A prospective multicenter study to evaluate the impact of cryotherapy on dysphagia and quality of life in patients with inoperable esophageal cancer.

BACKGROUND: Dysphagia palliation in inoperable esophageal cancer continues to be a challenge. Self-expandable metal stents have been the mainstay of endoscopic palliation but have a significant risk of adverse events (AEs). Liquid nitrogen spray cryotherapy is an established modality that can be used with systemic therapy. This study reports the outcomes of cryotherapy, including dysphagia and quality of life (QoL), in patients receiving systemic therapy. METHODS: This was a prospective multicenter cohort study of adults with inoperable esophageal cancer who underwent cryotherapy. QoL and dysphagia scores before and after cryotherapy were compared. RESULTS: 55 patients received 175 cryotherapy procedures. After a mean of 3.2 cryotherapy sessions, mean QoL improved from 34.9 at baseline to 29.0 at last follow-up (P < 0.001) and mean dysphagia improved from 1.9 to 1.3 (P = 0.004). Patients receiving more intensive cryotherapy (≥ 2 treatments within 3 weeks) showed a significantly greater improvement in dysphagia compared with those not receiving intensive therapy (1.2 vs. 0.2 points; P = 0.003). Overall, 13 patients (23.6 %) received another intervention (1 botulinum toxin injection, 2 stent, 3 radiation, 7 dilation) for dysphagia palliation. Within the 30-day post-procedure period, there were three non-cryotherapy-related grade ≥ 3 AEs (all deaths). The median overall survival was 16.4 months. CONCLUSION: In patients with inoperable esophageal cancer receiving concurrent systemic therapy, adding liquid nitrogen spray cryotherapy was safe and associated with improvement in dysphagia and QoL without causing reflux. More intensive treatment showed a greater improvement in dysphagia and should be considered as the preferred approach.

Addressing Drug Resistance in Cancer: A Team Medicine Approach.

Drug resistance remains one of the major impediments to treating cancer. Although many patients respond well initially, resistance to therapy typically ensues. Several confounding factors appear to contribute to this challenge. Here, we first discuss some of the challenges associated with drug resistance. We then discuss how a 'Team Medicine' approach, involving an interdisciplinary team of basic scientists working together with clinicians, has uncovered new therapeutic strategies. These strategies, referred to as intermittent or 'adaptive' therapy, which are based on eco-evolutionary principles, have met with remarkable success in potentially precluding or delaying the emergence of drug resistance in several cancers. Incorporating such treatment strategies into clinical protocols could potentially enhance the precision of delivering personalized medicine to patients. Furthermore, reaching out to patients in the network of hospitals affiliated with leading academic centers could help them benefit from such innovative treatment options. Finally, lowering the dose of the drug and its frequency (because of intermittent rather than continuous therapy) can also have a significant impact on lowering the toxicity and undesirable side effects of the drugs while lowering the financial burden carried by the patient and insurance providers.

Sarcopenia supersedes subjective global assessment as a predictor of survival in colorectal cancer.

