Characteristics and incidence of infections in patients with multiple myeloma treated by bispecific antibodies: a national retrospective study on the behalf of G2I and Intergroupe Francophone du Myélome

OBJECTIVES

Bispecific antibodies (BsAbs) are an effective treatment used in relapsed or refractory multiple myeloma. Despite a well-tolerated safety profile, infectious events appear to be frequent in clinical trials. Real-world data on epidemiology, characteristics, risk factors, and outcomes of infections in patients treated with BsAb are still needed.

METHODS

A retrospective, multicentre study in BsAb-treated patients with multiple myeloma was performed in 14 French centres from December 2020 to February 2023. The primary objective was to describe the incidence of infections that required hospitalization, specific treatment, or adaptation in BsAb administration.

RESULTS

Among 229 patients with multiple myeloma treated with BsAb, 153 (67%) received teclistamab, 47 (20%) received elranatamab, and 29 (13%) talquetamab. We reported a total of 234 infections, including 123 (53%) of grade of ≥3. Predominant infections affected the respiratory tract (n = 116, 50%) followed by bacteraemias (n = 36, 15%). The hospitalization rate was 56% (n = 131), and 20 (9%) infections resulted in death. Global cumulative incidence of the first infection was 70% in all patients, 73% in patients treated with B-cell maturation antigen-targeting, and 51% with GPRC5D-targeting BsAb. In univariate analyses, corticosteroids for cytokine release syndrome (CRS)/immune effector cell-associated neurotoxicity syndrome (ICANS) were associated with a higher risk of first infection (HR = 2.13; 95% CI, 1.38-3.28), whereas GPRC5D-targeting BsAb and anti-bacterial prophylaxis were associated with a lower risk (HR = 0.53; 95% CI, 0.3-0.94 and HR = 0.65; 95% CI, 0.46-0.9). Fine and Gray multivariate model found that only corticosteroids for CRS/ICANS were correlated with a higher risk of first infection (HR = 2.01; 95% CI, 1.27-3.19).

DISCUSSIONS

The implementation of preventive measures that aim to mitigate the risk of infection under BsAb is pivotal, notably in patients who received corticosteroids for CRS/ICANS.

Multicentric lymphoma in a donkey with intestinal and bone marrow involvement

BACKGROUND

Lymphoma is a common neoplasm in horses but is reported much less commonly in donkeys. In this case report, we describe the macroscopic, microscopic and immunohistochemical features of a multicentric lymphoma with intestinal and bone marrow involvement.

CASE PRESENTATION

A geriatric female donkey with history of chronic lameness was found dead. Post-mortem examination revealed advanced emaciation, periodontal disease, left front foot laminitis and multiple, soft, white to yellow tan intestinal transmural masses, up to 12 cm in diameter. Cytology suggested a round cell intestinal neoplasm. The femur of the left hint limb was double the size of the normal contralateral, with suspected neoplastic infiltration and replacement of bone marrow and bone. Histologically we diagnosed a lymphoma in the intestine and left femur. Immunohistochemically, the neoplastic cells showed CD3 immunolabelling, supporting a diagnosis of a multicentric T-cell lymphoma.

CONCLUSIONS

To the authors' knowledge, this is the first time multicentric lymphoma is diagnosed in donkeys. Further studies of the genetic background, clinical, laboratory, histopathologic, and immunohistochemical, as well as the pathogenesis of lymphoma, is needed to better understand the uniquely low frequency of this neoplasm in donkeys.

The Role of Genetic Analysis in Distinguishing Multifocal and Multicentric Glioblastomas: An Illustrative Case

Introduction

Glioblastomas can manifest as multiple, simultaneous, noncontiguous lesions. We genetically analyzed multiple glioblastomas and discuss their etiological origins in this report.

Case Presentation

We present the case of a 47-year-old woman who presented with memory impairment and left partial paralysis. Radiographic imaging revealed three apparently noncontiguous lesions in the right temporal and parietal lobes extending into the corpus callosum, leading to diagnosis of multicentric glioblastomas. All three lesions were excised. Genetic analysis of the lesions revealed a TERT promoter C228T mutation, a roughly equivalent amplification of EGFR, and homozygous deletion of CDKN2A/B exclusively in the two contrast-enhanced lesions. Additionally, the contrast-enhanced lesions exhibited the same two-base pair mutations of PTEN, whereas the non-enhanced lesion showed a partially distinct 13-base pair mutation. The other genetic characteristics were consistent. Rather than each having arisen de novo, we believe that they had developed by infiltration and are therefore best classified as multifocal glioblastomas.

Conclusion

Our findings underscore anew the possibility of infiltration by glioblastomas, even within regions devoid of signal alterations on T2-weighted images or fluid-attenuated inversion recovery images. Genetic analysis can play a crucial role in differentiating whether multiple glioblastomas are multifocal or multicentric.

Is unicentric familial papillary thyroid microcarcinoma different from multicentric?

BACKGROUND

Familial papillary thyroid microcarcinoma (FPTMC) appears to be more aggressive than sporadic papillary thyroid microcarcinoma (SPTMC). However, there are authors who indicate that unicentric FPTMC has a similar prognosis to SPTMC. The objective is to analyze whether unicentric FPTMC has a better prognosis than multicentric FPTMC.

DESIGN AND METHODS

Type of study: National multicenter longitudinal analytical observational study.

STUDY POPULATION

Patients with FPTMC.

STUDY GROUPS

Two groups were compared: Group A (unicentric FPTMC) vs. Group B (multicentric FPTMC).

STUDY VARIABLES

It is analyzed whether between the groups there are: a) differentiating characteristics; and b) prognostic differences.

STATISTICAL ANALYSIS

Cox regression analysis and survival analysis.

RESULTS

Ninety-four patients were included, 44% (n = 41) with unicentric FPTMC and 56% (n = 53) with multicentric FPTMC. No differences were observed between the groups according to socio-familial, clinical or histological variables. In the group B a more aggressive treatment was performed, with higher frequency of total thyroidectomy (99 vs. 78%; p = 0.003), lymph node dissection (41 vs. 15%; p = 0.005) and therapy with radioactive iodine (96 vs. 73%; p = 0.002). Tumor stage was similar in both groups (p = 0.237), with a higher number of T3 cases in the group B (24 vs. 5%; p = 0.009). After a mean follow-up of 90 ± 68.95 months, the oncological results were similar, with a similar disease persistence rate (9 vs. 5%; p = 0.337), disease recurrence rate (21 vs. 8%; p = 0.159) and disease-free survival (p = 0.075).

CONCLUSIONS

Unicentric FPTMC should not be considered as a SPTMC due to its prognosis is similar to multicentric FPTMC.

Clinical features and treatment outcomes of Castleman disease in children: a retrospective cohort in China

Castleman disease (CD) is a rare lymphoproliferative disorder of undetermined etiology. Unicentric CD (UCD) and multicentric CD (MCD) are two phenotypes of CD diagnosed by the histopathology of lymph nodes. We attempted to describe a pediatric CD cohort to optimize the management of this disease. We reviewed the medical records of pediatric patients diagnosed with CD between April, 2004, and October, 2022, at the Children's Hospital of Fudan University. Prognosis information was collected in January, 2023, by telephone inquiry. Twenty-two patients with UCD and 2 patients with MCD were identified, all with hyaline vascular (HV) type. The median ages at diagnosis were 10.75 years (IQR 8, 12.81) for UCD and 14.42 years (IQR 13.42, 15.42) for MCD. The most common lesion location of UCD was the neck (9/22, 40.91%) and abdomen (9/22, 40.91%). Systematic symptoms occurred on 10/22 (45.45%) patients with UCD and 1/2 (50%) patients with MCD, and abnormal laboratory indexes were detected in both. Resection and biopsy were performed on all patients. One out of two patients with MCD also received rituximab for upfront therapy. After a median of 4 years (IQR 1.5, 6) of follow-up time, the overall survival was 100% and the complete remission rate in UCD was 63%. There was no relapse or progression.

