Prevalence and co-incidence of geriatric syndromes according to the ECOG performance status in older cancer patients

Background

Geriatric syndromes may be more common in older cancer patients than in those without cancer. Geriatric syndromes can cause poor clinical outcomes. The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) is often used as a clinically reported functional status score in oncology practice.

Methods

Our study was designed as a cross-sectional study and included 218 older cancer patients. This study aimed to determine the prevalence and relationship of geriatric syndromes according to the ECOG-PS in older cancer patients.

Results

The mean age of 218 participants was 73.0 ± 5.6 years, with 47.7% being women and 52.3% men in our study. ECOG-PS 0, 1, and 2 groups contained 51, 39, and 10% of the patients, respectively. The mean number of geriatric syndromes in the ECOG 0, 1, and 2 groups was 2.3 ± 2.2, 4.3 ± 2.4, and 5.7 ± 2.1, respectively (p < 0.001). After adjusting for age and sex, it was determined that dynapenia was 2.9 times, probable sarcopenia was 3.5 times, frailty was 4.2 times, depression was 2.6 times, malnutrition was 3.3 times, insomnia 2 was.2 times, falls was 2.5 times, and the risk of falling (TUG) was 2.4 times more likely in those with ECOG-PS 1 compared to those with ECOG-PS 0. In addition, it was found that dynapenia was 6 times, probable sarcopenia was 6.8 times, frailty was 10.8 times, depression was 3.3 times, malnutrition was 6.3 times, the risk of falling (Tinnetti Balance) was 28 times, and the risk of falling (TUG) was 13.6 times more likely in those with ECOG-PS 2 compared to those with ECOG-PS 0.

Conclusion

Our study found that the prevalence of geriatric syndromes increased as the ECOG-PS increased. Geriatric syndromes and their co-incidence were common in older cancer patients, even in normal performance status. Oncologists should incorporate geriatric syndromes into the decision-making process of cancer treatment to maximize the impact on clinical outcomes in older patients with cancer.

Local interventions for colorectal cancer metastases to liver and lung

BACKGROUND

Colorectal cancer is a common cause of cancer-related deaths. About 1/3 of all cases present with distant metastasis, with the liver as the leading site and the lung as the most common extra-abdominal site.

AIMS

It was aimed to evaluate the clinical characteristics and the outcomes of colorectal cancer patients with liver or lung metastasis who had received local treatments.

METHODS

This is a retrospective, cross-sectional, and descriptive study. The study was performed with colorectal cancer patients that referred to the medical oncology clinic of a university hospital between December 2013 and August 2021.

RESULTS

A total number of 122 patients who have received local treatments were included. Radiofrequency ablation was applied in 32 patients (26.2%), metastasis was surgically resected in 84 patients (68.9%), and stereotactic body radiotherapy was preferred in six patients (4.9%). At the first follow-up control after completion of local or multimodal treatment, no residual tumor was determined with radiological assessment in 88 patients (72.1%). The median progression-free survival (16.7 months vs 9.7 months) (p = .000) and the median overall survival (37.3 months vs 25.5 months) (p = .004) of these patients were significantly better than the patients with residual disease.

CONCLUSIONS

Local interventions that are applied to highly selected patients may improve the survival of metastatic colorectal cancer patients. A close follow-up after local therapies is important to diagnose recurrent disease because repeated local interventions may be possible to achieve better outcomes.

Differentiation of lung and breast cancer brain metastases: Comparison of texture analysis and deep convolutional neural networks

PURPOSE

Metastases are the most common neoplasm in the adult brain. In order to initiate the treatment, an extensive diagnostic workup is usually required. Radiomics is a discipline aimed at transforming visual data in radiological images into reliable diagnostic information. We aimed to examine the capability of deep learning methods to classify the origin of metastatic lesions in brain MRIs and compare the deep Convolutional Neural Network (CNN) methods with image texture based features.

METHODS

One hundred forty three patients with 157 metastatic brain tumors were included in the study. The statistical and texture based image features were extracted from metastatic tumors after manual segmentation process. Three powerful pre-trained CNN architectures and the texture-based features on both 2D and 3D tumor images were used to differentiate lung and breast metastases. Ten-fold cross-validation was used for evaluation. Accuracy, precision, recall, and area under curve (AUC) metrics were calculated to analyze the diagnostic performance.

RESULTS

The texture-based image features on 3D volumes achieved better discrimination results than 2D image features. The overall performance of CNN architectures with 3D inputs was higher than the texture-based features. Xception architecture, with 3D volumes as input, yielded the highest accuracy (0.85) while the AUC value was 0.84. The AUC values of VGG19 and the InceptionV3 architectures were 0.82 and 0.81, respectively.