BACKGROUND: Sarcopenia, the presence of skeletal muscle mass depletion, can be objectively quantified, whereas subjective global assessment (SGA) is a widely utilized subjective instrument to assess nutritional status. Both the presence of sarcopenia and SGA-assessed malnutrition, in isolation, have been shown to be associated with worse overall survival in a wide range of cancers. However, there is no research evaluating the independent prognostic significance of both the presence of sarcopenia and malnutrition as part of the same analysis. We investigated the impact of sarcopenia on overall survival in colorectal cancer specifically controlling for malnutrition. METHODS: We examined a consecutive case series of 112 patients with colorectal cancer first seen at our institution between August 2012 and October 2017. Using computed tomography (CT) imaging, the cross-sectional area of muscles at the L3 vertebral level was measured and then divided by height squared to calculate skeletal muscle index (SMI). Sarcopenia was defined as SMI ≤38.5 cm2/m2 for women and ≤52.4 cm2/m2 for men. SGA assessments were completed within 2 weeks of CT imaging. The association of sarcopenia and malnutrition with overall survival was assessed using univariate and multivariate Cox regression analysis. RESULTS: Median age at presentation was 53.3 years. Sixty-six (58.9%) patients had metastatic disease at diagnosis. Using SMI, 46 (41.1%) patients were sarcopenic, while 66 (58.9%) were non-sarcopenic. Using SGA, 69 (61.6%) patients were assessed as well-nourished, while 43 (38.4%) were malnourished. Of 69 patients classified as well-nourished by SGA, 22 (31.9%) were sarcopenic. Similarly, of 43 patients categorized as malnourished by SGA, 19 (44.2%) were non-sarcopenic. On multivariate analysis, after adjusting for age, gender, tumor stage, BMI, treatment history and SGA, patients with sarcopenia had 3 times greater risk of mortality compared to those without sarcopenia (p = 0.001). The median survival of patients with both sarcopenia and malnutrition (n = 24) was 14.6 months (95% CI: 10.5 to 18.6) compared to the median survival of 25.9 months (95% CI: 7.8 to 44.0) in patients who were either sarcopenic or malnourished but not both (n = 41; p = 0.001). The median survival of patients who were non-sarcopenic and well nourished (n = 48; p = 0.001) was 38.6 months (95% CI: 25.6 to 51.6). CONCLUSIONS: The exploratory study suggests that presence of sarcopenia supersedes the presence of malnutrition as a predictor of survival in colorectal cancer. Co-existence of sarcopenia and malnutrition is associated with worse survival in colorectal cancer compared to just one of those conditions being present. Prospective studies with large sample sizes are needed to confirm these findings.

Therapeutic and prophylactic gastrectomy in a family with hereditary diffuse gastric cancer secondary to a CDH1 mutation: a case series.

BACKGROUND: Gastric cancer is the fifth most prevalent and the third most lethal cancer worldwide, causing approximately 720,000 deaths annually. Although most cases of gastric cancers are sporadic, one of its inherited forms, hereditary diffuse gastric cancer (HDGC), constitutes about 1-3% of cases. Interestingly, females in families with HDGC are also predisposed to developing lobular breast cancer (LBC). Recent analyses have identified loss-of-function germline mutations in cadherein-1 (CDH1) as a culprit in HDGC and LBC. This discovery fueled several sequencing analyses and case series reports analyzing the pattern of inheritance of CDH1 and its propensity to induce HDGC. In 2015, a multinational and multidisciplinary task force updated the guidelines and criteria for screening, diagnosing, and managing HDGC. CASE PRESENTATION: Here, we present a case series of three siblings with family history of HDGC who tested positive for the CDH1 mutation and describe their surgical treatment course, post-operative management, and follow-up as they pertain to the updated guidelines. CONCLUSIONS: Despite recent updates in guidelines in the diagnosis and management of HDGC, the disease remains challenging to address with patients given the high level of uncertainty and the comorbidities associated with prophylactic intervention. We strongly recommend that an interdisciplinary team inclusive of clinical and surgical oncologists, along with geneticists, social work, and psychological support, should follow the patients in a longitudinal and comprehensive manner in order to achieve full recovery and return to normalcy, as with our patients.

Liquid nitrogen spray cryotherapy for dysphagia palliation in patients with inoperable esophageal cancer.

BACKGROUND AND AIMS: Dysphagia is a debilitating symptom in patients with inoperable esophageal cancer that contributes to poor quality of life and worsening nutritional status. The 2 most commonly used palliative modalities for dysphagia are radiation therapy and esophageal stent placement. However, radiation therapy is limited by adverse events (AEs) and total dose, and stent placement has a high rate of AEs, including reflux, migration, and chest pain. A relatively new modality of liquid nitrogen endoscopic spray cryotherapy has been described as salvage when other options have been exhausted and when patients are no longer receiving systemic therapy. We evaluated the safety and efficacy of cryotherapy as the primary modality for relieving dysphagia in inoperable esophageal cancer including patients receiving systemic cancer therapy. METHODS: This is a retrospective, multicenter, consecutive case series of 49 inoperable esophageal cancer patients undergoing palliative endoscopic cryotherapy at 4 specialized cancer centers from May 2014 to May 2016. The primary outcomes were change in dysphagia scores between pre- and postcryotherapy and AEs. Dysphagia was measured using a 5-point Likert scale: 0, no dysphagia; 1, dysphagia to solids; 2, dysphagia to semisolids; 3, dysphagia to liquids; 4, dysphagia to saliva. RESULTS: Thirty-nine men and 10 women with a mean age of 58 years underwent a total of 120 cryotherapy treatments. The mean dysphagia score improved significantly from 2.4 precryotherapy to 1.7 postcryotherapy (improvement of .7 points; P < .001). Minor AEs were seen in 6 of 120 (5.0%) cryotherapy treatments (1 intraprocedural and 5 postprocedural). In addition, 1 patient developed a severe intraprocedural AE of dilation-related perforation, whereas another patient developed a benign stricture requiring dilation. CONCLUSIONS: This preliminary retrospective study suggests that liquid nitrogen spray cryotherapy may be safe and effective for dysphagia palliation in inoperable esophageal cancer. Large prospective studies are needed to confirm these findings and identify patient and procedure characteristics associated with the greatest benefit.

