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Volume 166, Number 1 • January/February 2014
Established 1844
Editor D. LUKE GLANCY, MD
Associate Editor L.W. JOHNSON, MD
BOARD OF TRUSTEES Chair, GEOFFREY W. GARRETT, MD Vice Chair, K. BARTON FARRIS, MD Secretary/Treasurer, RICHARD PADDOCK, MD ANTHONY P. BLALOCK, MD D. LUKE GLANCY, MD LESTER W. JOHNSON, MD FRED A. LOPEZ, MD EDITORIAL BOARD MURTUZA J. ALI, MD RONALD AMEDEE, MD SAMUEL ANDREWS, II, MD BOB BATSON, MD EDWIN BECKMAN, MD GERALD S. BERENSON, MD C. LYNN BESCH, MD JOHN BOLTON, MD MICHELLE BOURQUE, JD JAMES N. BRAWNER, III, MD BRETT CASCIO, MD QUYEN CHU, MD GUSTAVO A. COLON, MD RICHARD COULON, MD LOUIS CUCINOTTA, MD VINCENT A. CULOTTA, JR., MD JOSEPH DALOVISIO, MD NINA DHURANDHAR, MD JAMES DIAZ, MD, MPH & TM, D r . PH JOHN ENGLAND, MD JULIO FIGUEROA, MD ELIZABETH FONTHAM, MPH, D r . PH EDWARD FOULKS, MD HENRY G. HANLEY, MD ELIAS B. HANNA, MD LYNN H. HARRISON, JR., MD ROBERT HEWITT, MD MICHAEL HILL, MD LARRY HOLLIER, MD JOHN HUNT, MD BERNARD JAFFE, MD NEERAJ JAIN, MD TRENTON L. JAMES, II, MD KEVIN KRANE, MD MAUREEN LICHTVELD, MD, MPH FRED A. LOPEZ, MD F. BROBSON LUTZ, JR., MD DAVID MARTIN, MD JORGE A. MARTINEZ, MD, JD ELIZABETH MCBURNEY, MD ELLEN MCLEAN, MD NORMAN E. MCSWAIN, JR., MD REINHOLD MUNKER, MD DAVID MUSHATT, MD JOSEPH NADELL, MD HAROLD R. NEITZSCHMAN, MD STEVE NELSON, MD NORA OATES, MD DONALD PALMISANO, MD, JD, FACS PATRICK W. PEAVY, MD ROBERTO QUINTAL, MD RAOULT RATARD, MD, MS, MPH & TM ROBERT RICHARDS, MD DONALD RICHARDSON, MD FRANK A. RIDDICK, JR., MD WILLIAM C. ROBERTS, MD DONNA RYAN, MD JERRY ST. PIERRE, MD CHARLES SANDERS, MD OLIVER SARTOR, MD CHARLES SCHER, MD RICHARD SPECTOR, MD JACK P. STRONG, MD PRAMILLA N. SUBRAMANIAM, MD KEITH VAN METER, MD DIANA VEILLON, MD HECTOR VENTURA, MD
F eatured A rticles
Zhuang Feng, MD, PhD
Blastic Plasmacytoid Dendritic Cell Neoplasm: Report of a Case Presenting With Lung and Central Nervous System Involvement and
2
Jun Zhou, MD Gail Bentley, MD
Review of the Literature
Genevieve F. Maronge, MD
The Supply of Hematolgoy/Oncology Specialists
10
Paragi Gururaja Ramnaryan, MD, MPH Perry G. Rigby, MD
Michael H. Moses, MD Mark W. Stalder, MD David T. Pointer Jr., BS Ryan Wong, MD Charles L. Dupin, MD Hugo St. Hilaire, MD, DDS
Treatment of Submucous Cleft Palate With Selective Use of the
15
Furlow Z-Palatoplasty
Marc Manix, MD Anthony Sin, MD
Distal Ventriculoperitoneal Shunt Catheter Migration to the
21
Right Ventricle of the Heart - A Case Report
Anil Nanda, MD, MPH, FACS
Brian Revis, MD
Malposition of a Hemodialysis Catheter in the Accessory Hemiazygos
26
Mohammad Kazem Fallahzadeh, MD
Vein
Neeraj Singh, MD
Lauren E. Richey, MD, MPH Elizabeth J. Carpenter, MD James M. Barbeau, MD, JD Christiane M. Hadi, MD, MPH
Rapid HIV Testing in a New Orleans Emergency Department is Effective in Identifying New HIV Diagnoses and in Linking Patients to
28
Care
D. Luke Glancy, MD
In Memoriam: Edward S. Connolly, MD
34
Sabrina L. Noah
Protecting the Private Practice of Medicine
35
D epartments
D. Luke Glancy, MD William P. Abide Jr., MD
ECG OF THE MONTH
36
Amaurosis Fugax in a 45-Year-Old Woman
Chris Stark, BS
RADIOLOGY OF THE MONTH
38
Jagan D. Gupta, MD Tracy Austin, MD
Progressive Slurring of Speech and Difficulty Reading in a
62-Year-Old Male
Enrique Palacios, MD Harold Neitzschman, MD
Faisal Musa, MD
CLINICAL CASE OF THE MONTH
41
Jorge A. Martinez, MD, JD Catherine Hebert, MD Matthew Safley, DO
Altered Mental Status and Headache in a Young Man
David Smith, MD Fred Lopez, MD
Theresa Nuttli, MD Robin R. McGoey, MD
PATHOLOGY IMAGE OF THE MONTH
46
Altered Mental Status, Alcohol Abuse, and Hyperammonemia
CHRIS WINTERS, MD GAZI B. ZIBARI, MD
Journal of the Louisiana State Medical Society
Blastic Plasmacytoid Dendritic Cell Neoplasm: Report of a Case Presenting With Lung and Central Nervous System Involvement and Review of the Literature
Zhuang Feng, MD, PhD; Jun Zhou, MD; Gail Bentley, MD
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematopoietic malignancy with almost invariably cutaneous involvement and poor prognosis. We report a case of BPDCN in a 58-year-old man who presented with skin, lymph node, bone marrow, peripheral blood, lung, and central nervous system involvement. To the best of our knowledge, central nervous system (CNS) involvement as initial presenta- tion has not been reported since the latest World Health Organization (WHO) classification of tumors of the hematopoietic and lymphoid tissues in 2008. Review of the literature was performed on BPDCN cases published in 2008-2013 in PubMed. The major clinical, histopathologic, immunophenotypic, and cytogenetic aspects of the disease were discussed. Dermatologists and dermatopathologists should be aware of this rare disease for which nearly half of the patients present with only cutaneous lesions at diagnosis, as it may allow for early diagnosis and appropriate treatment.
