Transplant versus no transplant in myelodysplastic syndrome and acute myeloid leukemia with TP53 mutation; a referral center experience

A remarkably high rate of post-transplant relapse in patients with TP53-mutated myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) calls to question the utility of allogeneic stem cell transplant (HSCT). We, therefore, performed a retrospective analysis to compare the outcomes between HSCT (N = 38) versus non-HSCT (N = 45) approaches. Patients in the HSCT cohort were younger (median age 63 vs. 72) while patients in the non-HSCT cohort more commonly had complex karyotype with chromosome 17 aberrancy and 5q deletion (p < .01). A total of 69 TP53 variants including 64 pathogenic variants, and 5 variants of undetermined significance were detected. Nine patients (4 in HSCT and 5 in non-HSCT) had multi-hit TP53 variants. After induction: 57.9% versus 56.6% in the HSCT versus non-HSCT cohort achieved morphologic complete remission. Median time to HSCT was 6 months and median follow-up was 15.1 months for HSCT and 5.7 months for non-HSCT. Median disease-free survival (DFS) and overall survival (OS) were 11.7 and 15.9 months for HSCT, and 4.1 and 5.7 months for non-HSCT cohorts, respectively. Non-relapse mortality at 12 months was 22% versus 44% for HSCT versus non-HSCT. In the HSCT cohort, the rate of grade II-IV acute and chronic graft-versus-host disease (GVHD) was 55% and 18%, respectively. None of the patients from the non-HSCT cohort were alive while four patients from the HSCT cohort were alive, in remission, and without GVHD (GRFS) at the time of abstraction. Better treatment strategies for patients with TP53-mutated MDS/AML remain an area of unmet clinical need.

Safety and Efficacy of Teclistamab in Patients with Relapsed/Refractory Multiple Myeloma: A Real-World Experience

Teclistamab is a B cell maturation antigen (BCMA)-directed bispecific antibody approved for relapsed/refractory multiple myeloma (RRMM) on the basis of the phase I/II MajesTEC-1 trial. Here we report clinical outcomes with standard-of-care teclistamab in a real-world RRMM population. A total of 106 patients from 5 academic centers who received teclistamab from August 2022 to August 2023 were included in this retrospective analysis, 83% of whom would have been considered ineligible for the MajesTEC-1 trial. All patients were triple-class exposed, 64% were penta-class refractory, and 53% had received prior BCMA-directed therapy. Cytokine release syndrome was observed in 64% of patients, and only 1 event was grade ≥3, whereas immune effector cell-associated neurotoxicity syndrome was observed in 14% of patients (3 events were grade 3 or 4). One-third (31%) of patients experienced at least 1 infection, with nearly half of these infections graded as severe (grade ≥3). The overall response rate (ORR) was 66%, and the complete or better response rate was 29%. The ORR was 47% for patients with extramedullary disease (EMD), 59% for patients with prior BCMA-directed therapy exposure, and 68% for patients with penta-refractory disease. At a median follow-up of 3.8 months, the median progression-free survival (PFS) was 5.4 months (95% CI, 3.4 months to not reached), while median overall survival was not reached. Patients with Eastern Cooperative Oncology Group Performance Status ≥2, EMD, and age ≤70 years had inferior PFS on multivariable analysis. Our study demonstrates reasonable safety and good efficacy of teclistamab in patients with RRMM treated in a real-world setting.

Evaluation of oncology infusion pharmacy practices: A nationwide survey

PURPOSE

Oncology care continues to evolve at a rapid pace including provision of infusion-based care. There is currently a lack of robust metrics around oncology infusion centers and pharmacy practice. The workgroup completed a nationwide survey to learn about oncology-based infusion pharmacy services offered. The objective was to highlight consistent, measureable oncology-based infusion pharmacy metrics that will provide a foundation to describe overall productivity including emphasis on high patient-safety standards.

METHODS

A nationwide survey was developed via a workgroup within the Vizient Pharmacy Cancer Care Group beginning in April 2019 and conducted electronically via the Vizient Pharmacy Network from September to November 2020. The survey was designed to capture a number of key metrics related to oncology-based infusion pharmacy services.

RESULTS

Forty-one sites responded to the survey. Responses highlighted hours of operation (median = 11.5), number of infusion chairs (median = 45). Staffing metrics included 7.1 pharmacist full-time equivalent (FTE) and 7.6 technician FTE per week. 80.5% of sites had cleanrooms and 95.1% reported both hazardous and nonhazardous compounding hoods. 68.3% of sites reported using intravenous (IV) technology, 50.0% measured turnaround time, and 31.4% prepared treatment medications in advance.

CONCLUSION

There was variability among oncology infusion pharmacy practices in regard to survey responses among sites. The survey results highlight the need for standardization of established productivity metrics across oncology infusion pharmacies in order to improve efficiency and contain costs in the changing oncology landscape. The survey provides insight into oncology infusion pharmacy practices nationwide and provides information for pharmacy leaders to help guide their practices.

Outcomes and prognostic assessment of post-transplant lymphoproliferative disorder

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Background: Post-transplant lymphoproliferative disorder (PTLD) is the most common malignancy after solid organ transplantation (SOT) in adults, apart from skin cancer. It is a serious and potentially fatal complication of chronic immunosuppression in SOT recipients. Methods: Institutional electronic health record (EHR), Epic was queried for PTLD patients evaluated at the University of Cincinnati Cancer Center 1991 - 2020. Relationships between clinical characteristics and time from diagnosis to death were assessed using t-test and ANOVA, with SAS 9.4. Overall survival (OS) was evaluated by Kaplan Meier estimates, from the date of PTLD diagnosis to death or last follow-up. Results: Sixty patients were identified with PTLD in the study period. A higher proportion of males (65%) and Caucasians (92%) was noted. The most common type of transplants were kidney (40%) and liver (32%). The median time from transplant to PTLD was 7.3 y and the median age at diagnosis was 54.5 y. The majority had monomorphic PTLD (60%) and presented as Stage IV (25%) or with end-organ dysfunction (67%). Most had extranodal involvement (67%), with GI (23%) being the most frequently involved site. EBV was positive in 32%. Immunosuppression was changed in 75% of the patients and most received rituximab-chemotherapy (55%), with two-thirds achieving a response. The 2-year OS was 55%. Gender (males 44%, females 14%; p = 0.0216), transplant type (lung 67%, liver 53%, kidney 21%, kidney-pancreas 0%; p = 0.0183) and treatment response (CR 20%, PR 29%, no response 100%; p = 0.0003) were significantly associated with mortality. Median time from PTLD diagnosis to death was 5.2 mo, being significantly shorter in liver transplant recipients (p < 0.0001), those managed by observation only (p < 0.0001) or with end-organ dysfunction at diagnosis (0.0072). A similar trend was noted in males, non-Caucasians, HLA-mismatch, and polymorphic PTLD, but this was statistically nonsignificant. Conclusions: This investigation highlights the prognostic risk factors of PTLD, that could be helpful in the management of the patients and guiding future research.[Table: see text]

