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The coexistence of extramedullary hematopoiesis and extramedullary multiple myeloma can occur and present as painful pelvic masses. In such a case, normal hematopoietic cells may outnumber clonal plasma cells, posing a diagnostic challenge.
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PURPOSE: Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue and not scheduled within 2 weeks of their first requested date. METHODS: We conducted a series of structured, interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration to critically review the scheduling process utilizing Lean Kaizen quality improvement methods. A new workflow was developed in which clinic staff scheduled CT scans before clinic discharge. Three months after our initial meeting, the new workflow was launched. We set a target of decreasing the percentage of overdue scans to below 20%. RESULTS: At baseline, 87% (65 of 75) of CT scans awaiting scheduling were overdue. Data were gathered at 5 and 10 weeks after implementation of our workflow. The percentage of CT scans overdue for scheduling was 17% (9 of 53) at 5 weeks and 0.97% (1 of 103) at 10 weeks after implementation. Clinic visit durations were not affected. CONCLUSION: The Lean Kaizen QI model was successful in decreasing the rate of oncology patients overdue for CT scan scheduling with minimal effects on clinic visit durations. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other outpatient clinics within our institution.
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Neoplasias , Proveedores de Redes de Seguridad , Humanos , Neoplasias/diagnóstico por imagen , Neoplasias/terapia , Oncología Médica , Tomografía Computarizada por Rayos X , TomografíaRESUMEN
INTRODUCTION: Psychosocial distress screening of cancer patients is an American College of Surgeons Commission on Cancer mandate for accredited cancer programs. We evaluated psychosocial distress in breast cancer patients to characterize risk factors for high distress scores at a safety net hospital. MATERIALS AND METHODS: The psychosocial distress screening form includes a list of potential issues and a distress score scaled from 1 through 10. Psychosocial distress screening results were retrospectively analyzed, along with patient demographics and clinical data. Cochran-Mantel-Haenszel test was applied to identify predictors for high distress scores, which were defined as a score of 5 and greater. RESULTS: 775 distress screens were completed by 171 breast cancer patients. High distress scores were reported in 21.3%. Patients who had no evidence of disease at time of screening were less likely to report a high distress score compared to those who were newly diagnosed or in active treatment (odds ratio 0.51, 95% CI, 0.38-0.68, P< .0001). Patients with high distress scores were more likely to report concerns with insurance (29.1% vs. 7.6%, P< .0001), transportation (16.4% vs. 4.6%, P< .0001), housing (15.2% vs 2.1%, P< .0001), sadness/depression (63.6% vs. 14.1, P< .0001), and physical issues (89.1% vs. 52.8%, P< .0001). CONCLUSION: Status of cancer at time of screening, particularly newly diagnosed cancer and active treatment of cancer were associated with high distress scores in this patient group. While there should be an emphasis to ensure patients with these risk factors receive psychosocial distress screening, routine periodic screening for all patients should continue to be implemented to ensure quality cancer care.
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Neoplasias de la Mama/psicología , Calidad de Vida/psicología , Proveedores de Redes de Seguridad , Estrés Psicológico/psicología , Adaptación Psicológica , Adulto , Ansiedad/psicología , Neoplasias de la Mama/terapia , Femenino , Humanos , Tamizaje Masivo/métodos , Persona de Mediana Edad , Atención al Paciente/métodos , Estudios Retrospectivos , Estrés Psicológico/etiologíaAsunto(s)
Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/terapia , Femenino , Humanos , MasculinoRESUMEN
Capecitabine-induced hypertriglyceridemia (CIHT) represents an increasingly significant treatment-related adverse event from capecitabine given its potential for both acute complications (acute pancreatitis) and chronic metabolic complications (cardiovascular disease). The incidence of CIHT is relatively rare and the majority of cases thus far reported have been managed with lipid-lowering therapy and/or discontinuation of capecitabine followed by resumption of the drug upon normalization of triglyceride levels. We present among the first U.S. cases of CIHT to be reported in the published literature and highlight management approaches for this rare but clinically relevant adverse event. Further understanding of the mechanisms of CIHT and its long-term adverse effects as well as effective preventive strategies, interventions, and monitoring strategies are prudent given the widespread and often prolonged use of capecitabine-based chemotherapy in gastrointestinal and other cancers.
