Resuscitation outcomes in patients with cancer: experience in a large urban cancer centre

PURPOSE

Hospitalized patients with cancer who experience cardiopulmonary arrest have historically low survival rates. This retrospective cohort study describes outcomes of patients at a large Canadian cancer centre who had a "code medical emergency" activated, and the use of pragmatic criteria to identify patients with poor survival following resuscitation.

METHODS

We included hospitalized patients with cancer who had a "code blue" activated between January 2007 and December 2018. Our primary outcome was intensive care unit (ICU) mortality. We developed pragmatic criteria to identify patients with "poor prognosis" for survival from cardiopulmonary resuscitation (CPR) based on disease status and candidacy for further cancer treatment. We used descriptive statistics to analyze the outcomes of poor prognosis patients.

RESULTS

Two hundred and twenty-five patients had a code blue activated. The median age was 61 yr, 52% were male, and 48% had a solid tumour. Overall, 173/225 (77%) patients survived the code blue; 164 were admitted to the ICU, where 49% (81/164) died; 31% survived to hospital discharge; and 16% (n = 27) were alive at one year. One hundred and twenty out of 225 (53%) required chest compressions; spontaneous circulation returned in 61% (73/120), and 12% (14/120) survived to hospital discharge. Patients meeting "poor prognosis" criteria (114, 51%) were more likely to die in the ICU (64% vs 35%; P < 0.001) or in hospital (86% vs 59%; P < 0.001), and more often had goals-of-care discussions prior to the code blue (46% vs 7%; P < 0.001). At one year, only 2% of poor prognosis patients were alive, compared with 24% of patients who did not meet any poor prognosis criteria.

CONCLUSION

Hospitalized patients with cancer requiring CPR have poor hospital and long-term outcomes. The proposed set of pragmatic criteria may be useful to identify patients unlikely to benefit from CPR and life support, to trigger early goals of care discussions, and to avoid potentially goal-discordant interventions.

Comparison of Kjeldahl Method for Determination of Crude Protein in Cereal Grains and Oilseeds with Generic Combustion Method: Collaborative Study

Seven laboratories participated in a collaborative study to extend the applicability of the AOAC generic combustion method for determination of crude protein in animal feed (990.03) to include determination in cereal grains and oilseeds. In the study, method 990.03 was compared with the AOAC mercury catalyst Kjeldahl method for determination of protein in grains (979.09) and crude protein in animal feed (954.01). The study also evaluated the effect on the results of fineness of grind. For determination of crude protein in grains and oilseeds by the combustion method, standard deviations for repeatability and reproducibility ranged from 0.10 to 0.37 and from 0.25 to 0.54, respectively, and relative standard deviations for repeatability and reproducibility ranged from 0.77 to 2.57% and from 1.24 to 3.15%, respectively. The combustion method was adopted first action by AOAC International for determination of crude protein in cereal grains and oilseeds containing 0.2- 20% nitrogen.

Determination of Arsenic, Cadmium, Cobalt, Chromium, Lead, Molybdenum, Nickel, and Selenium in Fertilizers by Microwave Digestion and Inductively Coupled Plasma-Optical Emission Spectrometry Detection: Collaborative Study

There is increasing regulatory interest in the non-nutritive metals content of fertilizer materials, but at present there is no consensus analytical method for acid digestion and instrument detection of those elements in fertilizer matrixes. This lack of method standardization has resulted in unacceptable variability of results between fertilizer laboratories performing metals analysis. A method has been developed using microwave digestion with nitric acid at 200C, followed by inductively coupled plasma-optical emission spectrometry instrument detection, for the elements arsenic, cadmium, cobalt, chromium, molybdenum, nickel, lead, and selenium. The method has been collaboratively studied, and statistical results are here reported. Fourteen collaborators were sent 62 sample materials in a blind duplicate design. Materials represented a broad cross section of fertilizer types, including phosphateore, manufactured phosphate products, N-P-K blends, organic fertilizers, and micro-nutrient materials. As much as possible within the limit of the number of samples, materials were selected from different regions of the United States and the world. Limit of detection (LOD) was determined using synthetic fertilizers consisting of reagent grade chemicals with near zero levels of the non-nutritive elements, analyzed blindly. Samples with high iron content caused the most variability between laboratories. Most samples reasonably above LOD gave HorRat values within the range 0.5 to 2.0, indicating acceptable method performance according to AOAC guidelines for analyses in the mg/kg range. The method is recommended for AOAC Official First Action status.

