Cancer Treatment

IV gammaglobulin for ITP before epidural anesthesisa.

The Cut-off platelet cound is not known. Older literature says: one hundred thousand.

While IVIG has some role in presurgical situations, plt. ct of sixty eight is probably not sufficient for the proposed surgery and would be justified. A recent review says:  "Normally, spinal or epidural anesthesia is considered safe if the platelet count is over 80,000/µl. However, the consistently low platelet counts in ITP seem to be less problematic than rapidly falling values due to other diseases, because this is often accompanied by platelet dysfunction or coagulopathy. In several studies neuraxial anesthesia was successfully performed with platelet counts between 50,000 and 80,000/µl. Nevertheless, the minimum safe platelet count for neuraxial blockade remains undefined in these patients."

 

Englbrecht JS, Pogatzki-Zahn EM, Zahn P.Spinal and epidural anesthesia in patients with hemorrhagic diathesis : Decisions on the brink of minimum evidenceAnaesthesist. 2011 Jul 31

IV gammaglobulin for ITP before epidural anesthesisa.

The Cut-off platelet cound is not known. Older literature says: one hundred thousand.

While IVIG has some role in presurgical situations, plt. ct of sixty eight is probably not sufficient for the proposed surgery and would be justified. A recent review says:  "Normally, spinal or epidural anesthesia is considered safe if the platelet count is over 80,000/µl. However, the consistently low platelet counts in ITP seem to be less problematic than rapidly falling values due to other diseases, because this is often accompanied by platelet dysfunction or coagulopathy. In several studies neuraxial anesthesia was successfully performed with platelet counts between 50,000 and 80,000/µl. Nevertheless, the minimum safe platelet count for neuraxial blockade remains undefined in these patients."

 

Englbrecht JS, Pogatzki-Zahn EM, Zahn P.Spinal and epidural anesthesia in patients with hemorrhagic diathesis : Decisions on the brink of minimum evidenceAnaesthesist. 2011 Jul 31

Ova-1 test

OVA-1 is not securely established to be superior to Ca-125. Although there was a study determined that incorporating OVA1 in lieu of CA125 improved the sensitivity of the ACOG referral guidelines (77% to 94%) and the negative predictive value (87% to 93%) while decreasing specificity (68% to 35%) and negative predictive value (87% to 93%), with similar outcomes in premenopausal women and those with early-stage disease that enabled the researchers to detect almost 80% of all missed malignancies and more than 90% of missed epithelial ovarian cancers.  Still, current American College of Obstetrics and Gynecology (ACOG) guidelines specify CA125 as the biomarker of choice in conjunction with other factors, including menopausal status, physical examination, family history, and imaging to determine patient risk levels and treatment plans.

SGO says: "As physicians who are expert in the care of women with gynecologic cancers, members of the SGO are supportive of scientific advances such as OVA1 that may help healthcare providers better detect when referral to a gynecologic oncologist is indicated. However, this test has not been approved for use as an ovarian cancer screening tool, nor has it been proven to result in early detection or reduce the risk of death from this disease. Results from the OVA1 test should not be interpreted independently, nor be used in place of a physician’s clinical assessment. Physicians are strongly encouraged to reference the SGO/ACOG Pelvic Mass Guidelines to determine an appropriate care plan for their patients."

Ueland F, DeSimone C, Seamon L, et al. The OVA1 test improves the preoperative assessment of ovarian tumors. Gynecol Oncol. 2010;116(3 suppl 1):S23.

http://www.nxtbook.com/ygsreprints/WKH/wkh_44130_vermillion_CommiteeOpinion/index.php?drml=shenderson@vermillion.com&drmp=drmvermillion

The Role of the Obstetrician-Gynecologist in the Early Detection of Epithelial Ovarian Cancer.  Committee Opinion No.477. American College of Obstetricians and Gynecologists. Obstet Gynecol; 117:742-6

Hypodiploid Acute lymphocytic leukemia

Children and adolescents with ALL and hypodiploidy with fewer than 44 chromosomes have a poor outcome despite contemporary therapy. Patients with hypodiploid leukemia cells (modal number less than 45) have a poor prognosis for cure. Event free survival (EFS) at 5 years was 20 percent in patients with hypodiploid leukemia compared to 75 percent in those patients with leukemia cells having modal numbers greater or equal to 45. Although the data are somewhat premature and the numbers of transplanted patients with hypodiploid leukemia are small, it is generally accepted that SCT in first remission offers a reasonable opportunity for cure. PDQ recommends risk stratification and stem cell transplantation for children with high risk, which included hypodiploidity.

Nachman JB, Heerema NA, Sather H, Camitta B, Forestier E, Harrison CJ, Dastugue N, Schrappe M, Pui CH, Basso G, Silverman LB, Janka-Schaub GE.Outcome of treatment in children with hypodiploid acute lymphoblastic leukemia.Blood. 2007 Aug 15;110(4):1112-5.

Raimondi SC, Zhou Y, Mathew S, et al. Reassessment of the prognostic significance of hypodiploidy in pediatric patients with acute lymphoblastic leukemia. Cancer. 98(12):2715-22. 2003.

http://www.cancer.gov/cancertopics/pdq/treatment/childALL/HealthProfessional/page2#Reference2.91

 

Non-Hodgkin's lymphoma followup guidelines

Guideliens disagree how long to follow lymphomas but the literaure favors those who do NOT recommend routine imaging. NCCN (DLCL and follicular) recommends:

•Repeating all positive studies at end of treatment
•Imaging every 3 to 6 months for 5 years, then yearly or as clinically indicated, based on disease site and clinical presentation

In contrast to the North American guidelines, the 2007 European Society of Medical Oncology (ESMO) specifically advises against routine imaging except to evaluate residual disease. These guidelines recommend:

•PET scan at end of treatment, if available
•Minimal radiologic examinations in patients with DLBCL at 6, 12, and 24 months after end of treatment, when indicated by site of disease

2007 International Working Group Guidelines for Lymphoma advise that follow-up will vary according to whether treatment was administered in a clinical trial or clinical practice, or whether it was given with curative or palliative intent. The panel advises against routine imaging given the lack of evidence supporting its role.

 

Zelenetz A, Abramson JS, Advani A, et al. NCCN Clinical Practice Guidelines in Oncology: Non-Hodgkin’s Lymphomas. Version 2, 2011. Available at: http://www.nccn.org/professionals/physician_gls/pdf/nhl.pdf.

Jost L. Newly diagnosed large B-cell non-Hodgkin’s lymphoma: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol 2007;18(Suppl 2):ii55–ii56.
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Cheson BD, Pfistner B, Juweid ME, et al. Revised response criteria for malignant lymphoma. J Clin Oncol 2007;25:579–586.

Cheson BD. The International Harmonization Project for response criteria in lymphoma clinical trials. Hematol Oncol Clin North Am 2007;21:841–854.