Overall survival of patients with cHL who progress after autologous stem cell transplant: results in the novel agent era

In the pre-novel agent era, the median postprogression overall survival (PPS) of patients with classic Hodgkin lymphoma (cHL) who progress after autologous stem cell transplant (ASCT) was 2 to 3 years. Recently, checkpoint inhibitors (CPI) and brentuximab vedotin (BV) have improved the depth and durability of response in this population. Here, we report the estimate of PPS in patients with relapsed cHL after ASCT in the era of CPI and BV. In this multicenter retrospective study of 15 participating institutions, adult patients with relapsed cHL after ASCT were included. Study objective was postprogression overall survival (PPS), defined as the time from posttransplant progression to death or last follow-up. Of 1158 patients who underwent ASCT, 367 had progressive disease. Median age was 34 years (range, 27-46) and 192 were male. Median PPS was 114.57 months (95% confidence interval [CI], 91-not achieved) or 9.5 years. In multivariate analysis, increasing age, progression within 6 months, and pre-ASCT positive positron emission tomography scan were associated with inferior PPS. When adjusted for these features, patients who received CPI, but not BV, as first treatment for post-ASCT progression had significantly higher PPS than the no CPI/no BV group (hazard ratio, 3.5; 95% CI, 1.6-7.8; P = .001). Receipt of allogeneic SCT (Allo-SCT) did not improve PPS. In the era of novel agents, progressive cHL after ASCT had long survival that compares favorably with previous reports. Patients who receive CPI as first treatment for progression had higher PPS. Receipt to Allo-SCT was not associated with PPS in this population.

90Yttrium Ibritumomab Tiuxetan (Zevalin) for the Treatment of Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: A Report of 5 Cases

Radioimmunotherapy (RIT) with radio-labeled monoclonal antibodies to CD20 produces a high response rate in patients with low-grade B-cell lymphomas. The use of this modality in patients with chronic lymphocytic leukemia (CLL) has been sporadic in clinical trials and was hampered by the extensive marrow involvement seen commonly in patients with CLL, which would produce a high risk for marrow aplasia after treatment with RIT. Herein, we report our experience with RIT in 5 patients with CLL or SLL showing short-lived responses and significant myelosuppression. After 90Y-ibritumomab tiuxetan treatment, the median time to relapse was 65 days, and no cases of MDS or AML were observed during follow-up. All patients experienced grade ≥3 thrombocytopenia and neutropenia, with median durations of 39.5 days and 107 days, respectively.

The impact of peri-operative chemotherapy on the outcomes of patients with non-metastatic cholangiocarcinoma

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Background: Cholangiocarcinoma is a rare malignancy with poor prognosis and outcome despite therapy. It accounts for 2.2% of all new cancer cases and 5% of all cancer deaths. Surgical resection is still the main therapeutic approach, whereas the role of peri-operative chemotherapy is debatable. Methods: The National Cancer Database (NCDB) was queried for patients diagnosed with non-metastatic biliary adenocarcinoma at age 18 or older between 2004 and 2019. After excluding patients with unknown timing of surgery and chemotherapy, patients who died within 90 days of the most definitive primary site surgery and patients lost to follow-up, we split the cohort into three groups according to the clinical stage (stage I-III). Then, we evaluated the overall survival (OS) between the different treatment modalities (surgery only, adjuvant chemotherapy and neoadjuvant chemotherapy) in each group. We studied the OS using Kaplan-Meier estimates and multivariate cox regression analyses to evaluate factors associated with OS. Results: A total of 35,260 patients with non-metastatic cholangiocarcinoma were included in the analysis, of which 50.4% were females, 83% Caucasians, 9.5% African Americans. The median age at diagnosis was 70 (range 18-90). 14,757 (41.9%) were stage I, 12,472 (35.4%) stage II and 8,031 (22.8%) stage III. 7,286 (20.7%) had surgical resection only, 8,144 (23.1%) had chemotherapy only, 6,964 (19.7%) had surgical resection with perioperative chemotherapy and 12,866 (36.5%) did not receive any treatment. We compared survival between different treatment modalities based on clinical stage. In stage I, we found patient who were treated with surgery only had better median OS (mOS) compared to adjuvant chemotherapy (65.7 vs 50.4 months, P<0.001) and no statistically significant difference between neoadjuvant chemotherapy and surgery only (mOS 79.8 vs 65.7 months, P=0.63). Whereas in stage II, patients who were treated with adjuvant and neoadjuvant chemotherapy had better mOS compared to those treated with surgery only (33.9 and 40.3 vs 29.9 months with P<0.001 and P=0.005, respectively). Same trend was seen in stage III, patients who were treated with adjuvant and neoadjuvant chemotherapy had better mOS compared to surgery only (22.6 and 41.5 vs 19.5 months, respectively with P<0.001 for all). In multivariate analysis, adjuvant and neoadjuvant chemotherapy did not affect the OS in all stages, except in stage III where neoadjuvant chemotherapy was associated with better OS (HR 0.646 95% CI 0.530-0.786; P<0.001). Conclusions: Adjuvant and neoadjuvant chemotherapy do not seem to have survival benefit in early stage (stage I and II) cholangiocarcinoma. Whereas neoadjuvant chemotherapy tends to improve OS in stage III.

