Margaret T. Mandelson

Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer.

BACKGROUND Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma. OBJECTIVE To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer. DESIGN Retrospective study. SETTING Single tertiary hospital. PATIENTS A total of 292 patients with malignant GOO. INTERVENTION Stent placement. MAIN OUTCOME MEASUREMENTS Post-stent placement survival and clinical outcome. RESULTS In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post-stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post-stent placement chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P < .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009). LIMITATIONS Retrospective study. CONCLUSIONS In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post-stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups.

Rare long-term survivors of pancreatic adenocarcinoma without curative resection

Long-term outcome data in pancreatic adenocarcinoma are predominantly based on surgical series, as resection is currently considered essential for long-term survival. In contrast, five-year survival in non-resected patients has rarely been reported. In this report, we examined the incidence and natural history of ≥ 5-year survivors with non-resected pancreatic adenocarcinoma. All patients with pancreatic adenocarcinoma who received oncologic therapy alone without surgery at our institution between 1995 and 2009 were identified. Non-resected ≥ 5-year survivors represented 2% (11/544) of all non-resected patients undergoing treatment for pancreatic adenocarcinoma, and 11% (11/98) of ≥ 5-year survivors. Nine patients had localized tumor and 2 metastatic disease at initial diagnosis. Disease progression occurred in 6 patients, and the local tumor bed was the most common site of progression. Six patients suffered from significant morbidities including recurrent cholangitis, second malignancy, malnutrition and bowel perforation. A rare subset of patients with pancreatic cancer achieve long-term survival without resection. Despite prolonged survival, morbidities unrelated to the primary cancer were frequently encountered and a close follow-up is warranted in these patients. Factors such as tumor biology and host immunity may play a key role in disease progression and survival.

Utility of Left Ventricular Ejection Fraction Measurements Before the Administration of Doxorubicin-Based Chemotherapy in Patients With Diffuse Large B-Cell Lymphoma

Objective To determine the utility of routine measurements of left ventricular ejection fraction (LVEF) before the administration of doxorubicin-based chemotherapy (DOX) in patients with diffuse large B-cell lymphoma (DLBCL). Patients and Methods We investigated the frequency of LVEF measurements before the initiation of therapy in 291 patients with DLBCL at our institution from January 1, 2001, through December 31, 2013, and reviewed whether LVEF varied in patients with an underlying risk of cardiac disease (CD), the relationship between LVEF and subsequent DLBCL treatment, and congestive heart failure (CHF) occurrence in DOX-treated patients. Results Left ventricular ejection fraction was measured in 258 patients before the administration of chemotherapy and was not associated with underlying CHF risk (P=.94). Left ventricular ejection fraction was normal in 243 patients (94%) and low in 15 patients. Doxorubicin-based chemotherapy was administered to 206 patients with normal LVEF (85%) vs 8 patients with low LVEF (53%) (P=.006). However, when previous CD was factored out, LVEF did not influence subsequent treatment decisions (P=.51). Congestive heart failure occurred in 18 patients, and the risk was similar in patients treated with and without DOX. For all patients who had LVEF measured, CHF incidence did not differ between patients who received DOX and those who did not (P>.99). Moreover, there was no difference in CHF incidence after receiving DOX between those who had normal and low LVEF results (P=.45). Conclusion The decision to administer DOX was influenced by LVEF status only when previous CD was factored out. Furthermore, CHF incidence posttreatment did not differ between patients who did and did not receive DOX. These preliminary findings challenge the practice of performing cardiac screening before DOX for patients with DLBCL.

Utility of Bone Marrow Biopsy and Aspirate for Staging of Diffuse Large B Cell Lymphoma in the Era of Positron Emission Tomography With 2-Deoxy-2-[Fluorine-18]fluoro-deoxyglucose Integrated With Computed Tomography

