Chloroma of the Bladder: A Case Report of Leukemia Progression Presenting as Hematuria

Myeloid sarcoma (MS) is a rare extramedullary manifestation of acute myelogenous leukemia (AML). The mass is composed of primitive myeloid cells that can occur in a variety of organs, most commonly the skin, lymph nodes, GI tract, bone, breast, and CNS. Involvement of the genitourinary tract is rare. Consensus on treatment of MS has not been established, but management typically involves systemic therapy, such as chemotherapy or allogeneic hematopoietic stem cell transplant as well as palliative local therapies such as radiation or surgery. Outcomes of MS using novel AML therapies, such as BCL-2 inhibitors or IDH inhibitors, remain undescribed. We describe a rare case of a 70-year-old man presenting with MS of the urinary bladder complicating known secondary AML (RUNX1 and IDH2 mutated). Prior to development of bladder MS, the patient had received decitabine, enasidenib, and venetoclax. Following diagnosis, he was treated with cytarabine and venetoclax. To our knowledge, this is the first case of bladder MS treated with a BCL-2 inhibitor.

Alternative chemoradiotherapy in anal carcinoma patients with mutations in thymidylate synthase and dihydropyrimidine dehydrogenase genes

BACKGROUND

5-fluorouracil (5-FU) and mitomycin-C (MMC) with radiotherapy (RT) remain an established treatment for patients with anal cancer (AC). Genetic mutations in two major metabolizing enzymes for 5-FU; dihydropyrimidine dehydrogenase (DPYD and thymidylate synthetase (TYMS), have been associated with clinical response and toxicity. However, their place in the treatment of AC remains undetermined.

METHODS

We retrospectively reviewed 21 patients with AC, including T2-4, N0-1, M0 or T1-4, N2-3, and M0 treated between 2012 and 2018. All patients were treated with 5-FU 1,000 mg/m²/day via continuous intravenous (IV) infusion 1-4 and 29-32, MMC 10 mg/m² IV bolus days 1 and 29 plus RT. Patients who developed ⩾3 grade toxicities were tested for the DPYD and TYMS genes. Treatment was either modified with reduced doses or changed to MMC 10 mg/m² day 1 and 29 with cisplatin 25 mg/m²/week plus RT. Toxicities and responses were collected.

RESULTS

Six out of 21 patients who developed ⩾3 grade toxicities including pancytopenia, neutropenia, thrombocytopenia, mucositis, nausea, rash, and nephritis were found to have genetic mutations: TYMS 2RG/3RC (n = 2), 3RG/3RC (n = 1), 2R/2R (n = 2), TYMS 3'UTR del/Ins (n = 2), and DPYD c.2864A > T heterozygous (n = 1). Two patients received 5-FU at a 50% reduced dose on days 29-32; one patient refused to receive 5-FU (continued with MMC and RT); one patient received only radiation therapy due to persistent pancytopenia despite the use of growth factors; two patients received an alternative regimen consisting of MMC 10 mg/m² on day 29 with cisplatin (CDDP) 25 mg/m²/week plus RT; and two patients received cisplatin/MMC with RT from the beginning as they were prospectively detected to have TYMS abnormalities prior to dosing the chemotherapy. These patients tolerated treatment very well with only grade 2 toxicities. All the patients (4/4) on cisplatin/MMC achieved clinical complete response (cCR), while four patients (4/15) on 5-FU/MMC reached cCR at the first assessment. Radiological response showed complete response at the end of 24 weeks assessment.

CONCLUSIONS

Molecular testing for DPYD and TYMS genes can allow us to identify patients who are most likely to respond or face severe toxicity to 5-FU in a potentially curable cancer. Combining radiation with CDDP with MMC in patients with AC is feasible. A prospective study based on pharmacogenetic testing comparing MMC/cisplatin with MMC/5-FU is indicated in patients with AC.

