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We present a case of immune thrombocytopenia following a living donor kidney transplant. Thrombocytopenia started two days after transplant and continued up to seven weeks after transplant despite an extensive workup, treatment with steroids, intravenous immune globulin, and alterations in immunosuppression and other medications. In the absence of platelet transfusions, the patient's platelet count remained

e21534 Background: Patients with melanoma frequently develop central nervous system metastases. Oligometastatic disease is often treated either by surgical resection or by stereotactic radiotherapy. This study investigates the trends and clinical outcomes of patients with melanoma who have undergone surgical procedures on the central nervous system during their hospitalization. Methods: A retrospective cohort study was performed based on admissions of adult patients who underwent craniectomy/surgical resection for metastatic melanoma from 2002 -2014 using the Nationwide Inpatient Sample database. The primary outcome measure was all-cause in-hospital mortality. Secondary outcomes included length of hospital stay(LOS) and discharge disposition (home/home with health care and skilled nursing facilities/long term acute care (SNF/LTAC)). Factors associated with in-hospital mortality were examined by multivariable logistic regression. We adjusted for patient and hospital characteristics, payer, and comorbid conditions. We also examined trends of mortality for the study years. P was kept at 0.05. Results: There were an estimated 5972 discharges of patients with melanoma undergoing craniectomy/surgical resection during the study period. Patients undergoing surgical interventions were typically males (69%) and whites (79%). 98% of procedures were performed at teaching hospitals. Unadjusted all-cause in-hospital mortality was 3.1%. There was no significant difference in mortality over 13 years. Age, gender, and race were not associated with increased in-hospital mortality. Median LOS was 5 days (IQR 3-9 days). LOS was longer in elderly and those with higher Charlson co-morbid index. Of the survivors, 76% were discharged to home or with home healthcare while 24% were discharged to SNF/LTAC. Patients with age > 65 (OR 2.9; 95%CI 2.2-3.9, p < 0.001) and those with higher Charlson co-morbid index (OR 1.2; 95%CI 1.1-1.3) had higher odds for being discharged to SNF/LTAC. Conclusions: Patients who undergo craniectomy/surgical resection for melanoma have a low in-hospital mortality rate. One quarter of patients are discharged to SNF/LTAC.

e23549 Background: The clinical course of soft tissue sarcomas is often dependent on the grade of the tumor. The incidence of soft tissue sarcomas have been known to be higher in males compared to females and more in African Americans compared to Caucasians (1995 to 2008 SEER data). The variability of incidence-based mortality in low grade and high grade soft tissue sarcomas with respect to gender and race over the past decade has not been well studied. This study analyzes the rates of incidence-based mortality from the years 2000 to 2016 amongst for both the grades, genders and racial groups. Methods: The Surveillance, Epidemiology, and End Results (SEER) Database was queried to conduct a nation-wide analysis for the years 2000 to 2016. Incidence-based mortality for all stages of low grade and high grade soft tissue sarcomas was queried and the results were grouped by race (Caucasian/White vs African American/Black) and gender. All stages and ages were included in the analysis and trend from 2000 to 2016 was analyzed. Results: Incidence-based mortality rates (per 10000) for low grade and high grade soft tissue sarcomas for both races and genders are shown in the table below. The incidence-based mortality rates for Caucasians are similar to African American in both grades and genders. Rates were not analyzed for American Indian and Asian/Pacific Islanders due to small sample size. Mortality rates of high grade soft tissue sarcomas were significantly higher compared to low grade tumors. A higher rate of mortality is noted in Caucasian males compared to African Americans males despite past observations of higher incidence in African Americans. There was no significant change in the rate when trended over the past decade (2007 to 2016). Conclusions: This study highlights the higher rate of incidence-based mortality in Caucasian males compared to African American males in the past 15 years despite a lower incidence reported in the 1995 to 2008 period. With no significant change in mortality rates/year noted during this time period, this study implies that soft tissue sarcomas in Caucasian males have worse outcomes. Further research is needed to understand the mechanism underlying this disparity. [Table: see text]

e17510 Background: Squamous cell carcinoma is the most common histological-subtype of oral cavity tumors and no major advances in its treatment have occurred recently. However, p16 positive tumors have been noted to have a better prognosis than p16 negative tumors. Older patients have increasingly been found to have p16 positive oral cavity cancers. This study explores the incidence based mortality of geriatric patients irrespective of p16 status. Methods: Data from Surveillance, Epidemiology, and End Results (SEER) Database was extracted to study the incidence-based mortality for the years 2000 to 2014. Incidence-based mortality for all stages of oral cavity tumors was queried and the results were grouped by age (geriatric vs. non-geriatric) and race (Caucasian/White, African American/Black, American Indian/Alaskan native and Asian/Pacific Islander). All stages and both genders were included in the analysis. T-test was used to determine statistically significant difference between various subgroups. Linear trend lines were used to visualize the mortality trends between various subgroups (Geriatric vs. Non- geriatric and Caucasian vs. African American). Results: Incidence-based mortality for oral cavity tumors has worsened since 2000 to 2014 for geriatric patients (p < 0.05) when compared to non-geriatric patients in both Caucasian/White patients and African American/Black patients. The results are summarized in the table below. Conclusions: The similarity in incidence-based mortality for geriatric patients with oral cavity tumors is high in all races and may imply age as a significant risk factor in these patients. A stage-specific, gender-specific and age-binned analysis may help differentiate these concerning trends. [Table: see text]

