S. Subbiah

Effect of palliative care services on the aggressiveness of end-of-life care in the Veteran's Affairs cancer population.

BACKGROUND Cancer care near the end of life (EOL) has become more aggressive over the years. Palliative care services (PCS) may decrease this aggressive cancer care in terminally ill cancer patients. Our objective was to observe the aggressiveness of cancer care near the EOL among Veterans Affairs cancer patients before and after the institution of a PCS team. We also assessed the time taken prior to death to initiate a PCS consultation and its effect on the aggressiveness of cancer care near the EOL. METHODS This is a retrospective chart review analysis performed at the local Veterans Affairs hospital looking at the last 100 patients in each of the years, 2002 and 2008, who died with active cancer. Only patients in 2008 had access to a PCS team. RESULTS In the last 30 days of life, compared to 2002, patients in 2008 had a higher incidence of: chemotherapy administration, more than one hospital admission, more than 14 days of hospital stay, intensive care unit admissions, and in-hospital deaths. Patients with timely PCS consults in 2008 appeared to have a lower incidence of: chemotherapy administration, more than one emergency department visit, more than one hospital admission, more than 14-day hospital stays, intensive care unit admissions, and deaths in the hospital. Timely PCS consults were associated with earlier and more frequent hospice referral. CONCLUSIONS Cancer care near the EOL has become more aggressive with time at one of the hospitals in the Veterans Affairs healthcare system (VAHS). Institution of a PCS service was unable to completely decrease this trend of increasing aggressiveness of cancer care near the EOL. However, timely PCS consults may help attenuate this aggressiveness.

Clinicopathological features and survival outcomes of primary signet ring cell and mucinous adenocarcinoma of colon: retrospective analysis of VACCR database.

BACKGROUND Signet ring cell carcinoma (SRCC) accounts for less than 1% of all colon cancers. We examined the clinicopathological features and prognosis of signet ring cell and mucinous adenocarcinoma (MCC) of colon. METHODS A total of 206 patients diagnosed with SRCC from 1995 to 2009 were identified from the VA Central Cancer Registry (VACCR) database. Age, race, histology, grade, lymph node status, stage and type of treatment received data were collected. RESULTS Out of 206 patients, 173 (84%) were white, 31 (15%) were black, and 2 patients were listed as unknown. Median age of diagnosis was 67 years as compared to 70 years for both mucinous cell (MCC) and non-mucinous adenocarcinoma (NMCC) of colon. Pathological T-stages were as follows: T1 =3%, T2 =5%, T3 =34%, T4 =26%, and unknown 32%. Of the total, 22.3% were located in cecum, 7.7% in appendix, 21.8% in ascending colon, 7.7% in hepatic flexure of colon, 11% in transverse colon, 2.9% in splenic flexure 4.4% in descending colon, and 15.5% in sigmoid colon. 46.5% were lymph node positive, 21% were lymph node negative, and 32.5% were unknown. SRCC were in general poorly differentiated tumors (57%), small proportion of patients included were well-differentiated tumors with focal signet ring cell pathology (10%) and in 33% grade was unknown. Among stage 3 patients, 34% patients received only surgery while 64% received surgery with adjuvant chemotherapy and 2% received chemotherapy alone. The stage specific 5-year survivals for SRCC, MCC and NMCC were--Stage I: 100%, 61%, and 41% respectively (P<0.0001); Stage II: 42%, 58% and 32% respectively (P<0.0001); Stage III: 19%, 41% and 47% respectively (P=0.0002); Stage IV: 1.5%, 7% and 31% respectively (P<0.0001). Median survival of SRCC compared to NMCC was 18.6 vs. 46 months (P<0.0001) and mucinous cell adenocarcinoma versus NMCC was 47.8 and 46 months (P=0.63) respectively. CONCLUSIONS SRCC of colon has poor survival rates compared to other histological subtypes. SRCC presents at an earlier age, has higher tumor grade and advanced stage at diagnosis when compared to mucinous and NMCC of colon. Due to rarity of this disease further prospective multi-institute studies are required for in-depth understanding of this disease.

Clinicopathologic factors associated with lymph node retrieval in resectable colon cancer: A veterans' affairs central cancer registry (VACCR) database analysis

A long‐term determinant of survival in resectable colon cancer is the involvement of regional lymph nodes. We evaluated the clinicopathologic factors associated with lymph node retrieval.

Assessment of prognostic factors after primary tumor resection in metastatic colon cancer patients: A Veteran's Affairs Central Cancer Registry (VACCR) analysis, 1995–2008

Resection of the primary tumor in metastatic colon cancer may occur for palliation of bleeding or obstruction despite distant metastases. This study evaluates clinicopathologic features that serve as prognostic markers in those patients with stage IV colon cancer who undergo resection of their primary tumor.

Apparent heparin resistance in a patient with infective endocarditis secondary to elevated factor VIII levels.

