Early Increases in Blood Pressure and Major Adverse Cardiovascular Events in Patients With Renal Cell Carcinoma and Thyroid Cancer Treated With VEGFR TKIs

BACKGROUND

Although VEGFR tyrosine kinase inhibitors (TKIs) are a preferred systemic treatment approach for patients with advanced renal cell carcinoma (RCC) and thyroid carcinoma (TC), treatment-related cardiovascular (CV) toxicity is an important contributor to morbidity. However, the clinical risk assessment and impact of CV toxicities, including early significant hypertension, among real-world advanced cancer populations receiving VEGFR TKI therapies remain understudied.

METHODS

In a multicenter, retrospective cohort study across 3 large and diverse US health systems, we characterized baseline hypertension and CV comorbidity in patients with RCC and those with TC who are newly initiating VEGFR TKI therapy. We also evaluated baseline patient-, treatment-, and disease-related factors associated with the risk for treatment-related early hypertension (within 6 weeks of TKI initiation) and major adverse CV events (MACE), accounting for the competing risk of death in an advanced cancer population, after VEGFR TKI initiation.

RESULTS

Between 2008 and 2020, 987 patients (80.3% with RCC, 19.7% with TC) initiated VEGFR TKI therapy. The baseline prevalence of hypertension was high (61.5% and 53.6% in patients with RCC and TC, respectively). Adverse CV events, including heart failure and cerebrovascular accident, were common (occurring in 14.9% of patients) and frequently occurred early (46.3% occurred within 1 year of VEGFR TKI initiation). Baseline hypertension and Black race were the primary clinical factors associated with increased acute hypertensive risk within 6 weeks of VEGFR TKI initiation. However, early significant "on-treatment" hypertension was not associated with MACE.

CONCLUSIONS

These multicenter, real-world findings indicate that hypertensive and CV morbidities are highly prevalent among patients initiating VEGFR TKI therapies, and baseline hypertension and Black race represent the primary clinical factors associated with VEGFR TKI-related early significant hypertension. However, early on-treatment hypertension was not associated with MACE, and cancer-specific CV risk algorithms may be warranted for patients initiating VEGFR TKIs.

Rituximab in the Treatment of Acquired Angioedema Secondary to Marginal Zone Lymphoma of the Spleen

Angioedema occurs in less than 1-2% of the population and amongst these cases, those with acquired angioedema are less prevalent than hereditary angioedema. Amongst cases of acquired angioedema, studies have shown that they were highly linked with an associated lymphoproliferative disorder, suspected secondary to the production of neutralizing autoantibodies from pathological B cell proliferation. We present a case of a patient who presented with recurrent episodes of angioedema and was found to have low C4 and C1 esterase function, initially concerning for a hereditary angioedema variant, who was subsequently found to have marginal B cell lymphoma mimicking hereditary angioedema.

Interplay of Immunosuppression and Immunotherapy Among Patients With Cancer and COVID-19

Importance

Cytokine storm due to COVID-19 can cause high morbidity and mortality and may be more common in patients with cancer treated with immunotherapy (IO) due to immune system activation.

Objective

To determine the association of baseline immunosuppression and/or IO-based therapies with COVID-19 severity and cytokine storm in patients with cancer.

Design, Setting, and Participants

This registry-based retrospective cohort study included 12 046 patients reported to the COVID-19 and Cancer Consortium (CCC19) registry from March 2020 to May 2022. The CCC19 registry is a centralized international multi-institutional registry of patients with COVID-19 with a current or past diagnosis of cancer. Records analyzed included patients with active or previous cancer who had a laboratory-confirmed infection with SARS-CoV-2 by polymerase chain reaction and/or serologic findings.

Exposures

Immunosuppression due to therapy; systemic anticancer therapy (IO or non-IO).

Main Outcomes and Measures

The primary outcome was a 5-level ordinal scale of COVID-19 severity: no complications; hospitalized without requiring oxygen; hospitalized and required oxygen; intensive care unit admission and/or mechanical ventilation; death. The secondary outcome was the occurrence of cytokine storm.

