Subset Of Elderly Patients Research Articles

Clinical and Epidemiological Profile of Elderly Hodgkin's Lymphoma in India.

BackgroundHodgkin’s lymphoma (HL) is a curable malignancy that commonly involves the younger population. However, HL can rarely occur in the elderly population (≥60 years) and probably has different biology as compared to the younger counterparts. There was a paucity of data on the clinical and epidemiological profile of the elderly subset with HL in Indian patients who are misdiagnosed and empirically treated as tuberculosis. We have done an analysis of this subset of elderly patients who were registered at our institute.MethodsA retrospective chart analysis of HL patients who presented to our center from 2008 to 2016 was conducted. Twenty-eight patients with HL of age ≥60 years were included in this study.ResultsElderly HL comprised 18.67% of the total HL patients registered during this period. The majority were male patients, and the mean age of presentation was 65.9±5.6 years. A Charlson Comorbidity Index (CCI) of ≥2 was seen in 30.77% of the patients. Among these, 84.62% of the patients presented with advanced-stage disease, and 57.69% of the patients presented with B symptoms, which was significantly associated with a high-risk international prognostic score (IPS). Histology-wise, mixed cellularity classical Hodgkin’s lymphoma (MCCHL) and nodular sclerosis classical Hodgkin’s lymphoma (NSCHL) were equally represented (30.76%). Of the patients, 50% had extranodal disease, with the liver being the most frequent site involved. One patient each had bone marrow involvement and bulky disease. CD30, CD15, and CD20 positivity was seen in 84.61%, 50%, and 26.92% of cases, respectively.ConclusionAmong elderly HL patients, males were more commonly represented than females, and patients more often presented with advanced disease and B symptoms and less often with bulky disease and mediastinal mass. Mixed cellularity classical HL is more common in the elderly subset, and significant comorbidities are present in a higher number of elderly HL patients.

Older Patients Demonstrate PROMIS Outcomes Comparable to Younger Cohorts After Carpal Tunnel Release.

The utility of Patient-Reported Outcomes Measurement Information System (PROMIS) in monitoring clinical progress after carpal tunnel release (CTR) in patients of different ages remains unknown. We sought to evaluate early PROMIS scores in elderly patients (ie, those aged ≥65 years) after CTR and compare those with all younger patients after CTR. Patients presenting to a single academic medical center for CTR between September 2018 and January 2020 completed PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) computer adaptive tests and answered a single 5-point Likert-scale question evaluating subjective changes in their condition following CTR. Patients were divided into 3 age groups, and preoperative and postoperative PROMIS scores were compared. In all, 214 patients fit inclusion criteria: 86 aged 18-54 years, 71 aged 55-64 years, and 57 aged ≥65 years. Subjective improvement was reported in 70.9% (n = 61), 84.5% (n = 60), and 71.9% (n = 41) of patients aged ≤54, 55-64, and ≥65 years, respectively. Patients aged ≤54 years showed significantly worse UE scores (P = .02), whereas those aged 55-64 years demonstrated significant worsening in all 3 PROMIS domains (P < .01). Patients aged ≥65 years who reported subjective improvement after CTR demonstrated significant improvement in PI scores (P = .03), whereas significant worsening of all PROMIS scores was observed in the subset of patients aged 55-64 years who reported subjective improvement (P < .01, .04, and .04 for PF, PI, and UE, respectively). Younger patients showed worsening in PROMIS scores after CTR, whereas elderly patients did not show similar magnitude reductions in PROMIS scores. Moreover, the subset of elderly patients endorsing subjective improvement after CTR had reduced PI scores, consistent with less postoperative pain limitations.

