Perioperative anesthetic management of very long-chain acyl-coenzyme a dehydrogenase deficiency

Very long-chain acyl-coenzyme A dehydrogenase deficiency is a rare disorder of β-oxidation fatty acid metabolism that results in susceptibility to hypoglycemia, liver failure, cardiomyopathy and rhabdomyolysis during catabolic situations. We report the case of a 10-year-old male undergoing a totally implanted central venous catheter placement during hospitalisation for rhabdomyolysis, who was successfully managed with general anesthesia with nitrous oxide, sevoflurane and remifentanil. No hypoglycemia occurred and creatine kinase levels did not increase in the perioperative period. We describe the challenges encountered and the strategies used to avoid further decompensation of the disease due to surgical stress.

Survival Disparities of Diffuse Large B-Cell Lymphoma in a Community-Based Inner-City Cancer Center

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) comprises approximately 30% of all non-Hodgkin lymphomas. Multiple studies have demonstrated race-based disparities in survival among patients with DLBCL across all stages of disease, in the era both before and after rituximab. The etiology for the racial disparities in survival among patients with DLBCL is still unknown. Moreover, the Revised International Prognostic Index (R-IPI), a tool that predicts the DLBCL patients' outcome, has not yet been validated in African Americans (AA).

PATIENTS AND METHODS

We conducted a cohort study of patients diagnosed with DLBCL from January 1, 2007, to December 31, 2017, from our tumor registry in a single community-based inner-city cancer center. We abstracted demographic, clinical, histopathologic, treatment, and R-IPI variables. A total of 181 patients (47.5%) with biopsy-proven DLBCL were included in the retrospective analysis. The median age was 65 years, 47% were men, 41% were AA, and 44% were white.

RESULTS

The AA group had a younger median age, higher lactate dehydrogenase levels, higher frequency of B symptoms, and higher HIV infection than the non-AA group. The AA group had significantly decreased median overall survival than the non-AA group (15.7 months; 95% confidence interval, 10.3 to 23.9, vs. 93.6 months; 95% confidence interval, 61.5 to 142.6, respectively; P < .001). The survival disparities persisted after excluding patients with HIV and who did not receive chemotherapy. In addition, AA race predicts a reduced survival by univariate and multivariate analysis.

CONCLUSION

AA with DLBCL may have a poorer prognosis than the non-AA population. Further studies should investigate the biology of DLBCL in the AA population.

Case Report: IgG multiple myeloma and chronic myeloid leukemia in a single patient

A 58-year-old man presented with recurrence of chronic myeloid leukemia (CML) after complete molecular remission in the setting of non-compliance with imatinib. He was restarted on imatinib and was also noted to have IgG kappa monoclonal gammopathy of undetermined significance (MGUS). The patient re-achieved molecular remission after resumption of imatinib, but his MGUS progressed to smoldering myeloma and he was eventually diagnosed with multiple myeloma (MM) and initiated on treatment for MM with thalidomide, bortezomib and dexamethasone. He has responded well to treatment of the myeloma and continues concurrent maintenance imatinib treatment for CML and is being evaluated for bone marrow transplant. The association of two concurrent hematological malignancies, CML and MM, is very rare and has been infrequently reported in literature. The pathophysiology of this has not yet been fully understood. This case report reviews the various theories to explain this and discusses the potential challenges of simultaneous treatment of MM and CML.

Metastatic clear cell endometrial carcinoma: an unusual cause of a common clinical presentation

A 60-year-old woman presented with melena for 2 weeks. She had undergone hysterectomy and bilateral salpingo-oophorectomy to treat clear cell endometrial carcinoma 10 months before the presentation. She was anaemic and tachycardic; abdominal CT scan revealed a large duodenal mass. Her gastrointestinal bleed was not amenable to endoscopic intervention, so she had emergent laparotomy, pancreaticoduodenectomy with duodenal mass excision. Histopathology confirmed that the duodenal mass was a metastatic deposit from her clear cell endometrial cancer. Postoperatively, she was frail and chose hospice care and she died 90 days postoperatively. Clear cell endometrial cancer is a rare subtype of endometrial cancer, that has a worse prognosis compared with the more common endometrioid subtype. The duodenum is a rare site for metastatic endometrial cancer, and we report this case to alert clinicians to the possibility of metastases to the small intestine in patients with clear cell endometrial cancer.