CONCLUSIONS

Our series demonstrated that HV-UCD was the most common type in children. Resection and biopsy were used for both deterministic diagnoses and treatments. Despite the high possibility to develop systematic inflammation, children with CD showed promising outcomes.

WHAT IS KNOWN

• Castleman disease is a rare lymphoproliferative disorder with limited cohort studies, especially in pediatrics. • The ubiquity of delayed confirmations and misdiagnoses points to a lack of knowledge about etiology and characteristics, which is a prerequisite for novel therapeutics.

WHAT IS NEW

• We retrospectively reviewed and analyzed the clinical and pathological symptoms, laboratory and imaging features, and treatment outcomes of a Chinese pediatric cohort with Castleman disease. • Our work may improve the recognition and optimize the management of this rare disease in children.

The role of cytoreductive surgery in multifocal/multicentric glioblastomas

PURPOSE

Multifocal/multicentric glioblastomas (mGBM) account for up to 20% of all newly diagnosed glioblastomas. The present study investigates the impact of cytoreductive surgery on survival and functional outcomes in patients with mGBM.

METHODS

We retrospectively reviewed clinical and imaging data of 71 patients with newly diagnosed primary (IDH1 wildtype) mGBM who underwent operative treatment in 2015-2020 at the authors' institution. Multicentric/multifocal growth was defined by the presence of ≥ 2 contrast enhancing lesions ≥ 1 cm apart from each other.

RESULTS

36 (50.7%) patients had a resection and 35 (49.3%) a biopsy procedure. MGMT status, age, preoperative KPI and NANO scores as well as the postoperative KPI and NANO scores did not differ significantly between resected and biopsied cases. Median overall survival was 6.4 months and varied significantly with the extent of resection (complete resection of contrast enhancing tumor: 13.6, STR: 6.4, biopsy: 3.4 months; P = 0.043). 21 (58.3%) of resected vs. only 12 (34.3%) of biopsied cases had radiochemotherapy (p = 0.022). Multivariate analysis revealed chemo- and radiotherapy and also (albeit with smaller hazard ratios) extent of resection (resection vs. biopsy) and multicentric growth as independent predictors of patient survival. Involvement of eleoquent brain regions, as well as neurodeficit rates and functional outcomes did not vary significantly between the biopsy and the resection cohorts.

CONCLUSION

Resective surgery in mGBM is associated with better survival. This benefit seems to relate prominently to an increased number of patients being able to tolerate effective adjuvant therapies after tumor resections. In addition, cytoreductive surgery may have a survival impact per se.

Illness-related parental stress and quality of life in children with kidney diseases

BACKGROUND

This cross-sectional study investigated quality of life (QoL) and illness-related parental stress in children with kidney diseases by (1) comparing mean levels of these two variables between several kidney disease categories; (2) exploring correlations between QoL and parental stress; and (3) describing which disease category reports lowest QoL and highest parental stress.

METHODS

We included 295 patients with a kidney disease (0-18 years) and their parents, followed at 6 reference centers for pediatric nephrology. Children's QoL was assessed by the PedsQL™ 4.0 Generic Core Scales, and illness-related stress by the Pediatric Inventory for Parents. All patients were divided into 5 kidney disease categories according to the multidisciplinary care program criteria prescribed by the Belgian authorities: (1) structural kidney diseases, (2) tubulopathies and metabolic diseases, (3) nephrotic syndrome, (4) acquired diseases with proteinuria and hypertension, and (5) kidney transplantation.

RESULTS

Child self-reports showed no differences in QoL between kidney disease categories, in contrast to parent proxy reports. Parents of transplant patients reported lower QoL in their child and more parental stress compared with the 4 non-transplant categories. QoL and parental stress were negatively correlated. Lowest QoL and highest parental stress scores were mainly found in transplant patients.

CONCLUSIONS

This study showed lower QoL and higher parental stress in pediatric transplant patients compared with non-transplants, based on parent reports. Higher parental stress is associated with worse QoL in the child. These results highlight the importance of multidisciplinary care for children with kidney diseases, with special attention to transplant patients and their parents. A higher resolution version of the Graphical abstract is available as Supplementary information.

Multiple solitary fibrous tumors of the pleura with multicentric and unilateral involvement: a case report

BACKGROUND

Solitary fibrous tumor of the pleura (SFTP) is a mesenchymal tumor. Patients with SFTP generally have only one lesion. We herein report an extremely rare case of multiple SFTPs that were multicentric and unilateral.

CASE PRESENTATION

The patient was a 21-year-old asymptomatic young man who was referred to our hospital due to abnormal shadows on a chest X-ray. Computed tomography showed 6 tumors of heterogeneous sizes in the left thoracic cavity. The tumors were suspected to be multiple benign or low-grade malignant thoracic tumors, and tumor resection was performed. The tumors had almost the same appearance, with uniform fibroblastic spindle cell proliferation, and arose from the pleura in microscopy. Immunohistochemical staining revealed that the tumor cells were positive for CD34, CD99, Bcl-2, and STAT6. Based on these findings, the tumors were diagnosed as multiple SFTPs with multicentricity. At 1 year and 6 months after the first surgery, 2 new lesions were found above the diaphragm, and these were resected. These tumors were arose from the pleura with a fibrous capsule structure. Their pathological findings were identical to the initial tumor without evidence of malignant transformation.

CONCLUSION

We experienced an extremely rare case of multiple SFTPs with multicentric and unilateral lesions.

Multicentric evaluation of a machine learning model to streamline the radiotherapy patient specific quality assurance process

PURPOSE

Patient-specific quality assurance (PSQA) is performed to ensure that modulated treatment plans can be delivered as intended, but constitutes a substantial workload that could slow down the radiotherapy process and delay the start of clinical treatments. In this study, we investigated a machine learning (ML) tree-based ensemble model to predict the gamma passing rate (GPR) for volumetric modulated arc therapy (VMAT) plans.

MATERIALS AND METHODS

5622 VMAT plans from multiple treatment sites were selected from a database of Institution 1 and the ML model trained using 19 metrics. PSQA analyses were performed automatically using criteria 3%/1 mm (global normalization, absolute dose, 10% threshold) and 95% action limit. Model's performance was evaluated on an out-of-sample test set of Institution 1 and on two independent sets of measurements collected at Institution 2 and Institution 3. Mean absolute error (MAE), as well as the model's sensitivity and specificity, were computed.

RESULTS

The model obtained a MAE of 2.33%, 2.54% and 3.91% for the three Institutions, with a specificity of 0.90, 0.90 and 0.68, and a sensitivity of 0.61, 0.25, and 0.55, respectively. Small positive median values of the residuals (i.e., the difference between measurements and predictions) were observed for each Institution (0.95%, 1.66%, and 3.42%). Thus, the model's predictions were, on average, close to the real values and provided a conservative estimation of the GPR.

CONCLUSIONS

ML models can be integrated into clinical practice to streamline the radiotherapy workflow, but they should be center-specific or thoroughly verified within centers before clinical use.

From the archives of MD Anderson Cancer Center Castleman disease involving the thymus gland: Case report and literature review

Castleman disease is a nodal based disease and very rarely involves the thymus gland. We report a 52-year-old man who was found incidentally to have a single thymic mass by computerized tomography scan. Thymectomy was performed, and the gross specimen showed a well-circumscribed, multi-loculated cystic mass. Histologic examination showed thymus involved by Castleman disease, hyaline-vascular variant. The lesion was characterized by lymphoid follicles with wide mantle zones, variably lymphocyte-depleted germinal centers with sclerotic radial blood vessels, and prominent interfollicular/stromal changes including numerous endothelial venules with sclerotic walls and hyaline sclerosis, scattered and frequent dysplastic follicular dendritic cells and foci of dystrophic calcification. Immunohistochemical analysis showed that the follicle mantle zones were composed of numerous B-cells positive for CD20, PAX5, and IgD. Antibodies specific for CD21 and CD23 highlighted prominent follicular dendritic cell networks within follicles. There was no evidence of human herpes virus 8. We searched the literature and could identify only 10 additional cases of thymic CD. Previously reported cases included 8 unicentric and 2 multicentric, classified pathologically as plasma cell variant (n = 4), hyaline vascular variant (n = 3), and mixed (n = 3). Thymectomy, as was done in the currently reported case, most often leads to the diagnosis of Castleman disease and was a mainstay of treatment in other reported cases.

