Outcomes of Patients with COVID-19 from a Specialized Cancer Care Emergency Room.

PURPOSE: Our goal was to identify discrete clinical characteristics associated with safe discharge from an emergency department/urgent care for patients with a history of cancer and concurrent COVID-19 infection during the SARS-CoV-2 pandemic and prior to widespread vaccination. PATIENTS AND METHODS: We retrospectively analyzed 255 adult patients with a history of cancer who presented to Memorial Sloan Kettering Cancer Center (MSKCC) urgent care center (UCC) from March 1, 2020 to May 31, 2020 with concurrent COVID-19 infection. We evaluated associations between patient characteristics and 30-day mortality from initial emergency department (ED) or urgent care center (UCC) visit and the absence of a severe event within 30 days. External validation was performed on a retrospective data from 29 patients followed at Fred Hutchinson Cancer Research Center that presented to the local emergency department. A late cohort of 108 additional patients at MSKCC from June 1, 2020 to January 31, 2021 was utilized for further validation. RESULTS: In the MSKCC cohort, 30-day mortality and severe event rate was 15% and 32% respectively. Using stepwise regression analysis, elevated BUN and glucose, anemia, and tachypnea were selected as the main predictors of 30-day mortality. Conversely, normal albumin, BUN, calcium, and glucose, neutrophil-lymphocyte ratio <3, lack of (severe) hypoxia, lack of bradycardia or tachypnea, and negative imaging were selected as the main predictors of an uneventful course as defined as a Lack Of a Severe Event within Thirty Days (LOSETD). Utilizing this information, we devised a tool to predict 30-day mortality and LOSETD which achieved an area under the operating curve (AUC) of 79% and 74% respectively. Similar estimates of AUC were obtained in an external validation cohort. A late cohort at MSKCC was consistent with the prior, albeit with a lower AUC. CONCLUSION: We identified easily obtainable variables that predict 30-day mortality and the absence of a severe event for patients with a history of cancer and concurrent COVID-19. This has been translated into a bedside tool that the clinician may utilize to assist disposition of this group of patients from the emergency department or urgent care setting.

Continuous Trastuzumab Therapy in Breast Cancer Patients With Asymptomatic Left Ventricular Dysfunction.

BACKGROUND: Adjuvant trastuzumab is a highly effective targeted treatment that improves survival for patients with HER2-positive breast cancer. However, trastuzumab interruption is recommended for patients who develop treatment-induced cardiotoxicity (i.e., decline in left ventricular ejection fraction [LVEF], with or without symptoms) and can lead to an incomplete course of treatment. We studied the cardiac safety of continuous trastuzumab therapy among patients with asymptomatic declines in LVEF. METHODS: We retrospectively evaluated patients with HER2-positive breast cancer treated with adjuvant trastuzumab at our institution between 2005 and 2010. Treatment-induced cardiotoxicity was defined by an absolute decrease in LVEF of ≥10% to below 55% or an absolute decrease of ≥16%. Logistic regression was used to determine the association between candidate risk factors and treatment-induced cardiotoxicity. RESULTS: Among 573 patients, 92 (16%) developed treatment-induced cardiotoxicity. Trastuzumab was continued without interruption in 31 of 92 patients with treatment-induced cardiotoxicity­all were asymptomatic with LVEF of ≥50% at cardiotoxicity diagnosis with median LVEF of 53% (range, 50%-63%), and none developed heart failure during follow-up. Risk factors associated with treatment-induced cardiotoxicity included age (p = .011), anthracycline chemotherapy (p = .002), and lower pretrastuzumab LVEF (p < .001). CONCLUSION: Among patients who develop asymptomatic treatment-induced cardiotoxicity with LVEF of ≥50%, continuous trastuzumab therapy appears to be safe.

Trastuzumab interruption and treatment-induced cardiotoxicity in early HER2-positive breast cancer.

