Rachel Rosovsky

Implementing multiplexed genotyping of non-small-cell lung cancers into routine clinical practice

BACKGROUND Personalizing non-small-cell lung cancer (NSCLC) therapy toward oncogene addicted pathway inhibition is effective. Hence, the ability to determine a more comprehensive genotype for each case is becoming essential to optimal cancer care. METHODS We developed a multiplexed PCR-based assay (SNaPshot) to simultaneously identify >50 mutations in several key NSCLC genes. SNaPshot and FISH for ALK translocations were integrated into routine practice as Clinical Laboratory Improvement Amendments-certified tests. Here, we present analyses of the first 589 patients referred for genotyping. RESULTS Pathologic prescreening identified 552 (95%) tumors with sufficient tissue for SNaPshot; 51% had ≥1 mutation identified, most commonly in KRAS (24%), EGFR (13%), PIK3CA (4%) and translocations involving ALK (5%). Unanticipated mutations were observed at lower frequencies in IDH and β-catenin. We observed several associations between genotypes and clinical characteristics, including increased PIK3CA mutations in squamous cell cancers. Genotyping distinguished multiple primary cancers from metastatic disease and steered 78 (22%) of the 353 patients with advanced disease toward a genotype-directed targeted therapy. CONCLUSIONS Broad genotyping can be efficiently incorporated into an NSCLC clinic and has great utility in influencing treatment decisions and directing patients toward relevant clinical trials. As more targeted therapies are developed, such multiplexed molecular testing will become a standard part of practice.

PREDICTION AND PREVENTION OF THROMBOEMBOLIC EVENTS WITH ENOXAPARIN IN CANCER PATIENTS WITH ELEVATED TISSUE FACTOR-BEARING MICROPARTICLES: A RANDOMIZED-CONTROLLED PHASE II TRIAL (THE MICROTEC STUDY)

Elevated levels of circulating tissue factor‐bearing microparticles (TFMP) have been associated with an increased risk of developing venous thromboembolism (VTE) in cancer patients. We performed a randomized phase II study to evaluate the cumulative incidence of VTE in advanced cancer patients with lower levels of TFMP not receiving thromboprophylaxis and those with higher levels of circulating TFMP randomized to enoxaparin or observation. The cumulative incidence of VTE at 2 months in the higher TFMP group randomized to enoxaparin (N = 23) was 5·6% while the higher TFMP group observation arm (N = 11) was 27·3% (Gray test P = 0·06). The cumulative incidence of VTE in the low TFMP was 7·2% (N = 32). No major haemorrhages were observed in the enoxaparin arm. The median survival for patients with higher levels of TFMP followed by observation was 11·8 months compared with 17·8 months on enoxaparin (P = 0·58). In a prospective randomized trial, increased numbers of circulating TFMP detected by impedance flow cytometry identified cancer patients with a high incidence of VTE. Enoxaparin demonstrated a clear trend towards reducing the rate of VTE in patients with elevated levels of TFMP, with an overall rate of VTE similar in magnitude to the lower TFMP group.

What Is the Evidence for the Off-label Use of Recombinant Factor VIIa (rFVIIa) in the Acute Reversal of Warfarin?

A 47-year-old man presents with hypovolemic shock. He takes warfarin as a result of a mechanical mitral valve insertion 5 years prior, his INR at presentation is 8.4 and emergent CT reveals a very large retroperitoneal he-matoma. Despite aggressive fluid and transfusion support he continues hypotensive, requiring ionotrope support. You are asked if he should receive recombinant factor VIIa. To examine current best evidence of the effect of recombi-nant factor VIIa (rFVIIa) on the reversal of warfarin-induced coagulopathy, we performed a comprehensive computerized literature search of the OVID database using the terms This strategy provided 22 hits. There were 4 additional studies gleaned from the reference list of 2 of the articles. Twelve papers were excluded: 7 were review articles, 5-11 3 described effects of clotting factor concentrates or vitamin K and not rFVIIa, 12-14 1 compared the in vitro antifibrinolytic activity of prothrombin complex concentrates to rFVIIa, 15 and 1 was a case report of rFVIIa in a phenindione overdose. 16 Five case series, 5 case reports, 1 retrospective case-control, 1 retrospective chart review, and 1 database review were retrieved. There was also 1 study involving healthy volunteers that included a dose finding study followed by a randomized controlled trial. The randomized double-blind placebo controlled trial was a pharmacokinetic-pharmacodynamic study of 28 healthy volunteers given acenocoumarol followed by rFVIIa (doses ranging from 5 to 320 μg/kg). The dose finding aspect of the study revealed that a single dose of 5 μg/kg normalized the INR for 12 hours and doses >120 μg/kg normalized the INR for 24 hours. The placebo had no effect on the INR. 2 Eight of the retrieved reports involved patients experiencing warfarin-related central nervous system (CNS) bleeds. In one case series, rFVIIa was given to 7 patients with acute CNS bleeds with pretreatment INRs ranged from 1.7 to 6.6. Within 10 minutes of dosing at a range of 10 to 40 μg/kg, all INRs were less than 1.5. All but 1 patient had also received vitamin K and 3 had received fresh frozen plasma (FFP). 17 Another case series presented 7 patients with nontraumatic intracranial hemorrhages (ICH) who received dose ranges of 15 to 90 μg/kg. The INR decreased from a mean of 2.7 (range 1.6-5.6) to a mean of 1.1. All patients also received either or both FFP and vitamin K. 18 Two additional patients with subdural hematomas were described in an abstract. 1 A …