Micro‐Abstract In clinical practice, routine bone marrow aspirate/biopsy (BMAB) may no longer be necessary for all patients with diffuse large B cell lymphoma (DLBCL) who are staged by positron emission tomography combined with computed tomography (PET‐CT), unless the results would change both staging and therapy. The prognostic implication of BMI identified by PET‐CT compared with BMAB remains unknown. Whether a PET‐CT precludes the need for a BMAB in patients with DLBCL remains to be evaluated in a prospective study. Background: About one‐third of patients with diffuse large B cell lymphoma (DLBCL) have lymphomatous bone marrow involvement (BMI) at the time of diagnosis, and bone marrow aspirate/biopsy (BMAB) is considered the gold standard to detect such involvement. [18F] fluorodeoxyglucose positron emission tomography combined with computed tomography (PET‐CT), has become standard pretreatment imaging in DLBCL and may be a noninvasive alternative to BMAB to ascertain BMI. Prior studies have suggested that PET‐CT scan may obviate the need for BMAB as a component for staging patients with newly diagnosed DLBCL, but this is not yet a standard of practice. The aim of this retrospective study was to determine the accuracy of PET‐CT in detecting BMI in DLBCL and to define 2‐year and 5‐year overall survival based on BMI by BMAB versus PET‐CT. Methods: We reviewed institutional records of all patients with newly diagnosed DLBCL between January 2004 and December 2013 who underwent pretreatment PET‐CT and BMAB. PET‐CT images were visually assessed for BMI, including the posterior iliac crest. Patients with primary mediastinal DLBCL, previous history or coexistence of another lymphoma subtype, and those with a nondiagnostic BMAB, and in whom the PET‐CT did not show marrow signal abnormality, were excluded from the analysis. Ann Arbor stage was determined using PET‐CT with and without the contribution of BMAB, and the proportion of stage IV cases by each method was measured. Results: Among 99 eligible patients, the median age was 62 years (range, 24‐88 years), 62 (63%) were male, 53 (53%) had elevated serum lactate dehydrogenase, and 17 (16%) had an Eastern Community Oncology Group performance status of > 2. Thirteen (12%) patients had more than 1 extra‐nodal site of lymphoma involvement. Revised International Prognostic Index score was 1 in 39 (37%) patients, 2 in 42 (40%) patients, 3 in 20 (19%) patients, and 4 in 4 (4%) patients. A total of 38 (36%) patients had BMI established by either PET‐CT (n = 24; 24%), BMAB (n = 14; 14%), or by both modalities (n = 12; 12%). Twelve (50%) of the 24 patients with positive PET‐CT had BMI by DLBCL, whereas only 2 (3%) of the 75 patients with negative PET‐CT showed BMI. BMAB upstaged 1 (2%) of the 53 stage I/II patients to stage IV. The sensitivity and specificity of PET‐CT scan to detect BMI by DLBCL was 86% (95% confidence interval, 51.9%‐95.7%) and 87% (95% confidence interval, 76%‐92%), respectively. Eighty‐five (86%) patients had concordant results between lymphomatous BMAB and PET‐CT (12 patients were positive for both; 73 patients were negative for both), and 14 (14%) patients had a discordant interpretation (2 patients were positive by BMAB and negative by PET‐CT, and 12 patients were negative by BMAB and positive by PET‐CT). The positive predictive value of PET‐CT was only 50%, whereas the negative predictive value was 98%. The accuracy of PET‐CT was 86%. Although patients with positive BMAB had inferior 5‐year overall survival estimates compared with those with negative BMAB (66% vs. 85%; P = .08), no such difference was demonstrated between PET‐CT‐positive and PET‐CT‐negative patients (79% vs. 83%; P = .30). Conclusions: In patients with newly diagnosed DLBCL, PET‐CT is accurate in detecting BMI by DLBCL. Although PET‐CT has a very high negative predictive value for BMI, it overestimates the number of cases with marrow involvement by DLBCL. In clinical practice, routine BMAB may no longer be necessary for all patients with DLBCL who are staged by PET‐CT, unless the results would change both staging and therapy. The prognostic implication of BMI identified by PET‐CT compared with BMAB remains unknown. Whether a PET‐CT precludes the need for a BMAB in patients with DLBCL remains to be evaluated in a prospective study.

Adenoma Prevalence in Blacks and Whites Having Equal Adherence To Screening Colonoscopy: The National Colonoscopy Study

Is the higher reported colorectal cancer (CRC) mortality in blacks versus whites in the United States due to pathology or disparities in screening? Our study used patient navigation (PN) to assist blacks and whites adhere to screening colonoscopy and compared adenomas detected in each group.