Samer Salah

Metastatectomy for extra-cranial extra-adrenal non-small cell lung cancer solitary metastases: Systematic review and analysis of reported cases

BACKGROUND Although patients with stage IV non-small cell lung cancer (NSCLC) have a poor prognosis, a subset of patients with solitary brain or adrenal metastasis have more favorable outcome following surgical resection. Nevertheless, the outcome and predictive factors for survival following metastatectomy for patients with other metastatic sites are not well defined. METHODS We performed a systematic review using PUBMED database for all articles which included patients with NSCLC and solitary metastasis to sites other than the adrenal gland or the brain who had undergone resection of their metastasis and definitive treatment of the primary lung cancer. Potential prognostic factors on survival including age, sex, histology, T and N stage of the primary tumor, synchronous vs. metachronous presentation, visceral vs. non-visceral metastasis and the use of perioperative chemotherapy were analyzed using multi-variable Cox proportional hazard model. RESULTS 62 cases were eligible for the analysis. The 5-year survival rate was 50% for the entire cohort. Mediastinal lymph node involvement was independently predictive of inferior outcome; 5-year survival rate 0% vs. 64% in favor of no involvement, p<0.001. Similarly, patients with intra-thoracic stage III disease had an inferior outcome compared to patients with stage II and stage I disease: 5-year survival rate 0% vs. 77% and 63%, respectively, p<0.001. Other factors have no effect on outcome. CONCLUSION Selected patients with distant metastatic NSCLC can achieve long term survival following metastatectomy and definitive treatment of the primary tumor. Mediastinal lymph node involvement is associated with poor prognosis.

Primary synovial sarcomas of the mediastinum: a systematic review and pooled analysis of the published literature.

Background. The aim of this systematic review is to attempt to provide a descriptive analysis for cases of synovial sarcoma (SS) arising in the mediastinum and to analyze prognostic factors. Methods. We performed PubMed database search in July 2013. Twenty-two studies, which included 40 patients, form the basis of this review. Demographic and disease-related factors were analyzed for possible influence on survival. Findings were compared with extremity SS studies reported in literature. Results. Sixteen cases (40%) presented with locally advanced unresectable disease, 2 (5%) with metastatic disease, and 22 (55%) with localized resectable disease. Median tumor size was 11 cm (range: 5–20 cm). Thirty patients were assessable for survival and had a 5-year OS of 36%. Completeness of resection was the only factor associated with significant improvement in OS (5-year survival of 63% and 0% in favor of complete resection, P = 0.003). Conclusion. Mediastinal SS is associated with poor prognosis as more cases are diagnosed at an advanced stage and with larger tumor size compared to extremity SS. Complete surgical resection is the only identified factor associated with better prognosis and may result in survival outcomes that are comparable with those for localized SS of the extremity.

Synovial sarcoma presenting with huge mediastinal mass: a case report and review of literature

BackgroundSynovial sarcoma presenting in the mediastinum is exceedingly rare. Furthermore, data addressing optimal therapy is limited. Herein we present a case where an attempt to downsize the tumor to a resectable state with chemotherapy was employed.Case presentationA 32 year female presented with massive pericardial effusion and unresectable huge mediastinal mass. Computed axial tomography scan - guided biopsy with adjunctive immunostains and molecular studies confirmed a diagnosis of synovial sarcoma. Following three cycles of combination Ifosfamide and doxorubicin chemotherapy, no response was demonstrated. The patient refused further therapy and had progression of her disease 4 months following the last cycle.ConclusionSynovial sarcoma presenting with unresectable mediastinal mass carry a poor prognosis. Up to the best of our knowledge there are only four previous reports where primary chemotherapy was employed, unfortunately; none of these cases had subsequent complete surgical resection. Identification of the best treatment strategy for patients with unresectable disease is warranted. Our case can be of benefit to medical oncologists and thoracic surgeons who might be faced with this unique and exceedingly rare clinical scenario.

