Differential Effects of Race, Socioeconomic Status, and Insurance on Disease-Specific Survival in Rectal Cancer

BACKGROUND

National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance.

OBJECTIVE

This study aimed to determine the independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted using the California Cancer Registry.

PATIENTS

This study included patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004, and December 31, 2017, with follow-up through November 30, 2018. Investigators determined whether patients received guideline-adherent care.

MAIN OUTCOME MEASURES

ORs and 95% CIs were used for logistic regression to analyze patients receiving guideline-adherent care. Disease-specific survival analysis was calculated using Cox regression models.

RESULTS

A total of 30,118 patients were examined. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians (HR, 0.80; 95% CI, 0.72-0.88; p < 0.001) and Hispanics (HR, 0.91; 95% CI, 0.83-0.99; p = 0.0279) had better disease-specific survival in the nonadherent group. Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the nonadherent group (HR, 1.56; 95% CI, 1.40-1.73; p < 0.0001) and the guideline-adherent group (HR, 1.18; 95% CI, 1.08-1.30; p = 0.0005). Disease-specific survival of the lowest socioeconomic status was worse in both the nonadherent group (HR, 1.42; 95% CI, 1.27-1.59) and the guideline-adherent group (HR, 1.20; 95% CI, 1.08-1.34).

LIMITATIONS

Limitations included unmeasured confounders and the retrospective nature of the review.

CONCLUSIONS

Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease-specific survival in the guideline-adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline nonadherent group and the guideline-adherent group. See Video Abstract at http://links.lww.com/DCR/B954 .

EFECTOS DIFERENCIALES DE LA RAZA, EL NIVEL SOCIOECONMICO COBERTURA SOBRE LA SUPERVIVENCIA ESPECFICA DE LA ENFERMEDAD EN EL CNCER DE RECTO

ANTECEDENTES: El cumplimiento de las guías de la National Comprehensive Cancer Network mejora los resultados del cáncer. En el cáncer de recto, el cumplimiento de las guías se distribuye de manera diferente según la raza/origen étnico, nivel socioeconómico y el cobertura médica.OBJETIVO: Determinar los efectos independientes de la raza/origen étnico, el nivel socioeconómico y el estado de cobertura médica en la supervivencia del cáncer de recto después de tener en cuenta las diferencias en el cumplimiento de las guías.DISEÑO: Este fue un estudio retrospectivo.ENTORNO CLINICO: El estudio se realizó utilizando el Registro de Cáncer de California.PACIENTES: Pacientes de 18 a 79 años diagnosticados con adenocarcinoma rectal entre el 1 de enero de 2004 y el 31 de diciembre de 2017 con seguimiento hasta el 30 de noviembre de 2018. Los investigadores determinaron si los pacientes recibieron atención siguiendo las guías.PRINCIPALES MEDIDAS DE RESULTADO: Se utilizaron razones de probabilidad e intervalos de confianza del 95 % para la regresión logística para analizar a los pacientes que recibían atención con adherencia a las guías. El análisis de supervivencia específico de la enfermedad se calculó utilizando modelos de regresión de Cox.RESULTADOS: Se analizaron un total de 30.118 pacientes. Los factores asociados con mayores probabilidades de cumplimiento de las guías incluyeron raza/etnicidad asiática e hispana, seguro de atención administrada y nivel socioeconómico alto. Los asiáticos e hispanos tuvieron una mejor supervivencia específica de la enfermedad en el grupo no adherente HR 0,80 (95 % CI 0,72 - 0,88, p < 0,001) y HR 0,91 (95 % CI 0,83 - 0,99, p = 0,0279). La raza o el origen étnico no fueron factores asociados con la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. La supervivencia específica de la enfermedad de Medicaid fue peor tanto en el grupo no adherente HR 1,56 (IC del 95 % 1,40 - 1,73, p < 0,0001) como en el grupo adherente a las guías HR 1,18 (IC del 95 % 1,08 - 1,30, p = 0,0005). La supervivencia específica de la enfermedad del nivel socioeconómico más bajo fue peor tanto en el grupo no adherente HR 1,42 (IC del 95 %: 1,27 a 1,59) como en el grupo adherente a las guías HR 1,20 (IC del 95 %: 1,08 a 1,34).LIMITACIONES: Las limitaciones incluyeron factores de confusión no medidos y la naturaleza retrospectiva de la revisión.CONCLUSIONES: La raza, el nivel socioeconómico y cobertura médica están asociados con la adherencia a las guías en el cáncer de recto. La raza/etnicidad no se asoció con diferencias en la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. Medicaid y el nivel socioeconómico más bajo tuvieron peor supervivencia específica de la enfermedad tanto en el grupo que no cumplió con las guías como en los grupos que cumplieron. Consulte Video Resumen en http://links.lww.com/DCR/B954 . (Traducción- Dr. Francisco M. Abarca-Rendon).