A case of middle-aged male with multicentric solid pseudopapillary neoplasm of the pancreas

Solid pseudopapillary neoplasm (SPN) of the pancreas is a low-grade, malignant pancreatic tumor that occurs predominantly in young females. In this report, an extremely rare case of multicentric SPNs in a middle-aged male is discussed. A 55-year-old man was incidentally found to have a mass in the pancreatic body on abdominal ultrasonography during a medical checkup. Contrast-enhanced computed tomography (CT) revealed masses with 50-mm and 25-mm diameters with internal calcification in the pancreatic body and tail, respectively. These masses had a gradually increasing enhancement pattern though the center of the pancreatic body mass and the periphery of the pancreatic tail lesion were non-enhancing. Magnetic resonance imaging revealed a hyperintense signal in the mass of the pancreatic tail suggestive of hemorrhage on T1-weighted imaging. Positron emission tomography-CT revealed abnormal uptake of fluorodeoxyglucose in both lesions. Endoscopic ultrasound-guided fine needle aspiration was performed on both lesions, and tumor tissue with a solid proliferation of poorly pleomorphic small cells was observed. The tumor cells were positive for CD10 in the cytoplasm and β-catenin in the nucleus. The patient was diagnosed with SPNs and underwent a successful distal pancreatectomy.

European multicenter prospective analysis of the use of maxillomandibular fixation for mandibular fractures treated with open reduction and internal fixation

INTRODUCTION

The goal of mandibular fracture treatment is to restore static and dynamic occlusal functions. Open reduction and internal fixation (ORIF) of these fractures can be associated with an intraoperative and/or postoperative maxillo-mandibular fixation (MMF). The aim of this study was to analyse the use of perioperative MMF and its effects on occlusal outcomes in the management of mandibular fractures.

MATERIAL AND METHODS

This multicentric prospective study included adult patients with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate, partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, type of ORIF (rigid, non-rigid or mixed), thickness and number of plates, modality of intraoperative MMF (arch bars, self-tapping and self-drilling screws [STSDSs], manual, other) and duration of postoperative MMF. The primary outcome was malocclusion at 6 weeks and 3 months. Statistical analyses were performed with Fisher's exact test or chi-square test, as appropriate.

RESULTS

Between 1 May 2021 and 30 April 2022, 336 patients, 264 males and 72 females (median age, 28 years) with mandibular fractures (194 single, 124 double and 18 triple fractures) were hospitalized. Intraoperative MMF was performed in all patients. Osteosynthesis was rigid in 75% of single fractures, and rigid or mixed in 85% and 100% of double and triple fractures, respectively. Excluding patients who underwent manual reduction, postoperative MMF (median duration, 3 weeks) was performed in 140 (64%) patients, without differences by type or number of fractures (p > 0.05). No significant difference was found in the incidence of malocclusion in patients with postoperative MMF (5%, 95% confidence interval [CI], 2-10%) compared to those without (4%; 95% IC, 1-11%) (p > 0.05).

CONCLUSION

Postoperative MMF was performed in more than half of the patients despite adequate fracture osteosynthesis, with wide variability amongst centers. No evidence of a reduction in the incidence of postoperative malocclusion in patients treated with postoperative MMF was found.

[Castleman disease]

The term "Castleman disease" covers a variety of entities that have very different clinical, biological, pathological and physiopathological features. In this issue, we review the characteristics of the unicentric Castleman disease, of the HHV8 associated multicentric Castleman disease and the idiopathic multicentric Castleman disease associated or not with TAFRO syndrome ("thrombocytopenia, anasarca, fever, reticulin myelofibrosis and/or renal insufficiency, organomegaly"). We detail the differential diagnostics of these entities.

Multifocal glioblastoma and hormone replacement therapy in a transgender female

Background

Glioblastoma multiforme represents approximately 60% of all brain tumors in adults. This malignancy shows a high level of biological and genetic heterogeneity associated with exceptional aggressiveness, leading to poor patient survival. One of the less common presentations is the appearance of primary multifocal lesions, which are linked with a worse prognosis. Among the multiple triggering factors in glioma progression, the administration of sex steroids and their analogs has been studied, but their role remains unclear to date.

Case Description

A 43-year-old transgender woman who has a personal pathological history of receiving intramuscular (IM) hormone treatment for 27 years based on algestone/estradiol 150 mg/10 mg/mL. Three months ago, the patient suddenly experienced hemiplegia and hemiparesis in her right lower extremity, followed by a myoclonic focal epileptic seizure, vertigo, and a right frontal headache with a visual analog scale of 10/10. Magnetic resonance imaging images revealed an intra-axial mass with poorly defined, heterogeneous borders, and thick borders with perilesional edema in the left parietal lobe, as well as a rounded hypodense image with well-defined walls in the right internal capsule. The tumor was resected, and samples were sent to the pathology department, which confirmed the diagnosis of wild-type glioblastoma.

Conclusion

This report identifies prolonged use of steroid-based hormone replacement therapy as the only predisposing factor in the oncogenesis of multifocal glioblastoma. It is an example that highlights the importance for physicians not to consider pathologies related to the human immunodeficiency virus rather than neoplasms in transgender patients in view of progressive neurological deterioration.

La maladie de Castleman : aspects anatomopathologiques

Histologically, Castleman's disease associates three subtypes: 1-the vascular hyaline (HV) subtype more often seen in unicentric forms; 2-the plasmacytic (PV) subtype, more frequently associated with the HHV8+ and idiopathic multicentric form; 3-the mixed subtype associating both HV and PV aspects that may be encountered in any type of Castleman's disease. If the diagnosis of unicentric (isolated mass) and multicentric HHV8+ Castleman's disease is easy, the diagnosis of the idiopathic multicentric form remains particularly difficult because it is at the crossroads of many other pathologies (infectious, tumoral and dysimmune), making an anatomoclinical comparison necessary. The role of the pathologist, in the context of disseminated lesions (polyadenopathy and splenomegaly), is to identify lesions that may be part of Castleman's disease, to systematically perform HHV8 testing and to perform complete phenotyping associated with molecular analysis (B and T-cell clonality) in order to rule out a lymphomatous process and certain infectious etilogies. In all cases, its role will be a warning bell and the diagnosis of Castleman's disease will be retained only after a rigorous anatomic and clinical confrontation. © 2022 Published by Elsevier Masson SAS on behalf of Société nationale française de médecine interne (SNFMI).

Multicentric infantile myofibromatosis with extensive involvement limited to bone

Infantile myofibromatosis (IM) is the most common benign fibrous tumor of infancy, characterized by the development of single or multiple nodules in the skin, soft tissues, bone, and/or viscera. Multicentric forms are less frequent and can affect different tissues simultaneously and their prognosis depends on their extension and visceral involvement. Rarely, these forms are limited to the skeleton, in which case the absence of extraosseous lesions makes it difficult to suspect this entity. We present the case of an infant with multiple radiolucent lesions involving the skull, ribs, spine, and long bones, discovered in a radiological study performed after a minor trauma. A broad differential diagnosis was considered based on the osteolytic and polyostotic nature of the lesions on imaging studies. This report details and illustrates the typical radiological findings in bony involvement of IM, which suggest this disorder over other diagnostic options.