The role of surgery in small differentiated thyroid cancer

INTRODUCTION

The incidence of small, differentiated thyroid cancer (DTC) cases has been increasing in the United States and the world mainly due to incidental detection because of widespread use of diagnostic modalities. While the option of active surveillance instead of surgical resection is getting more popular, there is still an open discussion about the best approach in these cases.

MATERIALS AND METHODS

The National Cancer Database was queried for patients diagnosed with non-metastatic small T1/N0 DTC between 2004 and 2016, who have known surgical status and Charlson comorbidity index of two or less. We evaluated the overall survival (OS) based on the surgery status using Kaplan-Meier estimates and multivariable cox regression analyses.

RESULTS

A total of 98,501 patients with non-metastatic small DTC were included, within which 96,612 (98.1%) were treated with surgery, and 1889 (1.9%) were not treated with surgery or other ablative modalities. We found that patients who were treated with surgery had better OS compared to patients who were not treated with surgery (mean OS 171 months vs 134.1 months, P < 0.001, median OS was not reached). This difference was still statistically significant even after we used propensity score matching for age, gender, race, Charlson-Deyo score, tumor size, and histology. On multivariate analysis, surgery was associated with better OS (HR 0.218; 95% CI: 0.196-0.244; P < 0.001). Same trend was found in subgroup analysis when we split the cohort according to tumor size (<1 and ≥1 cm), histology (follicular, papillary and Hurthle cell carcinoma), and age (<55 years vs ≥55 years).

CONCLUSION

Patients with non-metastatic small DTC who were treated with surgery had significant improvement in OS compared to patients who were not treated with surgery. Notwithstanding the limitations of the current analysis, these results call for caution prior to recommending routine surveillance for all patients with small DTC.

Impact of perioperative chemotherapy on survival outcomes among patients with metastatic colorectal cancer to the liver

Aim: Compare overall survival (OS) between adjuvant and neoadjuvant chemotherapy and analyze the effect of chemotherapy on OS. Materials & methods: National Cancer Database was queried for patients diagnosed with metastatic colorectal adenocarcinoma with isolated liver metastases between 2004 and 2016. We evaluated the OS and chemotherapy effect using Kaplan-Meier estimates and multivariable cox regression analyses. Results: Total 6883 patients with metastatic colorectal cancer and liver metastases were included, of which 6042 patients were treated with surgery and chemotherapy and 841 patients were treated with surgery only. Patients who received neoadjuvant chemotherapy had better OS compared with patients who received adjuvant chemotherapy. Conclusion: Patients with colorectal cancer with isolated liver metastases who were treated with neoadjuvant chemotherapy had better OS compared with adjuvant chemotherapy.

Clinical Characteristics and Survival Outcomes of Primary Effusion Lymphoma: A National Cancer Database Study

INTRODUCTION

Primary effusion lymphoma (PEL) is a rare HHV8(+) non-Hodgkin lymphoma associated with HIV infection or other causes of immunosuppression. Large-scale studies describing the natural history of this entity are lacking.

MATERIALS AND METHODS

National cancer database (NCDB) was queried for patients diagnosed with PEL between 2004 and 2016. All patients age ≥ 18 years diagnosed with PEL were included. We excluded patients with multiple primary malignancies or lost follow-up. Kaplan-Meier and multivariate cox regression were used in the analyses.