Population-Based Analysis of National Comprehensive Cancer Network (NCCN) Guideline Adherence for Patients with Anal Squamous Cell Carcinoma in California

PURPOSE

We analyzed adherence to the National Comprehensive Cancer Network treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival.

METHODS

This was a retrospective study of patients in the California Cancer Registry aged 18 to 79 years with recent diagnoses of anal squamous cell carcinoma. Predefined criteria were used to determine adherence. Adjusted odds ratios and 95% confidence intervals were estimated for those receiving adherent care. Disease-specific survival (DSS) and overall survival (OS) were examined with a Cox proportional hazards model.

RESULTS

4740 patients were analyzed. Female sex was positively associated with adherent care. Medicaid status and low socioeconomic status were negatively associated with adherent care. Non-adherent care was associated with worse OS (Adjusted HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). DSS was worse in patients receiving non-adherent care (Adjusted HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001). Female sex was associated with improved DSS and OS. Black race, Medicare/Medicaid, and low socioeconomic status were associated with worse OS.

CONCLUSIONS

Male patients, those with Medicaid insurance, or those with low socioeconomic status are less likely to receive adherent care. Adherent care was associated with improved DSS and OS in anal carcinoma patients.

Factors associated with COVID-19 vaccine acceptance and hesitancy among residents of Northern California jails

Carceral facilities are high-risk settings for COVID-19 transmission. Factors associated with COVID-19 vaccine acceptance and hesitancy among incarcerated individuals are poorly understood, especially among jail residents. Here, we conducted a retrospective review of electronic health record (EHR) data on COVID-19 vaccine uptake in custody and additionally administered a survey to assess reasons for vaccine hesitancy, sources of COVID-19 information, and medical mistrust among residents of four Northern California jails. We performed multivariate logistic regression to determine associations with vaccine acceptance. Of 2,564 jail residents offered a COVID-19 vaccine between March 19, 2021 and June 30, 2021, 1,441 (56.2%) accepted at least one dose. Among vaccinated residents, 497 (34.5%) had initially refused. Vaccine uptake was higher among older individuals, women, those with recent flu vaccination, and those living in shared housing. Among 509 survey respondents, leading reasons for vaccine hesitancy were concerns around side effects and suboptimal efficacy, with cost and the need for an annual booster being other hypothetical deterrents to vaccination. Vaccine hesitancy was also associated with mistrust of medical personnel in and out of jail, although this association varied by race/ethnicity. Television and friends/family were the most common and most trusted sources of COVID-19 information, respectively. Overall, vaccine acceptance was much lower among jail residents than the local and national general population. Interventions to increase vaccination rates in this setting should utilize accessible and trusted sources of information to address concerns about side effects and efficacy, while working to mitigate medical and institutional mistrust among residents.

Estimating Lower Limb Kinematics Using a Reduced Wearable Sensor Count

GOAL

This paper presents an algorithm for accurately estimating pelvis, thigh, and shank kinematics during walking using only three wearable inertial sensors.

METHODS

The algorithm makes novel use of a constrained Kalman filter (CKF). The algorithm iterates through the prediction (kinematic equation), measurement (pelvis position pseudo-measurements, zero velocity update, flat-floor assumption, and covariance limiter), and constraint update (formulation of hinged knee joints and ball-and-socket hip joints).