Resistant fabric warming is a viable alternative to forced-air warming to prevent inadvertent perioperative hypothermia during hemiarthroplasty in the elderly

Surgical site infection (SSI) is associated with inadvertent perioperative hypothermia (IPH). This can be prevented by active patient warming. However, results from comparisons of warming techniques are conflicting. They are based mostly on elective surgery, are from small numbers of patients, and are dominated by the market leader, forced-air warming (FAW). Furthermore, the definition of hypothermia is debatable and systematic reviews of warming systems conclude that a stricter control of temperature is required to study the benefits of warming. To analyse core temperatures in detail in a large subset of elderly patients who took part in a randomized trial of patient warming following hemiarthroplasty who had received constant zero-flux thermometry to record their temperature. Regression models with a fixed effect for warming group and covariates related to temperature were compared for 257 participants randomized to FAW or resistant fabric warming (RFW) from a prior clinical trial. Those in the RFW group were-0.08°C cooler and had a cumulative hypothermia score-1.87 lower than those in the FAW group. There was no difference in the proportion of hypothermic patients at either <36.5°C or <36.0°C. This is the first study to provide accurate temperature measurements in patients undergoing a procedure predominantly under regional rather than general anaesthetic. It shows that RFW is a viable alternative to FAW for preventing IPH during hemiarthroplasty. Further studies are needed to measure the benefits of patient warming in terms of clinically important outcomes.

Acute myeloid leukaemia in patients we judge as being older and/or unfit.

The definition of older age in AML is arbitrary. In the context of the clinical studies, it starts with age ≥60 or ≥65years and in recent years ≥70 or 75, depending on the selection of the studied population. In clinical practice, with older age, we often mean that the patient is unfit for intensive chemotherapy. Higher age overlaps with categories such as worse performance status, unfitness, comorbidities, poor-risk cytogenetics, adverse mutation patterns, age-related clonal haematopoiesis and specific disease ontogeny. Intensive induction therapy can result in prolonged overall survival, at least in a subset of elderly patients aged up to 75years despite the reluctance of some physicians and patients to use treatment regimens perceived as toxic. Venetoclax and azacitidine combination is the new standard of comparison for persons unfit for intensive therapy. New oral hypomethylating agent CC-486 as maintenance therapy led to a prolonged overall survival in a randomized trial of patients ≥55years of age who were in first complete remission, but not eligible for allogeneic stem cell transplantation. Any therapy is better than no therapy, but a substantial proportion of older patients still receive only palliative care. Making a decision for AML diagnosed in older age should be individualized and shared through the dialog with the patient and relatives or cohabitants, considering medical issues and social factors including personal goals. Although we are witnesses of the advances in basic research and therapy, we are still a very long way from curing older patients with AML.

Autoreactive Peripheral Blood T Helper Cell Responses in Bullous Pemphigoid and Elderly Patients With Pruritic Disorders.

Bullous pemphigoid (BP) is a prototypic autoimmune disorder of the elderly, characterized by serum IgG autoantibodies, namely anti-BP180 and anti-BP230, directed against components of the basal membrane zone that lead to sub-epidermal loss of adhesion. Pruritus may be indicative of a pre-clinical stage of BP, since a subset of these patients shows serum IgG autoantibodies against BP230 and/or BP180 while chronic pruritus is increasingly common in the elderly population and is associated with a variety of dermatoses. Clinical and experimental evidence further suggests that pruritus of the elderly may be linked to autoimmunity with loss of self-tolerance against cutaneous autoantigens. Thus, the objective of this study was to determine autoreactive T cell responses against BP180 in elderly patients in comparison to patients with BP. A total of 22 elderly patients with pruritic disorders, 34 patients with bullous or non-bullous BP and 34 age-matched healthy controls were included in this study. The level of anti-BP180 and anti-BP230 IgG serum autoantibodies, Bullous Pemphigoid Disease Area Index (BPDAI), and pruritus severity were assessed for all patients and controls. For characterization of the autoreactive T cell response, peripheral blood mononuclear cells were stimulated ex vivo with recombinant BP180 proteins (NH2- and COOH-terminal domains) and the frequencies of BP180-specific T cells producing interferon-γ, interleukin (IL)-5 or IL-17 were subsequently determined by ELISpot assay. Patients with BP showed a mixed Th1/Th2 response against BP180 while autoreactive Th1 cells were identified in a minor subset of elderly patients with pruritic disorders. Furthermore, our T cell characterization revealed that therapeutic application of topical clobetasol propionate ointment in BP patients significantly reduced peripheral blood BP180-specific T cells, along with clinically improved symptoms, strongly suggesting a systemic immunosuppressive effect of this treatment.

