Prevalence, Patterns, and Predictors of Venous Thromboembolic Events in Patients Undergoing Salvage Chemotherapy and Autologous Stem Cell Transplantation for Relapsed Lymphomas.

BACKGROUND AND OBJECTIVES: Almost 25% of patients with lymphoma may have relapse or develop refractory disease, and a majority of such patients undergo salvage chemotherapy and autologous stem cell transplantation (ASCT). Data on venous thromboembolism (VTE) in this setting are scarce. This study aimed to investigate the prevalence and factors that may increase the risk of VTE in such patients. PATIENTS AND METHODS: Adult patients who were diagnosed with lymphoma and received salvage chemotherapy and ASCT were included in the study, and the subgroup with radiologically confirmed VTE were identified. Correlations between different clinical and laboratory variables and VTE were evaluated. RESULTS: A total of 216 patients (median age, 31 [range, 19-60] years) were enrolled in the study. Most patients (n = 140, 64.8%) had Hodgkin's lymphoma, while 54 (25.0%) had diffuse large B-cell lymphoma. A total of 36 (16.7%) patients had VTE, mostly as upper extremity deep vein thrombosis (n = 28, 77.8%); 18 (50%) of the cases were related to central venous catheter insertion. Thrombosis rates were higher among patients with high lactate dehydrogenase (LDH) level (29.2% vs. 5.9%, p < 0.001), those with mediastinal involvement (25.9% vs. 11.5%, p = 0.025). and those with longer hospital stay (22.3% vs.9.5%, p = 0.036). In the multivariate analysis, high LDH level (odds ratio (OR), 6.53; p < 0.001), mediastinal involvement (OR, 2.70; p = 0.005) and hospital stay ≥24 days (OR, 2.71; p = 0.007) were all associated with significantly higher VTE rates. CONCLUSION: Patients with relapsed lymphoma undergoing salvage chemotherapy and ASCT are at higher risk for VTE, especially in those with high LDH level, mediastinal involvement, and prolonged hospital stay. If no contraindications exist, thromboprophylaxis might be considered in these settings.

Abiraterone acetate for treatment of ectopic Cushing syndrome caused by ACTH-producing neuroendocrine tumor: a case report.

Background: Ectopic Cushing syndrome (EAS) secondary to an adrenocorticotropin hormone (ACTH)-releasing neuroendocrine tumor (NET) is a rare diagnosis that can be resistant to standard treatments. Abiraterone acetate (AA) is a selective and irreversible inhibitor of 17α-hydroxylase/17,20-lyase that blocks adrenal steroidogenesis, including cortisol synthesis. In this case, we present the novel use of AA in treating malignant EAS by blocking cortisol synthesis. Case Description: We present a case in which a middle-aged female diagnosed with EAS secondary to metastatic ACTH-releasing NET who presented with progressively worsening weakness, diagnosed with glucocorticoid-induced myopathy associated with autonomic dysregulation. Due to her tenuous clinical status, the patient was not a candidate for any invasive procedures. She was treated with AA which led to a rapid quantitative reduction in the serum cortisol levels and hemodynamic improvement. This temporizing measure allowed for clinical stability, the patient underwent adrenal artery embolization and abiraterone was discontinued. The patient did not experience any further decline in her strength, her symptoms related to myopathy slowly improved, she was discharged to a rehabilitation facility. Conclusions: This case illustrates how the inhibition of cortisol caused by AA can be effectively used in the management of EAS. The potent and rapid effects of AA in blocking endogenous cortisol production may be considered as a temporizing measure in the treatment of malignant EAS.

Breast Cancer in Geriatric Patients: Current Landscape and Future Prospects.

Breast cancer is the most common cancer diagnosed among women worldwide and more than half are diagnosed above the age of 60 years. Life expectancy is increasing and the number of breast cancer cases diagnosed among older women are expected to increase. Undertreatment, mostly due to unjustifiable fears of advanced-age and associated comorbidities, is commonly practiced in this group of patients who are under-represented in clinical trials and their management is not properly addressed in clinical practice guidelines. With modern surgery and anesthesia, breast surgeries are considered safe and is usually associated with very low complication rates, regardless of extent of surgery. However, oncoplastic surgery and management of the axilla can be tailored based on patients'- and disease-related factors. Most of chemotherapeutic agents, along with targeted therapy and anti-Human epidermal growth factor receptor-2 (HER2) drugs can be safely given for older patients, however, dose adjustment and close monitoring of potential adverse events might be needed. The recently introduced cyclin-D kinase (CDK) 4/6-inhibitors in combination with aromatase inhibitors (AI) or fulvestrant, which changed the landscape of breast cancer therapy, are both safe and effective in older patients and had substituted more aggressive and potentially toxic interventions. Despite its proven efficacy, adjusting or even omitting adjuvant radiation therapy, at least in low-risk older patients, is safe and frequently practiced. In this paper, we review existing data related to breast cancer management among older patients across the continuum; from resection of the primary tumor through adjuvant chemotherapy, radiation and endocrine therapy up to the management of recurrent and advanced-stage disease.