INTRODUCTION Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematopoietic malignancy. The recognition and nomenclature of BPDCN has been dramatically evolving. BPDCN was first described by Adachi et al. in 1994 as a CD4+CD56+ cutaneous lymphoma. The World Health Or- ganization (WHO) classification of tumors of hematopoietic and lymphoid tissue in 2001 named it as blastic natural killer (NK)-cell lymphoma due to its CD56 expression. 1 Later, the European Organisation for Research and Treatment of Cancer (EORTC) classification of cutaneous lymphoma renamed it as CD4+CD56+ hematodermic neoplasm in 2005. 2 BPDCN was first suggested of dendritic cell origin by Lucio et al. in 1999. More recently, it was confirmed as a tumor of precursor plasmacytoid dendritic cells (PDCs) (Chaperot et al., 2001; Chaperot et al., 2004). PDCs produce type 1 interferon (IFN1) and play an important role in the modulation of innate and adaptive immunity. PDCs are produced in the bone marrow and account for less than 0.1% peripheral blood mononuclear cells. When immune response is activated, PDCs can be recruited into lymph nodes, tonsils, spleen, and mucosa-associated lymphoid tissue. 3 PDCs generally are not identified in skin and sub- cutaneous tissue, and how cutaneous involvement almost invariably occurs in BPDCN is unclear. In 2008, the latest
WHO classification renamed it as BPDCN as a distinct entity under the category of myeloid neoplasm. 4 The etiology of BPDCN is not, but it has been suggested to be associated with acute myeloid/myelomonocytic leukemia (Petrella et al., 2005; Herling et al., 2007). The literature of formerly called blastic NK-cell lym- phoma published prior to 2008 may be heterogeneous because CD56 can be expressed in other hematopoietic lineages, including true NK lymphoma and acute myeloid leukemia with monocytic differentiation. In addition, markers recently developed for PDCs, including CD123 (the interleukin-3 receptor), blood dendritic cell antigen 2 (BDCA2/CD303), 5 and T-cell leukemia/lymphoma 1 (TCL1) and CD2-associated protein (CD2AP), 6 were rarely tested in the literature published prior to 2008. In this article, we report a case of BDPCN presenting with skin, lymph node, bone marrow, peripheral blood, lung, and central nervous system involvement and have reviewed the literature since the latest WHO classification of tumors of hematopoietic and lymphoid tissue in 2008 to delineate the characteristics of the disease. METHODS Light microscopy slides were prepared from paraffin- embedded tissue sections and stained with routine hema-
2 J La State Med Soc VOL 166 January/February 2014
Figure 1: (A) Bone marrow core biopsy showing a hypercellular marrow with diffuse infiltrate of tumor cells (H&E 400x). (B) Bone marrow aspirate smear showing infiltrate of tumor cells with high nuclear cytoplasmic ratio, irregular nuclei, finely dispersed chromatin, prominent nucleoli, grey-blue agranular cytoplasm with a clear intracytoplasmic vacuole and pseudopodia-shaped cytoplasmic extension (Wright-Giemsa stain 1000x under oil immersion).
CASE REPORT A 58-year-old man presented with a two-week history of generalized weakness, fatigue, and dyspnea on exertion in December 2009. On examination, the patient had a 5 cm soft, non-tender, purplish-red nodular skin lesion on the right forearm that grew larger over the past couple of weeks. There were also multiple small purplish papular lesions on the face, back, and left shoulder. Bilateral cervical multiple enlarged lymph nodes were present. Upon admission, he had anemia and thrombocytopenia with white blood cell 5,400/ul, hemoglobin 10.1 g/dl, and platelets 84,000/ul. Bone marrow core biopsy showed a markedly hypercellular marrow that was diffusely replaced bymedium-sized blasts with high nuclear cytoplasmic (N:C) ratio, scant pale cyto- plasm, irregular nuclear contour, and prominent nucleoli occupying more than 90% of marrow space (Figure 1A). Fewmitotic figures were also noted. Bone marrow aspirate smears showed a predominance of blasts with high N:C ratio, grey-blue agranular cytoplasm with a clear intracy- toplasmic vacuole, pseudopodia-shaped cytoplasmic exten- sion, finely dispersed chromatin, and prominent nucleoli, comprising more than 90% of the cells (Figure 1B). By im- munohistochemistry (IHC), the blasts were positive for CD2 (weak), CD4 (strong), CD56, CD43, CD68 (weakly positive), and CD45 (weak non-specific staining) but were negative for CD1a, CD3, CD8, CD20, CD117, TDT, myeloperoxidase, lysozyme, and TIA-1. Immunophenotypic analysis of bone marrow by flow cytometry identified 89% CD45-positive cells with expression of CD4, CD56, TDT and cytoplasmic CD3, partial expression of CD2, CD5, and CD7, but nega- tive for surface CD3, CD13, CD16, CD19, and CD57. CT thorax showed a 4.8 x 8.5 cm consolidation within the right lower lung andmultiple enlargedmediastinal lymph nodes. Transbronchial lung biopsy showed lung parenchyma in-
toxylin and eosin after fixation in 10% neutral buffered formalin. Immunohistochemical analyses were performed on formalin-fixed paraffin-embedded tissue sections using the avidin-biotin-peroxidasemethod and antibodies to CD3, CD4, CD5, CD8, CD10, CD20, CD43, CD45, CD56, CD57, CD68, and terminal deoxynucleotidyl transferase (TDT). CD123 was performed by Mayo Clinic. Three-color flow cytometric analysis (FACScan, Becton Dickinson, Mountain View, CA) was performed on fresh cell suspension and cerebrospinal fluid (CSF) using antibodies to CD2, CD3, CD4, CD5, CD7, CD13, CD16, CD19, CD56, CD57, and TDT. In situ hybridization for Epstein-Barr virus (EBV), encoded small mRNAs (EBER) were performed. Cytogenetic studies were performed with standard protocols. Q banding was used for chromosome identification and karyotypes were defined according to the International System for Human Cytogenetic Nomenclature. Fluorescence in situ hybridiza- tion (FISH) analysis was performed using LSI TCR alpha/ delta dual color break-apart DNA probe (Vysis, Downers Grove, IL). The LSI TCR alpha/delta probe was a mixture of two probes that hybridize to the opposite sites of 14q11.2 with spectrum green on the telomeric side and spectrum orange on the centromeric side of the breakpoints. Gene rearrangement studies of the joining (J) region of the B-cell immunoglobulin heavy chain (IgH) and/or the T-cell recep- tor (TCR) gamma chain were analyzed utilizing polymerase chain reaction (PCR) amplification to detect the presence of monoclonal populations whichwere visualized as a discrete band in the range of 160 base pairs (bp) to 190bp for the TCR gamma region and 75bp to 150bp for the JH region of the IgH, respectively. Literature review was conducted by searching PubMed (U.S. National Library of Medicine) with the following keyword “blastic plasmacytoid dendritic cell neoplasm”.