Short- and long-term results after laparoscopic floppy Nissen fundoplication in elderly versus non-elderly patients.

Background:Laparoscopic anti-reflux surgery could be of benefit in a subset of elderly patients with gastroesophageal reflux disease. However, there are few reports that have evaluated the long-term results. This study examined the effects of age on the short- and long-term (for at least 5 years) outcomes after laparoscopic Nissen fundoplication (LNF).Patients and Methods:Patients were divided into four groups as follows: young (18–49); adult (50–69); and elderly (70–84), and very elderly (85–91). The database (recorded prospectively) included operating duration, conversion, intra- and early post-operative complication and late outcomes. Mean follow-up was 14.5 years (range 5–24 years).Results:Five hundred and sixty-nine patients met the inclusion criteria: young n = 219 (38.4%); adult n = 248 (43.5%); elderly n = 91 (16.0%) and very elderly n = 11 (1.9%). Hiatal hernia (type I and III) was significantly less frequent in young and adult patients (P < 0.0001). The operation was significantly longer in elderly and very elderly patients (P < 0.001); the use of drains (P < 0.001) and grafts (P < 0.0001) for hiatal hernia repair was less in young and adult patients. The hospital stay, conversion (5.4%), intra-operative and early post-operative complications were not influenced by age. Dysphagia was evenly distributed among the groups. Forty-eight (8.4%) patients had recurrence: 15 in the young group (6.8%), 18 in the adult group (7.2%), 11 in the elderly group (12%) and 4 in the very elderly group (36.3%) (P < 0.0001).Conclusions:Age does not influence short- and long-term outcomes following LNF. Control of reflux in the elderly is worse than adult patients. Therefore, ageing is a relative contraindication to LNF.

Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort

BackgroundEndovascular aneurysm repair (EVAR) has decreased the perioperative mortality for patients undergoing abdominal aortic aneurysm repair and has increased the rates of elective aneurysm repair in the elderly. However, Medicare will not cover abdominal aortic aneurysm screening for beneficiaries over 75 years of age. Consequently, abdominal aortic aneurysm treatment in this population depends on incidental detection. Targeted coverage for screening in this population, however, might be beneficial for a subgroup of patients. MethodsTo identify a subset of elderly patients who would potentially benefit from an expanded screening policy, we reviewed all patients greater than 75 years old undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2016. We used Cox regression with multivariable fractional polynomials to construct a risk model for 5-year survival in elderly patients to identify a subpopulation who might benefit the most from screening and performed internal validation using the bootstrapping technique. ResultsWe identified 10,676 patients greater than 75 years old undergoing elective EVAR. Although perioperative mortality varied with age, it was only 2.1% in the oldest group of patients (>85 years). Significant predictors included in our final risk model for 5-year survival in the elderly included age, aortic diameter, hemoglobin, current smoking, white race, body mass index, renal function, congestive heart failure, statin use, chronic obstructive pulmonary disease, and ejection fraction. The risk model produced risk scores ranging from a possible −2 to 33. The mean and median risk score were 6.9 and 6.0, respectively, with a right skew. We categorized the risk scores into four groups: −2 to 4 points, 5-8 points, 9-13 points, and more than 13 points, with associated 5-year survivals of 88%, 79%, 68%, and 49%, respectively. The model showed adequate discrimination and calibration, with a C-statistic of 0.69 and a calibration score of 0.99 (predicted 5-year survival of 0.78 compared with an observed 5-year survival of 0.77) and a Brier score of 0.15. Internal validation demonstrated an optimism-corrected C-statistic of 0.69 and a calibration slope of 1.0. ConclusionsElective EVAR in elderly patients chosen to undergo repair is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening into all but the highest risk group based on expected postoperative 5-year survival to justify removing this Medicare coverage restriction.