RESULTS

Of the 219 PEL patients included in the analysis, 179 (82%) were males, 161 (74%) Caucasian and 49 (22%) African American. Median age at diagnosis was 60 ± 19 years and median OS (mOS) was 8.5 months. One hundred and fifteen were HIV+, 63 HIV-, 111 received chemotherapy, and 101 did not. Patients who received chemotherapy had better mOS compared to patients who did not receive chemotherapy (13 vs. 3 months, P < .001). This difference was observed in HIV+ patients (22.97 vs. 1.97 months, P = .006), but not in HIV- patients (6.24 vs. 8.20 months, P = .752). On multivariate analysis, chemotherapy treatment was associated with better OS (HR 0.502 95% CI 0.324-0.777; P = .002), whereas HIV status did not affect the OS (HR 0.6 95% CI 0.3-1.4; P = .258).

CONCLUSION

This largest retrospective analysis on PEL revealed that current chemotherapeutic approach is significantly beneficial for HIV+ patients but not for HIV- patients. The rapid advancement in HIV treatment might be playing a role in survival improvement among HIV+ patients. Novel therapies are needed to improve the survival of patients with PEL, especially in HIV- patients.

MICROABSTRACT

PEL is a rare HHV8(+) non-Hodgkin lymphoma. Using national cancer database, we studied clinical characteristics, and outcomes of 219 PEL patients. We found that chemotherapy significantly improved overall survival in HIV+ patients. However, a similar survival improvement was not seen in HIV- patients. Significant improvement in efficacy of antiretroviral therapy is likely contributing to the survival improvement in HIV+ patients.

Outcomes of classic Hodgkin lymphoma, relapsed within one year of diagnosis, in the era of novel agents

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Background: Primary refractory disease (PRD) and early relapse (ER) are predictors of poor prognosis in classic Hodgkin lymphoma (cHL). In this multicenter retrospective study, we describe outcomes of PRD and ER in pts with relapsed/refractory (R/R) cHL treated with salvage therapy (ST) and autologous stem cell transplant (ASCT). Methods: Of 14 sites, adult patients with R/R cHL who received ST and underwent ASCT were enrolled. PRD was defined as progression on frontline chemoimmunotherapy or within 6 months of diagnosis. ER was defined as relapse from 6 months-1 yr of diagnosis. Pts who relapsed >1 yr of diagnosis were called late relapses (LR). Study objectives were Overall response rates (ORR), CR rates, PFS, and OS. Results: Of 986 total pts, 160 had PRD, 365 had ER and 461 had LR. Significantly higher number of pts with PRD, but not ER, had bulky disease (41% vs 27%, p<0.01) and B symptoms (53% vs 38%, p<0.001) than LR. Higher proportions of pts with PRD and ER required >1 line of ST (44% vs 30% vs 23%, p<0.001) before ASCT and received BV maintenance (25% vs 24% vs 16%, p<0.05). When adjusted for B symptoms and Bulky disease, PRD and ER had significantly lower ORR (65% vs 76% vs 84%, p<0.001) and CR (37% vs 46% vs 57%, p<0.001) to first ST than LR. Pts with PRD and ER had significantly lower PFS (56.3%, 61.4%, vs 77.6%, p<.0001) and OS (93% vs 89% vs 94%, p=0.01) than LR. In pts with ER, Brentuximab/bendamustine (BBV) and brentuximab vedotin/nivolumab (BV/nivo) had a trend towards higher ORR (92% vs 92% vs 75%) but significantly higher CR (79.2% vs 76% vs 42%, p<0.01) than platinum based chemotherapy (PBC). In pts with PRD, BBV and BV/Nivo had a statistically insignificant trend towards higher ORR and CR than PBC. The table shows 2 yr PFS by type of ST in PRD, ER, LR. There was no difference in PFS by time to relapse in BV/nivo, CPI and miscellaneous agents. BV/Nivo had a significantly higher PFS than PBC in PRD (88% vs 48%, p<0.05) and ER (95% vs 57%, p<0.05). There was no difference in PFS of PBC and other ST in PRD, ER or LR. OS was not significantly associated with type of ST in either group. Conclusions: PRD and ER are associated with lower response to ST and survival after ASCT compared to late relapse. In pts with PRD and ER, BV/Nivo has high ORR and CR and leads to significantly higher PFS comparable to pts with late relapse and may be preferable ST regardless of time to relapse. [Table: see text]

Impact of intensive multimodal treatment on the outcomes of patients with anaplastic thyroid cancer