Unicentric Castleman disease was misdiagnosed as pancreatic mass: A case report

BACKGROUND

Castleman’s disease (CD) is a lymphatic proliferative disorder of unknown cause and is rarely seen clinically. It has been divided into unicentric and multicentric types. Unicentric CD (UCD) occurs as a solitary enlarged mass and mediastinal lymph nodes are the most common site. Surgical excision has proven to be curative for UCD. Multicentric CD (MCD) appears as a systemic disease with peripheral lymphadenopathy. MCD had a poor response to surgery and monoclonal antibodies with rituximab have become a research hotspot.

CASE SUMMARY

A 44-year-old woman presented with a pancreatic mass during routine physical examination. She had no obvious symptoms, such as fever, abdominal pain, abdominal distension, or jaundice. Ultrasound examination indicated a hypoechoic mass between the body of the pancreas, left lobe of the liver and stomach. It had a clear boundary, irregular shape, uneven echo, and no obvious blood flow signals. To clarify the diagnosis, contrast-enhanced ultrasound examination was performed, which showed a benign pancreatic lesion. Neuroendocrine or solid pseudopapillary tumor was a possible diagnosis. The patient underwent further contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging, which were suggestive of solid pseudopapillary tumor or neuroendocrine tumor. All the examinations failed to give a definitive diagnosis, and the patient underwent surgery. The final pathological and immunohistochemical results showed that the mass was CD.

CONCLUSION

This case highlights when lymphadenopathy is encountered clinically, CD should be considered and a biopsy should be performed.

The prior infection with SARS-CoV-2 study (PICOV) in nursing home residents and staff - study protocol description and presentation of preliminary findings on symptoms

Background

The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has presented itself as one of the most important health concerns of the 2020’s, and hit the geriatric population the hardest. The presence of co-morbidities and immune ageing in the elderly lead to an increased susceptibility to COVID-19, as is the case for other influenza-like illnesses (ILI) or acute respiratory tract infections (ARI). However, little is known, about the impact of a previous or current infection on the other in terms of susceptibility, immune response, and clinical course. The aim of the “Prior Infection with SARS-COV-2” (PICOV) study is to compare the time to occurrence of an ILI or ARI between participants with a confirmed past SARS-CoV-2 infection (previously infected) and those without a confirmed past infection (naïve) in residents and staff members of nursing homes. This paper describes the study design and population characteristics at baseline.

Methods

In 26 Belgian nursing homes, all eligible residents and staff members were invited to participate, resulting in 1,226 participants. They were classified as naïve or previously infected based on the presence of detectable SARS-CoV-2 antibodies and/or a positive RT-qPCR result before participation in the study. Symptoms from a prior SARS-CoV-2 infection between March and August 2020 were compared between previously infected residents and staff members.

Results

Infection naïve nursing home residents reported fewer symptoms than previously infected residents: on average 1.9 and 3.1 symptoms, respectively (p = 0.016). The same effect was observed for infection naïve staff members and previously infected staff members (3.1 and 6.1 symptoms, respectively; p <0.0001). Moreover, the antibody development after a SARS-CoV-2 infection differs between residents and staff members, as previously infected residents tend to have a higher rate of asymptomatic cases compared to previously infected staff members (20.5% compared to 12.4%; p <0.0001).

Conclusions

We can postulate that COVID-19 disease development and symptomatology are different between a geriatric and younger population. Therefore, the occurrence and severity of a future ILI and/or ARI might vary from resident to staff.

HPV status and therapeutic initial strategy impact on survival and oncologic outcomes: 5-year results from the multicentric prospective cohort of oropharyngeal cancers Papillophar

PURPOSE

After the 2 years of follow-up, we aimed to evaluate at 5 years the impact of human papillomavirus (HPV) status, tobacco, and initial treatment approach on progression-free survival (PFS) and overall survival (OS) of patients with oropharyngeal cancer (OPC) in France.

METHODS

Papillophar study was designed as a prospective cohort of 340 OPC patients in 14 French hospitals. HPV-positive status (21.7%) was defined with PCR (positivity for HPV DNA and E6/E7 mRNA). Cox proportional hazard models were used to assess the relationship between PFS, OS, HPV, and other prognostic factors. The combined effect of HPV status with smoking, stage, or initial treatment on PFS was also evaluated.

RESULTS

HPV-pos patients had better PFS than HPV-neg patients (HR = 0.46; 95% CI: 0.29-0.74), and worse for older patients (HR for 5-year age increase = 1.14), UICC stage 4 from the 7th TNM classification compared to stage 1-2 (HR = 2.58; CI: 1.33-5.00), and those having had radiotherapy (HR = 2.07; 95% CI: 1.36-3.16) or induction chemotherapy (HR = 2.11; 95% CI: 1.32-3.38) instead of upfront surgery. HPV-neg patients encountered a larger incidence of loco-regional disease than HPV-pos patients (31.5% and 14.0%, respectively, p = 0.0001). Distant metastases proportion was similar. HPV-neg patients developed more second primary tumor than HPV-pos patients (11.7% vs. 3.3%, p = 0.02).

CONCLUSIONS

5-year follow-up confirms the specifically improved prognosis in HPV-positive patients. The prognosis is nevertheless significantly modified through clinical and therapeutical variations.

Study protocol P-MAPS: microbiome as predictor of severity in acute pancreatitis-a prospective multicentre translational study

Background

Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients.

Methods

We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality.

Discussion

If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future.

Trial registration: ClinicalTrials.gov Identifier: NCT04777812

Dichotomic response to interleukin-6 blockade in idiopathic multicentric Castleman disease: two case reports

Background

Human herpervirus-8/human immunodeficiency virus negative Idiopathic multicentric Castleman disease (iMCD) is a lymphoproliferative disorder sustained by a pro-inflammatory condition of hypercytokinemia mostly mediated by Interleukin-6 (IL-6). According to iMCD consensus guidelines, anti-IL-6 blockade should be the first-line therapy for iMCD. However, despite the existing therapeutic alternatives, a large proportion of iMCD patients still lacks an effective therapy.

Case presentation

Here, we report two real-life iMCD cases with a different response to IL-6 blockade. The first presented patient obtained a prompt resolution of symptoms and a complete regression of adenopathies after IL-6 blockade therapy administration. Conversely, the second patient did not respond neither to Rituximab and Etoposide association nor to IL-6 blockade therapy (both Siltuximab and Tocilizumab). Furthermore, Intravenous immunoglobulin, Cyclosporine A, Sirolimus and anti-Interleukin-1 Anakinra were all attempted without any results. Since no treatment was successful, after a further confirmation of iMCD diagnosis by a second lymph node biopsy, patient has been candidate for thalidomide, cyclophosphamide and prednisone association therapy.

Conclusions

The iMCD cases we reported are coherent with the evidences that IL-6 blockade is a safe and an effective therapy for iMCD. Despite this, more than half of patients do not respond to anti IL-6 drugs. In such cases, therapeutic alternatives could be represented by Sirolimus, targeting PI3K/AKT/mTOR signaling or by associations of conventional drugs such as thalidomide, cyclophosphamide and prednisone. However, the two reported iMCD cases, confirm the need to more deeply investigate iMCD pathogenesis and to better dissect the heterogeneity of the disease in order to develop novel, effective therapeutic strategies.

A systematic review of multifocal and multicentric glioblastoma

Multiple glioblastoma multiforme (GBM) is classified as multifocal and multicentric GBM according to whether there is communication between the lesions. Multiple GBM is more genetically heterogeneous, aggressive and resistant to chemoradiotherapy than unifocal GBM, and has a worse prognosis. There is no international consensus on the treatment of multiple GBM. This review discusses some paradigms of multiple GBM and focuses on the heterogeneity spread pathway, imaging diagnosis, pathology, molecular characterization and prognosis of multifocal and multicentric GBM. Several promising therapeutic methods of multiple GBM are also recommended.

Cryoablation for Secondary Renal Cell Carcinoma After Surgical Nephrectomy

PURPOSE

To retrospectively evaluate the clinical outcomes of cryoablation for secondary renal cell carcinoma for patients with a history of nephrectomy for initial renal cell carcinoma.

