VITREOUS SEEDING OF RENAL CELL CARCINOMA IN A PATIENT RECEIVING CHECKPOINT INHIBITORS

PURPOSE

To describe a case of vitreous seeding with tractional retinal detachment as a result of metastatic renal cell carcinoma in a patient on systemic checkpoint inhibitors.

METHODS

Case report.

RESULTS

A 44-year-old Hispanic woman with a history of renal cell carcinoma with metastases to the lungs, adrenal glands, hilar lymph nodes, and peritoneum presented with a complaint of severe floaters and blurry vision of the right eye for two months. She was found to have dense, web-like vitreous opacities and a peripheral tractional retinal detachment of the right eye. Pars plana vitrectomy, membrane peeling, endolaser, air-fluid exchange, gas injection, and vitreous biopsy were performed. The vitreous and membranes were sent for cytology with stains, including AE1/AE3, PAX-8, CK-7, CA-IX, AMACR, and S-100. Cytology revealed crowded groups of glandular cells, some in papillary-like formations. Positive stains included AE1/AE3, PAX-8, CK-7, CA-IX, and AMACR.

CONCLUSION

Cytology and pathology demonstrated that vitreous seeding of metastatic renal cell carcinoma without an ocular mass lesion. It is hypothesized that the use of checkpoint inhibitors played a role in allowing for the atypical and previously unreported seeding of renal cell carcinoma to the vitreous.

Analysis of Posterior Vitreous Detachment and Development of Complications Using a Large Database of Retina Specialists

PURPOSE

To examine the incidence of complications after posterior vitreous detachment (PVD) through an extended follow-up period and to identify patient-specific factors associated with a greater incidence of complication.

DESIGN

Multicenter, retrospective observational study.

PARTICIPANTS

Eyes with acute PVDs between 2015 and 2019 were identified through the Vestrum Health database.

METHODS

Complications (vitreous hemorrhage, retinal break, and retinal detachment) were evaluated after acute PVD at presentation and throughout the 6-month follow-up period.

MAIN OUTCOME MEASURES

Rate of complications throughout the 6 month follow-up period after PVD and odds of complications by patient-specific factors.

RESULTS

A total of 9635 eyes were included. The rate of any complication was 25.0%, isolated vitreous hemorrhage was 13.1%, retinal breaks without detachment was 16.0%, and retinal detachment was 4.2%. The majority of each complication was noted at presentation; however, 8.0% of isolated vitreous hemorrhages, 19.2% of retinal breaks without detachment, and 25.8% of retinal detachments were first noted within the 6-month follow-up period. Men experienced a significantly higher rate of any complication than women (30.0% versus 21.7%, P < 0.001), as well as retinal breaks and retinal detachments at both presentation and within 6-month follow-up. Patients with pseudophakia experienced significantly higher rates of delayed retinal detachment than phakic eyes (odds ratio, 1.85 [1.13, 3.04], P = 0.01). Among eyes with lattice/peripheral retinal degeneration, 44.2% experienced any complication throughout the clinical course. The presence of a retinal break in the fellow eye and retinal detachment in the fellow eye was associated with a significantly increased rate of any complication at any time point (retinal break: P < 0.0001; retinal detachment: P = 0.02), as well as each individual complication within the 6 month follow-up period. Among eyes with vitreous hemorrhage at presentation, 42.0% had a concurrent or delayed retinal break and 10.5% had concurrent or delayed retinal detachments.

CONCLUSIONS

A clinically significant proportion of PVD-related complications are detected late, warranting extended follow-up, especially in higher-risk groups such as men, pseudophakic eyes, eyes with lattice/peripheral retinal degeneration, and eyes with a history of retinal breaks or detachment in the fellow eye.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Total circulating cell-free DNA as a prognostic biomarker in metastatic colorectal cancer before first-line oxaliplatin-based chemotherapy

BACKGROUND

Metastatic colorectal cancer (mCRC) is a heterogeneous disease where prognosis is dependent both on tumor biology and host factors. Total circulating cell-free DNA (cfDNA) has shown to harbor prognostic information in mCRC, although less is known about the biological correlates of cfDNA levels in this patient group. The primary objective was to evaluate the prognostic value of pretreatment cfDNA in patients receiving the first-line oxaliplatin-based chemotherapy for mCRC, by using a predefined upper limit of normal (ULN) from a cohort of presumed healthy individuals. The secondary objective was to model cfDNA levels as a function of predefined tumor and host factors.

