History Of Metastatic Cancer Research Articles

Unusual testicular metastatic localization of Ewing’s sarcoma: case report

BackgroundEwing’s sarcoma is a rare form of bone cancer that can also affect soft tissues. In some cases, it can spread to other parts of the body, including the testicles, causing testicular metastases. To our knowledge, no testicular metastasis of Ewing’s sarcoma has been reported in the literature.SummaryWe report an original case of an 18-year-old patient who presented with bilateral testicular masses revealing an exceptional metastasis of metastatic bone Ewing sarcoma under chemotherapy for one year. It was difficult to diagnose synchronous bilateral testicular metastases of Ewing’s sarcoma due to the low frequency of these metastases. However, given the history of metastatic cancer, the data from the clinical examination, and the results of ultrasound, it should be considered and included in the differential diagnosis.ConclusionDespite the uncommon occurrence of secondary testicular metastasis, it should be considered in the differential diagnosis when encountering such a clinical presentation.

Association of Laparoscopic Approach With Improved Short-Term Outcomes in Patients With Hematologic Malignancy Undergoing Splenectomy.

Patients with hematologic malignancies undergo splenectomy for both diagnostic and therapeutic purposes. Although minimally invasive surgery continues to be increasingly utilized for a variety of abdominal operations, no large-scale data has compared the postoperative outcomes for laparoscopic vs open splenectomy in patients with hematologic malignancy. Patients with a diagnosis of hematologic malignancy who underwent laparoscopic and open splenectomy between 2015 and 2020 were queried using the ACS-NSQIP database. 30-day outcomes of laparoscopic vs open splenectomy were compared. Out of 430 patients included in the study, 52.6% were male, with a mean age of 63.4 ± 13.1years. 233 patients (54.2%) underwent laparoscopic splenectomy. On bivariate analysis, laparoscopic surgery was associated with lower rates of 30-day mortality [2.1% vs 11.7% (P < .001)] and morbidity [9.0% vs 24.4% (P < .001)]. On multivariate regression, elective operations (OR .255, 95%CI: 0.084-.778, P = .016) and laparoscopic surgery (OR .239, 95%CI: 0.075-.760, P = .015) were independently associated with lower mortality, while history of metastatic cancer (OR 3.331, 95%CI: 1.144-9.699, P = .027) was associated with higher mortality. Laparoscopic surgery (OR .401, 95%CI: 0.209-.770, P = .006) and steroid use (OR 2.714, 95%CI: 1.279-5.757, P = .009) were the only two factors independently associated with 30-day morbidity. Laparoscopic surgery was also associated with shorter hospital length of stay (median 3 [IQR:3] vs 6 [IQR:7] days). Laparoscopic splenectomy was associated with lower 30-day mortality and morbidity, and shorter length of stay in patients with hematologic malignancies. These data suggest that laparoscopic approach, when feasible, may be preferred for splenectomy in this patient population.

Safety and efficacy of transcatheter edge-to-edge repair (TEER) in patients with history of cancer.

Surgical therapy has been a long-standing option for valvular heart disease, in patients with history of cancer, it carries an increased risk of complications. Transcatheter edge-to-edge repair (TEER) for mitral regurgitation, represents a less invasive option. However, patients with history of cancer have generally been excluded from trials. A retrospective cohort analysis was performed on de-identified, aggregate patient data from the TriNetX research network. Patients 18≥years of age, who had undergone TEER between January 1, 2013 and May 19, 2021, were identified using the CPT codes and divided into two cohorts based on a history of cancer. Subgroup analysis was performed based on history of systemic antineoplastic therapy. Odds ratio and log-rank test were used to compare the outcomes over 1 and 12-months. In matched cohorts (503 patients in each, mean age 77.7years, men 55 vs 58%, white 84 vs 87% in non-cancer and cancer cohorts respectively), the risk of heart failure exacerbation, all-cause mortality and all-cause hospitalizations were similar at 1 and 12months among patients undergoing TEER. Risk of major complications (ischemic stroke, blood product transfusion and cardiac tamponade) were also similar. In the cancer cohort, hematologic/lymphoid malignancies were the most common (28.0%) and 12.5% patients had a history of metastatic cancer. There was no significant difference in heart failure exacerbation or all-cause mortality based on history of systemic antineoplastic therapy. Overall outcomes following TEER are similar in patients with a history of cancer and should be considered in selected patients in this population.