RESULTS

Evaluation of the algorithm using an optical motion capture-based sensor-to-segment calibration on nine participants (7 men and 2 women, weight [Formula: see text] kg, height [Formula: see text] m, age [Formula: see text] years old), with no known gait or lower body biomechanical abnormalities, who walked within a [Formula: see text] m ² capture area shows that it can track motion relative to the mid-pelvis origin with mean position and orientation (no bias) root-mean-square error (RMSE) of [Formula: see text] cm and [Formula: see text], respectively. The sagittal knee and hip joint angle RMSEs (no bias) were [Formula: see text] and [Formula: see text], respectively, while the corresponding correlation coefficient (CC) values were [Formula: see text] and [Formula: see text].

CONCLUSION

The CKF-based algorithm was able to track the 3D pose of the pelvis, thigh, and shanks using only three inertial sensors worn on the pelvis and shanks.

SIGNIFICANCE

Due to the Kalman-filter-based algorithm's low computation cost and the relative convenience of using only three wearable sensors, gait parameters can be computed in real-time and remotely for long-term gait monitoring. Furthermore, the system can be used to inform real-time gait assistive devices.

Population-based analysis of National Comprehensive Cancer Network (NCCN) guideline adherence for patients with anal squamous cell carcinoma in California

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Background: Oncology-specific evidence-based treatment guidelines aim to improve cancer care. Our study analyzed adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival. Methods: Patients aged 18 to 79 years diagnosed with anal squamous cell carcinoma (SCC) between January 1, 2004 and December 31, 2017 with follow-up through November 30, 2018 were identified in the California Cancer Registry. Patient demographics, socioeconomic status (SES) and tumor stage were identified. We determined whether patients received NCCN guideline-adherent care (AdC) by pre-defined criteria. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression for receiving AdC. Overall survival (OS) and disease specific-survival (DSS) were calculated using Cox regression models. Results: Of 4,740 patients with a diagnosis of anal SCC in California, 926 (19.5%) did not receive AdC (non-AdC). Non-AdC had worse DSS (HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001) and worse OS (HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). Females were more likely to receive AdC (OR 1.38, 95% CI = 1.18, 1.62, p < 0.0001). Medicaid patients were less likely to receive AdC (OR 0.75, 95% CI = 0.57, 1.00, p = 0.0476). Patients with the lowest SES were less likely to receive AdC (OR 0.65, 95% CI = 0.50, 0.83, p = 0.0007). Characteristics associated with DSS and OS included female gender, black race, Medicare/Medicaid, and SES (particularly, lower-middle SES). Conclusions: NCCN guideline-adherent care was associated with improved disease-specific and overall survival in anal SCC patients in California.

Population-based analysis of guideline adherence for patients with rectal cancer in California

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Background: The goal of oncology-specific evidence-based treatment guidelines is to improve cancer care. We sought to analyze adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines for rectal cancer in the state of California and the associated impacts on survival. Methods: Patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004 and December 31, 2017 with follow-up through November 30, 2018 were identified in the California Cancer Registry. Patient characteristics such as age, race, insurance status, socioeconomic status (SES), marital status, and tumor stage were identified. In addition, based on available data our investigators determined whether patients received NCCN guideline-adherent care. Odds ratios (OR) and 95% confidence intervals (CI) were used for logistic regression to analyze patients receiving NCCN adherent care. Disease specific-survival analysis was calculated using Cox regression model. Results: A total of 30,118 patients identified with diagnosis of rectal cancer in California, 16,442 (54.6%) of whom did not receive guideline-adherent care. Disease specific-survival was worse for those who did not receive NCCN adherent care with hazard ratio (HR) 1.52 (95% CI 1.41 - 1.63, p < 0.0001). Compared to Caucasians as a referent group, Asians (in aggregate) were more likely to receive guideline adherent care and had better disease specific survival with adjusted HR 0.88 (95% CI 0.80 -0.97, p = 0.008). Also compared to Caucasians, Hispanics were more likely to receive guideline adherent care and had better disease specific survival HR 0.90 (95% CI 0.83 – 0.98, p < 0.015). As compared to managed care insured patients, uninsured patients were least likely to receive care and were observed to have worse disease specific survival adjusted HR 1.34 (95% CI 1.18 – 1.54, p < 0.0001). Patients with Medicaid were also significantly associated with lower survival HR 1.39 (95% CI 1.26 – 1.53, p < 0.0001) – and the CIs indicate Medicaid and uninsured were not statistically different from each other. Comparing to patients with highest SES as a referent group, patients with lowest SES were least likely to receive guideline adherent care and also were observed to have worse disease-specific survival with HR 1.22 (95% CI 1.09 – 1.36, p < 0.0004). Conclusions: In this population-based analysis of rectal cancer patients in California, guideline-adherent care was associated with improved survival.

