Fallo ovárico prematuro en supervivientes a un tumor sólido: puntos clave de manejo / Primary ovarian insufficiency in cancer survivors: Keys to optimal management

Introducción: La insuficiencia ovárica prematura (POI) conlleva importante morbilidad, causando infertilidad, disfunción sexual, disminución de la densidad ósea, riesgo cardiovascular, alteraciones emocionales y mortalidad precoz. Objetivo: Conocer la incidencia y el manejo actual de la POI en supervivientes a un tumor sólido en la infancia y/o adolescencia en nuestro medio. Material y métodos: Estudio observacional multicéntrico. Mujeres entre 12 y 18 años con diagnóstico de tumor sólido y criterios clínicos y/o analíticos de POI. El riesgo se estima según los criterios «The Pediatric Initiative Network of the Oncofertility Consortium». Resultados: Incidencia de 1,5 (30 casos de POI). Edad media 14±2,09. Los tumores sólidos que más se asociaron a la POI fueron: sarcoma de Ewing, tumores cerebrales y germinales. El 83% de los casos no realizó preservación previa al tratamiento. Un 63% no referían menarquia al diagnóstico de la POI. El 97% cumplían criterios de alto riesgo de toxicidad gonadal, a pesar de ello el 47% no realizó ninguna vigilancia previa al diagnóstico. La mediana de tiempo tras el diagnóstico y la aparición del evento es de 43,5 y 29,5 meses tras finalizar tratamiento. Las curvas de Kaplan-Meier, muestran que al 30% de los casos, aparecen en los 2 años tras el diagnóstico y las mujeres con estadio puberal 1 desarrollan insuficiencia más tardíamente que aquellas con estadio 5. Conclusiones: El seguimiento de mujeres en riesgo de la POI, es susceptible de mejora. Las herramientas actuales facilitan conocer el riesgo al planificar los tratamientos del tumor y realizar vigilancia, educación, diagnóstico precoz, preservación e instauración de tratamiento sustitutivo. Todo ello, supondría importantes mejoras en salud.(AU)

Introduction: Primary ovarian insufficiency (POI) carries significant morbidity, causing infertility, sexual disfunction, decreased bone density, cardiovascular risk, emotional distress and early mortality. Objective: To know the incidence and current management of POI in childhood/adolescent solid tumour survivors. Material and methods: We conducted a multicentre observational study. It included female patients aged 12 to 18 years with a diagnosis of solid tumour and meeting clinical or biochemical criteria for POI. The risk was estimated based on the criteria of the Pediatric Initiative Network of the Oncofertility Consortium. Results: We found an incidence of 1.5 (30 cases of POI): The median age at the time of the event was 14 years (standard deviation, 2.09). The solid tumours associated most frequently with POI were Ewing sarcoma and brain and germ cell tumours. Eighty-three percent of patients did not undergo fertility preservation. Sixty-three percent reported not having undergone menarche at the time of ovarian failure. Ninety-seven percent were at high risk of gonadal toxicity, yet 47% were not monitored before the diagnosis. The median time elapsed to the occurrence of the event was 43.5 months after diagnosis and 29.5 months after completing treatment. The Kaplan-Meier curves showed that approximately 30% of POI cases developed within 2 years of diagnosis and that women at Tanner stage 1 developed insufficiency later than women at Tanner stage 5. Conclusions: There is room for improvement in the followup of women at risk of POI in Spain. The tools currently available facilitate risk assessment at the time of treatment planning and allow the implementation of monitoring, education, early diagnosis, fertility preservation, and replacement therapy as needed. All of this would achieve significant improvement in health outcomes.(AU)

Melanoma amelanótico del iris en un niño hispano de 7 años con perforación del globo subclínica / Amelanotic iris melanoma in a 7 year-old hispanic boy with subclinical globe perforation

Describimos el caso de un melanoma amelanótico del iris en un niño hispano de 7 años con perforación del globo subclínica. El melanoma uveal raramente ocurre en niños. La mayoría de los pacientes jóvenes afectados se presentan en la etapa de la pubertad, son caucásicos y con ojos claros. Debido a su rareza, estos tumores pueden no ser reconocidos o ser diagnosticados erróneamente. Destacamos el diagnóstico diferencial y las opciones terapéuticas

