Download OncOlOgy PrOgram - Loyola Medicine

Oncology
Program
2014 Annual Report
Mission Statement
Trinity Health Mission Statement
We serve in Trinity Health, in the spirit of
the Gospel, to heal body, mind and spirit to
improve the health of our communities, and
to steward the resources entrusted to us.
Loyola University Health System is
committed to excellence in patient care
and the education of health professionals.
We believe that our Catholic heritage and
Jesuit traditions of ethical behavior, academic
distinction and scientific research lead to
new knowledge and advance our healing
mission in the communities we serve. We
believe that thoughtful stewardship, learning
and constant reflection on experience
improve all we do as we strive to provide
the highest-quality health care.
We believe in God’s presence in all our
work. Through our care, concern, respect
and cooperation, we demonstrate this belief
to our patients and families, our students and
each other. To fulfill our mission, we foster
an environment that encourages innovations,
embraces diversity, respects life and values
human dignity. We are committed to going
beyond the treatment of disease. We also
treat the human spirit.
Brand promise
The people of Loyola promise patients
that we go beyond the illness to treat
the whole person.
The Cardinal Bernardin Cancer Center is located on the east side of the campus and faces First Avenue. Parking is available in a parking lot
in front of the building and valet parking is available at the entrance. A coffee bar is located just inside the building on the first floor. Named in
honor of the late Archbishop of Chicago Joseph Cardinal Bernardin, the cancer center was the first free-standing facility in Illinois dedicated
to cancer research, diagnosis, treatment and prevention. Loyola’s cancer center contains all outpatient cancer care along with extensive
research laboratories, offices and educational space. Many of the multidisciplinary clinics within the cancer center provide a one-visit, oneteam approach, providing patients with a diagnosis and treatment plan in the same day. Patients can see their physician, have lab work done,
undergo chemotherapy and have cancer care-related prescriptions filled, among many other services in the building.
Table of Contents
Introduction
Chairman’s message .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. 3
Member list
Oncology committee members and specialties . . . . . . . . . . . . . . . . . . . 5
Oncology services
Services available .
.
.
.
.
.
.
Primary site table
Statistical breakdown of 2014 cases
Data analysis
Narrative results of 2014 cases
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. 6
. . . . . . . . . . . . . . . . . . . . . . 7
.
.
.
.
.
.
.
.
.
.
.
Cancer incidence
Cancer incidence by sex and site comparison with national and state
.
.
.
.
.
.
.
.
.
.
.
. 9
.
.
.
.
.
.
.
.
.
.
13
Patient care evaluation study of leukemia
Leukemia study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Patient care evaluation of larynx cancer
Larynx study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Glossary
Definitions and references . . . . . . . . . . . . . . . . . . . . . . . . . 53
2014 Oncology Program Annual Report • 1
Message from the Chairman
The year 2014 brought combined improvements to the wide
array of cancer services available to patients of Loyola
University Medical Center, American College of Surgeons
Accredited Oncology Program. It is with great pleasure to
offer my congratulations to the entire cancer team from
administration to all clinical and volunteer staff in this
institution to providing high quality cancer care to our
patients, meeting and exceeding the standards set by our
Cancer Program.
This report provides an overview of the Program’s
organization of services and highlights a statistical summary
in a narrative, tabular and graphic form of all cancer cases
diagnosed and treated at Loyola University Medical Center.
Through our commitment and determination the
accomplishments of the Oncology program is wholly
dependent upon the tireless efforts of a team of caring
professionals, without whom we could not strive to reach our
goal in providing oncology service of highest caliber.
In 2014, Loyola Medical Center Cancer Program was
granted a three year accreditation and received the
Outstanding Achievement Award for receiving a
commendation rating for all standards.
Loyola’s Cardinal Bernardin Cancer Center offers a
multidisciplinary approach to cancer care, which brings
together a wide range of medical experts who evaluate
conditions and provide a comprehensive treatment plan,
often on the first visit. The Cardinal Bernardin Cancer Center
offers the latest treatments delivered with compassionate
care. Patients also have the opportunity to participate in
national research studies with new drug therapies, and
they have access to complementary and supportive care,
including art therapy, massage therapy, biofeedback, pain
management, nutritional counseling, psychotherapy and
pastoral care. In 2014, low dose lung screening CT was
offered at Loyola University Medical Center. The screening
for lung cancer is done using non-invasive, low-dose CT
technology. Loyola offers screening with low-dose computed
tomography (CT) for people at high risk for lung cancer, the
only recommended screening test for the disease.
2 • Loyola University Health System
Millions of Americans are living with a personal history
of cancer, and that number continues to grow each year.
Whether these patients are in the midst of cancer treatment
or celebrating remission, Loyola Medicine believes every
cancer patient deserves compassionate care through
diagnosis, treatment and beyond.
Our team offer innovative (HIPEC) heated intraperitoneal
chemotherapy treatment of abdominal cancers. According to
research studies, when it is used for appropriate candidates
as part of a multidisciplinary treatment approach in an
experienced setting, outcomes will be favourable compared
to standard combination therapy, with the added benefit of
shorter-term side effects.
Intrabeam intraoperative radiation therapy, also known
as IORT, is another of the many ways Loyola Medicine’s
expertly trained doctors use advanced technology for cancer
treatment. IORT is a radiation treatment that is administered
during surgery to deliver a concentrated dose of radiation
therapy directly into the cavity where a tumor has been
removed.
As a cancer survivor patient, healthcare needs have been
forever altered, and Loyola is committed to providing the
specialized care necessary to help each patient bridge
the gap between their oncologist and cancer team to
their primary care physician. The first of its kind in the
Midwest, the Cancer Survivorship Program at the Loyola
Cardinal Bernardin Cancer Center is designed to help
patients transition from patient to survivor. Loyola’s cancer
survivorship program is staffed by a physician director,
psychologist and nurses. In addition, our cancer patients
have access to the Coleman Foundation Image Renewal
Center, which provides all patients with access to the
following professionals: Genetic counselors, Nutritionists,
Pastoral care and Social workers
At Loyola, our goal is to improve the quality of patients’ lives
following cancer treatment, and to empower them, their
family and caregivers through education and advocacy.
During National Breast Cancer Awareness Month, breast
cancer survivors were invited to the “Bedazzle Your Bra”
event that occurred on October 28th 2014.
In 2014, Loyola University Medical Center became the
first hospital in Illinois to use a new MRI-ultrasound
imaging system that can result in fewer biopsies and better
treatment decisions for prostate cancer patients. U.S. News
& World Report has ranked Loyola University Medical Center
as the No. 3 hospital in Illinois.
Loyola Medicine has also expanded its cancer treatment
services to include the most advanced, precise form
of radiation treatment available today – proton therapy.
Through a unique clinical affiliation with the Northwestern
Medicine Chicago Proton Center – the region’s only proton
therapy center – Loyola Medicine has been increasing
access to the latest technologies and treatments to the
people and families we care for.
Loyola University Health System has entered into a clinical
affiliation agreement with Porter Regional Hospital in
Northwest Indiana. The affiliation has complemented the
quality care that patients receive at Porter Regional Hospital
by expanding access to academic research and clinical
care in Northwest Indiana. The Oncology Service Line also
worked closely with Michiana Hematology Oncology of
Indiana to establish a monthly clinic at their Mishawaka IN
location for patients referred for bone marrow transplant
consultation. The opportunity to establish this clinic
has presented itself through the relationship Michiana
Hematology Oncology has with St. Joseph Regional Medical
Center of South Bend IN, a Trinity affiliated organization.
Michiana Hematology Oncology is a multi-specialty oncology
group practice of sixteen physicians with specialties in
Hematology, Oncology, Gynecologic Oncology, and Radiation
Oncology. The practice has seven locations to include
South Bend, Crown Point, Elkhart, Mishawaka, Plymouth,
and Westville, and treats approximately ninety percent of all
cancers in their region. The first Transplant clinic in Indiana
was conducted February 18 by Patrick Stiff, MD.
2014 Oncology Program Annual Report • 3
Member List
The Cancer Committee membership is multidisciplinary, representing physicians from the diagnostic and treatment
specialties and non-physicians from administrative and supportive services. The following list of Committee members
in 2014 reflects the multidisciplinary nature of the Cancer Committee.
Memeber
Specialty
Constantine Godellas, MD
Oncology Program Committee Chairman
Gerard Abood, MD
Oncology Program Cancer Liaison Physician
Carol Bier-Laning, MD
Surgical Oncology
Davide Bova, M.D.
Diagnostic Radiology
Krista Curley, RHIA
Director, HIM, LUMC
Violeta Dimovic, CTR
Manager, Oncology Data Management
Maria Estrada
Oncology Data Management
Debbie Fager
ACS Representative
Linda Flemm, RN, APN, AOCNS
Nursing
Kathleen Fujiu, RN, BA, BSN, MBA, OCN
Nurse Manager 6 West, Coordinator
Megan Giblin
ACS Nurse Navigator
Sister Fran Glowinski
Associate Chaplain, Pastoral Care
Kathy Grego, RHIT, CTR
Oncology Data Management, Coordinator
Ewa Jaraczewska
Manager, Orthopedic Surgery & Rehabilitation
Elizabeth Henry, MD
Hematology/Oncology
Kelli Hutchens, MD
Pathology
Margaret Liotta-David, DO
Assistant Professor OB/Gyne Cancer Center
Tess McCoo
Radiation Therapy
Edward Melian, MD
Radiation Therapy
Angelique Mercier
Genetic Counselor
Stephanie Mills, RHIT
Oncology Data Management
Laura Morrell
Social Work, Cancer Center, Coordinator
Patricia Mumby, PhD
Professor, Psycho-Oncology
Janet Palutsis, RN
Assistant Manager Clinic A Cancer Center
Gayle, Payonk
Cancer Service Line, Oncology Support Ex Director
Ceil Petrowsky, RN MSN CCRC
Manager Cancer Clinical Trials Office
Mark Speyer, MD
Palliative Care
Sheryl Svoboda
Dietician, Cancer Center
Peter Tortorice
Manager, Pharmacy Oncology
Prepared by: V. Dimovic, CTR
4 • Loyola University Health System
Surgical Oncology
Otolaryngology
Medical Services
All patients at the Cardinal Bernardin Cancer Center begin with a visit to one of the center’s specialty or multidisciplinary
clinics. There, the patient and family meet with the cancer specialist responsible for establishing an individual treatment
plan and coordinating care. Within our unique multidisciplinary setting, a patient will meet with a team of cancer experts
that may include surgeons, medical oncologists, radiation oncologists, radiologists, pathologists and plastic surgeons. These
specialists work together to evaluate a patient’s condition. During the same visit, patients might also meet with a nutritionist,
nurse, social worker or other supportive staff.