Retrospective analysis of elderly patients with DLBCL: Single center experience with FIL

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Background: Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype of Non-Hodgkin’s Lymphoma (NHL). According to the SEER database, median age of diagnosis is 67 with 30% of cases diagnosed in patients greater than 75. 1/3 of patients older than 80 do not receive therapy for this potentially curable disease. The Lymphoma Italian Foundation (FIL) tool has been shown to help objectively identify elderly DLBCL patients most likely to benefit from therapy with curative intent. The tool identifies patients as “Fit,” “Unfit,” or “Frail” based on age, comorbidities, and ability to perform activities of daily living. We retrospectively applied the FIL tool to patients treated at our center to evaluate its efficacy in identifying elderly patients most likely to benefit from curative chemoimmunotherapy. Methods: Research protocol was approved by University of California, Irvine IRB. We identified patients with a diagnosis of systemic DLBCL and age ≥70 between January 1, 2010 and November 8, 2018. Medical charts were used to retrospectively apply the FILtool. Results: A total of 86 patients were identified. Mean age was 77. Ratio of germinal center (GC) DLBCL to non-GC was approximately 1:1. 23 patients were categorized as Fit, 8 as Unfit, and 55 as Frail. 96% of Fit, 100% of Unfit, and 91% of Frail patients were evaluated. Rates of complete responses (CR) to initial therapy with curative intent were 77% (17/22) in Fit, 88% (7/8) in Unfit, and 44% (22/50) in Frail patients. CR rate was not different between Fit and Unfit (p>0.05), but the CR rate in Frail patients was significantly reduced compared to the other groups combined (p<0.01). Among Fit and Unfit patients, only one death was treatment-related, but in the Frail group, 6 deaths were related to treatment. Conclusions: Our data suggest that the FILTool is useful in identifying Frail patients that perhaps should be treated with reduced dose-intensity. Additionally, our findings support that Fit and Unfit patients benefit from treatment with curative intent. Future studies will apply the FIL tool prospectively to further validate these findings. [Table: see text]

Merkel cell carcinoma: long-term follow-up of a single institution series and clinical outcomes by immunological status

Merkel cell carcinoma (MCC) usually arises in sun-exposed areas of older patients and might be more aggressive in the immunocompromised. We performed a retrospective chart review of 40 consecutive MCC patients treated at our institution between the years 2006-2017. Clinical and epidemiologic data were utilized and therapy and survival were analyzed. Compared to Surveillance, Epidemiology, and End Results (SEER) data, our population was entirely Caucasian (100% versus 95%; P=0.11) and male predominant (75% versus 63%; P=0.11). The median age was 76. The patients more often had Tumor-Node-Metastasis (TNM) stage I disease (50% versus 39%; P=0.00003) and a primary tumor size <2cm (57.5% versus 34%; P<0.01). They received more frequently lymph node dissection (70% versus 63%, P=0.002) compared with the SEER findings. We identified a subset of immunocompromised patients (n=10) who presented with more stage III disease (40% versus 33%; P=0.021). Time to death averaged 290.1 days in this subset versus 618.2 days (P<0.001) in immunocompetent patients and their likelihood of death was 5 times higher. As clinical outcomes in MCC patients vary by immunological status, a multidisciplinary tumor-board approach may better optimize individual patient management.

Inferior outcomes in immunocompromised Merkel cell carcinoma patients: Can they be overcome by the use of PD1/PDL1 inhibitors?

