Chairman’s Letter

Michael J. Hennessy
In this issue of The American Journal of Hematology/Oncology®, the use of case reports takes center stage. Whether serving as the first line of evidence for new interventions or sounding the alarm to indicate challenges that exist for established therapy, case reports can contribute to the knowledge and education of medical students, residents, and fellows.

These reports can serve as medical students’ first experience with medical writing by establishing a foundation for eventual manuscript preparation. I encourage our readers to continue to foster this academic spirit so that all—patients and their clinicians—may benefit.

But before we explore the case reports, Shlomit Strulov Shachar, MD, and Hyman B. Muss, MD, address the challenge of assessing treatment response in patients with metastatic breast cancer in their article, “Assessing Treatment Response in Metastatic Breast Cancer.” Despite a multitude of approved agents, there have been no convincing major advances in the overall survival of patients with metastatic breast cancer. Also, the assessment of treatment response has become more complicated with advances in imaging and technology, notably the measurement of circulating tumor cells. The researchers contend that response assessment outside of clinical trial settings should involve minimal testing unless it is necessary to evaluate continuing or worsening signs and symptoms. They note that physical examination can suffice, with imaging used less frequently. When liver metastasis is involved, assessing liver enzymes in patients with initial elevations is very helpful, with imaging reserved to confirm progression.

Male breast cancer accounts for less than 1% of all breast cancers according to a study in 2003 by Weir et al. However, the time from onset of symptoms to diagnosis in men is longer than in women (approximately 22 months), and as a result, men often present with later-stage disease, most likely due to a lack of awareness that men can develop breast cancer. Genetically, while male BRCA1 mutation carriers have approximately a 1.2% risk of developing breast cancer, male BRCA2 mutation carriers have a 6.3% lifetime absolute risk of breast cancer. This is a 100-fold higher risk than exists in the general male population. In their article, Lucy R. Kahn, BSc (Hons) MB ChB MRCSEd, and J. Michael Dixon, BSc (Hons) MB ChB MD FRCS FRCSEd, discuss the case of a 43-year old man who presented in 2002 with a painless breast lump and a strong family history of breast cancer. The patient underwent surgery and endocrine therapy, followed by a regimen of 4 cycles of epirubicin and 8 cycles of cyclophosphamide plus methotrexate plus fluorouracil, with adjuvant radiotherapy. What the authors detail is this patient’s subsequent progression and eventual systemic therapy with exemestane, and then, tamoxifen. The patient has had stable disease for the past 4 years on tamoxifen.

In “How to Refine Treatment Choice in Follicular Lymphoma: From Low Tumor Burden to High-Risk Follicular Lymphoma,” authors Peter A. Riedell, MD, and Brad S. Kahl, MD, both from the Washington University School of Medicine, emphasize the importance for oncologists to assess a number of patient-specific factors, including age, disease burden, comorbidities, and coping mechanisms for the treatment of patients with follicular lymphoma, the most common subtype of indolent non-Hodgkin lymphoma. Their article focuses on the current treatment approach of watch-and-wait, in light of the introduction of the anti-CD20 monoclonal antibody rituximab.

Two cases of immune thrombocytopenia, characterized by anti-platelet autoantibody production and enhanced platelet destruction, bring to light the role of C1 esterase inhibitor (C1-INH), according to an article by Erin Roesch, MD, and Catherine Broome, MD, both from the Lombardi Comprehensive Cancer Center. In their article, “Complement Blockade with C1 Esterase Inhibitor in Refractory Immune Thrombocytopenia,” they hypothesize that complement activation/deposition may play an important role in persistent thrombocytopenia in refractory ITP, and blockade of the classical pathway with C1-INH may lead to prolonged platelet survival.

As always, we hope you find this current issue educational and thought-provoking and we welcome your opinions, perspectives, and suggestions on topics. 
Michael J. Hennessy, Sr
Chairman and Chief Executive Officer

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