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Figure 2: (A) Skin punch biopsy showing a superficial and deep dermal predominantly perivascular infiltrate of tumor cells (H&E 20x). (B) Skin biopsy showing dense infiltrate of tumor cells with irregular nuclei, fine chromatin, and prominent nucleoli (H&E 500x under oil immersion). (C-D) Tumor cells showing positivity for CD4 (C) and CD56 (D) (IHC 500x under oil immersion).
volved by the same tumor cells. Fine needle aspiration of subcarinal lymph node showed infiltrate of the tumor cells. CSF showed detection of CD4+CD56+ tumor cells compris- ing 32%of CD45-positive cells by flow cytometry. Peripheral blood smears showed circulating blasts. Cytogenetic analy- sis showed normal male karyotype 46, XY. 20 FISH analysis showed no translocation affecting TCR A/D constant re- gion. Gene rearrangement studies of TCR gamma and JH of IgH were negative. Serological studies showed that the patient was positive for EBVVCA IgG (3.30; reference range 0.00-1.09) and negative for EBV VCA IgM (0.13; reference range 0.00-1.09). The patient was diagnosed with BPDCN and treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy for six cycles, as well as intrathecal therapy. The patient achieved only partial remission and subsequently was treated with ICE (ifosfamide, carboplatin, and etoposide) chemotherapy for two cycles. While waiting for bone marrow transplantation
(BMT), the patient had a relapse of the disease with newly developed multiple 1-1.5 cm slightly raised red lesions on the extremities in August 2010. Skin punch biopsy showed a superficial and deep dermal predominantly perivascular infiltrate of tumor cells with irregular nuclei, fine chromatin, and prominent nucleoli. By IHC, the tumor cells were posi- tive for CD4 and CD56 but negative for CD3. The patient was treatedwith BEAM (carmustine, etoposide, cytarabine, and melphalan) chemotherapy, along with targeted radia- tion for the skin lesions, but showed only partial response. The patient then receivedmatched related donor allogeneic peripheral blood stem cell transplantation (SCT) in August 2010. In January 2011, the patient had another relapse of the disease with new skin lesions. By IHC, skin punch bi- opsy showed the tumor cells were positive for CD4, CD43, CD56, and CD123 and negative for CD3, CD5, CD8, CD20, CD57, CD68, and TDT (Figure 2A-2D). EBER by in situ hybridization was negative. Complete blood count showed
4 J La State Med Soc VOL 166 January/February 2014
pancytopenia. The patient was given high-dose cytosine arabinoside (ara-C) chemotherapy and attained clinical re- mission. Unfortunately the disease relapsed again in April 2011 with multiple new skin lesions and 80% blasts in the peripheral blood. Due to resistant/refractory to treatment, comfort and supportive measures were given to the patient. The patient died of the disease 17 months after diagnosis. DISCUSSION Clinical Features Since BPDCNwas classified as a distinct entity byWHO in 2008, more than 200 cases that meet the new diagnostic criteria have been reported in the literature. 4 BPDCN is a rare hematopoietic malignancy without known predispos- ing factors. It has a male-to-female ratio of 2.6-2.7:1. 3,7,8 Most patients are elderly with a median age of 62-67 years at the time of diagnosis. 3,7-9 Pediatric cases as young as 4 years of age 10 and a unique congenital case of a 3-day-old baby (Yang et al., 2012), although much less common, have been reported. The diagnosis is generally based on skin biopsy. BPDCNusually presents with solitary, multiple, or general- ized skin or subcutaneous lesions in the presence or absence of systemic involvement such as peripheral blood, bone marrow, and lymph nodes. 4 The skin lesions can bemacules, papules, plaques, or nodules and range in size from 0.5 to 12 cmwith a median size of 3 cm at diagnosis. 8,10 Ulceration is not a feature, although Jegalian et al. reported a 12-year-old female patient presenting with a 12 cm ulcerated cutaneous lesion died from infectious complication six months after diagnosis. 10 In the largest case series since 2008 by Dalle et al., all 47 patients had cutaneous involvement (100%) at diagnosis, with 40% as solitary lesion, 38% as multiple le- sions affecting one or two areas, and 21% as disseminated skin disease. 7 Systemic involvement at diagnosis usually occurs in bone marrow (48%-68%), peripheral blood (33%- 73%), and lymph nodes (24%-41%). 7-9 Initial presentation at uncommon sites including maxilla, breast, kidney, liver, spleen, and lung has been reported in very rare cases. 10,11 To the best of our knowledge, our patient is the first case presentingwith CNS involvement since the latestWHO clas- sification in 2008. By literature studies, no cases with CNS involvement at diagnosis were reported, although relapse in the CNS was documented in few cases. 12,13 Nearly half of BPDCN patients (35%-48%) presented with only cutaneous disease at diagnosis. 7-9 Nonetheless, systemic involvement eventually develops with progression of the disease. Leuke- mic disease without cutaneous involvement at presentation, albeit rare, has been reported. 8,12,14 Although response occurs after treatment, relapse invariably occurs, and fatal outcome occurs rapidly. Complete remission (CR) after initial treat- ment was seen in 47%-68%patients with amean relapse-free period of 12.6 months (range 2-42 months). 7-9 BPDCN has an aggressive course and a poor prognosis with a mean survival of 16.7 months. 7 In an Austrian study of 33 patients, there was no difference in survival between patients with
