Immunotherapy Efficacy in Advanced Hepatocellular Carcinoma in a Diverse and Underserved Population in the United States.

Background :   Incidence of hepatocellular cancer (HCC) in the Bronx is 61% higher than the rest of New York State. Underserved populations are not well represented in clinical trials of immune checkpoint inhibitors (ICI). Methods: Demographics were tabulated for 194 patients treated with ICI at the Montefiore-Einstein Comprehensive Cancer Center (MECCC) between 2017 and 2022. Categorical variables were analyzed by Chi-squared test, and survival was analyzed using Kaplan-Meier (KM) curves. Results: MECCC patients were 40.7% Hispanic and 20.6% Black, compared with 3% and 2%, respectively, in the landmark IMbrave 150 study. Median overall survival (mOS) on ICI was 9.0 months, 25.0 months for the 100 (51.5%) favorable-prognosis Child Pugh A (CPA) patients included in HCC clinical trials. Disease control rate (DCR) was 58.5% among 123 evaluable patients per mRECIST 1.1. Baseline liver function, as defined by CP and the Model for End-Stage Liver Disease-Sodium (MELD-Na), correlated with survival (p < 0.001). Hepatitis C Virus (HCV) and alcoholism were over-represented relative to National Cancer Institute (NCI) data (56.2% vs 4.7% and 38.7% vs 8.2%, respectively). HCV treatment correlated with prolonged survival in infected patients (p = 0.0017). AFP decline correlated with response (p = 0.001). Hispanic patients lived longer when clinical variables were controlled for (mOS 52 vs 23 months; p = 0.011). Conclusion: In an underserved HCC population, ICI yielded a DCR of 58.5% and low rates of severe toxicity. This work highlights ICI efficacy in minority groups, a need for earlier HCC diagnosis and for studies of genetic and environmental factors in Hispanics with HCC.

Pulmonary haemorrhage and extensive arterial thrombosis with anabolic steroid abuse.

Anabolic-androgenic steroids (AASs) are commonly implicated in thromboembolic events but rarely cause diffuse alveolar haemorrhage. We report the case of a Caucasian man in his late 40s who was consuming supratherapeutic doses of AAS and presented with shortness of breath and haemoptysis. Chest imaging showed bilateral patchy infiltrates in the lungs with diffuse blood throughout the airways on bronchoscopy. Extensive infectious and autoimmune workup were unremarkable. The patient then developed right foot ischaemia and was found to have extensive aortic and bilateral lower extremity arterial thrombosis. Anticoagulation was attempted despite haemoptysis. Thrombectomy procedures were unsuccessful and the patient eventually developed worsening rhabdomyolysis requiring intubation and bilateral amputation. His clinical condition continued to worsen and he passed away 10 days after admission. This case highlights the rare synchronous occurrence of two life-threatening complications secondary to anabolic steroid abuse which can pose a significant diagnostic and therapeutic challenge for clinicians.

Healthcare providers' experiences of continuing care for older adults with cancer during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has caused great strain on older adults with cancer and their healthcare providers. This study explored healthcare providers' reported changes in cancer care, clinical barriers to care, patient questions, and the overall experiences of caring for older adults with cancer during the COVID-19 crisis. METHODS: The Advocacy Committee of the Cancer and Aging Research Group and the Association of Community Cancer Centers developed a survey for healthcare providers of adults with cancer, inquiring about their experiences during the pandemic. Responses from the survey's four open-ended items were analyzed by four independent coders for identification of common themes using deductive and inductive methods. RESULTS: Participants (n = 137) represented a variety of demographic and clinical experiences. Six overall themes emerged, including (1) telehealth use, (2) concerns for patient mental health, (3) patient physical and social isolation, (4) patient fear of contracting COVID-19, (5) continued disruptions to cancer care, and (6) patients seeking guidance, particularly regarding COVID-19 vaccination. Questions fielded by providers focused on the COVID-19 vaccination's safety and efficacy during older adults' cancer treatment. CONCLUSIONS: Additional resources (e.g., technology support, established care guidelines, and sufficient staffing) are needed to support older adults with cancer and healthcare providers during the pandemic. Future research should explore universally effective in-person and virtual treatment strategies for older adults with cancer. IMPLICATIONS FOR CANCER SURVIVORS: Persistence of telehealth barriers, particularly a lack of infrastructure to support telehealth visits, social isolation, and restrictive visitor policies as a result of COVID-19, negatively impacted the mental health of older adults with cancer.