Azacitidine-induced cryptogenic organizing pneumonia: a case report and review of the literature

BackgroundMyelodysplasia syndrome is a heterogeneous group of hematological disorders that are characterized by abnormal morphology and cytopenias of bone marrow elements. Azacitidine is a hypomethylating agent that is commonly used in treatment of myelodysplasia syndrome. We present an extremely rare case of cryptogenic organizing pneumonia following therapy with azacitidine and a review of the relevant literature. This is the fifth case of azacitidine-induced interstitial lung disease and the sixth one due to hypomethylating drugs; of interest, this is the first reported case that has occurred after the second cycle. Our case report highlights an important, potentially treatable and rare side effect of azacitidine and hypomethylating agents in general that might be overlooked by oncologists. Furthermore, our review of the literature showed heterogeneity in the clinical outcome which might, in part, be due to delay in initiating corticosteroids treatment.Case presentationA 67-year-old white man presented with worsening shortness of breath and mild productive cough that started 1 week prior to his presentation. An initial chest X-ray showed infiltration of both lung fields. Radiographic findings of computed axial tomography, results of bronchoscopy and a lung biopsy were consistent with cryptogenic organizing pneumonia. The patient showed variable clinical response to steroids and he remained dependent on home oxygen.ConclusionsWe concluded that there is a recognizable potentially life-threatening toxicity due to organizing pneumonia secondary to azacitidine in the setting of myelodysplasia syndrome treatment. This toxicity is not limited to the first cycle as in previous cases; furthermore, pleural effusion can be associated with this toxicity. Health care professionals should be aware of this recognizable side effect. Early recognition and timely management are critical to prevent permanent lung fibrosis.

Choroidal metastasis secondary to prostatic adenocarcinoma: Case report and review of literature

Choroidal metastasis from prostate adenocarcinoma is exceedingly rare. Furthermore, data addressing the optimal therapeutic strategy is limited. A 62-year-old male patient with metastatic prostate cancer was found to have a choroidal metastasis after complaining of decreased vision in his left eye. Following treatment with external beam radiotherapy, complete response in the choroidal metastasis was demonstrated. A literature search was undertaken to highlight the therapeutic options for this rare presentation. Choroidal metastasis secondary to adenocarcinoma of the prostate is exceedingly rare, as only eight cases have been reported so far. External beam radiotherapy is an effective therapeutic modality.

Choroidal metastasis as the sole initial presentation of metastatic lung cancer

Choroidal metastasis as an initial presenting feature of metastatic lung cancer is exceedingly rare. External beam radiotherapy (EBRT) is an effective and widely accepted therapeutic modality. However, data addressing the effectiveness of other treatment strategies is limited. We present a patient with choroidal metastases secondary to lung cancer and review the relevant literature. A 25-year-old male presented with deterioration of vision. His evaluation revealed bilateral choroidal metastasis secondary to adeno- carcinoma of the lung. Unfortunately, his vision continued to deteriorate despite treatment with EBRT and chemotherapy. Choroidal metastasis as an initial presentation of metastatic lung cancer is exceedingly rare, as only 30 cases have been reported. EBRT and systemic chemotherapy are effective therapeutic modalities. This case report could prove helpful to clinicians faced with a similar exceedingly rare scenario.

Cement pulmonary embolism as a complication of percutaneous vertebroplasty in cancer patients

BackgroundVertebroplasty is a minimally invasive procedure commonly performed for vertebral compression fractures secondary to osteoporosis or malignancy. Leakage of bone cement into the paravertebral venous system and cement pulmonary embolism (cPE) are well described, mostly in patients with osteoporosis. Little is known about the clinical sequelae and outcomes in cancer patients. In this study, we report our experience with cPE following vertebroplasty performed in cancer patients.MethodsRecords of all consecutive cancer patients who underwent vertebroplasty at our institution were retrospectively reviewed. The procedure was performed via percutaneous injection of barium-opacified polymethyl-methacrylate cement.ResultsA total of 102 cancer patients with a median age of 53 (19–83) years were included. Seventy-eight (76.5%) patients had malignant vertebral fractures, and 24 (23.5%) patients had osteoporotic fractures. Cement PE was detected in 13 (12.7%) patients; 10 (76.9%) patients had malignant fractures, and the remaining three had osteoporotic fractures. Cement PE was mostly asymptomatic; however, 5 (38.5%) patients had respiratory symptoms that led to the diagnosis. Only the five symptomatic patients were anticoagulated.Cement PE was more common with multiple myeloma (MM); it occurred in 7 (18.9%) of the 37 patients with MM compared with only three (7.3%) of the 41 patients with other malignancies. No difference in incidence was observed between patients with osteoporotic or malignant vertebral fractures.ConclusionsCement PE is a relatively common complication following vertebroplasty and is mostly asymptomatic. Multiple myeloma is associated with the highest risk. Large-scale prospective studies can help identify risk factors and clinical outcomes and could lead to better prevention and therapeutic strategies.