Incidence of and factors associated with catheter-related bloodstream infection in patients with advanced solid tumors on home parenteral nutrition managed using a standardized catheter care protocol.

BACKGROUND: Catheter-related bloodstream infections (CRBSIs) are associated with high morbidity and mortality as well as increased medical costs. Cancer patients, who are often immunocompromised, are susceptible to CRBSI while receiving home parenteral nutrition (HPN). We evaluated the incidence of and factors associated with CRBSIs in cancer patients undergoing HPN managed using a standardized catheter care protocol. METHODS: This is a retrospective cohort study of 335 cancer patients receiving HPN between January 2012 and July 2015. The primary outcome of interest was the incidence of CRBSI expressed as events per 1000 HPN days. HPN days were calculated from the start date with the home infusion provider until the discontinuation of HPN, or the removal of the venous access device (VAD), or the death of the patient. The VADs used were either peripherally inserted central catheters (PICCs) or a subcutaneous implanted port or tunneled central catheters (TCCs). Univariate Poisson regression analyses were used to determine the variables associated with CRBSIs. RESULTS: Of 335 patients, 193 were females and 142 were males. The most common cancer types were colorectal, pancreatic, ovarian and stomach. A total of 408 VADs in 335 patients were studied, covering a total of 29,403 HPN days. Of 408 VADs, 206 (50.5%) were ports, 191 (46.8%) were PICCs, and 7 (2.7%) were TCCs. The median duration of HPN was 54 days. A total of 16 CRBSI episodes were recorded (8 in ports, 7 in PICCs and 1 in TCCs). The median duration from the start of HPN to the development of CRBSI episodes was 43.5 days. The overall incidence of CRBSI per 1000 HPN days was 0.54 (95% confidence interval: 0.32-0.86). Upon univariate analysis, no variables were found to be statistically significantly associated with CRBSI incidence. CONCLUSIONS: We found a low rate of CRBSI following a standardized catheter maintenance protocol in a high-risk oncology population undergoing HPN.

Safety of endoscopy in cancer patients on antiangiogenic agents: A retrospective multicenter outcomes study.

BACKGROUND/AIMS: The use of antiangiogenic agents (AAs) in cancer treatment has increased because they offer survival benefit in combination with cytotoxic chemotherapy. Given their potential to cause gastrointestinal (GI) perforation and bleeding, it is currently recommended that AAs be held for 28 days before and after surgery. However, there are no specific guidelines which address their use around endoscopic procedures because data regarding the safety of endoscopy in cancer patients while on AAs is scarce despite the fact that these patients often require endoscopy. This study investigated the safety of endoscopy in cancer patients receiving AAs. METHODS: This is a retrospective multicenter study of a consecutive case series of 445 cancer patients undergoing endoscopy within 31 days of administration of AAs at 5 specialized cancer centers between April 2008 and August 2014. Endoscopies were classified into two different categories based on the risk of GI bleeding and perforation: low and high. The primary outcome measures were procedure-related adverse events (AEs) and death within 30 days of endoscopy. The severity of AEs was classified according to the common terminology criteria for adverse events (CTCAE) version 4.0. The incidence of AEs and mortality was calculated using the total number of patients as the denominator. RESULTS: 445 cancer patients with a mean age of 54 years underwent a total of 545 endoscopies. Median time duration from AAs to endoscopy was 11 days. Of 545 endoscopic procedures, 398 (73%) were low-risk and 147 (27%) were high-risk. There were 3 procedure-related AEs: esophageal perforation (grade 3) two days after an EGD, pancreatitis (grade 5) a day after failed ERCP, and bleeding from the gastrostomy site (grade 1) two days after an EGD. Of 445 patients, 29 (6.5%) died within 30 days of the procedure with no deaths deemed procedure-related. The most common causes of death were terminal cancer (n = 10), hepatic decompensation (n = 5) and sepsis (n = 4). CONCLUSION: In this retrospective study, the rate of endoscopy-related AEs in patients on AAs appears to be low when performed in specialized cancer centers. However, future prospective studies are needed to confirm this finding.

