Ping-Ying Chang

Diffuse large B-cell lymphoma: sites of extranodal involvement are a stronger prognostic indicator than number of extranodal sites in the rituximab era.

Abstract The National Comprehensive Cancer Network (NCCN) International Prognostic Index (IPI) is an enhanced prognostic tool that has identified some specific extranodal sites as a poor prognostic factor. We retrospectively analyzed 148 Taiwanese patients with newly diagnosed diffuse large B-cell lymphoma receiving rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP)-like regimens from January 2001 to December 2010 at the Tri-Service General Hospital. In univarate analysis, ≥ 2 extranodal involved sites had no significant prognostic relevance (p = 0.108), although extranodal involvement of the lung/pleura, liver, lower urinary tract or bone marrow was a statistically significant poor prognostic factor (p < 0.001). In multivariate analysis, specific extranodal sites had a stronger predictive value for poor prognosis (relative risk 3.654, 95% confidence interval 1.514–8.815, p = 0.004) compared with the number of extranodal sites involved. This finding suggests that specific extranodal involved sites have prognostic value in the R era.

Stage III Colon Cancer: The Individualized Strategy of Adjuvant Chemotherapy for Aged Under and Over 70.

Background The aim of this study was to examine the specific chemoregimens selected for adjuvant therapy in the patients with stage III colon cancer. We investigated the trends in chemotherapeutic prescribing patterns and looked for adequate therapeutic setting for these patients. Methods 288 patients presenting with stage III colon cancer and undergoing adjuvant therapies after curative surgery for more than 3-month were enrolled between January 2006 and December 2011. Demographic characteristics and therapeutic factors were analyzed, including age, gender, histological grade, tumor sizes, tumor location, pathologic stage, performance status, serum carcinoembryonic antigen, regimens selection, interval from the operation to the start of adjuvant therapy and prolonged adjuvant therapy. Kaplan– Meier methods were utilized for drawing survival curves and Cox model was used to analyze survival, prognostic factors. Results The analysis showed that the patients aged under 70 received more intensive therapies than those aged over 70 (P<0.001). Later, advanced analysis in therapeutic factors was conducted between the patients aged under 70 and those over 70. In the patients aged under 70, significant differences in 4-year overall survival (OS) were noted between UFUR (oral tegafur-uracil plus leucovorin) groups and FOLFOX (5-FU plus oxaliplatin) [65.6% versus (vs) 89.8%, relative risk (RR) 3.780, 95% confidence interval (CI) 1.263–11.315, P = 0.017]. There were also differences in 4-year OS between these patients with and without oxaliplatin-contained regimens (92.1% vs 83.4%, respectively, RR 0.385, 95% CI 0.157–0.946, P = 0.037). In addition, the patients who received intravenous or combined therapy also had higher 4-year OS than those only received oral regimens (92.1% vs 76.6%, P = 0.077), though the finding did not reach statistical significance. In contrast to the survival benefits of above therapeutic settings for the patients aged under 70, there was less advantage in the old patients when they received intensive therapies or even oxaliplatin-contained regimens. Prolonged cycles of adjuvant therapy resulted in no significant benefit to survival rates regardless of ages. Conclusions The adequate individualized therapeutic strategy plays an important role for stage III colon cancer. Our findings suggested that benefit of oxaliplatin-contained therapy is limited to patients aged under 70 and oral fluoropyrimidines may be an effective option for old patients. In addition, prolonged adjuvant setting is suggested to be unbeneficial for managing stage III colon cancer.

Retroperitoneal metastatic adenocarcinoma complicated with necrotizing fasciitis of the thigh in a patient with advanced rectal colon cancer.

Background: Necrotizing fasciitis of the thigh due to colon cancer has not been previously reported, especially during radiotherapy. Case Presentation: A 73-year-old woman admitted to our hospital was diagnosed with sigmoid colon cancer that had spread to the left psoas muscle; radiotherapy was performed. Three months after the initiation of radiotherapy, the patient developed gait disturbance, poor appetite and high fever and was therefore admitted to the emergency department of our hospital. Blood examination revealed generalized inflammation with a high white blood cell count and C-reactive protein level. Computed tomography of the abdomen revealed fluid and gas tracking from the retroperitoneum into the intramuscular plane of the grossly enlarged right thigh. Consequently, emergent debridement was not performed and conservative therapy was done. The patient died. Conclusion: Necrotizing fasciitis of the thigh due to the spread of rectal colon cancer is unusual, but this fatal complication should be considered during radiotherapy in patients with unresectable colorectal cancer.

Prognostic Significance of Initial Serum Albumin and 24 Hour Daily Protein Excretion before Treatment in Multiple Myeloma.

