Background With a minimum follow up of 2 years, the TAX324 study demonstrated a significant survival benefit of induction chemotherapy (IC) with docetaxel, cisplatin and 5FU (TPF) versus cisplatin and 5fluorouracil (PF) followed by chemoradiotherapy with carboplatin delivered as sequential therapy (ST) in locally advanced head and neck cancer (LAHNC). We report the long term results with 5 years minimum follow-up. Methods TAX324 was a randomized, open-label phase 3 trial comparing three cycles of TPF IC (docetaxel 75 mg/m2 of body-surface area, followed by intravenous cisplatin 100 mg/m2 and 5fluorouracil 1000 mg/m2 per day administered as a continuous 24-hour infusion for 4 days) with three cycles of PF (intravenous cisplatin 100 mg/m2, followed by fluorouracil 1000 mg/m2 per day as a continuous 24-hour infusion for 5 days). Both regimens were followed by 7 weeks of chemoradiotherapy with concomitant weekly carboplatin (AUC1.5). Randomization was performed centrally with the use of a biased-coin minimization technique. At study entry, patients were stratified according to the site of the primary tumor, nodal status (N0 or N1 vs. N2 or N3), and institution. For this long term analysis, data was gathered retrospectively. Overall survival (OS) and progression-free survival (PFS) were the primary endpoints. Data as of December 1, 2008 were analyzed. Tracheostomy and gastric feeding tube dependence were used as surrogates for treatment related long term toxicity. The median follow-up was 72.2 months (mo) (IQR for TPF =33 mo, PF =34 mo and for all pts =34 months). The analysis was based on data from all 501 patients. 61 patients were lost to follow-up and their data as of the initial analysis in 2005 was used. Findings OS was significantly better with TPF versus PF (HR=0.74, 95%CI: 0.58–0.94), with an estimated 5-yr survival rate of 0.52 and 0.42 in the TPF and PF arms, respectively. Median survival time was 70.6 mo (95%CI: 49.0–89.0 mo) with TPF versus 34.8 mo (the 95%CI: 22.6–48.0 mo) in the PF group (p=0.014). PFS was also significantly better with TPF (38.1 mo; 95%CI 19.3–66.1 mo vs. 13.2 mo, 95%CI 10.6–20.7 mo; HR= 0.75, 95%CI: 0.60–0.94). Subjects with hypopharyngeal and laryngeal cancer had significantly superior PFS with TPF (HR=0.68, the 95%CI: 0.47–0.98). No significant difference for dependence on gastric feeding tubes and tracheotomies was detected between the treatment groups. In the TPF arm 3 out of 91 patients (3%) remained feeding tube dependent (no information in 40 cases) while 8 out of 71 (10%) patients required feeding tubes in the PF arm (no information in 30 cases). 6 out of 92 (7%) patients had tracheostomies (no information in 39) versus 8/71 (13%) (no information in 30) in the TPF and PF groups, respectively. Interpretation IC with TPF provides long term survival benefit compared to PF in LAHNC. Patients who are candidates for IC should be treated with TPF.
Background The coronavirus disease 2019 (COVID-19) pandemic overwhelmed healthcare systems, highlighting the need to better understand predictors of mortality and the impact of medical interventions. Methods This retrospective cohort study examined data from every patient who tested positive for COVID-19 and was admitted to White Plains Hospital between March 9, 2020, and June 3, 2020. We used binomial logistic regression to analyze data for all patients, and propensity score matching for those treated with hydroxychloroquine and convalescent plasma (CP). The primary outcome of interest was inpatient mortality. Results 1,108 admitted patients with COVID-19 were available for analysis, of which 124 (11.2%) were excluded due to incomplete data. Of the 984 patients included, 225 (22.9%) died. Risk for death decreased for each day later a patient was admitted [OR 0.970, CI 0.955 to 0.985; p < 0.001]. Elevated initial C-reactive protein (CRP) value was associated with a higher risk for death at 96 hours [OR 1.007, 1.002 to 1.012; p = 0.006]. Hydroxychloroquine and CP administration were each associated with increased mortality [OR 3.4, CI 1.614 to 7.396; p = 0.002, OR 2.8560, CI 1.361 to 6.160; p = 0.006 respectively]. Conclusions Elevated CRP carried significant odds of early death. Hydroxychloroquine and CP were each associated with higher risk for death, although CP was without titers and was administered at a median of five days from admission. Randomized or controlled studies will better describe the impact of CP. Mortality decreased as the pandemic progressed, suggesting that institutional capacity for dynamic evaluation of process and outcome measures may benefit COVID-19 survival.
Chylothorax, which is defined as the presence of chyle in the pleural space, is often caused by malignancy. However, chylothorax as a result of underlying CLL is exceedingly rare in the literature. Chyle contains fat soluble vitamins and lymphocytes, meaning that its collection into the pleural space may further exacerbate the immunosupressed state of an individual with CLL. Here, we report three cases of patients with CLL who developed chylothorax, and their management. Chylothorax, although rare with CLL, should be considered in the differential diagnosis when patients with CLL present with pleural effusions, especially if recurrent. Discovery of a chylothorax may indicate the need for further treatment of CLL.
Metastatic disease to the breast accounts for less than 1% of all breast carcinoma. Here we describe an unusual case of a 34-year-old black female with history of sickle cell trait who presented to her gynecologist with bilateral palpable breast masses. Based on initial workup including pathology results from biopsies of both breast masses, she was diagnosed with bilateral breast cancer. However further radiographic imaging revealed a large right kidney mass suspicious for primary renal neoplasm along with lung and bone lesions. This prompted re-review of the initial breast pathology. Sickled erythrocytes were identified and results of an additional immunohistochemical panel revealed positive expression of PAX 8, vimentin, Oct3/4, and loss of INI1, confirming the diagnosis of metastatic renal medullary carcinoma. We discuss the importance of considering renal medullary carcinoma in the differential diagnosis when evaluating young patients with sickle cell hemoglobinopathies who present with aggressive metastatic disease.
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