Orbital and ocular adnexal Mucosa-Associated Lymphoid Tissue (MALT) lymphomas: a single-center 10-year experience

Orbital and ocular andexal Mucosa-Associated Lymphoid Tissue Lymphoma (MALT) or ocular adnexal MALT lymphoma (OAML) is the most common of all eye non-Hodgkin lymphomas. Autoimmune inflammatory disorders and chronic infections are important etiological factors and CD5 and CD43 (sialophorin) tumor markers are significant negative prognostic factors. Disease signs and symptoms can occur a long time before diagnosis. Varieties of treatment options are available. The aim of this retrospective analysis was to compare the efficiency of different treatment options and to investigate disease outcome. Twenty OAML patients, diagnosed in the Clinic of Hematology, Clinical Centre of Serbia, between 2003 and 2013, were enrolled. In most cases, OAML developed in the eighth decade with greater incidence in the male population. Median age was 67.5 years. The median period between the appearance of local signs and symptoms and diagnosis was 7 months. The dominant sign at presentation was swelling of involved tissue (40%). The most common was orbital involvement (55%). All patients had localized disease. Observed laboratory parameters on presentation showed low disease activity. Sialophorin prognostic significance was not registered. Our patients were initially treated differently but there was no significant difference in progression-free survival (PFS) due to initial treatment option (p = 0.2957). Median PFS was 22 months (3-89), and 5-year PFS was 60%. Median overall survival (OS) was 43 months (1-105) and 5-year OS 95%. Eight patients (40%) relapsed and one patient died due to non-hematological complications. In our experience, most modern induction treatment options appear to result in the same, favorable outcome.

Xerostomia after radiotherapy. What matters--mean total dose or dose to each parotid gland?

PURPOSE

Xerostomia is a debilitating side effect of radiotherapy in patients with head and neck cancer. We undertook a prospective study of the effect on xerostomia and outcomes of sparing one or both parotid glands during radiotherapy for patients with squamous cell carcinoma of the head and neck.

METHODS AND MATERIALS

Patients with locally advanced squamous cell carcinoma of the head and neck received definitive (70 Gy in 2 Gy fractions) or adjuvant (60-66 Gy in 2 Gy fractions) curative-intent radiotherapy using helical tomotherapy with concurrent chemotherapy if appropriate. Group A received < 26 Gy to the left and right parotids and group B received < 26 Gy to either parotid.

RESULTS

The study included 126 patients; 114 (55 in group A and 59 in group B) had follow-up data. There were no statistically significant differences between groups in disease stage. Xerostomia was significantly reduced in group A vs. group B (p = 0.0381). Patients in group A also had significantly less dysphagia. Relapse-free and overall survival were not compromised in group A: 2-year relapse-free survival was 86% vs. 72% in group B (p = 0.361); 2-year overall survival was 88% and 76%, respectively (p = 0.251).

CONCLUSION

This analysis suggests that reducing radiotherapy doses to both parotid glands to < 26 Gy can reduce xerostomia and dysphagia significantly without compromising survival. Sparing both parotids while maintaining target volume coverage and clinical outcome should be the treatment goal and reporting radiotherapy doses delivered to the individual parotids should be standard practice.

Autologous transplant in the treatment of severe aplastic anemia--a case report

The initial use of immunosuppressive therapy (IST) in severe aplastic anemia (sAA) or reapplication of IST-centered methods following disease relapse is successful only in well-selected patients. The potential treatment by autologous stem cell (SC) transplant in sAA is still an innovative/pioneering therapeutic approach. To our best knowledge, this is the second published case of autologous SC transplant in sAA. The aim of this work was to optimize mobilization and timing for SC harvesting - using our own controlled-rate cryopreservation - with higher CD34(+)/CD90(+) subset yield and recovery in order to obtain complete and long-term hematopoietic reconstitution following autologous SC transplant. We report a 35 year-old sAA male patient who initially underwent IST using rabbit ATG and Cyclosporine A (CsA). He was supportive transfusion dependent for the whole period of IST-phase. After the second IST-cycle, polymorphonuclear (PMN) cell count increase (>2.0 × 10(9)/L) was observed, when SC mobilization, two large volume leukapheresis procedures and following autologous transplant were performed. The yields of harvested CD34(+) and CD34(+)/CD90(+) cells were 5.75 × 10(6)/kgbm and 1.7 × 10(6)/kgbm, respectively. The quantity of applied CD34(+) and CD34(+)/CD90(+) cells in autologous SC transplant were 5.45 × 10(6)/kgbm (7-AAD(CD34)(+)(viability)=95.42%) and 1.63 × 10(6)/kgbm (7-AAD(CD34)(+)(/CD90)(+)(viability)=95.42%), respectively. Hematopoietic reconstitution registered due to second month after autologous SC transplant and he is 24 months in complete medullar, hematological and clinical remission, with normal cytogenetic status - applying only continuous CsA therapy. The results obtained strongly confirm that in sAA, with no allogeneic SC donor, autologous transplant can result in a successful clinical outcome. We suggest that CD34(+)/CD90(+) subset count in peripheral blood and/or cell-harvest could be more valuable predictive factor than total CD34(+) quantity of optimized collection-timing and superior treatment efficacy of autologous SC transplant in sAA.