CONCLUSION

CNNs achieved superior diagnostic performance in differentiating brain metastases from lung and breast malignancies than texture-based image features. Differentiation using 3D volumes as input exhibited a higher success rate than 2D sagittal images.

The risk of malnutrition and its clinical implications in older patients with cancer

AIM

Malnutrition is a common geriatric syndrome with multiple negative outcomes including mortality. However, there is a scarcity of literature that focuses on the relationship between malnutrition risk and its clinical implications on geriatric syndromes and mortality among cancer patients. The aim of this study is to determine the clinical importance of malnutrition risk in geriatric oncology practice.

METHOD

180 patients with cancer who were ≥ 65 years were included in the study. All patients were questioned in terms of geriatric syndromes, including polypharmacy, frailty, probable sarcopenia, fall risk, dynapenia, depression, cognitive impairment, insomnia, and excessive daytime sleepiness. Mini Nutritional Assessment scores > 23.5 and 17-23.5 were categorized as well-nourished and malnutrition risk, respectively.

RESULTS

Of the 180 patients (mean age 73.0 ± 5.6 years, female: 50%), the prevalence of malnutrition risk was 28.9%. There was no statistically significant difference between the groups in terms of age, gender, education, marital status, body mass index, and comorbidities except for chronic obstructive pulmonary disease (p > 0.05). After adjustment for age, sex, and body mass index; polypharmacy (odds ratio [OR]: 3.17; 95% confidence interval [CI], 1.48-6.81), reduced calf circumference (OR: 3.72; 95% CI, 1.22-11.38), fall risk (OR: 2.72; 95% CI, 1.03-7.23), depression (OR: 6.24; 95% CI, 2.75-14.18), insomnia (OR: 4.89; 95% CI, 2.16-11.05), and frailty (OR: 2.44; 95% CI, 1.75-3.40) were associated with malnutrition risk compared to well-nourished patients (p < 0.05). Median survival in patients with malnutrition risk was 21.3 months (range 14.1-28.4 95% CI) and median survival in patients who were defined as well nourished was not reached (p < 0.001).

CONCLUSION

The risk of malnutrition was associated with a higher risk for all-cause mortality in older patients with cancer, and was associated with many geriatric syndromes, including polypharmacy, fall risk, frailty, insomnia, and depression.

The correlation between skeletal muscle index and anxiety in patients with lung cancer on the first day of chemotherapy

Aim: To evaluate the relationship between anxiety and skeletal muscle index (SMI) levels in lung cancer patients on the first day of chemotherapy. Materials & methods: This cross-sectional study included 108 patients. We analyzed patient characteristics, SMI levels, pain status and predicted anxiety factors. Results: Anxiety was detected in 61% of patients. SMI levels were significantly lower in the high anxiety group than the low anxiety group (p < 0.001). A significant correlation was observed between anxiety and SMI levels (r = -0.292; p = 0.002). Anxiety levels were significantly correlated with trait anxiety (r = 0.618; p < 0.001) and visual analog scale-pain (r = 0.364; p < 0.001). SMI (odds ratio: 0.94), trait anxiety (odds ratio: 1.12) and visual analog scale pain (odds ratio: 1.28) were independent risk factors for anxiety after adjusting for sex, stage and Eastern Cooperative Oncology Group performance status. Conclusion: Our study highlighted that higher anxiety scores were significantly correlated with lower SMI levels. We found that SMI, pain and trait anxiety were independent risk factors for anxiety.

The effect of sarcopenia on erlotinib therapy in patients with metastatic lung adenocarcinoma

Erlotinib, a tyrosine kinase inhibitor, has been shown to improve the survival of patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer. Sarcopenia is a status with increasing importance in lung cancer, and it may predict a poor prognosis. We aimed to evaluate the impact of sarcopenia on erlotinib therapy and prognosis in patients with EGFR-mutated (exon 19 or 21 L858R) metastatic lung adenocarcinoma. Sarcopenia was defined as skeletal muscle index ≤39 cm2/m2 for women and ≤55 cm2/m2 for men. The patient characteristics, inflammation parameters, clinical and survival outcomes of the erlotinib therapy were examined according to sarcopenia status. We also analyzed the erlotinib treatment-related toxicity. Seventy-two patients were included in our retrospective study, and the mean age of the patients was 63.7 years. A total of 39 (54.2%) patients were diagnosed with sarcopenia. Patients with sarcopenia had a poor prognosis and had a shorter median progression-free survival (PFS) than patients without sarcopenia (10.5 months vs. 21.8 months, p=0.002). Sarcopenia (HR 2.08) and C-reactive protein > 6.5 mg/L (HR 2.57) were determined as independent poor prognostic factors for PFS of erlotinib therapy. Treatment-related toxicity occurred in 34.7% of patients treated with erlotinib, and sarcopenia did not significantly affect treatment-related toxicity. We also found that sarcopenia significantly affected the response to erlotinib. The expected survival outcomes may be low when erlotinib therapy is used in patients with sarcopenia and metastatic lung adenocarcinoma. This study showed that survival and clinical outcomes could be better predicted by detecting sarcopenia in patients with lung cancer using erlotinib.

