Impact of the COVID-19 Pandemic on a Cancer Fast-Track Programme

Introduction

The COVID-19 pandemic has disrupted many aspects of clinical practice in oncology, particularly regarding early cancer diagnosis, sparking public health concerns that possible delays could increase the proportion of patients diagnosed at advanced stages. In 2009, a cancer fast-track program (CFP) was implemented at the Clinico-Malvarrosa Health Department in Valencia, Spain with the aim of shortening waiting times between suspected cancer symptoms, diagnosis and therapy initiation.

Objectives

The study aimed to explore the effects of the COVID-19 pandemic on our cancer diagnosis fast-track program.

Methods

The program workflow (patients included and time periods) was analysed from the beginning of the state of alarm on March 16th, 2020 until March 15th, 2021. Data was compared with data from the same period of time from the year before (2019).

Results

During the pandemic year, 975 suspected cancer cases were submitted to the CFP. The number of submissions only decreased during times of highest COVID-19 incidence and stricter lockdown, and overall, referrals were slightly higher than in the previous 2 years. Cancer diagnosis was confirmed in 197 (24.1%) cases, among which 33% were urological, 23% breast, 16% gastrointestinal and 9% lung cancer. The median time from referral to specialist appointment was 13 days and diagnosis was reached at a median of 18 days. In confirmed cancer cases, treatment was started at around 30 days from time of diagnosis. In total, 61% of cancer disease was detected at early stage, 20% at locally advanced stage, and 19% at advanced stage, displaying time frames and case proportions similar to pre-pandemic years.

Conclusions

Our program has been able to maintain normal flow and efficacy despite the challenges of the current pandemic, and has proven a reliable tool to help primary care physicians referring suspected cancer patients.

Ten-year assessment of a cancer fast-track programme to connect primary care with oncology: reducing time from initial symptoms to diagnosis and treatment initiation

Background

Cancer is the second leading cause of mortality worldwide. Integrating different levels of care by implementing screening programmes, extending diagnostic tools and applying therapeutic advances may increase survival. We implemented a cancer fast-track programme (CFP) to shorten the time between suspected cancer symptoms, diagnosis and therapy initiation.

Patients and methods

Descriptive data were collected from the 10 years since the CFP was implemented (2009-2019) at the Clinico-Malvarrosa Health Department in Valencia, Spain. General practitioners (GPs), an oncology coordinator and 11 specialists designed guidelines for GP patient referral to the CFP, including criteria for breast, digestive, gynaecological, lung, urological, dermatological, head and neck, and soft tissue cancers. Patients with enlarged lymph nodes and constitutional symptoms were also considered. On identifying patients with suspected cancer, GPs sent a case proposal to the oncology coordinator. If criteria were met, an appointment was quickly made with the patient. We analysed the timeline of each stage of the process.

Results

A total of 4493 suspected cancer cases were submitted to the CFP, of whom 4019 were seen by the corresponding specialist. Cancer was confirmed in 1098 (27.3%) patients: breast cancer in 33%, urological cancers in 22%, gastrointestinal cancer in 19% and lung cancer in 15%. The median time from submission to cancer testing was 11 days, and diagnosis was reached in a median of 19 days. Treatment was started at a median of 34 days from diagnosis.

Conclusions

The findings of this study show that the interval from GP patient referral to specialist testing, cancer diagnosis and start of therapy can be reduced. Implementation of the CFP enabled most patients to begin curative intended treatment, and required only minimal resources in our setting.

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Our CFP easily connects GPs and hospital specialists.

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Our CFP shortens assessment time in patients with suspected cancer, adding to quality care.

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Our CFP decreases emotional stress in patients without cancer.