Hypothalamic dysfunction in a patient with primary lymphoma of the central nervous system

A 60-year-old woman with no previous history of chronic disease or malignancy presented with intense back and left leg pain and sleep disturbances. The patient had been treated unsuccessfully for the past 6 months with analgetics. Magnetic resonance imaging showed a soft tissue tumor in the L5-S1 region that involved the spinal canal, and a pathohistological analysis of the tumor specimen confirmed the presence of non-Hodgkin, diffuse large B cell lymphoma. After the diagnosis was confirmed, malaise, nausea, and vomiting developed. Multislice computed tomography of the endocranium showed focal infiltration of the hypothalamus and lateral ventricle; dissemination of a systemic lymphoma was excluded. Therapy was initiated as per the De Angelis protocol. After intravenous and intrathecal administration of metotrexate, the patient developed signs of central diabetes insipidus, which responded to therapy with an antidiuretic hormone analog. Despite the obvious infiltration of the hypothalamus, we cannot exclude an idiosyncratic effect of methotrexate on the central diabetes insipidus.

Clinical characteristics of patients with lymphoproliferative neoplasms in the setting of systemic autoimmune diseases

Clinical features of 40 lymphoproliferative neoplasm patients in the setting of systemic autoimmune diseases managed in the Clinic of Hematology during 1994-2006 were analyzed retrospectively. The classification of systemic autoimmune disease patients was as follows: 15 systemic lupus erythematosus--SLE, 11 rheumatoid arthritis--RA, 12 Sjögren's syndrome--SS, 1 scleroderma, and 1 dermatomyositis. Patients comprised 31 women and 9 men of mean age 55 years (range 33-76). Systemic autoimmune diseases preceeded the development of lymphoproliferative neoplasms in 37/40 (92.5%) patients. Mean latency period between the onset of systemic autoimmune diseases and lymphoproliferative neoplasms occurrence was significantly longer in RA (113 months) than in SLE (75 months) and SS patients (65 months)--P < 0.05. The most frequent lymphoproliferative neoplasms were non-Hodgkin's lymphoma--NHL (35/40; 88%), diffuse large B-cell lymphoma (DBCL)--12 (34%), follicular lymphoma (FC)--7 (20%), small lymphocytic (SL), and marginal zone lymphoma (MZL)--5 (14%) each. The primary site of NHL was extranodal in 18/35 (51.5%) cases. Advanced disease on diagnosis (III + IV clinical stages), constitutional symptoms, and bulky disease were diagnosed in 27/35 (77%), 26/35 (74%), and 3/35 (8.5%) patients, respectively. The overall survival (OS) was as follows (months): DBCL-12, FC-63, SLL-60, and MZL-48. There was no association between the lymphoproliferative neoplasm histological subtype and the systemic autoimmune diseases type or antirheumatic treatment P > 0.05. Our findings are in line with earlier reports showing a high proportion of patients with advanced disease, constitutional symptoms, extranodal manifestations, high grade histology, and low OS in the systemic autoimmune diseases setting.

