Trends in hospitalizations among patients with colorectal cancer: Results from the National Inpatient Sample (2007 through 2017)

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Background: Colorectal cancer is the second leading cause of cancer-related deaths in the United States with a rising incidence, especially in young adults. Care for patients with colorectal cancer is associated with significant health care costs and expenditures. We analyzed trends in admissions and outcomes related to hospitalizations in patients with colorectal cancer. Methods: We retrospectively interrogated the National Inpatient Sample for admissions in patients with colorectal cancer from 2007 – 2017. Records were stratified based upon the anatomical site and were analyzed for various inpatient outcomes. SAS version 9.4 (SAS Institute Inc.) was used for statistical analysis. Results: A total of 1,962,705 admissions were identified. About 50.2% patients were males, 64.4% were white and median age was 67.7 (53.8-81.6). Majority (47.8%) of the admissions that were coded for anatomical location of malignancy were for ascending colon cancer. 60.7% of the admissions were non-elective and Medicare was the primary payer for 58.6% of admissions. Most patients admitted for colon cancer belonged to the lower income quartile (28.3%) and were concentrated in large (58.9%), urban teaching hospitals (53.4%) in Southern US (38.8%). Hypertension (53.6%) and diabetes mellitus (18.6%) were the most common co-morbidities (p < 0.0001). Average in-hospital mortality was 4.9% and was lower in patients with ascending colon cancer (2.9, p < 0.001). Median length of stay was 5 days, but was higher in patients with transverse colon cancer (9 days, p < 0.0001). Median cost of hospitalization was found to be $12,295 and was significantly higher for patients with descending colon malignancy ($16,369, p < 0.0001). The number of annual hospitalizations stayed steady overall; the number of annual hospitalizations increased by 98.6% for rectosigmoid cancer. Conclusions: Despite highest number of hospitalizations, patients with ascending colon cancer had lowest in-hospital mortality. Cost of hospitalization and median length of stay were highest for patients with descending colon and transverse colon respectively. Number of annual hospitalizations has significantly increased for rectosigmoid cancer. Our findings may help inform physicians and healthcare administrators to devise appropriate strategies to efficiently channelize healthcare resources in order to decrease the overall economic burden associated with hospitalizations in patients with colorectal cancer.

Cardiovascular complications of immune checkpoint inhibitor therapy

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Background: Cardiac toxicity has largely been underestimated toxicity of checkpoint inhibitors. There have been several cases of myocarditis and fatal heart failure reported in patients treated with checkpoint inhibitors. We did a retrospective analysis of data of adverse effects of drugs that has been made available to public by the FDA. Methods: The FDA has made the data on adverse effects of various treatments available to general public through the FDA Adverse Events Reports System (FAERS) public dashboard. We investigated the cardiac toxicities of various immune check point inhibitor therapies available at FDERS for the years 2017-2018. Results: The reviewed the reported side effects of pembrolizumab, nivolumab, atezolizumab, avelumab, durvalumab and ipilimumab from FDA data. A total of 36,848 toxicities from immunotherapies were reported. Out of that, 2316(6.2 %) were cardio toxicities and 816 were fatal. The most common cardiac complications were as follows: myocarditis (15%), atrial fibrillation (13%), pericardial disease including pericardial effusion (13%), cardiac failure (17%) and coronary artery disease (19%). Approximately 50%, 43%, 40% 22% and 15 % of cases with myocarditis, ischemic heart disease, cardiac failure, atrial fibrillation and pericardia disease were fatal. Conclusions: Out of the reported cases of adverse reaction to check point inhibitor, 6.2% were cardio toxicities. 35% of cardio toxicities were fatal. Half of the cases who developed myocarditis died. There was no statistical difference in rate of cardiotoxicities caused by PD1, PDL1 or CTLA 4 inhibitors.

Annual colorectal cancer screening in rural community clinics using the fecal immunochemical test (FIT): Second and third year screening

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Background: Colorectal cancer (CRC), the second leading cause of cancer death in the US, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low income individuals, adults with low literacy and those living in rural areas. Methods: Randomized controlled trial to assess the effectiveness of 2 health literacy informed phone follow-up strategies to improve annual screening with Fecal Immunochemical Test (FIT) in 4 rural community clinics. Eligible patients, age 50-75, were recruited. After consenting, a research assistant (RA) recommended screening and gave literacy and culturally appropriate education using a pamphlet, the FIT kit, simplified instructions and a demonstration of how to use it, At 4 weeks patients who had not returned their kit receive either 1) a personal follow-up call (PC) from a central RA using motivational interviewing skills and reminding them to complete FIT kits; or 2) an automated follow-up call (AC) using plain language and motivational messages encourages patients to complete the FIT. During years 2 and 3, FIT kits were mailed to patients. Follow-up call procedures previously used were followed. Results: 620 patients not up-to-date were enrolled: 308/AC & 306/PC; 66% were African American, 55% women; 40% had limited literacy. During Year 1, 69% completed screening in AC arm versus 67% in PC arm. During Year 2, percentage screened decreased: 40% screened in AC arm and 37% in PC arm. Number of patients that needed at least one follow-up called increased: 74% in both arms needed at least 1 reminder call. Among those called, 19% in the AC arm completed their kit versus 15% in the PC arm. To date in Year 3, 32% screened in AC and 34% in PC. Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, use of “teach back” to confirm understanding with a follow-up call if needed, facilitated completion rates of all patients, particularly those with limited literacy. The less costly and time consuming automated call was equally effective as a personal call. Screening rates in years 2 and 3 declined. CRC screening with FIT is only effective when completed annually. Clinical trial information: RSG-13-021-01 - CPPB.

Is stereotactic radiosurgery of brain metastases in patients with poor performance status worthwhile?

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Background: Performance status is a consistent predictor of outcome in people with advanced disease. Variable prognosis has not led to the exclusion of patients with Karnofsky performance scores of < 70 from treatment of brain metastases (BRM) with stereotactic radiosurgery (SRS). The role of SRS for BRM in individuals with poor performance status (PPS) has not been elucidated to date. To better understand the prognostic utility of SRS in this particular patient cohort, we assessed the longevity periods of our treated PPS subjects with BRM. Methods: A retrospective review of patients with BRM treated by SRS during a 10-year period (2000-2009) identified 22 adult individuals with PPS; PPS was defined by the presence of severe hemiparesis or cerebellar ataxia. The primary endpoint of the analysis was survival because of some limitations in the obtained data. The mean follow-up was 26 months (range: < 1 to 144 months). Results: The mean age was 55.8 years, and the majority of the subjects were female. Most of the patients were younger and diagnosed with solitary brain metastasis. The synchronous primary malignant tumor was not yet under control in a third of the patients, and extracranial metastases were noted in 45% of the subjects. Thirteen people (59%) died within two months after therapy, and nine patients (41%) lived for two years or longer. The overall crude survival rates at 1 year and 5 years were 41% and 18%, respectively. Treatment response information was not available in the short-survival group because of early demise. Intracranial tumor control was achieved in the long-term survivors, considering that BRM progression requiring repeat SRS was not observed in any instance. Characterization of the two groups with different longevities was not possible. Conclusions: Early mortality was not predominant in this limited experience, and the observed prolonged survival suggests that SRS still represents a valuable treatment option for individuals with PPS and BRM.

