EUH Hunt Conference: What is the prognosis for adenocarcinoma of the lung?

The Bottom Line: There is an overall survival rate of less than 5 years.

  • Stage I: 68-92%
  • Stage II: 53-60%
  • Stage III: 13-36%
  • Stage IV: 0-10%

Reference: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 114774, Non-small cell lung cancer; [updated 2018 May 01, cited 15 May 2018]; [about 31 screens]. Emory access required.

Summary: Five-year survival is only 5-8% in patients with unresectable NSCL cancer. Patients with untreated T1 tumors have a survival rate of 9%. Five-year mortality is higher in men than in women.

5-year survival for patients with lung and bronchus cancer by stage at diagnosis:

  • 18% with disease at all stages
  • 55% with localized disease
  • 28% with regional disease
  • 4% with distant stage disease

A study considering intervention and age found that older age and less intervention is associated with poorer survival:

  • > 80 years: 47% no radiation/surgery, 7.4% 5-year survival
  • 70-79 years: 28% no radiation/surgery, 12.3% 5-year survival
  • < 70 years: 19% no radiation/surgery, 15.5% 5-year survival

Additional Information: DynaMed Plus provides breakdowns by stage, age, and other factors.

For information on the staging of lung cancer, see the IASLC Lung Cancer Staging Project.

Posted in EUH, Prognosis, Teaching pearls

EUH Hunt Conference: A review of Horner syndrome

The Bottom Line: Horner syndrome results from an interruption of sympathetic innervation to the eye. The classic triad is unilateral ptosis (slight narrowing of the ocular fissure), miosis (smaller pupil on the affected side), and anhidrosis (lack of perspiration on the forehead or face). Horner syndrome is not likely to cause any functional visual disturbance but is of great importance clinically as a “red flag” warning that the oculosympathetic pathway has been interrupted and thus there may be potentially life-threatening lesions in the head, neck, and chest.

Reference: Martin TJ. Horner syndrome: a clinical review. ACS Chem Neuroscience. 2018 Feb 21;9(2):177-186. Doi:10.1021/acschemneuro.7b00405

Summary: The first, and perhaps most important, aspect of evaluating suspected Horner syndrome is a careful history. The history often reveals an obvious cause, such as trauma or neck/chest surgery, or will show that the Horner syndrome had been present for many years and therefore may not require an extensive investigation. The history may also reveal other symptoms that would help localize the lesion causing the Horner syndrome. A careful examination is obviously also critical, as other causes of anisocoria or ptosis may need to be considered rather than Horner syndrome, and concomitant signs (for example, a sixth nerve paresis) may help localize a potential lesion. After this, pharmacologic testing can be helpful to confirm diagnosis. Many clinicians will elect not to evaluate Horner syndrome if it has been present for greater than two years.

Though often benign or idiopathic, the cause of Horner syndrome can be very threatening or even lethal, so understanding how to recognize, diagnose, and appropriately evaluate Horner syndrome is important to all clinicians.

Posted in Background question, Diagnosis, EUH, Teaching pearls

EUHM Report: What are the common presentations of hepatic abscess?

The Bottom Line: Most cases of hepatic abscess present at advanced age. One study reported a mean age > 57 years.19 This finding suggests that older individuals are more susceptible to bacterial infection and thus abscess formation.  Most of the symptoms of hepatic abscess are due to infection and are nonspecific and it can be quite difficult to diagnose in a timely manner.  The most commonly reported signs and symptoms (Table 2. Page 162) include fever in most but not all cases, abdominal pain, and hypotension

Mavilia, M. G., Molina, M., & Wu, G. Y. (2016). The Evolving Nature of Hepatic Abscess: A Review. Journal of Clinical and Translational Hepatology, 4(2), 158–168.

Hepatic abscess remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system.  Hepatic abscess can be defined as an encapsulated collection of suppurative material within the liver parenchyma, which may be infected by bacterial, fungal, and/or parasitic micro-organisms

Posted in EUHMidtown | Tagged

EUH Hunt Conference: What is the prognosis for patients with HIV-negative PCNSL?

The Bottom Line: Patients diagnosed with primary central nervous system lymphoma (PCNSL) who are HIV-negative have a higher prognosis compared to those with PCNSL who are HIV-positive. While the median survival range is from 10-20 months for HIV-positive PCNSL patients, there is more variability for HIV-negative patients, survival ranging from 12 to 37 months or longer.

References: Bayraktar, S., Bayraktar, U.D., Ramos, J.C. et al. Primary CNS lymphoma in HIV positive and negative patients: Comparison of clinical characteristics, outcome, and prognostic factors. J Neurooncol. 2011;101(2): 257-265.

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 115176, Primary central nervous system lymphoma; [updated 2017 Nov 29, cited 2018 April 25]; [about 14 screens].

Fadul CE & Ely P. Schmidek and Sweet’s Operative Nurosurgical Techniques. [Internet]. Philadelphia: Saunders; 2012 Jun. Chapter 12: Management of primary central nervous system lymphomas;[cited 2018 April 25]; p.149-159.

Gerstner ER, Batchelor TT. Primary Central Nervous System LymphomaArch Neurol. 2010;67(3):291–297. doi:10.1001/archneurol.2010.3

Norden, A.D., Drappatz, J., Wen, P.Y. et al. Survival among patients with primary central nervous system lymphoma, 1973-2004. J Neurooncol. 2011;101(3): 487-493.