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Background: Anaplastic thyroid cancer (ATC) is a rare and aggressive type of thyroid malignancy with very poor prognosis and outcome despite therapy. The rarity of this disease and the poor functional status of ATC patients limit the ability to conduct clinical trials, thus there is a lack of large, controlled trials to guide treatment and evaluate the benefit of combined modality therapy. Methods: The National Cancer Database (NCDB) was queried for patients diagnosed with ATC at age 18 or older between 2004 and 2018. After excluding patients with unknown number of treatment modalities, Charlson-Deyo score of 3 or more and patients lost follow-up, we split the cohort into three groups according to the number of treatment modalities they received. Treatment modalities include surgery, radiation, and systemic therapy. Then, we evaluated the overall survival (OS) between the three groups. We studied the OS using Kaplan-Meier estimates and multivariate cox regression analyses to evaluate factors associated with OS. Additionally, propensity score matching (accounting for age, gender, race, Charlson-Deyo score, and clinical M stage) was used for more robust results. Results: A total of 3,460 patients with ATC were included in the analysis, of which 1,472 (42.5%) either received one type of therapy or did not receive any therapy (group1), 1,092 (31.6%) received bimodal therapy (group 2), and 896 (25.9%) received trimodal therapy (group 3). We found that group 3 had better OS compared to group 1 and group 2 (median OS 9.1 months vs 1.7 months and 4.9 months, respectively with P < 0.001 for all). Propensity score matching yielded 896 patients in each group. We found that group 3 had better OS compared to group 1 and group 2 (median OS 9.1 months vs 1.9 months and 5.2 months, respectively with P < 0.001 for all). Same trend was found in subgroup analysis when we split the cohort according to the metastatic status; in M0 group (median OS was 10.4 months vs 1.9 months and 6.1 months, respectively with P < 0.001 for all), in M1 group (median OS was 5.9 months vs 1.4 months and 3.7 months, respectively with P < 0.001 for all). On multivariate analysis, group 1 and group 2 were associated with worse OS compared to trimodal treatment (HR 2.721; 95% CI: 2.466 - 3.002 and HR 1.434; 95% CI: 1.299 - 1.582, P < 0.001 for all). Conclusions: Patients with ATC who were treated with intensive trimodal therapy had statistically significant improvement in OS compared to patients who received less intense therapy. This survival benefit was observed in both metastatic and non-metastatic groups. While we acknowledge the limitations of this retrospective analysis, our results showed the critical role of intensive therapy approach in this aggressive malignancy.

Controversial risk factors for cholangiocarcinoma

INTRODUCTION

Cholangiocarcinoma is a rare malignancy accounting for 3% of gastrointestinal cancers in the USA. While multiple risk factors for cholangiocarcinoma are established, other potential risk factors are still controversial. Herein, we used a large national database to investigate possible risk factors and associations.

METHOD

We used the National Inpatient Sample database to review all admissions between 2011 and 2015. We grouped patients based on the presence and absence of cholangiocarcinoma. Using multivariate logistic regression analysis, we assessed the association between obesity, alcohol abuse, smoking, diabetes mellitus and cholangiocarcinoma.

RESULTS

Out of 30 9552 95 admissions, 20 030 had cholangiocarcinoma. Cholangiocarcinoma patients were older (67 ± 12.8 vs. 57 ± 20.6; P < 0.001) and had fewer female patients (48 vs. 59%; P < 0.001). Multivariate logistic regression analysis showed that diabetes mellitus was associated with cholangiocarcinoma (OR, 1.04; 95% CI, 1.01-1.08; P < 0.001). On the other hand, alcohol, smoking and obesity were all inversely associated with cholangiocarcinoma (OR, 0.75; 95% CI, 0.69-0.81; P < 0.001), (OR, 0.75; 95% CI, 0.71-0.79; P < 0.001) and (OR, 0.71; 95% CI, 0.67-0.75; P < 0.001), respectively. In addition, compared to Whites, Hispanic and Asian/Pacific Islander races were more associated with cholangiocarcinoma (OR, 1.27; 95% CI, 1.21-1.34) and (OR, 1.79; 95% CI, 1.67-1.92) (P < 0.001 for all), respectively, whereas African American race was inversely associated with cholangiocarcinoma (OR, 0.85; 95% CI, 0.81-0.89; P < 0.001).

CONCLUSION

Patients with a diagnosis of diabetes mellitus or from certain ethnic groups (Hispanic and Asian/Pacific Islander) are associated with increased risk for cholangiocarcinoma.