Association between primary care and acute care services utilization in the year following diagnosis of breast cancer

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Background: Primary care physicians (PCPs) play a pivotal role during cancer diagnosis. Lack of access to primary care has been linked to worse outcomes including increased mortality in patients with cancer. Higher PCP continuity of care has been associated with lower likelihood of acute care services use among breast cancer survivors, however the impact of PCP utilization is not well studied in those newly diagnosed. This study examines the association between PCP visits and emergency department (ED) use and hospitalization in the year following diagnosis of breast cancer. Methods: Electronic medical records of women newly diagnosed with primary breast cancer from 2013 to 2019 at a single institution (Tufts Medical Center, Boston, Massachusetts) with an established PCP in the same system were retrospectively reviewed. Demographic (age at diagnosis, menopausal status, race/ethnicity), clinical (Charlson Comorbidity Index (CCI), Eastern Cooperative Oncology Group (ECOG) performance status, body mass index, mental health disorder, chronic pain syndrome), and tumor (histology, stage, grade, hormone receptor (HR) positivity, HER2 status) characteristics were extracted in addition to information on treatment modalities (if patient received surgery, radiation (RT), chemotherapy (CT), endocrine therapy (ET), ovarian suppression (OFS)). Univariate and multivariate logistic regression models were used to examine associations between frequency of PCP visits and ED use and hospitalizations within a year after diagnosis of breast cancer. Results: Of 182 women ages 33-93 (mean 60) years old, 131 (72%) were postmenopausal, 116 (64%) Caucasian; 176 (97%) had stages 1-3, and 157 (86%) had HR positivity. In the year following diagnosis, 178 (98%) received surgery, 127 (67%) RT, 142 (78%) ET, 19 (10%) OFS, 70 (39%) CT; 68 (37%) had ≤1 PCP visit, and 45 (25%) had 4-10 PCP visits. Increased PCP visits correlated with advancing age, increased BMI, greater mental health disorders and chronic pain syndromes, and increasing CCI and ECOG score. After adjusting for these confounders and tumor and treatment characteristics, logistic regressions showed that while frequency of PCP visits was not associated with hospitalizations (univariate: OR = 1.02, 95% CI [0.53, 1.62], p = 0.93; multivariate: OR = 0.35, 95% CI [0.05, 1.50], p = 0.184), increased PCP visits tended toward association with increased ED use (univariate: OR = 1.12, 95% CI [0.97,1.29], p = 0.124; multivariate: OR = 1.15, 95% CI [0.94, 1.41], p = 0.188), however did not demonstrate statistical significance. Conclusions: Primary care utilization was not associated with acute care services utilization in women newly diagnosed with breast cancer. Higher PCP utilization tended toward correlation with increased ED use. These findings may help in evaluating multidisciplinary care support in patients newly diagnosed with breast cancer.

Alternative chemoradiotherapy to treat locally advanced (LA) anal carcinoma (AC) in patients (pts) with mutations in thymidylate synthase (TYMS) and dihydropyrimidine dehydrogenase (DPYD) genes: A case series

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Background: 5-FU and mitomycin-C (MMC) with radiotherapy (RT) remain an established treatment for pts with LA (T2-4, N0-1, M0 or T1-4, N2-3, M0) AC. Genetic mutations in 2 major metabolizing enzymes for 5-FU; DPYD and TYMS have been associated with clinical response and toxicity. However their place in treatment of AC remains undetermined. Methods: We retrospectively reviewed 21 pts with LA AC treated between 2012 - 2018. All pts were treated with 5-FU 1,000mg/m2/day continuous IV infusion 1–4 and 29–32, MMC 10mg/m2 IV bolus Days 1 and 29 plus RT. Acute toxicity was recorded and discussed during weekly multidisciplinary meetings. The worst grade was scored from start of treatment until 30 days after the last fraction of radiotherapy according to the NCI-CTCAE, v4.03. Tumor response was evaluated by DRE and palpation of inguinal nodes during treatment, at the end of treatment, and radiological imaging 4–6 weeks after completion of treatment. Pts who developed ≥3 toxicities were tested for DPYD and TYMS genes (2 major polymorphisms has been associated with altered TYMS: polymorphic 28bp tandem repeat polymorphism in 5’-untranslated region (5’UTR) into TYMS sequence enhancer region (TSER) and TYMS 1494del, is a 6-base pair (bp) deletion polymorphism in 3’-UTR. Results: 6/21 ptsdeveloped severe toxicities (Caucasians; 5 females, 1 male; age range: 42 -68 yrs) consisting of grade ≥3 pancytopenia, neutropenia, thrombocytopenia, mucositis, nausea, rash and nephritis. The most common genetic mutations found in these pts included TYMS 2RG/3RC (2), 3RG/3RC (1), 2R/2R (2), TYMS 3 ' UTR del/Ins (2) and DPYD c.2864A>T heterozygous (1). Treatment was changed in 2 pts to MMC 10 mg/m2 Day 1 and 29 with cisplatin 25 mg/m2/week plus RT. These 2 pts reached pCR at 70 days and other 4 pts at 140 days. Conclusions: Molecular testing for DPYD and TYMS genes can allow us to identify pts who are most likely to respond or face severe toxicity to 5-FU. Combining radiation with MMC and cisplatin in pts with LA AC is feasible and EORTC is currently comparing this combination with MMC/5-FU in a large phase III trial.