Pancreaticoduodenectomy is justified in a subset of elderly patients with pancreatic ductal adenocarcinoma: A population-based retrospective cohort study of 4,283 patients

BackgroundThe survival benefit of pancreaticoduodenectomy (PD) in elderly patients with pancreatic ductal adenocarcinoma (PDAC) is still unclear. MethodsData pertaining to elderly (age ≥75 years) and younger (age <75 years) patients with potentially curable PDAC who underwent pancreaticoduodenectomy in the period 2004–2013 were extracted from the Surveillance, Epidemiology, and End Results database. The Cox proportional hazards model and stratified Kaplan-Meier survival analyses were performed. ResultsA total of 4283 patients (3256 younger patients and 1027 elderly patients) were included. On multivariate analysis, advanced age (age ≥75 years) was not found to be an independent risk factor for diseases specific survival (DSS). Survival analysis disaggregated by gender, tumor size, American Joint Committee on Cancer stage, and tumor differentiation showed comparable DSS in younger and elderly patients (log-rank test). Among patients with poorly-differentiated or undifferentiated tumors, those in the elderly age-group experienced shorter DSS as compared to that of younger patients (poorly-differentiated: elderly vs. younger, 32.779 months vs. 42.198 months, P = 0.043; undifferentiated: elderly vs. younger, 17.500 months vs. 43.028 months, P = 0.210). However, PD was still warranted for elderly patients with poorly-differentiated tumors (surgery vs. without surgery, 32.779 months vs. 11.490 months, P < 0.001). Patients with undifferentiated tumors experienced a non-significant survival benefit after PD (surgery vs. without surgery, 17.500 months vs. 11.699 months, P = 0.330). ConclusionsAdvanced age (age ≥75 years) is not an independent risk factor for DSS. PD is justified in a subset of elderly PDAC patients; however, it should be performed in a high-volume center to minimize the risk of post operative complications. Future studies should explore individualized treatment strategies for elderly patients with undifferentiated tumors.

The genicular nerve: radiofrequency lesion application for chronic knee pain.

We investigated the short- and medium-term effectiveness of genicular nerve radiofrequency (RF) applied in patients with chronic knee pain due to osteoarthritis. Radiofrequency was performed in 49 patients with a diagnosis of knee osteoarthritis. VAS and WOMAC were measured at baseline and at 1, 4, and 12 weeks postprocedure. Under fluoroscopic guidance, the cannula was advanced percutaneously towards the area connecting the shaft to the epicondyle. The RF electrode was inserted through the cannula and the electrode tip temperature was raised to 80 °C for 90 s. One RF lesion was made for each genicular nerve. Mean patient age was 64 ± 10.6. VAS score before the procedures was 8.9 ± 0.8, while 1, 4, and 12 weeks after the procedure it was 4.73 ± 3.23, 3.89 ± 2.9, and 3.93 ± 2.95, respectively. WOMAC score before the procedures was 64.26 ± 7.29, while 1, 4, and 12 weeks after the procedures it was 44.93 ± 13.18, 42.81 ± 13.15, and 43.04 ± 13.36, respectively. RF neurotomy of genicular nerves led to significant pain reduction and functional improvement in a subset of elderly patients with chronic knee osteoarthritis pain, and thus may be an effective treatment in such cases.

Karyotype plus NPM1 mutation status defines a group of elderly patients with AML (≥60 years) who benefit from intensive post-induction consolidation therapy.