Prognostic and predictive value of microsatellite instability status among patients with colorectal cancer

Objectives: Compare overall survival (OS) between microsatellite instability (MSI) high and MSI-stable and analyze the effect of chemotherapy on OS. Methods: National cancer database was queried for patients diagnosed with colorectal adenocarcinoma between 2010 and 2016. We evaluated the OS and the chemotherapy effect using Kaplan-Meier estimates and multivariate Cox regression analyses. Results: Total of 30,436 stage II patients and 30,302 stage III patients were included. In stage II with high-risk features and MSI-high, patients who received chemotherapy had better OS compared to patients who didn't receive chemotherapy. The same was found in stage II with no high-risk features and MSI-high group. Conclusion: Stage II colorectal cancer patients with high-risk features and MSI-high who received chemotherapy have better OS compared to patients who didn't receive chemotherapy.

The impact of gender and HPV status on anal squamous cell carcinoma survival

BACKGROUND

Anal cancer is a rare entity and the effect of gender and HPV status on survival is controversial. We aimed to evaluate the difference in overall survival (OS) according to gender and analyzed the effect of HPV status on OS.

PATIENTS AND METHODS

The National Cancer Database (NCDB) was queried for patients with anal squamous cell carcinoma between 2004 and 2016. We evaluated the OS based on gender and HPV status using Kaplan-Meier estimates and we used multivariate Cox regression analyses to evaluate factors associated with overall survival.

RESULTS

A total of 6133 patients with known HPV status were included for analysis. In the non-metastatic group, male gender was associated with worse OS (HR 1.50, 95% CI 1.32-1.70; P<0.001) whereas HPV status did not affect the OS (HR 1.08, 95% CI 0.96-1.22; P=0.213). In the metastatic group, there was no difference in OS based on gender (HR 1.29, 95% CI 0.91-1.82; P=0.148), whereas HPV-negative status was associated with worse OS (HR 1.52, 95% CI 1.09-2.12; P=0.014).

CONCLUSION

Females had better OS only in non-metastatic anal squamous cell carcinoma (ASCC). HPV-negative status was associated with worse OS only in metastatic ASCC.

Association of non-alcoholic fatty liver disease and polycystic ovarian syndrome

Background

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder in women. Women with PCOS have androgen excess as a defining feature. They also have increased insulin resistance and obesity, which are also risk factors for non-alcoholic fatty liver disease (NAFLD). However, published data regarding PCOS as independent risk factor for NAFLD remain controversial. Therefore, we conducted this study to evaluate the association between PCOS and NAFLD using a large national database.

Methods

We identified adult female patients (≥18 years) with PCOS using the National Inpatient Sample database between 2002 and 2014. The control group included patients who did not have a diagnosis of PCOS. Multivariate logistic regression analysis was performed to study the association of NAFLD with PCOS.

Results

Out of a total of 50 785 354 women, 77 415 (0.15%) had PCOS. These patients were younger (32.7 vs 54.8; p<0.001) and more likely to be obese (29.4% vs 8.6%; p<0.001) compared with non-PCOS patients. However, the PCOS group had less hypertension (23.2% vs 39.8%), dyslipidaemia (12% vs 17.8%) and diabetes mellitus (18.1% vs 18.3%) (p<0.001 for all). Using multivariate logistic regression, patients with PCOS had significantly higher rate of NAFLD (OR 4.30, 95% CI 4.11 to 4.50, p<0.001).

Conclusion

Our study showed that patients with PCOS have four times higher risk of developing NAFLD compared with women without PCOS. Further studies are needed to assess if specific PCOS treatments can affect NAFLD progression.

Colorectal Cancer Epidemiology: Recent Trends and Impact on Outcomes

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer related deaths in the world with an estimated number of 1.8 million new cases and about 881,000 deaths worldwide in 2018. The epidemiology of CRC varies significantly between different regions in the world as well as between different age, gender and racial groups. Multiple factors are involved in this variation, including risk factor exposure, demographic variations in addition to genetic susceptibility and genetic mutations and their effect on the prognosis and treatment response. In this mini-review, we discuss the recent epidemiological trend including the incidence and mortality of colorectal cancer worldwide and the factors affecting these trends.

New paradigms in the treatment of low-risk thyroid cancer

INTRODUCTION

Thyroid cancer is the most common endocrine malignancy. Multiple different staging systems have been introduced and used for differentiated thyroid carcinoma (DTC).

AREAS COVERED

In this literature review we provide an overview of the standard options for management of patients with low risk differentiated thyroid cancer.

EXPERT OPINION

Surgery is considered the first and most important step in managing DTC with goal to remove all the malignant foci in order to achieve cure and increase the survival with least chance of recurrence. Many studies have been conducted to determine the best surgical approaches and how aggressive surgeries should be in order to achieve the best outcomes regarding efficacy as well as safety. Radioactive iodine (RAI) therapy has also been a part of the treatment regimen and is used for different purposes with three main goals: post-surgical ablation, adjuvant therapy and persisted/recurrent disease treatment. Radiation therapy, on the other hand, is still not recommended to be used routinely in DTC because of the conflicting data of its benefit.