Genetic map construction and QTL mapping of resistance to blackleg (Leptosphaeria maculans) disease in Australian canola (Brassica napus L.) cultivars

Genetic map construction and identification of quantitative trait loci (QTLs) for blackleg resistance were performed for four mapping populations derived from five different canola source cultivars. Three of the populations were generated from crosses between single genotypes from the blackleg-resistant cultivars Caiman, Camberra and (AV)Sapphire and the blackleg-susceptible cultivar Westar(10). The fourth population was derived from a cross between genotypes from two blackleg resistant varieties (Rainbow and (AV)Sapphire). Different types of DNA-based markers were designed and characterised from a collection of 20,000 EST sequences generated from multiple Brassica species, including a new set of 445 EST-SSR markers of high value to the international community. Multiple molecular genetic marker systems were used to construct linkage maps with locus numbers varying between 219 and 468, and coverage ranging from 1173 to 1800 cM. The proportion of polymorphic markers assigned to map locations varied from 70 to 89% across the four populations. Publicly available simple sequence repeat markers were used to assign linkage groups to reference nomenclature, and a sub-set of mapped markers were also screened on the Tapidor x Ningyou (T x N) reference population to assist this process. QTL analysis was performed based on percentage survival at low and high disease pressure sites. Multiple QTLs were identified across the four mapping populations, accounting for 13-33% of phenotypic variance (V (p)). QTL-linked marker data are suitable for implementation in breeding for disease resistance in Australian canola cultivars. However, the likelihood of shifts in pathogen race structure across different geographical locations may have implications for the long-term durability of such associations.

Splenectomy with chemotherapy vs surgery alone as initial treatment for splenic marginal zone lymphoma

AIM: To evaluate the clinical characteristics of splenic marginal-zone lymphoma (SMZL) following antigen expression and the influence of therapeutic approaches on clinical outcome and overall survival (OS).

METHODS: A total of 30 patients with typical histological and immunohistochemical SMZL patterns were examined. Splenectomy plus chemotherapy was applied in 20 patients, while splenectomy as a single treatment-option was performed in 10 patients. Prognostic factor and overall survival rate were analyzed.

RESULTS: Complete remission (CR) was achieved in 20 (66.7%), partial remission (PR) in seven (23.3%), and lethal outcome due to disease progression occurred in three (10.0%) patients. Median survival of patients with a splenectomy was 93.0 mo and for patients with splenectomy plus chemotherapy it was 107.5 mo (Log rank = 0.056, P > 0.05). Time from onset of first symptoms to the beginning of the treatment (mean 9.4 mo) was influenced by spleen dimensions, as measured by computerized tomography and ultra-sound (t = 2.558, P = 0.018). Strong positivity (+++) of CD20 antigen expression in splenic tissue had a positive influence on OS (Log rank = 5.244, P < 0.05). The analysis of factors interfering with survival (by the Kaplan-Meier method) revealed that gender, general symptoms, clinical stage, and spleen infiltration type (nodular vs diffuse) had no significant (P > 0.05) effects on the OS. The expression of other antigens (immunohistochemistry) also had no effect on survival-rate, as measured by a χ² test (P > 0.05).

CONCLUSION: Initial splenectomy combined with chemotherapy has been shown to be beneficial due to its advanced remission rate/duration; however, a larger controlled clinical study is required to confirm our findings.

More than a third of non-gastric malt lymphomas are disseminated at diagnosis: a single center survey

Mucosa-associated lymphoid tissue (MALT) lymphomas are extranodal B-cell tumors that generally follow an indolent course. The gastrointestinal tract is the most common site of MALT lymphoma, comprising 50% of all cases. The tissue lesions are often localized, have high therapeutic response rates with late relapses with a long overall survival (OS). The patients with non-gastric lesions may follow a different clinical course and many of them present with disseminated disease. This study reports a series of 51 patients with non-gastric MALT lymphoma. Twenty patients (39.2%) presented with disseminated disease, seven (13.7%) patients had two MALT mucosal sites involved and eight (15.7%) had involvement of three or more mucosal sites. At presentation, 17 (33.3%) patients had the lymph node and 12 (23.5%) the bone marrow involvement. Following various combinations of treatment, complete remission was achieved in 40 (81.6%), and partial remission in three of the 49 treated patients with no difference in response rates between different disease stages. Relapse occurred in 12/43 (27.9%) patients among whom eight (18.6%) recurred in the presenting organ system. Five patients (9.8%) died because of a rapid disease progression after a median follow-up of 56 months; two patients with primary lung lesions, 1 patient with secondary intestinal disease, and 2 patients suffered transformation to diffuse large B-cell lymphoma. No significant difference in survival was found between localized and disseminated disease (log rank 0.05, df = 1, P = 0.81). A patient age > or = 60 yr at diagnosis and presentation with the nodal disease were found to be statistically significant negative prognostic factors (P < 0.05). Median OS was not reached after 145 months of follow-up, with the estimated OS being 88% at 2 yr, and 78% at 5 yr.

