[Show abstract][Hide abstract] ABSTRACT: Head and neck cancer (H&NCa) patients have an increased risk of malnutrition and dysphagia because of their malignancy and the adverse events of therapy. Most of these patients require gastrostomies. Four percent to 7% of H&NCa patients are unable to undergo per oral percutaneous gastrostomies. Transnasal endoscopy is an option for gastrostomy placement in selected patients.
Clinical, epidemiologic characteristics and outcomes of transnasal PEG (t-PEG) placement.
Tertiary care hospital, The University of Texas MD Anderson Cancer Center.
All patients who underwent t-PEG placement.
Epidemiology, adverse events, and outcomes of t-PEG placement.
Sixteen patients underwent t-PEG placement from January 2010 to May 2013. All patients had H&NCa and 56.3% had metastasis. Indications for the transnasal approach were airway compromise, malignant oropharyngeal obstruction, and trismus, among others. All procedures were successful using a 20F gastrostomy tube, push technique, anesthesiologist-guided propofol sedation, and/or nasotracheal intubation. Of all patients, 68.8% were white and 68.8% were men. Mean age was 54 years, and mean body mass index was 20.87. Two patients had a total of 2 adverse events: poor wound healing and wound site infection. Of all patients, 18.75% had leukopenia, 6.25% neutropenia, and 50% lymphopenia. Mean white blood cell count, absolute neutrophil count, and absolute lymphocyte count were 8.6 × 10(9)/L, 6.57 × 10(9)/L, and .93 × 10(9)/L, respectively. Eleven patients were alive, 2 were lost to follow-up, and 3 had died at the time of review.
Retrospective analysis, small cohort, patient selection bias.
t-PEG placement is a viable and safe option for H&NCa patients when the standard endoscopic approach is not feasible.
No preview · Article · Oct 2013 · Gastrointestinal endoscopy
[Show abstract][Hide abstract] ABSTRACT: The impact of clinical and cardiovascular parameters on post TIPS survival has been poorly defined. This study aims to evaluate the role of multiple factors, including race, liver pathology, pre-TIPS MELD, change in MELD post-TIPS (ΔMELD), and EKG and echocardiographic parameters, as predictors of 90 day survival after TIPS.Materials and MethodsA retrospective institutional review was performed on 121 consecutive patients that underwent successful TIPS placement between January 2006 and December 2011. MELD was calculated within 30 days prior to TIPS and also 15 to 45 days after TIPS. Echocardiographic and EKG parameters were obtained within 6 months before and after TIPS. Race, procedural indication, and liver pathology were also documented. Univariate and multivariate analysis was then performed to look at 90-day mortality predictors.Results96 of the patients had a minimum of 90 day follow-up, and calculations were based on these patients. Mean age was 55. 55% of patients had HCV and 49% had alcohol related liver disease. Pre and post-TIPS MELD scores were 15.4 and 17.6, respectively. On EKG, mean pre and post TIPS QTc were 461 and 469. 18 patients (19%) died within 90 days of the procedure. In univariate analysis, pre-TIPS MELD (OR=1.33, p<0.001), ΔMELD >4 post-TIPS (OR=1.34, p=0.001), post-TIPS MELD >18 (OR=8.72, p<0.001), and pre-TIPS QTc >480 (OR=7.00, p=0.01) were statistically significant predictors of 90-day mortality. In multivariate analysis, pre-TIPS MELD (OR=1.59, p=0.004) and ΔMELD >4 post-TIPS (OR=1.4, p=0.006) were the only statistically significant predictors of 90 day mortality. Sex, race, age, liver pathology, procedure indication, and echocardiography were not statistically significant predictors in 90 day mortality.Conclusion
Pre-TIPS MELD and ΔMELD >4 post-TIPS are strong predictors of 90-day mortality. Other factors such as race, cardiac parameters, procedure indication, and liver pathology are unreliable in predicting 90 day mortality.
No preview · Article · Apr 2013 · Journal of Vascular and Interventional Radiology
[Show abstract][Hide abstract] ABSTRACT: Hepatitis C virus (HCV) is a known carcinogen with considerable genetic heterogeneity: six different genotypes have been identified. HCV genotype distribution varies from country to country. In the United States, the most prevalent genotypes are 1a, and 1b followed by genotypes 2, and 3.
