Months In Older Patients Research Articles

Symptomatic Waldenstrom's Macroglobulinemia (WM) in Young Patients: Disease Characteristics and Outcome.

Introduction: WM is a disease of the elderly with a median age of 70 years in most series. Advanced age is recognized as an adverse prognostic feature and age > 65 years has been included among the 5 adverse covariates in the recently reported International prognostic Scoring System for WM (Morel et al, ASH 2006). There is little information regarding the incidence of disease features and outcomes after treatment of young patients (≤ 50 years of age) with symptomatic WM.Patients and methods: Our database includes 220 patients with previously untreated, symptomatic WM. These patients were separated in two groups according to age ≤ 50 years and >50 years at the time of initiation of treatment. Clinical and laboratory characteristics, response to treatment, overall survival (OS) and disease-specific survival (DSS) were compared among the two groups.Results: Twenty-two patients (10%) were ≤ 50 years of age at the time of initiation of treatment. The incidence of clinical and laboratory features was similar among young and older patients: gender (p=0.3), B-symptoms (p=0.3), splenomegaly (p=0.9), lymphadenopathy (p=0.1), anemia (p=0.3), median serum IgM level (p=0.6), hyperviscosity syndrome (p=0.7), elevated β2-microglobulin (p=0.3) and IgM related disorders (p=0.6). primary treatment consisted of chlorambucil, nucleoside analogs or rituximab-based regimens with equal distribution among young and older patients. At least partial response was observed in 73% of young patients and in 57% of older patients (p=0.16). The median OS was not reached in young patients and it was 106 months in older patients (p=0.07). The median DSS was not reached in young patients and it was 116 months in older patients (p=0.2).Conclusion: 10% of patients with WM are ≤50 years at the time of treatment initiation. Their clinical and laboratory features and response to treatment are similar to those of older patients. Overall survival tend to be longer in young patients, but when deaths unrelated to WM or complications of treatment are excluded, survival times among young and older patients are similar.

CyberKnife Stereotactic Radiotherapy for Patients with Malignant Glioma

The CyberKnife is a new frameless image-guided radiosurgical modality. The authors report on their experience using the CyberKnife in 25 patients with malignant gliomas. Twenty-five patients with histologically proven malignant gliomas (18 glioblastoma: GB, 7 anaplastic astrocytoma: AA) were treated with the CyberKnife at Konan St. Hill Hospital between June 1998 and November 2002. CyberKnife therapy was performed on 44 lesions (31 GB lesions, 13 AA lesions) in the 25 patients. The median target volume was 19.1 mL (range: 0.3 - 90.2). The median prescribed dose was 20.3 Gy (range: 13.9 - 26.4). Patient-, tumor-, and treatment-related variables were analyzed by univariate analysis, and survival curves were generated by the Kaplan-Meier product limit. In the 18 GB patients, the median survival after diagnosis was 20.7 months (82.6 weeks) with a mean follow-up of 85.7 weeks. Of the 7 AA patients, 6 were alive at the time of analysis with follow-up periods ranging from 11.4 to 52.8 months. Patients younger than 70 years had a median survival after diagnosis of 37.1 months, compared to 12.4 months for older patients (p = 0.003). Similarly, patients with well-controlled lesions had a median survival after diagnosis of 39.8 months compared to 16.0 months for those with uncontrolled lesions (p = 0.031). Late delayed radiation necrosis was seen in 1 GB patient. No other patient suffered acute or delayed neurological morbidity after CyberKnife therapy. This is the first report of CyberKnife stereotactic radiotherapy applied to the treatment of malignant gliomas. The frameless and painless CyberKnife stereotactic radiotherapy has the potential to be as useful for treatment of malignant glioma as other radiosurgical modalities.

New Medicare Benefit Could Have Unexpected Treatment Consequences

New Medicare Benefit Could Have Unexpected Treatment Consequences

Prognostic Factors and Outcome of Older Patients with Symptomatic Multiple Myeloma: A Study of the Greek Myeloma Study Group (GMSG).

