ABSTRACT
There are very few data available regarding the pattern of first metastases in resected mucosal melanomas (MMs) as well as the response of advanced MM to cytotoxic therapy. A retrospective, single-institution cohort was assembled of all patients with advanced/unresectable MM between 1995 and 2012 who had received systemic therapy with available imaging (N=81). Responses to first-line and second-line systemic therapy were assessed using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. The relationship between response, overall survival, and clinical covariates was investigated using Cox proportional hazards regression. Primary sites included anorectal (N=31, 38%), vulvovaginal (N=28, 35%), head and neck (N=21, 26%), and gallbladder (N=1, 1%) mucosa. Seven percent of patients had their first relapse in the brain. Cytotoxic therapy represented 82 and 51% of first-line and second-line regimens. The best response achieved in the first-line setting was similar for single-agent [10%; 95% confidence interval (CI): 1-32%] and combination alkylator therapy (8%; 95% CI: 2-21%). Median overall survival from first-line treatment was 10.3 months (95% CI: 8.7-13.9 months). Patients with elevated lactic dehydrogenase [hazard ratio (HR): 1.87, 95% CI: 1.10-3.19, P=0.020] and Eastern Cooperative Oncology Group performance status 1-2 (HR: 1.69, 95% CI: 1.05-2.72, P=0.030) had a higher risk of death, whereas patients with 12-week objective responses had a lower risk of death (HR: 0.12, 95% CI: 0.04-0.41, P<0.001). Cytotoxic systemic therapy has modest activity in advanced/unresectable MM, belying its adjuvant benefit. Patients whose tumors have an objective response to therapy have a lower probability of death. Brain imaging should be considered in routine surveillance.
Subject(s)
Antineoplastic Agents/therapeutic use , Anus Neoplasms/drug therapy , Gallbladder Neoplasms/drug therapy , Head and Neck Neoplasms/drug therapy , Melanoma/drug therapy , Vaginal Neoplasms/drug therapy , Vulvar Neoplasms/drug therapy , Adult , Aged , Aged, 80 and over , Antineoplastic Agents, Alkylating/therapeutic use , Antineoplastic Agents, Immunological/therapeutic use , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Anus Neoplasms/pathology , Female , GTP Phosphohydrolases/genetics , Gallbladder Neoplasms/pathology , Head and Neck Neoplasms/pathology , Health Status Indicators , Humans , L-Lactate Dehydrogenase/blood , Male , Melanoma/genetics , Melanoma/secondary , Membrane Proteins/genetics , Middle Aged , Molecular Targeted Therapy , Mucous Membrane , Mutation , Proportional Hazards Models , Proto-Oncogene Proteins B-raf/genetics , Proto-Oncogene Proteins c-kit/genetics , Response Evaluation Criteria in Solid Tumors , Retrospective Studies , Survival Rate , Vaginal Neoplasms/pathology , Vulvar Neoplasms/pathologyABSTRACT
New York State (NYS) established guidelines for nonoccupational post-exposure prophylaxis (nPEP) to HIV in 1997. To assess current nPEP practices in NYS Emergency Departments (EDs), we electronically surveyed all ED directors in NYS, excluding Veterans' Affairs hospitals, about nPEP and linkage-to-care protocols in the EDs. Basic descriptive statistics were used for analysis. The response rate was 96% (184/191). Of respondents, 88% reported evaluating any patient with a possible nonoccupational exposure to HIV, in accordance with NYS guidelines. Of these, 83% provided the patient with a starter pack of medications, while 4% neither supplied nor prescribed antiretroviral drugs in the ED. Sexually transmitted infection screening, risk reduction counseling, and education about symptoms of acute HIV seroconversion were performed inconsistently, despite NYS guidelines recommendations. Only 22% of EDs confirmed whether linkage to follow-up care was successful. Most NYS EDs prescribe nPEP to appropriate patients but full implementation of guidelines remains incomplete.