Clinical Characteristics, Prognostic Factors and Treatment Outcomes of Patients with Bone-Only Metastatic Breast Cancer.

Introduction: Bone is the most frequent site of breast cancer metastasis. Differences between those who present with de novo bone-only metastasis (BOM) and those who progress to bone-only disease following a diagnosis of early-stage breast cancer are not clear. Such differences in clinical course might have an impact on the aggressiveness of treatment. This study presents the clinical and pathological features, along with treatment outcomes, of breast cancer patients with BOM in relation to the timing and type of bone metastasis. Patients and Methods: Patients with breast cancer and BOM were retrospectively reviewed. De novo BOM was defined as bone metastasis diagnosed at presentation or within the first 4 months of follow-up. Treatment outcomes of patients with de novo, compared to those with subsequent BOM, are presented. Results: 242 patients, median age (range) at diagnosis was 52 (27-80) years were enrolled. The majority of the patients (77.3%) had de novo BOM with multiple sites of bone involvement (82.6%). At a median follow-up of 37.7 months, the median overall survival (OS) for patients with de novo BOM disease was significantly shorter than those who developed so subsequently; 40.8 months (95% CI, 51.1-184.1) compared to 80.9 months (95% CI, 36.4-47.9), p < 0.001. Tumor grade, hormone receptor status and type of bone lesions (lytic versus sclerotic) had a significant impact on survival outcomes. Conclusion: Breast cancer with de novo BOM is a distinct clinical entity with unfavorable prognosis and is associated with shorter survival. Several risk factors for poor outcomes were identified and might inform treatment plans.

Vitiligo-Like Lesions in a Patient with Metastatic Breast Cancer Treated with Cyclin-Dependent Kinase (CDK) 4/6 Inhibitor: A Case Report and Literature Review.

BACKGROUND: Cyclin-dependent kinase (CDK) 4/6 inhibitors have revolutionized the treatment landscape of hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer, with an impressive efficacy and safety profile. Cytopenia is the main adverse event, which is both predictable and manageable. Here, we report a case of CDK4/6 inhibitor-induced vitiligo-like lesions. Vitiligo or vitiligo-like lesions are a rare adverse event; only a few cases are reported in the literature. CASE PRESENTATION: A 71-year-old female patient was diagnosed initially with early-stage right breast cancer (HR+/HER2-) and was treated with breast-conserving surgery followed by chemotherapy, radiotherapy, and hormonal therapy. A few years later, she developed metastatic disease to the hilar lymph nodes, and to multiple skeletal sites, including the left scapula, left shoulder, left iliac bone, and dorsal vertebrae, for which she was treated with ribociclib and letrozole. While on treatment, she developed hypopigmented lesions involving both hands, feet, and face, which were described as vitiligo-like lesions. CONCLUSION: CDK4/6 inhibitor-induced vitiligo is a rare and unpredictable adverse event. This case report highlights the rarity of this adverse event, the dilemma related to the optimal treatment, and decisions related to continuation, holding, or switching CDK4/6 inhibitors.

From clinical trials to clinical practice: the use of everolimus and exemestane in the treatment of hormone receptor-positive metastatic breast cancer: real-world data.

Everolimus combined with exemestane can modulate endocrine resistance. The combination showed significant improvement in progression-free survival (PFS) in phase III clinical trials for hormone receptor positive metastatic breast cancer patients. It also showed serious adverse events. We evaluate the efficacy and prevalence of serious adverse events in a real-world setting. We retrospectively examined 91 breast cancer patients; all were previously treated with chemotherapy and fulvestrant (84% and 59%, respectively). After a 13-month median follow-up, 29% had a partial response, and 32% had stable disease. The PFS was 7.8 months. Due to adverse events, 19% of patients stopped the treatment, while 31% required a dose reduction. Despite enrolling heavier-pretreated patients, our real-world outcome for the efficacy and safety of the exemestane and everolimus match those of the clinical trials. Such results should assure clinicians and lead to wider adoption of this oral, chemotherapy-sparing regimen.

Late presentation and suboptimal treatment of breast cancer among Syrian refugees: a retrospective study.

OBJECTIVES: The crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management of Syrian patients with breast cancer treated at our institution. METHODS: We retrospectively collected data on Syrian refugees treated for breast cancer over the past 10 years at our center. Management was compared against our approved clinical practice guidelines. RESULTS: A total of 113 patients were eligible and included. The median age (range) at diagnosis was 47 (21-84) years and most women presented with locally advanced or metastatic disease (n = 74, 65.5%). Breast-conserving surgery and breast reconstruction were performed in 27 (33.8%) and 11 (35.4%) patients, respectively. Only a few patients received targeted (35.5%) or advanced endocrine therapy (30.0%). In total, 37 (32.7%) patients had considerable deviations from our institutional treatment guidelines and had worse outcomes. CONCLUSIONS: Syrian refugees with breast cancer present late, have more advanced-stage disease, and are more likely to receive delayed and suboptimal therapy. An international systematic approach for cancer care among such vulnerable populations is urgently needed.