MATERIALS AND METHODS

Thirty patients with 40 renal tumors who had undergone a nephrectomy for initial renal cell carcinoma and cryoablation for renal cell carcinoma as a secondary treatment during the period from April 2014 to December 2018 at a single center institution were enrolled. The patients' overall survival, local control, relapse-free survival, change of renal function, and complications were evaluated. The clinical factors of relapse-free survival were also evaluated.

RESULTS

The 5 year overall survival rate was 94.5%, the 5 year local control rate was 89.3%, and the 5 year relapse-free survival rate (RFSR) was 56.3%. There was an average reduction in renal function of 8.5% after 1 year, and > grade 3 complications occurred in only one case. The RFSR in the patients whose initial stage was T3 was 0%, significantly lower than the 70.4% RFSR in the patients whose initial stage was T1 or T2.

CONCLUSION

Cryoablation for secondary renal cell carcinoma after nephrectomy was safe and provided good local control with preserved renal function. However, the indications for cryoablation should be carefully considered for patients with T3-stage initial renal cell carcinoma, because of the high risk of relapse.

LEVEL OF EVIDENCE

III.

A multicenter and observational study of the Ambu™ AuraGain™ laryngeal mask in adult patients

PURPOSE

The main objective of this study was to evaluate the performance of the Ambu™ AuraGain™ device by determining its main parameters of use and complications.

METHODS

A total of 250 adult ASA physical status i to iii patients from five hospitals in Spain who received general anaesthesia with a supraglottic airway (SGA) device were enrolled in this study.

RESULTS

The primary outcome was analysed for 244 patients and a median OLP of 32 cm H2O (IQR 28-36 cm H2O) was obtained. Insertion was achieved at first attempt in 85% of cases, and overall in 98% of cases, in a median time of 15 s (12-22.5). We applied manoeuvres in 61% of patients to facilitate the process. Ventilation was effective in 97.2% of the interventions (95% CI 0.99-0.94) throughout the procedure. Insertion of the gastric tube was easily performed in 99.6% of the patients, and the vocal cords were viewed by fibrobronchoscopy in 96.3% of cases. Logistic regression analysis identified the use of sizes smaller than those recommended as a risk factor for low OLP (< 25 cm H2O). The main complication recorded was the presence of blood when withdrawing the SGA device (15%).

CONCLUSIONS

Our results confirm that the use of AuraGain allows airway management in a reliable and effective way achieving high OLP and low incidence of associated complications, establishing it as a useful alternative in the routine clinical setting of anaesthesiologists. AuraGain performance was consistent in all five centres.

Is ultrasonographic evaluation sensitive enough to detect multicentric papillary thyroid carcinoma?

Background

This study aimed to investigate the preoperative ultrasonographic (US) evaluation of multicentric papillary thyroid carcinoma (PTC) and to evaluate the association of US findings with lymph node metastasis and extracapsular extension in PTC.

Methods

Preoperative US evaluations of patients with PTC who underwent total thyroidectomy were retrospectively investigated. Pathological perspectives and US features of PTC were analyzed. The sensitivity of US in detecting multicentric PTC was evaluated.

Results

The present study included 89 PTC patients who underwent total thyroidectomy. In total, 164 nodules were detected by preoperative US. Significant differences in US pattern were found between benign and malignant nodules. Of the 89 patients with PTC, 33 (37.08%) cases were confirmed as multicentric PTC by operation and pathological examination, 22 (66.67%) of which were bilateral. Before surgery, only 23 patients were suspected as multicentric PTC based on US findings. Pathological examination revealed that malignant nodules in 17 (51.51%) patients with multicentric PTC had been missed by preoperative US. The malignant nodules that went undetected by US were micronodulars (1-4 mm). Furthermore, ultrasonography was less sensitive for the diagnosis of metastatic lymph nodes in the neck. US had more than 80% sensitivity for detection of extracapsular extension of cases.

Conclusions

US evaluation is not sensitive enough to detect multicentric PTC. The minute size of some nodules in multicentric PTC, may lead to them being missed by US evaluation. Ultrasonography is an optional tool for the detection of extracapsular extension, but it is less sensitive for diagnosing lymph node metastasis.

Multicentric Exophytic Primary Spinal Cord Glioblastoma Mimicking Teratoma

Primary spinal cord glioblastoma is an extremely rare disease that shows dismal prognosis. Here we report the first case, to our knowledge, of multicentric primary spinal cord glioblastoma presenting with exophytic involvement mimicking teratoma. A 12-year-old girl presented to our hospital with a 6-month history of back pain and progressive paraplegia. Spinal magnetic resonance imaging findings were suspicious for spinal teratoma with cerebrospinal fluid dissemination. The patient underwent laminotomy and laminoplasty from T10-S2 and subtotal resection of the tumor was achieved. Histopathological analysis revealed typical histological indications of glioblastoma. After surgery, the patient underwent further adjuvant therapy consisting of radiotherapy and temozolomide. However, 8 months after surgery, the follow-up magnetic resonance imaging scan revealed tumor recurrence with intracranial dissemination. The patient is still alive at the current stage (9 months after surgery).

The French paediatric cohort of Castleman disease: a retrospective report of 23 patients

BACKGROUND

Castleman disease (CD) is a rare non-malignant lymphoproliferation of undetermined origin. Two major disease phenotypes can be distinguished: unicentric CD (UCD) and multicentric CD (MCD). Diagnosis confirmation is based on histopathological findings in a lymph node. We attempted to survey all cases of paediatric CD identified to date in France to set up a national registry aiming to improve CD early recognition, treatment and follow-up, within the context of a new national reference center (http://www.castleman.fr).

METHODS

In 2016, we e-mailed a questionnaire to members of the French paediatric immunohaematology society, the paediatric rheumatology society and the Reference Centre for Castleman Disease to retrospectively collect cases of paediatric CD (first symptoms before age 18 years). Anatomopathological confirmation was mandatory.

RESULTS

We identified 23 patients (12 girls) with a diagnosis of UCD (n = 17) and MCD (n = 6) between 1994 and 2018. The mean age at first symptoms was 11.47 ± 4.23 years for UCD and 8.3 ± 3.4 years for MCD. The mean diagnosis delay was 8.16 ± 10.32 months for UCD and 5.16 ± 5.81 years for MCD. In UCD, the initial symptoms were isolated lymph nodes (n = 10) or lymph node associated with other symptoms (n = 7); fever was present in 3 patients. Five patients with MCD presented fever. No patients had HIV or human herpesvirus 8 infection. Autoinflammatory gene mutations were investigated in five patients. One patient with MCD carried a K695R heterozygous mutation in MEFV, another patient with MCD and Duchenne myopathy carried two variants in TNFRSF1A and one patient with UCD and fever episodes carried two heterozygous mutations, in IL10RA and IL36RN, respectively. Treatment of UCD was mainly surgical resection, steroids, and radiotherapy. Treatment of MCD included tocilizumab, rituximab, anakinra, steroids, chemotherapy, and splenectomy. Overall survival after a mean of 6.1 ± 6.4 years of follow-up, was 100% for both forms.

CONCLUSION

Paediatric CD still seems underdiagnosed, with a significant diagnosis delay, especially for MCD, but new international criteria will help in the future. Unlike adult CD, which is strongly associated with HIV and human herpesvirus 8 infection, paediatric CD could be favored by primary activation of innate immunity and may affect life expectancy less.

Polyostotic osteoid osteoma: A case report

Osteoid osteomas are common, benign osteoblastic tumors that can occur in any bone in the body. They are almost always solitary, with only rare reports of multiple tumors in the same patient. When multiple, they typically are found within the same bone. We present a unique case of a young female athlete who presented initially at 16 years old with a right tibial osteoid osteoma and later at 18 years old with a right acetabular osteoid osteoma. Our case demonstrates the rare entity of polyostotic osteoid osteoma, the potential limitations of MRI in the diagnosis of osteoid osteoma, and the utility of radiofrequency ablation in the treatment of osteoid osteoma.