We report an unusual case of an amelanotic melanoma in a 7 year old hispanic child with subclinical globe perforation. Uveal melanoma rarely occurs in children. Young affected patients are mostly light-colored eye Caucasian adolescents. Since they are not common, these tumors are usually not recognized and misdiagnosed. Differential diagnoses and therapeutic options are outlined

Neurooncología: por una subespecialidad transversal y colaborativa / Neuro-oncology: towards a cross-cutting and collaborative sub-specialty

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Laryngeal Rhabdomyosarcoma in a dog: case report / Rabdomiossarcoma na laringe em cão: relato de caso

The larynx is part of the upper respiratory tract and is responsible for phonation. It allows air to pass between the pharynx and the trachea, but prevents food from entering the airways. Laryngeal neoplasms, including rhabdomyosarcomas, are uncommon in dogs. However, these tumors can trigger numerous progressive clinical signs related to respiratory difficulty and altered phonation. The diagnosis of laryngeal cancer should be made based on the history and symptoms of the patient, combined with complementary tests. The treatment of choice is surgical excision, combined or not with chemotherapy. In view of the low incidence of laryngeal cancer, the objective of the present work was to describe a case of laryngeal rhabdomyosarcoma detected during necropsy of an adult dog and diagnosed by histopathology, in addition to raising awareness about the importance of the diagnosis and early therapy for the quality of life and survival of affected patients. The results showed that the location of the tumor impaired its early diagnosis. Although malignant, the animal did not develop metastases as has been described in the literature.(AU)

A laringe é um dos órgãos que compõem o trato respiratório superior, sendo também responsável pela fonação. Permite a passagem do ar entre a faringe e traqueia, mas impede que alimentos adentrem as vias aéreas. As neoplasias laringeanas, incluindo os rabdomiossarcomas, são incomuns em cães, porém, quando presentes, desencadeiam inúmeros sinais clínicos progressivos relacionados à dificuldade respiratória e à alteração na fonação. O diagnóstico das neoplasias na laringe deve ser baseado no histórico e na sintomatologia do paciente, associado a exames complementares. O tratamento de eleição é a exérese cirúrgica, concomitante ou não com a quimioterapia. Desse modo, diante da baixa incidência desse tipo neoplásico, inclusive na laringe, o objetivo do atual trabalho é descrever o caso de rabdomiossarcoma em laringe, detectado durante o exame de necropsia de um cão adulto e diagnosticado por histopatologia, bem como conscientizar sobre a importância do diagnóstico e da terapêutica precoce na qualidade de vida e sobrevida dos afetados. De acordo com a descrição do caso, pode-se admitir que a localização da neoplasia prejudicou o diagnóstico precoce e que, apesar de esta ser maligna, não houve metástases conforme descrição na literatura.(AU)

Impact of a medication therapy management service offered to patients in treatment of breast cancer

ABSTRACT Cancer has high morbidity and mortality rates related to medication use and produce a costly impact in health care. Thus, patients require constant monitoring and proper coordination of care between different professionals. This study aimed to evaluate the impact generated by a Medication Therapy Management service (MTM) offered to patients with breast cancer in use of polypharmacy. Observational, exploratory, descriptive and retrospective study of a MTM service that included 93 patients. Sociodemographic and clinical data related to pharmacotherapy and the processes associated with the systematization of the service were collected and analyzed. Patients were followed-up by the MTM service on average for 18 months (±4.31) and 185 drug-related problems (DRP) were identified, an average of two DRP per patient. Of these DRP, 48.11% were resolved and 49.73% were in the resolution process. The most common DRP were in the categories of Indication (37.84%), followed by Safety (23.78%). The safety category showed the highest resolution rate (59.09%). The study revealed an increased risk of DRP for patients with three or more comorbidities and using 5 or more medications. The process of systematization of a MTM service in oncology was associated with positive outcomes.