Genomic profiling and outcomes of BRAF V600E mutated papillary thyroid cancer

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Background: BRAF (BRAF mut) is the most common mutation in PTC (45% prevalence). It is associated with a higher clinical stage, tumor recurrence, absence of tumor avidity, and treatment failure. Methods: BRAF WT or BRAF mut (n = 538) PTC tumors tested with NextGen Sequencing on DNA (592 genes or WES) and RNA (WTS) by Caris Life Sciences (Phoenix, AZ) were analyzed. PD-L1 expression was tested by IHC (22c3 antibody, ≥1 combined positive score (CPS) being positive). Real world overall survival (rwOS) was obtained from insurance claims data, calculated from treatment start to last contact. Time-on-treatment (TOT) is calculated from start to end of treatment. Kaplan-Meier estimates were used for comparison. Statistical significance was determined using Fisher’s-Exact/Mann Whitney/X2 test with Benjamini-Hochberg correction. Differential gene expression was analyzed using the Limma R package (q < 0.001, logFC > 1.5, -log10 FDR > 20). Gene Set Enrichment Analysis (GSEA) was used with a p < 0.01 cutoff. Results: BRAF mut were found in PTC (69%, 369/538) but not in the follicular subtype (0/117). No gender difference was seen in BRAF mut PTC (F: 53%, 297/538). BRAF mut were more prevalent in metastases compared to primary/local tumors (42% vs. 30%) and BRAF mut was highest in metastatic lymph nodes (55%, 130/235). TERT promoter was the most common mutation in both BRAF mut and WT groups but higher in BRAF mut (64% vs 40%, q < 0.0001), while NRAS (0.2% vs 23%, q < 0001), HRAS (0% vs 8.8%, q < 0001), KRAS (0.4% vs 5.4%, q < 0001), and EIF1AX (0% vs 6.6%, q = 0.0005) mutations were more prevalent in BRAF WT PTC. PD-L1 expression was higher in the BRAF mut patients compared to WT (37% vs 22%, q < 0.01). BRAF mut PTCs were associated with higher immune cell infiltrate including M1 macrophages, and Treg cells, but lower M2 macrophages, NK cells, CD4+ T cells, and myeloid dendritic cells (all q < 0.01). GSEA analysis revealed enrichment in IL6, JAK, and STAT3 signaling, inflammatory response, apoptosis, and interferon gamma response (all NES = 1.5 - 1.8, p < 0.01) gene sets. DCSTAMP was the most differentially expressed gene in BRAF mut tumors relative to WT (logFC = 4.4). When comparing BRAF mut with WT, no significant difference in rwOS was seen (NR vs 50 mo, HR 0.73, P> 0.2). In BRAF mut patients, treatment with multikinase inhibitors (n = 32) was associated with longer rwOS compared to BRAF inhibitor treatment (n = 37) (61 mo vs 27 mo, HR 0.364, P< 0.05). Despite small patient number, data suggests BRAF mut patients may benefit from immunotherapy (n = 4) when compared to BRAF inhibitors (n = 31) (TOT, HR = 0.35, p = 0.07). Conclusions: Our data highlights new genomic signatures that indicate potential new, while also validating current targets for BRAF mut PTC: higher PD-L1 expression, immune infiltrate, and inflammatory gene signature. Clinical trials are needed to assess the best sequencing of therapies used in this group, particularly TKIs vs BRAF inhibitors and the role of immunotherapy.

Impact of p16 Status and Anatomical Site in Anti-PD-1 Immunotherapy-Treated Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma Patients

In head and neck squamous cell carcinoma (HNSCC), anti-PD-1 inhibitors are approved for recurrent/metastatic (R/M) disease and anticipated to expand to other indications. The impact of p16 status and anatomical site on overall survival (OS) in immunotherapy-treated HNSCC patients remains unresolved. We performed a retrospective analysis of R/M HNSCC patients receiving anti-PD-1 immunotherapy at our academic medical center with an extensive community satellite network. Fifty-three R/M HNSCC patients were treated with anti-PD-1 immunotherapy and had a median OS of 6 months. Anatomical site was associated with distinct OS; oropharynx and larynx patients have superior OS compared to oral cavity patients. Analysis of the OPSCC subset showed p16+ status as a favorable, independent prognostic biomarker (HR 7.67 (1.23-47.8); p = 0.029). Further studies to assess the link between anatomical site, p16 status, and anti-PD-1 treatment outcomes in large cohorts of R/M HNSCC patients managed in real-world clinical practices and clinical trials should be prioritized.

Managing Recurrent Metastatic Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) treatment is often associated with high morbidity especially in the recurrent and/or metastatic (R/M) setting, limiting effective treatment options. Local disease control is important. Therefore, local therapies including reirradiation and salvage surgery, either alone or in combination with systemic treatment, may be used for selected patients with R/M HNSCC. Although chemotherapy and targeted agents have modest efficacy in HNSCC, the advent of immunotherapy has revolutionized the treatment paradigm of R/M HNSCC. Multiple trials have resulted in the past 5 years advocating for its use alone or in combination with chemotherapy.

Hypothyroidism in Head and Neck Squamous Cell Carcinoma Patients Receiving Radiotherapy With or Without Immune Checkpoint Inhibitors

OBJECTIVES/HYPOTHESIS

Hypothyroidism is a relatively common complication of head and neck squamous cell carcinoma (HNSCC) treatment. The objective of this study was to determine whether the addition of programmed death ligand-1 (PD-1) or programmed death ligand-1 (PD-L1) inhibition (anti-PD-1/PD-L1 therapy) to standard treatment increases the risk of hypothyroidism in HNSCC.

STUDY DESIGN

Retrospective Cohort.