Pediatric frostbite: A 10-year single-center retrospective study

OBJECTIVE

To describe frostbite (freezing cold injured tissue) in children and intrinsic (psychological and behavioral) and extrinsic (meteorological and safety hazard) factors related to the injury.

METHODS

Retrospective chart review of children <18 years old referred to a regional pediatric hospital for frostbite, to determine the demographics, environment, and risk factors related to injuries.

RESULTS

47 patients met the inclusion criteria. Median age was 15 years (IQR 12-16). All injuries occurred between November and March. 49% were admitted to the hospital and frostbite was associated with use of alcohol (53%), cigarettes (34%), marijuana (23%), and symptoms of depression (with and without suicidal ideation) (32%). Frostbite injury treated with conservative wound management presented at <-6°C and injury that underwent surgical procedures occurred at temperatures ≤-23°C (p=0.001). Longer exposure duration also significantly increased the likelihood of a surgical procedure (p<0.001). Intoxication and lack of supervision were two common factors, with lack of supervision at time of injury most common among patients 0-12 years (64%), and intoxication most common among patients ages 13-17 (61%).

CONCLUSION

Frostbite injuries in children begins at temperatures <-6°C; with risk of tissue loss increasing at temperatures below -23°C. Lack of supervision and intoxication are major risk factors for frostbite in children. Two-thirds of younger children were unsupervised, whereas intoxication was frequently related to frostbite in adolescents. Both of these factors can be addressed through an education-based prevention program.

Abstract 4308: 3D nuclear telomeric signatures define circulating tumor cells (CTCs) and characterize CTC subpopulations in intermediate risk prostate cancer patients

Intermediate risk prostate cancer is a current medical challenge since the patients in this group can either be stable or progress, and there is no predictor for individual risk. Stratifying these patients would spare the patients unnecessary treatment or indicate the start of treatment immediately without losing precious time. Currently, prostate specific antigen (PSA) is used as evidence for biochemical progression. A more sensitive biomarker is needed to detect disease progression earlier and more reliably.

We have isolated circulating tumor cells (CTCs) using a filtration-based device (ScreenCell). We subsequently performed the genetic characterization of the captured CTCs on a single cell basis. Using three-dimensional (3D) nuclear telomere imaging and quantitative analysis of 3D telomeric signatures of CTCs, we have characterized CTCs in the blood of the patients and have identified patient subgroups with one or more groups of CTCs. 380 samples of intermediate risk prostate cancer all revealed the presence of CTCs. However, the CTCs found were not genetically identical. Marked heterogeneity was seen, and three main groups of CTC profiles were defined based on TeloView software our group developed earlier. Repeat samples taken 6 months intervals define stable, mildly changing and significantly altered 3D profiles indicative of disease stability vs. progression.

Citation Format: Awe A. Julius, Adam Yan, Nidhi Shah, Klewes Ludger, Alexandra Kuzyk, Michael Xu, Ramy Boles, Jeff Saranchuk, Darrel Drachenberg, Sabine Mai. 3D nuclear telomeric signatures define circulating tumor cells (CTCs) and characterize CTC subpopulations in intermediate risk prostate cancer patients. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4308. doi:10.1158/1538-7445.AM2014-4308

Facial paralysis due to benign parotid tumors

On rare occasions, facial paralysis associated with a parotid tumor need not denote malignancy. We present two cases in which, contrary to appropriate conventional wisdom, facial paralysis resulted from benign mixed tumors. Each patient presented over 8 years following primary surgical excision. In neither patient was a mass palpable, and facial paralysis was the sole sign of recurrent disease. Each patient had been followed up for several months with a presumptive diagnosis of Bell's palsy prior to discovery of recurrent tumor by radiologic imaging. In each case, at operation the tumor was found to infiltrate the temporal bone via the stylomastoid foramen. Facial paralysis presumably resulted from extrinsic compression of the facial nerve. These two cases add to the few previous reports of facial paralysis due to benign parotid gland tumors.