Introduction: Prospective randomized trials have shown that high dose therapy with autologous stem cell transplantation may improve the survival of patients with multiple myeloma (MM). This procedure is usually applied to patients ≤70 years of age. Nevertheless, many patients with MM are diagnosed at an older age and are usually treated with conventional chemotherapy. We performed a retrospective analysis in order to compare the prognostic factors and outcome of younger patients with myeloma (≤ 70 years) with those of older patients (>70 years). We also applied the recently proposed International Staging System (ISS) for multiple myeloma in the two groups of patients.Patients and Methods: Since 1987, 1162 patients with symptomatic myeloma requiring treatment have been included in the data base of GMSG. Patients with asymptomatic myeloma were not included. 357 patients (31%) were > 70 years at the time of initial treatment. Multiple clinical and laboratory variables were evaluated in patients >70 years of age and in younger patients. Furthermore, the same variables were assessed for possible correlation with prognosis in patients >70 years of age.Results: The only variable that was different between the two groups of patients was the ISS with older patients presenting more often with advanced ISS (p=0.02). Older patients received more often primary treatment with standard alkylating agents - corticosteroid combinations whereas younger patients received more often primary treatment based on high dose pulse dexamethasone (VAD etc) (p=0.001). Response to treatment was similar but patients ≤ 70 years had a median survival of 40 months versus 29 months for older patients (p<0.001). Variables associated with shorter survival for the group of older patients were: anemia, thrombocytopenia, hypercalcemia, renal impairment, more extensive bone marrow plasmacytosis, elevated serum LDH and advanced ISS (2+3). A Cox regression analysis showed, that adjusting for the effects of other factors, elevated LDH, bone marrow plasmacytosis and advanced ISS retained prognostic significance in this group of older patients (median survival of 12 months, 22 months and 21 months respectively). However patients >70 years of age with ISS 1 had a relatively long median survival of 55 months.Conclusions: The clinical and laboratory characteristics of older patients with MM are similar to those of younger patients but older patients tend to present with more advanced ISS. The survival of older patients is shorter than that of younger patients. Elevated serum LDH, advanced ISS, and increased bone marrow plasmacytosis may identify older patients with particularly bad prognosis. Older patients with poor prognosis should be entered into clinical trials in order to see if treatment with new agents or combinations would prolong their survival. The application of ISS in patients >70 years of age permitted the identification at diagnosis of a subgroup of patients with ISS 1 who had a relatively good prognosis.

Effects of Long-term Exercise Rehabilitation on Claudication Distances in Patients With Peripheral Arterial Disease: A Randomized Controlled Trial

To determine if improvements in physical function and peripheral circulation after 6 months of exercise rehabilitation could be sustained over a subsequent 12-month maintenance exercise program in older patients with intermittent claudication. Seventeen patients randomized to exercise rehabilitation and 14 patients randomized to usual care control completed this 18-month study. Patients exercised three times per week during the first 6 months of a progressive exercise program, followed by two times per week during the final 12 months of a maintenance program. Patients were studied at baseline, 6 months, and 18 months during the study. Eighteen months of exercise rehabilitation increased the initial claudication distance by 373 meters (189%) (P <.001), the absolute claudication distance by 358 meters (80%) (P <.001), walking economy by 11% (P <.001), 6-minute walk distance by 10% (P <.001), daily physical activity by 31%, and maximal calf blood flow by 18% (P <.001). These changes were similar to those found after 6 months of exercise rehabilitation (P = NS), and were significantly greater than the changes in the control group throughout the study (P <.05). Improvements in claudication distances, walking economy, 6-minute walk distance, physical activity level, and peripheral circulation after 6 months of exercise rehabilitation are sustained for an additional 12 months in older patients with intermittent claudication using a less frequent exercise maintenance program.

ENDOSCOPIC TREATMENT OF URINARY INCONTINENCE: LONG-TERM EVALUATION OF THE RESULTS

We report on the use of polydimethylsiloxane for endoscopic treatment of urinary incontinence in children with neurogenic bladder and discuss our results to determine optimal criteria for patient selection. A total of 44 children (19 males) have been treated endoscopically for urinary incontinence since 1995. Etiology was spina bifida in 35 cases. Previous surgery had been performed on 24 patients, including bladder neck reconstruction with (17) or without bladder augmentation. Mean patient age at injection was 13 years (range 7 to 17). A single transurethral injection was given in 23 cases, 2 in 17 and 3 or more in 4. Mean volume at each injection was 3.5 cc and for each patient the total volume injected was 5.7 cc. Mean delay between 2 injections was 6 months (range 3 to 15). Followup ranged from 6 to 53 months (median 28). Of the patients 15 (34%) are dry (continent greater than 4 hours, no urinary pad during the day), 11 (25%) are improved (continent 2 to 3 hours, occasional pad) and 18 had poor results. In the entire series only gender and preoperative hyperactivity influenced the results, as the best results were achieved in females with a stable bladder (44% of girls versus 21% of boys were cured). Good results persisted at 12-month followup in patients treated with only 1 injection (until 36 months for older patients) and after the last of 2 injections. Of the patients treated with 3 or more injections 1 was dry at 12-month followup and treatment failed in 3. Injection of polydimethylsiloxane at the bladder neck achieved continence in 34% of neurogenic bladder cases. Results were better in girls with a stable bladder. Results deteriorated in the first 12 months of followup. No more than 3 injections are advised if a satisfactory result is not achieved.