Impact of racial disparities on potential years of life lost due to gynecologic cancer in the United States: Trends from 1975 to 2017 based on SEER database.

INTRODUCTION: We assessed potential years of life lost (PYLL) in women secondary to gynecologic cancers (cervical, uterine, ovarian, vaginal, vulvar, and other) in the United States from 1975 to 2017 using SEER database. We also highlight racial disparities and economic costs of mortality from gynecologic malignancies. METHODS: PYLL up to and including age 75 years were calculated [75 - (age at diagnosis + overall survival)] after stratifying for tumor site. Subgroup comparison was done using nonparametric method Kruskal-Wallis H with post-hoc analysis. Linear regression model was used to calculate every five-year incremental trends. Productivity losses were calculated using mortality data multiplied by age-adjusted estimated total lifetime productivity. RESULTS: Total 304,995 patients were included with 1,472,152.67 PYLL from 1975 to 2017. Median PYLL for cervical cancer (12.58 years) was higher than other gynecologic malignancies (0.83, 6.00, 0.67 and - 0.25 years respectively for uterine, ovarian, vaginal and vulvar cancers). The median PYLL for Non-Hispanic White (NHW) population was lower than women from other racial groups for uterine, ovarian and vulvar cancers. From 1975 to 2017, median PYLL trend in the entire cohort showed a steady increment (p < 0.001, B1 = 1.65 years). Most rapid rise was noted in cervical cancer (p < 0.001, B1 = 2.68 years) and Hispanic population (p < 0.001, B1 = 1.92). Total productivity loss was $79 billion during 1975-2017 with maximum loss seen in uterine cancer and NHW population. CONCLUSION: Ours is the first study to analyze PYLL in gynecologic malignancies and estimate productivity losses due to premature deaths. Data shows a clear trend pointing towards racial and ethnic disparities.

Healthcare providers' attitudes towards delay in cancer treatment during COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has created unprecedented obstacles leading to delays in treatment for older adults with cancer. Due to limited resources at the height of the pandemic, healthcare providers were constantly faced with ethical dilemmas regarding postponing or rescheduling care for their patients. MATERIALS AND METHODS: Two survey-based studies were conducted at different time-points during the pandemic looking at factors affecting oncology care providers' attitudes towards delay in treatment for older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. Change in provider attitude over time was analyzed by comparing responses from the 2020 and 2021 surveys. Data analysis included descriptive statistics and chi-squares. RESULTS: In 2020, 17.5% of respondents were strongly considering/considering postponing cancer treatment for younger patients (age 30 and below), while 46.2% were considering delaying treatment for patients aged >85. These responses were in stark contrast to the results of the 2021 survey, where only 1.4% of respondents strongly considered postponing treatment for younger patients, and 13.5% for patients aged >85. DISCUSSION: All recommendations to postpone treatment for older adults with cancer must be made after mutual discussion with the patient. Throughout the COVID-19 pandemic, oncology care providers had to consider multiple factors while treating patients, frequently making most decisions without appropriate institutional support.

Hereditary Thrombophilia Testing Among Hospitalized Patients: Is It Warranted?

Background Hereditary thrombophilias (HTs) are a group of inherited disorders that predispose the carrier to venous thromboembolism (VTE). It is estimated that 7% of the population has some form of HT. Although testing for HT has become routine for many hospitalized patients, knowing when to order the tests and how to interpret the results remains challenging. In the United States, there are no clear guidelines regarding testing for HT. We conducted a study to evaluate the utilization of HT testing among hospitalized patients to examine its impact on immediate management decisions and overall cost burden. In addition, we discuss the common reasons for healthcare providers to order these tests and review the data behind these reasons in the literature. Methodology A retrospective analysis of 2,402 patients who underwent HT testing between February 1, 2016, and January 31, 2018, was conducted. Eligible patients had at least one HT test ordered during hospitalization. The primary outcome was to determine the incidence of positive actionable tests. A positive actionable test was defined as a positive result that changed the anticoagulation intensity, type, or duration. Patients with a history of previous VTE, ongoing medical conditions requiring life-long anticoagulation, or unprovoked VTE were considered non-actionable. Results Among the 2,402 patients, 954 patients met the inclusion criteria with a mean age of 54 years. A total of 397 (41.6%) tests were ordered for acute VTE, while the rest were for non-VTE conditions, such as stroke, pregnancy complications, peripheral artery diseases, and others. Only 89 positive tests were actionable (14% of the positive tests, and 9.3% of the total ordered tests). There was a statistically significant association between increasing age and having both a positive test result (p = 0.006) and an actionable test (p = 0.046). The total cost of ordering these tests was estimated to be $566,585. Conclusions HT testing in the inpatient setting did not alter management in many cases and was associated with increased healthcare costs. The decision to order these tests should be individualized based on the clinical scenario.