Treatment of large juvenile nasopharyngeal angiofibroma

The management of large juvenile nasopharyngeal angiofibromas with intracranial extension is controversial. We review our experience since 1980 with eighteen patients with juvenile nasopharyngeal angiofibroma. A diagnostic and treatment approach consisting of preoperative magnetic resonance imaging, embolization of feeding branches from the external carotid artery, and attempted complete resection was used in seven patients with intracranial disease since 1987. Serial magnetic resonance images were used for followup. Intracranial disease that was persistent or recurrent and demonstrated subsequent growth was irradiated (35 to 45 cGy). Extracranial tumor recurrences were reexcised. We advocate this approach as a safe and effective alternative to primary irradiation and its sequelae.

Significance of abnormal indium In 111-labeled leukocyte accumulation in the head and neck region

The localization of occult infection is often a difficult clinical problem. In 1975, labeling of leukocytes with indium In 111 became technically feasible, and subsequent clinical experience with 111In-labeled leukocyte scanning demonstrated high sensitivity and specificity for acute infection. To our knowledge, experience with white blood cell scanning in the head and neck has not been previously reported. The University of California, San Francisco, experience with 111In-labeled white blood cell scanning was reviewed. Between 1982 and 1987, 520 whole-body 111In-labeled leukocyte studies were performed, of which 60% were interpreted as abnormal. Eighteen studies were abnormal in the head and neck region, and the medical records of these patients were retrospectively reviewed. Abnormal findings correlated with other evidence of disease that involved mucosal surfaces, the neck, and the mediastinum. Sites in the nasopharynx with nasogastric tubes and tracheotomy sites were abnormal without associated clinical evidence of infection. Further clinical experience is needed to correlate white blood cell scan findings with disease in the head and neck and to define the role of the scan in diagnosis and management of otolaryngological disorders.

A monoclonal antibody to squamous cell carcinoma

Monoclonal antibody 17.13.Cl.10 is a murine IgM kappa monoclonal antibody (Mab) that stains frozen section squamous cell carcinoma (SCC) homogeneously and intensely with a sensitivity greater than 98%, including 106/107 SCC specimens from the head and neck. It was produced using a human laryngeal SCC as immunogen and screened using frozen section human tissue. Monoclonal antibody 17.13.Cl.10 faintly stains the basal layer of normal squamous epithelium, does not stain normal organ tissue other than myoepithelial cells, and reacts with few non-SCC tumors. It, therefore, may be a useful adjunct to standard histopathologic criteria for the diagnosis of SCC. It may prove helpful in the investigation of tumor-associated antigens. Despite major technical and immunologic problems, monoclonal antibodies to functional tissue-specific tumor-associated antigens have the potential to play a major role in imaging and in treatment in the future.

Cisplatin, doxorubicin, and 5-fluorouracil chemotherapy for salivary gland malignancies: a pilot study of the Northern California Oncology Group

Seventeen patients with advanced or recurrent salivary gland cancer were treated with cisplatin, doxorubicin, and 5-fluorouracil combination chemotherapy (PAF). Two patients achieved a complete response and four patients achieved a partial response, for an overall response rate of 35%. Six of the nine patients who received PAF in the neoadjuvant setting did not respond and proceeded to surgery and/or radiation therapy. No difference in response rate was found between those patients treated for recurrent disease v those treated with neoadjuvant chemotherapy. All three patients with adenocarcinoma responded. The response duration in patients with metastatic or recurrent disease ranged from 6 to 15 months. The PAF regimen was delivered primarily in the outpatient setting and was associated with acceptable toxicity. PAF demonstrates activity in salivary gland malignancies, and further evaluation of this combination seems warranted.

Salivary gland tumors. Fine-needle aspiration vs frozen-section diagnosis

We examined the relative accuracy of fine-needle aspiration biopsy (FNAB) and frozen section (FS) in the diagnosis of salivary gland tumors; FNAB completely and accurately diagnosed 35 (88%) of 40 cases, including ten (100%) of ten nonneoplastic lesions, 20 (87%) of 23 benign, and five (71%) of seven malignant tumors. No complications were encountered with this procedure. These results compare favorably with previously published reports. Twenty-one of 40 tumors diagnosed by FNAB and FS at surgery. Sixteen (76%) of 21 of these were correctly diagnosed by FNAB, and 15 (71%) of 21 by FS. Cystic lesions gave the most diagnostic difficulties both on FNAB and FS. Worldwide, FNAB has been demonstrated to be a cost-effective, accurate, and safe procedure. Furthermore, the use of FNAB allows for better preoperative management and overall treatment planning.