Hepatosplenic T-cell lymphoma (HSTL): A SEER data analysis

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Background: HSTL is a very rare neoplasm accounting for less than one percent of non- Hodgkin lymphomas. The most common presentation of the patient with HSTL is marked hepatosplenomegaly and thrombocytopenia without lymphadenopathy. We performed SEER data analysis for the patients with HSTL to investigate the socio-economic factors and survival outcomes for this rare disease. Methods: Data from 92 adult patients registered in the SEER data with diagnosis of HSTL, between year 1998-2012 and follow up through 2013 were analyzed. Impact of patient demographics (sex, age, and race, year of diagnosis, family income, education, unemployment) and treatment characteristics (delivery of radiotherapy and tumor directed surgery) on survival were evaluated via univariate analysis. Results: The mean age of diagnosis 40.4 ± 18 years (see table). The education, income and employment are zip code level based on 2000 census data. The annual income is cost of living adjusted median family income. The education is the percentage of people in patient’s zip code with college education. The median survival was 13 months. Out of the factors analyzed only surgery and radiation affected survival. The median survival for the patient who got tumor specific surgery was 20 months , compared to 8 months for those who did not get tumor specific surgery(p = 0.04). Conclusions: HSTL is more common in younger population with majority of patient less than 64 years of age. Also, it is more common in males. Age, sex, race, income, employment, education and year of diagnosis do not affect survival. Unfortunately, SEER database does not have details about chemotherapy or bone marrow transplant. Previous literature in form of case reports and case series has suggested splenectomy for management of HSTL. Our data suggest that pts who underwent tumor specific surgery had improved outcomes. [Table: see text]

Faster ways of pursuing quality control using EHR (Electronic Health Record)

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Background: In this era of electronic health records (EHR), quality monitoring can be a fast repetitive process. Having access to the relational database of the EHR permits rapid case identification and quality indicator determination. We hereby describe evaluation of hepatitis B testing prior to rituximab administration, a quality measure as per ASCO guidelines. Methods: We connected SQL Query Manager with EPIC Clarity database. Using the object model for medication orders, location and department, we used SQL language to build a temporary dataset of all patients who have a completed order for a Rituximab infusion at a specific department location within the past 6 months. Using the dataset obtained in step 2, we created a smaller dataset with one row for each patient. We updated each unique patient row by updating columns for the count of completed Rituximab infusions, the first infusion date and the last infusion date. We then updated each row from a query of the order procedure and results object model. The unique patient id and component id are the key fields for this query. The Hepatitis B surface antigen and core antibody results were queried from up to 6 months prior to the initial rituximab dose. We looped through the dataset and compared the first Rituximab start date with the Hepatitis B testing date. If the testing date is before the drug administration date, a Boolean column was updated to indicate a 1 for passing the quality measure and a 0 for not passing. Finally, we reviewed that chart of any patients who fail the electronic quality measure check as some Hepatitis B testing may be represented in scanned results and these scanned results cannot be queried. Results: When the final SQL query runs, it takes less than a minute to see the result set. The query can be run at any interval or date range. Once the SQL procedure is created, there is essentially no labor and very low costs to run procedure at specific time intervals. Conclusions: Quality control is integral for improvement in patient care. Doing quality monitoring can be labor intensive, expensive, repetitive and time consuming. By using the relational database created and maintained by the EHR we can accomplish the quality control in faster way that is time and cost effective.

Effect of insurance status on receiving standard quality care treatment in patients with stage III colon cancer

45

Background: NCCN (National comprehensive Cancer network) recommends adjuvant chemotherapy for stage 3 colon cancer patients. National Cancer Data Base (NCDB) data were analyzed to investigate the impact of insurance status on receiving standard quality of care with adjuvant chemotherapy for stage 3 colon cancer patients. Methods: Data was analyzed from 11,563 men and women, between ages 18-80 years, registered in the NCDB who were diagnosed with stage 3 colon cancer between 1998 and 2011 and had follow-ups to end of 2012. The primary predictor variable was payer status and the outcome variable was treatment received. Additional variables addressed and adjusted for included sex, age, race, Charlson Comorbidity index, education, income, distance traveled facility type and diagnosing/treating facility. Results: Among these 11,563 patients, the mean age at diagnosis was 60.3 years (median, 61 years). The mean ages at diagnosis were 53.3, 54.9, 53.9, 69.6, and 58.2 years for uninsured, private, Medicaid, Medicare and unknown payer status, respectively. In multiple logistic regression analysis, after adjusting for secondary predictor variables, payer status was a statistically significant predictor of not receiving adjuvant chemotherapy. Relative to privately insured patients, patients with Medicaid were 2.20 times, Uninsured were 2.16 times, Medicare was 1.76 times, and unknown insurance were 2.25 times more likely not to receive adjuvant chemotherapy, respectively. Compared to age group 18-49 years, patient with age group 50-64 years, 65-74 years and 75+ years were 1.59, 2.54 and 5.59 times more likely to not to received adjuvant chemotherapy, respectively. Of the factors analyzed, age, comorbidity index, insurance and distance travelled to treatment center were statistically significant predictors of a patient not receiving adjuvant chemotherapy. Conclusions: We observed that payer status has a statistically significant relationship with stage 3 colon cancer patients not receiving adjuvant chemotherapy. This remained true after adjusting for other predictive factors. Further research is necessary to investigate how the treatment disparities are associated with different types of insurance.

