Management of symptomatic ascites in hospice patients with paracentesis: a case series report.

Refractory ascites causes significant distress to patients and can be managed in various ways. In hospice patients where the goal of care is to preserve comfort and foster better quality of life, diuretics should be tried first; however, in resistant cases, home-based paracentesis should be entertained. Home-based paracentesis is a safe and simple procedure that can be done blindly, if done under standard precautions there is minimal associated risk of bleeding, infection or perforation and no need for pre or post-laboratory testing or the correction of high international normalization ratio or thrombocytopenia. Home-based paracentesis is cost effective, provides immediate symptomatic relief, good patient and caregiver satisfaction and obviates the associated distress to the patient and family of transporting the patient for either outpatient or inpatient paracentesis.

Sunitinib rechallenge in metastatic renal cell carcinoma patients.

BACKGROUND: Sunitinib was a standard initial therapy in metastatic renal cell carcinoma (mRCC). Given the fact that many patients progressed through many available therapies and antitumor activity had been demonstrated with sequential vascular endothelial growth factor-targeting approaches, a retrospective review was performed of the experience of rechallenge with sunitinib in sunitinib-refractory mRCC. METHODS: mRCC patients who received sunitinib therapy after disease progression on prior sunitinib and other therapy were retrospectively identified. Patient characteristics, toxicity, clinical outcome, Response Evaluation Criteria in Solid Tumors (RECIST) objective response rate, and progression-free survival (PFS) were recorded. RESULTS: Twenty-three mRCC patients who were rechallenged with sunitinib were identified. Upon rechallenge, 5 patients (22%) achieved an objective partial response. The median PFS with initial treatment was 13.7 months and 7.2 months with rechallenge. Patients with >6-month interval between sunitinib treatments had a longer PFS with rechallenge than patients who started the rechallenge within 6 months (median PFS, 16.5 vs 6.0 months; P=.03). There was no significant difference in outcome to sunitinib rechallenge based on number or mechanism of intervening treatments. Substantial new toxicity or significantly increased severity of prior toxicity was not seen during rechallenge in this cohort. CONCLUSIONS: Sunitinib rechallenge had potential benefits and was tolerated in select metastatic RCC patients. Additional prospective investigation was warranted.

Clinical outcome in metastatic renal cell carcinoma patients after failure of initial vascular endothelial growth factor-targeted therapy.

OBJECTIVES: To characterize and evaluate the efficacy of second-line therapy in patients who had progressed on initial anti-vascular endothelial growth factor (VEGF) therapy. METHODS: Between 2005 and 2007, patients with mRCC who received second-line therapy after 1st-line VEGF-targeted therapy were identified across 7 cancer centers. RESULTS: A total of 645 mRCC patients received first-line VEGF-targeted therapy, of which 216 patients received second-line VEGF-targeted therapy (sunitinib, n = 93; sorafenib, n = 80; bevacizumab, n = 11; axitinib, n = 8) or mammalian target of rapamycin (mTOR)-inhibiting agents (temsirolimus, n = 21; everolimus, n = 3). On multivariate analysis, a higher baseline Karnofsky performance status score before first-line therapy predicted which patients were more likely to receive second-line therapy (P <.0001). The median time to treatment failure of second-line therapy was 4.9 months for anti-VEGF therapy and 2.5 months for mTOR inhibitors (P = .014) (HR: 0.52, CI: 0.29-0.91 and HR: 0.495, CI: 0.27-0.9 after adjusting for Memorial Sloan-Kettering Cancer Center prognostic factors and histology, respectively). Overall survival from start of second-line therapy was not significantly different (14.2 vs 10.6 months respectively; P = .38). CONCLUSIONS: Baseline Karnofsky performance status is an independent predictor of receiving second-line targeted therapy. Patients who receive a second-line anti-VEGF drug appear to have a similar overall survival to those who receive a second-line anti-mTOR drug.

Clocking delirium: the value of the Clock Drawing Test with case illustrations.

Screening for impaired cognition is very important in geriatric and palliative medicine. There are several validated screening tools for delirium; the Confusion Assessment Method, The Memorial Delirium Assessment Scale, and the Bedside Confusion Scale. The Clock Drawing Test, which was initially described in 1963, has also been used to assess cognition and is validated in Alzheimer's disease and in elderly hospice patients with a negative predictive value greater than 0.95. The Clock Drawing Test is quickly and easily performed by patients and can be kept in the patient's medical record for future reference. However, very few studies have used the Clock Drawing Test to assess delirium in cancer and even fewer have used the Clock Drawing Test to determine response to interventions for delirium.

Narrative review: furosemide for hypercalcemia: an unproven yet common practice.

Although primary hyperparathyroidism is the most common cause of hypercalcemia, cancer is the most common cause requiring inpatient intervention. An estimated 10% to 20% of all patients with cancer have hypercalcemia at some point in their disease trajectory, particularly in advanced disease. Aggressive saline hydration and varying doses of furosemide continue to be the standard of care for emergency management. However, a review of the evidence for the use of furosemide in the medical management of hypercalcemia yields only case reports published before the introduction of bisphosphonates, in contrast to multiple randomized, controlled trials supporting the use of bisphosphonates. The use of furosemide in the management of hypercalcemia should no longer be recommended.