Programs and services
Below is a list of our programs and services for cancer care: loyolamedicine.org
Adrenal Cancer
Art Therapy
Hematology/Oncology Services
Anal Cancer
Cancer Survivorship Program
Home Care and Hospice
Bone Cancer
Caregivers Class for Bone Marrow
Transplant Patients
Image Renewal Center
Bone Marrow Transplantation
Breast Cancer
Breast Care
Breast Oncology Center
CAN-HELP Cancer
Information Service
Cancer Genetics
Evaluation Program
Cancer Risk Assessment
and Prevention
Cancer-Pediatric
Hematology and Oncology
Through our membership in the
Children’s Oncology Group, we
participate in clinical trials and
studies for pediatric conditions such
as: (Leukemia, Lymphoma, Brain
Tumors, Neuroblastoma, Wilm’s Tumor,
Rhabdomyosarcoma & Other Soft
Tissue Sarcoma, Bone Malignancies)
Centers for Fitness
Melanoma Clinic
Chaplain Services
Networking and Support
GroupsNeuro-Oncology Clinic
Chemotherapy Classes
Nutrition Services
Clinical Research
Orthopedic Oncology
Coleman Foundation Image
Renewal Center
Psychology Support Services
Gastroenterology Services
Gastrointestinal Oncology Center
Gynecologic Oncology Services
Head and Neck Oncology Clinic
Hematology Clinic
Radiation Oncology Services
Sarcoma Oncology
Screening and Early
Detection - Cancer
Skin Cancer and Mohs
Micrographic Surgery Center
Speech Therapy
Surgical Oncology
Thoracic and Lung Oncology
Program and Urologic Oncology
Clinic
*click on bolded programs and services to view website page.
2014 Oncology Program Annual Report • 5
Primary Site Table 2014
The following table summarizes the primary sites
by gender for 2014. The top five most frequent
occurring cancers at Loyola University Medical
Center in 2014 were: breast, lung, prostate, thyroid
and colorectal.
Analytic: A cases first diagnosed and / or receiving first course treatment at the
facility, or diagnosed at autopsy.
Non-Analytic: Any case diagnosed at another facility and receiving all first
course treatment at that facility, then seen at Loyola University Medical Center
for subsequent treatment.
6 • Loyola University Health System
Table: 1
Primary Site
All Sites
Male
Female
Analytic
1269
1387
2656
Non-analytic
Total
335
2991
Oral cavity
99
56
155
20
175
Lip
Tongue
Oropharynx
Hypopharynx
Other
2
40
3
5
49
3
14
0
5
34
5
54
3
10
83
1
8
1
0
10
6
62
4
10
93
Digestive System
265
177
442
51
493
Esophagus
Stomach
Colon
Rectum
Anus/Anal Canal
Liver
Pancreas
Other
15
19
39
35
7
75
53
22
4
16
47
25
6
30
35
14
19
35
86
60
13
105
88
36
2
8
13
9
1
8
3
7
21
43
99
69
14
113
91
43
Respiratory System
131
103
234
20
254
Nasal / Sinus
Larynx
Lung/Bronchus
Other
7
33
89
2
5
3
93
2
12
36
182
4
0
8
12
0
12
44
194
4
Blood and bone marrow
90
76
166
42
208
Leukemia
Multiple Myeloma
Other
45
24
21
45
18
13
90
42
34
18
17
7
108
59
41
Bone
2
7
9
0
9
Connective/soft tissue
14
18
22
2
24
Skin
100
54
154
21
175
Melanoma
Other
88
12
49
5
137
17
19
2
156
19
Breast
3
351
354
19
373
Female Genital
0
206
206
16
222
Cervix Uteri
Corpus Uteri
Ovary
Vulva
Other
0
0
0
0
0
24
118
42
16
6
24
118
42
16
6
3
6
6
1
0
27
124
48
17
6
Male Genital
229
0
229
26
234
Prostate
Testis
Other
208
8
13
0
0
0
208
8
13
26
3
1
234
11
14
Urinary System
163
78
241
37
278
Bladder
Kidney/Renal
Other
67
90
6
26
50
2
93
140
8
20
17
0
113
157
8
Brain and CNS
37
63
100
24
124
Brain (Benign)
Brain (Malignant)
Other
2
5
30
2
10
51
6
15
81
0
3
21
6
18
102
Endocrine
53
149
202
23
225
Thyroid
Other
39
14
130
19
169
33
16
7
185
40
Lymphatic System
62
39
101
25
126
Hodgkin’s Disease
Non-Hodgkin’s
9
53
1
38
10
91
5
20
15
111
Unknown Primary
14
7
21
2
23
Other/Ill-Defined
7
13
20
3
23
Data Analysis
Graph 1: Incidence per Year
Data shows that the number of cases diagnosed and treated at Loyola University Medical Center in 2014.
3000
2500
# of cases
2000
1500
# of cases
1000
500
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
In most of the 2014 cases, a total of 51% (1498), patients
received their initial diagnosis at LUMC; 36% (1085)
of patients were diagnosed elsewhere, but came in our
facility to be treated; 2% (73) of patients were diagnosed
at our facility and all their first course of therapy was done
elsewhere; and 11% (335) of the patients came here for
treatment of recurrent disease. (See Figure 1) Total 2,991
Most of the 2014 cases, 56% (1,471) of the patients
were seen from Cook county, followed by 17% (460)
from DuPage, 8% (204) from Will, 4% (116) from Kane.
Out-of-state cases accounted for 3% (84) and the
remaining others accounted for 12% (321).
Figure 1: Class of Case
Figure 2: Cases by Diagnosis County
11%
2%
12%
3%
4%
56 %
51%
8%
36%
Class 0
Cook
Class 1
Class 2
Class 3
17%
DuPage
Will
Kane
Out of State
Other
2014 Oncology Program Annual Report • 7
Data Analysis
For all analytical cases, the most frequent site is
Breast 33% (354). Next in frequency is the Prostate
with 20% (208), Lung 17% (182); Thyroid with 16%
(169) and finally Colorectal with 14% (146)
(See Graph 2) Total Cases 1059
For new analytic cases 52% (1387 ) were female
and 48% (1269) male. Graph 3 below shows that the
diagnosis of cancer was most found in the 60-69 year
range for males and females.
Graph 2: Five Major Sites
Graph 3: Age by Sex
416
351
350
300
332
Female
300
208
200
288
250
150
130
89 93
100
74 72
39
50
3
Breast
# of Cases
# of Cases
350
Male
250
0
401
400
250
Male
Female
200
103
150
123
0
Prostate
286
100
Lung
Thyroid
82
Colorectal
0
80
56
50
9
4
00-09
12
9
10-19
14
33
32
12
20-29 30-39 40-49 50-59
60-69 70-79
14
80-89 90-99
Age of Patients
Male
Female
0-9
9
4
10-19
9
12
20-29
14
33
30-39
32
82
40-49
80
56
50-59
288
332
60-69
416
401
70-79
286
250
80-89
123
103
90+
12
14
1269
1387
Total (2,548)
For all analytic combined staged cases: (146) were stage 0;
(840) Stage I; (447) Stage II; (350) Stage III; (431) Stage
IV, (95) Unknown Stage and (347) accounted for nonapplicable cases for staging.
Graph 4: AJCC Stage by Sex
600
500
Male
Female
400
# of Cases
Table 2: Age by Sex
Age Range
300
200
100
0
0
I
II
III
IV
AJCC Stage
8 • Loyola University Health System
UNK
N/A
Cancer Incidence by Sex and Site with the
State and National
Table 3: Males
Site
LUMC %
(N=1,269)
Year 2014
Illinois %
(N=32,588)
Year 2013
National %
(N=855,220)
Year 2014
Prostate
16.3
25.8
27.2
Kidney
7.1
4.5
4.6
Lung
7.0
14.7
13.6
Skin
6.9
4.1
5.4
Liver
5.9
2.9
2.9
Colorectal
5.8
10.0
8.3
Bladder
5.3
6.6
6.6
Non-Hodgkin’s
4.2
4.2
4.5
Pancreas
4.2
2.7
2.8
Leukemia
3.5
3.0
3.5
The American Cancer Society
National estimates for site and sex
distribution for all races were used
to compare the estimates with
Loyola University Medical Center
data and the State of Illinois Cancer
Statistics. The numbers reported are
percentages of the total cases by sex.
For the male population as compared
to both the state and the nation,
we observed quite a high incidence
of Kidney, Skin (Melanoma), Liver
and Pancreas, but a lower level of
Prostate, Lung, and Colorectal.
For the female population as
compared to the state and nation, we
observed quite a high incidence of
Thyroid, Corpus Uteri, Skin, Pancreas
and Ovary, but a lower level of Breast,
Lung, Bladder, and Colorectal.
Table 4: Females
Site
LUMC %
(N=1,387) Year
2014
Illinois %
(N=32,086)
Year 2013
National %
(N=810,320)
Year 2014
Breast
25.3
29.4
28.7
Thyroid
9.3
4.3
5.9
Corpus Uteri
8.5
6.7
6.5
Lung
6.7
13.3
13.4
Colorectal
5.2
9.4
8.0
Kidney
3.6
2.8
3.1
Skin
3.5
3.2
4.3
Leukemia
3.2
3.0
2.7
Ovary
3.1
2.6
2.7
Non-Hodgkin’s
2.7
3.8
4.0
2014 Oncology Program Annual Report • 9
Patient Care Evaluation
Study of Leukemia
2010-2014
Elizabeth Henry, MD
Hematology/Oncology
Quality Medical Director
10 • Loyola University Health System
Violeta Dimovic, CTR
Manager, Oncology Data
Cancer Program
Patient Care Evaluation
Leukemia is a cancer of the early blood-forming cells.
Most often, leukemia is a cancer of the white blood cells,
but some rare leukemias start in other blood cell types.
Leukemia is often described as being either acute (fast
growing) or chronic (slow growing). There are actually
many types of leukemia. They differ based on what types
of cells they start in, how quickly they grow, which people
they affect and how they are treated.
Acute myeloid leukemia (AML, also called acute
myelogenous leukemia) involves the rapid growth
of myeloid cells. It occurs in both adults and children.
Leukemias are further classified as myeloid or lymphoid,
depending upon the type of white blood cell that makes
up the leukemia cells. A basic understanding of the normal
development of blood cells is needed to understand the
different types of leukemia. Normal blood cells develop
from stem cells that have the potential to become many
cell types. Myeloid stem cells develop in the bone marrow
and become immature white cells called myeloid blasts.