Brain metastases as first manifestation of advanced cancer: exploratory analysis of 459 patients at a tertiary care center

Symptomatic brain metastases (BM) are a frequent and late complication in cancer patients. However, a subgroup of cancer patients presents with BM as the first symptom of metastatic cancer. Here we aimed to analyze the clinical course and prognostic factors of this particular BM patient population. Patients presenting with newly diagnosed BM without a history of metastatic cancer were identified from the Vienna Brain Metastasis Registry. Clinical characteristics and overall survival were retrieved by chart review. 459/2419 (19.0%) BM patients presented with BM as first symptom of advanced cancer. In 374/459 (81.5%) patients, an extracranial primary tumor, most commonly lung cancer, could be identified within 3 months after BM diagnosis. In 85/459 (18.5%) patients no extracranial primary tumor could be identified despite comprehensive diagnostic workup within the first 3 months after diagnosis of BM. Survival of patients with identified extracranial tumor differed only numerically from patients with cancer of unknown primary (CUP), however patients receiving targeted therapy after molecular workup showed significantly enhanced survival (20 months vs. 7 months; p = 0.003; log rank test). The GPA score showed a statistically significant association with median overall survival times in the CUP BM patients (class I: 46 months; class II: 7 months; class III: 4 months; class IV: 2 months; p < 0.001; log rank test). The GPA score has a strong prognostic value in patients with CUP BM and may be useful for patient stratification in the clinical setting. Comprehensive diagnostic workup including advanced imaging techniques and molecular tissue analyses appears to benefit patients by directing specific molecular targeted therapies.

Trastuzumab-Associated Posterior Reversible Encephalopathy Syndrome in a Patient With Metastatic Gastric Cancer

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome of seizures, headache, altered mental status and posterior cerebral white matter edema on neuroimaging. The exact pathophysiology of PRES is unclear. However, blood brain barrier vascular endothelial dysfunction has been proposed. Trastuzumab is rarely reported as a cause of PRES. To our knowledge, this is second reported case of trastuzumab-associated PRES, and the first case in a gastric cancer patient. Case summary: A 51-year-old female with a history of hypertension and stage 4, HER-2 positive, gastric adenocarcinoma with peritoneal, bone and lymph nodes metastasis. She presented with an episode of tonic clonic seizure. She did not have any previous history of seizures. The patient was diagnosed with stage 4 cancer two years ago. She was started on trastuzumab, cisplatin and capecitabine for 3 cycles and continued trastuzumab till her presentation (last cycle was 4 weeks prior to presentation). Her vital signs and labs are shown in table 1. A Brain MRI w/wo contrast (figure 1) showed bilateral, symmetric areas of T2 FLAIR hyperintensity involving the occipital and posterior parietal lobes. There was no evidence of acute stroke, intracranial hemorrhage or intracranial metastasis. This was suggestive of PRES. A multi-disciplinary discussion involved medicine, neurology and oncology teams decided that PRES could be due to the toxic effect of trastuzumab or hypertension. They decided to discharge patient on levetiracetam, continue trastuzumab, strictly control the BP and repeat the MRI in 3 months. During that period, the patient's BP was controlled on multiple encounters with all readings < 140/90. A repeated brain MRI w/wo contrast showed persistent T2 FLAIR hyperintensity in the occipital and posterior parietal lobes suggestive of PRES. Trastuzumab was held for 1 month. The patient was admitted shortly with worsening epigastric pain and concern of disease progression. An EGD (figure 2) showed a large, malignant looking, partially obstructing mass in the gastric body with no active bleeding. She died after 2 days of cardiac arrest. Conclusion: PRES has been reported with some chemotherapeutic protocols. Whether the toxic effect of the chemotherapy alone or history of metastatic cancer is responsible is not fully understood. It is extremely important to rule out other common causes of PRES, especially poorly controlled hypertension.Figure: Brain MRI w/wo contrast. A) T2-TSE, B) T2- FLAIR sequence. Showing a bilateral, symmetric areas of T2 FLAIR hyperintensity involving the posterior parietal and occipital lobes. There was no evidence of acute stroke, intracranial hemorrhage, hydrocephalus, dural venous sinuses thrombosis or intracranial metastatic disease.Figure: EGD showing a large malignant looking, friable, fungating, ulcerated mass in the gastric body.Table: Table. Patient's vital signs and laboratory workup

