Sonam Puri

Physician–pharmacist collaboration for oral chemotherapy monitoring: Insights from an academic genitourinary oncology practice

Background Oral chemotherapy is being routinely used in metastatic castrate-resistant prostate and renal cell cancer. Although convenient, these drugs require monitoring for adherence, toxicity, and drug interactions to maximize outcomes. Oncology pharmacists have the training and expertise that place them in an optimal position to collaboratively provide medication therapy management. Methods A board-certified oncology pharmacist, working in collaboration with a medical oncologist, initiated an oral chemotherapy–monitoring program. The pharmacist provided education, completed medication therapy management; monitored for adherence and toxicity; and recommended treatment of toxicity and supportive care issues. Patient encounters included one of the following: collaboration with medical oncologist visit, pharmacist visit, or telephone or email follow-up between visits. Results From December 2012 to May 2014, the pharmacist had 123 encounters with 20 patients with either metastatic prostate (n = 17) or renal cell cancer (n = 3). All patients were males (median age 80 years). Most encounters were clinic visits, in collaboration with physician visit or alone (52%); 36% were telephone encounters, and 11.3% were email follow-ups. Medication-related problems were identified in 25% of the 315 assessments made. Problems included: adverse drug reactions, 40%; inappropriate therapy, 20%; and noncompliance, 18%. Recommendations included: modification of laboratory monitoring, 25%; cancer or non-cancer therapy modification, 12%; drug discontinuation, 6.9%. Non-cancer therapy-related drug information and coordination of care accounted for 30% of recommendations. Conclusion Our program led to identification of a number of potentially clinically significant issues for patients on oral chemotherapy and demonstrated the benefit of the pharmacist in the multidisciplinary team to assist in addressing them.

The forgotten disease: Bilateral Lemierre’s disease with mycotic aneurysm of the vertebral artery

Patient: Male, 25 Final Diagnosis: Lemierre’s disease Symptoms: Back pain • fever • headache • tachycardia • tachypnoe Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare disease Background: Lemierre’s disease, also known as the forgotten disease, postanginal sepsis, or necrobacillosis, was first reported in 1890 by Courmont and Cade, but it was Dr. Andre Lemierre, a professor of microbiology, who described this disease in 1936. The typical causative agent is Fusobacterium necrophorum, although other organisms may be involved. The pathogenesis of Lemierre’s disease is not well understood. It is characterized by a primary oropharyngeal infection associated with septicemia, internal jugular vein thrombosis, and metastatic septic emboli. Case Report: We report a case of Lemierre’s disease with bilateral internal jugular vein (IJV) thrombosis and metastatic septic emboli to the lungs and brain, associated with epidural abscess and mycotic aneurysm of the vertebral artery, which is quite rare in Lemierre’s disease. This is the first report of a case of Lemierre’s disease associated with mycotic aneurysm of the vertebral artery. Conclusions: Lemierre’s disease is a rare and perplexing medical entity. Clinical suspicion should be high in previously healthy young adults presenting with fever and neck pain following oropharyngeal infection. Dr. Lemierre stated that ‘symptoms and signs of Lemierre’s disease are so characteristic that it permits diagnosis before bacteriological examination’. The prognosis of patients with Lemierre’s disease is generally good, provided prompt recognition and appropriate treatment.

Pericardial synovial sarcoma: challenges in diagnosis and management.