Carcinoma of the tonsillar region

A retrospective analysis of 171 patients with carcinoma of the tonsillar region is presented. The majority of patients (79%) presented with stage III and IV disease. Three year determinate survival was 81% - T1, 74% - T2, 59% - T3, and 20% - T4. The presence of nodal disease decreased survival by one half. Radiotherapy alone was highly successful in controlling early T1 and T2 lesions of the tonsillar fossa. Surgery alone or combined radiotherapy and surgery was more successful than radiotherapy in controlling early T1 and T2 lesions of the tonsillar pillar. More advanced T3 and T4 lesions also did poorly with radiotherapy alone. An analysis of these results and a review of the literature is presented.

Intracranial complications of frontal sinusitis

Frontal sinus infections can spread to the intracranial space so fast that the clinical situation often becomes far advanced before a complication is recognized. Retrograde septic thrombophlebitis is the most common pathway of extension. A review of recent experiences with fulminating frontal sinusitis and its intracranial complications such as subdural empyema, brain abscess, epidural abscess, and meningitis is presented. Neurologic features of intracranial invasion are interpreted. Good results have been achieved by immediate and aggressive surgical and medical measures.

Malignant tumors of salivary glands. A university experience

The management of salivary gland neoplasms continues to be a challenging clinical problem. Despite recent advances in histopathological classification, agreement among head and neck surgeons concerning optimum treatment is lacking. In attempts to eradicate the more malignant varieties of these tumors, surgeons have performed radical and multilating surgery. Radiation therapy has not been considered efficacious in many centers. A review of 93 maligant salivary gland tumors from 1955 to 1973 at the University of California, San Francisco, suggests that these tumors may be more radiosensitive than once thought. Radiation therapy combined with conservative surgical procedures may be as successful and perhaps more rational treatment than radical surgery alone.

Squamous cell carcinoma of the soft palate

We performed a retrospective study of 106 patients with carcinoma of the soft palate who were treated at two university hospitals. Computer analysis using a new interactive data base program called MING was made to determine Berkson-Gage survival and Gehan tests of statistical significance. Statistically significant associations with an increased survival included the following: smaller lesions, a clinically negative neck examination. well- and moderately well-differentiated histopathologic features, radiation therapy dose of less than or equal to 6,300 rads, absence of a simultaneous primary, and surgical salvage. No statistically significant differences were seen with age, sex, stage, or the number of days during which patients were treated with radiation therapy. There appears to be a need for a prospective, multi-institutional, randomized therapy study to solidify treatment policy. Consideration should be given to combine surgery-radiation vs radiation therapy alone.

Upper airway obstruction due to coccidioidomycosis

The inpatient experience regarding coccidioidomycosis of head and neck was reviewed at the University of California Medical Center, San Francisco and affiliated hospitals. Four cases in which upper airway obstruction required otolaryngological consultation and intervention are reviewed in detail. History, epidemiology and pathophysiology of coccidioidomycosis involving upper airway are discussed. Suggestions for diagnosis and management are outlined.

Management and rehabilitation of the facial nerve in parotid surgery

The facial nerve is the single most important consideration in the surgical management of most parotid disorders. Its surgical anatomy should be well known by the head and neck surgeon. Very few conditions of the parotid gland necessitate the sacrifice of the facial nerve. When this decision is made, the benefits to be derived should be very thoughtfully measured against the tremendous cosmetic and functional sequelae that follow, and the patient should understand preoperatively to the fullest the magnitude of this decision and all its consequences. Most facial nerve deficits resulting from injury or sacrifice of the nerve can be and are best repaired by either direct anastomosis or autografting using a donor sensory nerve. Such restorations of the neuromuscular mechanism yield a physiologic result that is as close to the preinjury state as possible, and this is reflected in cosmetic and functional recoveries that are generally superior to any other of a variety of rehabilitative techniques. In all patients with a paralyzed face, extremely close attention must be given the involved eye to minimize the hazards of corneal injury.

Mucormycosis

Three cases of mucormycosis are presented; two with unusual aspects: one with previously unreported involvement of the mandible, and one presenting as a cavernous sinus thrombosis. Review of the literature reveals a limited number of survivors. Survival in two of the cases presented here suggests that early diagnosis, aggressive therapy with surgery, and amphotericin B should improve the prognosis.