Index to Predict In-hospital Mortality in Older Adults after Non-traumatic Emergency Department Intubations.

IntroductionOur goal was to develop and validate an index to predict in-hospital mortality in older adults after non-traumatic emergency department (ED) intubations.MethodsWe used Vizient administrative data from hospitalizations of 22,374 adults ≥75 years who underwent non-traumatic ED intubation from 2008–2015 at nearly 300 U.S. hospitals to develop and validate an index to predict in-hospital mortality. We randomly selected one half of participants for the development cohort and one half for the validation cohort. Considering 25 potential predictors, we developed a multivariable logistic regression model using least absolute shrinkage and selection operator method to determine factors associated with in-hospital mortality. We calculated risk scores using points derived from the final model’s beta coefficients. To evaluate calibration and discrimination of the final model, we used Hosmer-Lemeshow chi-square test and receiver-operating characteristic analysis and compared mortality by risk groups in the development and validation cohorts.ResultsDeath during the index hospitalization occurred in 40% of cases. The final model included six variables: history of myocardial infarction, history of cerebrovascular disease, history of metastatic cancer, age, admission diagnosis of sepsis, and admission diagnosis of stroke/ intracranial hemorrhage. Those with low-risk scores (<6) had 31% risk of in-hospital mortality while those with high-risk scores (>10) had 58% risk of in-hospital mortality. The Hosmer-Lemeshow chi-square of the model was 6.47 (p=0.09), and the c-statistic was 0.62 in the validation cohort.ConclusionThe model may be useful in identifying older adults at high risk of death after ED intubation.

Effect of discharge to subacute rehabilitation (SAR) on hospitalized patients with progressive gastrointestinal (GI) cancer.

41 Background: SAR may be an alternative when hospice is declined. However, the outcomes of discharges to SAR in cancer patients with progressive (chemotherapy-refractory) disease are not known. We examined the characteristics and outcomes of patients with debility from progressive metastatic GI cancer who were discharged to SAR after an admission to our center. Methods: An institutional electronic database was queried to identify patients of the GI medical oncology service of Memorial Sloan Kettering Cancer Center who had been discharged to a SAR facility. Patient exclusion criteria were: incomplete follow-up, non-metastatic cancer, low grade neuroendocrine tumors, patients receiving first-line chemotherapy or with newly diagnosed cancer awaiting planned chemotherapy, patients off treatment with a remote history of metastatic cancer, and a primary admitting diagnosis representing an acute complication of cancer treatment. Results: From 2008-2014, 22 patients meeting criteria were identified. Median overall survival from the time of discharge to SAR was 0.8 months (range 0.2-5.2 months). Of the 22 patients, 7 (32%) died at the SAR. Twelve (55%) and 19 (86%) died within 1 and 3 months of discharge to SAR, respectively. For 7 patients (32%), documentation indicated that hospice, instead of SAR, had been recommended by clinicians but declined by family. Nine patients (41%) ultimately were transitioned to hospice within 3 months of discharge to SAR. Eight (36%) were readmitted to hospital within 1 month of discharge to SAR. Two (9%) were able to follow up with their medical oncologist for an outpatient appointment after discharge to SAR. None of the 22 patients received further chemotherapy after discharge to SAR. Conclusions: SAR is not a productive alternative to hospice in hospice-eligible patients with GI malignancies.In patients with metastatic GI cancers whose diseases had progressed beyond first-line therapy and who were hospitalized for reasons other than acute reversible toxicity, discharges to SAR were not associated with either prolonged survival or resumption of chemotherapy. These data can help inform decisions and establish goals of care in advanced GI cancer patients.

