Secondary primary malignancies after treatment with chemo-immunotherapy in treatment-naïve patients with CLL: a systematic literature review

OBJECTIVES

In chronic lymphocytic leukemia (CLL), therapy-related cytotoxicity and the resulting immunodeficiency are thought to contribute to the development of secondary primary malignancies (SPM). Here we analyzed clinical trial data on the occurrence of SPM following chemo-immunotherapy (CIT) regimens in treatment-naïve CLL patients.

METHODS

A systematic literature search was conducted covering multiple databases between 2003-2019. Data from relevant clinical trials on the proportion of patients with SPMs were extracted. Then the number of SPM patients/person-years was calculated by taking into account the trials' follow-up time. Finally, a random-effects meta-analysis to pool the rates from individual studies was performed.

RESULTS

We identified 22 studies reporting SPM data available for analysis. Random-effects meta-analysis estimated that the number of SPM patients/1000 person-years was 24 (95%CI: 19-29). Results from trials with cancer-specific data indicated 19 (95%CI: 14-26) solid and 9 (95%CI: 6-12) hematological SPM patients/1000 person-years. These estimations did not change significantly when sub-groups were analysed by CIT regimens.

CONCLUSION

Although pooling data with the intention to analyze adverse event rates is challenging, our study concluded that in case of CIT regimens, SPM should be considered an important adverse outcome. Different regimens showed similar trends; however, other clinical and demographic factors have a profound impact in this respect.

Secondary primary lung cancer after esophageal cancer: a population-based study of 44,172 patients

BACKGROUND

The present study aimed to assess the survival, incidence, and characteristics of secondary primary lung cancer (SPLC) after esophageal cancer (EC-LC).

METHODS

The patients with esophageal cancer (EC) who developed SPLC and patients with first primary lung cancer (LC-1) were retrospectively reviewed in the Surveillance, Epidemiology, and End Results 18 registries covering 2000-2016. Overall survival and characteristics were compared between patients with EC-LC and patients with LC-1. The independent relation between a history of EC and death was evaluated by calculating hazard ratios in multivariate Cox regression analysis propensity score-matching analysis, and multiple imputation for cases with missing information.

RESULTS

In comparison with the general population, the patients with EC had a higher risk for developing secondary primary lung cancer (SIR =1.86, 95% confidence interval (CI): 1.69-2.05). A history of EC was found to be an independent risk factor of death for lung squamous carcinoma (LUSC) and lung adenocarcinoma (LUAD) patients in localized stage based on multivariate Cox regression analysis, propensity score-matching analysis and multiple imputation.

CONCLUSIONS

There is a significantly increased risk of secondary primary lung cancer in EC survivors and a history of EC adversely affects overall survival in individuals who subsequently develop localized LUSC and LUAD. Clinicians should moderately strengthen lung tissue protection during the management of EC patients.

Second Primary Malignancy in Patients with Hypopharyngeal Carcinoma: A SEER-Based Study

Background

A population-based analysis of the risk of secondary primary malignancy (SPM) in patients with hypopharyngeal carcinoma (HPC) has been lacking in the literature. Therefore, we conducted this study to determine the risk factors and assess the effects of SPM on the overall survival (OS) and cancer-specific survival (CSS) of patients with HPC.

Methods

Data on selected patients diagnosed with HPC from the Surveillance, Epidemiology and End Results (SEER) database between 1973 and 2015 were examined through logistic regression, Cox regression and nomogram methods.

Results

The overall risk of SPM in patients with HPC was higher than that in the general population (SIR: 2.77; P < 0.05). The specific-site, including the oral cavity, pharynx, digestive system, respiratory system and endocrine system, had a relatively higher risk of SPM. The overall risks of the subgroup of people 55–75 years of age and all subgroups of sex, race and latency were significantly elevated. In addition, patients with HPC were more likely to have been diagnosed in 2010–2015 (vs 2004–2009; P = 0.002), to be unmarried (vs married; P = 0.008), to have distant metastasis (vs no metastasis; P = 0.016) and to have had no surgery for the first tumor (vs surgery for the first tumor; P = 0.021), and these aspects were associated with a significantly elevated risk of developing SPM. SPM was independently associated with better OS and CSS. The OS and CSS in patients with HPC with SPM were better than those in patients without SPM (log rank P < 0.0001). The C indexes of the nomogram constructed with ten influencing factors including SPM were 0.681:0.699 for OS and 0.705:0.724 for CSS (training cohort:validation cohort).

