Aaron J Franke

Total Neoadjuvant Therapy: A Shifting Paradigm in Locally Advanced Rectal Cancer Management

Abstract Colorectal carcinoma is the second leading cause of cancer‐related deaths in the United States, with rectal cancer accounting for approximately one‐third of newly diagnosed cases, thus representing a major socioeconomic health burden. Although minimally invasive procedures (ie, transanal excision) may be appropriate for a subset of patients with small, superficially invasive tumors, a more comprehensive trimodality approach with neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy is recommended for medically operable patients with nonmetastatic, locally advanced rectal cancer (LARC). Although such multimodality therapy has markedly reduced local recurrence rates, there remains an estimated 5‐year distant relapse rate of 35%, representing the leading cause of death in this population. This review critically assesses the literature regarding neoadjuvant therapy for LARC, as well as the available evidence to support selective exclusion of individual modalities from the contemporary therapeutic paradigm, including controversies of nonoperative management, selective radiation sparing, and neoadjuvant systemic therapy. Through the review of existing data and the anticipated results of ongoing clinical trials, we outline the pragmatic opportunities for future investigation into questions of efficacy, safety, and ultimate improvements to the current status quo.

Management of Malignant Bowel Obstruction Associated With GI Cancers

For many patients with GI malignancies, the seeding of the abdominal cavity with tumor cells, called peritoneal carcinomatosis, is a common mode of metastases and disease progression. Prognosis for patients with this aspect of their disease remains poor, with high disease-related morbidity and complications. Uniform and proven practices that provide optimal palliative care and quality of life for these patients are needed. The objective of this review is to critically assess the current literature regarding palliative strategies in the management of peritoneal carcinomatosis and associated symptoms in patients with advanced GI cancers. Despite encouraging results in the select population where cytoreductive surgery and intraperitoneal chemotherapy are indicated, the majority of patients who develop peritoneal carcinomatosis in the setting of GI cancers have poor prognosis, with malignant bowel obstruction representing a common terminal phase of their disease process. For all patients with peritoneal carcinomatosis, aggressive symptom control and early multimodality palliative care as further outlined should be sought.

Pericardial effusion as an atypical initial presentation of extra-gonadal nonseminomatous germ cell tumor: a case report and literature review

Abstract Extra gonadal germ cell tumors have variable clinical presentations and locations. We report a case of an extra-gonadal germ cell tumor in a 26-year-old male who presented with chest pain. Imaging revealed a large pericardial effusion with underlying mass invading the pericardium. Pericardial effusion is an extremely rare initial site of diagnosis or site of metastasis for malignancy. This case illustrates the importance of a thorough history and physical examination, broad differential diagnosis, and to keep in mind serious complications from rare presentations of disease.

PTLD: Survival and analysis of prognostic factors in a cohort of 138 patients from a single institution

regression analyses were performed to identify predictors of OS for each subtype and B‐cell subgroup. Results: OS was significantly different among polymorphic (median 18 months), Hodgkin‐type (15 months), monomorphic B‐cell (14 months) and monomorphic T‐cell neoplasms (7 months, p < 0.001, Figure 1a). Significant differences in OS among B‐subgroups were not detected, but there was a trend towards decreased survival in Burkitt‐type PTLD (Figure 1b). Kidney transplant and treatment with reduction of immunosuppression were associated with increased OS in multivariable analysis in B‐cell neoplasms. Younger age and immunosuppression with azacitidine were associated with decreased OS in T‐cell neoplasms. Conclusions: Histologic subtype represents an important factor in PTLD prognosis, with T‐cell monomorphic subtype exhibiting a particularly poor OS. The possibility of lower survival in certain subsets of B‐cell PTLD should be explored in future studies and suggests the need for subtype‐specific treatment strategies to improve outcomes.