METHODS

This is a retrospective, single institutional cohort study. Patients who received radiotherapy (RT) for HNSCC were identified in the electronic medical record. Patient factors collected include age, sex, body mass index (BMI), smoking status, alcohol use, Charlson comorbidity index, and HNSCC treatment records. The rate of hypothyroidism for patients with HNSCC receiving RT (+/- chemotherapy and surgery) (RT group, n = 101) was compared to that of HNSCC patients receiving RT (+/- chemotherapy and surgery) + anti-PD-1/PD-L1 therapy, either concurrently or after RT (RT + anti-PD-1/PD-L1 group, n = 38).

RESULTS

There was no significant difference in the rate of clinical or subclinical hypothyroidism between the two groups. Multinomial logistic regression found no significant difference in hypothyroidism based on age, sex, or BMI.

CONCLUSIONS

The addition of anti-PD-1/PD-L1 therapy to standard HNSCC treatment does not significantly increase the risk of developing hypothyroidism.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2413-E2419, 2021.

Immunotherapy in gastroesophageal cancers: Current state and future directions

While gastroesophageal (GE) cancers are one of the most common cancers worldwide, unfortunately, the mortality remains high. Commonly used treatment options include surgical resection, chemotherapy, radiotherapy, and molecular targeted therapy, which improve survival only minimally; thus, affirming the dire need for exploring alternative strategies to improve patient outcomes. Immunotherapy, which has revolutionized the world of oncology, has somewhat lagged behind in GE malignancies. Tumor-associated microenvironment and regulatory T cells, alongside cell cycle checkpoints, have been proposed by various studies as the mediators of carcinogenesis in GE cancers. Thus, inhibition of each of these could serve as a possible target of treatment. While the approval of pembrolizumab has provided some hope, it is not enough to override the dismal prognosis that this disease confers. Herein, we discuss the prospects of immunotherapy in this variety of cancer.

Coincident remission of ankylosing spondylitis after autologous stem cell transplantation for multiple myeloma

INTRODUCTION

Ankylosing spondylitis is an autoimmune disease with chronic inflammation of the spine and sacroiliac joints that is commonly treated with immunosuppressants including disease-modifying antirheumatic drugs and anti-tumor necrosis factor alpha therapy.

CASE REPORT

A 75-year-old female with active ankylosing spondylitis on treatment with etanercept was referred to us for newly diagnosed IgG kappa free light chain multiple myeloma. After failing induction with revlimid, bortezomib, and dexamethasone, she was initiated on carfilzomib. Following the achievement of adequate response to induction, she underwent an autologous hematopoietic stem cell transplant selected for CD34+ cells with melphalan 200mg/m² conditioning regimen. Given high-risk cytogenetics, i.e. monosomy 17 (17p) and hypodiploidy, she received two cycles of carfilzomib consolidation post-transplant. The patient tolerated the transplant well with successful engraftment and achieved complete remission of multiple myeloma with no detectable M spike, negative immunofixation study, and normalization of light chain ratio. While being off etanercept since the transplant, she noticed complete relief from joint pains related to her ankylosing spondylitis without a need to use the pain-relieving medications.Management and outcome: The patient has sustained remission of ankylosing spondylitis for two years post-transplant without flares or symptoms. She continues to remain off immunosuppressants.

DISCUSSION

Although our patient had a coincident and unprecedented resolution of ankylosing spondylitis after receiving the hematopoietic stem cell transplant, this case consolidates the idea of transplant as a potential treatment option for ankylosing spondylitis and other rheumatological conditions.

0734 Does Noise Masking Improve Sleep Consolidation In Patients Weaning From Prolonged Mechanical Ventilation?

Introduction

Sound masking is a noise reduction strategy that adds a mixed-frequency blend of ambient sound to the environment and may improve sleep. Critically ill patients often cite noise as one of the main factors preventing sleep while they are cared for in an intensive care unit (ICU). The effect of sound masking on sleep in patients weaning from prolonged mechanical ventilation is unknown.

Methods

12-hour overnight polysomnography was obtained in eight patients undergoing weaning from prolonged mechanical ventilation. None had hearing impairment, delirium, sedation or agitation. In random order, patients were exposed to sound masking half of the recording time. Noise events were defined a 10dB increase from baseline or any sound peak over 75dB. Arousals or awakenings were attributed to noise if they occurred within 5 seconds of the noise event.

Results

Environmental sound was 61.7± 0.9 dB (mean±SE) during sound masking and 55.9±1.4 dB during no sound masking. During sound masking, there were fewer sound events per hour of sleep when compared to no sound masking (4.1/hr vs 9.3/hr p=0.03). The percentage of sound events leading to a subsequent arousal or awakening with sound masking was less than during no sound masking:11% vs 22% (p=0.04). Arousal index and fragmentation index (arousal and awakenings/hr of sleep) were similar between the two conditions. In a post-study survey, five patients reported improved sleep quality with sound masking while the remaining three reported no difference.

Conclusion

Sound masking decreases sound-induced arousal from sleep in patients being weaned from prolonged mechanical ventilation.

Support

Veterans Administration Research Service

Incidence of hypothyroidism in head and neck squamous cell carcinoma patients receiving radiotherapy with and without immune checkpoint inhibitors

