Mucoepidermoid pancreatic cancer is an exceedingly rare subtype of pancreatic cancer, with very little information regarding its diagnosis, treatment, and patterns of metastases. Here, the authors present the first reported case of cutaneous metastases of mucoepidermoid pancreatic cancer.

There is a broad range of possible diagnoses for an elevated beta human chorionic gonadotropin (β-hCG) in the absence of intrauterine or ectopic pregnancy. When women of child bearing potential undergo evaluation for clinical trial, it is often unclear what course of evaluation to take when a pregnancy test is positive. We describe the clinical course of a patient with widely metastatic mucinous ovarian carcinoma with metastasis to the peritoneum, lymph nodes and liver. The patient was found to have a mildly elevated β-hCG during initial evaluation for clinical trial. Extensive work up for ectopic pregnancy, trophoblastic disease, and phantom β-hCG were negative. The patient's β-hCG levels continued to rise until initiation of therapy. She was treated on a phase I protocol with restaging scans revealing a partial response. The β-hCG was retested and declined in conjunction with her response, consistent with paraneoplastic β-hCG. Here, we propose a decision making algorithm to evaluate a patient with an elevated β-hCG undergoing assessment for clinical trial.

The United States has a well-documented shortage of primary care providers (PCPs) and oncologists. Cancer survivors are living longer because of advances in treatment, and, consequently, more are seeking survivorship care from PCPs; this trend is predicted to continue. One proposed solution is to increase the use of nurse practitioners (NPs). However, most NP programs do not provide adequate training or education that is specific to the needs of long-term cancer survivors. .

Although accumulated evidences have demonstrated the patients with some types of tumors benefit from anti-programmed death-1 (PD-1) monoclonal antibody, the possible synergistic effect of combination of PD-1 inhibitor and radiotherapy still needs to be explored. A phase II trial was conducted to assess the clinical efficacy and safety of multisite stereotactic radiation therapy (SRT) or stereotactic body radiation therapy (SBRT) combined with PD-1 inhibitor and GM-CSF for the treatment of chemo-refractory patients. Materials/Methods: Participants had multi-metastatic solid tumors progressing beyond at least first-line chemotherapy. They were treated with SRT/SBRT (3 doses of 8Gy) for one metastatic site. On the second day after radiotherapy, PD-1 inhibitor 200 mg once was intravenously administered and GM-CSF 200 mg daily was subcutaneously injected for 2 weeks. This course was repeated every 3 weeks, targeting a second metastatic site. Triple-combination therapy was given for at least 2 cycles. After the combination therapy, maintenance with PD-1 inhibitor was administered until disease progression or unacceptable toxicity. The primary end points included safety, toxicity, progression-free survival (PFS) and overall survival (OS). Results: A total of 15 patients were enrolled. The median number of metastatic lesions was 8(95%CI, 5.5 to 20.5) and the median sum of the longest diameter of all measurable lesions was 158.0mm (95%CI, 98.9 to 287.3mm). All patients completed two cycles or more of the triple-combination therapy. Some remarkable tumor regression was observed at both the irradiated focus and distant metastatic sites at the time of evaluation. The median PFS was 3.3 months (95%CI, 2.3 to 7.2months). Treatmentrelated adverse events of any grade occurred in 13 (86%) patients, and grade 3 and higher adverse event like pneumonitis occurred in 2 (13.0%) patients. Conclusion: A combined therapy consisting of SRT/SBRT, GM-CSF and PD-1 inhibitor is well tolerated. With the new chemo-free regimen, myelosuppression hasn't been detected and gastrointestinal side effects remained low. Our data suggest triple-radioimmunotherapy could result in greater synergistic efficacy. They are considered as a new treatment option for patients with chemotherapy-refractory metastatic solid tumors.

PURPOSE In an effort to promote cost-conscious, high-quality, and patient-centered care in the palliative radiation of painful bone metastases, the National Quality Forum (NQF) formed measure 1822 in 2012, which recommends the use of one of the four dose-fractionation schemes (30 Gy in 10 fractions, 24 Gy in 6 fractions, 20 Gy in 5 fractions, or 8 Gy in a single fraction). We investigated whether a custom electronic health record (EHR) alert system improved quality measure compliance among 88 physicians at a large academic center and institutional network. METHODS In March 2018, a multiphase alert system was embedded in a custom web-based EHR. Prior to a course of palliative bone radiation, the alert system notified the user of NQF 1822 recommendations and, once prescription was completed, either affirmed compliance or advised a change in treatment schedule. Rates of compliance were evaluated before and after implementation of alert system. RESULTS Of 2,399 treatment courses, 86.5% were compliant with NQF 1822 recommendations. There was no difference in rates of NQF 1822 compliance before or after implementation of the custom EHR alert (86.0% before March 2018 v 86.9% during and after March 2018, P = .551). CONCLUSION There was no change in rates of compliance following implementation of a custom EHR alert system designed to make treatment recommendations based on national quality measure guidelines. To be of most benefit, future palliative bone metastasis decision aids should leverage peer review, target a clear practice deficiency, center upon high-quality practice guidelines, and allow flexibility to reflect the diversity of clinical scenarios.