Sirolimus experience in adult patients with vascular malformations

AIM

Sirolimus, a mammalian target of rapamycin inhibitor, inhibits cell growth and proliferation by controlling ribosome biogenesis and protein synthesis in vascular anomalies and cancers. However, most sirolimus studies on vascular anomalies were conducted in the pediatric population, with limited data in adults. In this study, we assessed the effectiveness and safety of sirolimus in adult patients with vascular malformation, a subtype of vascular anomaly.

METHODS

We conducted a retrospective analysis of adult vascular malformation patients aged over 16, treated at Hacettepe University Cancer Institute from January 2013 to September 2022. Patient demographics and clinical characteristics were recorded. The primary outcome was the efficacy of sirolimus evaluated by response and disease control rates. The disease control rate was defined as the cumulative percentage of complete or partial responses, along with stable disease. The secondary endpoint was toxicity and safety.

RESULTS

38 patients with a median age of 21 (IQR: 18-33) were recruited. Prior to sirolimus treatment, 57.9% of patients had undergone other therapeutic interventions, predominantly sclerotherapy and surgery. The median follow-up time during sirolimus treatment was 18.5 (IQR: 11.3-74.5) months. The disease control rate was 92.1% (35/38). Head-neck localization was associated with better response rates (p = .001). Sirolimus was generally well tolerated and grade 1 or 2 oral mucositis (n = 4) and skin rash (n = 3) were the most common side effects.

CONCLUSION

In this study, we found sirolimus was efficacious and well tolerated in adult patients with vascular malformation.

Effect of hypoxia-inducible factor-1 alpha expression on survival in patients with metastatic cervical squamous cell carcinoma treated with first-line chemotherapy and bevacizumab

This study addresses the gap in understanding the prognostic relevance of hypoxia-inducible factor-1 alpha (HIF-1 alpha) expression in metastatic cervical squamous cell carcinoma (SCC) patients undergoing anti-vascular endothelial growth factor-based therapy. A retrospective multicenter study (n = 34) explored HIF-1 alpha expression via immunohistochemistry in patients treated with platinum chemotherapy and bevacizumab. Median progression-free survival (PFS) was significantly lower in the HIF-1 alpha low score group compared to the high score group (4.9 vs 12.9 months, P = 0.014). Similarly, the median overall survival (OS) was significantly reduced in the HIF-1 alpha low score group (8.3 vs 20.4 months, P = 0.006). This study, the first of its kind, highlights the prognostic significance of HIF-1 alpha expression in metastatic cervical SCC patients treated with bevacizumab-based therapy.

Comprehensive analysis of orbital lymphoma in a Turkish cohort: clinical characteristics, histological subtypes, treatment modalities, prognostic factors, and implications for management

The study analysed the clinical characteristics, treatment approaches, and survival outcomes of 97 consecutive patients with orbital lymphoma (OL) over a 25-year period at. The median age of the patients was 57.6 years, and 59.8% (n = 58) were male. Marginal zone lymphoma constitutes the most prevalent subtype, accounting for 67% of cases, whereas other common subtypes include diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, Burkitt lymphoma, and T-cell lymphomas. Unilateral involvement was observed in the majority of cases (72.3%). Common clinical presentations included mass (30.9%), swelling (26.8%), and epiphora (11.3%). Of the patients, 7.2% received rituximab alone, 14.4% received radiotherapy alone, 48.5% received chemotherapy, 27.8% received radiotherapy plus rituximab, 22.7% received radiotherapy plus chemotherapy, and 5.2% underwent surgery as the first-line treatment. During a median follow-up of 4.3 years, 15.5% of patients experienced relapse or disease progression. The 5-year and 10-year progression-free survival rates were 84.1% and 79.1%, respectively. This study contributes to our understanding of OLs and provides a foundation for further investigations in this field. Male gender, presence of B symptoms, advanced stage, secondary orbital lymphoma, aggressive histological subtype, and elevated serum lactate dehydrogenase levels were associated with poorer (either inferior or worse) progression-free survival.

A Single-Center Retrospective Analysis of Kaposi's Sarcoma: Is There a Relationship Between Emmprin/CD147 Expression and Biological Behavior?