Trastuzumab improves outcomes among patients with HER2-positive breast cancer but is associated with a risk of treatment-induced cardiotoxicity (TIC). It is unclear how frequently TIC leads to trastuzumab interruption outside of prospective trials, and how TIC is managed in clinical practice. Patients with HER2-postive breast cancer receiving adjuvant trastuzumab from 2005 to 2010 were identified (n = 608). We evaluated the incidence, risk factors, and management of trastuzumab interruption due to TIC. In total, 488 (80 %) patients were treated with anthracycline prior to trastuzumab. Trastuzumab was interrupted in 108 (18 %) patients. Cumulative trastuzumab dose was lower in the interrupted group (median 86 vs. 108 mg/kg, p < 0.0001). The most common reason for interruption was TIC (66 of 108 patients): 20 had symptomatic heart failure and 46 had asymptomatic left ventricular ejection fraction (LVEF) decline. Patients with trastuzumab interruption for TIC were older (54 vs. 50 years, p = 0.014) with lower LVEF before anthracycline (63 vs. 67 %, p < 0.0001) and trastuzumab (62 vs. 67 %, p < 0.0001) therapy. Mean LVEF at baseline, TIC diagnosis, and follow-up after trastuzumab interruption was 63, 45, and 55 %, respectively. Thirty-three of 66 patients with TIC were re-challenged with trastuzumab, and five patients had recurrent LVEF decline. In clinical practice, trastuzumab interruption is common and most often due to TIC, with most patients receiving anthracycline prior to trastuzumab. Cardiac dysfunction improves after trastuzumab interruption but may not fully recover to baseline. Strategies to minimize cardiotoxicity and treatment interruption should be investigated to prevent persistent left ventricular dysfunction in affected patients.

Cardiac metastases from head and neck cancer mimicking a myocardial infarction.

Cardiac metastases from head and neck cancer are rare. We present 2 patients with primary head and neck cancer found to have cardiac metastases. Electrocardiograms showed a persistent acute infarction pattern due to myocardial tumor infiltration. No cardiac symptoms were present. Both patients died of metastatic disease.

Mature cystic retroperitoneal teratoma with well differentiated renal elements: relation to spinal dysraphism.

Retroperitoneum is a relatively uncommon site for pediatric teratomas. Rarely, such tumors can have an intraspinal extension and few cases of retroperitoneal teratomas associated with spinal dysraphism have been reported. Teratomas consist of tissues arising from all three embryonic layers. However, mature renal tissues in the form of glomeruli and tubules are sparingly found in teratomas. A 15-day-old female presented with spina bifida occulta and on evaluation a cystic presacral mass was detected. Intraoperatively the cyst was found densely adherent to the hemivertebrae but not entering the spinal canal. Histopathological examination confirmed a mature cystic teratoma but also demonstrated presence of mature renal elements in the cyst wall. The teratomas lying in proximity to spine and associated with spinal dysraphism are likely to contain mature renal tissues or even nephroblastic elements. It supports the dysembryogenic model of origin of intradural teratomas from native progenitor cells rather than aberrantly migrated germ cells.

Cancer survivorship: cardiotoxic therapy in the adult cancer patient; cardiac outcomes with recommendations for patient management.

Many types of cancer are now curable or, if not cured, becoming a chronic illness. In 2012, it was estimated that there were more than 13,500,000 cancer survivors in the United States. Late outcomes of these survivors are increasingly related to cardiovascular disease, either as a consequence of the direct effects of cancer therapy or its adverse effects on traditional cardiac risk factors (eg, obesity, hypertension, dyslipidemia, and diabetes mellitus). This article describes the therapies that have led to advances in cancer survival and the acute and chronic cardiovascular toxicities associated with these therapies. Recommendations are made for the surveillance and management of cancer survivors. Published guidelines on the subject of cardio-oncology are reviewed in light of clinical experience caring for these patients. To supplement this cancer-related knowledge base, appropriateness criteria and guidelines for cardiac care in the general population were extrapolated to cancer survivors. The result is a series of recommendations for surveillance and management of cardiovascular disease in cancer survivors.