Introduction: Pericardial synovial sarcoma is an extremely rare tumor with poor prognosis. Timely diagnosis and aggressive multimodal management improves patient outcome. We present our experience of diagnosis and management of a young patient with monophasic synovial sarcoma arising from pericardium. Case: A 27-year-old man presented with dyspnea and cough of three weeks duration. Examination revealed sinus tachycardia, distant heart sounds and elevated jugular venous pressure. Chest X-ray showed widened mediastinum. Transthoracic echocardiogram (TTE) noted large pericardial effusion with tamponade physiology. Therapeutic pericardiocentesis yielded hemorrhagic fluid. Computed tomography (CT) of the chest showed persistent pericardial effusion and a left anterior mediastinal mass. Left anterior thoracotomy, pericardial window and left anterior mediastinotomy were done, revealing a well-encapsulated gelatinous tumor originating from the pericardium. Histology and immunohistochemical profile showed the tumor to be a monophasic synovial sarcoma. Fluorescent in-situ hybridization (FISH) was positive for SS18 (SYT) gene rearrangement on chromosome 18q11, substantiating the diagnosis. Work-up for metastases was negative. Neo-adjuvant chemotherapy with high dose ifosfamide led to substantial reduction in the size of the tumor. The patient underwent surgical resection and external beam radiation therapy (EBRT) post surgery. He had symptom-free survival for 8 months prior to local recurrence. This was managed with left lung upper lobectomy and follow-up chemotherapy with docetaxel. The patient is currently stable with an acceptable functional status. Conclusion: In patients with pericardial effusions of unknown etiology, multiple modalities of cardiac imaging must be employed if there is suspicion of a pericardial mass. CT and magnetic resonance imaging (MRI) are useful to evaluate for pericardial thickening or masses in addition to TTE. Treatment of synovial sarcoma is not well established. Surgery is the cornerstone of treatment. In non-resectable tumors, aggressive neo-adjuvant chemotherapy with ifosfamide followed by surgical resection and EBRT may lead to improved outcome.

An update on newer monoclonal antibodies in lymphoma therapy

In 2014, an estimated 9.4% of all new cancers in the US were accounted to hematological cancers. Most of these cancers have a B-cell origin and on the cell surface express antigen CD20-known to restrict B-cells. Considering the intrinsic immune status of the patients receiving chemotherapy, monoclonal antibodies (mAbs) are designed to provide active or passive immunotherapy. Clinical success of rituximab-anti-CD20 mAb in the treatment of lymphoma has led to the development of newer generations of mAb to increase the anti-tumor activity. Hence, recent advances in lymphoma therapy are being built on the conventional prototype of anti-CD20 mAb-rituximab. Our review is an update on the advances in lymphoma therapy using mAb against CD20 including the second generation-ofatumumab, veltuzumab, ocrelizumab, and the third-generation mAbs-ocaratuzumab and obinutuzumab.

Phase I/II study of nivolumab and ipilimumab combined with nintedanib in advanced NSCLC.

TPS9112Background: Combination immunotherapy with nivolumab and ipilimumab has proven clinical activity in NSCLC. There is growing evidence to suggest that the tumor microenvironment (TME) may inte...

Subcutaneous metastasis from recurrent basaloid squamous cell carcinoma of the esophagus

Background Esophageal cancer is the 11th most common cause of cancer mortality in the United States. It is aggressive in nature and has an ability to spread rapidly through direct extension, lymphatic spread, or hematogenously. With an estimated incidence of 1%, cutaneous metastases from esophageal cancer are extremely rare. Case presentation In this case study and review, we describe a case of recurrent esophageal basaloid squamous cell carcinoma presenting as multiple, rapidly progressing and tender subcutaneous nodules. A 69-year-old male with history of basaloid squamous cell carcinoma of the esophagus treated with concurrent chemoradiation, presented to his oncologist with complaints of a large, painful nodule at the nape of his neck approximately two years after completing treatment. On further examination, he was noted to have multiple, well circumscribed, solid, tender nodules on his abdominal wall along with a painful nodule on the pulp of his index finger. Histopathology from all sites revealed skin infiltration by high-grade invasive basaloid subtype of squamous cell carcinoma, similar to patient’s prior known and treated primary esophageal cancer. Further imaging work up showed extensive metastatic disease involving lung, liver, and brain. Conclusion Esophageal squamous cell carcinoma rarely metastasize to the skin. Subcutaneous nodules can be the first presentation of recurrent disease. The lesions are commonly confused with skin infections and treated inappropriately with antibiotics, leading to delay in diagnosis of recurrent disease. Early biopsy of suspicious lesions should be performed, especially in patients with history of cancer, such that prompt diagnosis and treatment can occur to maximize patient outcomes.