Fertility counseling and sperm banking among adolescents and adults treated for cancer with curative intent in a developing country.

PURPOSE: In developing countries, a higher percentage of patients develop cancer at a younger age. Cancer survival rates have significantly improved, highlighting the importance of survivorship programs that address late complications related to cancer itself or its treatment. The purpose of this study is to estimate the prevalence of fertility counseling and sperm banking and related factors among at-risk males newly diagnosed with cancer and planning to receive a potentially curative anticancer therapy. METHODS: Medical records and hospital database of young male patients with newly diagnosed cancers and planned to start chemotherapy were reviewed for fertility counseling and sperm cryopreservation. Additionally, a self-administered questionnaire was utilized. RESULTS: A total of 186 patients, mean age 32.9 (range: 18-53) years, were included. Non-Hodgkin's lymphoma 59 (31.7%), leukemia 48 (25.8%), and Hodgkin's lymphoma 26 (14.0%) were the most common tumors encountered. A total of 129 (75.0%) respondents received fertility counseling prior to their treatment, and this rate was higher among patients with early-stage disease (82.4% vs. 58.1%, p = 0.038). However, sperm banking was performed by 33.1% of the whole study group but was significantly higher among single patients (53.4% vs. 17.7%, p < 0.001), those who had no children (51.8% vs. 14.3%, p < 0.001), and among highly educated patients (47.6% vs. 17.1%, p = 0.001). Patients failed to do sperm banking because they were not informed about the risk of infertility (26.2%) or service availability (25.4%). Fear of treatment delay was a reason in 20.0%. CONCLUSIONS: Fertility counseling and sperm banking among cancer patients are not optimal. Many patients failed to do sperm banking because of avoidable reasons. Better communication and patients' education will probably improve the utilization of this vital service.

Clinical Course and Complications of Catheter and Non-Catheter-Related Upper Extremity Deep Vein Thrombosis in Patients with Cancer.

Patients with cancer have an increased risk of venous thromboembolism. Upper extremity venous system is a peculiar site, and little is known about the clinical course in patients with cancer. Electronic medical records were searched for patients with cancer with a diagnosis of upper extremity venous thrombosis. Individual patient data were reviewed. Eighty-seven patients were identified, and the median age was 52.4. The most common underlying malignancies were breast (23.0%), colorectal (18.4%), and gastroesophageal (18.4%). Median time from cancer diagnosis to upper extremity venous thromboembolism (UEDVT) was 3.44 months. Subclavian vein was the most common involved site (56.3%) and 54.0% patients had a central venous catheter; 50.6% of patients developed a complication; pulmonary embolism (PE) in 9.2%, superior vena cava (SVC) syndrome in 14.9%, and 26.4% had postthrombotic syndrome. In patients with isolated single vein thrombosis, complications were higher in the subset with internal jugular vein involvement compared to other sites (68.2% vs 52.2%) as were complications in patients with non-catheter-related thrombosis compared to patients with a central venous catheter in place (55% vs 27.7%). Median overall survival from time of cancer and UEDVT diagnoses was 29.6 and 13.25 months, respectively. In conclusion, UEDVT is an uncommon event. Around 50% developed a complication including PE, SVC or postthrombotic syndromes. Larger studies are needed to better identify risks associated with thrombosis and the best therapeutic approach and duration in this unique subset of patients with cancer.

Cement pulmonary embolism as a complication of percutaneous vertebroplasty in cancer patients.

BACKGROUND: Vertebroplasty is a minimally invasive procedure commonly performed for vertebral compression fractures secondary to osteoporosis or malignancy. Leakage of bone cement into the paravertebral venous system and cement pulmonary embolism (cPE) are well described, mostly in patients with osteoporosis. Little is known about the clinical sequelae and outcomes in cancer patients. In this study, we report our experience with cPE following vertebroplasty performed in cancer patients. METHODS: Records of all consecutive cancer patients who underwent vertebroplasty at our institution were retrospectively reviewed. The procedure was performed via percutaneous injection of barium-opacified polymethyl-methacrylate cement. RESULTS: A total of 102 cancer patients with a median age of 53 (19-83) years were included. Seventy-eight (76.5%) patients had malignant vertebral fractures, and 24 (23.5%) patients had osteoporotic fractures. Cement PE was detected in 13 (12.7%) patients; 10 (76.9%) patients had malignant fractures, and the remaining three had osteoporotic fractures. Cement PE was mostly asymptomatic; however, 5 (38.5%) patients had respiratory symptoms that led to the diagnosis. Only the five symptomatic patients were anticoagulated. Cement PE was more common with multiple myeloma (MM); it occurred in 7 (18.9%) of the 37 patients with MM compared with only three (7.3%) of the 41 patients with other malignancies. No difference in incidence was observed between patients with osteoporotic or malignant vertebral fractures. CONCLUSIONS: Cement PE is a relatively common complication following vertebroplasty and is mostly asymptomatic. Multiple myeloma is associated with the highest risk. Large-scale prospective studies can help identify risk factors and clinical outcomes and could lead to better prevention and therapeutic strategies.