Novel targeted therapies for advanced non-small lung cancer.

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer accounting for almost 80%-85% of all lung cancer cases. Unfortunately, more than half of the patients will be diagnosed with advanced disease at the time of presentation, which makes their disease incurable. Historically, the 5 year overall survival for advanced NSCLC was 5%. However, there has been a significant increase in our understanding of the genetic basis of NSCLC, which has led to development of both immunotherapy and targeted therapy agents. This has improved the 5 year overall survival to become within the range of 15%-50% depending on certain mutations and biomarkers. Over the last decade the United States Food and Drug Administration (FDA) has approved almost 20 new targeted therapies and clinical trials are still undergoing to evaluate more novel agents. In this review, we will present recent updates on novel targeted therapies.

Multisystem Inflammatory Syndrome in Adults or Hemophagocytic Lymphohistiocytosis: A Clinical Conundrum in Fully Vaccinated Adults With Breakthrough COVID-19 Infections.

Hyperinflammatory syndrome with breakthrough coronavirus disease 2019 (COVID-19) infection in a fully vaccinated patient is not a common finding. To the best of our knowledge, this is the first such case of a patient who received the Spikevax/Moderna (elasomeran mRNA-1273) vaccine. The patient exhibited clinical characteristics consistent with both multisystem inflammatory syndrome in adults (MIS-A) and hemophagocytic lymphohistiocytosis (HLH), thus posing a diagnostic challenge. Multi-inflammatory syndrome in COVID-19 patients is frequently seen in the pediatric population, but it is a rare entity in adults especially after receiving COVID-19 vaccination. The pathophysiology of MIS-A is not completely understood yet, but it is believed that this likely occurs due to antibody-mediated immune dysregulation. There is a possibility of enhanced serologic response in patients like ours who are vaccinated and have breakthrough COVID-19 infection, thus paving the way for overwhelming antibody-mediated immune activation. There is a significant overlap between symptoms of MIS-A and other hyperinflammatory syndromes such as HLH; hence, a high degree of clinical suspicion and thorough diagnostic workup is required to explore all differentials. Our case raises concerns regarding the lack of clear algorithms and guidelines to diagnose and manage MIS-A in adults post-COVID-19 vaccination.

Analysis of Clinical Characteristics and Survival in Patients With Functional Neuroendocrine Tumors of Gastrointestinal Origin.

OBJECTIVES: Functional neuroendocrine tumors (FNETs) are characterized by excess secretion of disease-specific hormones. In this study, we attempted to define survival trends in patients with some of these uncommon tumors. METHODS: Using the Surveillance, Epidemiology, and End Results database, 529 patients with FNETs (gastrinoma, insulinoma, glucagonoma, VIPoma, and somatostatinoma) were identified. We analyzed patient and tumor characteristics, overall survival, and cancer-specific survival. RESULTS: Functional neuroendocrine tumors were found to be more predominant in White patients older than 50 years. Most common FNETs were gastrinoma (56.3%) and insulinoma (23.8%). Most FNETs were found in the pancreas, with the second most common location being the small bowel. Surgery was the primary modality of treatment, used in 55.8% of the cases. Median overall survival was 9.8 years (95% confidence interval [CI], 7.9-11.8) with a median cancer-specific survival of 18.5 years (95% CI, 12.8-24.2). In multivariate analysis, age >50 years (hazard ratio [HR], 2.7; 95% CI, 2.02-3.64), no surgical resection (HR, 1.88; 95% CI, 1.43-2.46), metastasis (HR, 3.0; 95% CI, 2.0-4.5), and poor differentiation were associated with poor survival. Site and histology did not have a significant impact on survival (P = 0.82 and 0.57 respectively). CONCLUSIONS: Our study highlights the most important prognostic factors for gastrointestinal FNETs.