Impact of different strategies of second-line stem cell harvest on the outcome of autologous transplantation in poor peripheral blood stem cell mobilizers

The optimal approach to obtain an adequate graft for transplantation in patients with poor peripheral blood stem cell (PBSC) mobilization remains unclear. We retrospectively assessed the impact of different strategies of second-line stem cell harvest on the transplantation outcome of patients who failed PBSC mobilization in our institution. Such patients were distributed into three groups: those who proceeded to steady-state bone marrow (BM) collection (group A, n = 34); those who underwent second PBSC mobilization (group B, n = 41); those in whom no further harvesting was carried out (group C, n = 30). PBSC harvest yielded significantly more CD34+ cells than BM collection. Autologous transplantation was performed in 30, 23 and 11 patients from groups A, B and C, respectively. Engraftment data and transplantation outcome did not differ significantly between groups A and C. By contrast, group B patients had a faster neutrophil recovery, required less platelet transfusions and experienced less transplant-related morbidity, as reflected by lower antibiotics needs and shorter hospital stays. In conclusion, remobilization of PBSC constitutes an effective approach to ensure a rapid hematopoietic engraftment and a safe transplantation procedure for poor mobilizers, whereas unprimed BM harvest does not provide any clinical benefit in this setting.

[The value of orbit magnetic resonance imaging in the diagnosis of blindness caused by giant cell arteritis]

INTRODUCTION

Giant cell arteritis (GCA) is a chronic vasculitis of middle-sized and large calibre vessels which occurs mainly in individuals aged over the age of 50. It chiefly affects the cranial branches of the arteries that originate in the aortic arch. Its most important characteristic symptoms include visual disorders, especially loss of sight; bilateral blindness, however, is infrequent.

CASE REPORT

We describe the case of an 81-year-old female who visited because of sudden blindness and bilateral retroocular pain. The neurological exploration only revealed bilateral amaurosis, dilated pupils with the phenomenon of papillary escape, and no alterations to the ocular fundus. Laboratory tests showed a haemoglobin level of 12 mg/dL, ESR of 71 mm/hr and CRP of 2.3. Magnetic resonance imaging (MRI) and computerised tomography of the brain without intravenous contrast showed findings compatible with small vessel ischemic phenomena. Because a vasculitic process was suspected, orbit RMI was performed and revealed signal hyperintensity in the soft intraconal parts with respect to the extraocular muscles. A biopsy study of the left temporal artery was compatible with GCA.

CONCLUSIONS

In cases of GCA with an atypical visual presentation, finding enhancement of the intraconal fat or of the optic nerve sheath in the RMI can support the suspicion of an arteritic process.

Soluble intercellular adhesion molecule-1 (s-ICAM-1/s-CD54) in diffuse large B-cell lymphoma: association with clinical characteristics and outcome

BACKGROUND

High serum levels of soluble intercellular adhesion molecule-1(s-ICAM-1/s-CD54) have been associated with adverse clinical features and poor outcome in chronic lymphocytic leukemia, Hodgkin's disease and non-Hodgkin's lymphoma, but their value in the different subtypes of non-Hodgkin's lymphoma has not been well addressed.

PATIENTS AND METHODS

Our aim was to study the serum levels of s-ICAM-1 in diffuse large B-cell lymphoma (DLBCL) and to correlate them with clinical characteristics and outcome. We analyzed the serum levels of s-ICAM-1 in a series of 55 patients with DLBCL diagnosed in a single institution. s-ICAM-1 levels were quantified by an immunoenzymatic assay. Median age was 62 years (range 22-96); 29 (53%) were male. Twenty-eight (51%) presented with advanced clinical stage (III/IV), 32 (58%) had extranodal involvement, 28 (51%) had high serum lactate dehydrogenase (LDH) and 23 (43%) had high beta2-microglobulin levels. All patients received anthracycline-containing regimens. Correlation between clinical variables and s-ICAM-1 levels were tested with the Mann-Whitney U-test and survival was plotted by the Kaplan-Meier method, and curves compared with the log-rank test.

RESULTS

Serum levels of s-ICAM-1 were significantly increased in patients with DLBCL compared with normal controls (589 +/- 487 versus 279 +/- 65 ng/ml, respectively; P <0.001). Higher levels of s-ICAM-1 were present in patients with B symptoms, advanced stage and increased LDH and beta2-microglobulin. s-ICAM-1 levels also correlated with achievement of a complete response. Patients with s-ICAM-1 over 668 ng/ml had a shorter time to treatment failure (TTF) (3-year TTF, 59% versus 20%, respectively; P = 0.01) and overall survival (OS) (3-year OS, 58% versus 22%, respectively; P = 0.04) than the remainders. When only low and low-intermediate risk patients in the international prognostic index score were considered, those with s-ICAM-1 over 668 ng/ml also had worse TTF and OS.