Renal failure is a common morbidity in multiple myeloma (MM). Although proteinuria has been increasingly reported in malignancies, it is not routinely used to refine risk estimates of survival outcomes in patients with MM. Here we aimed to investigate initial serum albumin and 24-hour daily protein excretion (24-h DPE) before treatment as prognostic factors in patients with MM. We conducted a retrospective analysis of 102 patients with myeloma who were ineligible for haematopoietic stem cell transplantation between October 2000 and December 2012. Initial proteinuria was assessed before treatment by quantitative analysis of 24-hour urine samples. The demographic and laboratory characteristics, survival outcome, and significance of pre-treatment 24-h DPE and albumin in the new staging system of MM were analyzed. Pre-treatment proteinuria (>300 mg/day) was present in 66 patients (64.7%). The optimal cut-off value of 24-h DPE before treatment was 500 mg/day. Analysis of the time-dependent area under the curve showed that the serum albumin and 24-h DPE before treatment were better than 24-h creatinine clearance rate and β2-microglobulin. A subgroup analysis showed that an initial excess proteinuria (24-h DPE ≥ 500 mg) was associated with poor survival status (17.51 vs. 34.24 months, p = 0.002). Furthermore, initial serum albumin was an independent risk factor on multivariate analysis (<2.8 vs. ≥2.8, hazard ratio = 0.486, p = 0.029). Using the A-DPE staging system, there was a significant survival difference among patients with stage I, II, and III MM (p < 0.001). Initial serum albumin and 24-h DPE before treatment showed significant prognostic factors in patients with MM, and the new A-DPE staging system may be utilized instead of the International Staging System. Its efficacy should be evaluated by further large prospective studies.

Interferon-alpha caused reversible parkinsonism.

Interferon has been used to treat chronic viral hepatitis and several malignancies. However, it may cause various neuropsychiatric adverse effects including parkinsonism. We report a rare case of interferon alpha-2a therapy-related parkinsonism in a 67-year-old man with metastatic papillary renal cell carcinoma and our experience of using Tc-99m-TRODAT-1 single photon emission computed tomography (SPECT) as a tool for evaluation of parkinsonism. Physicians should be alert to the possibility of interferon alpha-2a-related parkinsonism.

Efficacy of Modified Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer: A Single Institution Experience in Taiwan

Background: Neoadjuvant chemoradiotherapy (NCRT) followed by total mesorectal excision is now recommended for patients with locally advanced rectal cancer (LARC). This retrospective study was aimed to analyze the treatment efficacy in LARC patients in a single institute. Materials and Methods: Rectal cancer patients with clinically T3, T4, or nodal positive (N1-2) diseases who received either NCRT or adjuvant chemoradiotherapy (ACRT) were retrospectively enrolled between 2007 and 2011. The treatment outcome and clinical characteristics of study population were compared. Results: There were 176 patients been enrolled with a mean age of 63.1 years. Totally, 123 (69.9%) patients received NCRT and 53 (30.1%) patients received ACRT, respectively. The median duration of follow-up was 43.3 months in NCRT group and 47.6 months in ACRT group. There was no significant difference about overall survival (OS), progression-free survival (PFS), and local relapse-free survival (LRFS) between two treatment groups. However, NCRT achieved pathological complete remission (pCR) of 27.6%. In addition, the patients with pathologically downstage after NCRT (the responders) had significantly better PFS (P ＜ 0.0001), local RFS (P=0.0468), and OS (P=0.0045), compared with non-responder after NCRT. Oxaliplatin-based NCRT did not significantly increase treatment response, OS and PFS, compared with other regimens in our analysis (P=0.29). Conclusions: In our cohort, NCRT achieved high pCR rate than those reported in previous literature. Although there was no significant improvement of OS, PFS, and LRFS in NCRT group, there was a significant improvement of LRFS, OS, and PFS in those responders after NCRT.

Delirium as the Abrupt Manifestation of Severe Anaphylactic Reaction to Oxaliplatin

Hypersensitivity reactions to oxaliplatin, either immediate or delayed-type, has been reported. It may occur in each cycle of infusion but is most common in the 7(superscript th) to 9(superscript th) cycles. Most patients develop allergic events like bronchospasm, rash, angioedema, tachycardia, hypotension, and fever during or just after oxaliplatin infusion. Herein, we report a heavily pretreated colon cancer patient who presented with skin rash and tachycardia after the 7(superscript th) infusion of oxaliplatin. During the next infusion two weeks later, similar symptoms occurred again, accompanied with acute anaphylactic reaction presenting as delirium. Diphenhydramine and anti-inflammatory medication were given promptly, and the patient’s consciousness was regained without any sequela. Oxaliplatin therefore needed to be withheld, and the patients treatment shifted to another regimen. Infusion-related allergic reaction is rare, but it can be a fatal event. To our knowledge, this is the first presented case with delirium as the first sign of anaphylactic reaction after oxaliplatin infusion. Prompt diagnosis with adequate resuscitation is important. Repeated infusion should be given carefully, and a desensitization protocol might be needed to avoid the same kind of allergic reaction.