PATIENTS AND METHODS

This was a retrospective post hoc study based on a prospective multicenter phase III trial, the NORDIC-VII study. DNA was purified from 547 plasma samples and cfDNA quantified by a droplet digital PCR assay (B2M, PPIA) with controls for lymphocyte contamination. Main clinical end point was overall survival (OS).

RESULTS

cfDNA was quantified in 493 patients, 54 were excluded mainly due to lymphocyte contamination. Median cfDNA level was 7673 alleles/ml (1050-1 645 000) for B2M and 5959 alleles/ml (555-854 167) for PPIA. High cfDNA levels were associated with impaired outcome; median OS of 16.6 months for levels above ULN and 25.9 months for levels below ULN (hazard ratio = 1.83, 95% confidence interval 1.51-2.21, P < 0.001). The result was confirmed in multivariate OS analysis adjusting for established clinicopathological characteristics. A linear regression model predicted cfDNA levels from sum of longest tumor diameters by RECIST, the presence of liver metastases and systemic inflammatory response as measured by interleukin 6 (F(6, 357) = 62.7, P < 0.001).

CONCLUSION

cfDNA holds promise as a minimally invasive and clinically relevant prognostic biomarker in mCRC before initiating first-line oxaliplatin-based chemotherapy and may be a complex entity associated with tumor burden, liver metastases and systemic inflammatory response.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00145314.

Investigation of goldmann perimetry in evaluation of patients for upper eyelid blepharoplasty

PURPOSE

To determine if preoperative Goldmann Visual Field (GVF) testing in patients with functional dermatochalasis accurately depicts the postoperative superior visual field (SVF) outcome.

METHODS

A prospective cohort study was done to compare preoperative and postoperative GVF field tests in patients undergoing upper eyelid blepharoplasty for treatment of dermatochalasis. This study was conducted in accordance with the Declaration of Helsinki and approved by the University of Arkansas for Medical Sciences institutional review board. A preoperative GVF was obtained with the eyelids in the natural position (untaped) and then again with excess skin elevated (taped). One month post-blepharoplasty, another GVF was conducted with eyelids untaped. The pre- and post GVF tests were analyzed to determine if preoperative testing accurately predicts the SVF improvement post-blepharoplasty.

RESULTS

Forty-six eyelids (23 patients) who underwent blepharoplasty for dermatochalasis were included. The preoperative testing underestimated 76% (35/46) of cases by a mean of 61%; and overestimated the final outcome in 24% (11/46) of cases by mean of 23%. Overall, the preoperative GVF testing underestimated the postoperative outcome by a mean of 35%.

CONCLUSION

Improvement of the SVF after a blepharoplasty is typically greater than the preoperative GVF testing predicts.

Results of a phase 1 trial combining ridaforolimus and MK-0752 in patients with advanced solid tumours

BACKGROUND

The phosphatidylinositol 3-kinase/protein kinase-B/mammalian target of rapamycin (PI3K-AKT-mTOR) signalling pathway is aberrantly activated in several cancers. Notch signalling maintains cell proliferation, growth and metabolism in part by driving the PI3K pathway. Combining the mTOR inhibitor ridaforolimus with the Notch inhibitor MK-0752 may increase blockade of the PI3K pathway.

METHODS

This phase I dose-escalation study (NCT01295632) aimed to define the dose-limiting toxicities (DLTs) and maximum tolerated dose (MTD) of combination oral ridaforolimus (rising doses starting at 20 mg, 5 days/week) and oral MK-0752 (1800 mg once weekly) in patients with solid tumours. No intrapatient dose escalation was permitted.