The Efficacy of BNT162b2 (Pfizer-BioNTech) and CoronaVac Vaccines in Patients with Cancer

Although vaccination is efficacious and prevents infection in the general population, there is limited data about Coronavirus disease‐19 (Covid‐19) occurrence after vaccination in cancer patients. It was aimed to evaluate the efficacy of BNT162b2 (Pfizer–BioNTech) and CoronaVac vaccines against Covid‐19 in patients with cancer. In this single‐center, retrospective, cross‐sectional, and descriptive study, the data of cancer patients referred to the medical oncology clinic of a university hospital were analyzed. The sample of the study consisted of cancer patients who had Covid‐19 or were vaccinated against Covid‐19. A total number of 2578 patients were included in the study. Of the patients, 2000 have never been infected with severe acute respiratory syndrome coronavirus and 578 patients have had a positive reverse‐transcription polymerase chain reaction (RT‐PCR) for Covid‐19. It was found that 2094 patients (81.2%) were fully vaccinated, and 484 patients (18.8%) did not receive full‐dose vaccination. A statistically significant difference in Covid‐19 occurrence was found between the patients who had full‐dose vaccination or not (p = 0.000). In in‐group comparisons of full‐dose vaccinated patients, while no difference was observed between two doses of BNT162b2 (Pfizer–BioNTech) and three doses of CoronaVac (p = 0.432), a statistically significant difference was observed between all other groups (p < 0.005). When the data of 578 patients who experienced Covid‐19 was analyzed, a statistically significant difference was observed between the groups who were full‐dose vaccinated and those who were not (p = 0.000). It is recommended that this vulnerable patient group should be prioritized in vaccination programs, and full‐dose vaccination (at least two doses of vaccines) should be completed as soon as possible.

Efficacy and safety profile of COVID-19 vaccine in cancer patients: a prospective, multicenter cohort study

Aim: To compare the seropositivity rate of cancer patients with noncancer controls after inactive SARS-CoV-2 vaccination and evaluate the factors affecting seropositivity. Method: Spike IgG antibodies against SARS-CoV-2 were measured in blood samples of 776 cancer patients and 715 noncancer volunteers. An IgG level ≥50 AU/ml is accepted as seropositive. Results: The seropositivity rate was 85.2% in the patient group and 97.5% in the control group. The seropositivity rate and antibody levels were significantly lower in the patient group (p < 0.001). Age and chemotherapy were associated with lower seropositivity in cancer patients (p < 0.001). Conclusion: This study highlighted the efficacy and safety of the inactivated vaccine in cancer patients. Clinical Trials Registration: NCT04771559 (ClinicalTrials.gov).

Metastatic Breast Carcinoma Mimicking Urothelial Carcinoma

Besides being the most frequently diagnosed cancer in women, breast cancer is the main cause of cancer-related deaths in this group of patients. Breast cancer frequently metastasizes to bone, lung, brain, and liver. Renal metastasis from the breast is extremely rare. Here we aimed to report a case of breast cancer with metastasis to bone and left renal pelvis. A 58-year old woman with a mass lesion in the left renal pelvis that mimicked urothelial carcinoma was referred to our clinic. The left nephroureterectomy procedure was performed, and the pathology revealed that a renal pelvis metastasis secondary to breast cancer.