These myeloid blasts further mature to become either red
blood cells, platelets, or certain kinds of white blood cells.
Lymphoid stem cells develop in the bone marrow to become
lymphoid blasts. The lymphoid blasts develop further into
T or B lymphocytes, special types of white blood cells. B
lymphocytes protect the body from invading germs (bacteria,
viruses and fungi) by maturing into plasma cells, which make
proteins called antibodies. The antibodies attach to the
germs which helps the immune system destroy them. There
are several types of T cells, each with a special job. Some
T cells can destroy germs directly, while others play a role
in either boosting or slowing the activity of other immune
system cells. Myeloid leukemias are made up of cells that
arise from myeloid blasts, while lymphoid leukemias arise
from lymphoid blasts. Knowing the type of cell involved in
leukemia is important in choosing the appropriate treatment.
We used the data base of the cancer registry at Loyola
University Medical Center (LUMC) to examine trends in
patient care and to determine patient outcomes and make
crude comparisons to national cancer database. Between
2010 and 2014, there were 423 new adult leukemia cases
diagnosed and / or treated at LUMC. The purpose of the
following analysis is to compare the population of leukemia
treated at LUMC with patients having the identical disease
who are listed in the national database. We will attempt to
explain any differences and propose specific interventions
or adjustments in data collection which may be helpful in the
future. These analyses will question whether or not similarity
treated patients have improved outcomes in a university
hospital based setting and whether this is a result of better
patient care.
The four main types of leukemia are acute lymphocytic
leukemia, chronic lymphocytic leukemia, acute myeloid
leukemia, and chronic myeloid leukemia.
Acute lymphocytic leukemia (ALL), also known as acute
lymphoblastic leukemia is the most common type of leukemia
in children, but it can also affect adults. In this type of
leukemia, immature lymphoid cells grow rapidly in the blood.
Study of Leukemia 2010-2014
Chronic lymphocytic leukemia (CLL) is a slow-growing
cancer of lymphoid cells that primarily affect older adults.
Chronic myeloid leukemia (CML, also known as chronic
myelogenous leukemia) primarily affects older adults.
According to the American Cancer Society, an estimated
52,380 new cases of leukemia are expected to be
diagnosed in the U.S in 2014 and 24,090 are expected to
die from leukemia. Leukemia is the tenth most frequently
occurring type of cancer in all races or ethnicities.
CLL, AML and CML are most prevalent in the seventh,
eighth and ninth decades of life.
Incidence begins to increase significantly among people with:
CLL – at age 50 years and older
AML– at age 50 years and older
CML– at age 65 years and older
2014 Oncology Program Annual Report • 11
According to the “Cancer Facts and Figures 2014”, the total estimated number of new leukemia cases in the United States
is shown in Table 1 for 2014.
Table 1: Estimated # of New Leukemia Cases for 2014 Year
Type
Male
Female
Total
Acute Lymphoblastic Leukemia
3,140
2,880
6,020
Chronic Lymphocytic Leukemia
9,100
6,620
15,720
Acute Myeloid Leukemia
11,530
7,330
18,860
Chronic Myeloid Leukemia
3.130
2,850
5,980
Other Leukemia
3,200
2,600
5,800
Total Estimated New Cases
30,100
22,280
52,380
Table 1: Source: Cancer Facts and Figures 2014. American Cancer Society; 2014
Facts 2014-2015 provides updates from The American Cancer Society’s Cancer Facts and Figures 2014 for estimated new blood cancer cases and estimated deaths due to blood cancers.
The incidence, prevalence and mortality data in Facts 2014-2015 reflect the statistics from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program,
Cancer Statistics Review (CSR) 1975-2011. The SEER Cancer Statistics Review was published online in April 2014 and updated in September 2014 (www.seer.cancer.gov). Incidence
rates by state are provided by the North American Association of Central Cancer Registries Cancer in North America.
Table-2 highlights the adult (ages 21 and older) leukemia cases diagnosed per year. Leukemia cases make up (~5%)
of Loyola’s overall cancer caseload. Of the patients from 2010-2014 year, 234 (55%) were male and 189 (45%) were
female. The adult male/ female distribution is very similar to the national figures. Loyola University Medical Center (LUMC)
incidence in Males is 55%), National Cancer Data Base (NCDB): 30,100/52,380=57%); and (LUMC incidence in Females
is 45%), (NCDB: 22,280/30.100=43%).
Table-2: Caseload /Year
LUMC
Total
2010
2011
2012
2013
2014
423 (100%)
72 (17%)
102 (24%)
97 (23%)
87 (21%)
90 (21%)
Adult age group ranged from 21 thru 99. Twenty-seven percent (114) of the patients were diagnosed between ages 60-69.
See Table-3; Graph -1below for details.
Table-3: Age by Sex (2006-2010)
Age Range
Male
Female
20-29
13
11
30-39
13
17
40-49
24
19
50-59
48
32
60-69
62
52
70-79
37
40
80-89
35
16
90-99
2
2
Total
234 (55%)
189 (45%)
12 • Loyola University Health System
Patient Care Evaluation
Graph-1: Age by Sex (2010-2014)
# of Cases
80
60
40
Male
Female
20
0
20-29 30-39 40-49 50-59
60-69 70-79
80-89 90-99
Age of Patients
We further reviewed the cases to identify if bone marrow
or peripheral blood blasts were tested for specific recurrent
genetic abnormalities such as:
Cytogenetics-Karyotyping of G-banded metaphase
chromosome
Interphase fluorescence in situ hybridization (FISH)
Reverse transcripts polymerase chain reaction (RT-PCR)
for fusion genes (eg, BCR_ABL)
In addition, flow cytometric DNA index/ploidy testing is
also done to assess for hyperdiploidy and hypodiploidy
Flow cytometric immunophenotyping technology was used
by pathology for the characterization and enumeration
of the normal and neoplastic cells. This plays a key role
in understanding the differentiation and maturation of all
the components of the human hematopoietic system. This
information provides the clinicians with data to supplement
morphologic and cytochemical methods and therefore
leading to the best classification of leukemia for deciding
on a patient’s prognosis and therapy, monitoring of treatment
and detection of residual disease or early relapse in
particular patients.
Study of Leukemia 2010-2014
A quality review of the 423 cases was conducted to
investigate any implausible data documented and the
transposed diagnostic confirmation code is translated
accordingly. We identified that 95% of the cases were
assigned a code “1” which identifies that that the cases
were diagnosed by a positive histology (histologic
confirmation (tissue microscopically examined). This
includes bone marrow aspiration and biopsy. Since this
is the definitive diagnostic test to confirm the diagnosis
of leukemia, all cases were assigned a code “1.” This was
not shown as error by the computerized checks of the
Electronic Registry Data Base (ERS) data base, therefore
it was not possible to identify the confirmation as a
discrepancy. Special instructions for coding hematopoietic
or lymphoid tumors needed to be applied.
The Hematopoietic and Lymphoid Database (Heme DB)
and Manual are vital to abstracting and coding
hematopoietic and lymphoid cancers. The database
is used to determine reportability, determine multiple
primaries, assign primary site, histology, and grade for
cases diagnosed on or after January 1, 2010.
2014 Oncology Program Annual Report • 13
Diagnostic Confirmation Codes to be
applied for Cancer Cases:
Microscopically confirmed
1:Positive histology
•Tissue specimen
•Bone marrow specimen
•CBC, WBC, peripheral blood smear for leukemia only
2:Positive cytology
3:Positive histology PLUS
•Positive immunophenotyping and/or
•Positive genetic studies
4:Positive microscopic confirmation, method not specific
Not microscopically confirmed
5:Positive laboratory test/marker study
6:Direct visualization without microscopic confirmation
7:Radiology and other imaging techniques without
microscopic confirmation
8:Clinical diagnosis only (other than 5, 6, or 7)
9:Unknown whether or not microscopically
The database is extremely informational. Each disease
type has information on morphology codes used in what
time periods, reportability, primary site, grade, module rule,
alternative names, definitions, abstractor notes, definitive
diagnostic methods, genetics data, immunophenotyping,
treatments, transformations to and from, same primaries,
corresponding ICD-9 and ICD-10 codes, signs and
symptoms, diagnostic exams, recurrence and metastasis,
and epidemiology and mortality.
According to North American Association of Central Cancer
Registries Cancer in North America, the correct code to
have been used was a “3”, if diagnosed after January 1,
2010. It states: “Assign code 3 when there is histology
positive for cancer and positive immunophenotyping and/or
positive genetic testing results”. Since there is a continuous
increase in the molecular and biological understanding
of leukemia, the disease classification, diagnostic and
therapeutic standards are likely subject to periodic
revisions. In order to spread excellence of uniform quality
it is necessary to adopt up-to-date common standards as
defined by the governing entities.
14 • Loyola University Health System
Further analysis on the 423 cases was conducted to
assess data quality for purposes of adding the appropriate
text in the pathology field and correcting the diagnostic
confirmation. All cases, after changes reflect concordance
for diagnostic confirmation as a “3” showing a 99% of the
cases were immunophenotyped. The test provides valuable
insight into whether the tumor cells contain a normal or
abnormal amount of DNA and the relative rate at which the
tumor is growing and therefore must be reported according
to standard guidelines. The data provided by cancer
registries are vital for public health surveillance, health
service planning, evaluation of the impact of intervention
on cancer incidence and survival, clinical auditing and
epidemiological research, health promotion and genetic
counseling. To fulfill these functions adequately, data
produced must be of high quality.
Flow cytometry techniques are utilized in clinical hematology.
Diagnostic evaluation of patients with leukemia, either at first
diagnosis or at relapse, all include immunophenotyping in
conjunction with morphology and histochemistry, cytogenetic
analysis and molecular studies. These measurements allow
for the differential analysis of normal and abnormal cells
within a peripheral blood or bone-marrow specimen leading
to the identification of particular leukemia subtypes.
According to the College of American Pathologists, a
partial list of the “2008 World Health Organization (WHO)
classification, neoplasms that are seen in the bone marrow
specimens are those that include Acute Myeloid Leukemia
(AML) with recurrent genetic abnormalities, therapy related
AML, AML, not otherwise specified, acute leukemias of
ambiguous lineage, precursor lymphoid neoplasms, mature
B-cell and mature T and NK-cell neoplasms. Documentation
of expression of antigens such as CD20, CD33 and CD52
can aid the clinicians of potential therapeutic options. In
Chronic Lymphocytic Leukemia, important biomarkers
include protein expression of CD38 and zeta-associated
protein of ZAP-70, normally expressed in T-cells and NK
cells, immunoglobulin heavy chains (IGVH) hypermutation
status, somatic mutations in tumor protein gene TP53,
receptor protein signaling NOTCH1, and abnormalities
in chromosomes 11, 12, 13q, and 17. Clear, concise and
accurate reporting of results is extremely important for
effective clinical management.
