Benjamin Leon Musher

Oncolytic viral therapy for pancreatic cancer

Outcomes of pancreatic adenocarcinoma (PDA) remain dismal despite extensive clinical investigation. Combination chemotherapy provides modest improvements in survival above best supportive care, and immunotherapy has thus far not proven effective. Nevertheless, growing insight into antitumor immunity and the tumor microenvironment has inspired the discovery of novel agents targeting PDA. Oncolytic viruses represent an emerging class of immunotherapeutic agents that have undergone extensive preclinical investigation and warrant further investigation in well‐designed clinical trials.

Rising Incidence of Colorectal Cancer Among Young Hispanics in Texas.

Goals: To investigate trends in colorectal cancer (CRC) incidence and survival among Hispanics in Texas. Background: The incidence of CRC is rising among young adults in the United States. Given Texas’ large Hispanic population, investigating CRC trends in Texas may provide valuable insight into the future of CRC epidemiology in an ever-diversifying US population. Study: Data from the Texas Cancer Registry (1995 to 2010) were used to calculate age-adjusted CRC rates based on the 2000 US standard population. Annual percentage change (APC) and 5-year cancer-specific survival (CSS) rates were reported by age, race/ethnicity, stage, and anatomic location. Results: Of 123,083 CRC cases, 11% occurred in individuals below 50 years old, 26% of whom were Hispanic. Incidence was highest among African Americans (AAs; 76.3/100,000), followed by non-Hispanic whites (NHWs; 60.2/100,000) and Hispanics (50.8/100,000). Although overall CRC incidence declined between 1995 and 2010 (APC, −1.8%; P<0.01), trends differed by age and race/ethnicity. Among individuals 50 years and above, the rate of decline was statistically significant among NHWs (APC, −2.4%; P<0.01) and AAs (APC, −1.3%; P<0.01) but not among Hispanics (APC, −0.6%; P=0.13). In persons aged 20 to 39 years, CRC incidence rose significantly among Hispanics (APC, 2.6%; P<0.01) and NHWs (APC, 2.4%; P<0.01), but not AAs (APC, 0.3%; P=0.75). CSS rates among Hispanics and NHWs were comparable across most age groups and cancer stages, whereas CSS rates among AAs were generally inferior to those observed among NHWs and Hispanics. Conclusions: Although CRC incidence has declined in Texas, it is rising among young Hispanics and NHWs while declining more slowly among older Hispanics than among older NHWs and AAs.

A rare presentation of choroidal metastasis from primary esophageal adenocarcinoma successfully treated with intensity-modulated radiation therapy

Purpose In this case report, we present a case of choroidal metastasis from a primary esophageal adenocarcinoma that was treated successfully with intensity-modulated radiation therapy. Observations A 65-year-old male with known stage IV esophageal adenocarcinoma presented with a central scotoma in his left eye and was ultimately found to have a large choroidal metastatic lesion with overlying subretinal fluid. IMRT was administered over the course of four weeks, resulting in restoration of the patients vision, regression of the metastatic lesion, and resolution of the subretinal fluid. As of 16 months following completion of radiation, there remains no evidence of choroidal recurrence or radiation-associated ocular complications. Conclusions and Importance: To our knowledge, this is the first published case report of a choroidal metastasis from esophageal cancer responding durably to IMRT. IMRT should therefore be considered a viable treatment option for this rare disease.

Identification of Educational Gaps Among Oncologists Who Manage Patients with Pancreatic Cancer

IntroductionPancreatic ductal adenocarcinoma (PDA) is associated with poor outcomes and presents oncologists with a myriad of clinical challenges. This study was conducted to assess oncologists’ practice patterns and to identify the greatest areas of need for future PDA continuing medical education (CME) programs.MethodsCase vignettes have been validated as an effective tool to assess how physicians approach and treat a wide array of diseases. In order to assess practice patterns for resectable, locally advanced unresectable, and metastatic PDA, an online case vignette survey was distributed to practicing medical oncologists.ResultsResponses from 150 US-practicing oncologists were analyzed, and several key opportunities for future CME programs were identified. For case 1 (patient with resectable PDA), 44% of oncologists did not select an evidence-based adjuvant chemotherapy regimen. For case 2 (patient with locally advanced PDA who develops metastases and neuropathy after first-line nab-paclitaxel/gemcitabine followed by chemoradiation), 57% of oncologists did not select an evidence-based second-line chemotherapy regimen, and 35% selected a regimen containing oxaliplatin, a chemotherapeutic known to cause neuropathy. For case 3 (patient with a pancreatic mass and liver metastases), only 34% of oncologists recommended a biopsy, chest imaging, and liver function tests which should be standard of care assessments with this presentation. For all three cases, clinical trial referral was selected by fewer than 5% of respondents.ConclusionsThis study identified appreciable discrepancies between oncologists’ recommendations and standard evidence-based guidelines. Well-designed CME programs may help to bridge the educational gaps identified and improve adherence to practice guidelines.

Prolapsed Gastric Gastrointestinal Stromal Tumor: A Rare Cause of Biliary Obstruction and Acute Pancreatitis

77-year-old woman presented with abdominal Apain and early satiety. Computed tomography of the abdomen (Figure A) showed a 6-cm submucosal mass (white arrow) on a stalk (black arrow) arising from the gastric fundus as well as several benignappearing liver lesions. Esophagogastroduodenoscopy (Figure B) demonstrated the same non-friable, nonobstructing gastric mass (white arrow) and its stalk (black arrow). While biopsy results were pending, the patient presented to the emergency department with acutely worsening abdominal pain, nausea, vomiting, and jaundice. Laboratory evaluation was significant for the following: alanine aminotransferase 83 U/L, aspartate aminotransferase 117 U/L, total bilirubin 4 mg/dL, and lipase 5315 U/L. Computed tomography imaging (Figure C) showed that the aforementioned mass had prolapsed into the duodenum (white arrow) and obstructed the ampulla of Vater, resulting in dilation of the common bile duct (white arrowhead), pancreatic duct (black arrow), and gallbladder. The mass was resected surgically, and microscopic evaluation (Figure D) revealed a low-grade spindle-cell neoplasm expressing CD117 (KIT), which is consistent with a gastrointestinal stromal tumor (GIST). The patient recovered well from surgery. Her serum bilirubin and lipase levels normalized, and postoperative imaging showed resolution of the pancreatobiliary ductal dilation. Because this GIST carried a low (<5%) risk for recurrence on the basis of its size (5–10 cm), location (stomach), and low mitotic rate ( 5 mitoses/50 high-power field), we did not recommend any adjuvant therapy. Comprising fewer than 1% of all gastrointestinal tumors, GISTs are intramucosal spindle-cell neoplasms that can arise throughout the gastrointestinal tract but are most commonly found in the stomach. Although they are frequently discovered incidentally, GISTs may cause early satiety, bloating, bleeding, pain, or frank bowel obstruction. Our patient presented with pancreatitis and biliary obstruction (manifested by elevated serum lipase and bilirubin levels and a radiographic “double-duct” sign) because of a prolapsed GIST obstructing the ampulla of Vater. Although gastric GISTs or polyps may infrequently prolapse through the pylorus into the duodenum, to our knowledge there are only 2 published case reports of gastric GIST causing pancreatitis and no published reports of gastric GIST causing both pancreatitis and biliary obstruction. After resection of a GIST, the consulting oncologist can assess recurrence risk on the basis of tumor size, mitotic rate, and anatomic location and, in turn, determine whether to recommend imatinib, which has been shown to improve recurrence-free survival in patients with resected intermediate or highrisk GIST.