Genetic and histologic spatiotemporal evolution of recurrent, multifocal, multicentric and metastatic glioblastoma

Glioblastoma is the most frequent and aggressive primary brain tumor, characterized by extensive brain invasion and rarely, systemic metastases. The pathogenesis of metastatic glioblastoma is largely unknown. We present the first integrated clinical/histologic/genetic analysis of 5 distinct brain and lung foci from a unique case of recurrent, multifocal, multicentric and metastatic glioblastoma. The initial right frontotemporal gliosarcoma received standard surgical/chemoradiation therapy and recurred 1.5 years later, co-occurring with three additional masses localized to the ipsilateral temporal lobe, cerebellum and lung. Synchronous metastatic lung carcinoma was suspected in this long-term smoker patient with family history of cancer. However, glioblastoma was confirmed in all tumors, although with different morphologic patterns, including ependymomatous and epithelioid. Genomic profiling revealed a germline FANCD2 variant of unknown significance, and a 4-gene somatic mutation signature shared by all tumors, consisting of TERT promoter and PTEN, RB1 and TP53 tumor suppressor mutations. Additional GRIN2A and ATM heterozygous mutations were selected in the cerebellar and lung foci, but were variably present in the supratentorial foci, indicating reduced post-therapeutic genetic evolution in brain foci despite morphologic variability. Significant genetic drift characterized the lung metastasis, likely explaining the known resistance of circulating glioblastoma cells to systemic seeding. MET overexpression was detected in the initial gliosarcoma and lung metastasis, possibly contributing to invasiveness. This comprehensive analysis sheds light on the temporospatial evolution of glioblastoma and underscores the importance of genetic testing for diagnosis and personalized therapy.

Multifocal and multicentric breast cancer, is it time to think again?

Multifocal multicentric breast cancer has traditionally been considered a contraindication to breast conserving surgery because of concerns regarding locoregional control and risk of disease recurrence. However, the evidence supporting this practice is limited. Increasingly, many breast surgeons are advocating breast conservation in selected cases. This short narrative review summarises current evidence on the role of surgery in multifocal multicentric breast cancer and shows that when technically feasible the option of breast conservation is oncologically safe.

Neuroimaging biomarkers for clinical trials in atypical parkinsonian disorders: Proposal for a Neuroimaging Biomarker Utility System

INTRODUCTION

Therapeutic strategies targeting protein aggregations are ready for clinical trials in atypical parkinsonian disorders. Therefore, there is an urgent need for neuroimaging biomarkers to help with the early detection of neurodegenerative processes, the early differentiation of the underlying pathology, and the objective assessment of disease progression. However, there currently is not yet a consensus in the field on how to describe utility of biomarkers for clinical trials in atypical parkinsonian disorders.

METHODS

To promote standardized use of neuroimaging biomarkers for clinical trials, we aimed to develop a conceptual framework to characterize in more detail the kind of neuroimaging biomarkers needed in atypical parkinsonian disorders, identify the current challenges in ascribing utility of these biomarkers, and propose criteria for a system that may guide future studies.

RESULTS

As a consensus outcome, we describe the main challenges in ascribing utility of neuroimaging biomarkers in atypical parkinsonian disorders, and we propose a conceptual framework that includes a graded system for the description of utility of a specific neuroimaging measure. We included separate categories for the ability to accurately identify an intention-to-treat patient population early in the disease (Early), to accurately detect a specific underlying pathology (Specific), and the ability to monitor disease progression (Progression).

DISCUSSION

We suggest that the advancement of standardized neuroimaging in the field of atypical parkinsonian disorders will be furthered by a well-defined reference frame for the utility of biomarkers. The proposed utility system allows a detailed and graded description of the respective strengths of neuroimaging biomarkers in the currently most relevant areas of application in clinical trials.

Clinicopathological Profile of Castleman's Disease in Indian Population: Experience From a Tertiary Care Center

Castleman's disease (CD), also known as angiofollicular lymph node hyperplasia, a rare, non-malignant chronic lymphoproliferative disease characterized by, uni or multicentric lymphadenopathy. There is limited information about the clinicopathological variations and associations of this entity. A total of 50 cases of CD were retrieved from the archives, between the years 2005-2017. The cases were divided into pediatric (0-18 years), young adult (age ≤ 40 years) and older adult groups (age > 40 years respectively). Detailed clinicopathological correlation was done. The age range was 6-74 years. There was a male predominance (M: F-1.6:1). The majority (72%; 36/50) of the patients were adults; 46% young adult and 28% older adult, while only 28% (14/50) were of pediatric. Majority (78%) showed features of unicentric Castleman disease (UCD) while rest 22% presented with multi centric Castleman disease (MCD). Systemic symptoms were more frequent in MCD as compared to UCD cases (p = 0.06). The majority of the cases (40/50; 80%) were of the hyaline vascular type. Two of the cases showed mixed histological feature. Out of 50 patients 29 patient's treatment details are available. Majority unicentric cases were cases surgically excised 14/17 (82.3%). Three patients 3/17 (17.6%) were treated with chemotherapy. In multicentric Castleman's disease group, six of the 12 cases with MCD were managed by chemotherapy. One patient died of progressive disease. Castleman disease has varied clinical presentation and is often associated with other diseases. A high degree of suspicion and careful histological examination is required in order not to miss this entity.

PIK3CA activating mutations are associated with more disseminated disease at presentation and earlier recurrence in glioblastoma

Phosphatidylinositol 3-kinase signaling promotes cell growth and survival and is frequently activated in infiltrative gliomas. Activating mutations in PIK3CA gene are observed in 6-15% of glioblastomas, although their clinical significance is largely undescribed. The objective of this study was to examine whether PIK3CA mutations are associated with a specific clinical phenotype in glioblastoma. We retrospectively reviewed 157 consecutive newly diagnosed glioblastoma patients from December 2009 to June 2012 who underwent molecular profiling consisting of targeted hotspot genotyping, fluorescence in situ hybridization for gene amplification, and methylation-specific PCR for O6-methylguanine-DNA methyltransferase promoter methylation. Molecular alterations were correlated with clinical features, imaging and outcome. The Cancer Genome Atlas data was analyzed as a validation set. There were 91 males; median age was 58 years (range, 23-85). With a median follow-up of 20.9 months, median progression-free survival (PFS) and estimated overall survival (OS) were 11.9 and 24.0 months, respectively. Thirteen patients (8.3%) harbored PIK3CA mutation, which was associated with younger age (mean 49.4 vs. 58.1 years, p = 0.02). PIK3CA mutation correlated with shorter PFS (median 6.9 vs. 12.4 months, p = 0.01) and OS (median 21.2 vs. 24.2 months, p = 0.049) in multivariate analysis. A significant association between PIK3CA mutation and more disseminated disease at diagnosis, as defined by gliomatosis, multicentric lesions, or distant leptomeningeal lesions, was observed (46.2% vs. 11.1%, p = 0.004). In conclusion, despite the association with younger age, PIK3CA activating mutations are associated with earlier recurrence and shorter survival in adult glioblastoma. The aggressive course of these tumors may be related to their propensity for disseminated presentation.

Two-stage surgery for intraperitoneal and retroperitoneal multicentric liposarcoma causing hydronephrosis: a case report

Background

Liposarcoma is a soft tissue sarcoma of adipocyte origin. Liposarcoma represents 20–30% of adult soft tissue tumors, which was most frequently seen in the retroperitoneal space in 45% and abdominal space in only 5% of cases, but the multicentric case is unknown. Herein, we describe a rare case of multicentric, large, intra-abdominal and retroperitoneal liposarcoma, one of which had caused infection and pressing the right ureter causing hydronephrosis, which was resected by two-stage surgery.