Abstract A096: Smartphone use and accessibility to Internet by cancer patients in a socioeconomically diverse community

Introduction: Hospitals are increasingly using different patient engagement platforms to improve patient education, engagement, and satisfaction. Most of these patient engagement platforms are smartphone based. This requires patient awareness and understanding of basic technology. Einstein Medical Center serves a large socioeconomically and racially diverse population in North Philadelphia. We undertook a feasibility study before introducing any patient education/engagement platforms in our population. Our primary objective was to assess the use of smartphones and Internet by cancer patients in a socioeconomically diverse population. Our secondary objective was to assess feasibility of introducing technological platforms to improve patient education, engagement and satisfaction.

Methods: A onetime cross-sectional survey of patients attending the outpatient clinic and infusion center were interviewed by a trained interviewer during a one-week period in July 2018. The questionnaire was designed to assess demographic information, questions related to patients' smartphone and Internet availability, and use for health.

Results: We surveyed 75 patients in one week (N=75). Their ages ranged from 21 to 91 years old. There were 25 (33.3%) male and 50 (66.7%) female patients. Around 32 patients had at least a college education and 42 had a high school level education or less. 53 (71.6%) patients owned a smartphone and all of those owners could browse the Internet and download applications on their phone. 20 (26.67%) patients used an iPhone platform and 34 (45.33%) patients used an Android smartphone. Most of the patients who had a smartphone were willing to download applications that can help monitor their cancer and health.

Conclusion: Though our hospital is located in a socioeconomically disadvantaged area, the vast majority of patients own a smartphone and are willing to use them to monitor their cancer care. We can confidently use this technological advancement to help improve patient education, engagement, and satisfaction in this setting.

Note: This abstract was not presented at the conference.

Citation Format: Rashmika R. Potdar, Arun Thomas, Claudia Dourado, Kamran Mohiuddin, Djeneba Audrey M. Djibo, John C. Leighton, Jean G. Ford. Smartphone use and accessibility to Internet by cancer patients in a socioeconomically diverse community [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A096.

Development of new cold antibodies in a patient with a history of warm autoimmune haemolytic anaemia

A 31-year-old male presented to our facility with complaints of shortness of breath and left-sided chest pain. On record review, it was revealed that he had been seen in 2014 for an almost identical presentation and had been found to have haemolytic anaemia with warm autoantibodies. Following his acute treatment during that hospital admission, he was lost to follow-up. During his subsequent admission, 5 years later, he was found to have a systemic autoimmune disorder with a superimposed acute bacterial infection leading to a second case of haemolytic anaemia and at this time with both cold and warm antibodies present. While his diagnosis was initially difficult to make due to both derangements in expected laboratory values and the mixed pattern of the haemolytic anaemia, he was promptly treated with intravenous immune globulin and steroids and was able to make a full recovery.

Prognostic Significance of Dementia in Older Adults with Solid Tumors

BACKGROUND

The public health burden of cancer and dementia in the geriatric population is well documented. There is limited data on how dementia predicts mortality among geriatric patients with solid tumors. The objective of this study is to determine the prognostic significance of dementia on survival in patients with solid tumors.

METHODS

We performed a 5-year retrospective study on elderly subjects aged ≥60 years with and without dementia that were diagnosed with solid tumors.