Primary Pancreatic Lymphoma: An Uncommon Presentation in the Pancreatic Tail.

Primary pancreatic lymphoma is a rare form of pancreatic cancer that represents a diagnostic and therapeutic challenge due to its rarity and presentation mimicking pancreatic adenocarcinoma. Herein, we report a case of a 57-year-old Caucasian male who presented with left-sided chest pain, epigastric pain, and melena. Abdominal imaging was remarkable for a large, necrotic mass near the tail of the pancreas extending into the splenic hilum and left kidney. Biopsy of the mass confirmed lymphoma of B-cell origin. The patient was diagnosed with Stage IV disease and started on chemotherapy. This case combines an uncommon presentation of lymphoma with a rarely documented primary site in the tail of the pancreas.

Probable Vancomycin Induced Neutropenia: A Case Report.

Vancomycin has been used for a long time to manage resistant gram-positive bacterial infections. Neutropenia is an uncommon and potentially serious adverse effect associated with vancomycin use. Herein we present a case of probable vancomycin induced neutropenia which resolved with discontinuation of the antibiotic. Since blood counts are monitored routinely these days in both outpatient and inpatient setting, due consideration needs to be given to vancomycin induced neutropenia in patients who are on long term antimicrobial therapy.

Growing Old Too Fast: A Rare Case of Werner Syndrome.

Werner syndrome (WS) is rare adult-onset progeria characterized by premature aging and early death. Patients develop normally until adolescence and usually present in early adulthood. Our case highlights a common presentation of this uncommon disease, wherein a 29-year-old non-obese male with no known risk factors developed uncontrolled diabetes, hypertriglyceridemia, and rapidly progressive atherosclerotic vascular disease. Careful observation with attention to the presence of characteristic physical features and subsequent genetic testing helped diagnose the patient with this uncommon progeroid syndrome. Our case adds to the literature about this rare disease especially in patients of middle-eastern descent and also highlights the importance of having a high index of suspicion for WS when the initial clinical presentation is atypical.

Zieve's Syndrome: An Under-reported Cause of Anemia in Alcoholics.

Anemia is a common finding in alcoholics. It is often multifactorial and caused by a combination of liver dysfunction, ineffective erythropoiesis, and poor nutrition. Zieve's syndrome (ZS) is a clinical syndrome that presents with a triad of jaundice, hemolytic anemia, and hyperlipidemia secondary to alcohol use. Herein, we present a case of a 58-year-old male with a history of liver cirrhosis who presented after a fall due to binge drinking and was found to have severe anemia. Workup was consistent with hemolytic anemia with no source of active bleeding. The patient was managed with supportive treatment and blood transfusions which improved his anemia. However, given his advanced liver disease, he developed encephalopathy and subsequently severe aspiration pneumonia. He died 18 days after admission.

Diffuse Large B-cell Lymphoma Presenting as Bilateral Renal Masses: Successful Treatment with Dose-adjusted REPOCH (Rituximab, Etoposide, Prednisone, Vincristine, Cyclophosphamide, Doxorubicin) Chemotherapy Regimen.

Diffuse large B-cell lymphoma (DLBL) is an aggressive type of non-Hodgkin lymphoma (NHL). Renal involvement in NHL is not uncommon in advanced stages; however, it is rare to have kidneys affected early in the course of the disease. Usual chemotherapy regimen for DLBL is rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone (R-CHOP). This is a case of a 50-year-old female diagnosed with DLBL who presented with bilateral renal involvement at disease onset and also underwent complete remission after six cycles of dose-adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (DA-REPOCH). Limited data exist on outcomes of patients with DLBL and renal disease who are treated with high-intensity regimes such as DA-REPOCH. It would be worth looking further into outcomes of DLBL patients especially with renal involvement on DA-REPOCH. Multicenter trials are required to demonstrate which of the two chemotherapy regimens (R-CHOP vs. DA-REPOCH) have better progression-free survival in this particular subset of patients.