OBJECTIVES

Emmprin (CD147/BSG) protein is estimated to play a key role in cell migration and chemoresistance in viral carcinogenesis. However, there are very limited studies investigating the CD147 in the oncogenesis of Kaposi's sarcoma-associated herpesvirus. This study aims to reveal the relationship between CD147 expression with histopathological parameters, disease pattern, and recurrence in Kaposi's sarcoma (KS).

METHODS

The study included 67 patients diagnosed with KS between January 1982 and September 2023. Clinical and histopathological features were analyzed retrospectively. HHV-8, CD31, and CD147 expressions were evaluated by immunohistochemistry.

RESULTS

Sixteen (24%) female and 51 (76%) male patients with median age of 64 (10-86) were included in the study. CD147 was positive in 57 (85%) cases and associated with nodular pattern (P = .001), presence of solid/fibrosarcomatous area (P = .005), and high mitotic activity (P = .035). The disease relapsed in 17 (27%) of the 63 patients with median 2 (0-12) years follow-up. While a 5-year relapse-free survival was 48.5% in the CD147 diffuse positive group, it was 83.4% in focal positive and 100% in negative cases (P = .029).

CONCLUSION

Our study exhibited the relationship between CD147 overexpression and recurrence in KS, but the inhomogeneity of the treatment groups and the small number of patients should also be considered. These findings may provide insight into the pathogenesis of KS and the development of targeted therapies in the future.

The safety and efficacy of first-line atezolizumab plus bevacizumab in patients with unresectable hepatocellular carcinoma: A multicenter real-world study from Turkey

The aim of the study was to evaluate the real-world clinical outcomes of atezolizumab and bevacizumab (Atez/Bev) as the initial therapy for advanced hepatocellular carcinoma (HCC). We retrospectively analyzed 65 patients treated with Atez/Bev for advanced HCC from 22 institutions in Turkey between September 2020 and March 2023. Responses were evaluated by RECIST v1.1 criteria. The median progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Cox regression model was employed to conduct multivariate analyses. The median age was 65 (range, 22-89) years, and 83.1% of the patients were male. A total of 1.5% achieved a complete response, 35.4% had a partial response, 36.9% had stable disease, and 26.2% had progressive disease. The disease control rate was 73.8% and associated with alpha-fetoprotein levels at diagnosis and concomitant antibiotic use. The incidence rates of any grade and grade ≥ 3 adverse events were 29.2% and 10.7%, respectively. At a median follow-up of 11.3 (3.4-33.3) months, the median PFS and OS were 5.1 (95% CI: 3-7.3) and 18.1 (95% CI: 6.2-29.9) months, respectively. In univariate analyses, ECOG-PS ≥ 1 (relative to 0), Child-Pugh class B (relative to A), neutrophil-to-lymphocyte ratio (NLR) > 2.9 (relative to ≤ 2.9), and concomitant antibiotic use significantly increased the overall risk of mortality. Multivariate analysis revealed that ECOG-PS ≥ 1 (HR: 2.69, P = .02), NLR > 2.9 (HR: 2.94, P = .017), and concomitant antibiotic use (HR: 4.18, P = .003) were independent predictors of OS. Atez/Bev is an effective and safe first-line therapy for advanced-stage HCC in a real-world setting. The survival benefit was especially promising in patients with a ECOG-PS score of 0, Child-Pugh class A, lower NLR, and patients who were not exposed to antibiotics during the treatment.

A chance in hopeless cancer: 5-year complete remission after oxaliplatin-based therapy in a patient with BRCA2 mutant metastatic pancreatic cancer

Pancreatic cancer is mostly metastaticat diagnosis. BR east CA ncer gene (BRCA) mutations are associated with platinum sensitivity in metastatic pancreatic cancer. However, curative surgery and complete remission are infrequent. In this report, we present a 42-year-old female patient diagnosed with BRCA-mutated pancreatic cancer with liver metastases. After 12 cycles of FOLFIRINOX, liver metastases disappeared and the patient underwent pancreaticoduodenectomy. The patient has been followed in complete remission for 5 years. To the best of our knowledge, the presented case is the longest recurrence-free survival after platinum-based therapy in metastatic pancreatic cancer with BRCA mutation. Our case emphasizes that investigating BRCA gene mutations at the time of diagnosis can be life-saving in these patients.

A rare benign tumor of the liver mimicking angiosarcoma: Anastomosing hemangioma

Anastomosing hemangioma of the liver (AHL) is a very rare condition and limited to a few cases. It is often confused with well-differentiated angiosarcomas and causes overtreatment. In this report, we present a 53-year-old female patient diagnosed with AHL. Since the tumor is rarely seen, it is important to define well the imaging and pathological features for preventing unnecessary surgeries and related morbidities.