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Background: Treatment for locally advanced head and neck squamous cell carcinoma (HNSCC) involves a combination of surgery, chemotherapy, and radiotherapy (RT). RT for HNSCC is a known risk factor for the development of hypothyroidism. Recently, anti-PD1 therapies have been approved for recurrent and metastatic HNSCC and are moving to the forefront of HNSCC care. Similarly, thyroid dysfunction is a common immune-related adverse event following anti-PD1 therapy. Whether the addition of anti-PD1 to RT increases the likelihood of developing hypothyroidism remains unknown. Methods: The rate of hypothyroidism in HNSCC patients receiving RT (+/- chemotherapy and surgery) was compared to HNSCC patients receiving RT + anti-PD1 therapy either concurrently or after RT. Exclusion criteria were preexisting thyroid dysfunction, RT dose < 45 Gy and patients with incomplete treatment records. We defined clinical hypothyroidism as an elevation of TSH with low T3, T4 or elevation of TSH with symptoms requiring levothyroxine initiation. Hypothyroidism incidence was compared using Fisher’s exact test. Results: 153 patients were evaluated. In the RT group (N = 103), patients received RT +/- surgery or chemotherapy. 82/103 (80%) were male, median age was 57 and primary tumor groups included oropharynx 62/103 (60%), larynx 29/103 (28%), oral cavity 9/103 (9%) and other 3/103 (3%). In the RT + anti-PD1 group (N = 50), 36/50 (72%) were males, median age was 57 and primary tumor groups included oral cavity 19/50 (38%), oropharynx 17/50 (34%), larynx 8/50 (16%), and other 6/50 (12%). In the RT group, median follow up after RT was 801 days. In the RT+ anti-PD1 group, median follow up was 595 days from RT and 388 days from anti-PD1. The rate of hypothyroidism was significantly higher in the RT group 22.3% (23/103) versus 6% (3/50)after anti-PD1 therapy (p = 0.011). Multinomial logistical regression found no significant difference in hypothyroidism based on age, sex, or BMI. Larynx as primary tumor location was an independent risk factor for development of hypothyroidism (OR 4.74, p = 0.002). Conclusions: The addition of anti-PD1 therapy to standard HNSCC treatments does not significantly increase the risk of developing hypothyroidism. In fact, this study finds a lower incidence of hypothyroidism in HNSCC patient receiving RT + PD1 therapy which may be due to shorter duration of follow up and lower proportion of laryngeal cancer patients who are at relatively higher risk for surgical hypothyroidism.

Wunderlichs syndrome in patient with sporadic bilateral angiomyolipomas - case report

We present the case report of bilateral renal angiomyolipomas in a 70-year-old patient. Spontaneous bleeding into the retroperitoneum and hemodynamic instability required an acute surgical revision with a left-sided nephrectomy. The contralateral angiomyolipoma was selectively embolized in the second period and subsequently resected.

Isolated testicular recurrence of B cell acute lymphoblastic leukaemia in an adult: rare case

An 80-year-old man who was previously diagnosed with Philadelphia+ B cell-acute lymphoblastic leukaemia (B-ALL) in remission post-allogeneic matched unrelated donor peripheral blood stem cell transplant. Five years later, he was found to have unilateral testicular relapse of Philadelphia+ B-ALL proven by pathology after radical orchiectomy. Bone marrow aspirate and biopsy did not show evidence of leukaemia. Patient was treated with adjuvant radiation therapy and started on dasatinib 50 mg daily. Given his age and absence of disseminated acutelymphoblastic leukaemia (ALL), no adjuvant chemotherapy was utilised. He is monitored with monthly PCR studies. At 1-year follow-up, no findings suggestive of recurrence of ALL have been identified and the patient is maintained on the dasatinib. Although isolated testicular recurrence is common among paediatric population, it is a rare event among adults as it is considered an immunological sanctuary for cancer cells.

Paravertebral Mass and Diffuse Lymphadenopathy in a Patient with Pyruvate Kinase Deficiency: Malignancy or Alternative Etiology?

Extramedullary hematopoiesis is common in chronic hemolytic anemias such as pyruvate kinase deficiency. It is commonly associated with hepatosplenomegaly or lymphadenopathy; however, it can rarely also present as a mass in the chest, abdomen, or paraspinal region. Here, we present a case of an adult patient with pyruvate kinase deficiency and history of splenectomy. He presented with sepsis and brisk leukocytosis secondary to pneumonia and was also found to have diffuse intraabdominal lymphadenopathy along with a paravertebral mass. The radiological findings raised concerns for a systemic lymphoproliferative disorder and there was a suggestion for further workup with a biopsy. However, given the patient’s underlying pyruvate kinase deficiency, we hypothesized that the paravertebral mass is likely a result of extramedullary hematopoiesis in the setting of bone marrow stress from infection and ongoing hemolysis; thus, we decided against biopsy. Repeat imaging six weeks after the presentation showed resolution of the paravertebral mass, which consolidated our hypothesis. This highlights the importance of avoiding invasive diagnostic procedures in asymptomatic patients with chronic hemolysis who may present with diffuse mass lesions.

A Case of Secondary Sclerosing Cholangitis in the setting of Non-Hodgkin's Lymphoma

Sclerosing cholangitis represents a spectrum of cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts. A 67-year-old Caucasian female with a history of breast cancer in remission, presented with jaundice and an exophytic mass at the base of the tongue. Laboratory data revealed cholestasis with alkaline phosphatase 953 U/L, total bilirubin 7.7 mg/dL, direct bilirubin 6.4 mg/dL, and gamma-glutamyltransferase 3369 U/L. Computed tomography (CT) scan showed widespread lymphadenopathy in the chest, abdomen, and pelvis concerning for lymphoma, acute pancreatitis and biliary dilation with hyperenhancement of the common bile duct wall. Diffuse intrahepatic biliary ductal dilatation and narrowing with multifocal stenosis of the proximal and distal aspects of the common bile duct was seen on magnetic resonance cholangiopancreatography (MRCP). Findings were consistent with sclerosing cholangitis. Pathology of the oral lesion revealed activin receptor-like kinase 1 (ALK1) positive anaplastic large cell lymphoma. Chemotherapy was initiated with cyclophosphamide, doxorubicin, adriamycin, vincristine, etoposide, and prednisone (CHOEP-14) regimen, which resulted in significant clinical improvement along with a remarkable decrease in the liver function tests. Non-Hodgkin's lymphoma (NHL) has only rarely been reported in the literature as a cause of secondary sclerosing cholangitis, i.e., only 0.2% to 2.0% of patients with NHL present with biliary tract obstruction. It is essential for gastroenterologists, oncologists, and radiologists to recognize sclerosing cholangitis occurring secondary to a systemic disease because early initiation of treatment can improve clinical outcome, as manifested by our case.