Although it is generally appreciated that a subset of elderly patients with acute myeloid leukemia (AML) may benefit from intensive consolidation, little is known about variables predicting such benefit. We analyzed 192 consecutive patients with de novo AML aged ≥60 years who were treated with intensive chemotherapy. About 115 patients (60%) achieved complete hematologic remission (CR). Among several parameters, the karyotype was the only independent variable predicting CR (P < 0.05). About 92% (105/115) of the CR-patients received up to four consolidation cycles of intermediate dose ARA-C. Median continuous CR (CCR) and disease-free survival (DFS) were 1.3 and 1.1 years, respectively. CCR, DFS, and survival at 5 years were 23%, 18%, and 15%, respectively. Only karyotype and mutated NPM1 (NPM1mut) were independent predictors of survival. NPM1mut showed a particular prognostic impact in patients with normal (CN) or non-monosomal (Mkneg) karyotype by Haemato-Oncology Foundation for Adults in the Netherlands (HOVON)-criteria, or intermediate karyotype by Southwest Oncology Group (SWOG)-criteria. The median CCR was 0.94, 1.6, 0.9, and 0.5 years for core-binding-factor, CN/Mkneg-NPM1mut, CN/Mkneg-NPM1-wild-type AML, and AML with monosomal karyotype, respectively, and the 5-year survival was 25%, 39%, 2%, and 0%, respectively (P < 0.05). Similar results (0.9, 1.5, 0.9, and 0.5 years) were obtained using modified SWOG criteria and NPM1 mutation status (P < 0.05). In summary, elderly patients with CN/Mkneg-NPM1mut or CBF AML can achieve long term CCR when treated with intensive induction and consolidation therapy whereas most elderly patients with CN/Mkneg-NPM1wt or Mkpos AML may not benefit from intensive chemotherapy. For these patients either hematopoietic-stem-cell-transplantation or alternative treatments have to be considered. Am. J. Hematol. 91:1239-1245, 2016. © 2016 Wiley Periodicals, Inc.

Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment

Background:Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.Methods:Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.Results:We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.Conclusion:Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

Abstract 10103: Improvement in Survival With Favorable Neurological Outcome in Elderly Japanese Patients With Out-of-Hospital Cardiac Arrest: A Nationwide Observational Cohort Study

Introduction: Although older age is associated with worse prognosis after cardiac arrest, little is known about the improvement in survival of very elderly patients with out-of hospital cardiac arrest (OHCA). Hypothesis: We aimed to evaluate the survival trends and predictors of favorable prognosis in this population. Method: We analyzed the records of 607,147 OHCA events obtained from a prospectively collected nationwide Utstein-style Japanese database from 2008 to 2012. The end-point was 1-month survival with favorable neurological outcome (Cerebral Performance Category Scale, category 1 or 2; CPC 1-2). Results: In total, 334,730 OHCA patients aged ≥75 years were eligible for analyses. The overall 1-month CPC 1-2 rate was 0.88% (2,933/334,730). OHCA aged 75-84 years had better 1-month CPC 1-2 rate than those ≥85years (1.18% [2,067/174,781] vs 0.54% [866/159,949], p &lt;0.0001). The 1-month CPC 1-2 rate improved in OHCA aged ≥75 years (0.73% [433/59,595] in 2008 to 0.96% [708/73,487] in 2012, p for trend &lt;0.001), even in only OHCA aged ≥85 years (0.42% [115/27,163] in 2008 to 0.65% [241/36,860] in 2012, p for trend &lt;0.0001). Multivariate logistic regression analysis indicated that bystander-witnessed arrest (adjusted odds ratio [aOR] 5.7, 95% confidential interval [CI] 5.2–6.3, p &lt;0.0001) and initial shockable rhythm (aOR 10.6, 95% CI 9.8–11.5, p &lt;0.0001) were significantly associated with 1-month CPC 1-2 rates of OHCA aged ≥75 years. OHCA with bystander witness and initial shockable rhythm had a higher 1-month CPC 1-2 rate than the others (11.14% [1,061/9,520] vs 0.58% [1,872/325,210], p &lt;0.0001, aOR 19.1, 95% CI 17.6–20.7, p &lt;0.0001). The 1-month CPC 1-2 rate of OHCA with initial unshockable rhythm also improved 0.42% (239/56,927) in 2008 to 0.60% (420/70,583) in 2012 (p for trend &lt;0.001); however, in OHCA without bystander witness, the 1-month CPC 1-2 rate did not improve between 2008 (0.19% [71/36,736]) and 2012 (0.28% [125/45,224]) (p for trend = 0.080). Conclusion: Data drawn from a large subset of elderly patients in Japanese registry suggest that rate of 1-month CPC 1-2 from OHCA have significantly improved during the study period; however, the OHCA outcome differed by bystander-witness and first documented rhythm.