Barriers to traditional palliative care for stage IV breast cancer patients, 2003-2012

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Background: Multiple factors may impact ability of patients with Stage IV breast cancer to access traditional palliative care (PC), which centers on disease-altering procedures such as surgery, radiation therapy, and chemotherapy. To further investigate barriers to accessing PC, the National Cancer Data Base data from 2003-2012 was analyzed. Methods: Data was analyzed from 55,490 patients diagnosed with Stage IV breast cancer registered in the National Cancer Data Base. The outcome variable was patient use of PC. The predictor variables included sex, age, race, Charlson Comorbidity index, insurance status, income, education, year diagnosed, distance travelled, facility type, diagnosing/treating facility, and diagnosis to treatment interval. Univariate analysis was used to determine the prevalence of palliative care according to predictor variables. Multivariate Logistic regression was used to investigate the effect of each predictor variable on patient use of PC while adjusting for all other predictive factors. Results: Of the 55,490 Stage IV breast cancer patients analyzed, 17.38% received palliative care. Radiation therapy (8.76%) and chemotherapy, hormone, and other systemic treatments (4.51%) contributed to the bulk of PC. In multivariate analysis, after adjustment for all other predictor variables, race, income, education, distance travelled, and diagnosis to treatment interval were each shown to significantly predict use of PC. Black and Asian patients were 11.4% and 26.1% less likely to use PC than their white peers. Lower zipcode income, higher zipcode education, and shorter distance travelled were predictors of increased PC use. Shorter diagnosis to treatment interval was a predictor of increased PC use; compared to patients with a 31+ day interval, those with a 0-7 day interval were 67.71% more likely to receive PC and 8-31 day interval, 37%. Conclusions: Using univariate and multivariate analysis, we identified factors that may act as barriers to access traditional palliative care for patients diagnosed with Stage IV breast cancer. We observed that race, income, education, distance travelled, and diagnosis to treatment interval significantly predicted the use of palliative care.

Improve optimal treatment in head and neck cancer patients (HNCA)

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Background: Since 2011, 50% of HNCA patients receiving concurrent chemoradiation with Cisplatin (CIS/XRT) have not been able to complete their therapy per protocol (dose over time interval) leading to suboptimal therapy. Based on historical data, the non-completion rate for patients HNCA receiving radiation/ high dose Cisplatin was 15%. We aim to improve this in our patients. Methods: A chart review of patients on CIS/XRT conducted and, using a Pareto Chart, the data indicated Acute Kidney Iinjury as the major cause for failure of completion. Using methodology from ASCO’s Quality Training Program, a process map for patients on treatment was created and an Ishikawa diagram (cause and effect) assisted in pinpointing breaks in processes. A telephone survey of surviving patients further clarified inadequacies. Using the Plan, Do, Study, Act (PDSA) improvement cycle, inadequacies were identified. Results: Chart review showed that significant side effects from treatment began around the 2nd cycle of Cisplatin in spite of adequate IV hydration following chemotherapy. Inadequate documentation of dietary and speech pathology consultations, patient weight and serum creatinine levels during treatment were noted. Patients reported minimal PEG tube education and infrequent use of PEG tube for hydration. Analysis of post treatment weight and creatinine level revealed a significant change in creatinine clearance. Checking daily weights, speech pathology and dietary consult prior to initiation of therapy, added hydration instructions to EPIC PEG tube instruction sheet, and nurse practitioner education and follow-up in symptom management clinic were part of the PDSA cycle interventions. If 2lb. weight loss, patients were brought in for repeat lab and IV hydration. Conclusions: Patients with advanced head and neck cancer are frail and subject to acute toxicity from chemotherapy. Change in Creatinine Clearance is a sensitive measure of renal damage/likely predictor of non-completion. Post-intervention patients had fewer unplanned admissions leading to lower costs. PDSA helped identify inadequacies in our education and monitoring processes. More post intervention data are needed to determine if true improvement in patient outcomes exist.

Oral alpha-lipoic acid to prevent chemotherapy-induced peripheral neuropathy: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

Chemotherapy-induced peripheral neuropathy is frequently a dose-limiting factor in cancer treatment and may cause pain and irreversible function loss in cancer survivors. We tested whether alpha-lipoic acid (ALA) could decrease the severity of peripheral neuropathy symptoms in patients undergoing platinum-based chemotherapy.

METHODS

Cancer patients 18 years or older were randomly selected to receive either 600 mg ALA or a placebo three times a day orally for 24 weeks while receiving chemotherapy regimens including cisplatin or oxaliplatin. Neuropathy was measured by the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) scale and the NCI Common Toxicity Criteria for Adverse Events neurotoxicity grades. Results from timed functional tests and the Brief Pain Inventory (BPI) were secondary endpoints.

RESULTS

Seventy of 243 (29 %) patients completed the study (24 weeks). Both the ALA and the placebo arms had a comparable drop-out rate. No statistically significant differences were found between the ALA and the placebo groups for FACT/GOG-Ntx scores, BPI scores, and patients' functional outcomes.

CONCLUSION

This strategy of oral ALA administration was ineffective at preventing neurotoxicity caused by oxaliplatin or cisplatin. High attrition rates due to poor patient compliance and manner of dosage administration in this trial demonstrated a lack of feasibility for this intervention. Future studies to explore ALA as a neuroprotective agent should take heed of the barriers confronted in this study.

Cervical cancer outcomes with the elimination of access to care disparities

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Background: Previous studies suggest lack of insurance and quality of care variations may drive disparities in cervical cancer (CC) survival, while equitable care may close these gaps. SEER based CC mortality between 2005-9 amongst white (W) and black (B) patients (pts) was 2.2 and 4.3/100,000 respectively. To define the role of equitable care on racial disparities we selected a population of pts with CC treated irrespective of the insurance status at the Feist-Weiller Cancer Center (FWCC). We hypothesized that disparities would be less pronounced at FWCC due to equitable care. Methods: A retrospective cohort study of 151 pts with FIGO Stage I-IV cervical cancer who had clinical staging, PET imaging and treatment at FWCC between 2005-9. Collected information included age, race, date of diagnosis, histology, stage, retroperitoneal lymph node (RPLN) status, treatment received, distance from the cancer center and payer status. The treatment parameters and outcomes were compared between ethnic and financial groups. Overall survival (OS) was assessed by using the Kaplan-Meier method and compared by log rank test. Results: Patients included 88 B, 66 W and 3 other pts with median age 46 years (23 – 84). Payer status included 45% uninsured, 35% medicaid, 15% medicare, and 5% other insurance. Histological type, stage, distance from treatment center and RPLN were equally distributed between groups. All pts completed standard treatment. There was no difference in PFS (p = 0.80) and OS (p = 0.23) between ethnic groups. In concordance with prior studies the following were associated with decreased OS; non-squamous histology, 15% pts (p=0.05), advanced stage (1b2-IV; p=0.04) and RPLN on imaging, 7% pts (p=0.008). Conclusions: Cervical cancer disparities are differentially distributed across the US hospital systems. There were no disparities identified at our institution relative to payer status with all pts receiving currently recommended treatment standards. Our findings indicate that delivery of equitable care can eliminate survival differences. Future research should assess the effect of emerging Accountable Care Organizations on the elimination of racial disparities in cancer treatment outcomes.