CONCLUSIONS

In DLBCL, s-ICAM-1 levels correlated with high tumor burden and lymphoma dissemination and may contribute to assessment of prognosis.

Changes in P-glycoprotein expression in gastric carcinoma with respect to distant gastric mucosa may be influenced by p53

BACKGROUND

The effectiveness of some chemotherapeutic agents used to treat gastric carcinoma patients may be impaired by the presence of P-glycoprotein (P-gp) and the status of p53. A modulation of P-gp expression by p53 or other alterations during tumorigenesis have been reported. The authors analyzed P-gp expression in relation to p53 and histopathologic features in gastric carcinoma.

METHODS

Forty-one resected gastric carcinomas and mucosa distant from the tumor were assessed for P-gp expression by immunohistochemistry with C494 and JSB-1 antibodies. p53 expression was also immunohistochemically assessed by DO7 antibody in tumor samples. P-gp and p53 expression were semiquantitatively analyzed according to the percentage of stained cells. Histologic type, grade, vessel invasion, and stage were also studied.

RESULTS

Moderate or high P-gp expression was detected in gastric carcinoma in 29 cases (71%) and in gastric mucosa remote from the tumor in 36 cases (88%). This reduction in P-gp expression was observed in 22% of the carcinomas, all but 1 being p53 immunonegative tumors. Thus, 8 (42%) of the p53 immunonegative carcinomas showed a loss of P-gp expression compared with their distant gastric mucosa. All p53 immunopositive carcinomas coexpressed P-gp. No correlation between P-gp expression and histologic type, grade, vessel invasion, or stage was found.

CONCLUSIONS

P-gp expression in gastric carcinomas is frequent and coexpression with p53 is found. The analysis of P-gp expression in carcinomas and distant mucosa show that it is not regulated by p53, but a loss of P-gp detected in some of these carcinomas is mainly associated with a lack of p53 protein accumulation.

Changes in P-glycoprotein expression in gastric carcinoma with respect to distant gastric mucosa may be influenced by p53

BACKGROUND

The effectiveness of some chemotherapeutic agents used to treat gastric carcinoma patients may be impaired by the presence of P-glycoprotein (P-gp) and the status of p53. A modulation of P-gp expression by p53 or other alterations during tumorigenesis have been reported. The authors analyzed P-gp expression in relation to p53 and histopathologic features in gastric carcinoma.

METHODS

Forty-one resected gastric carcinomas and mucosa distant from the tumor were assessed for P-gp expression by immunohistochemistry with C494 and JSB-1 antibodies. p53 expression was also immunohistochemically assessed by DO7 antibody in tumor samples. P-gp and p53 expression were semiquantitatively analyzed according to the percentage of stained cells. Histologic type, grade, vessel invasion, and stage were also studied.

RESULTS

Moderate or high P-gp expression was detected in gastric carcinoma in 29 cases (71%) and in gastric mucosa remote from the tumor in 36 cases (88%). This reduction in P-gp expression was observed in 22% of the carcinomas, all but 1 being p53 immunonegative tumors. Thus, 8 (42%) of the p53 immunonegative carcinomas showed a loss of P-gp expression compared with their distant gastric mucosa. All p53 immunopositive carcinomas coexpressed P-gp. No correlation between P-gp expression and histologic type, grade, vessel invasion, or stage was found.

CONCLUSIONS

P-gp expression in gastric carcinomas is frequent and coexpression with p53 is found. The analysis of P-gp expression in carcinomas and distant mucosa show that it is not regulated by p53, but a loss of P-gp detected in some of these carcinomas is mainly associated with a lack of p53 protein accumulation.