Is more surgery better for patients with gallbladder cancer? A survival analysis of extended versus simple cholecystectomy

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Background: Gallbladder cancer (GBC) is a rare cancer; the minority of patients have resectable tumor at diagnosis. Based on retrospective, single-institution data, extended cholecystectomy (EXT) has been recommended over simple cholecystectomy (CHOL) in >T1 tumors; however, effect of EXT on survival is unclear. Thus, we evaluated the survival of patients with resectable GBC at our institution. Methods: Retrospective analysis from 1/1/2005 to 1/1/2016 for patients with GBC. Patients with advanced or metastatic disease were excluded. The Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Results: 68 patients with GBC; 26 (38%) with early disease. Twelve patients had EXT. Patient/tumor characteristics are shown in Table. Median RFS was 22 months (95% CI: 9-not reached) and OS was 25 months (95% CI: 15-not reached) for the entire cohort. Median RFS was increased in CHOL (30 months) relative to EXT (9 months); p=0.73. OS appeared similar between the two groups (25 vs. 23 months for CHOL and EXT group, respectively). Conclusions: EXT appears to improve RFS with no effect on OS in patients with early GBC. Due to the limitations of small sample size and retrospective analysis, multi-institutional collaborations are necessary to better identify optimal management. [Table: see text]

Toxicity disparities between Hispanics and non-Hispanics enrolled in clinical trials in south Texas

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Background: The U.S. Hispanic (H) population is estimated to increase from 55 million in 2014 to 119 million in 2060, growing from 17% to 29% of the total population. H are underrepresented in cancer trials. A review of practice-changing oncology trials showed only 3.9% of included patients were H. Disparities have been identified in time to diagnosis, treatment and outcomes in H patients, including those on clinical trials, despite uniform stage, treatment, and follow-up. Given our institution’s history of strong H accrual, we aimed to look at the rate of enrollment and toxicity in our early phase cancer trials of H compared with non-Hispanic whites (NHW). Methods: We retrospectively reviewed charts of patients enrolled in Phase I trials at UTHSCSA to assess rates of selected toxicities, death, hospitalizations and reasons for withdrawal from phase 1 trials. The following toxicities were recorded: anemia, neutropenia, neuropathy, nausea, vomiting, and fatigue. All H patients were compared to randomly selected statistical controls. Patients who were on multiple trials were excluded. Results: Of the 520 patients reviewed, 376 (72.3%) self-identified as H, 123(23.7%) as NHW, and 448 (86.2%) of patients had a solid tumor diagnosis. H and NHW with solid tumors are compared in the Table. They were similarly matched for sex, but H were noted to be older and more likely to receive cytotoxic therapy. Rates of patients experiencing any grade 3/4 toxicity or hospitalization were similar as shown. H were more likely to withdraw from trial due to disease progression. Conclusions: This retrospective analysis shows H patients did not experience significantly more toxicities in early phase clinical trials at an academic center in a minority-majority community. Prospective data collection is needed to provide more detailed information in the disparities that exist in toxicity and outcomes in H compared with NHW in cancer trials. [Table: see text]

Sideroblastic anemia

Sideroblastic anemias are a heterogenous group of disorders that have as a common feature with the presence of ringed sideroblasts in the marrow. We present a case of young female, nursing student who presented with increasing palpitation, fatigue and exertional shortness of breath for the last one year. She had a low hemoglobin and high serum iron. Anemia with iron overload prompted us to do bone marrow study and there were 19% ringed sideroblasts and iron overload fulfilling the diagnosis of sideroblastic anemia. We searched for secondary causes of ringed sideroblast but could not find any culprit. Her cytogenetics report was normal and genetic analysis was not done due to financial reason. Since the diagnosis 3 months back, patient is on pyridoxine, folic acid, deferasirox and still needs regular blood transfusion suggesting that she may be pyridoxine refractory and may develop iron overload.