Large Bowel Obstruction following Endoscopic Spray Cryotherapy for Palliation of Rectal Cancer Bleeding.

We report a unique case of a 79-year-old woman with metastatic rectal cancer who developed bowel obstruction following endoscopic cryotherapy with liquid nitrogen for palliation of bleeding in the rectum. She developed abdominal distention and pain following the procedure. Computed tomography of the abdomen revealed a paraumbilical hernia containing a segment of transverse colon resulting in partial bowel obstruction. It appears that the recurrent freeze-thaw cycles with poor decompression of the colon despite active venting suction during cryotherapy may have resulted in bowel distention and collapse, causing conformational changes resulting in partial bowel obstruction due to a paraumbilical hernia.

Methylmalonic Acid and Homocysteine as Indicators of Vitamin B-12 Deficiency in Cancer.

BACKGROUND/AIMS: Normal or high serum vitamin B-12 levels can sometimes be seen in a B-12 deficient state, and can therefore be misleading. High levels of Methymalonic Acid (MMA) and Homocysteine (HC) have been identified as better indicators of B-12 deficiency than the actual serum B-12 level itself. We evaluated the prevalence of vitamin B-12 deficiency using appropriate cut-off levels of vitamin B-12, MMA and HC, and determined the relationship between serum levels of vitamin B-12, MMA and HC in cancer. METHODS: This is a cross-sectional study using a consecutive case series of 316 cancer patients first seen at Cancer Treatment Centers of America® (CTCA) at Midwestern Regional Medical Center between April 2014 and June 2014. All patients were evaluated at baseline for vitamin B-12 (pg/mL), MMA (nmol/L) and HC (µmol/L) levels. In accordance with previously published research, the following cut-offs were used to define vitamin B-12 deficiency: <300 pg/mL for vitamin B-12, >260 nmol/L for MMA and >12 µmol/L for HC. The relationship between B-12, MMA and HC was evaluated using Spearman's rho correlation coefficient and cross-tabulation analysis. Receiver Operating Characteristic (ROC) curves were estimated using the non-parametric method to further evaluate the diagnostic accuracy of vitamin B-12 using Fedosov quotient as the "gold standard". RESULTS: Mean age at presentation was 52.5 years. 134 (42.4%) patients were males while 182 (57.6%) were females. Median vitamin B-12, MMA and HC levels were 582.5 pg/mL, 146.5 nmol/L and 8.4 µmol/L respectively. Of 316 patients, 28 (8.9%) were vitamin B-12 deficient based on vitamin B-12 (<300 pg/mL), 34 (10.8%) were deficient based on MMA (>260 nmol/L) while 55 (17.4%) were deficient based on HC (>12 µmol/L). Correlation analysis revealed a significant weak negative correlation between vitamin B-12 and MMA (rho = -0.22) as well as B-12 and HC (rho = -0.35). ROC curves suggested MMA to have the best discriminatory power in predicting B-12 deficiency. CONCLUSION: Vitamin B-12 is poorly correlated with MMA and HC in cancer. Using serum vitamin B-12 alone to evaluate B-12 status in cancer may fail to identify those with functional deficiency. A thorough clinical assessment is important to identify patients that may have risk factors and/or symptoms suggestive of deficiency. These patients should have additional testing of MMA and HC regardless of their B-12 levels.