cutaneous disease only and patients with both cutaneous and extracutaneous diseases. 15 Initial staging results did not affect survival. 7,15 Therefore, even though BPDCN presents with only cutaneous diseases in almost half of the cases, it has been suggested these patients should also be treated with initial aggressive therapy. Treatments Due to its rarity and dramatically evolving recognition, no standard treatment is available, and patients usually receive multiple regimens. First-line treatments are vari- able, including palliative care, monochemotherapy, non- Hodgkin’s lymphoma (NHL)-type, acute myeloid leukemia (AML)-type and acute lymphoblastic lymphoma (ALL)- type, radiation therapy, and BMT/SCT. Previous studies on formerly called blastic NK-cell lymphoma/agranular CD4+CD56+ hematodermic neoplasm demonstrated that CHOP/CHOP-like regimen was inadequate; AML-type regimen was associated with a poor prognosis; and hyper- CVAD regimenwas associatedwith a favorable prognosis. 16 Dalle et al. showed that, when used as first-line therapy, CHOP/CHOP-like regimens and radiation therapy had a mean relapse free survival of five and five and a half months respectively compared to 25.3 months with BMT. 7 In a re- cent retrospective study of 39 BPDCN patients (Roos-Weil et al., 2013), allogeneic SCT in first remission was associ- ated with favorable survival, while age, donor type, stem cell source, and chronic graft versus host disease (GVHD) had no significant impact on outcomes. In a case series of six BPDCN patients (Dietrich et al., 2010), two patients without allogeneic SCT died rapidly of the disease at six and 13 months after first-line treatment; two patients with allogeneic SCT in active disease achieved CR but relapsed at six and 18 months after transplantation; and two patients with allogeneic SCT in remission remained disease free at 57 and 16 months after SCT. The authors suggested that allogeneic SCT in first CR should be considered in patients up to 70 years of age. Dalle et al. showed that survival of patients with BMT was significantly higher (31.3 months vs. 12.8 months) than those without BMT. 7 Ham et al. (2012) reported a 26-year-old patient who was treated with AML- type chemotherapy followed by allogeneic SCT in first CR-achieved long-term disease free survival at 30 months after diagnosis. Jegalian et al. indicated that BPDCN was less aggressive in pediatric patients than in adult patients. Of the total 25 pediatric patients, all three patients who received AML-type therapy were dead at the time of clini- cal follow-up. In contrast, among 14 patients who received ALL-type therapy, only one patient who presented with a 12 cm ulcerated cutaneous lesion died of therapy related infectious complications. The authors suggested that, for pediatric patients, high-riskALL-type chemotherapy should be used as first-line treatment, and SCTmay be reserved for those with relapse of disease or on their second remission. 10 Interestingly, Dohm et al. (2011) reported a patient after allogeneic SCT developed fulminant leukemic progression
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Table 1: Summary of the immunophenotypic profiles of BPDCN Antibody Expression
Reference
CD2 CD3 CD4 CD5 CD7
variable, + in 33%-51%
8,9,15
-; rare cases cytoplasmic CD3+
11,18,20
+ (80%-100%)
4,6,14,15,17,21-23
-; one case +
19
-; a few cases + (subset or focal)
10,11
CD33 CD43
-; rare cases +
8,13
+ (96%)
4,6,14,15,17,21-23 4,6,14,15,17,21-23
CD45RA
+ (dim)
CD56 CD68
+ (75%-100%)
6,14,15,17,21-23
variable, + in 52%-85%, cytoplasmic dots in some cases
8-10,15
CD34
-; rare cases + -; rare cases +
4 4
CD117
TdT
variable, + in 14%-63%
9-12, 15
CD123
+ (75%-100%) + (82%-100%) + (50%-100%)
6,14,15,17,21-23 6,14,15,17,21-23 6,14,15,17,21-23 6,14,15,17,21-23 6,14,15,17,21-23 6,14,15,17,21-23
TCL1
BDCA2/CD303
CD2AP
+ (45%-95%)
BCL11A
+ (83%-100%) + (90%-100%)
CLA
CD19, CD20, CD22, CD79a, PAX5
- -
4,7-10 4,7-10
EBER
MPO, Lysozyme
-
4,6,14,15,17,21-23
S100
variable, + in 75% children, + in 16%- 25% adults
3,8,10
Table 1: Summary of the immunophenotypic profiles of BPDCN, or blastic plasmacytoid dendritic cell neoplasm. BPDCN; BDCA2/ CD303, blood dendritic cell antigen 2; TCL1, T-cell leukemia/lymphoma 1; CD2AP, CD2-associated protein; CLA, cutaneous lymphocyte antigen; BCL11A, B-cell lymphoma/leukemia 11A; MPO, myeloperoxidase; TdT, terminal deoxynucleotidyl transferase; EBER, EBV-encoded nuclear RNA.
during extracorporeal photopheresis for GVHD. Whether extracorporeal photopheresis stimulates malignant trans- formation of PDCs remains to be determined, but careful clinical selection of GVHD treatment might be warranted. Morphology Histopathologically, BPDCN in the skin is character- ized by a diffuse infiltrate of medium-sized blasts with high N:C ratio, scant cytoplasm, finely dispersed chromatin, and prominent nucleoli in the dermis underlying a Grenz zone without epidermotropism present. Cota et al. showed that the typical blasts were seen in 44% of skin biopsy specimens of BPDCN, with the majority (56%) of cases presenting as
a rather pleomorphic infiltrate with admixed blastoid cells in the background. 15 On bone marrow aspirate smears, the blasts have scant agranular cytoplasm with eccentrically located nucleus and perinuclear hof. 4 On cytology prepara- tion, the blasts have round to oval nuclei, finely dispersed chromatin, prominent nucleoli, scant pale-blue agranular cytoplasm, occasional cytoplasmic microvacuoles, and pseudopodia-shape cytoplasmic extension. 8,13 Immunophenotype The immunophenotypic profiles of BPDCN are sum- marized in Table 1. BPDCN characteristically expresses CD4, CD56, CD43, CD45, and PDC-associated antigens
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Table 2: Summary of the specificity of immunohistochemical profiles of BPDCN vs. myeloid leukemia cutis BPDCN %
Myeloid leukemia cutis %
CD123
75-100 82-100 50-100
9-17 9-17
TCL1
BDCA2/CD303
3 4
CD2AP
45-95
BCL11A
83-100 90-100 80-100 75-100
25 78
CLA
CD4
9-61
CD56
52
MPO
0
30-67
Table 2: Summary of the specificity of immunohistochemical profiles of BPDCN versus myeloid leukemia cutis. 6,14,15,17,21-23