Cases of Merkel cell carcinoma have become increasingly more common in the last two decades, and its incidence has been predicted to climb further. Immunosenescence might explain in part the higher Merkel cell carcinoma prevalence in seniors aged 70 and older. This cancer might also be more aggressive in immunocompromised patients. In a subset of immunocompromised Merkel cell carcinoma patients, we identified significant lymphopenia and a more advanced disease stage compared with their immunocompetent counterparts. Time to death in this cohort was much shorter than in immunocompetent subjects, and their likelihood of death from Merkel cell carcinoma was five times higher. Avelumab approval in 2017 represents an important step forward in the therapy of Merkel cell carcinoma. Hopefully, PD1/PDL1 inhibitors will improve survival in immunocompromised Merkel cell carcinoma hosts, traditionally linked with inferior clinical outcomes.

Cystic acne due to imatinib therapy for chronic myelocytic leukemia

Imatinib mesylate is a tyrosine kinase inhibitor used in the treatment of several malignancies. Its use, however, is associated with a number of toxic effects including adverse cutaneous reactions. Herein, we present a case of facial cystic acne in a patient receiving imatinib therapy for chronic myelocytic leukemia. This side effect resolved with cessation of therapy. To the best of our knowledge, this clinical entity has never been previously reported in the medical literature.

Clinico-epidemiologic characteristics and patterns of care in Merkel cell carcinoma: Data from a single-institution series

e21049

Background: Merkel cell carcinoma (MCC) is associated with increased sun exposure. There is an average of 348 days of sunshine per year in our geographic area. Methods: With the IRB approval, we performed a retrospective chart review of all consecutive MCC patients seen at our institution between 2006-2017. Clinico-epidemiologic data such as age, gender, race, stage, tumor size, stage at presentation, and disease course were collected. Therapy and survival were analyzed. Using the surveillance, epidemiology, and end results program (SEER), we identified 4,256 patients with MCC from the years 2006-2013. We compared our data with the SEER findings . Statistical analysis: Chi-square and Fishers’ exact tests were used to assess the significance of associations in large and small populations, respectively. Survival analyses were performed using the Cox proportional hazards. Results: We identified 40 patients with MCC (n = 40) with a median age of 77. Compared to SEER data, our population was entirely Caucasian (100% vs. 95%; p = 0.11) and male predominant (75% vs. 63%; p = 0.11). The patients in our cohort were diagnosed more often with TNM stage I (50% vs. 39%; p = 0.00003) and found to have more often a primary tumor size < 2cm (58% vs. 34%; p < 0.01). Our patients were more frequently treated with lymph node dissection (70% vs. 63%, p = 0.002) and radiation therapy (60% vs. 50%; p = 0.24). Conclusions: Compared to the general population, MCC patients treated at our institution had similar mean age at diagnosis, gender and racial distribution and radiation treatment frequency (all p-values > 0.05). However, our patient population was significantly more likely to be diagnosed at stage I disease, have a primary tumor size less than 2 cm and receive lymph node dissection. Final statistical analysis, including survival analysis, and significance are to be discussed.

Clinicopathologic features and survival in immunocompromised vs. immunocompetent patients with Merkel cell carcinoma: An exploratory analysis of a series of consecutive patients

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Background: Clinicopathologic characteristics and outcomes between immunocompromised and immunocompetent Merkel cell carcinoma (MCC) patients may differ. Methods: With approval of IRB, we conducted retrospective analysis in 40 consecutive patients with MCC treated at our institution in 2006-2016. 10 patients were immunocompromised and 30 immunocompetent. Immunosuppressed patients included patients with organ transplantation (n = 3), chronic lympocytic leukemia (n = 2), metastatic skin cancer post chemotherapy (n = 1), rheumatoid arthritis on azathioprine (n = 1), myasthenia gravis on mycophenolate mofetil (n = 1), follicular lymphoma post chemotherapy (n = 1) and human immunodeficiency virus infection (n = 1). Clinicopathologic features, therapy and survival were compared between two cohorts. Significance of associations was assessed via Fishers' exact test. Survival analysis was performed via Cox proportional model and 95% confidence intervals (CI). Results: Compared to immunocompetent MCC patients, the immunocompromised had an absolute male predominance (100% vs. 67%; p < 0.01), more TNM stage III disease (40% vs. 33%; p = 0.021) but less lymphovascular invasion (30% vs. 7%; p < 0.01). They received more chemotherapy (50% vs. 30%; p < 0.01) and radiation therapy (80% vs 57%; p < 0.01). Survival was worse in immunocompromised subjects (average time to death 290.13 days vs. 618.2 days (p < 0.001), and they were 5 times more likely to die (RR = 5.01, 95% CI = 1.49-16.86). Conclusions: Immunocompromised MCC patients displayed significantly shorter survival than their immunocompetent counterparts. They were all male, with more advanced disease but less lymphovascular invasion. They received more chemo- and radiotherapy presumably due to a more advanced stage. As our study is limited by sample size, larger studies are needed to confirm the significance of our findings.