Heparin resistance (HR) is defined as increasing requirements of heparin to maintain a therapeutic activated partial thromboplastin time (aPTT). It is commonly associated with antithrombin deficiency, increased heparin clearance and elevations in heparin binding proteins. Elevated factor VIII levels can cause decrease the aPTT levels (anticoagulant effect) without disturbing heparin activity measured by anti-Xa assay (antithrombotic effect) leading to an apparent heparin resistant state rather than a true heparin resistance. We highlight the importance of increasing awareness of apparent HR and early distinction from true resistance to avoid major life threatening hemorrhagic complications. We hereby report an unusual case of heparin resistance due to increased factor VIII levels in an elderly male with infective endocarditis.

Effect of Surgical Intervention on Survival of Patients With Clinical N2 Non-Small Cell Lung Cancer: A Veterans' Affairs Central Cancer Registry (VACCR) Database Analysis.

Background:Optimal management of locally advanced non–small cell lung cancer (NSCLC) lacks consensus. A retrospective analysis of patient data entered in the Veterans Affairs Central Cancer Registry was conducted to evaluate these issues. Patients and Methods:Data of patients with cT1-4, cN2, and cM0 NSCLC diagnosed in the VA Health System between 1995 and 2003 were evaluated. Age, sex, race, smoking history, TNM stage, treatment, and overall survival were abstracted. Survival was compared using multivariate Cox proportional hazards regression analysis. Results:Of the 7328 patients analyzed, 7218 (98.5%) were male, 6061 (82.7%) were white, and 321 (4.4%) were never smokers. The treatment received included: none, 23.8%; chemotherapy alone, 14.3%; radiation alone, 23%; and chemoradiation (sequential or concurrent), 31.4%. Only 7.5% of patients had a surgical resection, with or without multimodality therapy. The median survival (months) of these patient groups were: surgery, 19.3; chemoradiation, 13; chemotherapy alone, 9.2; radiation alone, 7.3; and no treatment, 4 (P<0.0001). African Americans had a significantly decreased risk of mortality compared with whites (hazard ratio 0.92; 95% confidence interval, 0.87-0.98). Conclusions:Inclusion of surgical resection as a treatment modality was associated with a better overall survival. Also, African Americans appeared to do better than whites. These hypothesis-generating findings should be useful in the ongoing pursuit of better treatment strategies for locally advanced NSCLC.

Spontaneous hemopericardium leading to cardiac tamponade in a patient with essential thrombocythemia.

Acute cardiac tamponade requires urgent diagnosis and treatment. Spontaneous hemopericardium leading to cardiac tamponade as an initial manifestation of essential thrombocythemia (ET) has never been reported in the literature. We report a case of a 72-year-old Caucasian female who presented with spontaneous hemopericardium and tamponade requiring emergent pericardiocentesis. The patient was subsequently diagnosed to have ET. ET is characterized by elevated platelet counts that can lead to thrombosis but paradoxically it can also lead to a bleeding diathesis. Physicians should be aware of this complication so that timely life-saving measures can be taken if this complication arises.

Systemic amyloidosis masquerading as iron deficiency anemia

Amyloidosis is characterized by deposition of amyloid fibrils in tissues causing progressive dysfunction of the affected organs. There are six types: primary (AL), secondary (AA), hemodialysis-related, hereditary, senile, and localized. Primary (AL) amyloidosis is associated with monoclonal light chains in serum and/or urine with 15 % of patients having multiple myeloma. Although internists and gastroenterologists encounter malabsorption syndrome frequently, primary amyloidosis is often overlooked. We report a case of primary amyloidosis presenting as iron deficiency anemia and review the literature related to this disorder. A 44-year-old healthy male presented with intermittent rectal bleeding, watery diarrhea, steatorrhea, dizziness and 13.6 kg weight loss over a year. On admission he was afebrile, tachycardic and hypotensive. Physical examination was unremarkable except for mild epigastric tenderness and reduced bowel sounds. Laboratory data include hemoglobin level of 6.8 g/dL, mean corpuscular volume of 76 fL, serum iron of 11 μg/dL, and ferritin of 6 ng/mL suggestive of iron deficiency anemia. Peripheral smear revealed hypochromia, anisopoikilocytosis and microcytosis. Coagulation studies and other routine biochemical tests were within normal ranges. Esophagogastroduodenoscopy and colonoscopy showed mild gastritis along with small internal and external hemorrhoids. He received 1,000-mg intravenous iron sucrose therapy and was discharged on oral iron supplements. Then on he had several admissions over a year with hypotension, dehydration and severe anemia requiring blood transfusions. Despite extensive investigations including repeat colonoscopy with biopsy, capsule endoscopy, stool studies, urine 5-hydroxyindoleacetic acid levels (5-HIAA), fecal fat, hydrogen breath tests (X2), serum and urine protein electrophoresis (SPEP, UPEP), no obvious cause for blood loss was evident except that on one of the admissions he had hematuria and further evaluation revealed hemorrhagic cystitis. Subsequently he underwent bone marrow biopsy, which showed increased plasma cells with lambda staining being predominant. Since the patient had features of malabsorption associated with increased plasma cells in the bone marrow a review of his pathology from small intestine, colon and urinary bladder was done. It showed amyloid deposition confirmed by a positive Congo red stain in the tissue samples as shown in Figs. 1, 2. The patient was diagnosed with primary AL amyloidosis and was treated with thalidomide and dexamethasone. Amyloidosis encompasses a group of disorders characterized by extracellular deposition of insoluble small molecular weight fibrillary, proteinaceous material in various tissues of the body [1]. Gastrointestinal (GI) involvement is common in reactive amyloidosis (60 %) while it is less common in primary amyloidosis [2]. The most frequent sites of infiltration are the descending duodenum (100 %), the stomach and colorectum (more than 90 %), and the esophagus (about 70 %) [3]. Clinical diagnosis of gut amyloidosis has been difficult as most of the symptoms mimic other common diseases, like gastroparesis, gastric or duodenal ulcers, perforation, malabsorption, GI bleeding and intestinal pseudo-obstruction [4]. Histological examination is required for an accurate diagnosis, irrespective of the organ(s) involved. Apple-green birefringence (when viewed with crossed polarized light) and red staining (under white R. Thota (*) :W. Gonsalves : T. Tashi Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE 68131, USA e-mail: ramyathota1@gmail.com