Evidence-Based Mini-Review: Should All Patients with Idiopathic Venous Thromboembolic Events Be Screened Extensively for Occult Malignancy?

Introduction A 52-year-old avid tennis player develops an idiopathic left lower extremity deep vein thrombosis. She has no medical problems except for hypertension. She is up to date with her age-specific cancer screening. She had a negative colonoscopy at age 50 and a recent mammogram and Pap smear with no concerning findings. She read that clots may be the first manifestation of cancer and she wonders if she needs an extensive workup to look for a hidden cancer.

Evidence-Based Guidelines—An Introduction

Recommendations in the form of clinical practice guidelines are increasingly common. Clinical guidelines are systematically developed statements designed to help administrators, practitioners and patients make decisions about appropriate health care for specific circumstances. In North America, guidelines developed by professional societies, government panels and cooperative groups are frequently used to measure quality, to allocate resources and to determine how health care dollars are spent. For clinicians, guidelines provide a summary of the relevant medical literature and offer assistance in deciding which diagnostic tests to order, which treatments to use for specific conditions, when to discharge patients from the hospital, and many other aspects of clinical practice.

An easily missed diagnosis: flank pain and nutcracker syndrome

A 27-year-old woman presented to her primary care doctors office with left flank pain. CT of the abdomen showed an isolated left renal vein thrombus. The clot was initially attributed to her oral contraceptive use; however, closer inspection of CT images revealed nutcracker phenomenon (compression of the renal vein between the superior mesenteric artery and abdominal aorta). Intravascular ultrasound imaging confirmed the diagnosis. Nutcracker syndrome is a rare condition, which if left untreated may cause damage to the left kidney. Although under diagnosed, there are several treatment options available ranging from simple surveillance to surgical resolution.

Endothelial stress products and coagulation markers in patients with multiple myeloma treated with lenalidomide plus dexamethasone: an observational study

In this prospective study of patients with relapsed or relapsed and refractory multiple myeloma (MM) treated with lenalidomide and dexamethasone, relationships between markers of endothelial stress and drug administration and incidence of venous thromboembolism (VTE) were assessed. Of 33 enrolled patients, laboratory and treatment data were available for 32 patients. Of these, 23 received pulsed dexamethasone (40 mg/day on days 1–4, 9–12 and 17–21 of each 28‐day cycle) and 9 received weekly dexamethasone (40 mg/day on days 1, 8, 15 and 21 of each cycle). The overall incidence of VTE was 9%. A decreasing trend in markers values was observed with intercellular adhesion molecule (P = 0·05), fibrinogen (P = 0·008), plasminogen activator inhibitor‐1 (P < 0·001), homocysteine (P = 0·002) and P–selectin (P < 0·001) during therapy. Compared with weekly dexamethasone, pulsed dexamethasone was associated with significantly greater variation in mean adjusted relative values of fibrinogen, P‐selectin and vascular endothelial growth factor (P < 0·001 for all comparisons), although there was no apparent association with VTE incidence. Lenalidomide plus dexamethasone affects endothelial stress marker levels in patients with advanced MM. The higher variation seen with pulsed dexamethasone suggests greater endothelial stress with this approach.

Case records of the Massachusetts General Hospital. Case 36-2013. A 38-year-old woman with anemia and thrombocytopenia.