To examine whether the distribution of HCV genotypes differed by cancer status among patients in the same area.
We reviewed epidemiologic and virological data of 636 patients with HCV infection evaluated at 3 institutions in Houston, Texas, in 2008 and 2009.
We included 129 cancer patients (53 with hematologic malignancies and 76 with solid tumors), 333 immunocompetent patients, and 102 HIV-co-infected patients. The prevalence of genotype 1 (G-1) was 66% among cancer patients, 84% among immunocompetents (P=0.00004), and 99% among HIV-co-infected patients (P<0.00001). G-2 and G-3 were more common in cancer patients than other patients. Demographics, risk factors, and duration of HCV infection were similar between cancer and immunocompetent patients. G-1 was more prevalent in immunocompetents (84%) than in patients with hepatocellular carcinoma (74%, P=0.08) or lymphoma (59%, P=0.001). G-2 was more prevalent in lymphoma patients (24%) than in immunocompetents (8%, P=0.003); cancer risk was 3 times as great with G-2 as with other genotypes (OR 3.72, 95% CI 1.38-9.76).
This multicenter retrospective study provides evidence of differences in HCV genotype distribution by underlying disease among geographically related patients and suggests a possible greater carcinogenic potential of some variants. Large-scale prospective studies are warranted to investigate HCV genotype distribution in other regions.
Full-text · Article · Mar 2012 · Journal of clinical virology: the official publication of the Pan American Society for Clinical Virology
[Show abstract][Hide abstract] ABSTRACT: Background: There is no evidence-based information about management of cancer pts with hepatitis C virus (HCV) infection. Unfortunately, studies that address HCV therapy exclude pts with cancer, in part because baseline hematologic abnormalities can be exacerbated by HCV therapy. We report the experience with the HCV clinic in our cancer center.
Methods: In 08/2009, a clinic devoted to managing the needs of HCV-positive pts with cancer was started in our center in a collaborative effort between hepatologists and infectious diseases (ID) specialists. HCV-infected pts were initially evaluated by ID. Pts with indications for antiviral treatment were initiated on pegylated interferon alfa 2 (a or b) plus ribavirin following AASLD/IDSA/ACG guidelines. Pts in which therapy was not recommended (e.g. unwillingness to undergo treatment, metastatic cancer, severe anemia, neutropenia, or thrombocytopenia) were followed by hepatologists.
Results: Sixty-five pts were seen between 8/09 and 5/11 in the clinic. The majority of pts (43 or 66%) had solid tumors, followed by lymphoma (13 or 20%). Fifteen pts (23%) were started on therapy; most of them (13 or 87%) were cancer survivors while 2 had active non-metastatic solid tumors. Frequent visits to monitor for adverse events (AE) were needed, with all patients requiring biweekly visits during the first 3 months of therapy; followed by monthly visits during the rest of the treatment period. The median number of visits was 12 (range 6-13). Among pts who completed therapy, sustained virological response and relapse were observed in 38% and 11% of pts, respectively. Depression requiring psychiatric evaluation and treatment occurred in 50% of treated pts. Hematopoietic growth factors were used in 38% of treated pts due to side-effects of HCV medication (e.g. anemia, neutropenia, or thrombocytopenia). Discontinuation of treatment because of significant AE was observed in 11% of pts. Progression of cancer occurring during therapy or the follow-up period did not occur in any cancer survivor.
Conclusion: Based on our standardized approach, we demonstrate that therapy is possible in this understudied population of HCV-infected pts. Close monitoring with a multidisciplinary approach is required for those started on therapy.
[Show abstract][Hide abstract] ABSTRACT: Vanishing bile duct syndrome (VBDS) refers to a group of disorders characterized by prolonged cholestasis as a result of destruction and disappearance of intrahepatic bile ducts. Multiple etiologies have been indentified including infections, neoplastic disorders, autoimmune conditions and drugs. The natural history of this condition is variable and may involve resolution of cholestasis or progression with irreversible damage. VBDS is extremely rare in human immunodeficiency virus (HIV)-infected patients and anti-retroviral therapy has never been implicated as a cause. We encountered a young pregnant female with HIV and VBDS secondary to anti-retroviral therapy. Here, we report her clinical course and outcome.
Preview · Article · Jul 2010 · World Journal of Gastroenterology