Sección de Oncología y Hematología Pediátricas del Hospital General Universitario Gregorio Marañón / Pediatric Oncology and Hematology Area of the Hospital General Universitario Gregorio Marañón

La Unidad de Oncología y Hematología Infantil del Hospital Gregorio Marañón comenzó su andadura en los años 70, presentando desde entonces un crecimiento progresivo y una modernización acorde con la evolución de la propia especialidad. En esta monografía se describe la organización de la sección, así como los recursos estructurales, las características del trabajo asistencial, la actividad docente e investigadora y la participación en diversos grupos de trabajo colaborativos o multidisciplinares. Se destaca la capacidad de abordaje integral de este tipo de patologías en todas las fases de las mismas, desde el diagnóstico al tratamiento, sin Olvidar el aspecto psicosocial o la atención paliativa en su fase terminal, si fuera necesario. En conjunto, se dibuja un cuadro que es una obra coral de muchos profesionales sanitarios (personal médico, psicooncología, enfermería, auxiliares...) y no sanitarios, pero cuyo tema principal es proporcionar la mejor asistencia posible al niño y a su familia (AU)

The Pediatric Oncology and Hematology Unit at the Gregorio Marañón Children's Hospital began its activity in the 705, presenting since then a progressive growth and modernization in accordance with the evolution of the specialty itself… In this paper we describe the organization of the section, our structural resources, the characteristics of care work, teaching and research activities and our participation in various collaborative or multidisciplinary work groups. It is remarkable the ability to comprehensively address this type of pathologies in its different phases, from diagnosis to treatment, without forgetting to mention the psychosocial aspect or palliative care in its terminal phase, if necessary. Altogether, a choral picture is drawn with the work of many health professionals (medical, psycho-oncology, nursing, assistants …) and non—health, but the main theme is to provide the best care for the child and his family (AU)

Prevenção de tromboembolismo venoso em hospital com perfil oncológico: como melhorá-la? / How can prevention of venous thromboembolism be improved in a hospital with an oncological profile?

Resumo Contexto Complicações do tromboembolismo venoso são encontradas frequentemente em pacientes internados, tanto em condições clínicas quanto em pós-operatórios. Objetivo Verificar a quimioprofilaxia utilizada para tromboembolismo venoso em pacientes oncológicos internados, antes e após a realização de um programa de esclarecimento da sua importância. Métodos Estudo de corte transversal realizado em três momentos distintos: inicialmente antes do programa de conscientização da importância da profilaxia do tromboembolismo venoso, durante o período em que foi realizada e um ano após a etapa anterior. Para fins estatísticos, os pacientes foram divididos em alto risco e baixo risco, e estratificados quanto a erro na quimioprofilaxia em: precisavam, mas não fizeram profilaxia; não precisavam, mas fizeram profilaxia; fizeram profilaxia não padronizada; e não podiam, mas fizeram profilaxia. Resultados Foram avaliados 399 pacientes internados, sendo 56 pacientes antes do início do programa de conscientização, 255 durante o programa e 88 após um ano. Antes da realização da semana de conscientização, apenas 35,7% dos pacientes estavam recebendo a quimioprofilaxia adequada; após a semana de conscientização, houve um aumento do número de prescrições corretas, que passou para 63,9% (p < 0,001). Após um ano sem as aulas de conscientização, a manutenção da quimioprofilaxia não foi tão eficaz, com uma tendência ao aumento do número de profilaxias incorretas (p = 0,081). Conclusão A quimioprofilaxia é utilizada em uma porcentagem muito pequena nos pacientes internados, sendo necessários programas de esclarecimento de sua importância na prevenção do tromboembolismo venoso e a realização de monitoramento contínuo para auxiliar na sua prescrição.