Cases at LUMC were histologically classified as distinct
subtypes of leukemia. The different histologies represented
among the cases showed a favorable prognostic type of
Acute Myeloid Leukemia which accounted for about 38%
(160) of all the cases. See Table 4 below for details.
Patient Care Evaluation
Table 4: Distribution by Histology and Gender
Cross-Tabulation Of Histology By Sex For Leukemia
Histology
Male
(NBR)
Female
(NBR)
Total
(NBR)
Percent
(%)
Mixed phenotype acute leukemia B/myeloid NOS
1
1
2
0.5
Mixed phenotype acute leukemia T/myeloid NOS
1
0
1
0.2
B lymphoblastic leukemia/lymphoma NOS
13
13
26
6.1
B lymphoblastic leukemia/lymphoma with t(922) (q34q11.2) BCR-ABL1
0
1
1
0.2
Chronic lymphocytic leukemia
48
18
66
15.6
Burkitt’s cell leukemia
4
4
8
1.9
Adult T-cell leukemia/lymphoma
1
1
2
0.5
Chronic lymphoproliferative disorder of NK-cells
1
0
1
0.2
Precursor cell lymphoblastic leukemia NOS (see also M-9727/3)
3
5
8
1.9
Precursor B-cell lymphoblastic leukemia (see also M-9728/3)
2
1
3
0.7
T lymphoblastic leukemia/lymphoma
2
1
3
0.7
Erythroleukemia
1
1
2
0.5
Myeloid leukemia NOS
3
2
5
1.2
Acute myeloid leukemia
93
68
160
38.0
Chronic myeloid leukemia
10
10
20
4.7
Acute promyelocytic leukemia
7
11
18
4.3
Acute myelomonocytic leukemia
4
4
8
1.9
Acute myelomonocytic leukemia with eosinophils
2
0
2
0.5
Acute myeloid leukemia without maturation
3
3
6
1.4
Acute myeloid leukemia with maturation
0
5
5
1.2
Chronic myelogenous leukemia BCR/ABL positive
7
10
17
4
Acute monocytic leukemia
2
6
8
1.9
Acute myeloid leukemia with multilineage dysplasia (see also M-9984)
5
5
10
2.4
Acute myeloid leukemia t(8)
3
1
4
0.9
Acute megakaryoblastic leukemia (C42.1)
0
1
1
0.2
Acute myeloid leukemia (megakaryoblastic) with t(122)(p13q13) RBM15-MKL1
0
2
2
0.5
Therapy-related acute myeloid leukemia and myelodysplastic syndrome NOS
2
4
6
1.4
Myeloid sarcoma
0
1
1
0.2
Hairy cell leukemia (C42.1)
3
2
5
1.2
Chronic myelomonocytic leukemia NOS
13
8
21
5
Overall Totals
234
189
423
100%
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 15
Leukemia stages vary based on disease
type. Factors affecting leukemia staging
and prognosis are:
•White blood cell or platelet count
•Age (advanced age may negatively affect prognosis)
•History of prior blood disorders
•Chromosome mutations or abnormalities
•Bone damage
•Enlarged liver or spleen
Acute Myelogenous Leukemia (AML)
subtypes and staging
Using a system known as French-American-British (FAB)
classification, AML is classified in eight subtypes, M0
through M7, based on:
•The number of healthy blood cells
•The size and number of leukemia cells
•The changes that appear in the chromosomes
of the leukemia cells
•Any other genetic abnormalities that have occurred
The eight acute myelogenous leukemia stages are
classified as follows:
Undifferentiated AML — M0: In this stage of acute
myelogenous leukemia, the bone marrow cells show
no significant signs of differentiation.
Myeloblastic leukemia — M1: Bone marrow cells show
some signs of granulocytic differentiation with or without
minimal cell maturation.
Myeloblastic leukemia — M2: Maturation of the
bone marrow cells is beyond the promyelocyte (early
granulocyte) stage. Varying amounts of granulocyte
maturation may be observed.
Promyelocytic leukemia — M3: Most of the abnormal
cells are early granulocytes, between myeloblasts and
myelocytes in their stage of development. The cells contain
many small particles and have nucleuses of varying size
and shape.
16 • Loyola University Health System
Myelomonocytic leukemia — M4: In this stage of
acute myelogenous leukemia, the bone marrow and
circulating blood have variable amounts of monocytes and
differentiated granulocytes in them. The percentage of
monocytes and promonocytes in the bone marrow is greater
than 20 percent. There may also be an increased number of
granular leukocytes called eosinophils, a type of granulocyte
that often has a two-lobed nucleus.
Monocytic leukemia — M5: This subset is further divided
into two different categories. The first is characterized by
poorly differentiated monoblasts with lacy-appearing genetic
material. The second subset is characterized by a large
number of monoblasts, promonocytes and monocytes. The
proportion of monocytes in the bloodstream may be higher
than that in the bone marrow.
Erythroleukemia — M6: This form of leukemia is
characterized by abnormal red blood cell-forming cells,
which make up over half of the nucleated cells in the
bone marrow.
Megakaryoblastic leukemia — M7: The blast cells in
this form of leukemia look like immature megakaryocytes
(giant cells of the bone marrow) or lymphoblasts
(lymphocyte-forming cells). M7 leukemia may be
distinguished by extensive fibrous tissue deposits (fibrosis)
in the bone marrow. Although the FAB classification is still
commonly used to group AML into subtypes, the World
Health Organization (WHO) has proposed a new acute
myelogenous leukemia staging system in an attempt to
more clearly communicate the patient’s prognosis (outlook).
This system divides Acute myelogenous leukemia (AML)
into broad groups:
•Acute myelogenous leukemia with certain genetic
abnormalities: Cellular testing is capable of identifying
specific genetic abnormalities:
•AML with a translocation between
chromosomes 8 and 21
•AML with a translocation or inversion
in chromosome 16
•AML with changes in chromosome 11
•APL (M3), which usually has translocation
between chromosomes 15 and 17
•AML with multi-lineage dysplasia: More than one
type of abnormal myeloid cell is involved.
Patient Care Evaluation
•A
ML from previous chemotherapy/radiation
•A
ML not otherwise specified: This includes AML cases
that don’t fall into any of the above groups, such as:
•Undifferentiated AML - M0
•AML with Minimal Maturation - M1
•AML with Maturation - M2
•Acute Myelomonocytic Leukemia - M4
•Acute Monocytic Leukemia - M5
•Acute Erythroid Leukemia - M6
•Acute Megakaryoblastic Leukemia - M7
•Acute Basophilic Leukemia
•Acute Panmyelosis with Fibrosi
•M
yeloid Sarcoma - Also called Granulocytic
Sarcoma or Chloroma
•U
ndifferentiated/biphenotypic acute leukemias:
This type of leukemia may exhibit features of both
lymphocytic and myelogenous leukemia. This may also
be refferd to as ALL with myeloid markers, AML with
lymphoid or mixed lineage leukemia.
Acute Lymphocytic leukemia (ALL) classification
based on immunophenotype
Immunophenotyping is a way to classify ALL. It factors in
the type of lymphocyte (T cell or B cell), as well as how
mature the cells are.
B-cell ALL staging
B lymphocytes, or B cells, are produced in the bone marrow.
They also mature there. B cells play a large role in humoral
immune response and serve the principal functions of making
antibodies against antigens and developing into memory B
cells after they have been activated by antigen interaction.
T-cell ALL staging
T lymphocytes, or T cells, leave the bone marrow before
maturation and move to the thymus, where they mature.
T cells play a central role in cell-mediated immunity. There
are several different subsets of T cells that have distinct
functions. The different subsets of T cells include Helper,
Cytotoxic, Memory, Regulatory, Natural killer and Gamma
Delta T cells.
Rai staging system for Chronic Lymphocytic
Leukemia (CLL) stages
Chronic lymphocytic leukemia stages in the Rai system
are defined by three main factors: the number of the
lymphocytes in the blood; whether or not the lymph
nodes, spleen or liver are enlarged; and the presence of
the blood disorders anemia (too few red blood cells) or
thrombocytopenia (too few platelets). The five stages
are labeled with Roman numerals 0-IV:
•Rai Stage 0 CLL: The levels of the lymphocytes are
too high, usually more than 10,000 in one sample.
There are no other symptoms at this point and other
blood cell counts are normal.
•Rai Stage I CLL: In addition to the high levels of
lymphocytes (lymphocytosis), the lymph nodes are
swollen. The levels of red blood cells and platelets
are still normal.
•Rai Stage II CLL: The number of lymphocytes
remains high and now the liver or spleen might
be larger than normal.
•Rai Stage III CLL: The excess amount of lymphocytes
begins to crowd out the red blood cells, resulting in
anemia. The lymph nodes may be swollen and the liver
or spleen may be larger than normal.
•Rai Stage IV CLL: The levels of red blood cells and
platelets drop below normal, causing anemia and
thrombocytopenia. The lymph nodes may be swollen
and the liver or spleen may be larger than normal.
The Rai system of chronic lymphocytic leukemia staging
is sometimes simplified into low (Stage 0), medium
(Stage I and II) and high (stage III and IV) risk categories.
There are three stages of CML.
•Chronic: This is the earliest phase of CML. The
majority of CML patients are diagnosed during this
phase as a result of mild symptoms particularly fatigue.
•Accelerated: If CML has not responded to treatment
well or was not detected during the chronic phase, it
sometimes becomes more aggressive, which can lead
to the accelerated phase. At this point, symptoms may
become more noticeable.
•Blastic: This is the most aggressive stage of chronic
myeloid leukemia. Blastic refers to having more than
20 percent myeloblasts or lymphoblasts. Symptoms
are similar to those of acute myeloid leukemia.
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 17
Monitoring the patient to see how they respond to treatment
is very important. Determining the stage of the disease and
patient’s response depends heavily on generating clear and
meaningful laboratory tests. If CML is responding well to
treatment based on the blood counts and or bone marrow,
3 months after starting treatment, the patient should have
a complete hematologic response (CHR) and some type of
cytogenetic response and reduction of the number of copies
of the BCR-ABL genes on the polymerase chain reaction
(PCR) test by 90% or more. If treatment is working well, 18
months after starting treatment, the patient should have:
complete hematologic response (CHR) and a complete
cytogenetic response (CCyR) and/or major molecular
response (MMR).
Some of the documented symptoms in the acute myeloid
leukemia (AML) cases reviewed were fatigue, weight loss,
bleeding, easy bruising, frequent infections and night sweats.
