Fauzia Rana

Predictors of Toxicity and Toxicity Profile of Adjuvant Chemotherapy in Elderly Breast Cancer Patients

Abstract:  Women older than 70 years have been underrepresented in breast cancer adjuvant chemotherapy trials due to concerns about toxicity, safety and tolerance of chemotherapy. The aim of our study was to assess the tolerance of chemotherapy in older women with breast cancer and determine patterns of toxicity including the impact of age, chemotherapy regimen, functional status and comorbid conditions on this toxicity. We retrospectively reviewed the charts of early stage (stages 1 and 2) breast cancer patients older than 70 years from 1998 to 2004. A total of 62 patients, with mean age of 74.3 years, were identified. Chemotherapy was completed in 89% patients. Overall 79% completed chemotherapy without any significant side‐effects, dose reductions, or breaks during chemotherapy. Using logistic regression model increasing age was not associated with early termination of chemotherapy (p = 0.19, OR: 0.868, 95% CI: 0.7–1.076). However, increasing age, lower functional status, and higher comorbidity index scores were associated with reduction in dose and breaks in chemotherapy. None of the patients who received pegfilgrastim prophylactically developed high‐grade neutropenia. Our study suggests that adjuvant chemotherapy is safe in elderly patients. Older patients with good functional status and low comorbidity index scores tolerate chemotherapy as well as the younger patients. Prophylactic use of pegfilgrastim may reduce occurrence of severe neutropenia and related toxicity such as febrile neutropenia in the elderly patient.

An unusual case of primary small cell neuroendocrine carcinoma of the breast.

Abstract:  Primary small cell neuroendocrine carcinoma of breast is a rare entity, with only case reports in literature. Histologically, these tumors are similar to small cell carcinoma of the lung with some evidence of ductal carcinoma‐in‐situ with areas of ductal, lobular, or papillary differentiation. Immunoreactivity for neuroendocrine markers is present in two thirds of cases, while 33–50% are positive for estrogen receptor or progesterone receptor. Her2/neu expression has not been reported in small cell carcinoma of the breast. Here we are presenting 53‐year‐old women with locally advanced primary small cell neuroendocrine carcinoma of breast. We will discuss clinicopathological findings, treatment options, prognosis and review of the literature on primary small cell carcinoma of breast.

Assessment of Cardiac Iron Deposition in Sickle Cell Disease Using 3.0 Tesla Cardiovascular Magnetic Resonance

Many patients with sickle cell disease receive blood transfusions as a life-saving treatment. However, excess transfusions may lead to increased body iron burden. Specifically, heart failure due to cardiac iron overload is the leading cause of death in these patients. The purpose of this study was to investigate the potential role of high-field 3.0-Tesla (T) cardiovascular magnetic resonance (CMR) for assessment of cardiac iron content by measuring the transverse relaxivity rate R2*. The R2* was measured in calibrated phantoms with different iron concentrations at 3.0T and 1.5T using optimized pulse sequences. Myocardial R2* was measured at 3.0T in a group of sickle cell disease patients with different disease stages, and the results were compared to the serum ferritin levels and hepatic R2*. The phantom R2* measurements at 3.0T were double those at 1.5T, and the measurements of both systems showed linear relationships with iron concentration. The 3.0T R2* was more sensitive than 1.5T in detecting low iron concentration. In patients, myocardial R2* had weak and good correlations with hepatic R2* and serum ferritin levels, respectively. Bland-Altman analysis showed low inter- and intra-observer variabilities. In conclusion, measuring myocardial R2* at 3.0T is a promising technique with high sensitivity and reproducibility for evaluating cardiac iron overload in sickle cell disease patients.

Breast Cancer and HIV in the Era of Highly Active Antiretroviral Therapy: Two Case Reports and Review of the Literature

Abstract:  The incidence of human immunodeficiency virus (HIV) infection is rising in US women; however its impact on breast cancer incidence, stage at presentation, response and treatment toxicity remains unknown. To address the impact of HIV infection and use of highly active antiretroviral therapy (HAART) on the natural history of breast cancer we present two cases of breast cancer in HIV‐infected women and also review the literature. A literature search was done on Medline using the key words HIV/AIDS, breast cancer, and HAART therapy, restricted to English language. There were mostly case reports and one large series of 20 cases reported by Hurley et al. Data concerning the impact of HIV infection and HAART therapy regarding pathogenesis, stage at presentation, tumor type, response, and toxicity associated with treatment were reviewed. The literature review shows that the breast cancer incidence is either same or less in HIV‐infected patients compared to the general population. However, the patients with HIV infection present with more advanced stage and aggressive disease, and they also have poor chemotherapy tolerance. The impact of HAART on breast cancer incidence in HIV‐infected patients is still unclear.