Abstract Background Complications of venous thromboembolism are common among both medical and surgical hospital patients. Objective To identify what, if any, pharmacological prophylaxis for venous thromboembolism was given to cancer patients in hospital before and after implementation of a program to raise awareness of its importance. Methods This was a cross-sectional study conducted in three phases at distinct times: before a program to raise awareness of the importance of prophylaxis against venous thromboembolism was implemented, during years when the program was being run, and 1 year after the end of the program. For statistical analysis, patients were classified as high risk or no risk and categorized on the basis of erroneous pharmacological prophylaxis, as follows: “needed prophylaxis, but were not given it”; “did not need prophylaxis, but were given it”; “were given nonstandard prophylaxis”; or “should not have been given prophylaxis, but were given it”. Results A total of 399 hospital patients were assessed: 56 before the awareness-raising program, 255 during the program and 88 1 year after the program was last run. Before any awareness-raising weeks, just 35.7% of the patients were being given the correct pharmacological prophylaxis; after awareness-raising weeks, the proportion of correct prescriptions increased to 63.9% (p < 0.001). After one year with no awareness-raising efforts, maintenance of pharmacological prophylaxis was no longer as effective, and there was a trend for the proportion of incorrect prophylaxis to increase (p = 0.081). Conclusions Pharmacological prophylaxis is given to a very small percentage of patients in hospital and programs are needed to raise awareness of its importance in the prevention of venous thromboembolism and continuous monitoring is needed to facilitate prescriptions.

The dawn of a new era in onco-cardiology: The Kumamoto Classification.

The term "onco-cardiology" has been used in reference to cardiotoxicity in the treatment of malignant disease. In actual clinical situations, however, cardiovascular disease (CVD) associated with malignant disease and the concurrence of atherosclerotic disease with malignant disease are commonly observed, complicating the course of treatment. Patients with malignant disease associated with coronary artery disease often die from the cardiovascular disease, so it is essential to classify these disease states. Additionally, the prevalence of these classifications makes it easy to manage patients with malignant disease and coronary artery disease. We divided the broad field of onco-cardiology into 4 classifications based on clinical scenarios (CSs): CS1 represents the so-called paraneoplastic syndrome. CS2 represents cardiotoxicity during treatment of malignant diseases. CS3 represents the concurrence of atherosclerotic disease with malignant disease, and CS4 represents cardiovascular disease with benign tumors. This classification facilitates the management of patients with malignant disease and coronary artery disease by promoting not only the primary but also the secondary prevention of CVD.

El enfermero de unidades hospitalarias oncológicas: perfil y capacitación profesional / O enfermeiro que atua em unidades hospitalares oncológicas: perfil e capacitação profissional / The nurse that operates in oncology unit hospital: profile and vocational training

Este es un estudio que tuvo como objetivo identificar el perfil de la enfermera que trabaja en las unidades hospitalarias de oncología. Se trata de una revisión integradora y la recolección de datos se llevó a cabo en cuatro bases de datos electrónicas en el período de marzo a mayo de 2013. Se seleccionaron 15 artículos publicados en el período 2004-2013. Los resultados se describen en dos categorías: 1. El perfil social y profesional de las enfermeras que trabajan en unidades hospitalarias de oncología y 2. Formación y preparación de la enfermera para actuar en unidades hospitalarias de oncología. Las enfermeras son mujeres, con edades comprendidas entre 23 y 57 años de experiencia en el campo, con la preparación académica suficiente para la graduación. Identifica la necesidad de un desarrollo científico y técnico profesional a través de la especialización, de postgrado, residencias, capacitación, cursos de actualización y la participación en conferencias. El estudio deberá aumentar la conciencia de las enfermeras y administradores de servicios de salud como el perfil y la preparación adecuada de los que trabajan en las unidades de oncología hospitalaria (AU)

Trata-se de um estudo que teve como objetivo identificar o perfil do enfermeiro que atua em unidades hospitalares oncológicas. É uma revisão integrativa e a coleta de dados foi realizada em quatro bases eletrônicas no período de março a maio de 2013. Foram selecionados 15 artigos, publicados no período de 2004 a 2013. Os resultados foram descritos em duas categorias: 1. O perfil social e profissional do enfermeiro que atua unidades hospitalares oncológicas e 2. Capacitação e preparo do Enfermeiro para atuar em unidades hospitalares oncológicas. Os enfermeiros são do sexo feminino, faixa etária entre 23 e 57 anos e experiência na área, com preparo acadêmico insuficiente durante a graduação. Identificam-se a necessidade de desenvolvimento profissional técnico-científico por meio de especializações, pós-graduação, residências, treinamentos, cursos de atualização e participação em congressos. O estudo deve provocar reflexão dos enfermeiros e gestores dos serviços de saúde quanto ao perfil e preparo adequado para a atuação em unidades hospitalares de oncologia