Results

The median age of the entire cohort was 65 years (interquartile range [IQR], 54-74) years and 6359 patients were female (52.8%) and 6598 (54.8%) were non-Hispanic White. A total of 599 (5.0%) patients received IO, whereas 4327 (35.9%) received non-IO systemic anticancer therapies, and 7120 (59.1%) did not receive any antineoplastic regimen within 3 months prior to COVID-19 diagnosis. Although no difference in COVID-19 severity and cytokine storm was found in the IO group compared with the untreated group in the total cohort (adjusted odds ratio [aOR], 0.80; 95% CI, 0.56-1.13, and aOR, 0.89; 95% CI, 0.41-1.93, respectively), patients with baseline immunosuppression treated with IO (vs untreated) had worse COVID-19 severity and cytokine storm (aOR, 3.33; 95% CI, 1.38-8.01, and aOR, 4.41; 95% CI, 1.71-11.38, respectively). Patients with immunosuppression receiving non-IO therapies (vs untreated) also had worse COVID-19 severity (aOR, 1.79; 95% CI, 1.36-2.35) and cytokine storm (aOR, 2.32; 95% CI, 1.42-3.79).

Conclusions and Relevance

This cohort study found that in patients with cancer and COVID-19, administration of systemic anticancer therapies, especially IO, in the context of baseline immunosuppression was associated with severe clinical outcomes and the development of cytokine storm.

Trial Registration

ClinicalTrials.gov Identifier: NCT04354701.

The impact of a hematopoietic cellular therapy pharmacist on clinical and humanistic outcomes: A RE-AIM framework analysis

BACKGROUND

The hematopoietic cellular therapy (HCT) pharmacist is an essential member of the multidisciplinary care team. Yet, standardized incorporation of a pharmacist at transplant centers remains challenging. Implementation science uses theory-driven and systematic approaches to integrate interventions into clinical practice. We describe our experience implementing an HCT pharmacist at our center and conducted a program evaluation using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.

OBJECTIVE

To evaluate the impact of HCT pharmacist medication management services on allogeneic stem cell transplant patients utilizing the RE-AIM framework.

STUDY DESIGN

We implemented one full-time equivalent pharmacist to provide medication management services through a collaborative practice agreement (CPA) to the allogeneic transplant population at a medium-sized center in rural Pennsylvania over a two-year period. The HCT pharmacist documented all in-person and telephonic care encounters in the electronic medical record. A pharmacist intervention tool was developed to document identified medication related problems (MRPs) with corresponding interventions and magnitude of intervention. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was utilized to evaluate the impact of the HCT pharmacist. Summary statistics including frequency and percentages were presented for categorical variables in RE-AIM domain.

RESULTS

Over the 2-year period, the HCT pharmacist followed 40 allogeneic patients at our institution accounting for 1531 patient encounters. The average duration of follow-up was 299 days. The HCT pharmacist medication therapy services were able to reach all allogeneic transplants at our institute. The HCT pharmacist managed 388 medications and identified 2156 medication related problems for which the pharmacist provided 2959 interventions. Time in therapeutic range of immunosuppression was 74% when managed by the HCT pharmacist through a CPA. Of the 24 patients and 9 caregivers who completed the patient satisfaction survey, 25 (76%) were strongly satisfied with their care. Pharmacy services were gradually adopted and expanded to incorporate additional populations, including 121 autologous transplant and 272 hematology patient encounters. The role of the HCT pharmacist was justified with hospital administration and sustained as a designated pharmacist role at our center.

CONCLUSION

The implementation of an HCT pharmacist service can positively impact patient care. The RE-AIM framework provides a methodological approach for programmatic evaluation and generalizability.