Ninety-eight premenopausal patients with stage IV breast cancer were treated with chemoimmunotherapy alone, or with combination oophorectomy – chemoimmunotherapy either simultaneously (chemoimmunotherapy within four weeks of oophorectomy) or sequentially (delayed chemoimmunotherapy until evidence of progressive disease or no response to oophorectomy). The chemoimmunotherapy consisted of a three-drug combination of Adriamycin, cyclophosphamide, and 5-fluorouracil or Ftorafur; immunotherapy consisted of either oral levamisole, BCG by scarification, or a combination of both. Forty patients underwent simultaneous oophorectomy–chemoimmunotherapy, with a response rate of 85% and a median duration of response of 25 months. Response rate of 69% and a median duration of response of 16.6 months was observed with the 29 patients who received sequential oophorectomy–chemoimmunotherapy. Another 29 patients were treated with chemoimmunotherapy alone and achieved a response rate of 87% and a median duration of response of 11.8 months. Though there were no significant differences in the response rate, patients treated with chemoimmunotherapy alone had a significantly shorter median duration of response (P < 0.05). This would suggest that oophorectomy in combination with chemoimmunotherapy is the most favorable treatment modality for premenopausal patients with advanced metastatic breast cancer.

Fifty patients with breast cancer refractory to endocrine manipulation and/or combination chemotherapy were treated with mitomycin-C 20 mg/m2 I.V. every 4-6 weeks and megestrol acetate 160 mg daily. Of 48 evaluable patients, 4% achieved complete remission (CR), 23% had partial remission (PR). Median duration of response for CR and PR was 7 months. Non-responders had a median survival of 2 months. The difference in survival of responders (both CR and PR) and non-responders was statistically significant at p less than 0.01 level. Attenuated doses of mitomycin-C were administered at increasing intervals due to cumulative myelosuppressive toxicity.

Sarcomatoid renal adenocarcinomas are rare, invariably fatal tumors. There is only one report of treatment of this tumor with chemotherapy. We report a case of an advanced sarcomatoid renal adenocarcinoma treated with chemo-immunotherapy consisting of cyclophosphamide, vincristine, Adriamycin (doxorubicin), DTIC, BCG, and sarcoma viral oncolysate. The patient had an objective response with a marked reduction in the size of the tumor mass. The residual tumor was removed surgically, and the patient remains in complete remission two years after the diagnosis was made.

Hematuria and renal failure developed in two patients with metastatic breast carcinoma while they were receiving nonspecific immunotherapy and chemotherapy. The electron microscopy picture was suggestive of immune-complex glomerulonephritis.

To the Editor .—We take issue with an article by Wiener and Sachs ( Arch Surg 113:126-127, 1978) who categorically state that routine liver scanning for metastatic disease in patients with breast cancer should be abandoned unless there is evidence of abnormal liver function. The strength of their argument is based almost soley on the ability to separate patients requiring a liver scan by means of liver function studies. The points are made that in eight patients with documented false-positive scans, seven of eight of these patients had normal liver function tests and therefore could have been spared the unnecessary liver scan. In those 19 patients with abnormal liver scans who had histological documentation of metastases, 16 of the 19 patients had abnormal liver function tests, indicating again that a positive liver scan can be predicted based on abnormal liver function tests. It is well known that liver function tests when

To the Editor.— With the development of increasingly more effective cancer chemotherapy drugs and drug combinations, more patients will be receiving this form of treatment. One of the major toxicities of several antineoplastic drugs is stomatitis. At times the stomatitis may be of such severity as to limit the dose of the drug used and thereby compromise effective chemotherapy and possibly lead to septicemia during periods of myelosuppression. It has been postulated that the incidence of stomatitis may relate to the degree of dental plaque formation and periodontal disease during cancer chemotherapy. 1 Based on this finding, before patients receive chemotherapy, it is important that they receive a thorough dental evaluation and necessary dental care along with oral hygiene by a dentist to lessen the degree of stomatitis and possibly prevent it from occurring.

