OBJECTIVES The aims of this study were to: 1) assess the feasibility of left ventricular (LV) vortex flow analysis using contrast echocardiography (CE); and 2) characterize and quantify LV vortex flow in normal subjects and patients with LV systolic dysfunction. BACKGROUND Vortices that form during LV filling have specific geometry and anatomical locations that are critical determinants of directed blood flow during ejection. Therefore, it is clinically relevant to assess the vortex flow patterns to better understand the LV function. METHODS Twenty-five patients (10 normal and 15 patients with abnormal LV systolic function) underwent CE with intravenous contrast agent, Definity (Bristol-Myers Squibb Medical Imaging, Inc., North Billerica, Massachusetts). The velocity vector and vorticity were estimated by particle image velocimetry. Average vortex parameters including vortex depth, transverse position, length, width, and sphericity index were measured. Vortex pulsatility parameters including relative strength, vortex relative strength, and vortex pulsation correlation were also estimated. RESULTS Vortex depth and vortex length were significantly lower in the abnormal LV function group (0.443 ± 0.04 vs. 0.482 ± 0.06, p < 0.05; 0.366 ± 0.06 vs. 0.467 ± 0.05, p < 0.01, respectively). Vortex width was greater (0.209 ± 0.05 vs. 0.128 ± 0.06, p < 0.01) and sphericity index was lower (1.86 ± 0.5 vs. 3.66 ± 0.6, p < 0.001) in the abnormal LV function group. Relative strength (1.13 ± 0.4 vs. 2.10 ± 0.8, p < 0.001), vortex relative strength (0.57 ± 0.2 vs. 1.19 ± 0.5, p < 0.001), and vortex pulsation correlation (0.63 ± 0.2 vs. 1.31 ± 0.5, p < 0.001) were significantly lower in the abnormal LV function group. CONCLUSIONS It was feasible to quantify LV vorticity arrangement by CE using particle image velocimetry in normal subjects and those with LV systolic dysfunction, and the vorticity imaging by CE may serve as a novel approach to depict vortex, the principal quantity to assess the flow structure.

Abstract:Although there has been significant progress in the survival of children and older adults with cancer in the last few decades, this has not been the case for adolescent and young adults (AYAs). Although there are multiple reasons why outcomes for AYAs have not improved over time, it is evident from studies that AYAs fare better when enrolled in clinical trials, yet they are much less likely to participate in trials when compared with children and older adults. The goal of this review is to understand the trends in clinical trial enrollment of AYA patients over time, recognize facilitators and barriers to enrollment, and evaluate methods that have been utilized in order to improve clinical trial enrollment for this group of patients. A systematic review of the literature was performed to search for articles related to AYA oncology and clinical trials. The articles that met all inclusion criteria were then subject to full-text review, which yielded 17 articles that used quantitative, qualitative, or mixed methods. The articles reviewed demonstrated that for AYA patients, survival and clinical trial enrollment have shown some improvement over time, yet participation in clinical trials is still relatively poor, particularly for older patients within this group. Major barriers to enrollment in clinical trials include limited access and availability of trials, as well as patient knowledge. We have introduced the 4 Ps Conceptual "Onion Skin" Model, which includes patient, partners, providers, and policies, with the goal of reducing barriers to trial enrollment. Interventions utilizing this model include the establishment of more AYA centers, increased collaboration among cooperative groups with the goal of creating more AYA-specific trials, and educating patients and providers about the benefits of participating in clinical trials. Further studies are needed to understand which interventions would be most successful in encouraging AYA patients to enroll in clinical trials.

Introduction Prognosis for patients with lymph node positive or metastatic penile squamous cell carcinoma remains poor. Chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP regimen) is recommended as a first-line option in this cohort of patients. No standard preferred subsequent-line therapy exists for patients with relapsed or refractory penile carcinoma following TIP chemotherapy. Molecular pathogenesis of penile cancer can be subdivided into human papilloma virus-dependent and human papilloma virus-independent pathways. Recent studies have demonstrated increased expression of programmed death ligand-1 in some penile tumors, commonly those that are human papilloma virus-negative. Given the rarity of penile carcinoma in industrialized countries and lack of effective therapies, checkpoint inhibitors may be an attractive treatment option for this subset of patients. Case report We report a case of metastatic penile cancer refractory to TIP chemotherapy, with a dramatic treatment response to ipilimumab and nivolumab. Molecular profiling of this tumor showed a high programmed death ligand-1 expression, high tumor mutational burden, high microsatellite instability, and alterations in DNA mismatch repair genes. Discussion This case highlights another dimension of information that may be gained with molecular genomic profiling of penile tumors, providing insight into the biologic behavior of this neoplasm and assessing for predictive biomarkers of response to immune checkpoint inhibitors.

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BACKGROUND Late relapses of early-stage germ cell tumors are rare. Most patients (-85%) with stage I seminoma are cured by radical orchiectomy. The detection of late relapse is challenging given the relative rarity of this phenomenon, and the fact that patients who have completed surveillance are usually not undergoing regular oncologic workup nor imaging. While many treatment options do exist for a patient with late relapse of seminoma, surgery is typically the mainstay as these tumors are generally thought to be more chemo-resistant. CASE SUMMARY In this article, we describe the management of a patient with an early-stage pure seminoma who was subsequently identified to have a recurrence two decades later. We provide a review of the literature not only focused on clinical factors and biology, but also the management of late recurrences specifically in pure seminoma and in prostate gland. CONCLUSION There is a paucity of data and treatment recommendations for this clinical entity, and a multidisciplinary approach emphasizing subspecialty expert consultation and patient education is imperative.