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Pregnancy, cancer, and radiation-a modern refresher.
No full textPURPOSE: Cancer occurs in ∼1 per 1,000 pregnancies; thousands of patients may require radiation procedures for diagnosis and treatment each year. This rare but high-risk scenario, coupled with fear of radiation, has created ambiguity in the ideal management of pregnant patients. Without a comprehensive guide for the use of radiation in imaging and treatment for pregnant cancer patients, it is difficult for providers to provide optimal patient-centered care without introducing disparities. The goal of this paper is to provide guidance on the use of radiation for screening, diagnosis, staging, and treatment of cancer, while highlighting gaps in existing knowledge and guidelines. The intention is that physicians, medical physicists, and patients could use this document as a resource for shared decision-making, ensuring safe and effective practice.
METHODS AND MATERIALS: A team of physicians and medical physicists with expertise in imaging, radiotherapy, and maternal fetal medicine was assembled, along with a patient advocate and lawyer. Existing guidelines and recent literature were reviewed. Authors also drew from their experience where published guidance was lacking.
RESULTS: The resulting document discusses best practice to guide use of radiation for cancer, as well as patient-centered care management and legal considerations.
CONCLUSIONS: It is possible to safely and effectively deliver radiation to pregnant patients in numerous circumstances. Use of radiation or other modalities should be discussed through shared decision-making with the physician and patient, contextualizing the maternal and fetal risk from treatments. Healthcare providers should support wide access to reproductive healthcare to allow equitable, evidence-based, patient-centered healthcare
Predictors of Peritoneal Surface Recurrence and Quantitative Association with Time to Relapse After Complete CRS/HIPEC for Colorectal Peritoneal Metastasis.
No full textBackground/objectives: Peritoneal surface metastases (PSMs) from colorectal cancer have high rates of peritoneal recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Prior studies dichotomize peritoneal recurrence into early and late, limiting insight into how clinicopathologic factors influence recurrence timing. This study aimed to identify predictors of peritoneal recurrence and quantify their continuous association with time to recurrence following CRS/HIPEC.
Methods: Patients undergoing CC-0 CRS/HIPEC for colorectal PSM from 2018 to 2024 were identified from a prospectively maintained database. The primary outcome was peritoneal surface recurrence. Variables included peritoneal cancer index (PCI), tumor location, histology, HIPEC regimen, and KRAS/BRAF/SMAD4 status. Factors with p \u3c 0.10 on univariable analysis were entered into multivariable logistic regression (recurrence: yes/no) and linear regression (time to recurrence).
Results: Among 133 patients, 64 (48.1%) developed peritoneal recurrence. Median time to recurrence was 41.4 weeks (IQR 24.9-74.0), and PCI was higher among those who recurred (median 11.0 vs. 5.0, p \u3c 0.01). Neither tumor stage, histology, intraperitoneal chemotherapy agent, nor molecular alterations were associated with increased risk of peritoneal recurrence. When controlling for PCI, right- and sigmoid-colon primaries independently predicted peritoneal recurrence compared to all other locations without influence on recurrence timing (right: OR 7.18; sigmoid: OR 6.54; p \u3c 0.01). Among patients who recurred, each one-point increase in PCI corresponded to a 2.43-week earlier relapse (p \u3c 0.01).
Conclusions: Nearly half of patients with colorectal PSM recurred despite complete CRS/HIPEC. Tumor location predicted peritoneal recurrence, while PCI independently shortened time to relapse. Modeling PCI as a continuous predictor refines postoperative risk stratification and may inform individualized surveillance strategies
Genomic determinants of response and resistance to pirtobrutinib in relapsed/refractory chronic lymphocytic leukemia.