Do statins enhance the antitumor effect of trastuzumab emtansine (T-DM1)?: Real-life cohort

Human epidermal growth factor receptor 2 (HER2)-targeting therapies have become crucial in the management of HER2-positive breast cancer. Trastuzumab emtansine (T-DM1) is a microtubule inhibitor and HER2-targeted antibody conjugate. T-DM1 resistance is most likely influenced by factors involved in the biological mechanisms of T-DM1 action. This study aimed to examine the efficacy of statins, which influence HER-2-based therapies via the caveolin-1 (CAV-1) protein, in female breast cancer patients receiving T-DM1. Our study included 105 patients with HER2-positive metastatic breast cancer treated with T-DM1. The progression-free survival (PFS) and overall survival (OS) of patients who received statins concurrently with T-DM1 versus those who did not were compared. During the median 39.5 (95% confidence interval [CI]: 35.6-43.5) months of follow-up, 16 (15.2%) patients received statins, and 89 (84.8%) patients did not. Median OS was significantly higher in patients using statins than in patients not using statins (58.8 vs 26.5 months, P = .016). The association between statin use and PFS did not reach statistical significance (34.7 vs 9.9 months, P = .159). Multivariate Cox regression analysis showed that better performance status (hormone receptor [HR]: 0.30, 95% CI: 0.13-0.71, P = .006), use of trastuzumab plus pertuzumab prior to T-DM1 (HR: 0.37, 95% CI: 0.18-0.76, P = .007) and use of statins with T-DM1 (HR: 0.29, 95% CI: 0.12-0.70, P = .006) were independent factors that prolong OS duration. Our study showed that T-DM1 is more effective at treating HER2-positive breast cancer in people who receive statins concurrently with T-DM1 than those who do not.

[Q Fever Endocarditis-Associated Immune Complex-Mediated Proliferative Glomerulonephritis: Fourth Case from Türkiye]

Q fever is a zoonosis caused by the intracellular gram-negative bacterium Coxiella burnetii. Infection can be asymptomatic, acute or can cause chronic disease. Chronic disease often presents with infective endocarditis (IE). Diagnosis of IE is difficult because the agent does not grow easily in standard blood cultures and valve vegetations are difficult to detect. Glomerular involvement in patients with Q fever endocarditis is limited to the case reports. In addition, a total of three cases of Q fever endocarditis from Türkiye have been published so far. In this case report, a fourth case of Q fever endocarditis from Türkiye accompanied by immune complex-mediated glomerulonephritis was presented. A 35-year-old male patient with a history of mitral and aortic heart valve replacement was admitted with complaints of fever, night sweats and involuntary weight loss. Cervical lymphadenopathy and hepatosplenomegaly were found during the examination. Laboratory investigations revealed anemia inflammation, acute kidney injury (AKI), hematuria and proteinuria. While no causative agent was detected in blood and urine cultures, no diagnosis could be made as a result of bone marrow and cervical lymph node biopsies.Transesophageal echocardiography was performed for the etiology of fever and revealed 7 mm vegetation on the prosthetic mitral valve. C.burnetii phase 1 IgG tested with indirect immunofluorescent antibody method was reported positive at 1/16384 titer and doxycycline and hydroxychloroquine treatments were initiated. Kidney biopsy for the etiology of AKI revealed focal segmental endocapillary proliferative glomerulonephritis with C3, C1q and IgM immunocomplex deposition. After the addition of methylprednisolone to the treatment, the patient's symptoms improved and creatinine and proteinuria levels decreased dramatically. Although Q fever is endemic in our country, it is detected in fewer numbers than expected. In addition to the difficulties in microbiological and clinical diagnosis, the low awareness of physicians about the disease is one of the important reasons for this situation. When the disease comes to mind, the diagnosis can be easily reached by serological methods. Therefore, Q fever should be investigated in the presence of lymphoproliferative disease-like findings fever of unknown origin and culture-negative endocarditis.