High-Dose Chemotherapy with Autologous Stem Cell Transplantation for Elderly Patients with Relapsed/Refractory Diffuse Large B Cell Lymphoma: A Nationwide Retrospective Study

The number of elderly patients with diffuse large B cell lymphoma (DLBCL) continues to increase but the data regarding autologous stem cell transplantation (ASCT) for elderly patients are limited. We analyzed 484 patients, ages 60 years or over, diagnosed with relapsed/refractory DLBCL who received ASCT from 1993 to 2010 in the Japan Society for Hematopoietic Cell Transplantation database. Median age was 64 years (range, 60 to 78). To evaluate the impact of age at ASCT, patients were classified into 3 groups: those between the ages of 60 to 64, 65 to 69, and 70 years or over. Overall nonrelapse mortality (NRM) at day 100, 1 year, and 2 years was 4.1%, 5.9% and 7.7%, respectively. NRM did not significantly differ among age groups (P = .60). Two-year progression-free survival (PFS) and overall survival (OS) were 48% and 58%, respectively. PFS and OS were significantly longer in patients 60 to 64 years old; however, the survival rate was acceptable even in those 70 or over, with a 2-year OS of 46%. ASCT is feasible in selected elderly patients and age alone should not be a contraindication for ASCT. Eligibility should be individualized and identification of a subset of elderly patients at high risk of treatment-related morbidity or mortality warrants investigation.

Multiple primary melanomas: do they look the same?

A series of studies has investigated epidemiological, clinical and genetic characteristics of patients with multiple primary melanoma (MPM). However, comparison of the clinical and dermoscopic features of MPM within a given individual has been described only in case reports. To describe the dermoscopic features of MPM for each given patient, and to evaluate the characteristics eventually associated with similar or dissimilar appearance. From the databases of three skin-lesion clinics in the U.S.A., Italy and Spain we collected the dermoscopic images of melanomas in patients diagnosed with MPM. Among 58 patients with MPM, we found that 53% of patients had dermoscopically similar melanomas and 47% of patients had dermoscopically different melanomas. In older patients 59% of melanomas were dermoscopically similar vs. 47% in younger patients (P=0·377). Similar thickness was associated with the occurrence of dermoscopically similar melanomas (19/30 cases, 63%; P=0·039). Most (65%) of the synchronous lesions were similar, compared with 36% of nonsynchronous lesions (P=0·029), and most (69%) of the melanomas on sun-damaged skin were similar, vs. 37% of melanomas on nonsun-damaged skin (P=0·015; odds ratio 3·88, 95% confidence interval 1·11-13·98). The percentage of dermoscopically different melanomas was higher in patients with a family history of melanoma (67% vs. 48%). MPMs in a given patient have almost the same chance of looking dermoscopically similar or different. However, a subset of elderly patients with sun-damaged skin may present multiple, similar, thin melanomas characterized by pigment-network and regression structures.

A matched-pair comparison of intensity-modulated radiation therapy with cetuximab versus intensity-modulated radiation therapy with platinum-based chemotherapy for locally advanced head neck cancer

We retrospectively compared the efficacy of intensity-modulated radiotherapy (IMRT) and cetuximab (IMRT/cetuximab) versus IMRT and platinum-based chemotherapy (IMRT/platinum) for locally advanced head neck squamous cell carcinoma (LAHNSCC). Thirty-one IMRT/cetuximab patients were matched 1:2 with 62 IMRT/platinum patients according to primary site and clinical stage. The primary endpoint was locoregional recurrence (LRR), and secondary endpoints included distant metastasis (DM), cause-specific survival (CSS), and overall survival (OS). Because of inherent selection bias, the IMRT/cetuximab cohort was significantly older and with a higher Charlson Comorbidity Index. IMRT/cetuximab and IMRT/platinum did not have significantly different LRR and DM (33 vs. 23 % at 2 years, P = 0.22; 17 vs. 11 % at 2 years, P = 0.40; respectively). IMRT/cetuximab had significantly worse CSS and OS (67 vs. 84 %, P = 0.04; 58 vs. 83 %, P = 0.001; respectively). However, for the subset of elderly patients ≥65 years old, there is no difference between the two cohorts for all endpoints (all P = NS). IMRT/platinum should remain the preferred choice of chemoradiotherapy for LAHNSCC, but IMRT/cetuximab may be a reasonable alternative for elderly patients.