Efficacy of trastuzumab and potential risk factors on survival in patients with HER2-positive metastatic gastric cancer

Aim: To evaluate the efficacy of trastuzumab and potential risk factors on survival in patients with HER2-positive metastatic gastric cancer. Methods: We retrospectively included 138 patients who were given trastuzumab-based chemotherapy as first-line treatment and analyzed the relationship between clinical response rates and maintenance treatment status and survival outcomes. Results: In the whole group, the median progression-free survival and overall survival were 10.2 and 16 months, respectively. Clinical response was obtained in 79% of patients. The median overall survival was 16.9 months in follow-up group and 19.0 months in the maintenance group in patients with clinical response. Continuation of maintenance trastuzumab created a significant survival advantage (p = 0.021). Eastern Cooperative Oncology Group performance status 2 (hazard ratio [HR]: 2.02), grade 3 (HR: 1.78) and more than four metastatic lesions (HR: 1.67) were determined as risk factors for death. Conclusion: We recommend the continuation of maintenance trastuzumab in patients with clinical response, but those with identified risk factors may not benefit from treatment because life expectancy may be low.

A comparison of anticholinergic burden in older patients with and without cancer

Aim: To compare anticholinergic burden (ACB) in older patients with and without cancer and evaluate the effects of ACB on geriatric syndromes. Methods: A total of 291 patients from the geriatric clinic and 301 patients from the oncology clinic were evaluated. ACB <2 was categorized as low ACB and ACB ≥2 was categorized as high ACB. A comprehensive geriatric assessment was performed on patients from the geriatric clinic. Results: ACB scores were significantly higher in patients without cancer compared with those with cancer (p < 0.005). Number of falls and Geriatric Depression Scale 15 scores were higher and Mini-Nutritional Assessment and Barthel/Lawton activities of daily living scores were lower in geriatric patients with high ACB scores compared with those with low ACB scores (p < 0.005). Conclusion: It is crucial to understand the potential effects of ACB for rational drug use and optimum cancer management in older patients with cancer.

Is the Duration of Temozolomide Predictive for Sequential Bevacizumab Treatment Responses in the Glioblastoma Multiforme Cancer Setting?

OBJECTIVE

To evaluate the predictive significance of the duration of temozolomide (TMZ) in patients with glioblastoma multiforme (GBM) who were treated with bevacizumab (Beva) as second-line setting.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Bezmialem Vakif University School of Medicine Hospital, Istanbul, Turkey, from January 2014 to September 2020.

METHODOLOGY

A total of 109 patients, 47 (43.1%) females and 62 (56.9%) males, were retrospectively included in the study. All patients received TMZ as first-line and Beva as second-line treatment. Kaplan-Meier method and Cox regression model were performed for survival and univariate/multivariate analyses, respectively.

RESULTS

Patients treated with first-line TMZ were divided into two groups according to the PFS. Group 1 is <9 months and group 2 is ≥9 months. Overall survival (OS) of group 1 and group 2 patients was evaluated  after the initiation of second-line bevacizumab treatment. The OS in group 1 was 7.8 months (6.9-8.6, 95% CI), and group 2 was eight months (6.4-9.5, 95% CI), but it was statistically non-significant (p = 0.837).

CONCLUSION

Duration of first-line TMZ treatment was not a predictor for OS of the GBM patients, who were treated with Beva as second-line setting. Key Words: Bevacizumab, Duration of treatment, Glioblastoma multiforme, Predictive score, Temozolomide.

Anxiety levels of breast cancer patients in Turkey during the COVID-19 pandemic

Aim: To assess the anxiety levels of breast cancer patients during the COVID-19 pandemic. Materials & methods: A total of 298 patients completed the State-Trait Anxiety Inventory (STAI-S and STAI-T) and the Visual Analogue Scale for Anxiety (VAS) and VAS for Anxiety in COVID-19 (VAS-CoV). Results: 144 patients were in the high anxiety category for STAI-S, and 202 patients were in the high anxiety category for STAI-T. STAI-T score was significantly high in the metastatic group (p = 0.017). VAS-CoV score in the hormonotherapy group was significantly higher than in the no-treatment group (p = 0.023). There was a positive correlation between VAS-CoV and VAS levels (r = 0.708, p < 0.001), VAS-CoV and STAI-S and STAI-T scores (r = 0.402, p < 0.001; r = 0.185, p = 0.001, respectively), and a negative correlation between education years and STAI-T scores (r = -0.172, p = 0.003). Conclusion: The COVID-19 pandemic is related to high anxiety levels in breast cancer patients.

COVID-19 pandemic is related to rapidly rising anxiety levels worldwide. Because of the high mortality of COVID-19 in cancer patients, changing treatment routines and disruptions of the healthcare system, cancer patients are the most affected population in this situation. Anxiety among females and breast cancer patients tend to be high, although anxiety levels in cancer patients during the pandemic period varies according to the cancer type, treatment status and sociodemographic factors. This study assessed the effect of the COVID-19 pandemic on breast cancer patients' anxiety levels according to treatment status and stage of the disease. A total of 298 breast cancer patients completed the universally validated anxiety questionnaires. Results demonstrated high trait anxiety in breast cancer patients, particularly in the metastatic group. The current findings highlighted the importance of intensive assessment and close monitoring of breast cancer patients' psychological situations. It is crucial to provide psychological support to breast cancer patients to contribute to both treatment and follow-up processes during the pandemic.