The relationship between circulating 25-hydroxyvitamin D and survival in newly diagnosed advanced non-small-cell lung cancer.

BACKGROUND: Serum 25-hydroxyvitamin D [25(OH)D], the major circulating form of vitamin D used for evaluating the vitamin D status of patients, has been associated with survival in a variety of cancers with conflicting evidence. We aimed to investigate this association in newly diagnosed advanced non-small-cell lung cancer (NSCLC) patients. METHODS: This was a consecutive cohort of 359 newly diagnosed stages III-IV NSCLC patients who underwent a baseline serum 25(OH)D evaluation prior to receiving any treatment at our institution between January 2008 and December 2010. We used the vitamin D categories of "deficient (<20 ng/ml)" and "not deficient (> = 20 ng/ml)". Cox regression was used to evaluate the prognostic significance of serum 25(OH)D after adjusting for relevant confounders. RESULTS: Mean age at diagnosis was 57.4 years. Of the 359 patients, 151 (42.1 %) were deficient in vitamin D at the time of diagnosis. The median survival in deficient and not deficient cohorts was 11.7 and 12.8 months respectively (p = 0.06). Season of diagnosis, performance status, smoking status and hospital location significantly predicted vitamin D status. On univariate Cox analysis, gender, stage of disease, hospital location, histologic subtype, subjective global assessment (SGA), performance status, smoking status, body mass index and serum albumin were significantly associated with survival (p <0.05 for all). On multivariate Cox analysis, six variables demonstrated statistically significant associations with survival: stage of disease, hospital location, histologic subtype, SGA, smoking status and serum albumin (p <0.05 for all). Serum vitamin D, which was borderline significant in univariate analysis, lost its significance in multivariate analysis. CONCLUSIONS: We found season of diagnosis, performance status and smoking history to be predictive of vitamin D status. Consistent with previously published research in advanced NSCLC, we did not find any significant association between pre-treatment serum 25(OH)D and survival in our patients.

Outcomes of systematic nutritional assessment and medical nutrition therapy in pancreatic cancer.

OBJECTIVES: We investigated the nutritional and survival outcomes of medical nutrition therapy by a registered dietitian, along with support from a dedicated nutrition and metabolic support team in pancreatic cancer patients requiring enteral or parenteral nutrition. METHODS: Subjective global assessment (SGA) was used to assess nutritional status in 304 pancreatic cancer patients. Using baseline and last SGA, patients were categorized into 3 groups: improved SGA, deteriorated SGA, and unchanged SGA. Kaplan-Meier and Cox regression were used to calculate survival after controlling for relevant confounders. RESULTS: One-hundred twenty-five (41.1%) patients had their SGA unchanged, 87 (28.6%) patients had "improved SGA," whereas 92 (30.3%) patients had "deteriorated SGA." On univariate survival analysis, the median survival was 7.8, 11.2, and 12.6 months for deteriorated, unchanged, and improved SGA groups, respectively. On multivariate analysis, change in SGA was independently predictive of survival. Patients with deteriorated SGA had 1.5 times (95% confidence interval, 1.1-2.1) greater risk of mortality compared to those with improved SGA. CONCLUSIONS: The majority of pancreatic cancer patients (70%) in our study either maintained or improved their nutritional status during cancer treatment. Improvement in SGA correlated with a significantly decreased risk of mortality independent of sex, previous treatment history, and evidence of biological anticancer activity.

The association between pre-treatment serum 25-hydroxyvitamin D and survival in newly diagnosed stage IV prostate cancer.