Prognostic risk score for the survival of elderly patients with acute myeloid leukaemia comprising comorbidities

Using various risk factor scores, we aimed to identify a subset of elderly patients with acute myeloid leukaemia (AML) for whom it was possible to assess the prognosis. We also aimed to develop a novel prognostic score system. This single centre study involved 102 patients of ≥60 years of age with non-promyelocytic AML. The adverse cytogenetic risk group appeared as the most significant independent prognostic factor for overall survival (OS). Our prognostic scoring system was developed after analysing prognostic risk factors and was applied for patients with favourable and intermediate (I and II) cytogenetic risk groups: age <65 years of age, normal lactate dehydrogenase (LDH) and a comorbidity score obtained applying the haematopoietic cell transplantation-specific comorbidity index (HCT-CI) < 3 = 0 points, in which age ≥65 years = 1 point and an elevated LDH score and HCT-CI ≥3 = 2 points. According to this prognostic model, patients without adverse cytogenetics were classified into three risk groups: favourable = 0-2 points, intermediate = 3-4 points and poor = > 4 points. The OS between these groups was highly significant (p < 0.001). The prognostic model developed in this study may refine the prognosis procedure of elderly AML patients without an adverse karyotype regarding OS, thereby guiding the treatment approach.

Imatinib (IM) and Interferon-Alpha (IFN-a) Maintenance Therapy Is Associated with Long-Term DFS in a Subset of Elderly Patients with Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ALL)

AbstractAbstract 1503▪▪This icon denotes a clinically relevant abstract Background:The frequent development of acquired resistance in patients with Ph+ALL initially responsive to tyrosine kinase inhibitor(TKI)-based regimens highlights the need for more effective post-remission therapy. Imatinib or dasatinib as single agents or combined with chemotherapy are commonly employed, but do not adequately prevent relapse. Interferon-alpha as treatment for bcr-abl positive leukemias has attracted renewed interest, fueled by preclinical observations suggesting that IFN-a may target leukemic stem cells. Proposed mechansims of IFN-a action include recruitment of dormant CML stem cells into the cell cycle, enhancing their susceptibility to eradication by TKIs. Whereas several recent randomized clinical studies in CML demonstrate greater efficacy of combined IFN-a and TKI compared to TKIs alone, no long-term clinical data on the combination of IFN-a and TKIs are available for patients with Ph+ALL. Aims:This prospective, open-label phase II study was designed to investigate the combination of low-dose IFN-a with imatinib mesylate (IM) 600mg daily as maintenance therapy in Ph+ALL patients in terms of hematologic and non-hematologic toxicity and the ability to adhere to the planned dose of the study drugs. In addition, we examined whether bcr-abl transcript levels and mutation status were predictive of relapse and remission duration. Outcome with study treatment is compared with that of patients with Ph+ALL who received the same initial therapy, followed by maintenance with imatinib alone. Patients and study design:Patients with Ph+ALL in first CR after receiving induction and consolidation chemotherapy according the GMALL protocol for elderly Ph+ALL who were not candidates for allogeneic stem cell transplantation (SCT). were eligible. MT consisted of IM at a single dose of 600 mg daily, combined with low dose subcutaneous interferon-alfa-2a (RoferonÒ) starting at 1 MU three times a week with dose escalation to a target dose of 3 MU three times a week as rapidly as tolerated. The trial was approved by the Ethics Committee of the University of Frankfurt, Germany. Results:19 elderly patients (median age 66 yrs; [60 – 75 yrs]) were enrolled in the combination study, 12 patients (median age 67 yrs; [58 – 75 yrs]) who received only IM as recommended MT after the same front-line therapy served as a control group. The median overall duration of MT is 26 mos. [3 – 110 mos]. Median overall survival for pts. receiving IM+ IFN-a is 5.4 yrs [2.5 – 11.4 yrs] vs. 2.9 yrs. [0.7 – 8.7 yrs] for pts. receiving IM alone (p=ns). For pts. receiving IM+ IFN-a, the median remission duration from start of maintenance is 2.2 yrs. [0.4–9.5 yrs] versus 0.75 yrs[0.1–7.6 yrs]. for patients receiving IM as MT (p=0.07).Three of 19 pts. are in ongoing CR 7.9, 8.6, and 10.4 years after start of maintenance. 4 pts. died in CR of causes unrelated to leukemia and 12 patients relapsed, 2 (16%) with isolated CNS involvement. Remission duration was independent of the number of previous cycles of intensive chemotherapy, of the MRD response during the first 6 mos. of intensive front-line therapy (16 mos. vs. 26 mos.) and of achievement of PCR negativity at any time during intial therapy. Surprisingly, the BCR-ABL transcript level at the start of MT likewise had no impact on time to disease recurrence. Prolonged MRD positivity without hematologic relapse occured in several patients. For pts. receiving IM as MT, 2 of 12 pts. are in ongoing CR 6.5 and 7.6 yrs. from start of maintenance. 2 of the 10 patients relapsed on MT with CNS involvement. Overall tolerability was acceptable, adverse events which lead to dose reductions for IFN-a were noted in 9 of 18 evaluable pts. Nine pts. suffered from moderate depression or fatigue. Hematologic toxicity during MT with IM+ IFN-a was mild with grade III cytopenia developing in only 2 pts. Conclusions:In elderly Ph+ALL pts. ineligible for allogeneic SCT, maintenance with IM in combination with low-dose IFN-a results in long-term sustained remissions in a substantial proportion of patients, with acceptable side effects. Surprisingly, the level of MRD was not predictive for remission duration. The lack of relationship between number of consolidation cycles and remission duration suggests IM+IFN-a MT may be effective even if started earlier during front-line therapy. Evaluation of the more potent 2nd generation TKI in combination with LD IFN-a as MT for Ph+ALL is warrented. Disclosures:Ottmann:Novartis: Honoraria, Research Funding; BMS: Honoraria, Research Funding.