This is a study that aimed to identify the profile of the nurse working in oncology hospital units. It is an integrative review and data collection was conducted in four electronic databases in the period March-May 2013. 15 articles published in the period 2004-2013 were selected. The results were described in two categories: 1. The social and professional profile of nurses who work oncological hospitals and 2. Training and preparation of the nurse to act in oncological hospitals. The nurses are female, aged between 23 and 57 years, experience in the field, with insufficient academic preparation for graduation. Identifies the need for professional technical and scientific development through specialization, graduate, homes, training, refresher courses and participation in conferences. The study should increase awareness of nurses and managers of health services as the profile and adequate preparation of working in hospital oncology units (AU)

Development, implementation, and initial evaluation of a foundational open interoperability standard for oncology treatment planning and summarization.

OBJECTIVE: Develop and evaluate a foundational oncology-specific standard for the communication and coordination of care throughout the cancer journey, with early-stage breast cancer as the use case. MATERIALS AND METHODS: Owing to broad uptake of the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) by health information exchanges and large provider organizations, we developed an implementation guide in congruence with C-CDA. The resultant product was balloted through the HL7 process and subsequently implemented by two groups: the Health Story Project (Health Story) and the Athena Breast Health Network (Athena). RESULTS: The HL7 Implementation Guide for CDA, Release 2: Clinical Oncology Treatment Plan and Summary, DSTU Release 1 (eCOTPS) was successfully balloted and published as a Draft Standard for Trial Use (DSTU) in October 2013. Health Story successfully implemented the eCOTPS the 2014 meeting of the Healthcare Information and Management Systems Society (HIMSS) in a clinical vignette. During the evaluation and implementation of eCOPS, Athena identified two practical concerns: (1) the need for additional CDA templates specific to their use case; (2) the many-to-many mapping of Athena-defined data elements to eCOTPS. DISCUSSION: Early implementation of eCOTPS has demonstrated successful vendor-agnostic transmission of oncology-specific data. The modularity enabled by the C-CDA framework ensures the relatively straightforward expansion of the eCOTPS to include other cancer subtypes. Lessons learned during the process will strengthen future versions of the standard. CONCLUSION: eCOTPS is the first oncology-specific CDA standard to achieve HL7 DSTU status. Oncology standards will improve care throughout the cancer journey by allowing the efficient transmission of reliable, meaningful, and current clinical data between the many involved stakeholders.

Number of excisions required to obtain clear surgical margins and prognostic value of AJCC T category for patients with eyelid melanoma.

AIMS: To determine the number of excisions needed to achieve clear margins and the prognostic value of the 7th edition of American Joint Committee on Cancer (AJCC) classification for eyelid melanoma. METHODS: Retrospective chart review of consecutive patients treated for eyelid melanoma from January 2006 through May 2013 by the senior author at a tertiary care cancer centre. RESULTS: Of the 64 patients (25 men and 39 women), clear surgical margins were achieved with a single excision in 38 patients (62%), 2 excisions in 21 patients (34%), and 3 excisions in 2 patients (3%). Need for repeat excision was not correlated with the size of the surgical margin (p=0.14) or AJCC TNM classification (p=0.15). Nodal disease at presentation was significantly associated with T category greater than T2b (p=0.0026) and shorter time to disease progression (p=0.007). Patients followed for a minimum of 1 year with T category greater than T2b had a significantly higher risk of nodal or distant metastasis (p=0.0061). CONCLUSIONS: More than a third of patients with eyelid melanoma required more than 1 excision to achieve clear margins, supporting delayed reconstruction for eyelid melanoma. Nodal metastasis at presentation was significantly correlated with AJCC T category and time to progression.

Integrative oncology: an overview.