Everolimus and/or Nivolumab-Associated Cytomegalovirus Colitis in a Patient with Metastatic Renal Cell Carcinoma

Everolimus-associated cytomegalovirus colitis is very rare in cancer patients. We present a case of cytomegalovirus colitis that occurred on using everolimus in a 64-year-old male with metastatic renal cell carcinoma who received pazopanib, nivolumab, and everolimus treatments, respectively. Although an increasing number of nivolumab-related cytomegalovirus colitis cases are reported recently, its mechanism of development is still unknown. Our study highlights that clinicians should remember cytomegalovirus reactivation in the presence of diarrhea or colitis in patients receiving everolimus and/or nivolumab. Further studies are needed to elucidate the relationship between immune checkpoint inhibitors and cytomegalovirus reactivation, and these will also be a guide to prevent other possible viral infections.

Lesson learned from the pandemic: Isolation and hygiene measures for COVID-19 could reduce the nosocomial infection rates in oncology wards

Introduction

It was previously demonstrated that seasonal influenza incidence was significantly decreased during the COVID-19 pandemic, possibly due to respiratory and hygiene precautions. From this point, we hypothesized that the COVID-19 precautions could lead to a decrease in nosocomial infection rates in oncology inpatient wards.

Methods

We evaluated the nosocomial infection rates in an inpatient palliative oncology ward in the first 3 months of the COVID-19 pandemic in our country and compared this rate with the same time frame of the previous year in our institution.

Results

The percentage of nosocomial infections complicating the hospitalization episodes were significantly reduced in the first 3 months of the pandemic compared to the previous year (43 vs. 55 nosocomial infection episodes; 18.6% vs. 32.2%, p = 0.002). The decrease in the nosocomial infections was consistent in the different types of infections, namely pneumonia (4.8% vs. 7.6%), urinary tract infection (5.2% vs. 7.6%), bacteremia (5.2% vs. 7%) and intraabdominal infections (2.6% vs. 3.5%). The median monthly disinfectant use was significantly increased to 98 liters (interquartile range: 82 – 114) in 2020 compared to 72 L (interquartile range: 36 – 72) in 2019 (p = 0.046).

Conclusion

The continuation of the simple and feasible hygiene and distancing measures for healthcare workers and patient relatives and adaptations for earlier discharge could be beneficial for preventing nosocomial infections in oncology wards. These measures could be implemented routinely even after the COVID-19 pandemic for patient safety, especially in settings with higher nosocomial infection rates like inpatients palliative care units.

Pulmonary nocardiosis caused by Nocardia abscessus mimicking pulmonary thromboembolism in a patient with atypical anti-glomerular basement membrane glomerulonephritis

Nocardia species are opportunistic bacteria that are frequently contagious by inhalation. Recently, Nocardia abscessus has been described as a different species. We report a 54-year-old male who presented with acute pleuritic chest pain, mimicking pulmonary thromboembolism on the 5th day of discharge from the hospital. The patient was receiving immunosuppressive therapy for newly diagnosed atypical anti-glomerular basement membrane disease. Thorax computed tomography revealed a 17x19 mm soft tissue lesion in the lateral segment of the middle lobe of the right lung. After further examinations, a biopsy decision was made and Nocardia abscessus was isolated in the aerobic culture of the aspiration material.

Importance of combined use of preoperative 18F-FDG PET/CT imaging and intraoperative 18F-FDG handheld gamma probe detection in recurrent papillary thyroid cancer

Radio-guided surgery using an intra-operative positron emission tomography (PET) probe in recurrent thyroid cancer (RTC) can be a useful method for tumor localization, verification of complete excision and to decrease operation time. We describe a case of RTC whose serum thyroglobulin (Tg) level was 5.6ng/mL. Preoperative fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) revealed two focal abnormalities in the anterior tracheal and right upper mediastinal regions and a handheld gamma probe was used intraoperatively to identify the hot areas seen on PET scan. Postoperative ¹⁸F-FDG PET/CT imaging after tumor excision was normal. This case shows that recurrent tumor can be localized correctly using ¹⁸F-FDG PET/CT and a surgical gamma probe.

Fine-needle aspiration washout in the diagnosis of cystic parathyroid adenoma

Cystic parathyroid adenomas are one of the rare causes of neck masses. Due to its rarity, it causes misdiagnosis and wrong treatments and has undesirable consequences. The measurement of parathyroid hormone in fine-needle aspiration washout fluid is a minimally invasive, safe method for the diagnosis of parathyroid cysts and seems to be more useful than Tc-99m sestamibi (MIBI) parathyroid single photon emission computed tomography (SPECT)/CT.