Uncommon Testicular Germ Cell Tumor Thrombus in Azygos Vein Detected by FDG PET/CT

ABSTRACT

A 40-year old man admitted to the nuclear medicine department to undergo PET/CT for restaging of known testicular germ cell tumor. The patient had a history of orchiectomy for left testis and left nephrectomy with retroperitoneal lymph node dissection. Histopathology revealed testicular germ cell tumor. During the follow-up period, there is a rapidly expanding mass in posterior mediastinum. PET reveals increased FDG activity in the azygos vein. Contrast-enhanced CT of the thorax showed distended azygos vein with heterogeneously enhancing thrombus and peripheral fat stranding. Findings are consistent with azygos vein tumor thrombosis related to testicular germ cell tumor.

A case report of fulminant hepatitis due to ribociclib with confirmed by liver biopsy in breast cancer

INTRODUCTION

Breast cancer is the most frequently diagnosed cancer in women worldwide. Ribociclib is now frequently used in the treatment of metastatic hormone-positive and human epidermal growth factor receptor 2 (HER 2)-negative breast cancer.

CASE REPORT

A 54-year-old woman with breast cancer presented at a clinic in November 2017 with multiple lung and bone metastases. After receiving multiple lines of treatment due to disease progression, ribociclib and fulvestrant were initiated. Grade 4 toxicity was observed due to ribociclib during follow-up, and ribociclib was discontinued permanently.Management & Outcome: Given that liver transaminases and bilirubin elevation persisted despite discontinuation of the treatment, other reasons for liver toxicity were investigated. Abdominal MRI showed no liver metastases, although there was acute hepatitis. A liver biopsy was performed to determine the etiology. The pathology result was compatible with drug-induced acute fulminant toxic hepatitis. After liver biopsy, prednisolone treatment was initiated, after which the laboratory findings normalized.

DISCUSSION

Although there are reported cases showing improvement in liver enzymes after ribociclib discontinuation, in our case, no recovery from hepatotoxicity was noticed. The treatment was changed to another hormonal pathway therapy option, exemestane. To the best of our knowledge, this is the first case in the literature reporting this rare side effect of ribociclib, which is a liver biopsy-proven fulminant hepatitis.

Systemic Inflammatory Markers for Prediction of Bevacizumab Benefit in Glioblastoma Multiforme

OBJECTIVE

 To evaluate the predictive significance of systemic inflammation markers (SIMs) in patients with glioblastoma multiforme (GBM), who were treated with bevacizumab (Beva).

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

The study was conducted at the Bezmialem Vakif University School of Medicine Hospital, Istanbul, Turkey, from January 2014 to September 2019.

METHODOLOGY

A total of 107 patients, 49 (45.8%) female and 58 (54.2%) male, were retrospectively included in the study. The cut-off values for the SIMs-C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte (NLR) platelet to lymphocyte ratio (PLR), and systemic immune-inflammatory index (SIII))-were defined by receiver operating characteristic (ROC) analysis. Overall survival (OS) was plotted using the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis was performed for univariate and multivariate analyses.

RESULTS

ROC analysis was performed to determine the optimal prognostic value of each parameter. CAR: 1.32, NLR: 2.9, PLR: 159, and SIII: 785 were determined as cut-off values for predicting OS based on the areas under the curve (AUC) in the ROC analysis. CAR at 0.626, had sensitivity of 67%, and specificity of 71% (p=0.129); NLR at 0.725 had sensitivity of 67%, and specificity of 79% (p=0.007); PLR at 0.675 had sensitivity of 67%, and specificity of 64% (p=0.036); and SIII at 0.685, had sensitivity of 56%, and specificity of 71% (p=0.026). A multivariate analysis demonstrated that CAR (p=0.006) and PLR (p=0.024) were independent prognostic factors for OS in patients with GBM, treated by Beva.

CONCLUSION

 The present study's findings suggest that pretreatment CAR and PLR might be an independent predictive marker for patients with GBM, who are treated by Beva. Key Words: C-reactive protein-to-albumin ratio (AR), Glioblastoma multiforme, Neutrophil-to-lymphocyteratio (NLR), Platelet-to-lymphocyte ratio (PLR), Predictive score.