The prognostic value of KRAS mutation in locally advanced rectal cancer

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Background: The prognostic value and prognostic value of the KRAS proto-oncogene mutation in colorectal cancer has been debated. Herein, we analyzed the National Cancer Database (NCDB) to assess the role of KRAS mutation as a prognostic marker in patients with locally advanced rectal cancer (LARC). Methods: We identified LARC patients treated with neoadjuvant chemoradiation from 2004-2015 excluding those with stage I/IV disease and unknown KRAS status.Multivariable logistic regression identified variables associated with KRAS positivity. Propensity adjusted univariable and multivariable analyses identified predictors of survival. Results: Of the 784 eligible patients, 506 and 278 were KRAS negative (KRAS-) and KRAS positive (KRAS+). Median survival was 63.6 months and 76.3 months for KRAS+ and KRAS-patients, with propensity adjusted 3 and 5-year survival of (79.9% vs. 83.6%) and (56.7% vs 61.9%) respectively (HR 1.56, p 1.074-2.272). Male sex, no insurance, and KRAS+ disease was associated with poorer survival on unadjusted and propensity adjusted multivariable analyses (Table). Conclusions: Our analysis of KRAS+ LARC suggest that KRAS+ disease is associated with poorer overall survival. Given the inherent limitations of retrospective data, prospective validation is warranted. [Table: see text]

Delay in time from diagnosis to treatment in metastatic melanoma, lung, and colon cancer

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Background: Delay in cancer treatment is anxiety provoking both for the patient and clinician. We conducted the study to evaluate the patterns of delay in treatment of patients with metastatic colon cancer, lung cancer and melanoma from diagnosis to the initiation of the treatment, and to identify the causes of delay. Methods: In this retrospective study, patients with metastatic colon cancer, lung cancer and melanoma diagnosed between 01/01/2016 to 12/31/2016 in a tertiary care network in the United States were studied. Data was collected from electronic health record (EHR) database, ‘Epic’. Variables such as demographic data, including patient age and gender, and type of cancer, and treatment received were analyzed. The causes of the delay were also evaluated when available. Results: Total number of patients in the study was 288. Mean age was 68.3 years (median 69 years) and 36% were alive at the time of data analysis. Male to female ratio was 1.4:1. 66.7% people had lung cancer, 30% had colon cancer and 3% had melanoma. 67 (23.6%) of total analyzed patients had denied definitive treatment and chose to undergo palliative management. Of the rest, most started treatment with chemotherapy (39.5%), followed by surgery (22.6%) and then radiation (14.6%). With the time of pathological diagnosis of the tumor taken as the date of diagnosis, mean delay from the day of diagnosis to the start of treatment in this study population observed was 27.7 days. 67 patients (23.3%) had a delay of more than 30 days, with the most common reason being systemic factors in 39 patients (58.2%), followed by patient factors in 23 patients (34.3%) and physician factors in 5 patients (7.5%). On logistic regression analysis, time from diagnosis to treatment didn’t predict mortality (OR = 0.99, 95% CI P = 0.10(0.97-1.002). Conclusions: Delay in treatment is common and the system factors one of the common reasons as exhibited by our study. Time from diagnosis to treatment didn’t predict mortality.

Vitamin D deficiency in patients with newly diagnosed cancer

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Background: Vitamin D deficiency (VDD) is pandemic in modern society. There has been increasing interest in vitamin D and its impact on cancer. A number of studies have been published on a possible link between VDD and cancer. However, because of inconsistent results, controversy remains in various aspects of vitamin D. In this study, we assessed the association of VDD with various cancers. Methods: A retrospective study was conducted in a tertiary care hospital network in western Pennsylvania. Electronic health record database was used to extract the data from patients seen in outpatient office with newly diagnosed cancer who had a measured 25-hydroxy vitamin D level at diagnosis between 02/2016 and 02/2018. VDD was defined as level less than 30 ng/dl. Patient demographics, smoking, and vitamin D status were used for multivariate logistic regression analysis in order to determine odds ratio (OR) of certain cancer type in our cohort. We used SPSS version 23 for statistical analysis. Results: A total of 934 patients (59.2% female) with cancer were included. Most patients, 86.4%, were Caucasian, and 10.8% African American (AA). VDD was found in 433 patients (46.4%) and more prevalent in men (n = 203, 53.3%), and AA (n = 65, 64.4%) in our cohort. The most common cancer type was breast cancer (30.9%), followed by prostate cancer (11.3%), lymphoma (11.1%), and lung cancer (7.8%). After adjusting to demographic characteristics and smoking status, VDD was significantly associated with pancreatic cancer (OR = 2.28, p = 0.02), and reversely associated with breast cancer (OR = 0.56, p = 0.001). VDD was also prevalent in colorectal cancer, but not statistically significant, (OR = 1.71, p = 0.064). Conclusions: Our study demonstrated that VDD is prevalent among cancer patients, especially in men and AA patients. There is a strong association between VDD and the malignancies of digestive system, particularly pancreatic cancer. Further studies are needed to assess the effect of VDD on disease-specific risk and cancer mortality as well as the impact of vitamin D supplement.

Aplastic anemia secondary to propylthiouracil: A rare and life-threatening adverse effect

Background

Propylthiouracil has been in use for more than half a century for the treatment of hyperthyroidism. While it is largely known to cause agranulocytosis, its association with aplastic anemia is rarely heard of. Our case will be the third in literature to suggest aplastic anemia as a manifestation of propylthiouracil, which unfortunately culminated in the death of the patient.

Case

A 67-year-old female, with recently diagnosed metastatic adenocarcinoma of the lung, developed hyperthyroidism after being started on Nivolumab and Iplimumab. After she developed atrial fibrillation, she was started on propylthiouracil to control the thyroid activity. Soon after that, she was admitted with severe neutropenia, which progressed to pancytopenia confirmed as aplastic anemia on a bone marrow biopsy. Despite discontinuation of propylthiouracil and aggressive treatment, she developed septic shock and multi-organ failure, leading to her death.

Conclusion

Aplastic anemia has been sparingly reported as an extremely rare complication of propylthiouracil. Further adding to the ambiguity is the unknown etiology and lack of specific therapy for the complication when attributed to propylthiouracil. The disease can carry an extremely poor prognosis if untreated, as proven by our case. Due to the same reasons, we recommend that further investigations be done to elucidate the pathogenesis and assist with treatment of the disease when caused by propylthiouracil.

Cerebral aspergillosis in a patient on ibrutinib therapy-A predisposition not to overlook

Ibrutinib has revolutionized the treatment of B-cell malignancies since its approval for chronic lymphocytic leukemia. It is also used in mantle cell lymphoma, diffuse large B-cell lymphoma, Waldenstrom's macroglobulinemia, among others. It is a Bruton's tyrosine kinase inhibitor that acts on B-cell receptor signaling pathway and predisposes to various infections due to its effects on neutrophils, monocytes and T cells. We present a case of cerebral invasive aspergillosis in a patient being treated with ibrutinib for relapsed chronic lymphocytic leukemia. It was hard to associate the condition to ibrutinib versus the chronic lymphocytic leukemia. The patient was successfully treated with a combination of voriconazole and micafungin, resulting in complete recovery and no residual deficits. This highlights the importance of recognizing the rare complication in those on ibrutinib and initiating the treatment immediately with appropriate antifungal agents to improve prognosis of this potentially fatal condition.