Second-line Chemotherapy in Older Patients With Metastatic Urothelial Carcinoma: Pooled Analysis of 10 Second-line Studies

Background Older patients with metastatic urothelial carcinoma (UC) are under‐represented in clinical trials, and data regarding outcomes for second‐line therapy is limited. Materials and Methods Individual data for patients with metastatic UC, aged ≥ 70 years, were pooled from 10 second‐line studies. The influence of potential prognostic factors on overall survival (OS) was assessed via univariate and multivariate Cox regression analysis. Results In total, 102 patients were included; the median age was 74.0 years (range, 70‐88 years). Second‐line chemotherapy was single‐agent in 42 (41%) patients and combination regimens in 60 (59%) patients. Median progression‐free and OS were 4.3 and 9.7 months, respectively. In multivariate analysis, age > 75 years, Eastern Cooperative Oncology Group performance status ≥ 1, serum hemoglobin < 10 g/dL, and non‐lymph node only metastasis predicted inferior OS. Median OS for patients with 0, 1, 2, and ≥ 3 adverse factors was unreached, 15.5, 9.8, and 4.8 months, respectively (P < .001). There was no difference in OS between patients treated with single‐agent or combination chemotherapy. Combination regimens were associated with higher occurrences of any ≥ grade 2 toxicity (80% vs. 38%; P < .001), ≥ grade 2 hematologic (78% vs. 12%; P < .001), and ≥ grade 2 gastrointestinal toxicity (36% vs. 7%; P < .001). Conclusion In this pooled analysis of older patients with metastatic UC, combination chemotherapy for second‐line treatment was associated with greater toxicity without improvement in OS. Eastern Cooperative Oncology Group performance status ≥1, serum hemoglobin < 10 g/dL, and age > 75 years predicted worse survival, whereas isolated lymph node metastasis predicted a favorable outcome. Micro‐Abstract We pooled individual data of older patients (≥ 70 years) from 10 studies that assessed second‐line chemotherapy for metastatic urothelial carcinoma. A prognostic model that separates the patients into 4 groups with significant differences in survival outcomes was developed. Furthermore, second‐line combination regimens, compared with single‐agent chemotherapy, were associated with increased toxicity without improved survival.

Factors associated with short recurrence-free survival in completely resected colon cancer

ABSTRACT Background: Several factors could affect disease recurrence in surgically resected colon cancer. While the role of certain factors such as cancer stage and grade is well established, the role of other factors (e.g., histological subtypes) is yet to be determined. Objective:Therefore, we conducted a study to evaluate the impact of several factors in recurrence-free survival (RFS) in patients who were disease free following surgical resection of the colon cancer. Design/Methods: Data were collected for patients with Stage I–III colon cancer who underwent complete surgical resection of the tumor between January 2010 and December 2015 in our institution. A total of 90 subjects met the inclusion criteria and were included in the study. The following factors were collected at the time of surgical resection of the colonic tumor: patient’s age, gender, colon cancer stage, grade and histological subtype, body mass index, hemoglobin A1c, and smoking history. Results: A total of 28 patients (31%) developed recurrence and had a mean follow-up time of 19.8 months (range: 2–54.4 months). Median RFS was 54.4 months with a 5-year RFS of 49%. Advanced colonic cancer stage and mucinous histological subtype were associated with shorter RFS with an HR of 2.37, 95% CI = 1.38–4.06, and 95% CI = 1.02–5.90, respectively. Current smokers or those who quit less than 15 years earlier tended to have worse RFS with an HR of 2.47, 95% CI = 0.98–6.27. Conclusion: Advanced colon cancer stage and mucinous histological subtype are independent risk factors for cancer recurrence and shorter RFS in completely resected colonic tumor.