ENDOSCOPIC TREATMENT OF URINARY INCONTINENCE: LONG-TERM EVALUATION OF THE RESULTS

We report on the use of polydimethylsiloxane for endoscopic treatment of urinary incontinence in children with neurogenic bladder and discuss our results to determine optimal criteria for patient selection. A total of 44 children (19 males) have been treated endoscopically for urinary incontinence since 1995. Etiology was spina bifida in 35 cases. Previous surgery had been performed on 24 patients, including bladder neck reconstruction with (17) or without bladder augmentation. Mean patient age at injection was 13 years (range 7 to 17). A single transurethral injection was given in 23 cases, 2 in 17 and 3 or more in 4. Mean volume at each injection was 3.5 cc and for each patient the total volume injected was 5.7 cc. Mean delay between 2 injections was 6 months (range 3 to 15). Followup ranged from 6 to 53 months (median 28). Of the patients 15 (34%) are dry (continent greater than 4 hours, no urinary pad during the day), 11 (25%) are improved (continent 2 to 3 hours, occasional pad) and 18 had poor results. In the entire series only gender and preoperative hyperactivity influenced the results, as the best results were achieved in females with a stable bladder (44% of girls versus 21% of boys were cured). Good results persisted at 12-month followup in patients treated with only 1 injection (until 36 months for older patients) and after the last of 2 injections. Of the patients treated with 3 or more injections 1 was dry at 12-month followup and treatment failed in 3. Injection of polydimethylsiloxane at the bladder neck achieved continence in 34% of neurogenic bladder cases. Results were better in girls with a stable bladder. Results deteriorated in the first 12 months of followup. No more than 3 injections are advised if a satisfactory result is not achieved.

Internal Low Energy Atrial Cardioversion: Efficacy and Safety in Older Patients with Chronic Persistent Atrial Fibrillation

Low-energy internal atrial cardioversion is a relatively new technique based on delivery of intracardiac shocks through transvenous catheters placed into the atria or the vessels. The aim of this study was to assess in older and younger patients with chronic persistent atrial fibrillation (AF) the efficacy and safety of transvenous low-energy internal atrial cardioversion performed without routine administration of sedatives or anesthetics. A prospective longitudinal study. A cardiological university hospital. 82 patients, divided into older (> or = 60 years) (n = 49) and younger (n = 33) subjects. Atrial defibrillation threshold for internal cardioversion, measured as leading edge voltage (V) and delivered energy (J) of effective shocks, percentage of patients maintaining sinus rhythm at short-term (within 3 days) and at long-term follow-up. Patients with chronic persistent AF, treated with oral anticoagulants for at least 3 to 4 weeks, were admitted to hospital. Following a clinical work-up, patients were subjected to low-energy internal atrial cardioversion with shock delivery according to a step-up protocol. Internal cardioversion was effective in restoring sinus rhythm in 90% (44/49) of the older patients and in 94% (31/33) of the younger patients. Shocks were effective at a mean energy between 6 and 8 joules (range 0.9-23) and administration of sedatives or anesthetics was required during the procedure in 22% (11/49) of older and in 48% (16/33) of younger patients (P = .026 at chi-square). No major complications occurred during the procedure. Pharmacological prophylaxis of AF recurrences was instituted immediately following the procedure. During inhospital stay and during the follow-up (mean 12 +/- 9 months for older patients and 15 +/- 10 months for younger patients), AF recurred in 39% (17/44) of older patients and in 16% (5/31) of younger subjects (P = .064 at chi-square). Internal low energy cardioversion is a very effective procedure for restoring sinus rhythm in patients with AF; it can be performed in older patients, and administration of sedatives or anesthetics can be avoided or minimized in a substantial proportion of subjects. Recurrences of AF in the long term tend to be higher in older subjects and intensive prophylaxis with antiarrhythmic drugs is required.

Lung Cancer in Patients < 50 Years of Age: The Experience of an Academic Multidisciplinary Program

To determine if the clinicopathologic features and survival of lung cancer patients < 50 years of age differ from those of older patients. Retrospective review of patients with primary bronchogenic carcinoma diagnosed at a single, multidisciplinary cancer center. A National Cancer Institute-designated comprehensive cancer center in urban Detroit, MI. All patients with primary bronchogenic carcinoma evaluated in the Multidisciplinary Lung Cancer Clinic at the Barbara Ann Karmanos Cancer Institute between 1990 and 1993. Of 1,012 patients with lung cancer, 126 (12.5%) were < 50 years old at diagnosis, with a median age of 44 years. The median age of the 886 patients > or = 50 years of age was 65 years. The gender (p = 0.08) and racial (p = 0.12) characteristics of the younger and older patient groups were not significantly different. More than 90% of patients in both groups were smokers. The incidence of adenocarcinoma was significantly higher in younger patients (48.4% vs 36.0%, p < 0.001), and early-stage disease was less frequently diagnosed in younger patients (4.8% vs 19.7%, p < 0.001). Younger patients were more likely than older patients to undergo treatment, including surgery and combined-modality therapy (p < 0.001). Median survival was 13 months in younger and 9 months in older patients, while overall survival was similar in younger and older patients (p = 0.13). Although younger patients with lung cancer present with more advanced-stage disease, their overall survival is similar to that of older patients, suggesting that lung cancer is not an inherently more aggressive disease in patients < 50 years of age.