BACKGROUND/AIMS: Emerging evidence in the literature suggests a positive association between serum 25-hydroxyvitamin D [25(OH)D], a standard indicator of vitamin D status, and survival in certain types of cancer. We investigated this relationship in newly diagnosed stage IV prostate cancer patients. METHODS: A consecutive cohort of 125 newly diagnosed stage IV prostate cancer patients underwent a baseline serum 25(OH)D evaluation prior to receiving any treatment at our institution between January 2008 and December 2011. We used the vitamin D categories of "deficient (<20 ng/ml)", "insufficient (20 to 32 ng/ml)", and "sufficient (>32 ng/ml)". Cox regression was used to evaluate the prognostic significance of serum 25(OH)D after adjusting for relevant confounders. RESULTS: Mean age at diagnosis was 60 years. Of the 125 patients, 32 (25.6%) were deficient, 49 (39.2%) were insufficient and 44 (35.2%) were sufficient in vitamin D at the time of diagnosis. The median survival in deficient, insufficient and sufficient cohorts was 47.8, 44.0 and 52.6 months respectively (p = 0.60). On univariate analysis, four variables demonstrated a statistically significant association with survival: nutritional status, bone metastasis, corrected serum calcium and serum albumin (p<0.05 for all). On multivariate analysis, five variables demonstrated statistically significant associations with survival: hospital location, age, bone metastasis, serum albumin and corrected serum calcium (p<0.05 for all). Serum vitamin D status was not significant on either univariate or multivariate analysis. CONCLUSION: Contrary to previously published research, we found no significant association between pre-treatment serum 25(OH)D and survival in newly diagnosed stage IV prostate cancer patients. The lack of a significant association between serum vitamin D and survival in our study could perhaps be due to the fact that the disease was far too advanced in our patients for vitamin D levels to have any impact on prognosis.

A longitudinal study investigating quality of life and nutritional outcomes in advanced cancer patients receiving home parenteral nutrition.

BACKGROUND: In cancer patients where gastrointestinal function is marginal and malnutrition significant enough to result in the requirement for intensive nutrition support, parenteral nutrition (PN) is indicated. This longitudinal study examined the quality of life (QoL) and nutritional outcomes in advanced cancer patients receiving home PN (HPN). METHODS: Fifty-two adult cancer patients (21 males, 31 females, average age 53 years) treated at a specialized cancer facility between April 2009 and November 2011 met criteria. QoL and nutritional status were measured at baseline and every month while on HPN using EORTC-QLQ-C30, Karnofsky Performance Status (KPS), and Subjective Global Assessment (SGA). Repeated measures ANOVA and Generalized Estimating Equations (GEE) were used to evaluate longitudinal changes in QoL and SGA. RESULTS: Cancer diagnoses included pancreatic (n = 14), colorectal (n = 11), ovarian (n = 6), appendix (n = 5), stomach (n = 4) and others (n = 12). Average weight loss 6-months prior to HPN was 13.2 kg (16.9%). Average weight at initiation of HPN was 62.2 kg. In patients with available follow-up data after 1 month (n = 39), there was a significant improvement in SGA, weight (61.5 to 63.1 kg; p = 0.03) and KPS (61.6 to 67.3; p = 0.01) from baseline. Similarly, after 2 months (n = 22), there was an improvement in global QoL (37.1 to 49.2; p = 0.02), SGA, weight (57.6 to 60 kg; p = 0.04) and KPS (63.2 to 73.2; p = 0.01) from baseline. Finally, after 3 months (n = 15), there was an improvement in global QoL (30.6 to 54.4; p = 0.02), SGA, weight (61.1 to 65.9 kg; p = 0.04) and KPS (64.0 to 78.7; p = 0.002) from baseline. Upon GEE analysis, every 1 month of HPN was associated with an increase of 6.3 points in global QoL (p<0.001), 1.3 kg in weight (p = 0.009) and 5.8 points in KPS (p<0.001). CONCLUSIONS: HPN is associated with an improvement in QoL, KPS and nutritional status in advanced cancer patients, irrespective of their tumor type, who have compromised enteral intake and malnutrition. The greatest benefit was seen in patients with 3 months of HPN, although patients receiving HPN for 1 or 2 months also demonstrated significant improvements.

The relationship between baseline nutritional status with subsequent parenteral nutrition and clinical outcomes in cancer patients undergoing hyperthermic intraperitoneal chemotherapy.