such as CD123, TCL-1, BDCA2 (CD303) without expression of T-cell, B-cell, and NK-cell or myelomonocytic lineage specific markers, although expression of CD2 and CD7 is not an uncommon finding. 4 CD4-negative cases 9,14,15 and CD56-negative 8-10,15 cases have rarely been reported in case reports. Despite CD123 and TCL1 being generally positive in BPDCN, CD123-negative and TCL1-negative cases were reported. 8,14,15,17 BPDCN also expressed BDCA2, CD2AP, BCL11A (B-cell lymphoma/leukemia 11A), and CLA (cutaneous lymphocyte antigen). 9,10,14,15 TDT-positive and HLA-DR-positive cases were not uncommon. 9-12,15 TDT was expressed in 14%-64% of cases. 9,10,15 Interestingly, our case showed that TdT was expressed in bone marrow by flow cytometry but not expressed in skin by IHC. Khoury et al. demonstrated that the level of TdT expression by IHC was higher in lymph node than in skin. 18 These findings may suggest different patterns of TdT expression in various in- volved tissues and potential association with various stages of the disease. CD2 was aberrantly expressed in 33%-52% of cases. 8,9,15 CD5 expression was extremely rare and reported in a single case on bone marrow specimen. 19 We speculate that the partial expression of CD5 in our case is either an aberrant expression or may represent neoplastic PDCs un- dergoing cell fate conversion to lymphoid phenotype. CD7 was expressed in a few cases, occasionally in the form of subset or focal positivity. 10,11 BPDCN was generally nega- tive for CD3, CD20, CD34, CD117, myeloperoxidase, and EBV. 8-10,14,15 Rare cases were reported to express cytoplasmic CD3. 11,18,20 CD34 and CD117 were expressed in rare cases (Adams et al., 2009; Chen et al., 2011). CD33 is generally negative, 9 but rare CD33-positive cases were reported. 8,13 CD68 was expressed in quite a few cases, and in some cases, in the formof cytoplasmic dots. 8-10 In three case series, CD68 positivity was 53%-86%. 8,9,15 Focal positivity of S100 was reported in three-fourths of pediatric cases (75%) and may represent a favorable prognostic factor, 10 whereas S100 was expressed in 17%-25% of adult patients. 3,8 Hashikawa et al. showed 8 out of 15 (53%) skin biopsy specimen-expressed
CXCL12, which was associated with high leukemic change and poor prognosis. 8 EBV antigens/EBV-encoded nuclear RNA (EBER) and T-cell/B-cell gene rearrangement were consistently negative. 8-10 The Specificity of PDC-Associated Antigens The diagnosis of BPDCN is largely based on the PDC- associated antigens such as CD123, TCL1, BDCA2, and CLA, but most of these markers have been shown to be expressed by other lesions as well. The specificity of PDC-associated antigens is summarized in Table 2. 6,14,15,17,21-23 Benet et al. showed that CD123 and CD303 (BDCA2) were expressed in 11 out of 123 (9%) and 4 out of 124 (3%) myeloid leukemia cutis (LC) cases, respectively. 21 Vitte et al. reported that, in 42 chronic myelomonocytic leukemia (CMML) patients with skin involvement, 45%-50% of the skin lesions expressed CD123, CD303 (BDCA2), and TCL1, indicating the associa- tion of BPDCN with myelodysplastic/myeloproliferative neoplasms such as CMML. 23 Cronin et al. revealed that CD123 was expressed in 4 out of 23 (17%) of myeloid leuke- mia cutis (LC) and 10 out of 12 (83%) of BPDCN cases, while TCL1 was expressed in 2 out of 23 (9%) of LC and 9 out of 11 (82%) of BPDCN cases. 17 In a study by Petrella et al. of 29 formerly called agranular CD4+CD56+ hematodermic neo- plasms (HN) cases and 18 myelomonocytic leukemia cutis (LC) cases, TCL1 was expressed in 26 out of 29 (90%) of HN and 3 out of 18 (17%) LC cases, while CLAwas expressed in 26 out of 29 (90%) of HN and 14 out of 18 (78%) of LC cases. 22 CLA as a skin lymphocyte homing molecule is rather non- specific for BPDCN, and has been reported to be universally expressed in myeloid LC and cutaneous T-cell lymphoma (Campbell et al., 2010; Sachdev et al., 2012). Marafioti et al. showed that CD2AP was expressed in 35 out of 37 (95%) of formerly called CD4+CD56+HN and 1/24 (4%) of LC cases, but not expressed in 24 CML, CMML, B-ALL, and T-ALL cases. In contrast, BCL11A was expressed in 39 out of 39 (100%) HN, 6 out of 24 (25%) LC, 1 out of 7 (14%) CML, 3 out of 5 (60%) CMML, 7 out of 7 (100%) B-ALL, and 4 out
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Table 3: Summary of the most frequent genomic alterations in BPDCN Change Chromosome Cytoband
% of patients
Candidate genes
Loss Loss Loss Loss Loss Loss Loss Loss Loss Loss Loss
13 12
q12.11-q34
50-78 50-67 50-66 50-55 21-44 33-36
RB1
p13.2 p21.3
CDKN1B, ETV6
9 9 5
CDKN2A, CDKN2B, MTAP
q34
NOTCH, TRAF2, CARD9
q23.1-a35.2 q11.2-a26.3 p22.2-p21.1 p13.4-p13.2 p13.3-p11.2 p22.3-p22.1
SMAD5, MSH3, MCC, APC
15
CYP1A1
3
29
PTPN23
19 17
22-29
CDKN2D, PRKCSH
22 21
TP53
7 6
MAD1L1
q23.3-q27
11-21
PARK2
Table 3: Summary of the most frequent genomic alterations in BPDCN. Adapted from ref. 25. BPDCN, blastic plasmacytoid dendritic cell neoplasm; CDKN, cyclin-dependent kinase inhibitor; MTAP, methylthioadenosine phosphorylase; TRAF2, tumor necrosis factor receptor-associated factor 2; CARD9, caspase recruitment domain; RB1, retinoblastoma tumor suppressor gene; CYP1A1, cytochrome P450 family 1 subfamily a polypeptide 1; PRKCSH, protein kinase C substrate 80K-H; PTPN23, protein- tyrosine-phosphatase-n23; MCC, mutated in colorectal cancer; APC, adenomatous polyposis coli tumor suppressor gene; PARK2, Parkinson protein 2; MAD1L1, mitotic arrest deficient-like 1; TP53, tumor protein 53. 9,12,24,25
of 5 (80%) T-ALL cases. 6 Therefore, it has been suggested that immunophenotypic analysis using a panel of antibodies including CD4, CD56, and at least 2 PDC-associated antigens (such as CD123, TCL1, BDCA2, CD2AP, and BCL11A), as well as specific markers to rule out other lineages, should be performed to confirm the diagnosis. Genetics Genetic studies are limited for BPDCN, and no defin- ing recurrent genetic abnormalities have been identified. BPDCN was shown to be associated with normal karyo- type 8,10,11,17 and variable genomic changes by conventional cytogenetic analysis, comparative genomic hybridization (CGH) and PCR. 9,12,24,25 The most frequent genomic altera- tions in BPDCN are summarized in Table 3. 9,12,24,25 Lucioni et al. showed deletion of 9p21.3 containing CDKN2A (en- coding p16-INK4a) and CDKN2B was found in 14 out of 21 (66.6%) patients and represented a worse prognosis factor (median overall survival of 11 months for homozygous loss versus 26 months for hemizygous loss). 9 Interestingly, Petrella et al. (2012) reported an 82-year-old male patient had normal karyotype on bone marrow specimen by con- ventional cytogenetic analysis; losses of chromosome 6, 12 (CDKN1B and ETV6), and 13 on skin biopsy specimen and additional losses of chromosome 2 and 5 on bone marrow specimen by CGH; loss of 2p, 5q, 12p (ETV6), and 13q but not 17 (TP53) on bone marrow specimen; and loss of ETV6 on snap-frozen skin sections by FISH analysis, suggesting that the difference in CGH results between skin and bone marrow specimens may reflect genomic alterations as-