Abstract 158: Patient Characteristics Associated with Appropriate Use of Aldosterone Antagonist in a National Cohort of Veterans Hospitalized with Heart Failure

Background: Only 1 in 3 eligible Veterans receives an aldosterone antagonist (AA) after HF hospitalization. Our objective was to characterize the patient characteristics associated with appropriate AA prescription. Methods: From the VA External Peer Review Program, we identified a nationwide sample of Veterans with preexisting HF who were discharged from a VA hospital with a principal diagnosis of HF from 10/02 to 07/09. Patients were considered eligible for AA if they had LVEF ≤ 40%, serum creatinine ≤ 2.5 mg/dL for men/≤ 2.0 for women, serum potassium ≤ 5.0 meq/L, and were prescribed a beta-blocker or ACE-inhibitor or ARB at discharge. Patient demographics, vital signs, medications, labs, and coexisting illnesses were compared between patients who filled a prescription for an AA within 90 days of discharge versus those who did not. To examine patient-level predictors of aldosterone blocker fill among eligible patients, we used a generalized estimating equation adjusted for selected covariates to account for within hospital clustering. A backward selection procedure was used for covariate selection with a criterion of p&lt;0.10 for model entry and termination. Results: Of the total cohort (n=14,534), 64% (n=9,355) were eligible for an AA (mean age 70 years, mean serum creatinine 1.4 mg/dL, 70% white, 1% female). Beta-blocker and ACE/ARB use were each &gt; 90%. AA use was significantly associated (p&lt;.05) with younger age, black ethnicity, lower systolic BP, higher body mass index, hospitalization prior to 2008, lower comorbidity score, DM, liver disease, electrolyte disorders, depression, discharge prescription of loop or thiazide diuretics, beta blocker, warfarin, lower serum sodium, lower serum creatinine, and with having no history of metastatic cancer or drug abuse. Age and BP accounted for the greatest percentage of total variability in AA use. Conclusions: Patient characteristics associated with AA prescription were primarily clustered in the domains of age, ethnicity, HF severity-associated variables, potential contraindications, and comorbid conditions. It is unclear whether the association of increasing age with lower AA use is a disparity to be overcome or a safety concern. Certain patient characteristics, not previously reported, were found to be associated with AA use and may partially explain apparent gaps in appropriate use among Veterans.

Aerosolized granulocyte macrophage colony-stimulating factor (GM-CSF) therapy in metastatic cancer.

A recent phase I study of aerosolized granulocyte macrophage colony-stimulating factor (GM-CSF) in patients with malignant metastases to the lungs demonstrated excellent tolerance and possible efficacy. This therapy was offered to other patients who refused "standard" treatment or when no effective therapy was available. Forty-five patients were treated; 40 had pulmonary metastases. Aerosolized GM-CSF (250 microg/dose) was administered twice a day using a 1 week on, 1 week off schedule. The mean interval between diagnosis and therapy was 32 months. Twenty-four patients had disease stabilization or partial regression. The mean duration of benefit was 10 months. This benefit was noted in 8 of 13 with a sarcoma, 6 of 14 with melanoma, and 5 of 12 with renal cell carcinoma. Eighteen patients reported mostly self-limiting toxicities. The frequency of certain melanoma-specific T lymphocytes in 1 patient with stable disease was found to have increased 10-fold after therapy. Aerosolized GM-CSF appears to have limited but promising efficacy in treatment of pulmonary metastatic disease. In one patient, we have evidence of upregulation of melanoma-specific cytotoxic T-cells. Further study is warranted to understand the impact of this therapy on the natural history of metastatic cancer.

Acute Toxic Delirium

Acute Toxic Delirium