Cholestatic jaundice: a unique presentation leading to the diagnosis of HLH with Hodgkin lymphoma, HIV and EBV

Haemophagocytic lymphohistiocytosis (HLH) is a syndrome of dysregulated immune activity with macrophage activation that can manifest as pancytopenia, coagulopathy and other laboratory abnormalities, usually progressing to multiorgan failure and death. This report documents the rarely reported association between HLH and Hodgkin's lymphoma (HL) with simultaneous HIV and Epstein-Barr virus (EBV) and complete resolution with chemotherapy. The patient initially presented with cholestatic jaundice. He was then found to have HL associated with HLH with coexistent HIV and EBV viraemia. A-Brentuximab-VD regimen for the lymphoma was initiated, resulting in rapid resolution of HLH and ultimately remission of HL. HLH is a syndrome known to have high mortality; thus, early diagnosis and prompt treatment are crucial. Usual presentation includes non-specific symptoms and can easily be overlooked. This case highlights the importance of diagnosing the condition in unusual settings and attempting treatment by targeting the cause of HLH, HL in our case.

A case of autoimmune haemolytic anaemia after 39 cycles of nivolumab

With growing use of nivolumab, rare but serious side effects have surfaced in some patients. We present a case of autoimmune haemolytic anaemia that developed after 39 cycles of nivolumab. A 78-year-old man with metastatic lung adenocarcinoma, refractory to multiple lines of chemotherapy was switched to nivolumab. After around 2 years of stable course on nivolumab, he developed transfusion-dependent anaemia with haemoglobin of 8.6 g/dL. Nivolumab was held immediately. Bone marrow biopsy findings were inconclusive of myelodysplastic syndrome. Further testing was suggestive of haemolysis with haptoglobin <10 mg/dL, elevated reticulocyte count and identification of immunoglobulin G antibody. Haemoglobin improved significantly with initiation of 1 mg/kg prednisone in addition to rituximab weekly × four doses. The development of transfusion-dependent anaemia with the exposure to cytotoxic chemotherapy usually raises the question for myelodysplastic syndrome. In contradiction, our patient was diagnosed to have a haematological autoimmune complication related to immunotherapy.

Mantle Cell Lymphoma Relapsing as Disease of Skin, Orbit and CNS: An Extremely Rare Presentation and a Review of Literature

Mantle cell lymphoma (MCL) is a form of non-Hodgkin’s lymphoma originating from mature B cells. The hallmark gene translocation (11:14) results in overexpression of cyclin D1. Affected extranodal sites include bone marrow and gastrointestinal tract, but skin, orbit or CNS are rarely involved. Twenty-four cases have reported involvement of skin by MCL, while orbital MCL is equally rare. Our case is the first to report relapsed MCL with involvement of the skin and orbit simultaneously without disease in the lymphatic system or the bone marrow. A 53-year-old female with stage IV MCL initially presented with pancytopenia, adenopathy and splenomegaly. She achieved complete remission after six cycles of rituximab and bendamustine. Within 4 weeks of treatment, she developed diplopia and a rash of the left breast. Skin biopsy showed lymphoma infiltrates with B-cell markers for MCL. MRI of the orbits and brain suggested orbital lymphoma. CSF cytology further confirmed MCL cells. At time of relapse, she continued to be in hematologic remission. She initiated intrathecal cytarabine and methotrexate along with ibrutinib. R-CHOP was then added to the regimen. Within 2 weeks of starting treatment, her skin disease resolved and she had improvement in vision. MCL commonly presents as a disseminated disease, resulting in high mortality. Involvement of the skin or orbit has been sparingly reported and always suggests aggressive disease. It thus poses a challenge to diagnose and treat the condition as evidenced by resolution of adenopathy and bone marrow disease. Due to the overall poor prognosis of MCL and its unique presentations, as demonstrated by our case, early detection and prompt treatment are crucial to survival.

Natural history of early first-trimester pregnancies implanted in Cesarean scars

OBJECTIVE

To describe the ultrasound findings and natural history of pregnancies implanted within or on Cesarean section scars in the first trimester of pregnancy.

METHODS

This was a prospective observational study of 10 women diagnosed with a pregnancy implanted in or on a Cesarean section scar in the first trimester, who declined medical intervention because of their desire to continue the pregnancy. The study population comprised women at < 12 weeks' gestation who were seen in our early pregnancy unit between January 2011 and September 2013. Nine women were followed up by serial ultrasound examinations and had detailed care plans for delivery at King's College Hospital (KCH). One woman was followed up and delivered at another teaching hospital. The first-trimester ultrasound findings were compared with the clinical outcome of the pregnancy.

RESULTS

The nine patients who were followed up at KCH developed ultrasound findings of morbidly adherent placenta (MAP) in the second and third trimesters. All 10 patients were diagnosed with MAP at the time of delivery by Cesarean section. The gestational age at delivery ranged from 26 to 38 weeks. The uterus was conserved in five patients, and Cesarean hysterectomy was performed in the remaining five. All three women with complete implantation of the gestational sac within the scar and two of three cases with placental lakes in the first trimester had hysterectomies. The two cases with bulging of the gestational sac out of the uterine contour had a preterm emergency hysterectomy due to placenta percreta. Histology confirmed placenta accreta in the five hysterectomy specimens. There were no fetal or neonatal complications.

CONCLUSIONS

Implantation of a pregnancy on or in a Cesarean section scar is a precursor of MAP; however, the degree of morbidity associated with this implantation is variable and difficult to predict based on first-trimester ultrasound findings only. The assessment of ongoing pregnancies implanted in Cesarean scars is most beneficial when performed between 7 and 9 weeks' gestation. Complete implantation within the myometrial defect, bulging of the trophoblast from the uterine contour and large placental lakes in the first trimester are ultrasound findings that may predict severe placenta accreta or percreta and consequently a poor outcome.