Causes of death in nodular lymphocyte predominant Hodgkin's lymphoma

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Background: Nodular lymphocyte-predominant Hodgkin’s lymphoma (NLPHL) accounts for 5% of all cases of HL. The outcomes of patients with NLPHL is generally regarded as better than those with classical HL. However, causes of death (COD) of patients with NLPHL have not been previously described. Methods: The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program was used to identify all patients with NLPHL diagnosed between 1990 and 2015. Patient characteristics and disease stage, using the Ann-Arbor system, was extracted and tabulated. COD were identified and proportions were calculated for deaths within 5 years and after 5 years of diagnosis for patients with early and late stage NLPHL. Results: We identified 1,937 cases of NLPHL. The majority were younger than 65 years (86%), white (70%), male (67%), and diagnosed between 2001-2015 (85%), when rituximab was introduced. Of all cases, 1336 (69%) were classified as early stage. At a median follow-up of 91 months (IQR 41, 152) for early stage disease, and 73 months (IQR 30-123) for late stage disease, the median cancer-specific or overall survival were not reached. The estimated 5-year survival was 92% and 81% for early stage and late stage disease, respectively. Of all patients with early stage NLPHL, 186 (14%) died by the end of 2015, and 87 (46%) deaths occurred within 5 years of diagnosis. During the first 5 years after diagnosis, COD was NLPHL in 30 (35%). Beyond 5 years from diagnosis, NLPHL was the COD in 27% followed by other cancers (23%), and cardiovascular disease (18%). Of all patients with late stage NLPHL, 107 (21%) died, and 75 (70%) of deaths occurred within 5 years of diagnosis. During the first 5 years after diagnosis, COD was NLPHL in 44 (59%). Beyond 5 years from diagnosis, cardiovascular disease was the COD in 25%, followed by NLPHL (22%). Conclusions: The prognosis of NLPHL is excellent. Of all patients with NLPHL, those with advanced stage disease are more likely to die of their disease within 5 years of diagnosis. Patients with early and advanced stage disease beyond 5 years of diagnosis are more likely to die of causes other than NLPHL.

Controversial risk factors for cholangiocarcinoma

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Background: Cholangiocarcinoma (CCA) is a relatively rare malignancy accounting for 3% of gastrointestinal cancers in the US. While multiple risk factors for CCA are established and well-studied, other potential risk factors are still controversial and not well established. Herein, we used a large national database to investigate possible risk factors and associations. Methods: We used the National Inpatient Sample (NIS) database to review all admissions between 2011 and 2015. We grouped patients based on the presence and absence of CCA using the appropriate ICD-9 codes. We used multivariate logistic regression to assess the association between obesity, alcohol abuse, smoking, diabetes mellitus (DM), and non-alcoholic fatty liver disease (NAFLD). Results: We reviewed 30,955,295 admissions of which 20,030 had CCA. CCA Patients were older compared to the rest of the patients (mean age 67 years ±12.8 vs. 57±20.6, P < .001) and had less female patients (48% vs 59%, P < .001). Patients’ characteristics are shown in the table. After adjusting for viral hepatitis B (HBV), viral hepatitis C (HCV), liver cirrhosis, inflammatory bowel disease (IBD), primary sclerosing cholangitis (PSC), and bile duct stones, logistic regression showed DM to be proportionately associated with CCA (OR = 1.04, 95%CI[1.01-1.08], P < .001), whereas alcohol, smoking and obesity were all inversely associated with CCA; OR = 0.75, 95%CI [0.69-0.81], P < .001, OR = 0.75, 95%CI [0.71-0.79], P < .001 and OR = 0.71, 95%CI [0.67-0.75], P < .001, respectively. In addition, compared to whites, Hispanic and Asian/Pacific Islander races were proportionally associated with CCA; OR = 1.27, 95%CI [1.21-1.34], P < .001, and OR = 1.79, 95%CI, [1.67-1.92], P < .001, respectively, while black race was inversely associated with CCA (OR = 0.85, 95%CI [0.81-0.89], P < .001). Conclusions: In our large database study, we found that patients with diagnosis of DM or being from certain minority ethnic groups are associated with increased incidence of CCA. Other factors like alcohol and smoking were associated with decreased incidence of CCA, but those factors may be under reported. This raises the need for further evaluation for these factors and their effect on CCA incidence and outcomes in those specific groups. [Table: see text]