Compliance with germline testing in pancreatic cancer in a rural tertiary care hospital

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Background: Pancreatic cancer is the 7th most common cause of cancer death worldwide and is projected to be the second leading cause of cancer death in the next decade. Personalized care is becoming more of a reality with pharmacological regimens targeting specific genetic mutations. In March 2019, the National Comprehensive Cancer Network (NCCN) guidelines were updated to recommend germline testing (GT) in all patients with pancreatic adenocarcinoma (PDAC) considering 1 in 10 may have a germline mutation (GM). The goal of this study was to quantify compliance with these recently updated guidelines. Methods: The electronic medical records and survivorship data of all patients diagnosed with PDAC between January 1, 2017 and October 1, 2020 were reviewed. April 1, 2019 was used as the transition point (TP) for guideline updates. Descriptive statistics for all variables were determined. The rate of ordered referrals to genetic counseling (GC), as well as completion rate, was calculated. Results: A total of 304 patients were diagnosed with PDAC during the study period (223 prior to the TP). A total of 54 patients were referred for GC and 41 had GT ordered. The rate of GC referrals ordered after the TP was significantly higher than before the TP (22/81, 26.6% vs. 32/223, 14.4%; p-value 0.010). Almost 60% of patients who had genetic evaluation had private insurance. The patients who completed GT were significantly more likely to have a documented family history of cancer (61.0% vs 4.2%; p-value <.0001Patients who completed GT had more problems on their problem list (median 10 vs 7, p = 0.001). The median overall survival (OS) for all patients in the study was 7.8 months (95% CI: 6.3-9.8). Conclusions: Overall compliance with the updated NCCN guidelines significantly improved; however, it was below 25%. This study showed that there may be some lingering bias toward GT in PDAC solely for those who have a family history of cancer. Although patients with stage IV PDAC have poor outcomes, GT may still improve surveillance for family members. The approval of olaparib in patients with BRCA1/2 mutations based on the POLO trial is likely to increase provider compliance as it provides a viable maintenance strategy in these patients. Patient complexity was unlikely to affect GT rate. Assessment of provider awareness was outside the scope of this study. There is need for continued advocacy for awareness and implementation of guidelines that highlight the importance of germline evaluation on prevention, surveillance, and treatment in pancreatic adenocarcinoma.

Case series review of neuroradiologic changes associated with immune checkpoint inhibitor therapy

While immuno-oncotherapy (IO) has significantly improved outcomes in the treatment of systemic cancers, various neurological complications have accompanied these therapies. Treatment with immune checkpoint inhibitors (ICIs) risks multi-organ autoimmune inflammatory responses with gastrointestinal, dermatologic, and endocrine complications being the most common types of complications. Despite some evidence that these therapies are effective to treat central nervous system (CNS) tumors, there are a significant range of related neurological side effects due to ICIs. Neuroradiologic changes associated with ICIs are commonly misdiagnosed as progression and might limit treatment or otherwise impact patient care. Here, we provide a radiologic case series review restricted to neurological complications attributed to ICIs, anti-CTLA-4, and PD-L-1/PD-1 inhibitors. We report the first case series dedicated to the review of CNS/PNS radiologic changes secondary to ICI therapy in cancer patients. We provide a brief case synopsis with neuroimaging followed by an annotated review of the literature relevant to each case. We present a series of neuroradiological findings including nonspecific parenchymal and encephalitic, hypophyseal, neural (cranial and peripheral), meningeal, cavity-associated, and cranial osseous changes seen in association with the use of ICIs. Misdiagnosis of radiologic abnormalities secondary to neurological immune-related adverse events can impact patient treatment regimens and clinical outcomes. Rapid recognition of various neuroradiologic changes associated with ICI therapy can improve patient tolerance and adherence to cancer therapies.

Feasibility of blood testing combined with PET-CT to screen for cancer and guide intervention

Cancer treatments are often more successful when the disease is detected early. We evaluated the feasibility and safety of multicancer blood testing coupled with positron emission tomography-computed tomography (PET-CT) imaging to detect cancer in a prospective, interventional study of 10,006 women not previously known to have cancer. Positive blood tests were independently confirmed by a diagnostic PET-CT, which also localized the cancer. Twenty-six cancers were detected by blood testing. Of these, 15 underwent PET-CT imaging and nine (60%) were surgically excised. Twenty-four additional cancers were detected by standard-of-care screening and 46 by neither approach. One percent of participants underwent PET-CT imaging based on false-positive blood tests, and 0.22% underwent a futile invasive diagnostic procedure. These data demonstrate that multicancer blood testing combined with PET-CT can be safely incorporated into routine clinical care, in some cases leading to surgery with intent to cure.