Age, gender, and racial differences in incidence and survival in primary CNS lymphoma

Background:

Primary central nervous system lymphoma (PCNSL) is a rare subtype of extranodal non-Hodgkin lymphoma that accounts for ∼4% of newly diagnosed central nervous system (CNS) tumours. The objective of this study was to analyse the epidemiology, incidence, and outcome of these rare tumours.

Methods:

Primary brain and CNS lymphoma cases were identified from the Surveillance, Epidemiology, and End Results (SEER) research data sets for the years 1980–2008 for analysis of trends in incidence and survival. SEER^*Stat v. 7.0.4 software was used to analyse the data.

Results:

The overall incidence rate of PCNSL was 0.47 per 100 000 person-years. The incidence was significantly higher in males compared with females, blacks aged 0–49 years at diagnosis compared with whites, and whites aged 50 years and older at diagnosis compared with blacks. After a significant decline in incidence between 1995 and 1999, incidence rates rose slightly; those aged 75+ years at diagnosis had the most dramatic increase in incidence rates over time. Five-year survival rates were significantly higher in whites compared with blacks aged 0–49 years at diagnosis, but was primarily driven by white women aged 0–49 years.

Conclusion:

There is an increase in incidence of PCNSL in the elderly, and elderly blacks have lower incidence compared with white population. Survival remains poor and is negatively dominated by factors associated with HIV infection and advanced age.

Management of maternal obesity prior to and during pregnancy

The prevalence of obesity is high and rising worldwide. The greatest prevalence of obesity is found in the western world and in urban developing countries. There is an increased maternal mortality associated with maternal obesity. There are increased risks of most maternal complications in pregnancy including pre-eclampsia, gestational and pre-existing type 2 diabetes mellitus and thromboembolic disorders. There is an increased perinatal mortality associated with maternal obesity; there are increased risks of congenital malformation, fetal macrosomia and indeed risks for the fetus as a child and adult in the years to come. There are increased risks of complications of pregnancy including caesarean section, traumatic delivery and a reduced chance of breastfeeding. Maternal obesity in pregnancy predicts long-term risks for that mother. The management includes increased surveillance for these risks and lifestyle modulation during pregnancy. This includes dietary measures and encouraging modest increase in exercise. Ideally, the mother should achieve closer to an ideal body mass index prior to pregnancy using lifestyle intervention but possibly with pharmacological therapy or bariatric surgery. The ideal weight gain for an obese mother is less than the ideal weight gain for a lean mother.

Pigment synthesizing melanoma (so-called animal type melanoma): a clinicopathological study of 14 cases of a poorly known distinctive variant of melanoma

AIMS

Pigment synthesizing melanoma (so-called animal type melanoma) (PSM) is a rare histopathological variant of melanoma so termed because of prominent melanin production and its similarity to a variant of melanoma seen in grey horses. The aim of this study was to report the clinicopathological characteristics of 14 cases of animal type melanoma.

METHODS AND RESULTS

Six patients were female and eight were male with ages ranging from 5 to 52 years (mean 31 years, median 39 years). The head and neck represented the most common site. The clinical diagnosis was of melanoma in seven cases, blue naevus in three cases, benign naevus in three cases and a pigmented basal cell carcinoma in one case. The histological diagnosis of PSM was predicated on the basis of an asymmetrical, predominantly intradermal tumour formed of deeply pigmented, round or short, spindle-shaped dendritic melanocytes with some degree of hyperchromatism and a single nucleolus. Cytological atypia was always present but was not pronounced. A prominent population of macrophages was invariably present. Four tumours were compound and 10 tumours were predominantly intradermal. The mitotic count was usually low, ranging from 1 to 5 per 10 high-power fields (mean 2). Perineural and lymphovascular invasion was not seen. The Breslow thickness ranged from 1.1 to 7.5 mm (mean 3.3 mm). Follow-up was available in 13 patients. The median follow-up period was 5 years. Six patients had no recurrence, three had local recurrence in the form of satellite nodules adjacent to the scar, four had spread to the regional lymph nodes and one patient had distant metastases to the liver. There were no deaths.

CONCLUSIONS

This study demonstrates that PSM is a distinctive, possible low-grade variant of melanoma usually lacking the histological features predictive of aggressive behaviour seen in ordinary melanoma. It should be managed in the same way as other melanomas with wide local excision.

The changes of metabolic profile and weight during Ramadan fasting

INTRODUCTION

Ramadan is the holiest month in the Islamic calendar and Muslims fast during this month. We designed this study to evaluate the effect of Ramadan fasting on plasma lipids and lipoproteins.

METHODS

This cohort study was performed during Ramadan in December 2002 (Islamic year 1423). The subjects were 81 students of Tehran University of Medical Sciences. We evaluated weight, body mass index (BMI), glucose, triglyceride (TG), cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein (VLDL), before and after Ramadan.

RESULTS

Body weight and BMI both decreased during Ramadan fasting in both genders. Glucose and HDL decreased and LDL increased significantly during fasting in Ramadan, but there was no significant change in total cholesterol, TG and VLDL. We did not find any association between TG, cholesterol, LDL, VLDL, HDL and the following variables: sex, body weight changes, and two or three instances of meals before Ramadan. Triglyceride level also increased in students with normal BMI while it decreased in overweight subjects.

CONCLUSION

This study indicated that Ramadan fasting led to a decrease in glucose and weight. Although there was a significant reduction in meal frequency, a significant increase in LDL and decrease in HDL was noted during Ramadan. It seems that the effect of Ramadan fasting on serum lipid levels may be closely related to the nutritional diet or biochemical response to starvation.

An unusual case of pneumonia

A previously healthy 37-year-old man was admitted with a two-month history of increasing shortness of breath and high temperature. A chest X-ray demonstrated bibasal shadowing and small bilateral pleural effusions; arterial blood gases demonstrated low pO2. Despite intravenous antibiotics no significant improvement was observed. A high-resolution chest computed tomography showed diffuse ground-glass opacification with segmental and subsegmental airways opacification, indicating fine fibrosis. Subsequently, open lung biopsy showed diffuse alveolar damage and a histopathological diagnosis of acute interstitial pneumonia (Hamman-Rich syndrome) was made. Antibiotics were stopped and high intravenous doses of steroids were given with a dramatic improvement in the patient's breathing and radiographic findings. The pathophysiological mechanisms of acute interstitial pneumonia and current therapeutic options are discussed.