Case presentation

The patient was a 46-year-old man who was referred for abdominal bloating and fatigue. Enhanced computed tomography showed a 23-cm intra-abdominal tumor and a 14.6-cm left retroperitoneal tumor. The intra-abdominal tumor which compressed the right ureter caused right unilateral hydronephrosis and deteriorated the renal function. The intra-abdominal tumor had also formed an intra-abdominal abscess. We performed emergent laparotomy and resected the intra-abdominal tumor. After the recovery of renal function, we resected the residual retroperitoneal tumor. Histopathological examination showed both tumors to be myxoid/round cell type liposarcoma. Considering clinical findings and their location, he was diagnosed with multicentric liposarcoma. He underwent adjuvant chemotherapy and has been alive without any recurrence for 9 months after the operation.

Conclusions

We successfully resected large intra-abdominal and retroperitoneal multicentric myxoid/round cell liposarcomas. A two-stage surgery was a rational choice as it provides time to confirm the recovery of renal function.

Harmonization of neuroimaging biomarkers for neurodegenerative diseases: A survey in the imaging community of perceived barriers and suggested actions

Introduction

Molecular, functional, and structural neuroimaging biomarkers are largely used to study neurodegenerative diseases, but their benefits to patients/science might be greatly enhanced by improving standardization and cross-validation. In this EU Joint Programme-Neurodegenerative Diseases Research-funded project, we surveyed the neuroimaging community to assess perceived barriers in multicentric neuroimaging harmonization and actions to overcome them.

Methods

An anonymous survey addressed researchers, clinicians, pharma industry, and professional associations, inquiring about both general and modality-specific harmonization barriers.

Results

Survey participants (459) represented an international (37 countries) multidisciplinary community. We identified two sets of funding actions, one proposing the creation of an updated hub of documents to help researchers plan and execute multicentric neuroimaging studies capitalizing from previous studies, and the other focused on modality-specific harmonization challenges in future neurodegenerative diseases clinical trials.

Discussion

This large survey of priorities and actions may help define harmonization calls launched by worldwide science funding agencies.

Synchronous Development of Multicentric Malignant Peripheral Nerve Sheath Tumors: Institutional Review

BACKGROUND

Malignant peripheral nerve sheath tumors (MPNSTs) are rare soft tissue sarcomas, with approximately 50% occurring in patients diagnosed with neurofibromatosis type 1 (NF-1). NF-1 occurs in approximately 1/3000 individuals, and given that the lifetime prevalence of MPNST is estimated at 8%-13%, synchronous development of separate MPNSTs is plausible. We sought to report the incidence of synchronous MPNST in a cohort of pathology-proven cases since 1994.

METHODS

Records since 1994 were queried and identified 192 patients with pathology-proven MPNST. Medical records of these patients were reviewed to search for patients with synchronous MPNSTs.

RESULTS

Retrospective review of 192 patients treated for MPNST at our institution (including 71 patients with NF-1) revealed only 1 patient with synchronous MPNSTs. A 48-year-old woman with NF-1 presented with progressive right upper and lower extremity pain and radicular symptoms. Biopsies of right sciatic and median nerve lesions revealed high-grade MPNST, and she underwent radiotherapy and complete resection of both masses. Due to initial nonspecific biopsy results and patient preference, treatment of the median nerve lesion was delayed by 8 months. She did not have recurrence of her disease at the 18-month follow-up.

CONCLUSIONS

Synchronous development of MPNST is unusual, with an incidence of 1.4% in our cohort of NF-1 patients with MPNSTs. Given the reported incidence of synchronous MPNST, the rate of malignant transformation in NF-1 may be overestimated. However, heightened suspicion for malignant transformation should continue in patients harboring a diagnosis of MPNST.

Metachronous multicentric giant cell tumour of bone

Metachronous multicentric giant cell tumour (GCT) of bone is rare. We report a case of a 21-year-old man with metachronous multicentric GCTs, with five (including one recurrence) documented lesions reported over a span of 9 years involving various sites, which included the fifth metacarpal bone of the right hand, the intermediate cuneiform bone of the right foot, the left proximal humerus and the lateral malleolus of the right tibia. The radiological appearance of these lesions in these various sites with correlation among clinical history, histopathology and the treatment approach is described in this report. He is undergoing regular follow-up and has now once again presented with recurrence of the right tibial lesion. The case is reported for its rarity.

Multicentric lymphoma in a Rottweiler dog with bilateral ocular involvement: A case report

A 10-year-old, male Rottweilerdog was presented to Small Animal Hospital of Tehran University with a history of lethargy, anorexia, weight loss, vomiting, polyuria, polydipsia and blindness. The dog showed symptoms of depression, high body temperature (39.2 ˚C), tachypnea (40 breaths min^-1) and cachexia. In ophthalmic examination, bilateral hyphema (hemmorrahge in anterior chamber of the eye) and blindness were detected. The pulse of the animal was normal (90 beats min^-1) and obvious general lymphadenopathy was determined. Lymph nodes were firm, freely movable, and painless on palpation. Initial differential diagnosis of lymphoma included lymphoma, metastatic neoplasia, lymphoid hyperplasia, and lymphadenitis. In hematology and cytology tests, this case was suspected to lymphoma. Immunohistochemical staining of neoplastic lymph node revealed that nearly 20.00 – 25.00% of neoplastic cells were strongly positive for anti CD3, whereas they were negative for both CD20 and CD79a. According to the microscopic and immunohistochemical findings, a diagnosis of T cell lymphoma was made. The present report is the first case of multicentric lymphoma with ocular metastasis in a dog in Iran.

Prognostic impact of multifocal and multicentric breast cancer versus unifocal breast cancer

PURPOSES

The clinical behavior of multifocal and multicentric breast cancers (MMBCs) is not well characterized. We conducted this study to ascertain whether patients with MMBCs have a worse prognosis than patients with unifocal breast cancers (UBC).

METHODS

The subjects of this retrospective study were 734 consecutive patients who underwent definitive surgery for invasive breast carcinoma at our hospital between January 2004 and December 2006. MMBC was defined as ≥ 2 separate invasive unilateral breast tumors and pathological T stage was redefined based on the sum of the maximum diameter of each tumor. We evaluated disease-free survival (DFS) using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Of the 734 patients, 136 (18.5%) had MMBC. The pathological T stage of 36 of the patients with MMBC was upstaged by adopting the sum of each focus. MMBC did not have any survival impact, but MMBC upstaged by the modified pathological T stage was associated with worse DFS than non-upstaging MMBC (P = 0.004). Multivariate analysis revealed that upstaging MMBC was an independent factor for poor prognosis and worse DFS (HR 2.757, P = 0.043).

CONCLUSIONS

MMBC itself may not be predictive of a worse prognosis; however, the sum of the invasive diameters of MMBC might be an important prognostic factor. Further studies are needed to confirm the prognosis associated with MMBC, taking into consideration the biological characteristics of each invasive focus.

[H3F3A mutated multicentric giant cell tumor of bone : A very rare primary bone disease]

This article presents the case of a metachronic multicentric giant cell tumor of bone (GCTB). The patient obtained his first diagnosis of GCTB in the left humerus at the age of 47 years. Furthermore, he suffered from a GCTB in the head of his 4th left metacarpal bone and from a recurrence of the latter. All tumors carried the characteristic H3F3A mutation, which was proven by Sanger sequencing and a mutation specific antibody. The case is the first description of a multicentric H3F3A mutated GCTB.

