Outcomes in patients with aggressive B-cell non-Hodgkin lymphoma after intensive frontline treatment failure

BACKGROUND

Salvage immunochemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation is the standard-of-care second-line treatment for patients with relapsed/refractory diffuse large B-cell lymphoma after first-line R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Outcomes after receipt of second-line immunochemotherapy in patients with aggressive B-cell lymphomas who relapse or are refractory to intensive first-line immunochemotherapy regimens (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab [R-EPOCH], rituximab, hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with methotrexate and cytarabine [R-HyperCVAD], rituximab, cyclophosphamide, vincristine, doxorubicin, and high-dose methotrexate alternating with ifosfamide, etoposide, and cytarabine [R-CODOX-M/IVAC]) remain unknown.

METHODS

Outcomes of patients with non-Burkitt, aggressive B-cell lymphomas and relapsed/refractory disease after first-line treatment with intensive immunochemotherapy regimens who received platinum-based second-line immunochemotherapy were reviewed retrospectively. Analyses were performed to determine progression-free survival (PFS) and overall survival (OS) from the time of receipt of second-line immunochemotherapy.

RESULTS

In total, 195 patients from 19 academic centers were included in the study. The overall response rate to second-line immunochemotherapy was 44%, with a median PFS of 3 months and a median OS of 8 months. Patients with early treatment failure (primary refractory or relapse <12 months from completion of first-line therapy) experienced inferior median PFS (2.8 vs 23 months; P < .001) and OS (6 months vs not reached; P < .001) compared with patients with late treatment failure. Although the 17% of patients with early failure who achieved a complete response to second-line immunochemotherapy experienced prolonged survival, this outcome could not be predicted by clinicopathologic features at the start of second-line immunochemotherapy.

CONCLUSIONS

Patients with early treatment failure after intensive first-line immunochemotherapy experience poor outcomes after receiving standard second-line immunochemotherapy. The use of standard-of-care or experimental therapies currently available in the third-line setting and beyond should be investigated in the second-line setting for these patients.

Visceral Thromboses in Pancreas Adenocarcinoma: Systematic Review

Within gastrointestinal malignancies, primary hepatocellular carcinoma and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity and speculatively improve oncologic outcomes. To perform a systematic review to study PVT, MVT, and SVT associated with PDAC, and to provide a comprehensive review. Medline/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Data Extraction and Assessment: Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English-language literature published between 2007 and 2016. Eleven articles were identified. Five case reports and 7 retrospective studies were found, with a total of 127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (n = 46), SVT in 52% (n = 65), and MVT in 13% (n = 15). Mean follow-up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in VT. All patients with nonvisceral thrombosis (eg, deep-vein thrombosis, pulmonary emboli) were therapeutically treated; in contrast, patients with VT only rarely received treatment. VT in PDAC is a frequent finding at diagnosis or during disease progression. Evidence to guide treatment choices is limited, and current management is based on inferred experience from nononcologic settings. Anticoagulation appears to be safe in VT, with most of the large studies recommending a careful assessment for patients at a high risk of bleeding.

Clinical impact of visceral thrombosis (VT) in pancreatic ductal adenocarcinoma (PDAC)

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Background: VT or splanchnic thrombosis is defined as thrombi within the hepato-portal venous system including; portal (PV), mesenteric (MV) and splenic vein (SV), as well as thrombi in renal or gonadal veins. Limited evidence has explored the prognostic significance, incidence and current clinical management of VT in patients with PDAC. Methods: We conducted an analysis of N = 95 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between 1/1/13 and 12/31/15 with PDAC who developed a VT either at presentation or which developed during the disease course. Results: N = 134 VT events (VTe) occurred. Median age of PDAC diagnosis was 62.5 yrs. Overall survival (OS) was 10.5 months (m); seven patients were still alive in 7/ 16. Time to develop first VTe was 4.3m (SD6.71, 0-31) and time to death from VTe development was 6.1m (SD 5.7,0-24). Subsequently, N = 42 pts developed a second VTe and N = 13 pts a third VTe. At time of VT diagnosis, N = 37 (38%) pts were asymptomatic, and N = 58 (61%) pts had an incidental finding. N = 39 (39%) pts were treated with short-term anticoagulation (STAC) ( < 1m) (N = 35 pts, treated with Low Molecular Weight Heparin (LMWH)). N = 45(46%) pts were treated with long-term anticoagulation (LTAC) ( > 1m) (LMWH N = 32, N = 11 pts were transitioned to an oral anticoagulant (NOAC)). Only N = 12(12%) pts were treated with a NOAC. N = 8 (8%) pts developed a bleeding complication from LTAC. OS for pts receiving LTAC was 4m vs 3m with STAC. Conclusions: In patients with PDAC, VT can frequently present as an incidental finding on routine abdominal imaging. The most common location is PV followed by MV and SV. We observed that AC is under-utilized in this setting despite a low bleeding complication rate. LMWH appeared to be the preferred treatment with LTAC, followed by use of a NOAC. PV was associated with reduced OS. Use of therapeutic anticoagulation for treatment of VT is limited by lack of data. Future large prospective studies should explore the role of AC and value in this setting.[Table: see text]