sociating with progression of the disease. Other sporadic genomic aberrations include loss of 1p31.3-33 (containing CDKN2C/p18) and gain of 16p/q, loss of 6q and 7p, t(1;6), t(9;22), t(11;19)(q23;p13.3), trisomy 7, gain of 9p24 and loss of 11q22, and loss of Y. Jardin et al. showed that TET2 (ten eleven translocation 2) and TP53 mutation were seen in 54% and 38% of BPDCN patients by using PCR. 12 Additionally, Wiesner et al. demonstrated that expression of cell cycle inhibitor p27 KIP1 (encoded by CDKN1B) and p16 INK4a (encoded by CDKN2A) was downregulated in tumor cells. 25 These findings suggest that loss of tumor suppressor genes such as CDKN1B, CDKN2A, ARF, CDKN2B, RB1, and TP53, and resultant functional loss of cell cycle checkpoint control- ling proteins, may lead to dysregulation of G1/S transition of the cell cycle and tumorigenesis. To the best of our knowledge, this is the first case of BPDCNwith central nervous system involvement as initial presentation since the latest WHO classification in 2008. Dermatologists and dermatopathologists should be aware of this rare disease for which nearly half of the patients present with only cutaneous lesions at diagnosis. The diagnosis of BPDCN is generally based on the skin biopsy and immu- nophenotypic analysis. High-dose chemotherapy followed by allogeneic SCT in first remission has been suggested to provide durable remission and favorable survival. REFERENCES 1. Chan JKC, Jaffe ES, Ralfkiaer E. Blastic NK-cell lymphoma. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. IARC, Lyon .
8 J La State Med Soc VOL 166 January/February 2014
cells. Am J Clin Pathol . 2007;127:687-700. 21. BenetC,GomezA,AguilarC, et al.Histologicandimmunohistologic characterization of skin localization of myeloid disorders: a study of 173 cases. Am J Clin Pathol . 2011;135:278-290. 22. Petrella T, Meijer CJ, Dalac S, et al. TCL1 and CLA expression in agranular CD4/CD56 hematodermic neoplasms (blastic NK-cell lymphomas) and leukemia cutis. Am J Clin Pathol . 2004;122:307- 313. 23. Vitte F, Fabiani B, Benet C, et al. Specific skin lesions in chronic myelomonocytic leukemia: a spectrum of myelomonocytic and dendritic cell proliferations: a study of 42 cases. Am J Surg Pathol . 2012;36:1302-1316. 24. Jardin F, Callanan M, Penther D, et al. Recurrent genomic aberrations combinedwith deletions of various tumour suppressor genes may deregulate the G1/S transition in CD4+CD56+ haematodermic neoplasms and contribute to the aggressiveness of the disease. Leukemia . 2009;23:698-707. 25. Wiesner T, Obenauf AC, Cota C, Fried I, Speicher MR, Cerroni L. Alterations of the cell-cycle inhibitors p27(KIP1) and p16(INK4a) are frequent in blastic plasmacytoid dendritic cell neoplasms. J Invest Dermatol . 2010;130:1152-1157.
2001:214-215. 2. Willemze R, Jaffe ES, Burg G, et al. WHO-EORTC classification for cutaneous lymphomas. Blood . 2005;105:3768-3785. 3. Jegalian AG, Facchetti F, Jaffe ES. Plasmacytoid dendritic cells: physiologic roles and pathologic states. Adv Anat Pathol . 2009;16:392-404. 4. Facchetti F, Jones DM, Petrella T. Blastic plasmacytoid dendritic cell neoplasm. WHO Classification of tumors of Hematopoietic and Lymphoid Tissues. IARC, Lyon . 2008:145-147. 5. Jaye DL, Geigerman CM, Herling M, Eastburn K, Waller EK, Jones D. Expression of the plasmacytoid dendritic cell marker BDCA-2 supports a spectrum of maturation among CD4+ CD56+ hematodermic neoplasms. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 2006;19:1555- 1562. 6. Marafioti T, Paterson JC, Ballabio E, et al. Novel markers of normal and neoplastic human plasmacytoid dendritic cells. Blood . 2008;111:3778-3792. 7. Dalle S, Beylot-Barry M, Bagot M, et al. Blastic plasmacytoid dendritic cell neoplasm: is transplantation the treatment of choice? Br J Dermatol . 2010;162:74-79. 8. Hashikawa K, Niino D, Yasumoto S, et al. Clinicopathological features and prognostic significance of CXCL12 in blastic plasmacytoid dendritic cell neoplasm. J Am Acad Dermatol . 2012;66:278-291. 9. Lucioni M, Novara F, Fiandrino G, et al. Twenty-one cases of blastic plasmacytoid dendritic cell neoplasm: focus on biallelic locus 9p21.3 deletion. Blood . 2011;118:4591-4594. 10. Jegalian AG, BuxbaumNP, Facchetti F, et al. Blastic plasmacytoid dendritic cell neoplasm in children: diagnostic features and clinical implications. Haematologica . 2010;95:1873-1879. 11. Borchiellini D, GhibaudoN, Mounier N, et al. Blastic plasmacytoid dendritic cell neoplasm: a report of four cases and review of the literature. J Eur Acad Dermatol Venereol . 2012. 12. Jardin F, Ruminy P, Parmentier F, et al. TET2 and TP53 mutations are frequently observed in blastic plasmacytoid dendritic cell neoplasm. Br J Haematol . 2011;153:413-416. 13. Zheng G, Schmieg J, Guan H, Ali SZ. Blastic plasmacytoid dendritic cell neoplasm: cytopathologic findings. Acta cytologica . 2012;56:204-208. 14. Facchetti F, Pileri SA, Agostinelli C, et al. Cytoplasmic nucleophosmin is not detected in blastic plasmacytoid dendritic cell neoplasm. Haematologica . 2009;94:285-288. 15. Cota C, Vale E, Viana I, et al. Cutaneous manifestations of blastic plasmacytoid dendritic cell neoplasm-morphologic and phenotypic variability in a series of 33 patients. Am J Surg Pathol . 2010;34:75-87. 16. Petrella T, Bagot M, Willemze R, et al. Blastic NK-cell lymphomas (agranular CD4+CD56+ hematodermic neoplasms): a review. Am J Clin Pathol . 2005;123:662-675. 17. Cronin DM, George TI , Rei chard KK, Sundram UN. Immunophenotypic analysis of myeloperoxidase-negative leukemia cutis and blastic plasmacytoid dendritic cell neoplasm. Am J Clin Pathol . 2012;137:367-376. 18. Khoury JD, Medeiros LJ, Manning JT, Sulak LE, Bueso-Ramos C, Jones D. CD56(+) TdT(+) blastic natural killer cell tumor of the skin: a primitive systemic malignancy related to myelomonocytic leukemia. Cancer . 2002;94:2401-2408. 19. Chang HJ, Lee MD, Yi HG, et al. A case of blastic plasmacytoid dendritic cell neoplasm initially mimicking cutaneous lupus erythematosus. Cancer Res Treat . 2010;42:239-243. 20. Herling M, Jones D. CD4+/CD56+ hematodermic tumor: the features of an evolving entity and its relationship to dendritic
Dr. Feng is with the Department of Pathology and Laboratory Medicine at Tulane University School of Medicine in New Orleans. Drs. Zhou and Bentley are with the Department of Pathology at the Detroit Medical Center and Wayne State University School of Medicine.