•Low levels of red blood cells, which can cause
fatigue and shortness of breath
•Low platelet counts, which can cause bleeding
•Low normal white blood cell counts, which can
lead to infection
•Vulnerability to bruising, bleeding and infections
In addition to these signs of bone marrow failure, enlarged
lymph nodes, an enlarged liver or spleen, or pain in the
bones or joints can occur.
Blood tests like, complete blood count (CBC), peripheral
blood smear and cytogenetic analysis to check for
changes in the chromosomes of the lymphocytes can
detect leukemia, a critical part of the evaluation that helps
determine the appropriate course of treatment. Bone
marrow aspiration, a type of biopsy to diagnose leukemia,
is also used. Other procedures used are CT scans, X-rays,
MRI’s and ultrasounds.
18 • Loyola University Health System
Making treatment decisions begins with the stage, or
progression of the disease. The stage is one of the most
important factors in evaluating treatment options. The
treatment of leukemia varies according to one’s age,
prognostic factors, general condition at diagnosis, and
results of the cytogenetic testing as mentioned previously
and the availability of a stem cell donor with matching tissue
type. The goal of treatment is a cure. Treatment for leukemia
can be divided into four phases:
•First phase — induction chemotherapy (remission) The
goal of this first phase is to clear the blood of leukemia
cells (blasts) and to reduce the number of blasts (very
immature cells) in the bone marrow to normal
•Second phase — consolidation chemotherapy
(post-remission). The purpose of the second phase
is to kill any residual cells and keep the cancer from
coming back (relapsing). The options for consolidation
treatment are either more chemotherapy or a stem cell
transplant, or combination of these two approaches.
•Third phase — maintenance chemotherapy
Maintenance involves giving a low dose of a chemo
drug for months or years after consolidation is finished.
Often used for one specific type of AML.
•Fourth phase — central nervous system (CNS)
prophylaxis This includes intrathecal chemotherapy:
infusing chemotherapy directly to the clear spinal fluid
to prevent recurrence of leukemia.
Loyola University Medical Center receives referrals for Stem
Cell Transplants from throughout the Midwest, including
other academic medical centers in Chicago. Loyola is among
the first centers to use umbilical cord donations for the
treatment of certain adult cancers. Loyola has a particular
expertise in treating patients who cannot find matching
donors from either their families or the National Marrow
Donor Program. Twenty years ago, only about 30 percent
of patients could find matching stem cell donors. At Loyola,
that percentage has increased to 95 percent, due to the use
Patient Care Evaluation
of cord blood transplants and other innovative techniques,
according to P. Stiff, MD, Director of Hematology/Oncology,
Medical Director of Loyola’s Cardinal Bernardin Cancer
Center, Vice Chairman of the Bone Marrow and Stem Cell
Transplantation Committee. Loyola has treated more blood
cancer patients with stem cell transplants than any other
center in Illinois and has one of the largest unrelated donor
transplant programs in the world.
Mismatched related donor or umbilical cord blood
donor — Some patients are offered treatment with cells from
a partially matched family member (called mismatched related
donor). The hematopoietic stem cell product may be specially
prepared to minimize the immune response in the patient.
Another alternative is to use umbilical cord blood, collected
from a healthy newborn infant at the time of delivery; this
blood is a rich source of hematopoietic stem cells.
Bone marrow transplantation (BMT) and peripheral blood
stem cell transplantation (PBSCT) are procedures that
restore stem cells that have been destroyed by high doses
of chemotherapy and/or radiation therapy. The types of
transplants are:
For patients who receive marrow or peripheral blood
stem cells (PBSC), neutrophil engraftment can occur as
early as 10 days after transplant but is more common
around 14-20 days. Patients who receive cord blood may
need more time to engraft (typically about 25 days but
sometimes as long as 42 days.
•Autologous transplants, patients receive their own
stem cells
•Syngeneic transplants, patients receive stem cells
from their identical twin
•Allogeneic transplants, patients receive stem cells
from their brother, sister or parent. A person unrelated
to the patients (an unrelated donor, this includes
umbilical cord blood) also may be used.
Matched donor — To help minimize the problems that can
be caused by the expected immune response, a donor who
has similar genetic makeup to the patient is preferred. The
cells will seem “less foreign” to the transplanted donor cells.
Siblings (ie, brothers and sisters who share the same parents
as the patient) are typically the only members of the family
that are tested for being a donor because they have a one in
four chance of sharing genetic characteristics with patient;
these characteristics are critical for the body to accept the
graft. In general, parents, children, and other relatives are not
suitable donors since they do not share the same parents,
and therefore do not have the same genetic material.
Treatment of leukemia may include chemotherapy, radiation
therapy, stem cell transplant and/ or immunotherapy.
Based on the findings during the retrospective analysis, the
stem source was not always documented in the progress
notes. Recommendations have been integrated through
educational projects and directives in aiming at identifying
the retrieval of the documentation on which the oncology
registry staff relies. A joint effort between the health care
provider and the oncology data staff is essential to achieve
complete and accurate documentation and to report the
diagnosis and procedures. Improving clinical documentation
and increasing communication across departments is an
important way to establish standards, exchange knowledge
and avoiding overall errors.
Among the 423 patients in this analysis, 20% (82) were
treated with stem cell transplant. Treatment options and
recommendations depended on several factors, including
the type and stage of leukemia, possible side effects,
patient’s preferences, age and overall health.
Matched unrelated donor — If no siblings are available, or
if testing the blood of the siblings does not reveal a match,
a matched unrelated donor may be used. The search for an
appropriate donor can be accomplished using transplant
registries throughout the world
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 19
Treatment combination for leukemia cases is indicated
in Table 5 below.
Table 5: Treatment Combination for Leukemia Cases
(Year 2010-2014)
Treatment Type
# of
Cases
Chemotherapy
192
None
62
Chemotherapy/Hormone
62
Chemotherapy/Radiation/Transplant
24
Chemotherapy/Transplant
20
Chemotherapy/Radiation/Hormonal/Transplant
18
Chemotherapy/Hormone/Transplant
20
Hormone
5
Chemotherapy/Radiation
4
Chemotherapy/Other
3
Immunotherapy
3
Other
3
Chemotherapy/Hormone/Other
3
Chemotherapy/Immunotherapy
3
Chemotherapy/Hormone/Immunotherapy
1
Total Cases
423
Transplanted stem cells can come from the patient
(autologous, an identical twin (syngenic), or different
individual (allogenic). The three sources of stem cells are
donor bone marrow, donor blood, and cord blood taken
from the umbilical cord and placenta after childbirth
Peripheral blood stem cells (PBSCs) are collected by
apheresis, a process in which the donor is connected
to a special cell separation machine via a needle inserted
in arm veins. Blood is taken from one vein and is circulated
though the machine which removes the stem cells and
returns the remaining blood and plasma back to the
donor through another needle inserted into the opposite
arm. Several sessions may be required to collect enough
stem cells to ensure a chance of successful engraftment
in the recipient.
A medication may be given to the donor for about one
week prior to apheresis that will stimulate the bone marrow
to increase production of new stem cells. These new
stem cells will be released from the marrow and into the
circulating or peripheral blood system; from there they
can be collected during apheresis.
Bone marrow harvesting involves collecting stem cells
with a needle placed into the soft center of the bone, the
marrow. Most sites used for bone marrow harvesting are
located in the hip bones and the sternum. The procedure
takes place in the operating room.
Note: Other/Differentiation inducing agents
20 • Loyola University Health System
Patient Care Evaluation
Table 6 below shows the transplant breakdown by histology and gender for 2010-2014 year.
Table 6: Histology by Gender. (Year-2010-2014)
Histology
Male
(NBR)
Female
(NBR)
Total
(NBR)
Mixed phenotype acute leukemia B/myeloid NOS
1
1
2
Mixed phenotype acute leukemia T/myeloid NOS
1
0
1
B lymphoblastic leukemia/lymphoma NOS
6
3
9
Burkitt’s cell leukemia
0
3
3
Adult T-cell leukemia/lymphoma
1
1
2
Chronic lymphoproliferative disorder of NK-cells
1
0
1
Precursor cell lymphoblastic leukemia NOS (see also M-9727/3)
1
2
3
Precursor B-cell lymphoblastic leukemia (see also M-9728/3)
2
0
2
T lymphoblastic leukemia/lymphoma
0
1
1
Erythroleukemia
1
0
1
Acute myeloid leukemia
27
12
39
Chronic myeloid leukemia
0
1
1
Acute myelomonocytic leukemia with eosinophils
1
0
1
Acute myeloid leukemia without maturation
1
0
1
Acute myeloid leukemia with maturation
0
1
1
Acute monocytic leukemia
1
2
3
Acute myeloid leukemia with multilineage dysplasia (see also M-9984
2
3
5
Acute myeloid leukemia t(8
1
0
1
Therapy-related acute myeloid leukemia and myelodysplastic syndrome NOS
1
0
1
Chronic myelomonocytic leukemia NOS
3
1
4
Overall Totals
51
31
82
The majority, 48%, of cases were identified as acute myeloid leukemia. From all the 82 adult cases, there was
99% that had allogenic transplants and one patient with chronic lymphoproliferative disorder of NK-cells had an
autologous peripheral blood transplant.
66% (54) were peripheral blood stem cells (PBSCs) transplant and the remaining 34% (28) were bone marrow.
According to the (HRSA) Health Resources and Services Administration Blood Cell Transplants Cord blood units
during 2014 year were used in 960 transplants. The National Cord Blood Inventory provided 544 cord blood units
for these transplants. Also, 1,225 transplants were performed using bone marrow and 4,068 transplants used
peripheral blood stem cells.
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 21
Graph 1: HRSA Health Resources and Services Administration Blood Cell Transplants
6,500
6,000
5,500
5,000
4,500
Cord Blood
4,000
Peripheral Blood
Stem Cells
3,500
Bone Marrow
3,000
2,500
2,000
1,500
1,000
500
0
’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10 ’11 ’12 ’13
Source: National Marrow Donor Program/By The Match FY 2013
According to the Center for International Blood and Marrow Transplant Research (CIBMTR) transplant activity from 2012 year by donor type and
cell source showed:
Table 7: # of Transplants by Donor Type and Cell Source (CIBMTR) Year-2012
Year-2012
Autologous
Related
Unrelated
Total
Bone Marrow
28
740
938
1,706
Cord Blood
106
28
797
931
Peripheral Blood
10,412
2,429
2,811
15,652
Total
10,546
3,197
4,546
18,289
22 • Loyola University Health System
Patient Care Evaluation
Table 8: # of Transplants by Disease Category & Donor Type (CIBMTR) Year 2012
Year 2012
Autologous
Related
Unrelated
Total
Acute Lymphoblastic Leukemia
5
469
592
1,066
Acute Myelogenous Leukemia
64
1,036
1,648
2,748
Chronic Lymphocytic Leukemia/Other Leukemia
3
117
185
305
Chrmonic Myeloid Leukemia
0
110
147
257
Other Acute leukemia
1
32
59
92
Allogenic hematopoietic cell transplants are curative but are associated with life-threatening complications. The chief risk
factor for death included older age and graft-versus-host disease (GVHD) and relapses, defined as disease recurrences.