Visceral thromboses (VT) in pancreas adenocarcinoma (PDAC): A systematic review

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Background: Within the spectrum of gastrointestinal malignancies, primary liver (HCC) and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity speculatively improve oncologic outcomes. Methods: Perform a systematic review to study occurrences of visceral thromboses (portal, mesenteric and splenic vein thromboses) associated with PDAC and provide a clinical review on this area. Main databased were searched; PubMed, EMBASE, Web of Science, Scopus, and the Cochrane library. Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English literature published after 2007 to 2016. Results: Eleven articles were identified. Five case reports and 7 retrospective studies were found with a total of N=127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (N= 46), SVT in 52% (N= 65), MVT in 13 %( N= 15). Mean follow up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in visceral thrombosis. All patients with non-visceral thrombosis (e.g. DVT, PE) were therapeutically treated, in contrast, to only rare occurrences with VT received treatment. Conclusions: Visceral thrombosis in PDAC can be a frequent finding at diagnosis or during disease progression. This literature analysis has shown VT to be a poor prognostic indicator for short term survival. Evidence to guide treatment choices are inadequate and current management is based on inferred experience from other non-oncologic populations. Anticoagulation appeared to be a safe modality in visceral thrombosis with most of the large studies recommending a careful assessment for patients with high risk of bleeding.

Pancreas Adenocarcinoma: Ascites, Clinical Manifestations, and Management Implications

BACKGROUND

Ascites develops in a subset of patients with pancreatic adenocarcinoma (PAC) at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions.

METHODS

We conducted a retrospective analysis of 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and with ascites either at presentation or that developed during the disease course.

RESULTS

For the 180 patients, the overall survival was 15 months. The time from diagnosis to ascites presentation was 11 months, and the survival time after ascites development was 1.8 months (range, 1.6-2.3 months; 95% confidence interval). Of 62 patients (34%) who had ascitic fluid analyzed, 36 (58%) had positive cytology. Fifty-one (82%) patients had a serum ascites albumin gradient ≥ 1, and 11 (18%) had serum ascites albumin gradient < 1. Sixty-four (36%) patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter; of these, 108 (93%) had a Tenckhoff catheter, 4 (3%) a Pleurx catheter, 4 (3%) a pigtail catheter, and 1 (1%) a Denver catheter. Eight (7%) patients required 2 catheters to be placed, and in 6 (5%), Tenckhoff catheters had to be removed. The main observed complications were spontaneous bacterial peritonitis in 7 (11%) managed with paracenteses versus 26 (23%) who had a catheter placed, catheter malfunction in 8 (7%), and acute renal failure in 6 (3%). After ascites development, 79 (44%) patients received active anti-cancer therapy, and 101 (56%) patients were managed with supportive care alone.

CONCLUSIONS

In patients with PAC who presented with or developed ascites, serial paracenteses and indwelling catheters are common methods used for providing symptomatic relief. The complication rate was higher with indwelling catheters, primarily related to infection (eg, bacterial peritonitis). Overall, ascites has a significantly negative prognostic import with a short median survival.

Presentation, clinical behavior, outcomes and therapies for patients with advanced pancreas adenocarcinoma (PAC) who present with or develop ascites

