The lost art of preventive oncology.

As the second most common cause of mortality worldwide, cancer is now prevalent in our society. The overall number of cases continue to rise each year and given the advancements in treatment strategies we now have a large population of cancer survivors. In the busy oncology clinic, patients often bring up the question of what caused their cancer. Oftentimes the answer is not very clear. This article is highlighting the role of oncology clinic in improving the awareness of overall health in patients and their families. The oncologist can play a crucial role in reducing the risk of malignancies in the family members of their patients. There is a need to have a quick discussion on the role of diet, exercise, vaccination against HPV, avoidance of smoking, alcohol, and other toxins such as pesticides in the oncology clinic.

Metastatic colorectal carcinoma to the right atrium: a case report and review of the literature.

BACKGROUND: Cardiac metastasis due to colon cancer is extraordinarily uncommon. Given the rarity of diagnosis, there is paucity of evidence and hence, no established guidelines for evaluation or clinical management strategy. CLINICAL PRESENTATION: We present the case of a 59 year old male with a previously treated colonic carcinoma who presented with new onset exertional dyspnea. He was noted to be having a right atrial mass on an echocardiogram performed at his cardiologist's office. Further workup with CT angiogram of the chest confirmed a right atrial mass measuring 4.0 cm. Serum CEA was normal. Biopsies of the right atrial mass demonstrated metastatic moderately differentiated colonic adenocarcinoma. Mismatch repair protein expression analysis by immunohistochemistry showed no loss of MLH1, MSH2, MSH6 or PMS2 expression. Next generation sequencing for RAS and BRAF mutations was negative. Patient received treatment with FOLFIRINOX/ bevacizumab with noted reduction in size of mass. CONCLUSION: To the best of our knowledge, this is the first report of next generation sequencing results available on a biopsy of metastatic colorectal cancer to the heart with the largest literature review of 31 reported cases of metastatic colorectal cancer to the heart. It will help direct clinical management and also adds evidence to the potential efficacy of treatment of this rare aggressive disease with chemotherapy in combination with VEGF inhibitors.

Hepatitis B Virus Reactivation in Cancer Patients Treated With Immune Checkpoint Inhibitors.

There have been unique adverse events reported with targeted blockade of programmed death-1 (PD-1), programmed death-ligand-1 (PD-L1), and cytotoxic T-lymphocyte-associated protein-4 (CTLA4), including immune mediated toxicities. Recently, there have been reports of hepatitis B reactivation (HBVr) occurring with PD-1/PD-L1 inhibitors, which may result in treatment delays, interruptions, or discontinuation. This retrospective literature review and analysis of the Food and Drug Administration's (FDA) Adverse Events Reporting System (FAERS) queried reported cases of "Hepatitis B reactivation" reported with the PD-1/PD-L1 inhibitors "Pembrolizumab," "Atezolizumab," "Nivolumab," "Durvalumab," "Avelumab," and "Ipilimumab" from initial FDA approval to June 30, 2020. Disproportionality signal analysis was determined by calculating a reporting odds ratio (ROR) and 95% confidence intervals (CI). The ROR was considered significant when the lower and upper limits of the 95% CI were >1 and confirmed by the Fisher exact test (P<0.05). Pembrolizumab had a strong signal associated with HBVr, with a ROR of 2.32 (95% CI: 1.11-4.28) (P=0.013) and was the only statistically significant finding. There were no reports of HBVr with Ipilimumab or Avelumab. Additional prospective studies should be conducted to validate the findings of this retrospective pharmacovigilance analysis to determine the risk of HBVr in patients receiving immune checkpoint inhibitors.

Acquired haemophilia as a paraneoplastic manifestation of pancreatic cancer.