Nasopharyngeal angiofibroma

Nasopharyngeal angiofibromas have traditionally been difficult tumors to manage. Their extreme vascularity has led to excessive bleeding during surgical removal, which often obscured the surgical field and contributed to high recurrence rates because of incomplete removal. High recurrence rates have also been due to failure to recognize the full size and extent of these tumors preoperatively by routine physical examination and X-ray techniques. A combined experience of the authors with over 45 cases from the University of Michigan and the University of California, San Francisco, is presented to review the problems in management of these tumors and to present techniques of diagnosis and management which have been used to overcome some of these problems. The most important advances in diagnosis have been the radiographic techniques of laminagraphy and carotid angiography. Previously unrecognized tumor extensions into the areas surrounding the nasopharynx have been quite clearly demonstrated by these techniques. Improved surgical treatment of these tumors by wider surgical exposure and removal, utilizing multiple approaches when necessary, and by better control of bleeding by ligation and embolization of the main arterial supply, has led to fewer recurrences.

The role of otolaryngology in primary care practice. Report of a survey

A survey was conducted to assess how family practitioners rated certain knowledge skills and procedures in the field of otolaryngology. A questionnaire was designed as the instrument of the survey, and family practitioners were asked to complete the questionnaire based entirely on their experience in practice. The results of the survey showed that the practitioners considered that the majority (64%) of the items ranged from necessary to imperative. A highly consistent response was obtained. We discuss implications for curriculum design based on such surveys.

Conservative management of Méniére's disease: Furstenberg regimen revisited

This study reviews twenty years' experience at the University of Michigan with 500 consectutive patients suffering from symptoms of Méniére's disease. An especially strong tradition of medical therapy of Méniére's disease has prevailed at the University of Michigan because of the influence of Albert C. Furstenberg, who developed and promoted the Furstenberg regimen of a low-sodium diet and diuretics. It has been our distinct clinical impression over the years that the Furstenberg regimen has been quite satisfactory in relieving the most disturbing symptoms of Méniére's disease in the vast majority of cases and often in patients who have failed other treatment programs. This study quantifies, as much as possible, our extensive experience with this disease and confirms for us the efficacy of this treatment. Relatively few operative procedures have had to be performed for conservative treatment failures in our hands. The success of this conservative management program has been largely dependent upon the strict adherence by the patient to a professionally prescribed, low-sodium diet. Occasional patients with chronic symptoms which are refractory to medical management continue to be a problem, particularly since it is in this group of patients that bilateral involvement tends to ultimately occur.

Chordomas: nasopharyngeal presentation and atypical long survival

Atypical clinical and pathological features of a cranio-cervical chordomas have prompted a review of these neoplasms at the University of Michigan Medical Center. Contrary to prior investigations, 92% of the spheno-occipital chordomas reported in this study clinically presented with a nasopharyngeal or intranasal mass. This high incidence indicates the requirement for an otorhinologic examination on all patients presenting with the neuro-ophthalmologic syndrome and roentgenologic findings characteristic of chordomas in this anatomical region. Special attenion is called to a histologically distinctive variant of chordoma - the "chondroid chordoma.' Apparently restricted to the cranio-cervical region, this variant has been associated with long survival.

Carcinoma in pleomorphic adenomas of salivary glands

Because of the variability of the histological appearance of a given mixed tumor of the salivary gland and because of “recurrences” following less than total removal, biologically benign (not capable of metastasis) mixed tumors have been considered malignant. The true malignant mixed tumor, or more commonly carcinoma, arising from preexisting mixed tumors are unusual and ill-defined in the literature. These tumors make up no more than 5% of the mixed tumor category and occur primarily in the parotid gland. In this report, we present a clinico-pathological appraisal of the malignant mixed tumor based on five cases from the University of Michigan Medical Center and relate our experience to that in the literature. The importance of recognizing the malignant mixed tumor, or “carcinoma ex-mixed tumor,” lies in the accelerated recurrence rate and surprisingly high metastatic rate manifested by this lesion. Minimal treatment is radical total excision. Wide, early excision of the primary “benign” stage of these mixed tumors should reduce the problem of ultimate “malignification.”