Fatal donor-derived Epstein-Barr virus-associated post-transplant lymphoproliferative disorder following reduced intensity volunteer-unrelated bone marrow transplant for myelodysplastic syndrome

Post-transplant lymphoproliferative disorders (PTLD) are a well recognised complication of conventional haemopoietic stem cell transplantation (HSCT). Reduced intensity HSCT involves intensive immunosuppression to permit engraftment. Thirty reduced intensity transplants with the FBC (fludarabine 150 mg/m2, busulphan 8 mg/m2, CAMPATH-1H 100 mg) protocol have been performed at our centre, with one confirmed EBV-positive PTLD. The female recipient developed a perforated viscus day +191 following HSCT from a volunteer unrelated male donor. A large caecal mass and a retroperitoneal abscess were excised, revealing an EBV-positive diffuse large B cell lymphoma confirmed by FISH to be of donor origin. More experience is required before the risk of PTLD in this setting can be assessed.

Penetration of anticancer drugs through solid tissue: a factor that limits the effectiveness of chemotherapy for solid tumors

Penetration of anticancer agents to cells distant from the vascular system is required for efficacy of cancer chemotherapy against solid tumors. Many solid tumors have a poorly formed blood vascular system with variable rates of blood flow and much larger intercapillary distances than those found in normal tissues. The requirement for drugs to penetrate several layers of tissue might pose a barrier to the effective treatment of solid tumors. Multicellular layers (approximately 200 microm thick) were grown in vitro on Teflon membranes from EMT6 murine and MCF7 human tumors and have been used to quantitate the penetration of four widely used anticancer drugs through solid tissue. The penetration of doxorubicin and mitoxantrone was limited and very slow (<10% of the rate of penetration through the Teflon membrane alone). The penetration of methotrexate and 5-FU was more rapid (approximately 30-50% of the rate of penetration through the Teflon membrane alone), but remains a substantial barrier to the effectiveness of these drugs. Strategies to improve the penetration of anticancer drugs through poorly vascularized tumor tissue have considerable potential to improve the outcome of chemotherapy for solid tumors.

Immuno-histochemical analysis of estrogen receptors on the malignant gallbladder tissue

Sex steroids play an important part in the functioning of normal gallbladder, formation of gallstones and possibly in the pathogenesis of gallbladder cancer. Steroids receptors have been previously demonstrated on normal and malignant gall bladder tissues. To study this phenomenon further, we correlated clinicopathological features and survival with estrogen receptor (ER) status of the tumour in 30 patients with histologically-proven adenocarcinoma of the gallbladder. Estrogen receptor assay was performed immuno-histochemically utilizing Universal Immunoperoxidase Staining Kit. Tumor tissue was obtained either surgically or with fine needle aspiration of the gallbladder mass. There were 27 females and 3 males. Eighteen patients had estrogen receptors expressed on the malignant tissue, 12 were negative. Comparison of clinicopathological characteristics and survival between the two groups demonstrated no significant difference in gender, mean age, marital status and parity. Similarly, presence of gallstones, histologic grade or survival did not correlate with the estrogen receptor status. There is, however, a trend in favour of poorly differentiated tumors being more often receptor negative. Further studies are necessary to elucidate the biologic significance of these receptors.

Changing patterns and re-distribution of antigen in poorly differentiated carcinomas: its implications in tumour diagnosis

The variability of expression of tumour-associated antigens via either antigenic heterogeneity or antigenic modulation presents a basic problem in immunohistochemical diagnosis of poorly/undifferentiated tumours. This work was designed to study antigenic expression on human resected epithelial tumours by a panel of most widely used antibodies (EMA, CEA, AUAI & Cytokeratin) in relation to tumour differentiation and polarization. It was observed that poorly differentiated carcinoma with loss of polarity show homogeneous membrane staining (with antibodies against EMA, CEA & AUAI) in contrast to either apical (luminal) or basolateral membrane staining in well differentiated counterparts. Biochemical studies have shown that apical and basolateral epithelial cell membrane domains have a characteristic set of glycoproteins. Tight junctions are essential for maintaining this functional polarization. It was concluded that structural and functional abnormalities of tight junctions in poorly differentiated carcinomas results in loss of polarity with progressive invasion of the cell surface by antigenic glycoprotein and resultant homogeneous individual cell antigenic expression in poorly differentiated carcinomas. This study demonstrates that antigenic expression on tumour cells is not static, but dynamic and heterogeneity of antigenic expression may well be due to biological factors such as spatial configuration of the lesion.

Is carcinoma breast a different disease in Pakistani population?

Carcinoma of the breast tends to be different in coloured and white races. Is this pattern also expressed in Pakistani population? To answer this query we carried out a retrospectively study of breast cancer on 193 cases who were divided into 2 groups i.e. less than and more than 50 years age groups. In the former group, 93% tumours were of grades II or III and approximately 51% were estrogen receptors negative. In more than 50 years age group, 75% tumors were in grade II and III, with almost 37% being estrogen negative tumors. Majority (75%) of the patients had over 6 cms lump with equal number having positive lymph node status. All these factors point to the fact that besides presenting late, our population has additional unfavourable prognostic factors.

Clinicopathological features and management of immunoproliferative small intestinal disease and primary small intestinal lymphoma in Pakistan

This study was performed to confirm the existence of immunoproliferative small intestinal disease (IPSID) in Pakistan. Clinicopathological features of 12 patients with histologically confirmed disease were analysed. Patients were mostly young males with median age of 24.6 years. Two thirds belonged to poor socioeconomic class. Main presenting features were chronic diarrhoea and weight loss. Eleven patients had radiologic evidence of malabsorption syndrome. Endoscopic findings of mucosal thickening, edema, and flattened villi were present in the majority. Patients had both secretory and non-secretory types of disease. Six patients presented with stage A disease. Four responded to antibiotics or steroids, although mucosal abnormalities persisted in three. Two stage A patients evolved into stage C disease, one was lost to follow-up, the other is alive with disease. Three patients presented with stage B disease. Two responded completely to chemotherapy, the third refused treatment and expired after 16 months. Three patients had stage C disease at diagnosis. They received aggressive combination chemotherapy and remain in complete remission with a median follow-up of 2.2 years. This is the first series of patients with IPSID reported from Pakistan. Clinicopathological features and therapeutic results are consistent with the experience elsewhere. Increased awareness may result in early diagnosis and better management.