BACKGROUND: The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising treatment option for selected patients with peritoneal carcinomatosis. This retrospective study investigated the relationship between baseline nutritional assessment with subsequent parenteral nutritional (PN) and clinical outcomes in cancer patients undergoing CRS and HIPEC. METHODS: A consecutive series of 60 patients undergoing CRS and HIPEC at our institution between January 2009 and May 2011. Subjective Global Assessment (SGA) was used to assess nutritional status. Patients were classified preoperatively as: well nourished (SGA-A), mildly-moderately malnourished (SGA-B), and severely malnourished (SGA-C). For PN, patients were divided into 2 groups: those who received PN (PN+) and those who did not receive PN (PN-). The primary outcomes of interest were length of stay (LOS), postoperative complications, ECOG performance status (PS) and survival. LOS was calculated as the number of days in the hospital post surgery. Performance status was measured on a scale of 0-4. Survival was calculated from the date of first visit to the date of death/last contact. RESULTS: Of 60 patients, 19 were males and 41 females. The mean age at presentation was 50.3 years. The most common cancer types were colorectal (n = 24) and gynecologic (n = 19) with the majority of patients (n = 47) treated previously before coming to our institution. 33 patients were SGA-A, 22 SGA-B and 5 SGA-C prior to surgery. Of a total of 60 patients, 31 received PN. Mean LOS for the entire cohort was 16.2 days (SD = 9.8). Mean LOS for preoperative SGA-A, SGA-B and SGA-C were 15.0, 15.2 and 27.8 days respectively (ANOVA p = 0.02). Overall incidence of complications was 26.7% (16/60). Complications were recorded in 9 of 33 (27.3%) preoperative SGA-A patients and 7 of 27 (25.9%) SGA-B + C patients (p = 0.91). The median overall survival was 17.5 months (95% CI = 13.0 to 22.1 months). Median survival for preoperative SGA-A and SGA-B + C cohorts was 22.4 and 10.4 months respectively (p = 0.006). CONCLUSIONS: The preoperative SGA predicts LOS and survival in cancer patients undergoing HIPEC. Future randomized clinical trials in this patient population should investigate the systematic provision of PN to all malnourished patients in the preoperative period for a minimum of 7-10 days with the continuation of PN in the postoperative period.

Colon carcinoma with unusual metastasis to the esophagus manifesting as multiple nodules and Dysphagia: management with systemic chemotherapy.

We present here the rare clinical case of a 44-year-old gentleman with metastasis from colon carcinoma to the esophagus presenting with multiple nodules and dysphagia, which was successfully managed with systemic chemotherapy. The patient presented at our institution with 3-month history of dysphagia almost 4 years after being operated for stage III carcinoma in the sigmoid colon. Endoscopic findings showed multiple nodules at the gastroesophageal junction and mid esophagus. Histological features and immunostains confirmed the diagnosis of metastatic colon carcinoma. Because of evidence of extensive metastatic disease in the spine and liver requiring systemic therapy, the patient was treated with chemotherapy with irinotecan and cetuximab, with subsequent improvement in tumor markers, liver metastasis and symptoms of dysphagia. Even though repeat endoscopy showed no improvement in esophageal nodules, the overall response to chemotherapy was positive. In conclusion, we present a very rare, previously unreported case of metastases from colon cancer to the esophagus presenting as non-obstructive nodules and dysphagia that responded to systemic chemotherapy.

Role of nutritional status in predicting quality of life outcomes in cancer--a systematic review of the epidemiological literature.

Malnutrition is a significant factor in predicting cancer patients' quality of life (QoL). We systematically reviewed the literature on the role of nutritional status in predicting QoL in cancer. We searched MEDLINE database using the terms "nutritional status" in combination with "quality of life" together with "cancer". Human studies published in English, having nutritional status as one of the predictor variables, and QoL as one of the outcome measures were included. Of the 26 included studies, 6 investigated head and neck cancer, 8 gastrointestinal, 1 lung, 1 gynecologic and 10 heterogeneous cancers. 24 studies concluded that better nutritional status was associated with better QoL, 1 study showed that better nutritional status was associated with better QoL only in high-risk patients, while 1 study concluded that there was no association between nutritional status and QoL. Nutritional status is a strong predictor of QoL in cancer patients. We recommend that more providers implement the American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines for oncology patients, which includes nutritional screening, nutritional assessment and intervention as appropriate. Correcting malnutrition may improve QoL in cancer patients, an important outcome of interest to cancer patients, their caregivers, and families.

