative pain score or peak expiratory flow rate.

Use of porcine dermal collagen graft and topical negative pressure on infected open abdominal wounds

This article reports on two cases in which porcine dermal collagen grafts were used successfully alongside topical negative pressure therapy in order to close open abdominal wounds in which severe infection was present.

Laparoscopic management of a torted appendix

Torted appendices are a rare occurrence but should be considered when encountering a haemorrhagic congested appendix on laparoscopy. As adhesions are rarely present, laparoscopic excision is usually a feasible option.

Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy

BACKGROUND

The authors present their experience with laparoscopic subtotal cholecystectomy for the management of Mirizzi's syndrome and their review of the literature.

METHODS

Over a period of 24 months, five cases of Mirizzi's syndrome were encountered, representing 1.5% of all the laparoscopic cholecystectomies performed in the authors' unit. The sex ratio was 4 females to 1 male, and the mean age of the patients was 66 years. All underwent a subtotal cholecystectomy.

RESULTS

All procedures were completed laparoscopically. Morbidities involved one case of biliary peritonitis and a one case of biliary leak requiring endoscopic stenting.

CONCLUSION

Mirizzi's syndrome cannot always be anticipated on the basis of preoperative staging, and often is encountered during the procedure. The "anatomic scenario" of this condition should be suspected for patients presenting with conditions such as empyema or mucocoele when there is a likelihood of stone impaction in the infundibulum of the gallbladder. Subtotal cholecystectomy with secure intraperitoneal biliary drainage appears to be a safe option for these patients.

An audit of cystic duct closure in laparoscopic cholecystectomies

BACKGROUND

Cystic duct leak is an infrequent but potentially serious complication of laparoscopic cholecystectomy. The aims of this audit were to assess the efficacy of locking absorbable clips for closing the cystic duct and to compare the results with those for simple clips used previously.

METHODS

The records for all laparoscopic cholecystectomies performed in one hospital over a 5-year period were reviewed. The results were compared using Fisher's exact test.

RESULTS

Of 518 laparoscopic cholecystectomies attempted, 24 were excluded. There was no difference in age or sex ratio between the two groups. Cystic duct leaks were identified either on endoscopic retrograde choloangio pancreatography or at laparotomy. No cystic duct leak occurred in any of the 344 locking clip cases, as compared with 3 leaks in the 146 (2%) simple clip cases (p < 0.03).

CONCLUSION

Locking clips are a safe and effective method for cystic duct closure. They are associated with a reduced cystic duct leak rate, as compared with that for simple clips.

Left subcostal closed (Veress needle) approach is a safe method for creating a pneumoperitoneum

BACKGROUND

The left subcostal closed approach utilizing the Veress needle has been the preferred method at one surgical practice for the past 5 years. The aims of this study were to determine whether this was a safe method for creating a pneumoperitoneum and its success rate.

METHODS

The medical records for all laparoscopic procedures performed at one practice from 1996 through 2001 were reviewed.

RESULTS

A total of 352 laparoscopic cases were reviewed. The median age of the patients was 55 years (range, 14-72), with a sex ratio of 1 male to 3.5 females. The left subcostal closed approach was not attempted in 8 patients (2%) due to left subcostal surgical scars. The left subcostal approach was successful in 342 of 344 attempts (99%). In 2 patients the method failed because the Veress needle hole could not be placed in the peritoneal cavity. An omental hematoma in one patient was the only complication.

CONCLUSION

The left subcostal closed approach is a safe and effective method for creating a pneumoperitoneum.

Spontaneous rupture of a left gastroepiploic artery aneurysm

Gastroepiploic aneurysms are extremely rare. They occur mainly in elderly men and in 90% of cases are ruptured at presentation. Visceral aneurysms though rare should be borne in mind in cases of unexplained haemorrhagic shock. We present a case of a 79-year-old man who presented with abdominal pain, hypotension and anaemia but no obvious source of bleeding. He had undergone a prior aorto-bifemoral graft. The patient refused an operation and died the following day.

A case of a destructive lesion of sphenoidal sinus

This interesting case deals with the possible origin of pituitary tumor from cell rests located outside the pituitary gland. In the present case we found an elderly lady presenting with a suspected mass lesion of the sphenoidal sinus, clinically suspected to be either an infective granuloma or a chordoma which finally turned out to be an adenoma of the pituitary gland.

Duodenal tamponade in the treatment of an intractable peptic ulcer bleed

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Japanese encephalitis with movement disorder and atypical magnetic resonance imaging

With the advent of magnetic resonance imaging, brain lesions associated with Japanese encephalitis are increasingly being recognized and correlated with movement disorder. Bilateral haemorrhagic thalamic infarcts on MRI, suggested as a characteristic finding in Japanese encephalitis were conspicuous by their absence in this case report of Japanese encephalitis.

Stimulation of nonspecific resistance by thymopentin and its analogs against Leishmania donovani infection in hamsters

Thymopentin and its analogs have been synthesized by the solution phase method of peptide synthesis and evaluated for their prophylactic efficacy against L. donovani infection in hamsters. Thymopentin and some of the analogs were found to stimulate nonspecific resistance of the host against Leishmania donovani infection in hamsters.

Characterization and optimization of absorbing plasma-enhanced chemical vapor deposited antireflection coatings for silicon photovoltaics

We have optimized plasma-enhanced chemical vapor deposition (PECVD) of SiN-based antireflection (AR) coatings with special consideration for the short-wavelength (<600 nm) parasitic absorption in SiN. Spectroscopic ellipsometry was used to measure the dispersion relation for both the refractive index n and the extinction coefficient k, allowing a precise analysis of the trade-off between reflection and absorption in SiN-based AR coatings. Although we focus on photovoltaic applications, this study may be useful for photodetectors, IR optics, and any device for which it is essential to maximize the transmission of light into silicon. We designed and optimized various AR coatings for minimal average (spectrally) weighted reflectance (? R(w) ?) and average weighted absorptance (? A (w) ?), using the air mass 1.5 global solar spectrum. In most situations ? R (w) ? decreased with higher n, but ? A (w) ? increased because k increased with n. For the practical case of a single-layer AR coating for silicon under glass, an optimum refractive index of ~2.23 (at 632.8 nm) was determined. Further simulations revealed that a double-layer SiN stack with an n = 2.42 film underneath an n = 2.03 film gives the minimum total photocurrent loss. Similar optimization of double-layer SiN/SiO(2) coatings for silicon in air revealed an optimum of n = 2.28 for SiN. To determine the allowable tolerance in index and film thickness, we generated isotransmittance plots, which revealed more leeway for n values below the optimum than above because absorption begins to reduce photocurrent for high n values.