Purpose: Radiotherapy (RT) is an effective treatment for localized gastric mucosa-associated lymphoid tissue (MALT) lymphomas unresponsive to antibiotic therapy; however, irradiating the stomach can result in significant radiation to the heart, a risk factor for cardiac disease. We analyzed the Surveillance, Epidemiology, and End Results database to evaluate outcomes related to cardiac disease among patients treated with RT for stage I gastric MALT. Materials and Methods: We identified adult patients treated between 1993 and 2014. The relationship between treatment modality (RT, chemotherapy, combination, and no treatment) and overall survival (OS), mucosa-associated lymphoid tissue-specific survival (MSS), non-mucosa-associated lymphoid tissue-specific survival (non-MSS), and cardiac-specific survival (CSS) was assessed using the Kaplan-Meier estimator and Cox proportional hazards analyses. Results: A total of 2996 patients (median follow-up, 5.6 y) were analyzed: 27.5% had received RT alone, 12.1% chemotherapy alone, 3.9% chemoradiotherapy, and 56.5% no/unknown treatment (including antibiotic therapy). Compared with RT alone, patients who received chemotherapy alone exhibited worse OS (hazard ratio [HR]: 1.67; 95% confidence interval [CI]: 1.32-2.10; P <0.001) and MSS (HR: 2.10; 95% CI: 1.36-3.23; P =0.001). Although CSS appeared worse in patients who received chemotherapy (HR: 1.56; 95% CI: 0.92-2.66; P =0.10), it was not statistically significant. When comparing orbital and gastric MALT patients, there was no significant difference in CSS (HR: 0.80; 95% CI: 0.49-1.31; P =0.38). Conclusions: RT improved survival among patients with stage I gastric MALT without increasing the risk of cardiac death. Those with gastric MALT exhibited similar CSS to those with orbital MALT. Although we cannot analyze nonfatal cardiac toxicity, these results suggest that, absent antibiotic therapy, RT should remain first-line treatment for early-stage gastric MALT.
Heparin-induced antibodies (HIA) are responsible for causing heparin-induced thrombocytopenia and thrombosis. Research has shown that the temporality of heparin-induced antibodies does not follow the classic immunologic response. The immunobiology of HIA generation remains unclear with varying in vitro and in vivo data. Outpatients undergoing hemodialysis (HD) are exposed to heparin chronically. The HIA immune response can therefore be investigated in vivo in this population.We examined the time between the start of HD using unfractionated heparin and HIA levels in 212 outpatients during a 6-year period. Antibodies were detected on enzyme-linked immunosorbent assay. HIA levels were analyzed to determine significance of the trend over time. HIA subgroups were also analyzed for correlation with subsequent thrombotic events and platelet count during follow up.Overall, the HIA response in HD was found to peak early with waning antibody response despite continued exposure to heparin. The peak prevalence of a strong immune response (optical density > 1.000) was early and short lived, while weaker immune response (optical density 0.400-1.000) persisted for the first 6 months then declined. The mean follow-up time per patient was 2.3 ± 1.4 years. Despite circulating HIA, including high titers, no patients developed HIT in this sample. There was no association between HIA and thrombocytopenia. There was increased incidence of thrombosis in patients with strong HIA compared to other groups, but this did not achieve statistical significance.The data suggest a significant temporal pattern of HIA in outpatients undergoing HD using unfractionated heparin. Positive HIA was not found to be significantly associated with thrombocytopenia or thrombosis risk in these patients. However, while not achieving statistical significance, subsequent thrombotic events occurred most frequently in the strong positive HIA group (optical density > 1.000). Further research into HIA and risk of thrombosis in this population is needed.
e24104 Background: There is a high rate of anemia present in cancer patients and anemia is also a common referral to a hematologist. Symptomatic anemia can significantly impair an individual’s functional status so identifying its cause is essential for improving quality of life. Correction of nutritional deficiencies, like iron, B12, and folate deficiency can improve hemoglobin counts, prevent recurrent PRBC transfusions, and can often resolve the anemia. In a busy academic hematology oncology practice, we hypothesize that it is easy to overlook performing a basic nutritional evaluation especially in the setting of other causes for anemia such as chemotherapy, hemolysis, blood loss, chronic kidney disease, and other disorders. We aim to evaluate the frequency of anemia workup in the hematology and oncology division at our academic institution. Methods: We conducted a retrospective study of all hematology oncology patients seen in our clinic who received a blood transfusion in 2021. All patients were 18 years old or order and received at least one-unit PRBC transfusion as an outpatient. One “transfusion event” was defined as any number of PRBC transfusions on a single day and any subsequent transfusions within a 90-day periods. A single patient, therefore, can have multiple distinct transfusion events. We analyzed whether patients received a “basic” anemia evaluation, defined as checking ferritin, iron saturation, B12, and folate levels within 3 months before or after the first transfusion, and whether a discrepancy in practice patterns exists between different hematology oncology subspecialties. Results: At the interim analysis, we identified 368 transfusion events for 275 patients. Those events were ordered by providers (physician, nurse practitioner, or physician assistant) in the following subspecialties: oncology (n = 20), malignant hematology (n = 18), classical hematology (n = 3), and fellow-in-training (n = 5). A basic anemia workup was missing in 58% (84 of 146), 27% (49 of 183), 23% (8 of 35), 40% (2 of 5) in the above groups respectively. For patients with macrocytic anemia defined as mean corpuscular volume (MCV) > 100 fL, 48% (38 of 79) did not have B12 or folate levels checked within 3 months before or after a transfusion event. For patients with MCV < 80 fL, 47% (14 of 30) did not have ferritin or iron saturation checked within 3 months before or after a transfusion event. Conclusions: We observed a high percentage of cancer and non-malignant hematology patients who did not receive a basic anemia evaluation within three months before or three months after a blood transfusion. A higher percentage of patients with solid tumors patients who required PRBC transfusions did not receive a basic anemia evaluation in a timely manner. Our study identified an area of quality improvement and need for intervention that can easily be overlooked in a busy academic hematology oncology practice.