Characterisation of MCP-600D and MCP-700D thermoluminescence detectors and their applicability for photoneutron detection

This paper presents the characteristics of two high-sensitive LiF:Mg,Cu,P thermoluminescence detectors (TLDs) named MCP-600D and MCP-700D [thermoluminescence detector (TLD) Poland]. Furthermore, the applicability of both detectors used as a paired system for photoneutron detection in a high-energy photon field at a linear accelerator is shown. For MCP-600D and MCP-700D, the batch homogeneity is within 22 and 14%, respectively (2 SD). Correction for the individual response of each TLD leads to a reproducibility of 5 and 4%, respectively Both TLD types reveal a linear detector response to dose up to 4 Gy. The energy dependence for both is within 2% for 4 and 6 MV photons. For a 15 MV photon beam, the MCP-600D shows a higher response (10%); compared with the MCP-700D (2%). The MCP-600D is capable of detecting extra doses due to photoneutrons in a 15 MV photon exposure; however, the signal for an open field of the used linear accelerator is in the order of the reproducibility. Using a kind of albedo technique allows detection of photoneutrons in the open photon field anyhow. The neutron detection limit is 10 microGy neutron dose per 1 Gy photon dose. Reproducibility of the TLDs, however, requires more than 10 detectors to determine results with an uncertainty of <5%.

Primary gastric mucosa associated lymphoid tissue lymphoma: Clinical data predicted treatment outcome

AIM: To determine clinical characteristics and treatment outcome of gastric lymphoma after chemotherapy and immuno-chemotherapy.

METHODS: Thirty four patients with primary gastric mucosa associated lymphoid tissue (MALT) lymphoma (Ann Arbor stages I to IV) were enrolled. All had upper gastric endoscopy, abdominal ultrasonography, CT and H pylori status assessment (histology and serology). After anti-H pylori treatment and initial chemotherapy, patients were re-examined every 4 mo.

RESULTS: Histological regression of the lymphoma was complete in 22/34 (64.7%) and partial in 9 (26.5%) patients. Median follow up time for these 31 responders was 60 mo (range 48-120). No regression was noted in 3 patients. Among the 25 (73.5%) H pylori positive patients, the eradication rate was 100%.

CONCLUSION: Using univariate analysis, predictive factors for overall survival were international prognostic index (IPI) score, hemoglobin level, erythrocyte sedimentation rate (ESR), and platelet numbers (P < 0.005). In addition to this, Cox proportion hazard model differentiate IPI score, ESR, and platelets as predictors of survival.

Dosimetric evaluation of a 2D pixel ionization chamber for implementation in clinical routine

In this paper we present the results of a dosimetric evaluation of a 2D ionization chamber array with the objective of its implementation for quality assurance in clinical routine. The pixel ionization chamber MatriXX (Scanditronix Wellhofer, Germany) consists of 32x32 chambers with a distance of 7.6 mm between chamber centres. The effective depth of measurement under the surface of the detector was determined. The dose and energy dependence, the behaviour of the device during its initial phase and its time stability as well as the lateral response of a single chamber of the detector in cross-plane and diagonal directions were analysed. It could be shown, that the detector's response is linear with dose and energy independent. Taking the lateral response into account, two different dose profiles, for a pyramidal and an IMRT dose distribution, were applied to compare the data generated by a treatment planning system with measurements. From these investigations it can be concluded that the detector is a suitable device for quality assurance and 2D dose verifications.

Evaluation of GafChromic EBT prototype B for external beam dose verification

The capability of the new GafChromic EBT prototype B for external beam dose verification is investigated in this paper. First the general characteristics of this film (dose response, postirradiation coloration, influence of calibration field size) were derived using a flat-bed scanner. In the dose range from 0.1 to 8 Gy, the sensitivity of the EBT prototype B film is ten times higher than the response of the GafChromic HS, which so far was the GafChromic film with the highest sensitivity. Compared with the Kodak EDR2 film, the response of the EBT is higher by a factor of 3 in the dose range from 0.1 to 8 Gy. The GafChromic EBT almost does not show a temporal growth of the optical density and there is no influence of the chosen calibration field size on the dose response curve obtained from this data. A MatLab program was written to evaluate the two-dimensional dose distributions from treatment planning systems and GafChromic EBT film measurements. Verification of external beam therapy (SRT, IMRT) using the above-mentioned approach resulted in very small differences between the planned and the applied dose. The GafChromic EBT prototype B together with the flat-bed scanner and MatLab is a successful approach for making the advantages of the GafChromic films applicable for verification of external beam therapy.