Clinicopathologic features and survival outcomes of primary signet ring cell carcinoma of colon: Retrospective analysis of VACCR database.

e14097 Background: Signet ring cell carcinoma accounts for less than 1% of all colon cancers. We examined the clinical pathological features and prognosis of signet ring cell carcinoma of colon Methods: A total of 206 patients diagnosed with signet ring cell carcinoma from 1995 to 2009 were identified from the VA Central Cancer Registry (VACCR) database. Age, race, histology, grade, lymph node status, stage and type of treatment received data were collected. RESULTS Out of 206 patients, 173 (83.9%) were white, 31 (15%) were black, and 2 patients were listed as unknown. Median age of diagnosis was 67 years as compared to 70 years for both mucinous and non-mucinous adenocarcinoma of colon. Pathological T-stages were as follows: T1 = 2.9%, T2=5.3%, T3=33.9%, T4= 25.7%, and unknown 32%. Of the total, 22.3% were located in caecum, 21.8% in ascending colon, 15.5% in sigmoid colon, 7.7% in appendix and hepatic flexure of colon, 11.1% in transverse colon, 2.9% in splenic flexure and 4.4% in descending colon. 33.5% were lymph node positive, 34.6% were lymph node negative, and 31.8% were unknown. Histological grade 3-(55.4%) was most commonly reported followed by grade 2 (7.3%), grade1 (2.5%), grade 4 (1.9%) and in 33% grade was unknown. 41.3% patients received only surgery while 34% received surgery with adjuvant chemotherapy, 7.3% received chemotherapy alone, 7.8% received radiation alone and 9% did not receive any therapy. 1 yr, 3 yr and 5 yr survivals for signet ring cell cancer compared to adeno carcinoma was 60% vs 80%, 33% vs 60%, and 24% vs 47% respectively. Median survival of signet ring cell carcinoma compared to mucinous and non mucinous adenocarcinoma was 19 mos, 48 mos and 67 mos respectively. CONCLUSIONS Signet ring cell carcinoma of colon has poor survival rates than other histological subtypes. Signet ring cell carcinoma presents at an earlier age, has higher tumor grade and advanced stage at diagnosis when compared to mucinous and non-mucinous adeno carcinoma of colon. Due to rarity of this disease further multi-institute studies are required for in-depth understanding of this disease.

Surgical outcomes of colorectal cancer in octogenarians: Survival analysis of the Veteran's Affairs population.

e14024 Background: Surgical resection of the primary tumor in the absence of metastatic disease is the treatment of choice for colorectal cancer. There is limited data evaluating surgical outcomes in the very elderly patients (≥80years). The purpose of this study was to evaluate surgical practice patterns and their effects on survival for patients ≥80 years of age. METHODS Retrospective analysis of 36,260 patients with colon cancer in the Veterans Affairs Central Cancer Registry between 1995 and 2009 was done. Demographic data, location of tumor, grade, stage, co-morbidities, therapy and survival data were extracted. RESULTS A total of 36,260 patients were identified with colon cancer and 5473 (15%) were octogenarians. Of the entire population, 97.3% were males, 82% were white and 16% were black. Among octogenarians, 4,111 (75%) received surgery while in the younger population, 25,166 (82%) received surgery. Median survival of patients who had surgery among the elderly compared to the younger population was 48 vs 99 mos (P<0.0001). Median survival was significantly higher among octogenarians who received surgery (50 vs 25 mos, P<0.001). The stage specific median survival with surgery among elderly compared to the younger population are stage 1-62 vs 143 mos (P<0.001), stage 2-53 vs 102 mos (P<0.001), stage 3-34 vs 63 mos (P<0.001). Elderly patients who received adjuvant chemotherapy had significantly better survival outcomes compared to those who did not receive adjuvant therapy (23 versus 64 mos). CONCLUSIONS Surgical resection rates and median overall survival are lower in octogenarians compared to their younger counterparts; however fit elderly patients do benefit from surgery and adjuvant therapy.