e23051 Background: The latest ASCO guidelines regarding tumor markers in breast cancer do not recommend routine monitoring of serum CA 15-3 (CA) levels alone as a marker for relapse. They do, however, acknowledge their use in conjunction with a patient’s history, physical exam, and diagnostic imaging. The study objective is to evaluate CA as a marker for relapse and determine its continued use in our patient population. Methods: We performed a retrospective analysis on female stage I-III breast cancer patients with an elevated CA marker treated in our cancer center between 2009-2014. Patients with metachronous or synchronous malignancies were excluded. Patients were categorized into three groups: Group 1 (elevated CA at relapse), Group 2 (normal CA at relapse, with elevation post-relapse), Group 3 (elevated CA without relapse). Categorical variables were collected to fulfill our objectives and the Fisher’s exact test was used to assess the correlation between them. The incidence rate and its 95% confidence interval were estimated based on the binomial distribution. Results: Out of 340 initially screened patients, 92 met our inclusion criteria: Group 1 (n = 25), Group 2 (n = 23), Group 3 (n = 44). The PPV for an elevated CA as a marker for relapse was 36% (95% CI: 26-48%). On routine surveillance, patients with elevated CA levels were more likely to have relapse if they presented with nausea (p = 0.02), myalgia (p = 0.003), or axial bone pain (p = 0.04). At relapse, an elevated CA was associated with fatigue (p = 0.02), myalgia (p = 0.01), liver metastases (p = 0.01), axial bone metastases (p = 0.005), and peripheral bone metastases (p = 0.0002). In patients with an elevated CA, a BMI < 25 had a higher incidence of relapse in comparison to those with a BMI ≥ 25 (p = 0.01). Conclusions: Our study suggests that a patient’s history, physical, and symptom-dictated imaging should be the main way to screen for relapse in stage I-III breast cancer. Based on the higher incidence of relapse in patients with both an elevated CA and symptoms of nausea, myalgia, or axial bone pain, we conclude that serum CA levels may be used as an adjunctive test in symptomatic patients. Our data also suggests that elevated CA levels may be less useful in detecting relapse in patients with BMI ≥ 25.
A 59-year-old Caucasian woman with multiple sclerosis presented with blurred vision in the right eye, floaters and flashes of light for 2 weeks. She had right-sided optic neuritis which was treated 8 years prior. There was a 20 pack-year smoking history. Examination was remarkable for right-sided temporal field loss and a palpable breast lump. Ophthalmological examination revealed right exudative retinal detachment, with ultrasonography demonstrating a choroidal mass with medium to high internal reflectivity. MRI was significant for a 14 mm intraocular metastasis (figure 1). On further questioning, the patient described haematuria. Urine cytology demonstrated large cells with high nuclear to cytoplasmic ratio, irregular nuclear borders …
Macrophage activation leading to multi-organ dysfunction/failure has been described in various hematologic disorders like hemophagocytic lympho-histiocytosis (HLH), also known as macrophage activation syndrome (MAS) and macrophage activation like syndrome (MALS). Congestive heart failure (CHF) appears to be an uncommon manifestation of macrophage activation. This novel entity of macrophage activation-associated cytokine-mediated CHF has not been well reported in the medical literature. We report two young female patients with acute CHF secondary to macrophage activation-associated cytokine storm. An extensive diagnostic workup was negative for other etiologies, such as ischemia, myocarditis, or infections. Their clinical, laboratory, and pathologic findings did not meet the diagnostic criteria for hemophagocytic syndrome (HPS)/MAS. However, both had laboratory and pathologic findings which were consistent with macrophage activation and cytokine storm. One patient met criteria for MALS. Therapeutically, our patients were promptly treated with steroids with or without anti-cytokine therapy with rapid restoration of cardiac function. Macrophage activation-induced disease may not always fulfil the diagnostic criteria for the currently known macrophage activation disorders. We suggest that markers of macrophage activation and cytokine levels should be part of the diagnostic workup in patients with otherwise unexplained acute CHF. Additional research is warranted to further elucidate the underlying mechanism of this disorder.
To evaluate prescribing practices for the anti-Xa reversal agent, andexanet alfa, to identify challenges in ordering and administering this medication, and to offer recommendations to improve patient safety.
