Primary testicular non-Hodgkin lymphoma: a single institution experience from India

BACKGROUND

Primary testicular non-Hodgkin lymphoma (NHL) is an uncommon extra nodal presentation, constituting 1% of all NHL. Median age at time of presentation is 60 years. Anthracycline based chemotherapies are most frequently used. There is not enough data on use of monoclonal antibody (Rituximab) in testicular NHL.

METHODS

We screened approximately eight hundred and fifty NHL cases registered from January 2002 to May 2008 and found six primary testicular NHL patients. These six cases were analyzed for baseline clinical features, investigations, staging, treatment and outcome variables.

RESULTS

Median age was 55 years (range 7-72 years) and median duration of symptoms was 3.5 months (range 1-8 months). All patients had testicular swelling and abdominal lymphadenopathy. Five patients (83%) had stage IV and one had stage IE disease. Majority had diffuse large B-cell histology (83%). All patients were treated with anthracycline based combination chemotherapy and CNS prophylaxis after local therapy except one pediatric patient who did not receive any local therapy. Four patients completed therapy and are on follow up while two patients having extensive disease with poor performance status died of neutropenic sepsis after 1-2 cycles of chemotherapy. The surviving four patients achieved complete remission and are without any recurrence with a median follow up of 26 months (1-78 months).

CONCLUSION

Primary testicular NHL is an uncommon entity and with current combined modality treatment and CNS prophylaxis, the outcome may be as good as nodal NHL.

Febrile neutropenia during acute myeloid leukemia therapy: Single institution experience from a developing country

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Background: Febrile neutropenia poses a major challenge during treatment of acute myeloid leukaemia (AML). Methods: Episodes of febrile neutropenia in 104 consecutive patients of AML admitted to the medical oncology ward between May 2001 and December 2006 were studied. There were 62 males and 42 females, median age 28 years (2–61 years). Results: 402 febrile episodes including 363 episodes of febrile neutropenia (180 in induction, 183 in consolidation) and 39 non-neutropenic episodes (18 in induction, 21 in consolidation) occurred. Clinical, microbiological and radiological foci could be detected in 51.1%, 22.2 %, and 31.1% episodes of febrile neutropenia during induction and 31.1%, 19.1% and 12.7% episodes during consolidation. Rates of documented infections during induction and consolidation were 74% and 52%. Respiratory (39.2%) and ear, nose, and throat ( 23.9%) were the commonest clinical sites during induction. Respiratory (21%) and central line infections (19.2%) were commonest during consolidation. Gram negative infections predominated (Pseudomonas aeruginosa, Klebsiella pneumoniae: major isolates). 32.5% of microbiologically proven infections during induction and 14.2% during consolidation were polymicrobial. Bronchopneumonia was the commonest radiological focus. There were 60 episodes of fungal infections (47 in induction, 13 in consolidation). There were: 1 definite: mucormycosis, 3 probable (1 case each: Candida krusei, Candida tropicalis in blood, 1 chronic disseminated hepatosplenic candidiasis), and 56 possible infections. Halo sign was seen in 18, sinusitis with bone erosion in 7. Infections accounted for 85% of the 20 deaths (induction: 18). Fungal infections and bronchopneumonia were major causes of mortality (p = 0.001). 3/4 enterococcal bacteremias were associated with mortality (p = 0.001). 6 cases of tuberculosis (5 pneumonias with necrotic mediastinal nodes, 1 Pott's spine) and 3 cases of malaria (1 cerebral malaria) were also detected. Conclusions: Induction was associated with greater morbidity and mortality. Prompt and proper institution of antibiotics and antifungals besides considering alternative diagnosis peculiar to the region (e.g. tuberculosis, malaria) may aid in better management.

No significant financial relationships to disclose.