Gender impact on renal cell carcinoma survival: A population-based analysis

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Background: Prior evidence has suggested that females diagnosed with renal cell carcinoma (RCC) present at an earlier stage compared to males, but a survival difference between males and females has been controversial. We aimed to evaluate the impact of gender on RCC survival in the US. Methods: Data of RCC patients diagnosed between 1973 and 2015 in the US was obtained using Surveillance Epidemiology and End Results (SEER) database. We studied the overall and cancer-specific survival of patients diagnosed with RCC in the US according to gender using multivariable covariate-adjusted Cox models and Kaplan-Meier test. Results: We reviewed 155,430 RCC patients, of which 96,656 were males, and 58,774 were females. The median overall survival of female patients was 122 months and was significantly higher than male patients (98 months). Cancer-specific survival showed similar trends with females having significantly higher survival (p-value < 0.001). Adjusted for age, race, stage and grade of cancer, undergoing cancer-targeted surgery, and marital status, female sex was associated with improved overall and cancer-specific survival outcomes; HR = 0.829 (p-value < 0.001), and HR = 0.923 (p-value < 0.001), respectively. Conclusions: Females have a significantly better overall and cancer specific survival compared to males diagnosed with renal cell carcinoma. In previous studies this disparity was attributed to the lower grade and earlier stage of RCC presentation in females, but gender-based disparity persisted in this analysis after adjusting for patient baseline and tumor characteristics. This raises the question of the hormonal effects on the progression of RCC.

Gender disparities in anal cancer incidence and mortality: A long-term US population-based analysis

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Background: Anal cancer is an uncommon malignancy accounting for less than 3% of gastrointestinal malignancies in the US. In this large database study, we aimed to re-evaluate the difference in the incidence and mortality trend in both genders. Methods: We used SEER 18 database to study anal cancer cases in the US during 2000-2016. Incidence and mortality rates of anal cancer were calculated by gender and were expressed by 1,000,000 person-years. Annual percent change (APC) was calculated using join point regression software. Results: We reviewed 25,418 patients with anal cancer, of which 61.4% were females. Incidence of anal cancers was 14.375 and 19.427 per 1,000,000 person-years, in males and females, respectively. Incidence rates of anal cancer significantly increased over the study period, but this increase was sharper in females (APC = 2.220%, 95%CI [1.924-2.517], P < .001) when compared to males (APC = 0.915%, 95%CI [0.303-1.531], P = .006). Mortality rates from anal cancer over the study period were 7.425 and 7.532 per 1,000,000 person-years, in males and females, respectively. Overall anal cancer mortality rates did not change between 2000-2009 but started to decrease starting from 2010 and this decrease became sharpest between 2014-2016; APC = -44.905%, 95%CI [-57.572- -28.457], P = .001). Mortality rates followed the same trend in both genders. Conclusions: Anal cancer incidence is increasing with significant increase in the incidence trend is noticed in females compared to males which is a change from the previous trend that was seen from 1973-2000. On the other hand, anal cancer mortality has started to decrease for the first time starting from 2010 with no difference in the mortality trend between males and females. This improvement in mortality rate can be explained by the improvement in early detection rate and possibly improvement in the treatment approach for these high-risk patients.

Racial disparities in the outcomes of transitional cell carcinoma of the bladder: A population-based analysis

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Background: Bladder cancer is the most common type of genitourinary malignancy and is the fourth most common cancer in men in the US. Transitional cell carcinoma (TCC) of the bladder accounts for most bladder cancer cases. Previous studies have observed racial disparities in the prognosis between white and black populations with very little mentioned about other ethnicities and race groups that are part of the United States population. We hereby, present a detailed and comprehensive analysis of racial disparities in TCC survival in the US. Methods: Using the data from surveillance Epidemiology and End results (SEER) database, we identified patients with TCC between 1992 and 2015. We used multivariable covariate-adjusted Cox models to analyze the overall and TCC-specific survival of patients according to their race. Results: We evaluated 176,388 patients with TCC and after we adjusted for age, sex, race, stage, grade, and undergoing cancer-targeted surgery, we found that Asians/Pacific Islanders and Hispanics had a better overall survival when compared to whites (HR= 0.792, 95% CI [0.761-0.824], P<.001 and HR = 0.941, 95% CI [0.909-0.974], P = .001, respectively). Asians/Pacific Islanders also showed better TCC specific survival (HR = 0.843, 95% CI [0.759-0.894], P<.001). Blacks had worse overall survival and TCC-specific survival (HR =1.221, 95% CI [1.181-1.262], P <.001 and HR =1.325, 95% CI [1.268- 1.384], P <.001, respectively). When stage IV TCC was analyzed separately, only Hispanics showed better overall and TCC specific survival when compared to whites (HR = 0.896, 95% CI [0.806-0.997], P = 0.044 and HR = 0.891, 95% CI [0.797-0.996], P = 0.42). Conclusions: Asians/Pacific Islanders have better overall and TCC-specific outcome while blacks have the worst outcome compared to whites. Hispanics have better overall and cancer specific survival in stage IV TCC. These disparities likely related to different and complex factors from lifestyle and chemical exposure to genetic factors. Further studies can help us more in understanding and approaching this malignancy in different race groups.