Early imaging marker of progressing glioblastoma: a window of opportunity

PURPOSE

Therapeutic intervention at glioblastoma (GBM) progression, as defined by current assessment criteria, is arguably too late as second-line therapies fail to extend survival. Still, most GBM trials target recurrent disease. We propose integration of a novel imaging biomarker to more confidently and promptly define progression and propose a critical timepoint for earlier intervention to extend therapeutic exposure.

METHODS

A retrospective review of 609 GBM patients between 2006 and 2019 yielded 135 meeting resection, clinical, and imaging inclusion criteria. We qualitatively and quantitatively analyzed 2000+ sequential brain MRIs (initial diagnosis to first progression) for development of T2 FLAIR signal intensity (SI) within the resection cavity (RC) compared to the ventricles (V) for quantitative inter-image normalization. PFS and OS were evaluated using Kaplan-Meier curves stratified by SI. Specificity and sensitivity were determined using a 2 × 2 table and pathology confirmation at progression. Multivariate analysis evaluated SI effect on the hazard rate for death after adjusting for established prognostic covariates. Recursive partitioning determined successive quantifiers and cutoffs associated with outcomes. Neurological deficits correlated with SI.

RESULTS

Seventy-five percent of patients developed SI on average 3.4 months before RANO-assessed progression with 84% sensitivity. SI-positivity portended neurological decline and significantly poorer outcomes for PFS (median, 10 vs. 15 months) and OS (median, 20 vs. 29 months) compared to SI-negative. RC/V ratio ≥ 4 was the most significant prognostic indicator of death.

CONCLUSION

Implications of these data are far-reaching, potentially shifting paradigms for glioma treatment response assessment, altering timepoints for salvage therapeutic intervention, and reshaping glioma clinical trial design.

Esophageal cancer: How far is close enough?

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Background: According to Surveillance, Epidemiology, and End Results (SEER) data, 5-year survival of esophageal cancer (EC) improved from 4.1% to almost 20% from 1975 to 2016, however, this is still poor compared to other cancers. Chitti et al describe temporal changes in EC mortality by geographic region across the United States (U.S.) and concluded that disparities exist. Other studies described survival disparities for rural communities specific to small cell lung carcinoma, cervical cancer, and breast cancer. Hung et al determined that 1 in 5 rural Americans lived > 60 miles from a medical oncologist. Studies performed outside of the U.S. described no difference in survival with travel distance. No studies on this topic have focused on gastrointestinal malignancy. Our study aimed to associated travel distance with travel time to a medical oncology treatment center as time can vary greatly with similar distances. We focused specifically on esophageal cancer considering its high mortality rate and significant effect on quality of life. Methods: We performed a descriptive analysis of a retrospective cohort (January 2008 – August 2019) of all individuals diagnosed with esophageal cancer using data from the institutional Oncology Tumor Registry, a regional cancer registry, and the electronic health records (EHR) of patients throughout a rural integrated health system in Pennsylvania. We geocoded home addresses using Google Maps Geocoding application programming interface (API) and the average driving distance and time to the nearest medical oncology treatment center was calculated using the Google Maps Distance Matrix API. Travel time compared to cancer stage was also assessed. Addresses listed over 100 miles were evaluated for documentation accuracy via the EHR. Results: A total of 1157 adult patients diagnosed with esophageal cancer was evaluated; of these, 433 had a documented outpatient chemotherapy infusion site visit. The mean travel distance to a medical oncology treatment center was 19.8 miles with a median of 16 miles; this correlated with a mean travel time of 28.2 minutes. Seventy-five percent of the population lived within 26 miles of an outpatient oncology center. The maximum distance traveled was 139 miles, which was confirmed via EHR chart review. Conclusions: This study shows that a rural population may not necessarily experience disparity in travel distance and time to a medical oncology treatment center. This was an exploratory study and further analysis will be needed to see if there was any statistically significant difference in survival based on distances when stratified by stage, age, treatment modality, etc.