209

Background: Ascites develops in a subset of patients with PAC at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions. Methods: We conducted a retrospective analysis of N = 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and ascites either at presentation or which developed during the disease course. Results: For the 180 patients, overall survival was 15 months. Time from diagnosis to ascites presentation was 11 months and survival time after ascites development was 4 months. Of 62 patients (34%) who had ascitic fluid analyzed, N = 36 (58%) had positive cytology, N = 51 (82%) patients had a serum ascites albumin gradient (SAAG) ≥ 1 and N = 11 (18%) had SAAG < 1.1. Sixty-four (36%) of patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter, from these, N = 108 (93%) had a Tenckhoff catheter, N = 4 (3%) Pleurx catheter, N = 3 (2%) Pigtail catheter and one (1%) a Denver catheter. Eight (4%) patients required two catheters to be placed and N = 6 (3%) Tenckhoff catheters had to be removed. Main observed complications: spontaneous bacterial peritonitis in N = 7 (11%) of patients managed with paracenteses vs. N = 34 (19%) who had a catheter placed, catheter malfunction in N = 8 (4%), acute renal failure in N = 6 (3%). After ascites development N = 79 (44%) of patients received active therapy and N = 101 (56%) patients were managed with supportive care alone. Conclusions: In patients with PAC the presence of ascites is a poor prognostic factor. Serial paracenteses and indwelling catheters are common methods used for alleviating patients’ discomfort. The complication rate was higher with indwelling catheters, primarily associated with infections (e.g. bacterial peritonitis) with low rates of complications occurring related to catheter malfunction, acute renal failure or bowel perforation.

Cases from the aerospace medicine residents' teaching file. Case #60. A Gulf War veteran and aviator with an occupational dermatitis

A Gulf War veteran and aviator with an occupational dermatitis is evaluated as to cause and ability to work in his normal occupation as well as flying duty. The effects of the Americans With Disabilities Act upon disabled workers, pilots and collective bargaining agreements is discussed.

Making alliances work. Interview by Donald E. Johnson

As hospitals face ever increasing competition and the need for deep cost cutting, participation in alliances and multihospital systems can make all the difference in assuring a hospital's survival, says Allen M. Hicks, president of the MidWest Medical Center in Indianapolis. Hicks was instrumental in building Voluntary Hospitals of America and other multihospital systems, but now he works in the for-profit hospital sector with Republic Health Care Corporation. In this interview with Health Care Strategic Management's Donald E. L. Johnson, he shares his views on the role that alliances should play today.

Lead exposure at uncovered outdoor firing ranges

Excessive lead exposure in shooting instructors at indoor firing ranges and covered outdoor firing ranges has been documented. The City of Los Angeles assessed exposure of its full-time shooting instructors at uncovered outdoor ranges via air monitoring and blood lead-level measurements. Results of these tests revealed that significant lead exposure and absorption can occur at outdoor firing ranges. The use of copper-jacketed ammunition may decrease air lead levels and decrease lead absorption by range instructors.

Parental occupational exposures and risk of childhood cancer: a review

We reviewed the literature in order to summarize the present knowledge on the association between parental occupational exposures to chemicals and the risk of childhood malignancy. The 32 studies pertaining to this topic were evaluated by considering various study qualities such as sample size, specificity of outcome, confounding, exposure specificity, and control selection. When evaluating the findings from any epidemiologic study, the potential sources of bias have to be considered. The selection of subjects, misclassification of exposure or outcome, and confounding from extraneous factors can contribute to a biased estimate of effect. Studies done to minimize these potential biases will be more valid, and these studies should be given the most weight when parental occupational exposures are evaluated as risk factors for childhood malignancy. We conclude that the preponderance of evidence supports the hypothesis that occupational exposure of parents to chemicals increases the risk of childhood malignancy. The parental occupational exposures implicated in childhood malignancy risk are exposure to chemicals including paints, petroleum products, solvents (especially chlorinated hydrocarbons) and pesticides, and exposure to metals. The available data do not allow the identification of specific etiologic agents within these categories of compounds. Future epidemiologic and toxicologic studies should be designed to pursue these leads.

Cold climate and cold temperature induced changes in the heat production and thermal insulation of sheep

Heat production and thermal insulation were measured in three groups of sheep, control, outdoor, and indoor, which were exposed to the effects of season, cold climate, and cold temperature respectively. The experiment was for 24 weeks, from November 1967 to April 1968. Sheep in the control, outdoor, and indoor groups gained 16.2, 10.0, and 14.9 kg respectively. Average feed intake in both control and outdoor groups was 2.65 kg hay/100 kg sheep per day. Food intake was highest in the indoor group and was inversely related to ambient air temperature. Resting heat production was constant throughout in the control group but increased with time in the outdoor group. Resting heat production in indoor sheep was related to intensity of prior cold exposure. Wool growth and thermal insulation did not differ significantly between groups. Critical temperature for the outside group fell from −15 °C in week 4 to −35 °C in week 20. After these trials, all sheep were shorn. The heat production of the shorn indoor group at −30 °C was greater, and that of the outdoor group was less than that of the controls. The results suggest that, in sheep, acclimation to cold temperatures induces rapid, brief increases in resting heat production and summit metabolism. Acclimatization to cold climates slowly induces a persistent elevation in resting heat production, but appears to reduce the initial metabolic response to an intense cold stimulus.