A case of cerebromedullospinal disconnection or "locked-in" syndrome after intraventricular methotrexate is described. This is an unusual complication of intraventricular methotrexate instillation. Ventral pontine infarction is postulated to be responsible for the syndrome.

Thirty-two patients with a diagnosis of primary inflammatory breast carcinoma were treated with combination chemoimmunotherapy consisting of 5-fluorouracil, doxorubicin hydrochloride (Adriamycin), and cyclophosphamide (FAC) plus BCG followed by radiation therapy. This group of patients was compared to a group of 32 consecutive historical controls treated with radiation therapy alone. The estimated mean disease-free interval for the FAC-BCG group was 16 months, compared to 9 months for the radiation therapy alone group (P less than 0.01). The estimated median survival for the FAC-BCG treated group was 24 months, compared to 18 months for the radiation therapy alone group (P = less than 0.03). The combined modality approach consisting of chemoimmunotherapy and radiation therapy significantly improved the disease-free interval and survival of patients with inflammatory breast carcinoma.

A patient receiving adjuvant chemoimmunotherapy for breast carcinoma developed urticaria secondary to cyclophosphamide, one of the drugs of the chemotherapy regimen. Chlorambucil, another alkylating agent, was substituted with no cross-sensitivity noted. ( Arch Intern Med 138:1725-1726, 1978)

To the Editor. — Campylobacter fetus commonly infects cattle and is transmitted venereally from the testes of bulls. In humans the route of infection is unclear, but man may acquire the disease by ingestion of contaminated water or food. 1 The infection usually occurs in adults with underlying disease such as chronic alcoholism or cardiovascular disease. However, it is uncommon in patients with malignant neoplasms. There have been isolated reports of C fetus infection associated with chronic lymphocytic leukemia, chronic myelogenous leukemia, hepatoma, and non-Hodgkin's lymphoma. 1 To our knowledge, this is the first report of the infection occurring in a patient with Hodgkin's disease. Report of a Case.— The patient is a 25-year-old man with a history of Hodgkin's disease, nodular sclerosis, stage IV with pulmonary involvement. Dysuria of two weeks' duration developed and was associated with urethritis and a purulent urethral discharge. Urine and urethral cultures were obtained

To the Editor.— There have been recent reports describing alterations in nail pigment with cancer chemotherapy. The changes occurred after various combinations of chemotherapeutic agents and consisted of transverse bands1-3and longitudinal bands.4We have recently encountered a woman with breast carcinoma in whom longitudinal nail banding developed prior to chemotherapy. Report of a Case.— A 49-year-old woman underwent a modified radical mastectomy in December 1975 for breast carcinoma, with six out of eight axillary nodes containing breast carcinoma. The patient was referred to our clinic for further evaluation of her condition. Findings from a physical examination were entirely normal without evidence of any abnormal skin pigmentation. All laboratory data were within normal limits. The patient was to receive postoperative radiation therapy to the peripheral lymphatics for local control and then adjuvant combination chemotherapy. The patient started radiation therapy on Jan 6, 1976, and within one week after

Spontaneous regression of breast carcinoma occurred in a patient with a malignant pleural effusion and bone metastases. The patient did not receive any form of hormonal manipulation or systemic chemotherapy. It is postulated that the spontaneous regression of the carcinoma may have been caused by immunological factors. ( Arch Intern Med 138:1734-1735, 1978)

Hyperpigmentation of the tongue and buccal mucosa was observed after administration of conbination chemotherapy containing doxorubicin. The pigmentation lessened after discontinuation of doxorubicin, suggesting this drug as the possible causative agent.

To the Editor.— E. S. Kurtides, MD, recently reported inThe Journal(238:28, 1977) on a patient with idiopathic thrombocythemia treated with busulfan in whom breast carcinoma developed. He also cited two reported cases of breast carcinoma developing in two patients with multiple myeloma (236:1609-1610, 1976), both were treated with melphalan and prednisolone, and one of the two patients received procarbazine hydrochloride in addition. We would like to report two cases of breast carcinoma occurring in patients treated with azathioprine. Report of Cases.—Case 1.— A 46-year-old woman had chronic active hepatitis in 1971 and was treated with azathioprine and prednisolone from May 1971 to December 1972, at which time the administration of prednisolone was discontinued. In June 1977 breast carcinoma was diagnosed in the left breast, and a left radical mastectomy was performed with no axillary metastases found. Case 2.— A 38-year-old woman had a donor-related (sibling) renal

Periodontal disease and dental plaque may predispose patients receiving antineoplastic drugs to stomatitis. Dental evaluation and appropriate treatment including oral hygiene are proposed to reduce the incidence and severity of stomatitis.

Excerpt To the editor: Breast carcinoma commonly metastasizes to the liver. When this occurs in a patient receiving chemotherapy, it indicates that chemotherapy has failed and must be discontinued....