RESULTS

Among 3,460 patients with solid tumors, 132 (3.8%) patients were found to have dementia. The median age at diagnosis was 71 years. Kaplan-Meier curves demonstrated that patients with dementia had an inferior median survival compared to the nondemented group (30 vs. 56 months; log-rank p < 0.001). Cox proportional hazard regression modeling identified age >80 years, female gender, diabetes mellitus, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, dementia, and radiation therapy as risk factors for decreased overall survival.

CONCLUSIONS

We demonstrated that dementia is associated with shorter overall survival in elderly patients with solid tumors.

Clinical outcomes of African American patients with advanced or metastatic non-small cell lung cancer on Nivolumab in a single community-based cancer center

African Americans (AA) have the highest incidence and mortality rates with lung cancer. They are diagnosed at an earlier age with more advanced disease. Programmed cell death protein-1 inhibitor, Nivolumab, was approved as a second-line agent after failure of platinum-based therapy for advanced or metastatic non-small cell lung cancer (NSCLC). The original studies leading to the approval of Nivolumab had insufficient AA patients, thus there is still inadequate knowledge on treatment outcomes among AA patients. Our primary study endpoints were to determine the median overall survival, 1-year overall survival rate, median progression-free survival, and 1-year progression-free survival rate of patients with advanced or metastatic non-small cell lung cancer on Nivolumab. Our secondary study endpoints were to determine the overall tumor response rate, median time to response, median duration of response, and incidence of treatment-related adverse events of grade 3 or 4. In this retrospective study, we reviewed the charts of 38 patients, 29 of which were AA, with advanced or metastatic NSCLC who received Nivolumab from March 1, 2015 until November 30, 2017 from a single community-based cancer center and compared our results with historical data. Adenocarcinoma was the most common histology (71%) among all patients. Seven (18%) continued to use Nivolumab while 21 (55%) discontinued the treatment mainly due to progression of the disease. The median overall survival was 21.4 months (95% CI 13.5-27.4) and 17.6 months (95% CI 11.5-27.6) for all the patients and AA, respectively. Both have statistically significant difference (P < 0.001) compared to the historical studies of Borghaei et al. and Brahmer et al. At 1 year, the overall survival rate was 73% (95% CI 50-86) and 66% (95% CI 40-82) for all patients and AA, respectively. The median progression-free survival was also statistically significant (P < 0.001) between all the patients 6.3 months (95% CI 2.8-8), AA 6.0 months (95% CI 2.3-8.0), and the said historical studies. The 1-year progression-free survival rate was 23% (95% CI 10-39) and 28% (95% CI 12-47) for all patients and AA, respectively. Overall tumor response rate which includes complete and partial responses was 21% (95% CI 10-37) and 24% (95% CI 10-43) for all patients and AA, respectively. The median time to response was 3 and 2.8 months for all patients and AA, respectively. The median duration of response was 3.8 and 4.0 months for all patients and AA, respectively. Treatment-related adverse events of grade 3 or 4 were reported in 8 and 10% in all patients and AA, respectively, similar to the rates previously shown. AA patients with advanced or metastatic NSCLC on Nivolumab had increased overall survival and progression-free survival with similar grade 3 or 4 treatment-related adverse events. Providing adequate access to immunotherapy is indispensable to maximize survival benefit for AA patients.

Role of Immune Checkpoint Inhibitors in Advanced or Recurrent Endometrial Cancer

Currently, treatment options for patients with advanced or recurrent endometrial cancer remain limited. The current standard of care treatment for advanced endometrial carcinoma is a platinum doublet chemotherapy. Second-line treatment options overall are very limited. There is no optimal treatment option for patients who show disease progression with first-line therapy. Therefore, novel and more efficacious therapies for patients with advanced or recurrent disease are needed. Immune checkpoint inhibitors have demonstrated a very impressive safety profile and anti-tumor activity in patients with programmed death-ligand 1 (PD-L1) positive endometrial cancer who were pre-treated with chemotherapy. We have done a detailed review of the literature to emphasize the role of immune checkpoint inhibitors in the treatment of metastatic or recurrent endometrial cancer.

