Targeting PD-L1 After Adjuvant Radiation in Subtotally Resected Primary Pineal Melanoma: A Case Report and Literature Review.

Primary melanoma of the pineal gland is a rare disease entity with an overall poor prognosis. Limited data exist to appropriately guide treatment decisions. Historical case reports have showed some success using a combination of surgical resection, radiotherapy, and chemotherapy, but long-term survival has been exceedingly rare. This report presents a female patient with a primary pineal melanoma who underwent subtotal resection followed by adjuvant focal radiation to the residual tumor. Immunohistochemistry identified a strong positivity for PD-L1 (70%). After radiation, systemic therapy with pembrolizumab was initiated with the plan to treat until progression. She has now completed 33 cycles of pembrolizumab without interruptions, complications, or disease progression. At the time of writing, the patient has had an excellent clinical outcome, with a durable near-complete response of >138 weeks. To our knowledge, this is the first patient with a pineal melanoma to be managed by targeting PD-L1. Furthermore, she has achieved the second longest overall survival and the longest progression-free survival reported in the literature.

The Impact of Low-Dose Cranial Boost on the Long-Term Outcomes of Adult Patients with High-Risk Acute Lymphoblastic Leukemia Undergoing Total Body Irradiation and Allogeneic Hematopoietic Stem Cell Transplantation.

PURPOSE: Total body irradiation (TBI) is an integral part of the conditioning regimen for patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic, hematopoietic, cell transplantation (allo-HCT). There are conflicting data in the literature regarding the utility of a cranial irradiation boost in high-risk adult ALL without evidence of preexisting central nervous system (CNS) involvement. This study investigates the posttransplant clinical outcomes of patients with high-risk adult ALL undergoing TBI conditioning for allo-HCT with or without a whole-brain boost, without overt CNS involvement at the time of diagnosis. METHODS AND MATERIALS: A retrospective cohort study was conducted using a medical record analysis. We identified 58 patients who were treated between January 1998 and December 2016, and met our preset inclusion criteria of adults (age >18 years old) who carried a pathologically confirmed diagnosis of CNS-negative, high-risk ALL, who underwent hematopoietic stem cell transplantation with TBI conditioning. A multivariate analysis of correlation between patient outcomes and collected categorical variables was assessed with stepwise Cox logistic regression. Survival analyses were assessed using the Kaplan-Meier technique with a log-rank test. RESULTS: With a median follow-up time of 5.3 years, there was a statistically significant improvement in actuarial 7-year CNS relapse-free survival (100% vs 76.4%; P = .043) in favor of patients undergoing a cranial boost. There was no statistically significant improvement in 7-year progression-free survival (78.3% vs 62.5%; P = .076) or overall survival (49.4% vs 43.5%; P = .921) with versus without a cranial boost. On multivariate analysis, the presence of a cranial boost was the only identified variable with an independent relationship to CNS relapse-free survival. CONCLUSIONS: Adult patients with high-risk, CNS-negative ALL were found to have a statistically significant improvement in CNS relapse-free survival and a trend toward improved progression-free survival with the inclusion of a cranial boost with TBI pretransplant conditioning. Our data indicate that further investigation into the use of cranial boost in this patient population is warranted.

Pentoxifylline and vitamin E drug compliance after adjuvant breast radiation therapy.

PURPOSE: Breast fibrosis is a common late effect after therapeutic irradiation that can result in pain, poor cosmesis, and functional impairment. Randomized trials have demonstrated that radiation fibrosis may be preventable with a medication regimen of pentoxifylline and vitamin E. This study investigates patient compliance with pentoxifylline therapy while examining possible correlations to compliance. METHODS AND MATERIALS: We identified 90 patients who were prescribed pentoxifylline (400 mg 3 times daily) and vitamin E (400 IU once daily) after adjuvant breast radiation. A retrospective cohort study was conducted using medical record analysis. Data were collected, including patient age, comorbid conditions, concurrent medications, duration of pentoxifylline and vitamin E therapy, dose adjustments, patient-reported side effects, and cause for discontinuation. A multivariate analysis of the correlation between medication compliance and these categorical variables was assessed with a χ2 analysis of independence. RESULTS: Patient compliance with pentoxifylline and vitamin E therapy was found to be poor in 33 of 87 patients (38%) in the cohort, necessitating either dose reductions or discontinuation of therapy. There was a statistically significant correlation between concurrent antiemetic therapy and successful completion of pentoxifylline regimen. Of those on antiemetic therapy, 89% completed pentoxifylline as prescribed versus 48% of those without antiemetics (P < .001). There was a statistically significant correlation between concurrent proton pump inhibitor (PPI) therapy and discontinuation of pentoxifylline. Of those on PPI therapy, 33% completed pentoxifylline versus 81% of those not on PPIs (P < .001). All other variables examined were not significantly correlated with compliance. CONCLUSIONS: Patient compliance with pentoxifylline appears to be worse in clinical practice compared with previously published studies. Nausea was the most frequently reported indication for treatment modification or discontinuation. Concurrent antiemetic therapy was correlated with strong regimen compliance, but concurrent PPI therapy was correlated with poor compliance, independent of comorbid conditions.