Graph 2: Causes of Death after Unrelated Donor Transplants (2011-2012)
12%
37%
4%
Primary Disease
8%
GVHD
Infection
Organ Failure
Second Malignancy
Other
17%
20%
CIBMTR CENTER FOR INTERNATIONAL BLOOD & MARROW TRANSPLANT RESEARCH
According to the annual report on data submitted to the CIBMTR by centers worldwide, the primary cause of death after
autologous transplant is primary disease. Among allogeneic transplant recipients, unrelated donor transplants have fewer
deaths related to the primary disease, however organ failure and infections are higher after unrelated donor transplants
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 23
Graph 3: Survival after HLA Match Sibling Donor (2002-2012)
100
p< 0.0001
Probability (%)
80
Early (n=7,607)
60
Intermediate (n=2,124)
40
20
0
Advanced (n=2,578)
0
1
2
3
Years
4
5
6
By Disease Status
CIBMTR CENTER FOR INTERNATIONAL BLOOD & MARROW TRANSPLANT RESEARCH
Graph 4: Survival after Unrelated Transplants for AML, 2002-2012
100
p<0.0001
Probability (%)
80
60
Early (n=7,365)
40
Intermediate (n=4,172)
20
Advanced (n=4,095)
0
0
1
2
3
Years
4
5
6
By Disease Status
CIBMTR CENTER FOR INTERNATIONAL BLOOD & MARROW TRANSPLANT RESEARCH
24 • Loyola University Health System
Patient Care Evaluation
The CIBMTR has data for 27,941 patients receiving a human leukocyte antigen, HLA-matched sibling (n=12,309)
or unrelated donor (n=15,632) transplant for AML between 2002 and 2012. Their disease status at the time of
transplant and the donor type are the major predictors of post-transplant survival. The 3-year probabilities of survival
after HLA-matched sibling transplant in this cohort was 58% ± 1%, 50% ± 1%, and 24% ± 1% for patients with
early, intermediate, and advanced disease, respectively. The probabilities of survival after an unrelated donor transplant
were 49% ± 1%, 47%± 1%, and 22% ± 1% for patients with early, intermediate, and advanced disease, respectively.
Table 9: AML-Adult Unrelated HCT Improved Survival Over Time
Transplants facilitated by NMDP/Be The Match
Year of HCT
Number of Cases
One-Year Survival
Two-Year Survival
2011-2013
3,809
60%
49%
2007-2010
3,574
57%
45%
2002-2006
2,285
48%
38%
1987-2001
1,606
31%
24%
In this analysis, relative survival rates with 95% confidence intervals are calculated as measures of survival. This method
is used to estimate cancer survival in the absence of other causes of death. This relative survival provides a measure of
excess mortality experienced by cancer patients without requiring cause of death information and the formulation is based
on the assumption of independent competing cause of death. Because survival statistics are based on large groups of
people, they cannot be used to predict exactly what will happen to an individual patient. No two patients are entirely alike,
and treatment and responses to treatment can vary greatly.
The 5-year survival rate depends on the subtype of leukemia. We conducted survival analysis on all cases that had
stem cell transplants from year 2005 through 2009. The different histologies represented among the cases showed
a favorable prognostic type of Acute Myeloid Leukemia. For this reason a survival analysis on adults was conducted,
with an age of >21, Acute Myeloid Leukemia.
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 25
Table 14: Histology by Gender (Year 2005-2009)
Histology
Male
Female
Total #
Acute leukemia NOS
2
0
2
Acute biphenotypic leukemia
0
1
1
Chronic lymphocytic leukemia
5
0
5
Precursor cell lymphoblastic leukemia NOS
4
3
7
Precursor B-cell lymphoblastic leukemia
1
5
6
Erythroleukemia
1
0
1
Myeloid leukemia NOS
1
4
5
Acute myeloid leukemia
13
14
27
Chronic myeloid leukemia
1
1
2
Acute promyelocytic leukemia
1
0
1
Acute myelomonocytic leukemia
3
1
4
Acute myeloid leukemia without maturation
3
1
4
Acute myeloid leukemia with maturation
0
2
2
Acute monocytic leukemia
3
4
7
Acute myeloid leukemia with multilineage dysplasia
1
0
1
Acute myeloid leukemia t(8)
2
1
3
Acute myeloid leukemia 11q23 abnormalities
0
1
1
Myeloid sarcoma
0
1
1
Chronic myelomonocytic leukemia NOS
1
0
1
Overall Totals
42
39
81
The relative survival, as mentioned above, is the observed survival (the proportion of leukemia patients surviving for
a specific time period) adjusted for expected mortality. The average age at diagnosis was 48 and the median age
at diagnosis for the 81 cases was 51.or under among both men and women. Survival by year from diagnosis for the
acute myeloid leukemia cases with stem cell transplants diagnosed from 2005 thru 2009 shows a relative survival
rate for 60 months of 41.2%.
26 • Loyola University Health System
Patient Care Evaluation
Table 15: Survival by Year for cases diagnosed from 2005-2009 year (# of cases-81)
Year
Relative
Survival (%)
Year 1
81.8
Year 2
57.0
Year 3
45.8
Year 4
43.5
Year 5
41.2
Observed survival for all leukemia cases diagnosed in 2003-2007 showed a 5 year survival of 42.0%.for LUMC
Table 16: LUMC Observed Survival for all Leukemias (2003-2007 Data)
Stage
Cases
0-Yr
1-Yr
2-Yr
3-Yr
4-yr
5-Yr
N/A
355
100
71.1
55.2
48.7
45.4
42.0
National reporting for observed survival showed a 5 year survival of 41.1%.
Table 17: National Observed for all Leukemia (2003-2007 Data)
Stage
Cases
0-Yr
1-Yr
2-Yr
3-Yr
4-yr
5-Yr
N/A
83,284
100
64.8
53.8
48.1
44.1
41.1
Table 18: LUMC Observed (2003-2007 Data) for Acute Myeloid Leukemia
Stage
Cases
0-Yr
1-Yr
2-Yr
3-Yr
4-yr
5-Yr
N/A
173
100
59.4
39.9
31.4
28.4
27.1
Table 19: National Observed (2003-2007 Data) for Acute Myeloid Leukemia
Stage
Cases
0-Yr
1-Yr
2-Yr
3-Yr
4-yr
5-Yr
N/A
31,151
100
44.1
30.4
25.6
23.1
21.6
Study of Leukemia 2010-2014
2014 Oncology Program Annual Report • 27
Improvements in survival in AML over the past decades have come primarily from improvements in post-remission therapy,
supportive care, and stem cell transplants. Findings of the survival reflect extraordinary dedication by physicians and staff to
improve the outcomes of the patients by continually refining transplantation to be a safer and more effective treatment.
Follow-up care for survivors includes surveillance for recurrence or development of a new cancer, assessing psychosocial
needs, counseling regarding preventive health, and testing for specific risk factors and late effects. Patients at our facility
are provided with a plan that includes information about cancer screening, surveillance for recurrence, the schedule on
which tests and examinations should be performed, long-term effects of treatment and their symptoms. Our physicians,
nurses, researchers and psychologists are experts and work collaboratively with the patient’s primary care physician from
time of diagnosis onward to ensure all health concerns is being met and create a plan for living well beyond cancer.
In conclusion, AML is markedly heterogeneous disease with variable response to therapy and survival. There have been
dramatic breakthroughs in the identifications of reproducible prognostic variable in this disease, in particular, the advances
in molecular biology as well as genomics technology have revolutionized the approach to leukemia and have added
substantially the understanding of biology and prognosis through identification of novel prognostic markers.
Improved supportive care techniques, including less toxic conditioning regimens, better treatment of and prophylaxis against
graft-versus-host disease, and better treatment of infections in neutropenic patients have all led to improved survival for
transplant recipients. In the future, further improvements in survival may be observed as personalized novel and effective
therapeutics with tolerable side effects profiles are developed.
Data source: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence - SEER 18 Regs Research Data + Hurricane Katrina
Impacted Louisiana Cases, Nov 2013 Sub (1973-2011 varying) - Linked To County Attributes - Total U.S., 1969-2012 Counties, National Cancer Institute, DCCPS, Surveillance Research
Program, Surveillance Systems Branch, released April 2014 (updated 5/7/2014), based on the November 2013 submission, American Cancer Society, American College of Surgeons;
facs.org, North American Association of Central Cancer Registries National Institutes of Health, Center for International Blood and Marrow Transplant (CIBMTR); http://bloodcell.transplant.
hrsa.gov/about/contractors/cibmtr/index.html
28 • Loyola University Health System
Patient Care Evaluation
Patient Care Evaluation
Study of Larynx Cancer
2010-2014
Carol Bier-Laning, MD, FACS
Otolaryngology
Associate Professor
Study of Larynx Cancer 2010-2014
Violeta Dimovic, CTR
Manager, Oncology Data
Cancer Program
2014 Oncology Program Annual Report • 29
Introduction
Laryngeal cancer is a type of cancer that affects the larynx,
an organ that plays an important role in breathing and
communicating. It contains the vocal cords, which give one
the sound needed to speak. The larynx is composed of three
different parts:
• glottis - the part of the larynx that contains the vocal cords
• supraglottis - the area above the glottis
• subglottis - area below the glottis
The American Cancer Society’s most recent estimates for
laryngeal cancer in the United States for 2014 are:
• About 12,630 newly diagnosed cases of laryngeal cancer
• About 3,610 deaths from laryngeal cancer
About 60% of laryngeal cancers start in the glottis (the area
containing the vocal cords themselves), while about 35%
develop in the supraglottic area (above the vocal cords). The
rest develop in either the subglottis (below the vocal cords)
or overlap more than one area so that it is hard to tell where
they started.
The initial presenting symptoms of cancer of the larynx
depend upon the site involved. Supraglottic cancers tend
to present late with symptoms of dysphagia, odynophagia,
hemoptysis, or referred otalgia. Stridor and hoarseness
are late findings. Palpable cervical lymphadenopathy is a
common presenting sign. Glottic cancers often present
early with hoarseness, and palpable lymphadenopathy is
uncommon. Late symptoms include dysphagia, odynophagia,
stridor, or cough. Subglottic cancer presents with dyspnea,
stridor, or palpable cervical lymphadenopathy.