Single-institution experience of small cell bladder cancer at a community center

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Background: Small cell bladder cancer (SCBC) is a rare malignancy with poor prognosis. Previous retrospective studies mainly focused on answering whether radical cystectomy is superior to radiation. Little is known about the disease characteristics and clinical course. Methods: Patients were identified via Geisinger cancer registry from 1991 to 2019, and retrospective chart review was performed through the electronic health records, EPIC. We described patient characteristics and outcomes. OS was measured from time of initial diagnosis to death or last follow up. Kaplan-Meier analyses were done on OS. Results: 50 patients were identified; 7 patients were excluded due lack of information. M: F≈1, 60% patients had pure small cell carcinoma (SCC) histology (≥ 95%), 37% with SCC and urothelial carcinoma mixed histology, MIB-1 index was 80-100%. Median OS for localized disease (IQR) was 22 months (9,73), and 11 months (7,16) for metastatic disease. For localized disease, OS were similar between patients with or without pure small cell history (P = 0.47). 8 patients were alive at 5 years; 3 patients received neoadjuvant chemotherapy followed by radical cystectomy, 2 patients underwent radical cystectomy alone, 2 patients had concurrent chemotherapy with radiation; 1 patient had complete pathological response to Cisplatin and etoposide chemotherapy, did not receive additional therapy and recurred 6 years later. Recurrence ranged from 6 to 79 months. 10 patients had disease progression despite of palliative chemotherapy. Conclusions: Small cell bladder cancer is a heterogenous disease, early stage disease can be curable but late recurrence does occur, continued surveillance is warranted even after 5 years. New treatment modality is in need to improve outcome for patients with metastatic disease.

EPID-34. GEODEMOGRAPHIC CLASSIFICATION OF GLIOBLASTOMA RISK IN A RURAL HOSPITAL SYSTEM: RELATIONSHIP TO TUMOR INCIDENCE AND OVERALL SURVIVAL

In 2019, a projected 86,000 persons in the US will be diagnosed with a primary brain tumor, with an estimated prevalence of 700,000. Glioblastoma (GBM) is the deadliest and most common of these tumors in adults with an overall survival ~15 months. Exposure to ionizing radiation is the single known environmental risk factor for GBM. Most research in the field is directed at treatment and tumor biology/classification. There is growing interest in geodemographics, disease prevention, and measuring quality-survival in GBM. We evaluated 622 GBM patients (2006 to 2018) in Northeastern/Northcentral Pennsylvania treated at one of the nation’s largest rural hospital systems. Each patient was geocoded (plotted longitude/latitude) address at time of diagnosis and we used medical records, projected 2015 Census, and Environmental Protection Agency data to develop risk maps. Preliminary evaluation of overall survival (OS) and incidence related to distance from hospital, age, sex, level of education, insurance, income, and income disparity (Gini coefficient measure of income inequality) was completed. Interestingly, all significant clusters of high GBM incidence lay along water-ways or overlapped with high coal mine reprocessing. Contrary to recent studies, there was no significant sex or distance (0mi to 150mi) impact on survival. However, each age-decile increase resulted in an average 9mo decrease in OS (37mo[< 40yo], 26mo [41-50yo], 17mo [51-60yo], 12mo [61-70yo], and 3mo [>71yo]). Counties with the lowest OS shared geodemographic characteristics such as fewer insured and lower incomes (low income inequality), and counties with more college educated persons had longer survival. Counties with higher GBM incidences had better insured percentages, lower incomes (high income inequality), and large polarity between high school uneducated and college educated persons. Rural populations potentially demonstrate unique geodemographic characteristics that might better predict disease outcomes. Studies in this area could influence improvements in public policy and prevention-focused health literacy opportunities.