Acquired haemophilia is a severe haematological disorder characterised by the presence of anti-factor VIII antibodies. Although rare, it can lead to serious bleeding complications. Acquired haemophilia can be seen in patients with malignancies as a paraneoplastic phenomenon. This is a case of a 52-year-old patient who presented with haematuria and retroperitoneal bleeding soon after being diagnosed with pancreatic adenocarcinoma and subsequently was found to have acquired haemophilia. The treatment of underlying malignancy with chemotherapy may accelerate the eradication of anti-factor VIII antibodies.

Patient's Knowledge and Use of Oral Non-Steroidal Anti-Inflammatory Drugs in a Rheumatology Clinic.

INTRODUCTION: We evaluated the knowledge of non-steroidal anti-inflammatory drugs (NSAIDs) including their dosage, side effects, contraindications, and drug interactions among the patients in an outpatient rheumatology clinic. METHODS: Patients in a rheumatology clinic completed a short survey assessing their knowledge of over-the-counter NSAIDs. RESULTS: The survey was provided to 400 participants and 275 (68.5%) were using over-the-counter (OTC) NSAIDs. The majority of the participants identified their commonly used NSAID. Almost a third were unaware of the contraindication of NSAIDs such as peptic ulcer disease, chronic kidney disease, and hypertension. Nearly 53.9% participants denied having any discussion of OTC medications with their providers. Two-thirds of the respondents reported seeing only the medication packaging for the dose determination (67.8%). CONCLUSIONS: The gap in patient knowledge of the potential side effects and the lack of discussion of OTC medications by the providers may be predisposing the patients to preventable side effects from NSAIDs.

Renal Cell Carcinoma Presenting as Pleural Effusion.

Renal cell carcinoma is well-known for its propensity to present in unusual ways, and renal cell carcinoma presenting as pleural effusion is extremely rare. Pleural effusion secondary to renal cell carcinoma constitutes only about 1% to 2% of all malignant pleural effusions. We report the case of a 34-year-old man with no significant past medical or surgical history who presented in the Emergency Department with dyspnea. Chest x-ray demonstrated right-sided pleural effusion; computed tomography (CT) reported right-sided effusion in the pleura with suspicious mass in the upper border of left kidney. CT-guided pleural tap was performed and cytology was positive for vimentin and common acute lymphocytic leukemia antigen (CD10), leading to the diagnosis of primary renal cell carcinoma presenting as unilateral pleural effusion. While lungs are the common site of metastasis, the presentation of renal cell carcinoma as pleural effusion or pleural metastasis without lung involvement is rare.

A Non-Operative Approach to Rectal Cancer after Chemo-Radiotherapy: Case Series and Review.

INTRODUCTION: Chemotherapy administered concurrently with radiotherapy for locally-advanced rectal cancer prior to surgery is a standard of care approach. A fraction of patients after chemo-radiotherapy achieve pathological complete remission. Our aim was to evaluate patients treated only with a non-operative approach of only chemo-radiotherapy followed by observation at a community cancer center. METHODS: Medical charts of the patients who were treated for locally advanced rectal cancer and treated with chemo-radiation therapy alone from January 1, 2000 through May 1, 2017 at a Midwestern cancer center were reviewed. The clinical course of the patients was followed from the time of the cancer diagnosis through their last available clinical record. RESULTS: A series of three cases were reviewed with locally-advanced distal rectal cancers treated with a non-operative approach. CONCLUSIONS: Watchful waiting for patients with locally advanced distal rectal cancer who have complete clinical response with neoadjuvant chemotherapy and radiation might be an effective treatment strategy.

Vitamin D deficiency and graft-versus-host disease in hematopoietic stem cell transplant population.

Vitamins are the organic compounds that have long been known to play a significant role in our body by functioning as hormones and antioxidants. Vitamin D, a fat-soluble vitamin, is the main regulator of calcium hemostasis in our body. At the same time, it is also known to show its potential effects on the immune system by modulating the differentiation, activation, and proliferation of T and B lymphocytes. The immunomodulatory properties of vitamin D are also known to have a crucial role in the prevention and treatment of graft-versus-host disease. Patients undergoing hematopoietic stem cell transplantation are particularly at risk of vitamin D deficiency. This review article expands our understanding of vitamin D, its immunomodulatory effects, and its role in prevention and treatment of graft-versus-host disease.