Argatroban in heparin-induced thrombocytopenia: rationale for use and place in therapy

Heparin-induced thrombocytopenia (HIT) is a recognized complication of heparin and requires urgent detection and treatment. HIT can be divided into two types, type I and type II, with type I being a transient decrease in platelet count without clinical consequence. For the purpose of this review, the term HIT refers to the immune-mediated type II that causes paradoxical thrombo-emboli. The aim of this review is to familiarize clinicians with a specific direct thrombin inhibitor, argatroban, in the treatment of HIT. Argatroban has been successfully employed in treating HIT in many different subsets of patients, including those with endstage renal disease on hemodialysis and in patients undergoing percutaneous coronary intervention and those with multiorgan dysfunction syndrome.

Primary Small Cell Carcinoma of the Tongue

The vast majority of small cell carcinoma develops from the lung and only about 2.5% of small cell cancer arises in extra pulmonary sites [1]. The extra pulmonary small cell carcinoma is recognized as a clinicopathological entity distinct from small cell carcinoma of lung; however it is still often confused with metastatic small cell lung cancer [2]. The most commonly reported extra pulmonary sites with small cell carcinoma are aero-digestive tract including nasal cavity, para nasal sinuses, salivary glands, larynx, trachea and thyroid gland [3]. It has also been rarely found in breast, urinary bladder, prostate gland, ovaries and cervix. The extra pulmonary small cell lung cancer shares the same histopathological features as small cell lung cancer and is also chemotherapy sensitive. The Extra pulmonary small cell lung cancer is more aggressive and typically demonstrates a poorer prognosis [4].

Pilot study on the occurrence of multiple cancers following cancer-related therapy at the University of Florida, Jacksonville (2011–2016)

New primary cancers can occur in patients with a previous cancer. Among the risk factors, therapies such as chemotherapy, radiotherapy, and hormonal therapy have been associated with the development of neoplasms. Second cancers most commonly develop 5–10 years after the initial tumor. We observe the implications of cancer-related therapy in the development of a new tumor. We looked at 602 patients who had their first cancer diagnosed in 2011 and calculated the number of different primary cancers between 2011 and 2016 for each patient. Twenty-four patients had a second cancer within 5 years from the first diagnosis and there were no patients with a third cancer. There was no statically significant difference in the rates of second cancers after exposure to chemotherapy, radiotherapy, hormonal therapy, or any combination of these (p=0.738). Of the second cancers reported after 2011, renal, uterine, cervical, and lung cancers were the most frequently reported. Additionally, there was no statically significant difference among the rates of second cancers in men versus women (p=0.467), as well as among whites versus blacks (p=0.318). We conclude that while new primaries can occur after one cancer, there was no increased risk after exposure to different cancer-related therapies. With increased focus on the primary disease, there is a higher likelihood of missing another primary lesion. This is important as the practical implications of managing multiple primaries are rarely discussed.

Flashes of light and floaters: an unusual presentation of urothelial carcinoma

A 59-year-old Caucasian woman with multiple sclerosis presented with blurred vision in the right eye, floaters and flashes of light for 2 weeks. She had right-sided optic neuritis which was treated 8 years prior. There was a 20 pack-year smoking history. Examination was remarkable for right-sided temporal field loss and a palpable breast lump. Ophthalmological examination revealed right exudative retinal detachment, with ultrasonography demonstrating a choroidal mass with medium to high internal reflectivity. MRI was significant for a 14 mm intraocular metastasis (figure 1). On further questioning, the patient described haematuria. Urine cytology demonstrated large cells with high nuclear to cytoplasmic ratio, irregular nuclear borders …

An Aggressive Form of Langerhan Cell Histiocytosis in an Adult: Therapeutic Challenges

Langerhans cell histiocytosis (LCH) is rare in adults. Regular follow-up is mandatory due to reoccurrence. A 35-year-old male with an incidental left iliac bone lesion was diagnosed with LCH. He later became symptomatic with hip pain and spread of the disease. Despite excision of the symptomatic iliac lesion, he had progression while on cytarabine and nivolumab, evidenced by increased bone pain and involvement of other bones on imaging. He underwent excision of the jaw lesion followed by vinblastine; he was pain free and had stable disease on PET imaging after 3 months. LCH is an uncommon neoplasia. Treatment is reserved for symptomatic patients while asymptomatic patients are observed. Follow-up is imperative due to the risk of reoccurrence. Despite surgical treatment together with one of the front-line agents for refractory disease, in this case cytarabine, he still had progression of the disease. Furthermore, the trial of nivolumab was of no benefit. This case highlights good response to vinblastine which is previously reported to have good success. No trials are published, and the optimal strategy has yet to be defined. LCH with multiple bony involvement can be aggressive and therapeutically challenging.

Isolated Right Testicular PAN (Polyarthritis Nodosa) presenting as Right Testicular Pain

Patient is a 30 year old male with no significant past medical history who repeatedly sought medical attention for debilitating right testicular pain. Initially he was symptomatically treated with non-steroidal anti-inflammatory medications for presumptive diagnosis of testicular trauma. A few months later he went to different emergency department and was treated with antibiotics for presumptive diagnosis of epididymitis. Finally at his third presentation he was hospitalized. Three testicular biopsies were taken and only the biopsy sample from the middle area of the right testes revealed polyarthritis nodosa. The Patient had no other signs and symptoms and this was likely isolated PAN of his right testes which is a very rare occurrence.