The impact of marital status on the survival of transitional cell carcinoma of the bladder

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Background: Marital status is one of the multiple lifestyle factors that affect the survival of several malignancies. Prior literature has demonstrated that married individuals have better survival in cases of transitional cell carcinoma (TCC). In this study, we aim to demonstrate the association in a large cohort of patients. Methods: Data of TCC patients with known marital status who were diagnosed between 1973 and 2015 in the US was obtained using the Surveillance Epidemiology and End Results (SEER) database. We compared the overall and cancer-specific survival of patients according to their marital status using Kaplan-Meier test and multivariable covariate-adjusted Cox models. Results: We reviewed 204,862 TCC patients, of which 64.26%, 10.64%, 1.01%, 7.31%, and 16.78% were married, single, separated, divorced, and widowed, respectively. Married patients had the highest overall survival (median 123 months), followed by single patients (median 111 months), divorced (median 102 months), separated (median 60 months), and widowed (median 43 months). Bladder cancer-specific survival followed relatively similar trends with married patients having significantly better survival when compared to other groups. When we adjusted for age, sex, race, stage, grade, and undergoing cancer-targeted surgery, married patients had better survival outcomes when compared to single patients (HR = 1.322, p-value < 0.001), separated patients (HR = 1.409, p-value < 0.001), divorced patients (HR = 1.358, p-value < 0.001), and widowed patients (HR = 1.242, p-value < 0.001). Conclusions: Our results demonstrate a clear survival advantage in cases of transitional cell carcinoma of the bladder with married individuals having the highest overall and cancer-specific median survival. These results shed the light on the lifestyle and the psychosocial factors, including the social support that married patients may have comparing to unmarried patients, and their effect on the disease prognosis and survival. Understanding the social and psychological factors associated with the observed disparity may help enhance management plans for affected patients.

Clinical outcome of patients diagnosed with myelodysplastic syndrome-unclassifiable (MDS-U): single center experience

Myelodysplastic syndrome unclassifiable (MDS-U) is a small subtype of myelodysplastic syndromes (MDS). However, rare literature exists in terms of natural progression and clinical outcome of patients with MDS-U. In the present study, we investigated the characteristics and the clinical outcomes of patients categorized as MDS-U based on 2008 World Health Organization criteria (WHO) in a single center comparing to other MDS groups. Out of eight hundred and two patients who met WHO criteria for MDS at our institution, ninety patients (11%) were initially classified as MDS-U. Upon pathological review, only half of the cases were confirmed to be MDS-U. With follow up, half of the MDS-U cases were reclassified to another subtype. We found neither significant difference in median overall survival nor in risk of transformation to acute myeloid leukemia when comparing MDS-U to other MDS groups. Additional larger studies are needed to confirm our results.

Cholinergic and peptidergic regulation of siphon/mantle function in the zebra mussel, Dreissena polymorpha

Neurotransmitter regulation of the siphon and adjacent mantle region of bivalves has not previously been examined. In the biofouling bivalve, Dreissena polymorpha, acetylcholine and FMRFamide both elicited contractions of siphon/mantle preparations. Hexamethonium bromide inhibited acetylcholine-elicited contractions but had no effect on FMRFamide-elicited contractions. FMRFamide-like immunoreactivity and chromatographic evidence for acetylcholine were found in central ganglia and the siphon/mantle region. Extracts of siphons, gonads, and gills, separated on Sephadex G-25, also contained macromolecules larger than acetylcholine and FMRFamide that caused siphon/mantle contraction. These results demonstrate regulation of contraction by several potential neurotransmitter agents in a new bivalve preparation, the siphon/mantle.