Comment on: Risk Factors for Survival After Lung Metastasectomy for Colorectal Cancer Patients

With a great interest, we have read the article ‘‘Risk Factors for Survival After Lung Metastasectomy in Colorectal Cancer Patients: A Systematic Review and Meta-Analysis’’ by Dr. Gonzalez and his colleagues. We appreciate the authors’ reference to our recent papers. However, an issue in their article is not referenced correctly to my paper. In Table 1, the authors report that the prognostic factor after pulmonary metasectomy from colorectal cancer was ‘‘normal CEA’’ and ‘‘no lymph node’’ in our study. This is not correct. ‘‘Normal CEA’’ and ‘‘no lymphatic invasion by pulmonary tumor’’ were the prognostic factors in our paper. No lymph node was not a significant prognostic factor because only a few patients had hilar or mediastinal (thoracic) lymph node involvement in our study. Patients with thoracic lymph node involvement were excluded from surgical indication and thoracic lymph node sampling or dissection was not routinely performed at my institution. Except for this minor issue, we agree with the conclusion of the article. The authors performed meta-analysis and showed that the prognostic factors after pulmonary metasectomy from colorectal cancer were disease-free interval (DFI), carcinoembryonic antigen (CEA), number of lung metastases, and thoracic lymph node involvement. Our recent international multicenter retrospective study also showed that DFI, CEA, and number of lung metastases were the prognostic factors. The authors reported that our study did not consider thoracic lymph node involvement as a potential determinant of outcome. However, this was not a very accurate description. Our study showed that thoracic lymph node involvement is a candidate for a prognostic factor because the univariate analysis showed that thoracic lymph node involvement was a significant prognostic factor. In our study, thoracic lymph node involvement was excluded from the multivariate analysis to avoid bias because the number of patients who underwent thoracic lymph node sampling or dissection was low. Therefore, we agree with the conclusion of the article. We hope the data from these large-scale studies will facilitate the establishment of novel algorithms for predicting prognosis after resection of pulmonary metastases from colorectal cancer, which may lead to the appropriate therapeutic strategies for pulmonary metastases from colorectal cancer.With a great interest, we have read the article ‘‘Risk Factors for Survival After Lung Metastasectomy in Colorectal Cancer Patients: A Systematic Review and Meta-Analysis’’ by Dr. Gonzalez and his colleagues. We appreciate the authors’ reference to our recent papers. However, an issue in their article is not referenced correctly to my paper. In Table 1, the authors report that the prognostic factor after pulmonary metasectomy from colorectal cancer was ‘‘normal CEA’’ and ‘‘no lymph node’’ in our study. This is not correct. ‘‘Normal CEA’’ and ‘‘no lymphatic invasion by pulmonary tumor’’ were the prognostic factors in our paper. No lymph node was not a significant prognostic factor because only a few patients had hilar or mediastinal (thoracic) lymph node involvement in our study. Patients with thoracic lymph node involvement were excluded from surgical indication and thoracic lymph node sampling or dissection was not routinely performed at my institution. Except for this minor issue, we agree with the conclusion of the article. The authors performed meta-analysis and showed that the prognostic factors after pulmonary metasectomy from colorectal cancer were disease-free interval (DFI), carcinoembryonic antigen (CEA), number of lung metastases, and thoracic lymph node involvement. Our recent international multicenter retrospective study also showed that DFI, CEA, and number of lung metastases were the prognostic factors. The authors reported that our study did not consider thoracic lymph node involvement as a potential determinant of outcome. However, this was not a very accurate description. Our study showed that thoracic lymph node involvement is a candidate for a prognostic factor because the univariate analysis showed that thoracic lymph node involvement was a significant prognostic factor. In our study, thoracic lymph node involvement was excluded from the multivariate analysis to avoid bias because the number of patients who underwent thoracic lymph node sampling or dissection was low. Therefore, we agree with the conclusion of the article. We hope the data from these large-scale studies will facilitate the establishment of novel algorithms for predicting prognosis after resection of pulmonary metastases from colorectal cancer, which may lead to the appropriate therapeutic strategies for pulmonary metastases from colorectal cancer.