Predicting survival in patients with advanced disease is challenging for health care providers. Accurate survival estimation using symptom assessment may assist physicians and patients in determining treatment options. This report analyzes prospective studies in adult patients with a median/mean survival of 6 months or less and identifies symptoms that are associated with decreased survival. To be included in this analysis, a study needed to have at least one symptom associated with decreased survival in a univariate or multivariate analysis. Twenty-two studies were identified and 15 symptoms were associated with decreased survival. Anorexia, delirium, and dyspnea were associated with decreased survival in most studies. Delirium and anorexia (but not dyspnea) were associated with decreased survival in most studies that included patients with a median survival of 30 days or less. More research is needed to investigate any associations between symptom characteristics and survival in patients with advanced disease. Short assessment tools using symptoms identified in this report, with a focus on symptoms that were found in multiple studies, need to be developed to better predict survival and guide patient treatment.

We present a 46-year-old Caucasian male who was referred to our facility for evaluation and treatment of acute myelogenous leukemia (AML-FAB M5b). Prior to coming to our facility, he failed 7+3 induction twice and high-dose Ara-C induction once. He presented to our institution with 87% blasts in his bone marrow, left orbital involvement, and a mediastinal chloroma. He was given 2,500 cGy of radiation to the left orbital region and enrolled in an experimental protocol using daunorubicin, Ara-C, topotecan, and etoposide. He subsequently failed this protocol and was then put on MEC (mitoxantrone, etoposide, and Ara-C). Because of CNS involvement of his leukemia, intraventricular methotrexate via an Ommaya reservoir was planned.The Ommaya reservoir was placed and cleared by neurosurgery prior to its use. The first dose of intraventricular MTX (MTX, 12 mg, with hydrocortisone, 25 mg, intrathecally) via the Ommaya was administered according to standard precautions and proceeded without any complications. Four days later, a second dose of intraventricular methotrexate was administered. Within 4 min of this dose, the patient went into generalized tonic clonic status epilepticus. The patient was given lorazepam, propofol, loaded with phenytoin, and intubated for airway protection.A CT scan and EEG were obtained. The CT scan showed a minute amount of postoperative pneumocephalus. Otherwise, the CT showed no gross abnormalities. The EEG was done about 3 hr after intubation and was markedly abnormal. It showed poorly developed background activities and diffuse slow-wave activities associated with voltage suppression, thereby indicating a postictal state. The patient's condition improved overnight, and he was extubated the next day.Four days later, a third dose intraventricular methotrexate was administered in an ICU setting. Prior to administration of the methotrexate, the patient's phenytoin level was checked and documented to be therapeutic. Again within 5 min, patient went into complex partial status epilepticus.Our team addressed the possibility that his seizures might have been secondary to physical irritation of the brain from manipulation of the Ommaya reservoir. However, injection of normal saline into the reservoir did not induce any seizure activity. We also investigated the methotrexate that was given to the patient. Correct concentrations of methotrexate were administered. We also did not believe that the methotrexate was contaminated. Therefore, we concluded that the status epilepticus was induced by the intraventricular methotrexate.In adult AML, patients with CNS involvement can be treated with high-dose cytarabine, intrathecal methotrexate, cranial irradiation, or combinations of these modalities [1]. For active meningeal leukemia, the standard of therapy is intrathecal or intraventricular methotrexate [2]. In childhood acute lymphoblastic leukemia, CNS therapy is highly recommended [3]. CNS therapy with irradiation and methotrexate is associated with a wide variety neurotoxicities, which have been categoriz...

19574 Background: In treating Stage III non-small cell lung cancer in the elderly, oncologists often empirically adjust treatment without clear guidelines. Identifying patient characteristics that impact prognosis will aid in creating better treatment algorithms in this patient population. Methods: A retrospective analysis was done on older patients (age > 70) treated for Stage III NSCLC (excluding “wet” IIIB) at the H. Lee Moffitt Cancer. Cox multivariate analysis identified variables impacting progression free survival, overall survival, treatment chosen, treatment interruptions, and hospitalizations. Correlation and regression tree analysis (CART) was performed to create potential decision making models. Results: 213 patients were evaluable. Multivariate analysis identified ECOG performance status (hazard ratio = 1.52, p = 0.005) and nodal status (HR = 1.36, p = 0.001) as negatively associated with PFS while BMI (HR = 0.96, p = 0.02) was positively associated. ECOG performance status (HR = 2.26, p < 0.0001), nodal status (HR = 1.18, p = 0.08), and CIRS3 (having a comorbidity classified as severity 3; HR = 1.33, p = 0.02) were negatively associated with OS. BMI (HR = 0.95, p = 0.002) and CIRSmean (mean CIRS-G severity score; HR 0.61, p = 0.01) were positively associated with OS. These variables were also identified as the most significant splitters, along with smoking status and pulmonary function, in CART analyses. Trees using PFS and OS as outcomes were created with receiver operating curves (ROC) ranging from 0.64–0.75. A CART analysis targeting treatment modality chosen had ROCs ranging from 0.49–0.78. Conclusions: Our multivariate analysis found ECOG performance status, nodal status, and severe medical comorbidity as negatively associated with survival. Unexpectedly, BMI (at initial treatment), independent of weight loss, was found to be positively associated. Also, the splitter variables identified by CART analysis were very similar to the general multivariate model, but the weights differed in the various analyses and subgroups of patients. The CART analyses suggest that we can create decision making models with a range of applicability comparable to those commonly considered useful for clinical guidelines, i.e. about 60% of straightforward application. No significant financial relationships to disclose.

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