Conclusion

Although the overall risk of SPM in patients with HPC was elevated, SPM did not decrease the OS and CSS in patients with HPC. This finding is inconsistent with clinical observations and thus requires further research and exploration. It possibly because HPC might have a shorter survival time, or the follow-up time was not long enough.

Second Primary Malignancies in Patients With Hepatocellular Carcinoma: A Population-Based Analysis

Background

Second primary malignancy (SPM) is becoming a threat for the health of cancer survivors. However, data on the features and results of patients with hepatocellular carcinoma (HCC) with SPMs are scarce. This study aimed to explore the characteristics of HCC patients with SPMs and to screen HCC patients who are at a high risk of developing SPMs.

Method

HCC patients diagnosed between 2000 and 2014 in the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. Eligible patients were divided into the only one primary malignancy and SPM groups. The Fine-Gray proportional subdistribution hazards model was used to explore the risk factors of developing SPMs, and a competing-risk model was established to predict the probability of developing SPMs for HCC patients after initial diagnosis. The calibration curves, concordance index (C-index), and decision curve analysis (DCA) were used to evaluate the performance of the nomogram.

Results

A total of 40,314 HCC patients were identified, 1,593 (3.95%) of whom developed SPMs 2 months after the initial diagnosis with a maximum follow-up time of approximately 18 years. The 3-, 5-, and 10-year cumulative incidence of SPMs were 2.35%, 3.12%, and 4.51%, respectively. Age at initial diagnosis, extent of disease, tumor size, and treatment were identified as the independent risk factors of developing SPMs and integrated into the competing-risk nomogram. The C-index of the nomogram was 0.677 (95% confidence interval 0.676-0.678), and the calibration curves showed an excellent agreement between the nomogram prediction and the actual observations. Furthermore, DCA indicated that the nomogram had good net benefits in clinical scenarios.

Conclusions

HCC survivors remain at a high risk of developing SPMs. The development of SPMs was associated with the clinical features and treatment strategies. A competing-risk nomogram was constructed to help surgeons identify the patients who are at a high risk of developing SPMs and contribute to the further management of SPMs.

Metastatic prostate adenocarcinoma and high-grade appendiceal mucinous neoplasm mimicking acute appendicitis in a post-radiation therapy patient

Prostate cancer is the most common visceral malignancy diagnosed in males. Surveillance for post-treatment neoplasms is very crucial. Here we report the first case of recurrent metastatic prostate cancer presenting as acute appendicitis in a background of a high-grade appendiceal mucinous neoplasm. In addition, this case also includes an unusually early presentation of a secondary primary malignancy after radiation therapy. A 70-year-old male with a history of prostate adenocarcinoma status post-proton radiation therapy presented with recurrent poorly differentiated prostate adenocarcinoma with disease progression and extra-prostatic extension. He underwent salvage proton therapy and testosterone replacement therapy. Two years later, the patient presented with right lower quadrant pain. A computed tomography scan showed perforated acute appendicitis with intra-abdominal abscess, which was treated with interval appendectomy. Upon histologic analysis, metastatic prostatic adenocarcinoma was noted in the appendiceal wall and mesoappendix. In addition, an incidental background of high-grade appendiceal mucinous neoplasm was found. Four months later, he presented with persistent abdominal pain, rapid weight loss, fatigue, and fever for 3 months. An abdominal CT scan revealed a 6.1 cm rectal mass. Pathologic analysis diagnosed an aggressive post-radiation spindle cell sarcoma, intermediate to high grade. The patient opted for palliative care. This case shows that a clinical presentation of acute appendicitis in an older patient may sometimes portend a neoplastic rather than infectious etiology. Clinical history and patient epidemiology should always be considered when evaluating an older patient with clinical signs and symptoms of acute appendicitis.

Colorectal Cancer in a Patient With Multiple Myeloma: A Treatment Dilemma

Multiple myeloma (MM) is a malignancy of plasma cells characterized by the clonal proliferation of plasma cells that produce monoclonal immunoglobulins. While typically considered to be incurable, advances in treatment options have led to remarkable improvements in survival for these patients. Accumulating evidence suggests an increased risk for the development of a secondary primary malignancy (SPM) in these patients, perhaps as a result of myeloma directed therapy or as an effect of their underlying disease process. Here we present a case of a patient who was diagnosed with an SPM while undergoing palliative treatment for multiple myeloma and a treatment approach.