SUV max of the most intense lesion on fdgpet/CT scan at baseline as a potential prognostic factor in stage IV (NSCLC): A retrospective review

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Background: Lung cancer is the leading cause of mortality in United States and worldwide. Stage IV lung cancer has poor prognosis with 5-year survival of 2%. Limited numbers of factors are known to predict survival in stage IV NSCLC (Non Small Cell Lung Cancer) including stage at diagnosis, Performance Status (PS), genomic expression profile. Earlier studies have found SUV max (Maximum Standardized Uptake Value) of primary lung tumor on FDGPET/CT (Fluoro Deoxy Glucose –Positron Emission Tomography/Computed Tomography) correlates with tumor doubling time and survival. However prior studies included stage I-IV NSCLC patients and SUVmax of primary lung tumor. Hence we performed this study with only clinical stage IVNSCLC who underwent FDGPET/CT scan at baseline to determine whether SUVmax value of most intense lesion has any prognostic significance. Methods: Retrospective review identified 46 patients (September 2004- September 2011) that were diagnosed with stage IV NSCLC at our institution. SUVmax of most intense lesion on FDG PET/CT scan was determined utilizing an automated program on a dedicated PET/CT workstation by a single nuclear medicine specialist. Cox regression analysis and Log-rank test were used to analyze data. Results: Descriptive statistics: Median age 61.6 (43.8-77.8), Females 17 (36%), African Americans 26 (56%), Performance status 0-1=36 (80%), number of metastatic sites 1-2=30 (65%), Adenocarcinoma 32 (70%), Chemotherapy 31 (61%), SUV max- primary (65%), other sites (35%). The patient population was subdivided into two groups using the median SUVmax of 17.8. The median survival of patients having SUV max ≤17.8 and SUVmax > 17.8 was 13.4 months and 4.5 months respectively (P =0.0269). Multivariate analysis indicated PS (HR=2.8), any chemotherapy (HR=2.56) and SUV max ≤ 17.8 (HR=1.98, P=0.04) predicted survival. Conclusions: SUV max of the most intense lesion at the time of presentation predicts worse outcome in stage IVNSCLC and needs to be validated in a prospective study. PETCT may be able to predict the areas that harbor resistant clones of cells, described in previous studies as tumor heterogeneity, which may confer prognostic significance.

Mortality risk factors and survival of colon cancer patient

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Background: It is estimated that 142,820 people will be diagnosed and 50,830 will die from colon cancer in U.S. in 2013. The known risk factors include age (>50 years old), personal history of colon polyp(s) and Inflammatory bowel disease, family history of colon cancer, hereditary syndromes, Black race, type II Diabetes Mellitus, obesity, physical inactivity, smoking and alcohol use. In order to improve colon cancer survivorship, current study explores factors that affect it. Methods: Data of 524,613 colon cancer patients between 1973 and 2009 was obtained from the Surveillance Epidemiology and End Results (SEER) program. Factors evaluated in this study were age at diagnosis, gender, race, annual household income, education, unemployment, and smoking. Clinical factors evaluated include SEER historic stage and treatments received. The definition of these factors was based on the SEER data dictionary. Kaplan-Meier method and log rank test was used to estimate and compare survivals. Cox regressions were used to identify risk factors that affect survival. Results: Characteristics of this half millions colon cancer patients were 51.3% of males, 84.4% of whites, and 70% of adjusted household income <$50,000. Primary site: Sigmoid Colon (30.84%), Cecum (22.7%), Ascending Colon (9.42%), and others (9.42%). Stage: Localized (37%), Regional (36.26%), Distant (20.01%), and Unstaged (6.63%). In multivariate analysis, adjusting for other factors, age (≤49 vs. 60-69, HR=0.57), female gender (HR=0.87), stage (localized vs. distant stage, HR= 0.15) and race (Black HR=1.38, vs. Asian) are significant factors in colon cancer survival. People living in areas with a high percentage of smokers have increased risk by 8%. People living in areas of higher unemployment have 6% increased risk. Household income and education level have relatively less effect on colon cancer survival (40-55k vs. 0-40k, HR=1.02). Conclusions: We conclude that in a large database, age, race, stage, smoking, and unemployment have significant impact on colon cancer survival. Other factors such as insurance status, detailed treatments, screening effect, individual life styles and etc. need further investigation.

Recurring breast and arm cellulitis in patients with early breast cancer

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Background: Breast and arm cellulitis (BAC) is a recognized risk following treatment for early stage breast cancer with case reports suggesting an incidence <3%. However, there is limited information relative to risk factors, management, recurring BAC and outcome. We reviewed all incidences of BAC in patients (pts) with early stage breast cancer seen at our institution and correlate with co-morbid conditions, recurrent BAC events and treatment outcomes. Methods: A review of all pts with Stage I-III breast cancer seen between 2001-2011 identified pts with at least 1 episode of BAC. Data on age, race, stage, treatments, co-morbid conditions, lymphedema, incidence and recurrence of cellulitis, and antibiotic (Abx) therapy was extracted. We defined incident BAC to occur >30 days post chemotherapy/radiation completion. Chi-square test was used to assess variables associated with BAC recurrence. Results: 391,603 breast cancer pts (2.5%) were identified with BAC with median age 59 years. The median interval between completion of primary treatment and incident cellulitis was 330 days (30 – 3,650 days). 13 out of 39 pts (33%) had recurring BAC (range 1-7 events). Median duration of Abx therapy was 30 days (7 – 2,190). Lymphedema (p=0.04), chemotherapy (p=0.01), Stage > I (p=0.02) and initial poor response to Abx (p=0.003) were significantly associated with recurring BAC. Positive bacterial cultures were obtained in 4 of 62 BAC events. Initial Abx failure was lowest with vancomycin (Vanc). A protracted course (30 days) of oral Abx after initial Vanc was associated with a lower risk of early recurrence. Chronic Abx therapy, for pts with 3 episodes, appeared to reduce subsequent recurrent episodes. Conclusions: Results indicate that while BAC is relatively uncommon following breast cancer therapy, pts with BAC are at significant risk for recurring events. Lymphedema, higher stage and initial poor response to Abx proofed as parameters for recurrence. Despite treatment with Abx a significant number will have recurring events. For pts presenting with these variables we recommend a protracted course of initial Abx. Pts with recurring BAC should receive chronic Abx suppressive therapy. This approach was associated with good long term control in our pts.