RESULTS

Twenty eight patients were treated on study. Ridaforolimus doses were escalated from 20 to 30 mg/day. Among 14 evaluable patients receiving ridaforolimus 20 mg, one DLT (grade 2 stomatitis, second episode) was reported. Among eight evaluable patients receiving ridaforolimus 30 mg, three DLTs were reported (one each grade 3 stomatitis, grade 3 diarrhoea, and grade 3 asthenia). The MTD was 20 mg daily ridaforolimus 5 days/week+1800 mg weekly MK-0752. The most common drug-related adverse events included stomatitis, diarrhoea, decreased appetite, hyperglycaemia, thrombocytopenia, asthenia and rash. Two of 15 (13%) patients with head and neck squamous cell carcinoma (HNSCC) had responses: one with complete response and one with partial response. In addition, one patient experienced stable disease ⩾6 months.

CONCLUSIONS

Combined ridaforolimus and MK-0752 showed activity in HNSCC. However, a high number of adverse events were reported at the MTD, which would require careful management during future clinical development.

The relationship between activation of phosphoinositide-specific phospholipase C and growth stimulation by Ca2+-mobilizing hormones in hepatocytes

Previous studies have shown that while vasopressin and angiotensin II are markedly more effective than norepinephrine and prostaglandin F2alpha in eliciting an acute elevation of inositol 1,4,5-trisphosphate (IP3), norepinephrine and prostaglandin F2alpha produce larger enhancement of DNA synthesis. This suggests that the initial activation of phosphoinositide-specific phospholipase C is not a common factor for the growth response to these agonists, but does not exclude a role of the integral of phospholipase C activity over a prolonged part of the prereplicative period, during which agonist-specific changes in responsiveness might occur. We show that vasopressin and angiotensin II also cause a prolonged elevation of cellular IP3 levels. which remain elevated for at least 60 min., while norepinephrine and prostaglandin F2alpha elevate IP3 levels slightly and transiently For vasopressin the dose-effect curves for IP3 accumulation and stimulation of DNA synthesis were closely parallel, while this was not the case for angiotensin II, norepinephrine, or prostaglandin F2alpha. After cultivation of the hepatocytes, hormone-stimulated IP3 accumulation rapidly declined, particularly in response to norepinephrine and prostaglandin F2alpha. When the IP3 response to norepinephrine and prostaglandin F2alpha was completely down-regulated, these agonists still enhanced the DNA synthesis. These results suggest that other mechanisms in addition to IP3 accumulation and Ca2+ release are likely to be involved in the growth stimulatory effects of the Ca2+-mobilizing agonists studied here, in particular for angiotensin II, norepinephrine, and prostaglandin F2alpha.

Trauma management in a war zone: the Lebanese war experience

Lessons learned from the Vietnam and Korean conflicts have emphasized the necessity of an organized preparedness for optimal management of casualties. The present report summarizes the experience of a tertiary care center in the present Lebanese war. Between 1975 and 1986, approximately 30,000 war casualties were treated at the American University of Beirut Medical Center (AUBMC). A disaster plan was implemented whenever more than 25 major trauma victims were received within 1 hour. In-field stabilization and emergency room (ER) thoracotomy were not employed. The results are illustrated by an analysis of 1,500 cases of abdominal trauma, (1,314 high-velocity gunshot wounds, 29 stab wounds, 157 blunt injuries). A total of 1,420 patients were operated on within 6 hours of admission and 711 within the first hour. Overall mortality was 130, 8.7%; 9.5% for gunshot wounds, 3.4% for stab wounds, and 2.5% for blunt trauma. One hundred forty-five patients or 9.7% had negative findings at laparotomy. The factors affecting mortality were hypotension on admission (26.5% for a BP less than 90 mm Hg and 2.8% for a BP higher than 90 mm Hg) and the presence of extra-abdominal injuries (14.4% with and 4.4% without). The chief causes of death were hemorrhage (3.7%), sepsis (2.1%), and ARDS (1.2%).