MNGI-14. PROGNOSTIC FEATURES OF MALIGNANT MENINGIOMA: EVALUATION OF AGGRESSIVE MENINGIOMAS WITHIN A LARGE RURAL HOSPITAL SYSTEM DATABASE AND FIRST REPORT OF A METASTATIC CHORDOID MENINGIOMA TO THE LUNG

Meningiomas comprise 37% of primary brain tumors, arise extra-axially from the arachnoid cap cells, and are typically identified by classic imaging and histopathologic features. Blacks, females, and people age 65+ have higher incidence rate - partially correlated with hormonal states, high body mass index, and known genetic predispositions. Prognostication is otherwise based on histopathologic findings and 90% of meningiomas are classified as benign (WHO grade I). Despite use of these prognostic tools, clinicians often observe a more divergent post-operative clinical course. While several pre-clinical studies have identified putative oncogenic influencers, many have failed to show correlation in human trials. Here, we evaluate a single institutional meningioma database stratified by geodemographic and clinical data to identify novel integrated prognostic indicators for aggressive tumor natural history. Our database contains 3,528 image-confirmed meningiomas between 1992–2019. This report focused on 415 pathology-confirmed cases between 2006–2019: WHO grades I, II, III were 73% (n=303), 25% (n=103), and 2% (n=9) respectively, 71% female predominance (n=294), median age at diagnosis 57-years-old, and 97.5% were white race. Thus far, full exome sequencing has been completed on >50% of cases and >80% have available tumor tissue for future testing as part of this rural Pennsylvania database with high incident aggressive and/or multiply recurrent meningiomas. We selected four representative cases to compare post-operative prognostication to observed clinical outcomes and provide molecular/genetic, histopathologic, treatment modality, comorbid, and other clinical features associated with morbidity/mortality. Included in this patient review is the first reported case of a rare (< 1%) chordoid meningioma, multiply recurrent despite 8-years of aggressive treatment modalities, including surgery, radiation, chemotherapy and androgen-blockade, with eventual extracranial metastasis to the lung, a meningiocarcinoma, if you will. Thorough interrogation of the completed database could yield novel predictive indicators of clinically aggressive meningiomas and guide clinical decision-making for optimized surveillance in high-risk patients.

Pegylated interferon alfa-2a for polycythemia vera or essential thrombocythemia resistant or intolerant to hydroxyurea

Prior studies have reported high response rates with recombinant interferon-α (rIFN-α) therapy in patients with essential thrombocythemia (ET) and polycythemia vera (PV). To further define the role of rIFN-α, we investigated the outcomes of pegylated-rIFN-α2a (PEG) therapy in ET and PV patients previously treated with hydroxyurea (HU). The Myeloproliferative Disorders Research Consortium (MPD-RC)-111 study was an investigator-initiated, international, multicenter, phase 2 trial evaluating the ability of PEG therapy to induce complete (CR) and partial (PR) hematologic responses in patients with high-risk ET or PV who were either refractory or intolerant to HU. The study included 65 patients with ET and 50 patients with PV. The overall response rates (ORRs; CR/PR) at 12 months were 69.2% (43.1% and 26.2%) in ET patients and 60% (22% and 38%) in PV patients. CR rates were higher in CALR-mutated ET patients (56.5% vs 28.0%; P = .01), compared with those in subjects lacking a CALR mutation. The median absolute reduction in JAK2V617F variant allele fraction was -6% (range, -84% to 47%) in patients achieving a CR vs +4% (range, -18% to 56%) in patients with PR or nonresponse (NR). Therapy was associated with a significant rate of adverse events (AEs); most were manageable, and PEG discontinuation related to AEs occurred in only 13.9% of subjects. We conclude that PEG is an effective therapy for patients with ET or PV who were previously refractory and/or intolerant of HU. This trial was registered at www.clinicaltrials.gov as #NCT01259856.