Persistent foot ulcer due to ruxolitinib therapy for primary myelofibrosis

Primary myelofibrosis is characterized by bone marrow fibrosis, splenomegaly and presence of JAK-2 V617F mutation in more than 90% of patients. Ruxolitinib is a Janus kinase inhibitor used for the treatment of primary myelofibrosis. We describe herein a persistent foot ulcer development attributed to ruxolitinib therapy. We are unaware of any previous reports of this phenomenon in the scientific literature. A thorough examination of the lower extremities is perhaps necessary before initiating this oral agent. If ruxolitinib therapy cannot be safely discontinued, diligent wound care and a course of antibiotics are warranted.

Durable Complete Response of Primary CNS Lymphoma in an 80-Year-Old Patient with Retroviral Infection

People aging with human immunodeficiencyvirus (HIV) present a unique set of challenges for their providers. Cardiovascular, metabolic, neurodegenerative, and renal disorders, and certain cancers are more common in this cohort, which is attributed to elevated rates of inflammation. Although survival remains compromised, integration of efficacious antiretrovirals and high-dose methotrexate (HD-MTX) was shown to improve clinical results in HIV-infected patients with primary central nervous system lymphoma (PCNSL). However, optimal management of PCNSL in the elderly is not known. We present the case of an 80-year-old patientwith HIV-associated PCNSL who achieved a durable complete response with HD-MTX andrituximab. He remains in complete remission 18 months after the diagnosis. Our case supports using the HD-MTX/rituximab combination in the very old subjects with HIV-related PCNSL.

Primary squamous cell carcinoma of the thyroid with complete response to radical radiotherapy and concurrent cisplatin-based chemotherapy

Chemoradiotherapy and/or surgery are both potentially radical treatments for squamous cell carcinomas. Squamous cell carcinomas are considered chemosensitive tumours compared to adenocarcinomas or anaplastic thyroid malignancies. A 76-year-old man was found to have T4bN0M0 primary squamous cell carcinoma of the thyroid with encasement of the internal carotid artery. The disease was deemed unresectable. Therefore, he was treated with radical radiotherapy with concurrent cisplatin-based chemotherapy. We discuss herein the aetiology, diagnosis and management of primary squamous cell carcinoma of the thyroid. We demonstrate success of chemoradiotherapy in an unresectable case of a rare and aggressive disease.

Multicentric Neuroendocrine Carcinoma of the Breast Presenting with Multiple Osteolytic Bone Metastases

An uncommon subtype of breast cancer, primary neuroendocrine carcinoma of the breast (NECB), usually presents as a single nodule arising in the breast tissue. Distant metastases at presentation are rare. Optimal management of advanced disease is still debated, given the lack of evidence stemming from clinical trials. We describe a patient who presented with clinically aggressive, multicentric NECB with multiple metastatic lytic bone lesions. Ihe disease responded to systemic therapy with an oral aromatase inhibitor and monthly biphosphonate infusions. We further review the existing literature on this intriguing clinicopathologic entity.

Prolonged Survival in Colon Cancer with Malignant Pericardial Effusion and Pulmonary Lymphangitic Carcinomatosis: A Case for Monoclonal Antibodies?