Erdheim-Chester disease, moving away from the orphan diseases: A case report

With approximately 750 cases reported, Erdheim-Chester disease is an exceedingly rare histiocyte cell disorder. Affected sites typically include long bones, large vessels and central nervous system. However, cutaneous and pulmonary involvement can also occur. The diagnosis is ascertained by identification of foamy histiocytes positive for CD68, CD163, and factor XIIIa on immunoperoxidase staining. Recently published literature have described an association between Erdheim-Chester disease and BRAF V600E mutation. This finding prompted the investigation of therapeutic possibilities with BRAF inhibitors, successful agents against other BRAF mutation-positive diseases. Vemurafenib, a BRAF kinase inhibitor, has been shown to be effective in BRAF V600E mutation-positive malignancies, such as NSCLC and melanoma, as well as in several case reports of Erdheim-Chester disease. We report a case of Erdheim-Chester disease diagnosed at our institution, treated with vemurafenib.

Latex agglutination test for the detection of urinary antigens in visceral leishmaniasis

This paper describes a new latex agglutination test ('KATEX') for the detection of leishmanial antigen in the urine of patients with visceral leishmaniasis. In preliminary laboratory trials, using urine collected from well-defined cases and controls from Brazil, Yemen and Nepal, the test had 100% specificity and a sensitivity between 68 and 100%. When used in a time-course experiment in cotton rats infected with Leishmania donovani, the test became positive 1 week after inoculation and antigen levels in urine declined rapidly after chemotherapy (the test was negative before the end of the course of treatment). Finally, in an integrated study performed in Sudan, KATEX was compared to microscopy and four different serological tests in a group of 73 patients having presented with clinical manifestations suggestive of visceral leishmaniasis. Compared to microscopy, KATEX performed better than any single serological test in predicting positivity and a particularly good result was obtained by combining KATEX and the direct agglutination test (DAT).

The direct agglutination test: a non-specific test specific for the diagnosis of visceral leishmaniasis?

Serology has an important role to play in the diagnosis of the severe clinical syndrome of visceral leishmaniasis (VL). The direct agglutination test (DAT), a simple agglutination test which requires no laboratory facilities, has become the preferred test, particularly for field studies. The nature of the antigens responsible for the agglutination of leishmanial promastigotes by the serum of VL patients is not known. A series of experiments which provide some clues to the molecular basis for the test and which indicate that there might be more in DAT than meets the eye is reported.

Synthetic peptide-based enzyme-linked immunosorbent assay for serodiagnosis of visceral leishmaniasis

Synthetic peptides, derived from the amino acid sequence of a Leishmania donovani clone, were used to develop an enzyme-linked immunosorbent assay (ELISA) for detecting antibodies against L. donovani. For this purpose, five peptides were conjugated to a protein carrier, human serum albumin (HSA), by using a heterobifunctional reagent, epsilon-maleimidocaproic acid N-hydroxysuccinimide ester, to obtain a well-defined product. The sensitivity and the specificity of the peptide-specific ELISA were determined with a panel of 106 serum samples from individuals living in areas where visceral leishmaniasis is endemic; sera from post-kala azar dermal leishmaniasis-infected patients and from individuals suffering from other infectious diseases were also included. ELISAs were performed with either a single peptide-HSA conjugate or a mixture of two peptide-HSA conjugates. Ninety-seven percent of the serum samples from patients with visceral leishmaniasis had detectable antibodies to one or more of the single synthetic peptides. ELISA with a single peptide-HSA conjugate proved to be less sensitive (less than 71%) but more specific (up to 93%) than ELISA with crude promastigote antigens (80% sensitivity and 79% specificity); when a combination of two different peptide-HSA conjugates was used, the test increased both in sensitivity and in specificity. Chemically defined peptide-protein conjugates improve the reproducibility and reliability of ELISA for the serodiagnosis of L. donovani infection.