Strategies to overcome barriers to accrual (BtA) to NCI-sponsored clinical trials: A project of the NCI-Myeloma Steering Committee Accrual Working Group (NCI-MYSC AWG)

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Background: Accrual to NCI clinical trials(CT)is often slower than planned at times mandating premature closure resulting in loss of valuable resources and delay of scientific progress. Methods: The NCI-MYSC AWG identified 10 potential BtA. SWOG, ECOG and Alliance investigators were queried and agreed that these barriers impede accrual (results stratified for academic and community sites). The MYSC AWG developed in collaboration with NCI and FDA strategies to overcome these barriers. Results: Strategies listed for the 3 most often cited BtA: 1. Reimbursement for CT related expenses:increase awareness of improved reimbursement for phase II CT; tailor reimbursement according to CT complexity; request funds from industry and other sources ( http://biqsfp.cancer.gov ) for qualifying ancillary CT components. 2. Spectrum of available treatment options influences CT participation: educate patients and providers about the significance of a new CT using social media, presentations at national meetings and by adding educational material to CT protocol; encourage opinion leaders and advocacy groups not to promote a new therapy as “standard” in the absence of phase III data. 3. Requirement of CT specific therapy at NCI designated sites only: “MYSC AWG Drug Administration Table” describes NCI/FDA approved rules for CT specific drug administration; CT protocol will outline which standard treatment components of a CT can be administered at any site as long as protocol specific guidelines are followed and conduct is supervised by enrolling investigator. Examples of additional strategies to overcome identified BtA: determine feasibility, indication and insurance coverage of CT specific tests during protocol development; discourage narrow eligibility criteria; avoid competing CT; allow up to 1 cycle of commercially available therapy prior to enrollment; CIRB support for phase II CT. Conclusions: The MYSC Accrual Working Group developed in collaboration with NCI and FDA strategies to overcome barriers to myeloma clinical trial accrual. These strategies may be applicable to NCI-sponsored clinical trials evaluating interventions in other diseases.

Cisplatin (CDDP) and radiation versus cetuximab (Cx) and radiation in locally advanced head and neck squamous cell cancer (SCHNC): A retrospective review

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Background: SCHNC is a common malignancy and approximately 60% of patients present with locally advanced disease. There is paucity of data directly comparing Cx and CDDP with concurrent radiation in locally advanced SCHNC. We retrospectively reviewed charts of patients treated with CDDP and/or Cx along with radiation in locally advanced SCHNC comparing efficacy and outcomes in an academic cancer center. Methods: Ninety-five patients with locally advanced SCHNC were treated with concurrent CDDP (100 mg/m2 day 1, 22, 43) or Cx (400mg/m2 on day -7 and 250mg/m2 weekly) at our institution between January 2006 and June 2011. Forty-four patients were treated with CDDP (group A), 24 with Cx (group B) and 27 were initially started on CDDP but were switched to Cx secondary to toxicity (group C). All patients received concurrent radiation treatments (66-70 Gy, 2.0 Gy/fraction). The selection of CDDP versus Cx was largely based on ECOG performance status (PS) and baseline renal function of the patients. Chi-square test, analysis of variance, and log-rank test was used for analysis. The three groups had similar baseline characteristics except for mean age of 61, 56 and 55 years in group A, B and C respectively; T4 tumors consisted of 44%, 75% and 41% in groups A, B and C respectively. Groups A, B and C had a combined ECOG 0 and I (PS) of 93%, 75% and 92%. Patients with ECOG III PS were excluded. Results: Oropharynx was the most common treated site (38%) followed by Larynx (35%). Complete response (CR) was seen in 77%, 17% and 67% in groups A, B and C respectively (P<0.001). Median progression free survival (PFS) was 16.6, 4.3 and 22.8 in groups A, B and C respectively (P<0.001) and median overall survival (OS) was >35, 11.6 and >32 months in groups A, B and C respectively (P<0.0001). Conclusions: Concurrent CDDP with radiation leads to better response rate PFS and OS as opposed to Cx though many patients treated with CDDP could not complete treatment due to toxicity. Randomized trial comparing the two should be considered.

Survival outcome of small bowel adenocarcinoma (SBA) in the last 12 years: Meta-analysis

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Background: Due to rarity, management of SBA is currently controversial. Despite results from several single institutional studies showing no survival benefit with adjuvant chemotherapy, data extrapolated from established colorectal cancer studies are commonly used to manage this cancer. Here we report results of a meta-analysis on data from 14 retrospective studies published in English between years 2000 and 2011. Methods: PubMed database was searched using relevant keywords. Patients with SBA were included. Studies involving ampulary, periampulary and ileocecal valve tumors were excluded. The combined location and stage distribution were adjusted by sample size of each study. Primary outcome for the magnitude of benefit analysis were OS. Hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted. A random-effect model according to the method of DerSimonian and Laird was used; a heterogeneity test was used. The effect of adjuvant chemotherapy and/or radiation treatment after curative surgery was evaluated. Effect of stage, grade, and positive lymph node ratio was also evaluated. Results: With available information within 14 studies, mean age of patients was 59.3(95% CI: 56.4 and 62.1). Duodenum was the most common site of primary tumor followed by the jejunum, ileum and not specified sites (59.27%, 23.49%, 11.42%, and 3.03%), respectively. Overall median survival was 17.2 months (95% CI: 13.9 and 20.5). Adjuvant treatment vs. non adjuvant treatment showed a HR of 1.17 (95% CI: 0.71-1.93) that was not statistically significant. HR for low grade vs. high grade tumors was 3.90 (95% CI: 2.15- 7.06). HR for stage was 3.09 (95% CI: 0.89-10.67, p=0.07) comparing high stage with low stage which suggested a marginally statistically significant effect. HR for positive lymph node ratio (LNR) was 4.63 (95% CI: 2.67-8.03). Conclusions: Our meta-analysis suggests adjuvant treatment after cancer directed curative intent surgery does not improve overall survival compared to observation in SBA. Grade of tumor and positive LNR are significant predicators of overall survival whereas stage has marginally significant effect on survival. Future trials investigating new or innovative adjuvant therapy in SBA are needed.

Evaluation of gemcitabine in patients with recurrent or metastatic squamous cell carcinoma of the head and neck: a Southwest Oncology Group phase II study

A phase II trial of gemcitabine (Gemzar), a nucleoside analogue with broad activity in solid tumors, was performed in patients with recurrent or metastatic squamous cell carcinoma of the head and neck. A total of 26 eligible patients were registered to receive a dose of 1250 mg/m2 weekly for 3 weeks, followed by a 1 week rest. Toxicity was evaluable in 26 patients. Nausea and vomiting occured in 11 and 6 patients, repectively. Grade 3 or 4 hematologic toxicities were infrequent. Two patients developed neutropenic infections. One patient developed fatal liver failure which was thought due to progressive liver metastases or infection 14 days after a single dose of gemcitabine. There were no objective treatment responses (95% CI 0-13%), with a median survival of 6 months in this highly resistant disease population. Gemcitabine is not considered active enough as monotherapy for further evaluation in this disease population.