Mortality of acute promyelocytic leukemia in a rural tertiary care center

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Background: Acute promyelocytic leukemia (APL) has a very good prognosis when diagnosed and treated promptly. Despite the excellent prognosis, early mortality remains high, ranging 17-40%. Geisinger Health System (GHS) has provided treatment for a significant number of APL patients, but mortality of APL at GHS has not been studied. We conducted a study to assess early mortality related to APL in GHS. Methods: Retrospective analysis was performed of patients diagnosed with APL from January 1988 to February 2019, determining the number of patients diagnosed and treated for APL in GHS, overall 30-day mortality rate, stratified by risk group (low, intermediate, high based on presenting white blood cell and platelet counts) and age above or below 55. Results: A total of 61 patients with APL were identified. Average age at diagnosis was 44.77 years (SD = 19.12). The death rates in patients in whom risk data was available was 7%, 9.3% and 11.6% respectively in the low, intermediate and high risk groups respectively. There was no statistically significant difference in the frequency distribution between risk categories for survival, χ2 = 1.03, p = .60. Between age groups, 8.3% of patients under age 55 died, whereas 18.3% of those 55 or older died. Survival between the two age groups was statistically significant, χ2 = 10.92, p = .001. Estimated 30-day overall mortality in the studied population was 16.39%; and 7.69%, 5.56% and 38.46% for the low, intermediate, high-risk patients respectively. Conclusions: Among patients diagnosed with APL in the GHS over the past 30 years, the early mortality rate has been comparable to reported mortality rates in centers around the world. Our study showed a statistically significant higher mortality rate in patients 55 years or older. Further study is planned to assess factors contributing to mortality and outcomes.

Current advances in Hodgkin's lymphoma

Hodgkin's lymphoma is a highly treatable malignancy. It has high cure rates yet there are many patients who relapse or are refractory to treatment. Traditionally, treatment has been with conventional chemotherapy; however, the development of brentuximab vedotin and immune checkpoint inhibitors has revolutionized the care of Hodgkin's lymphoma. This is a review of the current advances in the management of Hodgkin's lymphoma and a review of ongoing clinical trials in the field.

Gastrointestinal stromal tumors: management of metastatic disease and emerging therapies

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Before the advent of tyrosine kinase inhibitors (TKIs) there were few treatment options available to patients with metastatic GIST. Surgery was the mainstay of treatment and the prognosis was dismal. With the advent of imatinib and second-line TKIs the prognosis of metastatic GIST has improved dramatically; however, there is still a need for therapies for patients with disease refractory to TKI therapy. Newer agents are under investigation and may have promise. This article discusses the current standard of care in terms of standard and investigational pharmacotherapy in the management of metastatic GIST.

Personalized medicine and treatment approaches in non-small-cell lung carcinoma

Chemotherapy has been the traditional backbone for the management of metastatic lung cancer. Multiple trials have shown the benefits of treatment with platinum doublets in lung cancer. This "one treatment fits all" approach was further refined by the introduction of targeted agents and discovery of subpopulations of patients who benefited from treatment with these agents. It has also become evident that certain histologic subtypes of non-small-cell lung cancer respond better to one cytotoxic chemotherapy versus others. This has led to the concept of using histology to guide therapy. With the introduction of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors and the discovery of activating mutations in the EGFR gene, further personalization of treatment for subgroups of patients has become a reality. More recently, the presence of a fusion gene, echinoderm microtubule-associated protein-like 4 - anaplastic lymphoma kinase (EML4-ALK), was identified as the driver mutation in yet another subgroup of patients, and subsequent studies have led to approval of crizotinib in this group of patients. In this article, efforts in personalizing delivery of care based on the histological subtypes of lung cancer and the role of K-RAS and EGFR mutations, EML4/ALK translocation, and ERCC1 (excision repair cross-complementing 1) and EGFR expression in choosing appropriate treatments for patients with advanced lung cancer are discussed. This article also reviews the problem of resistance to EGFR tyrosine kinase inhibitors and the ongoing trials that target novel pathways and mechanisms that are implicated in resistance.