Dr. Joanna Lopez (Medicine): A 38-year-old woman was admitted to this hospital because of anemia and thrombocytopenia. The patient had been well until approximately 3 months before admission, when fatigue, malaise, and light-headedness developed that she attributed to a viral illness. Three weeks before admission, fatigue worsened, and dyspnea on exertion, bruising on the legs, dark urine, and headache developed. She reported that she “felt like staying in a bed all day” and needed assistance with showering. Two days before admission, she went to another hospital. The physical examination was reportedly normal, as were the results of coagulation tests. Screening for antibodies to the human immunodeficiency virus (HIV) and a rapid plasma reagin test were negative; other test results are shown in Table 1. She was admitted to the other hospital. Examination of the peripheral-blood smear reportedly revealed normal morphologic features of the white cells, a reduced platelet count, spherocytes, and polychromatic red cells. A direct antiglobulin test (Coombs’ test) was positive, and warm-reacting and cold-reacting autoantibodies were reportedly present. Results of serum and urinary protein electrophoresis were normal. Glucocorticoids (methylprednisolone at a dose of 150 mg twice daily for 2 days, followed by prednisone at a dose of 70 mg twice daily) were administered, as were ondansetron and folate, but the patient’s condition did not improve (Table 1). Computed tomographic (CT) scans of the abdomen and pelvis, obtained after the intravenous administration of contrast material, were normal. On the second night, hypotension developed but improved after the intravenous administration of fluids. On the third day, the hematocrit was 16.8%. One unit of packed red cells was transfused, and pantoprazole was administered. The patient was transferred to this hospital because of difficulty finding additional red-cell units that were compatible with her antibody screen. On admission, the patient reported a weight loss of 2.3 kg during the previous week, intermittent blurred or double vision in both eyes, and for the previous 3 months, transient vesicular lesions on the thighs that resolved spontaneously Case 36-2013: A 38-Year-Old Woman with Anemia and Thrombocytopenia

Warfarin-Induced Skin Necrosis in a Patient with Heparin-Induced Thrombocytopenia: Two Diseases or One?

A 64-year-old woman with colon carcinoma presented with subsegmental pulmonary emboli. Platelet count on presentation was 598 ×109/l. The patient was anticoagulated with intravenous heparin. By hospital day 3, heparin was replaced with enoxaparin and warfarin. On hospital day 6, the patient developed a 20 × 15 cm area of necrotic skin on her left hip and a 1 × 3 cm area of necrosis on her right hip. By that time, her platelet count had fallen to 433 ×109/l. Three days later (hospital day 9), anticoagulation was switched from the combination of enoxaparin and warfarin to argatroban. Her platelet count reached a nadir of 82 ×109/l by the 12th hospital day. The areas of skin necrosis had never been sites of heparin injection. Heparin/platelet factor 4 antibody, sent on hospital day 9, returned positive and 14C-serotonin release assay was also positive. This case illustrates that processes underlying heparin-induced thrombocytopenia (HIT) may also underlie warfarin-induced skin necrosis. Skin necrosis may be the earliest manifestation of HIT and need not be accompanied by thrombocytopenia. This patient’s course illustrates that HIT should be considered in all patients presenting with skin necrosis while receiving anticoagulation with heparin or a combination of heparin and warfarin.

Genotyping Lung Cancer Is an Investment in the Future

TO THEEDITOR:Intheircost-effectivenessanalysisof ALKtesting and crizotinib treatment, Djalalov et al 1 put a price tag on this emerging standard of care to shed light on its sustainability in a world of rising health care costs and limited resources. 2 Although we favor prudent measures that decrease health care costs, we believe it is important to distinguish money wasted from money invested. We believe that detecting and treating ALK-positive lung cancer is part of a new paradigm that has significantly improved cancer care and, as such, deserves our investment and advocacy. It is especially challenging to assess proximal costs when the future payoff is immeasurable. This is such a fast-moving field that the single, static, Markov model that the authors used is already out of date. The authors observe that the major driver of cost effectiveness is drug price. 1 To foster cost effectiveness, they point out the need for increased drug effectiveness, cheaper molecular testing, and lower drugprices.Weagree.Fortunately,thesethreetrendsaretakingshape. Discoveryhasaccelerated,andtheUSFoodandDrugAdministration hasgrantedbreakthroughtherapydesignationstatustotwonewALK inhibitors, ceritinib (LDK378) and alectinib (RO5424802), with at least seven other ALK inhibitors in early-phase testing. 3,4 The efficacy observed in phase I studies of these new drugs, plus the favorable survival and dramatic quality-of-life improvement demonstrated in a recently published phase III study of crizotinib, 5 indicate that the utilityestimatesusedinthisinitialcostanalysisarealreadyoutofdate. It is our hope that competition in the marketplace and limits on exclusive production based on patent law will ultimately bring down the price of these drugs over time. Regarding molecular testing, we find the representation in the modelofidentifyingpatientswith ALK-positivelungcancerbyDjala