High risk of relapse with intermediate dose cytarabine for consolidation in young favourable-risk acute myeloid leukaemia patients following induction with 7+3: a retrospective multicentre analysis and critical review of the literature

Following the 2017 European LeukemiaNet (ELN) guidelines, we changed our practice from using high-dose cytarabine (HIDAC-3 g/m² q12h-D1,3,5) to intermediate-dose cytarabine (IDAC-1·5 g/m² q12h-D1,3,5/D1-3) for consolidation in young(<60 years) favourable-risk acute myeloid leukaemia (AML) patients. We assessed the clinical impact of this practice change. Of 80 patients, 51 received HIDAC prior to the protocol change, and subsequently, 29 received IDAC. The three-year risk of relapse was significantly higher with IDAC [61%; 95% confidence interval (CI) 40-82] compared with HIDAC (22%; 10-34), P < 0·01. Our findings suggest HIDAC, rather than IDAC, is the preferred dose for single-agent cytarabine consolidation in young, favourable-risk AML following 7+3 induction.

Impact of adjuvant chemotherapy on outcomes in appendiceal cancer

BACKGROUND

The impact of using adjuvant chemotherapy following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with appendiceal adenocarcinoma is not known. The aim of this study was to assess the impact of adjuvant chemotherapy following complete cytoreduction in patients with appendiceal adenocarcinoma.

METHODS

Retrospective medical record review of all patients with appendiceal adenocarcinoma treated at our institution between 2006 and 2015. Kaplan-Meier plots were used to summarize overall survival (OS) and relapse-free survival over time, and log-rank tests and Cox proportional hazards models were used to test for differences in survival between groups.

RESULTS

A total of 103 patients with appendiceal adenocarcinoma received care at our institution during the study period. Complete cytoreduction (cytoreductive score 0-1) was achieved in 68 patients (66%). Of these 68 patients, 26 received adjuvant chemotherapy. The most common regimens were capecitabine (n = 11), capecitabine plus oxaliplatin (n = 7), and 5-FU plus oxaliplatin (n = 6). Tumor histopathology and grade, and the ability to achieve complete cytoreduction were significant predictors of overall survival. The median OS for non-low-grade and well-differentiated tumor patients who received adjuvant chemotherapy following complete cytoreduction was 9.03 years, compared to 2.88 years for patients who did not receive adjuvant chemotherapy (P = .02). Among low-grade and well-differentiated tumor patients who underwent complete cytoreduction, there was no statistically significant difference in OS between those who received adjuvant chemotherapy and those who did not.

CONCLUSION

Adjuvant chemotherapy seems to have benefit in appendiceal cancer patients with non-low-grade or well-differentiated tumor type but not in low-grade or well-differentiated tumors.

Cardiac Imaging Methods for Chemotherapy-related Cardiotoxicity Screening and Related Radiation Exposure: Current Practice and Trends

BACKGROUND

Radiation exposure is a serious concern with usage of serial multigated acquisition (MUGA) scans (7.8mSv/study) for chemotherapy-related cardiotoxicity (CRC) screening. The current practice with respect to the imaging modalities chosen for cardiotoxicity screening and related radiation exposure has not been studied.

MATERIALS AND METHODS

We performed a serial cross-sectional study from 2011 to 2014, evaluating the relative usage of the three imaging modalities for CRC screening.

RESULTS

MUGA scan usage decreased from 30.4% to 16.7%, echocardiogram (Echo) utilization increased from 68.7% to 80.4% and cardiac magnetic resonance (CMR) usage increased from 0.9% to 2.9% in the 4-year period. Estimated total radiation exposure and secondary cancer risk can increase significantly in certain subgroups when MUGA scan is employed for serial cardiac imaging.

CONCLUSION

Increased awareness of radiation risks from MUGA, as well as increasing focus on early detection of cardiotoxicity using Echo and CMR, are possible reasons behind the observed trends.

Recurrent pleural effusions and cardiac tamponade as possible manifestations of pseudoprogression associated with nivolumab therapy- a report of two cases

Background

Checkpoint inhibitors are a class of agents that employ host’s adaptive immune defenses in fighting cancer. With many new indications and several ongoing clinical trials in a variety of malignancies, the usage of these agents is set to increase significantly. One of the key challenges patients and physicians face while using these drugs is with the appropriate assessment of response to therapy.

Case presentation

We are reporting two patients with lung cancer who were treated with nivolumab and experienced rapidly accumulating recurrent pleural effusions requiring multiple thoracenteses (6 and 4 times each for patient 1 and 2 respectively) with in the first few weeks of initiation of therapy and also developed pericardial effusion with cardiac tamponade requiring pericardiocentesis. Both patients had prior history of malignant spread to pleural and pericardial space in their disease course. Therapy was continued in the first patient with spontaneous resolution of effusions after 8 weeks and the disease showed near complete response to treatment on imaging at 16 weeks. Second patient declined to continue further treatment with nivolumab after 3 cycles due to recurrent effusions and cardiac tamponade, although there was some evidence of clinical response at discontinuation.

Conclusions

Patients with history of malignant involvement of visceral spaces should be monitored closely for rapidly accumulating effusions and particularly for cardiac tamponade, after initiation of therapy with nivolumab. This presentation could represent pseudoprogression, and continuation of therapy with close monitoring is prudent as long as effusions are manageable and there is no definitive evidence of progression elsewhere.