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BACKGROUND: Pertuzumab has improved pathologic complete response rates when compared with other chemotherapeutics in the treatment of HER-2 positive breast cancer patients. AIMS: We sought to determine if axillary lymph node dissections (ALNDs) yielding at least the national standard of 10 lymph nodes is lower in patients who received neoadjuvant pertuzumab. METHODS AND RESULTS: A retrospective database identified patients who underwent ALND for breast cancer. We compared the axillary lymph node retrieval rates in those who received or did not receive neoadjuvant pertuzumab. Of 139 breast cancer patients who underwent ALND, fewer than 10 axillary lymph nodes were found in 41.7% of patients who received neoadjuvant pertuzumab (P < 0.01) and 18.6% of patients who received neoadjuvant therapy without pertuzumab (P = 0.01). CONCLUSION: Neoadjuvant chemotherapy was associated with a significantly lower rate of "adequate" ALNDs as defined by current guidelines. The patient subset that received neoadjuvant pertuzumab was more likely to have fewer than 10 axillary lymph nodes retrieved.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , Antineoplásicos Inmunológicos/uso terapéutico , Neoplasias de la Mama/tratamiento farmacológico , Escisión del Ganglio Linfático , Terapia Neoadyuvante , Adulto , Anciano , Axila , Neoplasias de la Mama/cirugía , Femenino , Humanos , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Receptor ErbB-2 , Estudios RetrospectivosRESUMEN
Phlegmasia cerulea dolens (PCD) is an aggressive and life-threatening form of venous thrombosis complicated by ischemic necrosis. Massive thrombosis extends to collateral veins resulting in venous congestion with fluid sequestration in the interstitium causing collapse of arterioles, which progresses to ischemia and, if severe, circulatory collapse and shock. The mortality rate for PCD is as high as 40%, especially when gangrene develops. PCD has been associated with acquired thrombophilias, including malignancy and antiphospholipid syndrome (APS). We present a unique case of a patient with PCD refractory to anticoagulant and thrombolytic therapy, whose fulminant course was attributed to concurrent cholangiocarcinoma and antiphospholipid antibodies identified by a positive lupus anticoagulant assay. This case highlights the importance of uncovering precipitating causes of thromboembolism, which may offer prognostic information and may necessitate therapy beyond anticoagulation and thrombolysis to reduce the morbidity of PCD. The current literature on PCD and APS, along with their associations with malignancy, is reviewed.
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Colangiocarcinoma/etiología , Gangrena/complicaciones , Inhibidor de Coagulación del Lupus/uso terapéutico , Tromboflebitis/complicaciones , Colangiocarcinoma/patología , Gangrena/diagnóstico , Gangrena/patología , Humanos , Inhibidor de Coagulación del Lupus/administración & dosificación , Masculino , Persona de Mediana Edad , Tromboflebitis/diagnóstico , Tromboflebitis/patologíaRESUMEN
BACKGROUND: Excisional biopsy is currently recommended for the analysis of lymphadenopathy suspicious for lymphoma. This study aims to evaluate the efficacy and safety of image-guided core needle biopsy (IGCNB) for the diagnosis of lymphoma using a standard protocol for tissue acquisition and analysis. METHODS: All IGCNBs from 2008 to 2014 performed under the study protocol were included in analysis. Demographics, pathology results, additional studies, and follow-up information were recorded. RESULTS: Seventy-three IGCNBs were performed in 71 consecutive patients. Lymphoma was diagnosed in 37 patients (51%). All 37 patients (100%) were subtyped and treated based on IGCNB results. The remaining 36 IGCNBs in 34 patients did not have subsequent diagnosis of lymphoma in a mean follow-up of 15 months (range, 0 to 54 months). There were no complications. CONCLUSIONS: IGCNB performed under a standard protocol is effective and safe and should be considered as an initial diagnostic tool for the evaluation of lymphadenopathy suspicious for lymphoma.
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Biopsia con Aguja Gruesa , Linfoma/diagnóstico , Adolescente , Adulto , Anciano , Diagnóstico Diferencial , Femenino , Humanos , Linfoma/patología , Masculino , Persona de Mediana Edad , Ultrasonografía IntervencionalRESUMEN
Alzheimer's disease (AD) and cerebrovascular disease are often comorbid conditions, but the relationship between amyloid-ß and in vivo vascular pathophysiology is poorly understood. We utilized a multimodal, multiscale optical imaging approach, including spatial frequency domain imaging, Doppler optical coherence tomography, and confocal microscopy, to quantify AD-dependent changes in a triple transgenic mouse model (3xTg-AD) and age-matched controls. From three months of age (naïve) to 20 months (severe AD), the brain tissue concentration of total and oxy-hemoglobin (Total Hb, ctO2Hb) decreased 50 and 70%, respectively, in 3xTg-AD mice. Compared to age-matched controls, significant differences in brain hemoglobin concentrations occurred as early as eight months (Total Hb: 126 ± 5 µM versus 108 ± 4 µM; ctO2Hb: 86 ± 5 µM versus 70 ± 3 µM; for control and AD, respectively). These changes were linked to a 29% vascular volume fraction decrease and 35% vessel density reduction in the 20-month-old 3xTg-AD versus age-matched controls. Vascular reduction coincided with increased brain concentration of amyloid-ß protein, vascular endothelial growth factor (VEGF), and endothelial nitric oxide synthase (eNOS) at eight and 20 months compared to the three-month baseline. Our results suggest that amyloid-ß blocks the normally reparative effects of upregulated VEGF and eNOS, and may accelerate in vivo vascular pathophysiology in AD.
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The incidence of Alzheimer's disease increases in people who have had an ischemic episode. Furthermore, APP expression is increased following ischemic or hypoxic conditions, as is the production of the Aß peptide. To address the question of why APP and Aß are increased in hypoxic and ischemic conditions we induced an ischemic episode in APP knockout mice (APP-/-) and BACE1 knockout mice (BACE-/-). We find that both APP-/- and BACE-/- mice have a dramatically increased risk of mortality as a result of cerebral ischemia. Furthermore, APP knockout mice have reduced cerebral blood flow in response to hypoxia, while wild-type mice maintain or increase cerebral blood flow to the same conditions. The transcription factor, serum response factor (SRF), and calcium-binding molecule, calsequestrin, both involved in vascular regulation, are significantly altered in the brains of APP-/- mice compared to wild type controls. These results show that APP regulates cerebral blood flow in response to hypoxia, and that it, and its cleavage fragments, are crucial for rapid adaptation to ischemic conditions.