Integrative oncology, the diagnosis-specific field of integrative medicine, addresses symptom control with nonpharmacologic therapies. Known commonly as "complementary therapies" these are evidence-based adjuncts to mainstream care that effectively control physical and emotional symptoms, enhance physical and emotional strength, and provide patients with skills enabling them to help themselves throughout and following mainstream cancer treatment. Integrative or complementary therapies are rational and noninvasive. They have been subjected to study to determine their value, to document the problems they ameliorate, and to define the circumstances under which such therapies are beneficial. Conversely, "alternative" therapies typically are promoted literally as such; as actual antitumor treatments. They lack biologic plausibility and scientific evidence of safety and efficacy. Many are outright fraudulent. Conflating these two very different categories by use of the convenient acronym "CAM," for "complementary and alternative therapies," confuses the issue and does a substantial disservice to patients and medical professionals. Complementary and integrative modalities have demonstrated safety value and benefits. If the same were true for "alternatives," they would not be "alternatives." Rather, they would become part of mainstream cancer care. This manuscript explores the medical and sociocultural context of interest in integrative oncology as well as in "alternative" therapies, reviews commonly-asked patient questions, summarizes research results in both categories, and offers recommendations to help guide patients and family members through what is often a difficult maze. Combining complementary therapies with mainstream oncology care to address patients' physical, psychologic and spiritual needs constitutes the practice of integrative oncology. By recommending nonpharmacologic modalities that reduce symptom burden and improve quality of life, physicians also enable patients to play a role in their care. Critical for most patients, this also improves the physician-patient relationship, the quality of cancer care, and the well-being of patients and their families.

Pharmacovigilance in oncology: pattern of spontaneous notifications, incidence of adverse drug reactions and under-reporting

The high toxicity and narrow therapeutic window of antineoplastic agents makes pharmacovigilance studies essential in oncology. The objectives of the current study were to analyze the pattern of spontaneous notifications of adverse drug reactions (ADRs) in oncology patients and to analyze the incidence of ADRs reported by outpatients on antineoplastic treatment in a tertiary care teaching hospital. To compose the pattern of ADR, the notification forms of reactions in oncology patients in 2010 were reviewed, and the reactions were classified based on the drug involved, mechanism, causality, and severity. To evaluate the incidence of reactions, a questionnaire at the time of chemotherapy was included, and the severity was classified based on the Common Terminology Criteria. The profiles of the 10 responses reported to the Pharmacovigilance Sector were type B, severe, possible, and they were primarily related to platinum compounds and taxanes. When the incidence of reactions was analyzed, it was observed that nausea, alopecia, fatigue, diarrhea, and taste disturbance were the most frequently reported reactions by oncology patients, and the grade 3 and 4 reactions were not reported. Based on this analysis, it is proposed that health professionals should be trained regarding notifications and clinical pharmacists should increasingly be brought on board to reduce under-reporting of ADRs.

Estudos de farmacovigilância são imprescindíveis em oncologia, pois os antineoplásicos possuem alta toxicidade e estreita janela terapêutica. Os objetivos deste estudo foram analisar o perfil das notificações espontâneas de reações adversas a medicamentos (RAM) em pacientes oncológicos e a incidência de RAM ao tratamento antineoplásico em um hospital terciário e universitário. Para compor o perfil de RAM, revisaram-se os formulários de notificação de reações em pacientes oncológicos do ano de 2010 e classificaram-se as reações conforme o medicamento envolvido, mecanismo, causalidade e gravidade. Para avaliar a incidência de reações, aplicou-se um questionário no momento da quimioterapia e a gravidade foi classificada pelos Critérios Comuns de Toxicidade. Apenas 10 reações foram notificadas ao Setor de Farmacovigilância, cujo perfil encontrado foi tipo B, grave, possível, e foram principalmente relacionadas aos compostos de platina e taxanos. Na análise da incidência das reações, observou-se que náusea, alopecia, fadiga, diarreia e distúrbio do paladar foram as reações mais frequentes relatadas por pacientes oncológicos, e as reações grau 3 e 4 não foram notificadas. De acordo com essas análises, propõe-se que os profissionais da saúde sejam treinados quanto às notificações e que farmacêuticos clínicos sejam cada vez mais inseridos neste contexto para redução da subnotificação de RAM.