The most important adverse prognostic factors for laryngeal
cancers include increasing T stage and N stage. Other
prognostic factors may include sex, age, performance status,
and a variety of pathologic features of the tumor, including
grade and depth of invasion.
The objectives of this study are to determine the
demographic breakdown of Loyola University Medical
Center (LUMC) laryngeal cancer patients, to characterize
the type of surgical procedures done, to assess the use of
radiation therapy and chemotherapy in the management
of this disease and compare the five-year survival rate with
national averages.
Methods
A retrospective study was conducted of patients primarily
treated for carcinoma of the larynx between 2010 and 2014
at Loyola University Medical Center. A total of 138 cases
that satisfied the inclusion criteria were analyzed. Among
these, most (85/138 62%) had their cancers diagnosed and
received all or part of their treatment at Loyola University
Medical Center (LUMC), thirty five percent (48/138 35%)
received all or part of their treatment at LUMC, but had their
cancers diagnosed elsewhere, and three percent (5/138,
3%) had their cancer diagnosed and treated elsewhere.
Laryngeal cancer cases make up approximately 2% of
Loyola’s overall cancer caseload.
Results
Diagnosis and Demographics
Table 1 highlights the larynx cancer diagnoses per year for the five year period from 2010-2014. During this period, the
highest incidence of laryngeal cancer occurred in 2013, with 37 of the cases (37/138, 27%) seen during that year. Over
this five year period at LUMC, 106 cases (77%) were diagnosed in males and 32 (23%) in females. This male/female
distribution is very similar to the national figures. The age of patients ranged from 40 to 89, with the majority presenting
between ages 60-69 (56/138, 41%; see Table 2 for details).
Table-1: Laryngeal Cancer Cases /Year
LUMC
Total
2010
2011
2012
2013
2014
138 (100%)
17
18
30
37
36
30 • Loyola University Health System
Patient Care Evaluation
Table 2: # of Laryngeal Cancer Cases by Age & Gender, 2010-2014
Age Range
Male
Female
40-49
7
1
50-59
24
12
60-69
46
10
70-79
19
5
80-89
10
4
Total
106
32
(LUMC (106) Male 77%)
Subsite Classification
When classified by anatomic location, 49 cases (35.5%)
were supraglottic carcinomas, 71 cases (51.4%) were glottic,
3 cases (2.2%) were subglottic, 14 additional cases (10.1%)
could not be further classified and one was documented as
unknown.
Table 3: Laryngeal Subsite: Year(s) 2010-2014
Subsite
# of Cases
% of Cases
Supraglottis
49
35.5%
Glottis
71
51.4%
Subglottis
3
2.2%
(NCDB (42,000) Male 79%)
Overlapping Lesion
14
10.1%
(LUMC (32) Females23%),
Unknown
1
.8%
(NCDB (10,875) Females 21%)
Total
138
100%
Because survival rates differ based on subsite, the
15 cases classified as overlapping or unknown were
further reviewed to determine if any of the imaging
or pathological findings documented the site, or if the
cancer registry abstractor defined the site as overlapping.
This audit was conducted to measure the accuracy
of registry data and to identify any other problematic
areas. Recommendations have been integrated through
educational projects and directives aiming at improving
the documentation on which the cancer registry staff relies.
Based on this further review, the glottis remained the most
frequent subsite at 59% and the overlapping location site
decreased from 9% to 0% of the cases.
Table 4: Laryngeal Subsite: (after audit) Year(s) 2010-2014
Study of Larynx Cancer 2010-2014
Subsite
# of Cases
% of Cases
Supraglottis
54
39%
Glottis
81
59%
Subglottis
3
2%
Overlapping Lesion
0
-
Unknown
0
-
Total
138
100%
2014 Oncology Program Annual Report • 31
Pathology
Pathological diagnosis for laryngeal cancer is achieved after biopsy which is generally obtained at direct laryngoscopy
under general anesthesia. The vast majority of all laryngeal malignancies are conventional squamous cell carcinomas (SCC)
and they vary according to their degree of differentiation. Glottic cancers are generally well differentiated and have a less
aggressive behavior in comparison with carcinomas at the other subsites of the larynx. SCC often arises in a background
of mucosal squamous dysplasia or carcinoma in situ and typically presents as islands, tongues and clusters of atypical cells
invading the laryngeal stroma. Features of squamous differentiation also comprise individual cell keratinization, intercellular
bridges and keratin pearls. Recognition of the less common variants like verrucous, spindle cell and basaloid SCC is
significant because their biological course often is different from that of conventional SCC.
Histological examination revealed the vast majority of laryngeal cancers to be squamous cell carcinoma (squamous cell
carcinomas 111, 80%, keratinizing squamous cell carcinoma (13, 9%). Five cases were classified as carcinoma in situ or
squamous cell carcinoma in situ (5, 4%). Other classifications included large cell, non-keratinizing squamous cell carcinoma
(5, 4%), squamous cell carcinoma spindle cell (3, 2%) and basal cell adenocarcinoma (1, 1%). Pathologic classification
showed 94 cases (68%) as well or moderately differentiated squamous cell carcinoma (grade I or II), 26 cases (19%) as
poorly differentiated squamous cell carcinoma (grade III or IV) and 18 (13%) cases were classified as unknown.
Table 5: Distribution by Histology and AJCC Stage (Year: 2010-2014)
0
1
2
3
4A
4B
4C
Total
Carcinoma in Situ
3
-
-
-
-
-
-
3
Squamous Cell Carcinoma in Situ
2
-
-
-
-
-
-
2
Squamous Cell Carcinoma NOS
-
38
11
20
38
1
3
111
Squamous Cell Carcinoma, Keratinizing
-
5
2
1
4
1
-
13
Squamous cell carcinoma large cell non-keratinizing
-
2
-
2
1
-
-
5
Squamous cell carcinoma spindle cell
-
1
2
-
-
-
-
3
Basal cell adenocarcinoma
-
-
-
-
1
-
-
1
Total
5
46
15
23
44
2
3
138
32 • Loyola University Health System
Patient Care Evaluation
Once the diagnosis of laryngeal cancer has been documented the disease is staged according to the TNM classification
system (stages I-IV) using the International Union against Cancer/American Joint Committee on Cancer (UICC/AJCC)
criteria. This system takes into account tumor size and location (T), lymph node involvement (N) and presence of distant
metastasis (M) (see Appendix A).
The stage distribution of larynx cancer cases at LUMC compared to national data is shown in Table 6 below.
Table 6: LUMC AJCC Stage comparison with National Data (2009-2013)
(2009-2013 years used for purposes of same year comparison with national data)
Recommendations from the commission on cancer
Stage
LUMC Year-(2009-2013) N=135
NCDB Year-(2009-2013) N=52,517
0
7 (5%)
3203 (6%)
I
50 (37%)
15216 (29%)
II
11 (8%)
7667 (15%)
III
22 (16%)
8957 (17%)
IV
45 (33%)
14762 (28%)
Unknown Stage
-
2352 (4%)
Total
135 (100%)
52517 (100%)
LUMC/ Loyola University Medical Center//NCDB /National Cancer Data Base (Data from 1,465 Hospitals)
Study of Larynx Cancer 2010-2014
2014 Oncology Program Annual Report • 33
Treatment
According to the National Comprehensive Cancer Network (NCCN), treatment options and recommendations depend on
several factors, including the type and stage of cancer, subsite location of cancer, potential side effects, and the patient’s
preferences and overall health. There are three main treatment options for laryngeal cancer: surgery, radiation therapy, and
chemotherapy. Generally speaking, early stage laryngeal cancers (Stage I or II) can be treated with radiation therapy alone
or surgery. Surgery options depend on the subsite and extent as well as other patient factors, but may include endoscopic
resection including laser resection and open partial laryngectomy (supraglottic laryngectomy or vertical hemilaryngectomy).
Advanced stage cancers (Stages III and IV) require multimodality therapy and may include concurrent chemoradiation
with surgical salvage if needed or surgery with radiation or chemoradiation depending on pathologic analysis. Surgery for
advanced stage cancers may include endoscopic or open partial laryngectomy and neck dissection or total laryngectomy
and neck dissection. The treatment of laryngeal cancer at LUMC by stage is shown in Table 7. The comparison of treatment
course between LUMC and date from the NCDB is shown in Table 8.
Table-7: LUMC: Laryngeal Treatment by Stage (Year 2009-2013)
Same years used for NCDB comparison purposes
Stage
0
Surgery Only
5
Radiation Only
II
III
IV
% (# of cases)
13
5
7
12
31% (42)
1
21
4
3
2
23% (31)
Surgery &Radiation
-
12
1
1
15
21% (29)
Radiation & Chemotherapy
-
1
1
7
4
10% (13)
Surgery, Radiation & Chemotherapy
-
-
2
10
-
9% (12)
No 1st Course Rx
-
3
-
1
1
4% (5)
Active Surveillance
1
-
-
-
-
.7% (1)
Chemotherapy Only
-
-
-
1
-
.7% (1)
Surgery & Chemotherapy
-
-
-
-
1
.6% (1)
Total
7
50
11
22
45
100% (135)
34 • Loyola University Health System
I
Patient Care Evaluation
Table 8: Treatment Combination Comparison: LUMC vs NCDB (Year 2009-2013)
First Course Treatment of Larynx Cancer Diagnosed in 2009, 2010, 2011, 2012, 2013 Loyola University Medical Center,
Maywood IL vs. All Types Hospitals in All States All Diagnosis Types - Data from 1465 Hospitals
# First Course Treatment
My (N)
Oth. (N)
My (%)
Oth. (%)
Column TOTAL
135
52517
100%
100%
1.
Surgery Only
42
8887
31.11%
16.92%
2.
Radiation Only
31
13959
22.96%
26.58%
3.
Surgery & Radiation
29
6148
21.48%
11.71%
4.
Radiation & Chemotherapy
13
12663
9.63%
24.11%
5.
Surgery, Radiation & Chemotherapy
12
3258
8.89%
6.2%
6.
No 1st Course Rx
5
4924
3.7%
9.38%
7.
Surgery & Chemotherapy
1
302
0.74%
0.58%
8.
Chemotherapy Only
1
1142
0.74%
2.17%
9.
Active Surveillance
1
74
0.74%
0.14%
10.