PCR analysis in the pathological diagnosis of Whipple's disease: emphasis on extraintestinal involvement or atypical morphological features

PCR analysis of species-specific bacterial 16S rRNA gene of Tropheryma whippelii was performed in biopsies from 10 cases of Whipple's disease (WD). In seven patients showing the typical clinical picture of WD, PCR was performed on the diagnostic intestinal biopsy. In the remaining three cases (an autopsy case of disseminated WD and two patients showing lymphadenopathy as the initial clinical presentation), PCR was done on lymph node specimens. In one of the lymph node biopsies, an unusual sarcoidlike granulomatous reaction had led to the diagnosis of sarcoidosis. The specific bacterial DNA was detected in all cases, both in intestinal biopsies and in lymph node specimens. Follow-up biopsies after antibiotic therapy were evaluated in two patients. The two follow-up biopsies were negative, although in both of them scattered nests of PAS-positive macrophages remained. The results of this study suggest that PCR analysis of species-specific sequences of the 16S rRNA of Tropheryma whippelii is a very useful tool for the pathological diagnosis of WD. It confirms the diagnosis of WD in intestinal biopsies as well as in extraintestinal sites, even when the morphological appearance is not typical. It is also the most precise technique for monitoring therapeutic effects.

Perianal disease of tuberculous origin: report of a case and review of the literature

PURPOSE

A case of anal tuberculosis in an otherwise asymptomatic patient with bleeding anal ulcers is presented. The clinical features of this entity and the problems in differential diagnosis between anal infectious vs. inflammatory diseases are discussed.

METHODS

The management and outcome of the case of an adult patient who presented with perianal ulcers is described.

RESULTS

On a three-drug antituberculous regimen, symptoms abated, radiographic infiltrates improved, and perianal ulcers healed.

CONCLUSION

Anal tuberculosis is an extremely rare disease. A tuberculous origin must be considered when the cause of perianal ulcers is unclear to avoid undesirable delays in the diagnosis and treatment of this disease.

Detection of P-glycoprotein in frozen and paraffin-embedded gastric adenocarcinoma tissues using a panel of monoclonal antibodies

AIMS

Most chemotherapeutic regimens used against gastric carcinoma include anthracyclines whose effectiveness can be impaired by the presence of P-glycoprotein. In order to obtain a reliable pattern of P-glycoprotein expression in these tumours an immunohistochemical study using a panel of anti-P-glycoprotein antibodies was performed in frozen and paraffinized tissues.

METHODS AND RESULTS

Frozen and paraffinized samples from 25 gastric carcinomas were immunohistochemically analysed using a panel of four anti-P-glycoprotein monoclonal antibodies including C219, MRK16, JSB-1 and C494. Semiquantitative analysis indicated that moderate or high P-glycoprotein levels were detected in 40% to 76% of gastric adenocarcinomas, depending on the anti-P-glycoprotein antibody used. The antibody C494 was the most sensitive in detecting P-glycoprotein in both frozen and paraffinized gastric carcinoma samples. Moreover, C494 showed a pattern of staining exclusively associated with the plasma membrane, in contrast to the cytoplasmic with reinforcement of plasma membrane pattern displayed by the other three antibodies. Significant differences in P-glycoprotein levels were obtained when C494 and MRK16 were used in frozen tissues. Finally, detection of P-glycoprotein in frozen samples did not improve when compared to paraffinized ones.

CONCLUSIONS

It appears that P-glycoprotein is frequently expressed in gastric adenocarcinomas, and the use of C494 complemented by JSB-1 is recommended for reliable detection of P-glycoprotein in this neoplasm.

Granulomatous interstitial nephritis associated with hydrochlorothiazide/amiloride

A 74-year-old woman developed acute renal failure and granulomatous interstitial nephritis associated with hydrochlorothiazide/amiloride. On stopping the drug the renal function improved, but not significantly. Around 20 months after prednisone administration, the renal function had stabilized, with a moderate degree of renal insufficiency. The case is discussed, and some aspects of acute interstitial nephritis induced by diuretics are briefly reviewed.

Obstructive jaundice due to hepatocarcinoma with intraductal growth. Report of a successful resection

We present a patient with hepatocellular carcinoma causing obstructive jaundice due to intraductal growth, diagnosed intraoperatively by cholangiography and histological examination, and radically treated by left lobectomy, extrahepatic biliary tract resection and Roux-en-Y hepaticojejunostomy. Survival after operation was 13 months. Other similar cases reported in the literature are reviewed.