Role of MRI in osteosarcoma for chemotherapy response evaluation and prediction: Correlation with histological necrosis

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Background:Histologic necrosis (HN), the current gold standard for response evaluation in osteosarcoma (OS), is accessible only after neoadjuvant chemotherapy (NACT) and may get affected by confounding factors. Thus, it would be useful to have surrogate markers of response evaluation and prognostication using magnetic resonance imaging (MRI) to individualize therapy. Method:Thirty-one treatment naïve OS patients received 3 cycles of NACT followed by surgery during 2006–2008. All patients underwent baseline and post-NACT conventional(C), diffusion-weighted (DW) and dynamic contrast enhanced (DCE) MRI. Taking ‘Huvos grading’ (good response >/= 90% HN) as reference standard, various parameters of MRI were compared with it. Tumor considered as ellipsoidal; volume (V), average tumor plane (ATP) and relative(r)-ATP (ATP/body surface area) were calculated using standard formula for ellipse. Receiver operating characteristic curves were generated to assess the best threshold and predictability. Sensitivity and specificity were calculated along with 95% confidence limits. After deriving thresholds for each parameter in univariable analysis, multivariable analysis was carried out. Results: Both pre-and post NACT, absolute and relative size parameters were well correlated with HN, though post NACT change in parameters did not. Apparent diffusion coefficient (ADC), either pre-and post NACT measurements or change following chemotherapy were not correlating well. However, on adjusting for volume, significant correlation was found. Thus, we could derive a new parameter diffusion per unit volume (DV= ADC /V). Change in shape of time intensity curve did not show significant correlation. Conclusions: In OS, NACT response can be assessed and predicted by conventional and DW- MRI early in the disease course which correlates well with HN. DV seems to be a sensitive substitute for response evaluation. For DCE-MRI, more sophisticated models in future studies might be useful. [Table: see text]

No significant financial relationships to disclose.

Imaging features of peripheral primitive neuroectodermal tumours

Primitive neuroectodermal tumours (PNETs) are a rare group of extremely aggressive small round cell tumours. Most commonly, they occur within the central nervous system. However, they also sporadically involve extracranial sites (peripheral PNETs). The chest wall is the most common of these sites, the imaging features of which have been well described in earlier studies. The present pictorial essay illustrates the imaging features of PNETs at various extracranial locations.

Etiopathophysiology of disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) involves activation of clotting as well as fibrinolytic pathways. Thrombosis from thrombin release results in end-organ damage, whereas consumption of coagulation factors results in bleeding. Sepsis is the commonest cause of DIC. The consumption of antithrombin in sepsis abrogates its anti-inflammatory role and so its low level is a poor prognostic marker in sepsis. The increased release of plasminogen activator inhibitor-1 (PAI-1) as seen in sepsis decreases fibrinolysis and promotes increased microvascular thrombosis. Here, we discuss the role of inhibitors of coagulation, cytokines, kinins, complement and vasoactive peptides in DIC.

Acute encephalopathy with parvovirus B19 infection in sickle cell disease

A 13 year old girl with haemoglobin Sbeta(+)thalassaemia developed simultaneous aplastic crisis and encephalopathy associated with parvovirus B19 (PB19) infection. Brain magnetic resonance imaging findings were consistent with central nervous system (CNS) vasculitis and her symptoms resolved with steroid therapy. Thus, PB19 induced CNS hypersensitivity vasculitis must be considered in the differential diagnosis of encephalopathy.

Implantable pumps for drug delivery to the brain

This article reviews the role of implantable pumps in the treatment of CNS tumors. Systemic administration of chemotherapeutic agents has been associated with various problems, including adverse systemic effects and decreased concentration of the drug at the target site. Continuous infusion of chemotherapeutic agents with implantable pumps have been used in an attempt to overcome these problems. Various different chemotherapeutic agents have been used for this purpose, and catheters have been placed in the intraspinal, intraventricular and intratumoral locations.

Olivopontocerebellar atrophy: a case report

A family with olivopontocerebellar atrophy is presented. Out of 7 siblings two male and one female were involved at a similar age of 5 years. Early onset of the disease is striking. The index case presented with progressively increasing choreiform movements and cerebellar signs. Magnetic resonance imaging morphology revealed the diagnosis.