Cauda equina compression in breast cancer--incidence and treatment outcome

PURPOSE

To determine the incidence and treatment outcome of compression of the cauda equina by metastatic disease in patients with breast cancer.

METHODS

A retrospective study of individuals diagnosed with breast cancer at a single institution during a 16-year period was undertaken.

RESULTS

Of the 1,283 patients studied, 15 (1.2%) developed cauda equina syndrome from metastatic disease. The median survival was eight months; ten (67%) survived for at least six months. Among the evaluable patients, pain was completely relieved in eight of ten women; complete resolution of neurologic deficits was observed in five of nine patients.

CONCLUSION

Metastatic breast cancer compression of the cauda equina and long-term survival of patients are infrequent occurrences. Beneficial responses can be mediated by radiotherapy.

A phase II trial of estramustine and etoposide in hormone refractory prostate cancer: A Southwest Oncology Group trial (SWOG 9407)

BACKGROUND

The combination of oral estramustine and oral etoposide has generated response rates of 40-50% in patients with hormone refractory prostate cancer in single institution trials. This study tested this regimen in a multi-institutional setting.

METHODS

Fifty-five patients were accrued over a period of 4 months between 1 March 1996 and 1 July 1996. Two patients were not analyzable and two patients were ineligible. They were given an oral regimen consisting of estramustine 15 mg/kg/day (capped at 1120 mg per day) and etoposide 50 mg/M(2)/day, days 1-21 every 28 days. Patients received a median of two cycles of therapy.

RESULTS

Toxicities included 11 patients (20%) with grades 3 or 4 granulocytopenia, 5 patients (10%) with grades 3 or 4 edema, and 3 patients (6%) with a thrombotic event. There were two treatment-related deaths, one as a result of anemia and the other as a result of a myocardial infarction. Of the 32 men who received at least 2 cycles of therapy, 7 men (22%) demonstrated a partial response to this regimen as measured by prostate-specific antigen (PSA) criteria of a 50% decline from pretreatment values.

CONCLUSIONS

This trial demonstrates the toxicity of estramustine delivered in high dose. It also illustrates the difficulty of conducting phase II trials in prostate cancer in the cooperative group setting where the experience and comfort level of oncologists with new agents is less than that of the physicians at the institution where the therapy was developed. As the activity of this regimen with low-dose estramustine is defined, further multi-institutional studies may be warranted.

Infusional CHOP chemotherapy (CVAD) with or without chemosensitizers offers no advantage over standard CHOP therapy in the treatment of lymphoma: a Southwest Oncology Group Study

PURPOSE

Two phase II studies were conducted to evaluate infusional cyclophosphamide, doxorubicin, vincristine, and dexamethasone chemotherapy, termed the CVAD regimen, alone (Southwest Oncology Group [SWOG] 9240) and with the chemosensitizers verapamil and quinine (SWOG 9125) to assess effects on response, survival, and toxicity in intermediate- and high-grade advanced-stage non-Hodgkin's lymphoma (NHL). The results were compared with the historic group of patients randomized to CHOP chemotherapy on Intergroup (INT) 0067 (SWOG 8516).

PATIENTS AND METHODS

All patients had biopsy-proven intermediate- or high-grade NHL (lymphoblastic histology excluded), were ambulatory and previously untreated, and had bulky stage II, III, or IV disease. One hundred twelve patients were registered on SWOG 9240 and received cyclophosphamide 750 mg/m(2) by intravenous bolus day 1, doxorubicin 12.5 mg/m(2)/d and vincristine 0.5 mg/d delivered as a continuous 96-hour infusion on days 1 through 4, and dexamethasone 40 mg/d orally on days 1 through 4 (CVAD). Cycles were repeated every 21 days for eight cycles. One hundred patients on SWOG 9125 received the same chemotherapy and the chemosensitizers verapamil 240 mg bid and quinine 40 mg tid. Chemosensitizers were begun 24 hours before chemotherapy and continued for a total of 6 days.

RESULTS

Eighty-one patients were eligible for each study. The complete response (CR) rates were 39% on SWOG 9125 and 31% on SWOG 9240. With a median follow-up of 5.8 years on SWOG 9125 and 4.5 years on SWOG 9240, the 2-year failure-free survival (FFS) rate was 42% on SWOG 9125 and 41% on SWOG 9240. Two-year overall survival (OS) rate was 64% on SWOG 9125 and 58% on SWOG 9240. These results are comparable to a 44% CR rate, a 2-year FFS of 46%, and 2-year OS of 63% observed in 225 patients treated with CHOP on INT 0067 (SWOG 8516).

CONCLUSION

CVAD combination chemotherapy alone or with the chemosensitizers verapamil and quinine is not promising therapy with respect to improved response or OS in intermediate- and high-grade advanced-stage NHL.

Radical combined treatment of locally extensive head and neck cancer in the elderly

PURPOSE

Few studies have described the effects of aggressive combined therapy for locally extensive head and neck cancer in the elderly. Our study evaluated the outcome of this particular cohort of patients after such treatments.

METHODS

Survival, failure, morbidity, and complication rates were determined retrospectively in 43 elderly patients with stage III or IV head and neck cancer who underwent curative surgery and postoperative radiotherapy (n = 33) or neoadjuvant, 3-drug chemotherapy plus radiotherapy (n = 10) between the years 1977 and 1992.

RESULTS

The crude survival rate at 3 years was 27% in patients managed by surgery plus radiotherapy, and 30% in individuals treated with chemoradiation; the corresponding locoregional failure rates were 23% and 30%; and the distant failure rates were 13% and 0%, respectively. The acute toxicity rate was 12% in the surgery plus radiotherapy group and 30% in the chemoradiation patients; the corresponding late complication rates were 0% and 10%. There were no toxic deaths.

CONCLUSION

Radical combined treatments can be performed safely and achieve long-term, disease-free survival in selected elderly patients with locally extensive head and neck cancer.

Radiotherapy with and without chemotherapy after breast conservation surgery for early stage breast cancer: a review of timing

PURPOSE

To evaluate the effects in women of the timing of breast irradiation (BI) in relation to the application or non-application of adjuvant chemotherapy after breast conservation surgery (BCS) for early stage cancer.

METHODS

Between October 1981 and June 1995, 47 women with stage I and II breast cancer underwent BCS. Twenty-six patients did not receive adjuvant chemotherapy (NAC) and 21 women did (AC). In the NAC group, BI commenced within (n = 9) or after (n = 17) seven weeks following BCS; in the AC group, 18 women received BI more than 24 weeks after BCS and three patients within 24 weeks.