Role of nutritional status in predicting the length of stay in cancer: a systematic review of the epidemiological literature.

BACKGROUND: Length of stay (LOS) has been used as a surrogate marker for patients' well-being during hospital treatment. We systematically reviewed all pertinent literature on the role of nutritional status in predicting LOS in cancer. METHODS: A systematic search of human studies published in English was conducted using the MEDLINE data base (all articles published as of December 2010). We searched using the terms 'nutritional status' and 'nutritional assessment' and 'nutritional screening' and 'malnutrition' in combination with the following terms: length of stay, length of hospital stay, duration of stay, and duration of hospitalization together with 'cancer' or 'oncology'. RESULTS: The MEDLINE search identified a total of 149 articles, of which only 21 met the selection criteria. Of the 21 studies, 10 studies investigated gastrointestinal cancer patients, 4 gynecological cancer, and 7 heterogeneous cancer. Eight studies used subjective global assessment (SGA) or patient-generated SGA (PG-SGA), 9 used serum albumin and/or BMI, and 4 used other methods of nutritional assessment. CONCLUSIONS: Validated nutritional tools such as SGA/PG-SGA are better predictors of LOS in gastrointestinal cancers requiring surgery than in nonsurgical gastrointestinal cancer patients. Correcting malnutrition may decrease the LOS and perhaps even lower the rate of hospital readmissions in this population.

Percutaneous endoscopic gastrostomy tube occlusion in malignant peritoneal carcinomatosis-induced bowel obstruction.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement for decompression in advanced peritoneal carcinomatosis with bowel obstruction is a safe and feasible palliative procedure. We describe a rare, previously unreported phenomenon of PEG tube occlusion by gastric mucosal herniation. METHODS: A consecutive case series of 73 patients with advanced abdominal carcinomatosis-induced bowel obstruction from January 2007 to June 2010. All patients had a 28 Fr (Bard) PEG tube placed for drainage. None of them were surgical candidates due to extensive peritoneal involvement. Patients with PEG tube occlusion as a result of gastric mucosal herniation were further evaluated. RESULTS: Nineteen patients were men and 54 were women. The mean age was 53.3 years. The most common cancer types were ovary, pancreas, colon, and stomach. All patients had PEG tube functioning well after the procedure with immediate relief of obstructive symptoms. Subsequently, 10 patients developed acute occlusion of PEG tubes with reoccurrence of obstructive symptoms. The time between the placement of the PEG tube and its occlusion ranged from 5 to 129 days. Repeat endoscopy showed the PEG tube occluded with gastric mucosa from the opposite wall. PEG tube was replaced with a 28 Fr balloon replacement tube leading to symptom improvement in all 10 patients. CONCLUSION: This rare but correctable phenomenon of obliteration of PEG tube from the gastric mucosa should be considered in any patient who develops intermittent occlusive symptoms. This phenomenon can be corrected by replacing the PEG tube with a ballooned replacement tube as well as occasional manipulation of the tube.

Renal cell carcinoma with unusual metastasis to the small intestine manifesting as extensive polyposis: successful management with intraoperative therapeutic endoscopy.

We present here a rare clinical case of a 53-year-old gentleman with metastasis from renal cell carcinoma (RCC) to the small intestine presenting with extensive polyposis and massive gastrointestinal bleeding which was successfully managed with intraoperative endoscopic polypectomy and segmental small bowel resection. The patient presented with melena 2 weeks after right nephrectomy for RCC. Capsule endoscopy found extensive polyposis throughout the small bowel, and the histological features confirmed the diagnosis of metastatic RCC. The patient eventually underwent laparotomy with intraoperative endoscopy of the entire small bowel. Most of the polyps were removed by snare polypectomy. Three segments of the small bowel with extensive transmural involvement had to be resected with primary anastomosis. In the 2 months following his surgery, the patient had no further evidence of gastrointestinal bleeding. The decision of meticulously removing close to 100 polyps by intraoperative endoscopy prevented the patient from requiring total small bowel resection and lifelong dependence on parenteral nutrition. In conclusion, gastrointestinal bleeding in a patient with known RCC should always trigger full gastrointestinal work-up including capsule endoscopy and, if necessary, double balloon enteroscopy.