Systemic treatment for hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the most common cancers with high mortality worldwide. Treatment options for patients with advanced stage HCC remain a great challenge. However, novel agents especially small molecule tyrosine kinase inhibitor and innovative immunotherapy demonstrate new promising therapeutic options for these patients. This review article summarizes systemic treatment options evaluated in HCC focusing on the most recently published data and ongoing studies.

Changes in Non-Small Cell Lung Cancer Tumor Location Secondary to Gastric Distension, Implications in the Context of Stereotactic Body Radiation Therapy.

OBJECTIVE: Stereotactic body radiation therapy (SBRT) facilitates highly conformal dose distributions to a targe tumor volume. Accurate tumor localization is extremely important, and lung tumors pose a unique challenge due to respiratory motion. Patients are required to fast before PET/CT but not before CT simulation and daily treatment, introducing potential variability from gastric distension. METHODS: A case was reviewed involving a patient with early-stage NSCLC which was simulated and treated with SBRT. PET/CT performed while fasting showed an isolated left lower lobe lesion. Following CT simulation, CT and PET/CT images were superimposed for comparison and treatment planning. RESULTS: Tumor location variation was apparent following image superimposition. Simulation CT showed significant gastric distension compared to PET/CT. The patient was resimulated while fasting, resulting in accurate and reproducible tumor localization for treatment planning. CONCLUSIONS: Gastric distension can alter tumor location and treatment volumes for radiotherapy planning, possibly resulting in inaccurate treatment administration.

Late Effects of Radiation Therapy in Pediatric Cancer Survivors.

The overall survival rates of many pediatric cancers continue to improve with each decade due to new advances in therapy. As this trend continues, the focus and importance of minimizing acute and long-term toxicity associated with treatment is paramount. While significant research regarding many of the late responses of normal tissues associated with radiation exposure has been established, future endeavors must be directed toward the identification of therapy related factors including radiation total dose, dose rate, exposure, and target treatment volumes. Awareness of short and long-term health risks of these patients is important and careful follow-up of long-term survivors is essential. In this report, we review some selected late adverse effects including the development of secondary malignancies, cardiotoxicity, physiological changes to glandular tissue, hormonal and reproductive changes to germ cells, and neurocognitive changes. Furthermore, we compared the differences regarding late effects of normal tissues associated with the use of proton versus photon radiotherapy, a topic that has received a great deal of attention in pediatric cancer and is increasing in utilization in the United States and world-wide.

Dosimetric and radiobiologic comparison of 3D conformal, IMRT, VMAT and proton therapy for the treatment of early-stage glottic cancer.

BACKGROUND: This study aims to compare dosimetrically and radiobiologically 3D conformal, intensity modulated radiation therapy (IMRT), RapidArc (RA) volumetric modulated arc therapy and proton therapy techniques for early-stage glottic cancer. METHODS: Ten patients were retrospectively selected. Photon treatment planning was performed using Eclipse External Beam Planning, and proton planning was performed using CMS Xio. The minimum, mean and maximum dose values for planning target volume (PTV), mean and maximum dose values for organ at risk, % of volume of PTV receiving at least 95% of the prescription dose, and D20, D50 and D90 of carotid arteries were compared. Biological response models of tumour control probabilities and normal tissue complication probabilities were calculated. RESULTS: IMRT, RA and proton plans versus three-dimensional conformal radiotherapy (3D-CRT) plans consistently provided superior PTV coverage and decreased mean dose to the thyroid and carotid arteries. CONCLUSION: All these three modalities showed superiority with less variation among themselves compared with 3D-CRT plans. Clinical investigation is warranted to determine if these treatment approaches will translate into a reduction in radiation therapy-induced toxicities.