RESULTS

In the NAC group, there was a trend toward more local and systemic failures plus a definite correlation with poorer survival (p = 0.05) when BI was initiated more than 7 weeks after BCS. In the AC group, the locoregional and systemic failures occurred only in women with a delay of BI exceeding 24 weeks; survival was not different between the subgroups.

CONCLUSION

An undue delay of BI should be avoided in patients after BCS whether they require adjuvant chemotherapy for early stage breast cancer or not.

Cranial irradiation in patients with brain metastasis: a retrospective study of timing

PURPOSE

A retrospective study was conducted to determine the importance of the interval between diagnosis of brain metastasis (BRM) and cranial irradiation (CI).

METHODS

The charts of 92 patients with a known diagnosis of cancer and suspected BRM as shown on radioimaging studies were reviewed retrospectively. The median interval between diagnosis and the onset of CI for BRM was five days; one group of 48 individuals received CI within an interval of five days, and another group of 44 patients after an interval of five days. Symptom palliation, objective responses to CI and survival were evaluated in both groups.

RESULTS

Neither symptomatic and objective responses to treatment nor overall survival differed significantly between the patient groups.

CONCLUSION

These observations suggest that while CI is beneficial to most patients with BRM, its timing after the diagnosis of BRM may not seriously affect patient outcome.

Multiple myeloma metastatic to the thigh: successful treatment with radiation therapy

A 64-year-old man with metastatic multiple myeloma in the thigh was treated with radiation therapy. After a total dose of 30 Gy/10 fractions, significant resolution of the tumor in the thigh was observed. This case confirms the accepted dictum that multiple myeloma is a radioresponsive neoplastic disorder.

Neoadjuvant chemotherapy and radiotherapy for inoperable head and neck cancer: the LSU-Shreveport experience

A retrospective review of 8 years of treatment in 2 hospitals in Shreveport showed that neoadjuvant chemotherapy with radiotherapy was performed in 39 patients with inoperable, locally advanced head and neck cancer. Twenty-two individuals treated by definitive radiotherapy alone served as historical controls. The cumulative survival rate at 4 years was 34% in patients managed by neoadjuvant chemotherapy with radiotherapy and 7% in patients treated by radiotherapy only. With the exception of greater acute toxicity seen in patients receiving neoadjuvant chemotherapy with radiotherapy, differences in locoregional failure, distant metastasis, and late complication rates were not observed between the patient groups.

Functional LCK Is required for optimal CD28-mediated activation of the TEC family tyrosine kinase EMT/ITK

Activation of CD28 on T lymphocytes initiates a cascade of intracellular events, which in concert with activation of the T cell receptor, culminates in production of cytokines and a functional immune response. One of the earliest biochemical changes observed following stimulation of CD28 is tyrosine phosphorylation. We have demonstrated that both the LCK and the EMT/ITK/TSK (EMT) intracellular tyrosine kinases are activated following cross-linking of CD28. Utilizing somatic cell mutants lacking LCK, we demonstrate that functional LCK is required for CD28-induced activation of EMT as evidenced by increased tyrosine phosphorylation and kinase activity. In support of a role for LCK in EMT activation, reconstitution of a LCK-negative Jurkat T cell line by transfection with normal LCK recreates CD28-mediated EMT activation. Furthermore, co-transfection of LCK and EMT into COS-7 cells showed that EMT becomes phosphorylated in the presence of LCK. In addition, increases in EMT association with CD28 were eliminated in a LCK-negative Jurkat cell line, but were restored following transfection of wild type LCK. The data are most compatible with a model in which LCK, either directly or indirectly, initiates EMT activation and association with CD28 following ligation of CD28.

Solitary plasmacytoma of the sacrum presenting as a pelvic mass: report of two cases

We describe two unusual cases of solitary plasmacytoma of the sacrum seen as a pelvic mass. Excessive bleeding, a distinct possibility, should be anticipated whenever a biopsy or resection of the tumor is considered. Because of the tumor's apparent radioresponsiveness and known evolution to multiple myeloma in some cases, radiotherapy and chemotherapy are recommended.

Long-term survival in small cell lung cancer with superior vena caval obstruction

Two patients were diagnosed with small cell lung cancer and superior vena caval obstruction. Successful palliation of symptoms with significant reduction in size of the intrathoracic lesion was achieved with radiation therapy and chemotherapy. Treatment resulted in complete remission with long-term (more than 3 years) survival. These two cases affirm the fact that, despite the generally recognized poor prognosis of small cell lung cancer associated with this syndrome, aggressive therapy can sometimes provide rewarding results.

Heparin-induced thrombotic thrombocytopenia

OBJECTIVE

To report a case of heparin-induced thrombotic thrombocytopenia (HITTS) and discuss the incidence, possible mechanisms, complications, and treatment for this syndrome.

DATA SOURCES

Case reports and review articles identified by MEDLINE from 1980 through 1991. Older articles located by manual searches.

DATA EXTRACTION

Data were extracted and reviewed from published sources. Cases were selected on the basis of case presentation, time of disease onset, pathophysiology of disease, and therapeutic options.

SETTING

A 600-bed university teaching hospital and an affiliated community hospital.

PATIENT

A 36-year-old woman with insulin-dependent diabetes mellitus, sepsis, adult respiratory distress syndrome, diabetic ketoacidosis, oliguric renal failure developed HITTS and subsequent gangrene of her right arm.

INTERVENTION

Immediate cessation of all heparin use and amputation of the patient's right arm.

RESULTS

The patient's condition improved progressively over the following 60 days and she was discharged to outpatient care.

CONCLUSIONS

Heparin has been associated with thrombocytopenia and thrombotic events. Laboratory tests for HITTS are unreliable and the diagnosis is usually suspected by the clinical presentation of the patient. Platelet counts should be monitored closely during heparin use. In the event of a marked decrease in platelet count associated with venous or arterial thrombosis, heparin therapy should be stopped immediately. If further anticoagulation is necessary, oral anticoagulants such as warfarin may be used instead. As the onset of warfarin may take several days to become therapeutic, aspirin, dipyridamole, or both may be used effectively. Healthcare workers should be aware that in these patients, the use of even small amounts of heparin can produce catastrophic results.

Ischiogluteal bursitis in cancer patients: an infrequently recognized cause of pain

We report eight patients with metastatic malignancy who developed severe back and leg pain caused by ischiogluteal bursitis. Careful evaluation excluded the possibility of bony metastases. Ischiogluteal bursitis is an easily diagnosed condition that can be effectively treated with local injection of corticosteroids. Recognition of this disorder will allow prompt therapy and unnecessary evaluation expenses.