No full textPirtobrutinib, a noncovalent, reversible Bruton tyrosine kinase inhibitor (BTKi), demonstrated efficacy in patients with chronic lymphocytic leukemia (CLL), resistant to covalent BTKi (cBTKi). We analyzed genomic correlations with response and resistance to pirtobrutinib in relapsed/refractory (R/R) patients with CLL pretreated with cBTKi enrolled in the phase 1/2 BRUIN trial. DNA sequencing was performed on peripheral blood mononuclear cells at baseline, on treatment, and at progressive disease (PD). Common alterations at baseline included mutations in BTK (43%), TP53 (38%), SF3B1 (25%), NOTCH1 (23%), ATM (19%), XPO1 (11%), PLCG2 (9%), BCL2 (8%), and 17p deletion (28%). Common baseline BTK mutations included C481S (85%), C481R (10%), C481F (6%), and C481Y (4%). At PD, 60 of 88 patients (68%) acquired ≥1 mutation, including 44% with acquired BTK mutations and 24% with other acquired mutations. A total of 55 acquired BTK mutations were detected in 39 patients, including gatekeeper mutations (T474I/F/S/Y/L, 26%), kinase-impaired L528W (16%), C481S/R/Y (5%), V416L (2%), and A428D (1%) and others proximal to the adenosine triphosphate-binding pocket, D539A/G/H (1%) and Y545N (1%). Decrease or complete clearance of BTK C481x was observed at PD in 36 of 43 patients (84%). Using a more sensitive assay, 37% (18/49) of acquired BTK mutations were detected at baseline at low allele frequency. Using a highly sensitive assay at progression, a similar frequency of acquired BTK mutations (39%) was detected, and all patients had detectable acquired mutations. This study highlights the complex clonal dynamics of BTK mutations in patients with R/R CLL undergoing pirtobrutinib treatment, and the extent of resistance without an obvious genomic driver. Trial registration: #NCT03740529 at www.ClinicalTrials.gov
Diverticular Disease.
No full textOur approach to the diagnosis and treatment of diverticulitis has evolved over the past 20 y. Routine use of antibiotics has decreased with recent studies suggesting simple cases of diverticulitis can be selectively managed without antibiotics. The criteria necessitating surgical intervention have also been amended as our understanding of the natural history of diverticulitis has grown. We favor selective use of antibiotics, percutaneous drainage, and surgery depending on the severity of the disease, patient factors, and clinical context
Climate Action and Decarbonization Advocacy.
No full textHealth professionals and health care organizations globally are beginning to recognize that climate change significantly threatens patient health and the sustainability of health care systems. To address these issues, health care professionals can use three approaches-mitigation, adaptation, and advocacy-to promote climate action, decarbonize the health care system, transform health care practice, and develop policies that protect the public. In this article, we discuss advocacy, focusing on the ways nurses can use their professional and personal voices to address climate change
Creating a Culture Change Around Stroke: Integrating Process Improvement to Reduce Door-to-Needle Time
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The Incidence of Malignancy and Autoimmune Disorders After Thymectomy: An Exploratory Study.
No full textObjectives: Thymectomy reportedly increases the risk of cancer, autoimmune disease, and death. Studies are few and data limited. We sought to determine the incidence of postoperative malignancy and autoimmune disease in patients who underwent thymectomy.
Methods: We conducted a retrospective review of adult patients undergoing thymectomy between 2008 and 2020. Postoperative cancers and autoimmune disease were diagnosed after thymectomy. Incidence rates were calculated using patient-years and compared to the National Cancer Institute\u27s (NCI) Surveillance, Epidemiology, and End Results (SEER) programme incidence of cancer for the US general population. Autoimmune disease rates were compared to previously published results.
Results: There were 226 patients with a median age of 55 years (interquartile range [IQR] = 39-67), mostly female (129, 57%) and non-smokers (132, 58%). At baseline, 117 (52%) had autoimmune disease, including 102 (45%) with myasthenia gravis. Eighty-four (37%) thymomas were identified. Median follow-up was 6.0 years (134 with \u3e5-year follow-up and 44 with \u3e10-year follow-up). We observed 13 (6%) new malignancies for an incidence of 0.87 cases/100 person-years (0.87%) and comparable to the NCI rate of 0.81 cases/100 person-years (0.81%). Incident cancers developed within the first 5 years after surgery at 0.92 cases/100 person-years (0.92%) or 4.6% cumulatively over 5 years, compared to NCI data at 4%. There were 19 (8%) new autoimmune diagnoses with an incidence rate of 1.3 cases/100 person-years (1.3%) and is higher than large population studies (0.7 cases/100 person-years for all ages).
Conclusions: Development of new cancers following thymectomy in the United States is similar to the general population. But we identified a higher incidence of autoimmune disease, matching prior studies
