Nay Min Tun

Risk of having BRCA1 mutation in high-risk women with triple-negative breast cancer: a meta-analysis.

Testing for BRCA1 mutation has important clinical implications such as identifying risk of second primary cancers and risk of cancer in the family. This study seeks to quantify the risk of having BRCA1 mutation in female breast cancer patients with triple‐negative phenotype compared with those with other phenotypes. We undertook a search of MEDLINE and EMBASE databases for relevant studies through 10 May 2013. Outcomes were calculated and reported as risk ratio and risk difference. 12 studies comprising 2533 breast cancer patients were included in the analysis. It was found that almost all eligible studies were performed on high‐risk population with breast cancer. By analyzing the incidence rates of BRCA1 mutation in patients with triple‐negative breast cancer (TNBC) and non‐TNBC, our meta‐analysis provides a relative risk of 5.65 [95% confidence interval (CI), 4.15–7.69] and risk difference of 0.22 (95% CI, 0.15–0.29). This implies that, in selected population with high‐risk features, women with TNBC are approximately five and a half times more likely to have BRCA1 mutation compared with non‐TNBC phenotype, and approximately two in nine women with TNBC harbor BRCA1 mutation. Triple‐negative phenotype significantly increases the risk of having BRCA1 mutation in high‐risk breast cancer patients compared with non‐TNBC.

A rare case of intracerebral hemorrhage complicating heparin-induced thrombocytopenia with thrombosis: a clinical dilemma ameliorated by novel use of plasmapheresis

We report a case of heparin-induced thrombocytopenia with thrombosis type 2 (HITT 2) that was first complicated by intracerebral hemorrhage (ICH) and later by deep venous thrombosis (DVT). HITT 2 was initially managed conventionally with argatroban, which was stopped when ICH was discovered. The size of ICH increased despite attempts to increase platelet count by platelet transfusions. At this point of the clinical dilemma, plasma exchange was utilized effectively to recover the platelet count and deter ICH progression. The clinical course was later complicated by DVT, for which fondaparinux was given. This case represents a rare clinical scenario of HITT 2 resulting in progressive ICH that excluded the use of antithrombotic agents as part of HITT therapy. We believe that the use of plasmapheresis as a salvage procedure in such situations is effective and life-saving. Physicians should be aware of plasmapheresis as a therapeutic option in HITT 2 in cases in which anticoagulation is contraindicated.

A Rare Concurrence of Leiomyomatosis Peritonealis Disseminata, Leiomyosarcoma of the Pelvis and Leiomyomatous Nodule of the Liver

Leiomyomatosis peritonealis disseminata (LPD) is a rare entity that is characterized by the presence of multiple subperitoneal or peritoneal smooth muscle nodules throughout the peritoneal surface mimicking a malignant process. LPD follows a benign course in general, and it is often found incidentally during abdominal surgery. There have been reported cases of LPD with malignant degeneration although the association is uncertain. Concurrent finding of LPD and leiomyosarcoma of the pelvis is very rare that could be coincidental, malignant transformation of LPD to leiomyosarcoma, or progression of undetected primary leiomyosarcoma. There are only a few previously reported cases in the literature. Herein, we report a case of 56-year-old woman with a history of leiomyoma of uterus who presented with progressive abdominal swelling secondary to mass lesions in the pelvis. The patient underwent exploratory laparotomy and debulking of the tumors, and the histologic examination of the tumors revealed coexistence of LPD and leiomyosarcoma. After recovery from the operation, core needle biopsy of the superficial, residual liver mass was obtained to investigate potential liver metastasis, and the histopathologic findings are consistent with leiomyoma which represents the first simultaneous occurrence of LPD, leiomyosarcoma, and leiomyomatous nodule of the liver.

Benefit and risk of primary thromboprophylaxis in ambulatory patients with advanced pancreatic cancer receiving chemotherapy: A systematic review and meta-analysis of randomized controlled trials

As vascular thromboembolism (VTE) is a leading cause of death in cancer patients, it has been postulated that primary thromboprophylaxis (PTP) in cancer patients might improve survival by reducing VTE occurrence. We performed a systemic review and meta-analysis of randomized controlled trials (RCTs) to investigate the benefit and risk of PTP with low-molecular-weight heparins (LMWHs) in ambulatory advanced pancreatic cancer (APC) patients receiving chemotherapy. We undertook a literature search using MEDLINE and EMBASE databases through May 2015. RCTs with reduction in symptomatic VTE as a primary or secondary endpoints were included. Mantel–Haenszel method was used to estimate the pooled event-based risk ratio as well as the pooled absolute risk difference with 95% confidence interval (CI). Seven hundred and thirty-eight APC patients were eligible for analysis. PTP lasted 3–6 months. The crude VTE incidence was 2.1 and 11.2% in LMWH and in control groups, respectively (risk ratio, 0.18; 95% CI, 0.083–0.39; P < 0.0001). The absolute risk difference in VTE was −0.092 (95% CI, −0.127 to −0.057; P < 0.0001), with an estimated number needed to treat of 11 patients to prevent one symptomatic VTE event. The pooled risk ratio for major bleeding was 1.25 (95% CI, 0.48–3.3, P = 0.65). Although these findings are encouraging to deploy PTP in APC patients receiving chemotherapy, uncertainties remain as to its survival benefit, optimal PTP duration, type and dose of LMWH, and costs of care. Therefore, adequately powered randomized phase III studies are warranted to address these questions.