Kaposi's sarcoma involvement of the bone marrow

Kaposi's sarcoma (KS) is a predominantly cutaneous malignancy with several clinical variants. Extracutaneous sites of involvement are uncommon in all disease variants except epidemic KS (human immunodeficiency virus related) and the African lymphadenopathic variant. Extracutaneous KS usually involves the lymph nodes, gastrointestinal tract, and respiratory tract. The authors report the first description of a patient with classic KS to have bone marrow involvement. Two additional patients with KS variants and bone marrow involvement have been described. Bone marrow tumor invasion should be considered in patients with KS and hematologic abnormalities.

Occult antithrombin III deficiency: a potentially lethal complication of the postphlebitic limb

Chronic venous insufficiency is a frequent sequel to lower extremity venous thrombosis. A relatively uncommon, but potentially lethal, cause of the thrombosis is congenital antithrombin III deficiency. Recognition and treatment of this occult deficiency is critical. The following report describes a family treated by the authors for this problem. In one generation of nine siblings, three males had documentation of the disease with functional antithrombin III levels in the range of 50% to 60%. Before evaluation for the deficiency one female sibling died at the age of 20 years as a consequence of a proven pulmonary embolus. Antithrombin III levels in another female sibling, who was free of symptoms, were normal (80% to 120%). Four other siblings who were free of symptoms (one female, three males) refused evaluation. All three men with the deficiency had severe, chronic, bilateral, lower extremity, venous insufficiency manifested by pain, varicosities, edema, pigmentation, and ulceration. Despite chronic warfarin therapy, one experienced recurrent pulmonary embolization with eventual loss of perfusion of the entire right lung. Ascending venography in the symptomatic males with the deficiency revealed evidence of recurrent and diffuse venous thrombosis with partial recanalization. Recurrent lower extremity venous thrombosis consequent to antithrombin III deficiency causes a particularly fulminant postphlebitic syndrome with characteristic venographic findings. Although potentially lethal if unrecognized and treated simply as venous insufficiency, chronic therapy with warfarin offers palliation and prolongs life.

Antinuclear antibodies in sickle cell disease

The frequency of antinuclear antibodies (ANA) and other antinuclear factors was prospectively evaluated in patients with sickle cell disease (SCD). Ten of 44 patients studied (22.7%) had positive ANA determinations at titers greater than or equal to 1:40 compared to 3 of 46 healthy controls (6.5%; p less than 0.03). Eight SCD patients had ANA titers of 1:160 or greater compared to none of the controls (p less than 0.003). No antibodies directed against other nuclear factors were found. An analysis of the patient histories revealed no statistical differences between the ANA-positive and ANA-negative SCD patients when correlated with disease activity.

Phase II evaluation of bisantrene in acute leukemia. A Southwest Oncology Group Study

Twenty-nine patients with heavily pretreated acute leukemia in relapse were treated with bisantrene (maximum dose 120 mg/m2/day x 5) in a phase II study. Twenty-seven of the 29 patients were evaluable for response, receiving a total of 53 courses of treatment. There were three complete remissions (11%) lasting 27, 107, and 115 days. One brief partial remission of 43 days was also seen for a total response rate of 15%. Toxicity was mainly limited to the expected myelotoxicity with minimal nonhematologic toxicity seen. Although the complete remission rate is low, an antileukemic effect was seen in the majority of the patients treated. Sixty-one percent of the patients had at least a 50% decrease in the circulating blast count and 32% had at least a 50% decrease in the number of bone marrow blasts. We conclude that bisantrene does have an antileukemic effect, but that the optimal starting dose is not yet established.

Parathyroid hormone and anaemia--an erythrocyte osmotic fragility study in primary and secondary hyperparathyroidism

Parathyroid hormone (PTH) has been shown in vitro to enhance erythrocyte osmotic fragility (EOF) and has been incriminated as a factor in the anaemia seen in patients with primary hyperparathyroidism and in patients with renal disease and secondary hyperparathyroidism. Enhanced EOF has also been shown in patients with chronic renal failure but did not correlate with PTH levels. We studied a group of patients with primary hyperparathyroidism with and without anaemia, and patients with secondary hyperparathyroidism and anaemia. We found that EOF studies in these patients did not differ from normal control groups and that there was no relation between PTH, EOF, and haematocrit in either study group. We conclude that PTH over a range of concentrations seen in vivo does not affect erythrocyte osmotic fragility or cause anaemia.

Reversible acute sensorineural hearing loss associated with essential thrombocytosis

The isolated occurrence of reversible acute sensorineural hearing loss associated with thrombocytosis without other neurologic or hematologic manifestations has not been previously reported in the English literature, to our knowledge. We treated a patient with essential thrombocytosis who developed acute sensorineural hearing loss associated with marked thrombocytosis and in whom the hearing loss reversed after plateletpheresis.

Immune thrombocytopenia and ulcerative colitis

We have described a patient with simultaneous onset of antibody-positive immune thrombocytopenic purpura and ulcerative colitis, an association that must be extremely rare. Although the colitis responded to steroid therapy, the thrombocytopenia required splenectomy. The antibody was monomeric, with HLA specificity against A3 and B8 platelets.

Predictive value of trypan blue exclusion viability measurements for colony formation in a human tumor cloning assay

Specimens (173) were evaluated to assess the predictive value of cell viability as measured by Trypan Blue exclusion on colony formation in a human tumor cloning system. Overall, there was no significant correlation between Trypan Blue exclusion-determined viability and colony formation in soft agar for these specimens (p = 0.43). This lack of significant correlation was maintained for primary, metastatic, solid, and fluid tumor specimens. These data suggest that, in this soft agar system, specimens containing cells with low Trypan Blue exclusion viability should not be excluded from testing, and that it may not be advantageous to plate on the basis of "viable cells" as measured by Trypan Blue exclusion.

The hypereosinophilic syndrome in acute lymphocytic leukemia

A 21-year-old white man presented with marked peripheral blood eosinophilia that later evolved into acute lymphocytic leukemia (FAB2 ALL). He died precipitously from refractory congestive heart failure immediately after antileukemic therapy was started. Autopsy revealed multiorgan infiltration with eosinophils and the typical cardiac findings of Löfflers endocarditis. Clinical and pathologic features of this and the 14 other cases of ALL and the hypereosinophilic syndrome (HES) reported in the English-language literature are described. The eosinophilia in these cases is reactive and resolves with successful leukemia remission induction. Hydroxyurea is effective in rapidly lowering eosinophil counts. Early use of hydroxyurea in this disease may improve patient survival and decrease the risk of sudden cardiac death.