Westin JR, Konoplev SN, Fayad LE, Medeiros L. Aggressive B-Cell Lymphomas. In: Kantarjian HM, Wolff RA. eds. The MD Anderson Manual of Medical Oncology, 3eNew York, NY: McGraw-Hill. Accessed April 25, 2018.

Summary: Factors such as age and type of treatment patients receive impact their overall survival rate. However, the most important prognostic factor is the status of the patient’s health prior to receiving treatment. Many patients can improve their condition by use of corticosteroids and thus be candidates for intensive chemotherapy-based regimens that are potentially curative (Westin, Konoplev, Fayad, and Medeiros, 2018).

Posted in EUH, Prognosis

EUH Dressler Conference: A review of cardiac sarcoidosis

The Bottom Line: Cardiac sarcoidosis (CS) is the cardiac manifestations of sarcoidosis, a systemic disease of unknown cause characterized by immune granulomas. Cardiac involvement is clinically apparent in 5% of patients with sarcoidosis, but detected in approximately 20% of white and black American persons and 70-80% of Japanese persons at autopsy. The classification of CS is based on disease course:

  • acute sarcoidosis (Lofgren syndrome) resolves spontaneously within 2 years
  • chronic sarcoidosis resolves within ≥ 3-5 years
  • refractory sarcoidosis characterized by progressive disease despite treatment

(DynaMed Plus, 2017)

References: Yatsynovich Y, Dittoe N, Petrov M, Maroz N. Cardiac sarcoidosis: A review of contemporary challenges in diagnosis and treatment. Am J Med Sci. 2018 Feb;355(2):113-125. Doi:10/1016/j.amjms.2017.08.009

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 306338, Cardiac sarcoidosis; [updated 2017 Mar 31, cited 2018 Apr 13]; [about 11 screens]. Available from Emory login required.

Summary: CS may be asymptomatic and is often presented by sudden death. Most deaths attributed to CS are caused by arrhythmias or conduction system disease, and congestive heart failure may occur. Current consensus on diagnosis relies on endomyocardial biopsy, in the absence of which, histologic proof of extracardiac sarcoid involvement is necessitated. The primary therapeutic approaches are broadly divided into two categories: pharmacological management and invasive or device oriented (Yatsynovich, Dittoe, Petrov, & Maroz, 2018).


Posted in Background question, EUH

VA Report: Why do some patients with heart failure experience severe sweating?

In Morgan and Nadas’s seminal study they reported that sweating was greater at rest in HF patients compared with controls. Moreover, recent studies suggest that HF patients have similar sweating responses to controls when exposed to passive wholebody heating (Table 1).

Table 1. A Summary of Findings From Key Studies to Date Examining Thermoregulation in the Context of HF

Balmain, B., Sabapathy, S., Jay, O., Adsett, J., Stewart, G., Jayasinghe, R., & Morris, N. (n.d.). Heart Failure and Thermoregulatory Control: Can Patients With Heart Failure Handle the Heat? Journal of Cardiac Failure., 23(8), 621-627.

A common finding among studies examining thermoregulation in the context of HF to date is that HF patients appear to demonstrate impaired heat-induced increases in SkBF compared with controls. Although the mechanisms responsible for impaired SkBF in HF are not yet well understood, it may be argued that the compensatory activation of neurohumoral mechanisms that increase with severity of the condition at least partially contribute to the blunted heat-induced rise in SkBF in HF patients

Posted in VA | Tagged

EUH Krakow Conference: Review of Kikuchi-Fujimoto Disease

Bottom line: “Kikuchi–Fujimoto disease, or Kikuchi’s disease, also known as histiocytic necrotizing lymphadenitis, is a rare, benign, self‐limiting condition characterized by cervical lymphadenopathy and fever….symptoms usually resolve spontaneously within 1–4 months. However, cervical lymphadenopathy can persist for up to 6 months and even 1 year. There is a possibility of recurrence, yet rates of only 3–4% have been reported. The treatment of Kikuchi’s disease is primarily supportive and aims to facilitate the relief of symptoms with the use of analgesics, antipyretics, and rest. In a more severe or protracted disease course, short‐duration oral corticosteroid therapy is the treatment of choice. There are no specific guidelines regarding the dosage or length of treatment. Hydroxychloroquine is another therapeutic option that has been used to achieve rapid clinical improvement in Kikuchi’s disease. The safety profile of hydroxychloroquine may make it a better alternative to long‐term, high‐dose corticosteroids as it has fewer adverse effects. Despite a lack of recommendation, intravenous immunoglobulin, given its immunomodulatory nature, has also been used successfully in patients with severe disease. The mortality rate with Kikuchi’s disease was calculated to be 2.1%. Patients diagnosed with Kikuchi’s disease should be subject to close long‐term monitoring for the possible development of SLE [systemic lupus erythematosus]. Kikuchi’s disease can precede the onset of SLE by years.”1 Review articles provides several histopathological and dermatological images of patients with the condition.

ReferenceMathew LM, Kapila R, Schwartz RA. Kikuchi-Fujimoto disease: a diagnostic dilemmaInt J Dermatol. 2016 Oct;55(10):1069-75. doi: 10.1111/ijd.13314. Epub 2016 May 21. 

Posted in Background question, EUH, Therapy