Traditionally, cardiac metastases and lymphangitic carcinomatosis have been associated with survival of only two to four months. We report herein a patient with malignant pericardial. effusion, and lymphangitic carcinomatosis due to colon cancer who remains in partial remission 12 months after the diagnosis. We postulate that the newer agents bevacizumab and cetuximab used in two different combination regimens contributed significantly to his longer survival. If confirmed, increased survival in this group of patients treated with novel regimens will have to be considered before any life-changing decisions (such as early referral to hospice) are made. In addition, a multitude of newer agents are in the pipeline and will soon join the battle against gastrointestinal malignancies, which could further increase survival in these patients.

Fixed Drug Eruption Late in the Course of Capecitabine Therapy

A fixed drug eruption (FDE) is a toxic skin effect thought to be caused by delayed cell-mediated hypersensitivity to a pharmaceutical agent. We report herein the first known patient with capecitabine-induced FDE that appeared relatively late in the course of adjuvant therapy for rectal cancer. The temporal association with capecitabine use and prompt disappearance after capecitabine discontinuation make this relationship probable. Knowledge about this dermatologic skin effect seen with oral fluoropyrimidines should avoid unnecessary diagnostic workup and provide the necessary patient reassurance.

Not all gastric masses are gastric cancer

Lung cancer metastasising to the gastrointestinal tract normally does not occur. However, as clinicians, we must be aware that lung adenocarcinoma, as in all cancers, can and will metastasise to any part of the body. We describe a case of a patient with a presumed primary gastric adenocarcinoma who presented with shortness of breath due to pleural effusion. Pathology from the pleural effusion was positive for primary lung adenocarcinoma. Further investigation revealed that the patient's gastric mass was misdiagnosed as gastric adenocarcinoma. We correctly diagnosed the mass as metastatic lung adenocarcinoma. This was very significant because the patient was transitioning to palliative care with possible tube feeding. After the correct diagnosis, her management drastically changed and her health improved. Clinical, pathological and medical management of lung cancer metastasis to the stomach are discussed.

Infarct distribution in subhuman primates after acute coronary occlusion

The extent of epicardial, endocardial and septal infarct was determined in 24 monkeys and five baboons 1 week after acute left anterior descending or diagonal branch coronary artery ligation. All 24 Macaca cynmologous monkeys had non-dominant left anterior descending coronary arteries. A snare ligature was placed just distal to the first diagonal branch for varying time periods (1, 2, 4, and 6 h followed by reperfusion or left in place permanently). In five baboons a chronic ligature was placed around a diagonal branch. All animals lived and were killed a week later. Histological mapping and planimetry of serial cross-sections were employed to quantify the extent and distribution of the infarct. All infarcts were transmural. The extent of epicardial infarct was significantly greater than the extent of endocardial infarct for 2 h ligations (3.5 +/- 0.87% of the left ventricle versus 2.4 +/- 0.58% of the left ventricle, P less than 0.05), the chronic left anterior descending coronary artery ligations (5.4 +/- 1.06% of the left ventricle versus 4.5 +/- 0.92% of the left ventricle, P less than 0.05 and for the chronic diagonal branch ligations (4.06 +/- 0.66% of the right ventricle + left ventricle versus 2.64 +/- 0.51+ of the right ventricle + left ventricle, P less than 0.02). It is evident, however, that the magnitude of this epicardial preponderance was not great and that, in general, the infarcts were transmural and rectangular in configuration.

Blood microaggregates and ultrafilters

The report presents three studies of post-traumatic pulmonary insufficiency (PTPI). In the first no significant pulmonary hemodynamic or ventilatory changes in severely shocked baboons resuscitated with shed fresh blood or stored blood were observed over 48 or 84 hours. Second, a post-mortem study of patients receving more than 5 units of blood within 24 hours of death showed sme microemboli in the lungs in about two thirds. Patients with multiple microthrombi had received an average of 20.6 units of blood; patients with some or no microemboli 15.5 and 6.3, respectively. Third in a review of the respiratory complications of 153 multiple-trauma patients, it was shown that the formerly severe problems with PTPI were now well managed clinically, that persistent respiratory failure was now occurring much later after injury, and occurred almost exclusively in patients with sepsis. Relation of the above data to previous reports in the literature led to the conclusion that the clinical significance of microaggregates in stored blood, if any, is low, and that ultrafiltration to remove microemboli only makes sense if it does not impede the rate of blood infusion and does not increase cost.