Treatment of an elderly patient with hepatocellular carcinoma: Counseling from the patient's point of view

showed that older recipient age is associated with lowerposttransplant survival rates. These investigatorsdeveloped an older recipient prognostic score using 5factors: ventilator status, diabetes mellitus, hepatitis Cvirus, creatinine levels 1.6 mg/dL, and combinedrecipient and donor age 120 years. When the olderrecipient prognostic score was >2 points, the 5-yearsurvival rate was less than 50% (typically a barrierindicating a futile liver transplant). Lipshutz et al.

Improving results for coronary artery bypass graft surgery in the elderly

The proportion of elderly patients undergoing isolated coronary artery bypass grafting (CABG) surgery has steadily increased. We have evaluated temporal trends in hospital outcomes of patients who were 75 years and older undergoing CABG (1990-2010) at our institution. Data were collected prospectively for 3483 consecutive patients who were 75 years and older (median 78 years; range 75-94) undergoing isolated CABG at our institution over three time cohorts: 1990-96 (n = 817), 1997-2003 (n = 1534) and 2004-10 (n = 1132). Overall mortality declined from 6.0% (49/817) in the earliest era (1990-96) to 1.9% (22/1132) in the most recent era (2003-10; P < 0.001). Mortality in low-risk patients (elective, primary surgery with the ejection fraction >40%) was 5.9% (13/220), 0.8% (4/514) and 0% (0/411) in the first, second and third eras, respectively (P < 0.001). Despite the overall increase in comorbidities in our elderly patients, the prevalences of certain risk factors such as poor LV function, urgency of surgery and reoperation have all declined with time. The independent risk factors for mortality in our population were congestive heart failure, left main disease, earlier year of operation, reoperation, preoperative myocardial infarction, cardiopulmonary bypass time, emergent/urgent surgery and peripheral vascular disease. Of these, earlier year of operation (OR: 3.0; 95% CI: 1.8-5.2) was the most significant predictor. Also, age >80 did not predict mortality. The principle finding from this analysis is a contemporary low operative mortality for CABG in an elderly patient cohort. Risk of death is particularly low in a low-risk subset of elderly patients with reasonable LV function undergoing elective, primary CABG.

AML: Early indication that lenalidomide may help subset of elderly patients

AML: Early indication that lenalidomide may help subset of elderly patients