J La State Med Soc VOL 166 January/February 2014 9
Journal of the Louisiana State Medical Society
The Supply of Hematology/Oncology Specialists
Genevieve F. Maronge, MD; Paragi Gururaja Ramnaryan, MD, MPH; Perry G. Rigby, MD
National hematology and oncology organizations and experts in the field, predict a shortage of hematology/ oncology specialists in the United States. Four types of hematology/oncology graduate medical education programs picked to represent direct patient care specialists are presented as physician supply in quantitative data proportional to the averages of the United States in this paper. The hematology/oncology physician production in Louisiana is similar to the average of all programs in the United States. The complexities of having several hematology/oncology graduatemedical education programs, alongwith other specialists, make physician supply more difficult to predict. The patient care demand will rise gradually as the population increases and aging of the population ensues. Technology proliferates, and reform adds patient numbers. As the US shortage of hematology/oncology specialists occurs, the state of Louisiana is tracking the United States in supply and will show the shortage in the same way, same timing, and for the same reasons.
INTRODUCTION There is a perpetual discussion and debate on the subject of physician shortage and particular attention paid to that of primary care. 1,2 The shortage in specialists’ fields is beginning to gain recognition, however. 3 This is quite relevant to the subspecialty of hematology/oncology in that cancer is a disease growing as the population increases and ages, and it requires a delicate and skillful approach to diagnosis and therapy, with lethal potential to the patient experiencing it. If we consider that the numbers of cancer deaths are decreasing over time, 4 along with increases in technology, we can infer that cancer care is improving. This does not indicate a decrease in patients or visits, however, as there are more patients surviving and living with can- cer, requiring more physicians. It is therefore vital that we assess our physician supply and how demand will be met now and in the future. Is there a shortage of physicians in the United States as a whole, what kind, and how is this assessed? Graduate Medical Education (GME) programs are ultimately the sup- ply line of physicians to renew the provision of healthcare, and these vary in size, type, and location. It is probable that they are not increasing the production of specialists fast enough as it relates to population change. 5 The demand is impacted by a population that is dynamic by growth and aging and complicated by technology and constant advancements in standards of care. Healthcare reform is an additional variable that is particularly relevant in this political climate. Quantitating a shortage of hematologists and oncolo-
gists is not a straightforward task and includes a number of factors, like number-per-population, number-per-cancer patients and cancer survivors, the geographic distribution among the states and rural and urban area, and the number of hematologists/oncologists in academics versus non- academic settings (in a field dependent on active research), cancer center locations and utilization, waiting time for appointments and visits, and quality of care in a setting where demand may outweigh supply. 6,7 Certainly there is a fraction of the cancer-patient population that suffer if they are delayed in receiving attention due to longwait times and delayed appointments, as well as other potential barriers, i.e., finance, transportation, and resources. METHODS A straightforward approach to begin an examination is to identify supply and demand. We used data from the 2010 AMA masterfile and the 2012 edition of Physician Characteristics and Distribution from the Division of Survey and Data Resources to examine the supply. 8 Figure 1 dem- onstrates the supply of hematology/oncology specialists as it relates to the population in the United States as compared to Louisiana. We evaluated four specialty programs that provide medical care to cancer patients: medical oncolo- gists, hematology alone, hematology/oncology, and oncol- ogy alone, as well as pediatric hematology/oncology. This demonstrates that Louisiana is comparable to the United States overall in supply. We then examined the demand. The demand is repre- sented by the current utilization patterns and delivery sys-
10 J La State Med Soc VOL 166 January/February 2014
supply be addressed by increasing physicians. GME is the direct source of practicing physicians in the US caring for cancer patients. To become a he- matologist/oncologist requires com- pletion of medical school, followed by a residency training program and then a fellowship in that specialty. We analyzed the residency feeder programs and trends over the last 15 years as shown in Figure 2, lacking sustained growth. Table 1 shows data from the AMA master file and the US Census Bureau from 2010 illustrating there are about 10,000 physicians in the adult care of hematology/oncol- ogy patients and approximately two physicians for every 100,000 people. In Louisiana, there were 146 adult hema- tology/oncology specialists, in equal proportion to that of the United States. Table 2 shows the total hematology/ oncology fellows in the US in 2011 per the Accreditation Council for Gradu- ateMedical Education (ACGME) data resource book. There are 1,570 fellows currently training in adult hematol- ogy/oncology. There are 637 fellows who complete their training and are added to the oncology workforce an- nually after completion of five to six years of post-graduate training. The number of practicing hema- tology/oncology physicians in the United States who are trained in a GME program in Louisiana and the number who remain in Louisiana after training is also relevant, shown in Table 3 with a net retention of 41%. The number of specialists practicing in Louisiana currently who did not
Figure 1: The supply of hematology/oncology specialists comparing the United States to Louisiana, related to a proportion of a population.