Surgery, Radiation & Hormone Therapy
-
11
-
0.02%
Survival
The tables below illustrate the observed 5-year survival rate calculated by the Actuarial Life Table Method (calculates
the proportion surviving to each point in time that death occurs) from Loyola University Medical Center:
Table 9: LUMC (Kaplan-Meier ) Survival Rates (%) Cases Diagnosed in 2006-2010 5 year survival
Years
0-Year
1-Year
2-Year
3-Year
4-Year
5-Year
Stage 0
100
100
100
100
100
100
Stage I
100
92.8
92.8
88.6
84.4
84.4
Stage II
100
94.4
94.4
81.8
81.8
69.2
Stage III
100
88
88
83.6
69.8
64.8
Stage IV
100
73.6
45.2
37.3
31.1
24.8
Study of Larynx Cancer 2010-2014
2014 Oncology Program Annual Report • 35
Survival date from the National Cancer Institute (NCI) by stage and laryngeal subsite is shown in Table 10.
Table 10: Larynx Survival Rates by Stage & Sub Types (NCI: Year-2003)
Sub-site
II
III
IV
Supraglottis
I
75-85%
55-65%
45-75%
15-35%
Glottis
85-95%
60-80%
55-70%
10-25%
Subglottis
–
30-40%
–
–
Discussion
Loyola University Medical Center is a high volume head and neck cancer center that treats nearly 40 laryngeal cancers
every year. Similar to national statistics, approximately ¾ of our patients are male, and over half present with glottic tumors.
About ⅓ of our patients present with Stage I disease, while another ⅓ present with Stage IV disease. The vast majority are
squamous cell carcinoma. We have all treatment modalities available at LUMC and work as a multidisciplinary team with all
cases presented prospectively at multidisciplinary tumor board. Slightly over ⅓ of patients are treated with surgery alone,
over the national average, while approximately 10% are treated with radiation and chemotherapy.
The results of this study demonstrate that stage at presentation remains a significant predictor of survival. Other
prognostic factors will likely be identified as research continues.
Areas in which we can improve include prospectively capturing data regarding tobacco, alcohol and drug use as well as oral
health. Additionally, we could benefit from collecting tumor samples. An IRB approved method to capture these data has
been developed, and will be put in place in the future. In conjunction with the cancer committee and cancer registrar, we
hope to add data fields that will answer important clinical questions for future retrospective analyses. Such an expanded
data base will provide important information for future studies. A recommendation of the cancer committee is to repeat
this study to assess compliance with patient guidelines and the success of collecting prospective data and tumor samples
as outlined above. A goal of Loyola University Medical Center is to collect high quality data so we can provide useful
information about cancer to our patients and the community.
In conclusion, the larynx plays a fundamental role in the maintenance of the airway, protecting the lungs from aspiration
and the production of speech. These facts must always be given consideration when a decision is made for the optimal
management of a laryngeal tumor. Organ preservation strategies, either surgical or non-surgical, have dominated the
treatment of early laryngeal lesions. Developments and integrated strategies, including endoscopic and open partial
laryngectomy procedures including use of the surgical robot, concurrent chemotherapy and radiation therapy, induction
chemotherapy, IMRT and aggressive supportive care with speech therapy, nutrition, physical therapy and specialized
head and neck nursing care have expanded the options for our patients. These advances in management strategies
aim at improved clinical outcome, retention of function, and superior quality of life. In the future, further refinements in
diagnostic and therapeutic techniques will allow physicians to better treat patients with laryngeal cancers. Positron emission
tomography (PET) scans may help diagnose lesions earlier and more accurately assess recurrence. Gene therapy may
offer alternative treatment options. Additionally, the identification of biomarkers to guide personalized treatment planning
promises to further enhance our ability to maximize outcome and minimize side effects.
36 • Loyola University Health System
Patient Care Evaluation
Appendix A: Laryngeal Cancer Staging, AJCC 7th Edition
Supraglottis
Subglottis
•T
1: Tumor limited to one subsite of supraglottis
with normal vocal cord mobility
•T1: Tumor limited to the subglottis
•T2: Tumor extends to vocal cord(s) with normal
or impaired mobility
-S
ubsites: False cords, arytenoids, suprahyoid
epiglottis, infrahyoid epiglottis, aryepiglotic folds
•T3: Tumor limited to larynx with vocal cord fixation
•T2: Tumor invades mucosa of more than one
adjacent subsite* of supraglottis or glottis or region
outside the supraglottis (e.g., mucosa of base of
tongue, vallecula, or medial wall of pyriform sinus)
without fixation of the larynx
•T4a: Tumor invades cricoid or thyroid cartilage
and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck, including deep
extrinsic muscles of the tongue, strap muscles,
thyroid, or esophagus) Note: extrinsic muscles
of the tongue are: genioglossus, hyoglossus,
styloglossus, and palatoglossus
•T3: Tumor limited to larynx with vocal cord fixation
and/or invades any of the following: postcricoid
area, pre-epiglottic tissues, paraglottic space, and/or
minor thyroid cartilage erosion (e.g., inner cortex)
•T4a: Tumor invades through the thyroid
cartilage, and/or invades tissues beyond the
larynx (e.g., trachea, soft tissues of the neck
including deep extrinsic muscle of the tongue,
strap muscles, thyroid, or esophagus)
Note: extrinsic muscles of the tongue are:
genioglossus, hyoglossus, styloglossus, and
palatoglossus
•T4b: Tumor invades prevertebral space, encases
carotid artery, or invades mediastinal structures
Glottis
•T
1: Tumor limited to the vocal cord(s), which
may involve anterior or posterior commissure,
with normal mobility
-T
1a: Tumor limited to one vocal cord
-T
1b: Tumor involves both vocal cords
•T4b: Tumor invades prevertebral space, encases
carotid artery, or invades mediastinal structures
Lymph Node Stage
•NX - Cannot be assessed
•N0 - No regional lymph nodes metastasis
•N1 - Single ipsilateral lymph node,
<= 3cm in greatest dimension
•N2
- N2a - Single ipsilateral lymph node,
3-6 cm in greatest dimension
- N2b - Multiple ipsilateral lymph nodes,
<= 6cm in greatest dimension
- N2c - Bilateral or contralateral lymph nodes,
<= 6cm in greatest dimension
•N3 - Lymph node(s) >6 cm in greatest dimension
Metastasis Stage
•T2: Tumor extends to supraglottis and/or subglottis
and/or with impaired vocal cord mobility
•MX: Distant metastasis cannot be assessed
•T3: Tumor limited to the larynx with vocal cord
fixation and/or invades paraglottic space, and/or
minor thyroid cartilage erosion (e.g., inner cortex)
•M1: Distant metastasis
•T4a: Tumor invades through the thyroid cartilage
and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck, including deep
extrinsic muscle of the tongue, strap muscles,
thyroid, or esophagus) Note: extrinsic muscles
of the tongue are: genioglossus, hyoglossus,
styloglossus, and palatoglossus
•T4b: Tumor invades prevertebral space, encases
carotid artery, or invades mediastinal structures
•M0: No distant metastasis
AJCC Overall Stage
•I - T1 N0
•II - T2 N0
•III - T3 N0, T1-3 N1
•IVA - T4a N0-2, T1-4a N2
•IVB - T4b any N, any T N3
•IVC - M1 (Cancer has spread to other parts
of the body, such as the lung, liver, or bone)
2014 Oncology Program Annual Report • 37
Glossary of Terms
Accession:The addition of new cancer cases to the Oncology Registry. Each patient is assigned a separate and
permanent number.
ACOS:
American College of Surgeons
ACS:
American Cancer Society
Class of Case:The class of case divides cases recorded in the database of the facility into categories of analytic and nonanalytic. Analytic data includes cases diagnosed at the accessioning facility and/or administration of any
of the first course of treatment after the *registry’s reference date. Non-analytic cases are first diagnosed
and receive all of first course of therapy at another institution, or are diagnosed at autopsy or by death
certificate only. Non-analytic cases are not usually included in routine treatment or survival statistics. Based
on category, the cancer program selects cases to be used by their facility or to be reported to the central
registry, as well as, the National Cancer Data Base (NCDB).
Analytic:
A case first diagnosed and / or receiving first course treatment at that facility, or diagnosed at autopsy.
Non-analytic:Any case diagnosed at another facility and receiving all of first course treatment at that facility, then seen at
Loyola University Medical Center for subsequent treatment.
Class 0Diagnosis at accessioning facility and the entire first course of treatment was performed elsewhere or the
decision not to treat was made at another facility.
>Patients who elect to be treated elsewhere.
>Patients who are referred elsewhere for treatment for any reason. For example, lack of special
equipment; proximity of a patient’s residence; financial, social or rehabilitative considerations
Class 1Diagnosis at the accessioning facility, and all or part of the first course of treatment was performed at the
accessioning facility.
Patients diagnosed at the accessioning facility whose treatment plan is either not to treat or
watchful waiting.
Patients diagnosed at the accessioning facility who refuse treatment.
Patients diagnosed at the accessioning facility who are not treatable or who were given palliative
care only due to age, advanced disease, or other medical conditions.
Patients diagnosed at the accessioning facility for whom it is unknown whether treatment was
recommended or administered.
Patients diagnosed at the accessioning facility for whom treatment was recommended, but it is
unknown whether it was administered.
Patients diagnosed at a staff physician’s office who receive their first course of treatment at the
accessioning facility. “Staff physician” refers to any medical staff with admitting privileges at the
accessioning facility.
Patients diagnosed at the accessioning facility who received all or part of their first course of
treatment in a staff physician’s office
38 • Loyola University Health System
Class 2Diagnosis elsewhere, and all or part of the first course of treatment was performed at the
accessioning facility.
Patient provided palliative care in lieu of first course treatment, or as part of the first course of treatment,
at the accessioning facility.
Class 3
Diagnosis and all of first course treatment done elsewhere.
Patient treated or managed at the accessioning facility, but first course of treatment information
is unknown.
Patient for whom the accessioning facility developed a treatment plan or provided “second opinion”
services, but the diagnosis and treatment was provided elsewhere.
Patient treated for a recurrence or progression for a previously diagnosed malignancy.
NCDB: The National Cancer Database
References
Illinois Cancer Facts & Figures American Cancer Society, Incidence 2014
AJCC Manual for Staging Seventh Edition
National Cancer Data Base American College of Surgeons, Commission on Cancer
Electronic Registry Systems Cancer Data Management Database Systems 2014
College of American Pathologists www.cap.org CAP Cancer Protocols
NCCN Guidelines in Oncology-v.2.2015 National Comprehensive Cancer Network, 2015
National Cancer Facts & Figures, ACS American Cancer Society, Inc., Surveillance Research, CDC, 2014
2160 S. First Ave. • Maywood, IL 60153
708-216-3862 • loyolamedicine.org
© 2016 Loyola University Health System. All Rights Reserved. • February 2016 • 20160201-02