Association between the findings of metachronous secondary primary malignancies and the number of Lugol-voiding lesions

This study was designed to evaluate the relation between dysplastic squamous epithelium in the esophageal mucosa and the development of metachronous secondary primary malignancies (mSPM) other than esophagus after endoscopic resection (ER) in patients with early esophageal squamous cell carcinoma (SCC). We studied 330 patients with early esophageal SCC who underwent ER as a post hoc analysis of a prospective multicenter cohort study (UMIN Clinical Trials Registry ID UMIN000001676). Lugol-voiding lesions (LVL) were graded into 3 categories (A = no lesion; B = 1 to 9 lesions; C ≥ 10 lesions). The following variables were studied: (i) the incidences of mSPM other than esophagus; (ii) the standardized incidence ratios (SIRs) of mSPM; (iii) the cumulative incidence and total number of mSPM other than esophagus; and (iv) predictors of mSPM other than esophagus on analysis with a multivariate Cox proportional-hazards model. After a median follow-up of 46.6 months, mSPM other than esophagus was diagnosed in a total of 73 patients (90 lesions). Among the 106 patients in group C, 37 patients had mSPM (51 lesions), including head and neck cancer in 14 patients (24 lesions) and gastric cancer in 12 patients (16 lesions). The SIR of mSPM was 3.61 in this study subjects. An increase in the LVL grade (A to B to C) was associated with a progressive increase in the cumulative incidence rate of mSPM other than esophagus (P = 0.017 for A vs. C, P = 0.023 for B vs. C). An increase in the LVL grade (A to B to C) was also associated with a progressive increase in the total number of mSPM other than esophagus per 100 person-years (primary events, relative risk [RR] = 1.66 and 3.24 for grades B and C, respectively, vs. A, P = 0.002 for trend; all events, RR = 1.81 and 4.66 for grades B and C, respectively, vs. A, P < 0.0001 for trend). LVL grade C was a strong predictor of mSPM other than esophagus (RR = 3.41 for A vs. C). LVL grade may be a useful predictor of the risk of mSPM other than esophagus after ER in patients with early esophageal SCC.

Cardiac ALL: Most Unusual Occurrence of Lenalidomide-associated Acute Lymphoblastic Leukemia with Subsequent Cardiac Involvement

Leukemic infiltration of the myocardium is an extremely rare complication and requires high clinical suspicion, as <5% pf patients are symptomatic. Commonly encountered cardiovascular complications are secondary to anemia, infections, and chemotherapy.

We present an unusual case of biopsy-proven myocardial B-cell acute lymphoblastic leukemia (ALL) in an elderly male on chronic maintenance therapy with lenalidomide, with a previous history of multiple myeloma (MM) and subsequent ALL. Lenalidomide is a Category 1 recommendation for primary and maintenance therapy of MM, but there is growing evidence of secondary primary malignancies (SPMs). Despite this increase in SPM, the overall survival (OS) benefit associated with the use of maintenance immunomodulatory (IMID) therapy in multiple myeloma outweighs the risk of SPMs. Only age-appropriate screening methods are recommended.

This case report serves as an important reminder of a rare manifestation of leukemia and presents as anecdotal evidence of response to the monoclonal antibody inotuzumab for visceral involvement of ALL, which has not been reported to our knowledge and requires further exploration.

Synchronous double cancers of colonic large cell neuroendocrine carcinoma and gastric squamous-cell carcinoma: a case report and review of literature

Either colonic large cell neuroendocrine carcinoma (LCNEC) or gastric squamous-cell carcinoma (SCC) is extremely rare, with a very poor prognosis due to the high rate of distant metastases. Here, we report the first case of synchronous double malignancies in form of colonic LCNEC and gastric SCC. A 66-year male underwent a right hemicolectomy for a mass obstructing the ascending colon and an emergent gastroscopic hemostasis for another hemorrhagic stomach mass. Histopathological examination confirmed colonic LCNEC displaying the characteristic of large, vesicular nuclei with variable amounts of cytoplasm and gastroscopic biopsy revealed poorly-differentiated gastric SCC. Immunohistochemical staining of LCNEC demonstrated positive activities for chromogranin A, synaptophysin, CD56, NSE, ki-67 (>95%), but negative for CD99, CK20 and TTF-1. The patient had suffered from an accelerated growth of multiple liver metastases after surgery, suggestive of concomitant tumor resistance (CR), and survived 2 months after discharge.