Figure 2: The residency feeder programs and trends over the last 15 years.
tems. This is overall complex and difficult to define and has been done by a number of methods, but regardless of vari- ous methods, we found there is a consensus as illustrated by the Association of American Medical Colleges (AAMC) 2008 workforce report. 9 The findings were “under any set of plausible assumptions, the United States is likely to face a growing shortage of physicians…” They also published a report in 2011 summarizing recent publications and sum- maries around the country from 33 states and six national organizations, as well as 22 different specialties that have all reached this same conclusion. 10 RESULTS Replacement of Physicians and Increasing Supply One answer to this growing demand is that short
train in Louisiana is 77, so this adds another dimension to examining needs and sources. This begs the question: how many hematology/ oncology doctors will be training in Louisiana in the next 10 years, and how many will practice in Louisiana? Likely, trends will continue, but increase is uncertain. Incidence rates of cancer in the United States and Loui- siana are integral to this analysis. Figure 3 shows a map of the incidence rates in the United States in 2008 per state as observed fromSurveillance, Epidemiology, and End Results Program (SEER) data. Specifically noted is that Louisiana is higher compared with most of the country, with an inci- dence of 468-487 cases per 100,000 people. So compared to the country as a whole, Louisiana has comparable numbers of hematologists/oncologists; however, there is a higher incidence of cancer overall.
J La State Med Soc VOL 166 January/February 2014 11
Journal of the Louisiana State Medical Society
Table 1: Data from the AMA master file and the US Census Bureau for 2010 US
Louisiana
Type of practicing specialty
N 100k population
N
100k population
Hematologist
1,512 4,275 4,268 1,255
0.49 1.38 1.38 0.41
21 58 67 18
0.46 1.28 1.48 0.40
Hematologist/Oncologist
Oncologist
Pediatric-Hematologist/ Oncologist
TOTAL
11,310
3.66
164
3.62
Table 2: The total hematology/oncology fellows in the United States in 2011 per the ACGME Data Source Book Total Hematology & Oncology Residents/Fellows in the United States Specialty N Hematology 32 Hematology & Oncology 1,450 Oncology 97 Pediatric - Hematology & Oncology 400 Total 1,979 Table 3: The practicing hematology/oncology physicians in the United States who are trained in Louisiana, 2004-2012 Retention of hematology/oncology fellows in Louisiana N Total hematology/oncology physicians trained in a Louisiana GME program 135 Total hematology/oncology physicians trained in a Louisiana GME program & practicing in state as hematologist/oncologist (direct patient care) 55 % retention 41
The analysis of SEER data for Louisiana (Figure 4) in a breakdown by parish shows that many areas have a higher incidence than that illustrated for Louisiana as a whole. There are also a number of rural areas in Louisiana where it is illustrated there is a high incidence of cancer without hematology/oncology practices in those vicinities, bring- ing up the issue of access to care. Other complexities and challenges of this situation include a high percentage of impoverished and underserved, lower socioeconomic status, and lower health literacy, making the task of delivering care even greater. DISCUSSION The surprise is that Louisiana hematology/oncology physicians are quantitatively proportional to the average of the United States, despite the displacements and distrac- tions of Hurricane Katrina. 11 Loss of physicians was early, and replacement was gradual. Production from supply is somewhat less than half of practicing physicians in Louisi-
ana, comparing recruitments. GME programs in the state had not reconstituted until after Katrina, which closed one program for several years (Louisiana State University School of Medicine inNewOrleans). Recruitment of types of hema- tology/oncology specialists, distribution and geography is also similar to corresponding US characteristics. The comparison of individual states data to the US averages is perhaps the best marker of the present quan- titative requirement. If the prediction of hematology/ oncology specialist’s shortage in the United States is actual, then Louisiana is also likely to experience a shortage. The characteristic of programs and physician mobility means recruitment across boundaries increases competition. Many changes occurring presently and simultaneously in specialty GME programs, not just hematology/oncology, increase complexity and hide unintended consequences. Expan- sion of hematology/oncology specialty programs should be considered in future planning to alleviate impending shortages, especially since the production time is many years in duration.
12 J La State Med Soc VOL 166 January/February 2014
Figure 3: Map of the incidence rates of cancer for Louisiana.
Figure 4
J La State Med Soc VOL 166 January/February 2014 13
Journal of the Louisiana State Medical Society
CONCLUSION GME programs in hematology/oncology should consider future expansion to offset a national shortage of practicing specialists, variable in individual states. Other measures improving practice efficiencies, educational programs, and distribution characteristics should also be explored. Matching individual state GME and practice and targeting US average proportions are measures to begin to focus on. Planning directions for cancer care and blood diseases should include GME increases, as well as recruit- ment, distribution, and physician quality. REFERENCE 1. Blumenthal D, et al. New Steam from an Old Cauldron. The Physician – supply debate. NEJM 2004; 350:17. 2. Cooper RA. States With More Physicians Have Better-Quality Health Care. Health Affairs (Web Exclusive) 2008:w91-w101. 3. Council on Graduate Medical Education Resource Paper - State and Managed Care Support for GME: innovation and implication. 4. Carla P, Kent E, Mariotto, et al. Cancer Survivors: A Booming Population. Cancer Epidemiology, Biomarkers, and Prevention 2011; 20:1996-2005. 5. Darves B: Physician Shortages in the Specialties Taking a Toll. www.nejmjobs.org 6. Erikson C, Salsberg E, Forte Gaetano, et.al: Future Supply and Demand for Oncologists: Challenges to Assuring Access to Oncology Services. J Oncology Practice March 2007; 3(2):79-86. 7. Hortobagyi GN: A Shortage of Oncologists? The American Society of Clinical Oncology Workforce Study. Am. Soc. Clin. Onc . April 20, 2007; 25(12):1468-1469. 8. 2010 Louisiana Specific AMA Physician Masterfile. 9. AAMC 2008 workforce: Complex of Physician Supply and Demand 10. AAMC 2011 report. Recent Studies and Reports on Physician Shortage in the U.S. 11. Rigby PG, Braun K, Hilton C, Pinsky W, et al. The Medical Education Commission Report 2007:GME is Recovering From Katrina. J LA State Med. Soc. 2009; 161:32-40. 12. Cooper RA: Expanding Physician Supply-An Imperative for Health Care Reform. The Pharos Spring 2010; 35-37.
Dr. Maronge is a Fellow in the Section of Hematology/Oncology at Louisiana State University School of Medicine in New Orleans. Dr. Ramnaryan is an Assistant Professor in the Department of Internal Medicine at the LSU School of Medicine in New Orleans. Dr. Rigby is a Professor of Medicine in the Section of Hematology/Oncology at LSU School of Medicine in New Orleans.
14 J La State Med Soc VOL 166 January/February 2014
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