Lymphocytic Platelet Satellitism.

We read with interest the recent report of Indranil Chakrabarti on platelet satellitism around polymorphonuclear leucocytes [1]. Even though it is a rare event as noted by the author, over thirty cases of neutrophilic platelet satellitism have been reported in the literature. By contrast, platelet satellitism around lymphocytes has rarely been mentioned in the literature. Therefore, we would like to take this opportunity to report our recent finding of lymphocytic platelet satellitism. A 76-year-old Hispanic man was evaluated for mild relative monocytosis without any other hematologic abnormalities. Examination of the peripheral blood smear revealed platelets rosetting lymphocytes with some platelets seemingly within the cytoplasm of lymphocytes (emperipolesis, which refers to the presence of an intact cell within the cytoplasm of another cell) (Fig. 1). Neither platelet aggregates nor satellitism around neutrophils was seen (inset). Smears prepared from the finger-prick blood sample did not show platelet satellitism. His white blood cell count was 8.8 9 10/L, hemoglobin 13.6 g/dL, and platelet count 150 9 10/L. Because the finger-prick smear demonstrated clearance of platelet satellitism, we assumed that the phenomenon was solely related to the anticoagulant ethylenediaminetetraacetic acid (EDTA). Platelet count in heparin or sodium citrate container or antiplatelet antibodies were not performed. There have been previous reports of platelet satellitism around neoplastic lymphoid cells and large granular lymphocytes [2–4]. In our patient, small to medium-sized normal lymphocytes were involved in both platelet satellitism and possible emperipolesis. The underlying mechanism is likely related to EDTA, antiplatelet antibodies, and activation of platelets rich in thrombospondin or some other cytoadhesive platelet a-granule proteins.

A case of thrombotic thrombocytopenic purpura in late pregnancy

TO THE EDITOR: Thrombotic thrombocytopenic purpura (TTP) was first described by Eli Moschowitz about 90 years ago [1]. TTP is caused by a severe deficiency in the protein A disintegrin and metalloprotease with thrombospondin 1 motifs 13 (ADAMTS13), a metalloprotease that cleaves ultra-large von Willebrand factor (vWF) multimers [2]. Deficiency in this enzyme causes the accumulation of large vWF multimers, which increase platelet adhesiveness and impair fibrinolytic activity with subsequent thrombotic occlusion of the microvasculature. TTP is a rare and potentially life-threatening disorder. The incidence rate of suspected TTP-hemolytic uremic syndrome (TTP-HUS) in the general population is 11 cases per 1,000,000 people [3], compared to the estimated incidence of one in 25,000 deliveries [4]. The clinical features of TTP may resemble those of the more common pregnancy complications, such as preeclampsia or of hemolytic anemia, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, the management of TTP is completely different from that of preeclampsia/HELLP. Here, we present the case of a young woman who developed TTP in late gestation.

A predictable but life-threatening complication of hydroxyurea in a patient with sickle cell anaemia: an experience learned from a Jehovah's Witness.

It is well known that hydroxyurea can cause pancytopaenia secondary to bone marrow suppression, which is reversible with short-term discontinuation of the therapy. However, it is important to note that bone marrow suppressive effects caused by hydroxyurea could be easily potentiated in patients with sickle cell anaemia complicated by chronic kidney disease (CKD). We present a case of a Jehovahs Witness with sickle cell anaemia, who developed severe bone marrow suppression due to the combined effects of hydroxyurea and CKD, resulting in a prolonged recovery period after discontinuation of hydroxyurea.

Are we seeing more obese breast cancer patients in Brooklyn

182 Background: Breast cancer is the most common female cancer in the US and the second most common cause of cancer death in women. Obesity has become a significant health challenge. The prevalence of obesity among non-Hispanic black women is reported to be approximately 50% with a prevalence of Class lll obesity of 5.2%. The objective of this study was to evaluate the severity of obesity in female breast cancer patients at our facility over the last three years. METHODS A retrospective study was conducted on 191 patients treated between January 2008 and December 2010 for breast cancer. Prevalence of obesity by class (Class I = BMI from 30 to 34.99 kg/m2, Class II = BMI from 35 to 39.99 kg/m2, Class IIl= BMI greater than 39.99 kg/m2) was calculated. Pearson chi-square statistic was used to investigate the relation between classes of obesity and stages of breast cancer (early stage = CIS to stage 2, advanced stage = stage 3 and 4). RESULTS Data from 191 breast cancer patients with BMI of 30 or more were analyzed. Class I constituted 39.3%, Class II 34% and class III 26.7%. The majority (75.9%) were diagnosed at an early stage, 24.1% diagnosed with advanced stage. Severity of obesity was not associated with the stage of breast cancer at diagnosis (c2= 0.004, df = 2, n = 191, p > 0.5). African American women constituted the majority (78.5%) of our study population. CONCLUSIONS Our study reveals an alarming rate of class lll obesity among our breast cancer patients. It does not show a correlation among obesity and stage of disease, The majority of patients have early stage, potentially curable breast cancer. Given the fact that obesity has been associated with an increase in mortality (cardiovascular mortality is 50% greater in obese people and 90% greater in severely obese persons in comparison with that for people of average weight) our study suggests that treatment of obesity may play an equally important role in achieving long term outcomes as treatment of breast cancer itself.