Multiple high-grade gliomas: epidemiology, management, and outcome. A systematic review and meta-analysis

Multiple high-grade gliomas (M-HGGs) are well--separated tumors, differentiated as multifocal (MF) and multicentric (MC) by their MRI features. The authors performed a systematic review and meta-analysis of literature examining epidemiology, clinical and radiological characteristics, management, and the overall survival from M-HGGs. According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and January 2017 was carried out. The authors identified studies that examined the prevalence rate, clinical and radiological characteristics, treatment, and overall survival from M-HGGs in patients with HGG. Data were analyzed using a random-effects meta-analysis model. Finally, we systematically reviewed demographic characteristics, lesion location, and surgical and adjuvant treatments. Twenty-three studies were included in this systematic review. The M-HGGs prevalence rate was 19% (95% CI 13-26%) and the hazard ratio of death from M-HGGs in the HGGs population was 1.71 (95% CI 1.49-1.95, p < 0.0001). The MC prevalence rate was 6% (CI 95% 4-10%), whereas MF prevalence rate was 11% (CI 95% 6-20%) (p < 0.0001). There were no statistically significant differences between MF and MC HGGs in gender, lesion location, histological type, and surgical treatment. Survival analysis of MC tumors showed that surgical resection (gross total resection or subtotal resection) is an independent predictor of improved outcome (HR 7.61 for biopsy subgroup, 95% CI 1.94-29.78, p = 0.004). The prevalence of M-HGGs is approximately 20% of HGGs. The clinical relevance of separating M-HGGs in MF and MC tumors remains questionable and its prognostic significance is unclear. When patient status and lesion characteristics make it safe and feasible, cytoreduction should be attempted in patients with M-HGGs because it improves overall survival.

Multicentric high grade oligodendroglioma: a rare entity

A 74 year old male presented with 1 month history of weakness in right upper limb and motor aphasia for 15 days. Magnetic resonance imaging (MRI) of the brain showed three discrete ring enhancing lesions. An image guided awake craniotomy and biopsy of a lesion was performed. The histopathological examination revealed it to be a grade III Oligodendroglioma. This was a rare case of multicentric high grade oligodendroglioma has never been reported in literature. We report such a case with relevant review of literature.

Detection of multicentric and contralateral breast cancers on MRI based on primary cancer biomarker status: will this change surgical or medical management?

PURPOSE

The utilization of staging preoperative breast MRI in biopsy-proven cancer patients varies based on institution and individual clinicians. It is unclear whether primary breast cancer subtype influences a clinician's decision to obtain a preoperative breast MRI based on likelihood of multicentric or contralateral disease, which may change surgical or medical management. Our purpose was to compare the four main breast cancer subtypes in our patient population (i.e., luminal A, luminal B, HER2 enriched and triple-negative) who underwent pretreatment staging MRIs to determine whether certain breast cancer subtypes are more likely to have multicentric or contralateral disease.

METHODS

We retrospectively reviewed 435 patients with biopsy-proven invasive breast cancer who had staging MRI.

RESULTS

Of these patients, 14 had biopsy-proven multicentric disease (3.2% of total) and 15 had biopsy-proven contralateral second tumor sites (3.4% of total). There was no statistically significant difference between primary tumor subtype and likelihood of multicentric or contralateral disease (p = 0.3065).

CONCLUSION

Pretreatment staging MRI can detect multicentric and/or contralateral additional tumor sites, which ultimately changes staging, treatment options, and outcomes for patients with biopsy-proven breast cancer. There is no correlation between primary breast cancer subtype and likelihood of multicentric or contralateral disease.

Multicentric Castleman disease of hyaline vascular variant presenting with unusual systemic manifestations: a case report

Background

Castleman disease is a rare lymphoproliferative disorder presenting with localized or disseminated lymphadenopathy and systemic manifestations. It can be categorized in numerous ways, such as unicentric versus multicentric, histopathological variants (hyaline-vascular, plasma cell, and mixed), or subtypes based on causative viral infections (human immunodeficiency virus, human herpesvirus-8, or Kaposi sarcoma herpesvirus). Presentation ranges from asymptomatic to symptoms involving multiple organs. Even though the exact mechanism of pathogenesis is unknown, treatment is directed toward possible etiologies such as interleukin-6, cluster of differentiation 20, and viral agents.

Case presentation

A 36-year-old Sri Lankan woman presented with generalized body swelling and foamy urine of 2 weeks’ duration. Examination revealed pallor; generalized edema; axillary, cervical, and inguinal lymphadenopathy; hypertension; and hepatomegaly. Investigations showed bicytopenia, nephrotic range proteinuria with hypoalbuminemia, hypogammaglobulinemia, and features of hyaline-vascular type Castleman disease in a lymph node biopsy. She was managed with rituximab and had good clinical improvement.

Conclusions

Castleman disease has a broad spectrum of clinical manifestations, disease pathogeneses, and associations and/or complications. Medical professionals need to be familiar with this spectrum because timely diagnosis and aggressive targeted therapy are the cornerstones of managing these patients.

Multicentric Squamous Odontogenic Tumor: A Case Report and Review of the Literature

Squamous odontogenic tumor (SOT) is a rare benign epithelial odontogenic neoplasm of the jaws. Both intraosseous and peripheral SOTs have been described in the English language literature. While most intraosseous SOTs occur as solitary lesions, a multicentric variant has also been previously described. Although the radiographic and microscopic features are identical for both solitary and multicentric clinical presentations, there are three significant differences between them. More specifically, multicentric SOT presents at an earlier age (third decade of life), has a slightly higher male to female ratio than the solitary type and has a marked predilection for African-Americans. Here we document the eighth reported case of multicentric SOT, which was diagnosed in a 43-year-old African-American male. In addition, we feature focal sebaceous metaplasia, a heretofore unknown microscopic feature of SOT. Clinical, radiological, and histopathological findings are discussed. The differential diagnosis, biological behavior and management modalities for SOT are also addressed.

Metachronous multiple thymoma with different clinical behavior and pathological findings

A 70-year-old woman presented with a nodule in the left hilum on a chest radiograph 3 years before. Another mass emerged caudal to the initial nodule and was diagnosed as thymoma. A surgical specimen revealed two components: an encapsulated rostral nodule and a caudal mass invading the left lung. Histological findings showed that the rostral nodule was a stage 1 type B2 thymoma, whereas the caudal mass was a stage 3 type B3 thymoma. Based on the differences in biological behavior and histological findings, we concluded that these tumors derived from multicentric origin.

Multicentric solid pseudopapillary neoplasms of the pancreas diagnosed by endoscopic ultrasound-guided fine needle aspiration: a case report

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor. This neoplasm usually arises as a single mass; multicentricity is exceptionally rare. We report the preoperative diagnosis of multicentric SPNs by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). A 32-year-old woman presented to the hospital with a pancreatic tumor that was detected on abdominal echography. Contrast-enhanced computed tomography (CT) scans revealed a 5-mm low-density mass in the body of the pancreas and a 10-mm mass in the tail of the pancreas. Magnetic resonance imaging (MRI) also revealed two tumors in the body and tail of the pancreas. On endoscopic ultrasonography (EUS), two indistinct and heterogeneous echogenic masses were found, and EUS-FNA was performed for each of these tumors. Cytological analysis revealed that the two masses were highly cellular with papillary groups of small, uniform, oval cells surrounding a fibrovascular core. Immunohistochemistry was positive for α-1 antitrypsin, vimentin, neuron-specific enolase (NSE), CD10, and progesterone receptor. These features confirmed the preoperative diagnosis of multicentric SPNs. The patient underwent laparoscopic distal pancreatectomy with splenectomy. The final pathologic diagnosis was multicentric SPNs. During 2 years of follow-up, she has not developed any recurrence.

Multicentric Type 3 Gastric Neuroendocrine Tumors

A 50-year-old woman with incidentally detected multiple gastric polyps and biopsy-proven neuroendocrine tumor (NET) was referred to our hospital. More than 10 polypoid lesions (less than 15 mm) with normal gastric mucosa were detected from the gastric body to the fundus. The serum level of gastrin was within the normal limits. There was no evidence of atrophic changes on endoscopy and serologic marker as pepsinogen I/II ratio. Computed tomography of the abdomen and pelvis revealed no evidence of metastatic lesions. She refused surgery, and we performed endoscopic polypectomy for almost all the gastric polyps that were greater than 5 mm. Although the histological examination revealed that all the removed polys were diagnosed as NET G1, three of them extended to the lateral or vertical resection margins, while two exhibited lymphovascular invasion. A follow-up upper endoscopy that was performed 6 months after the diagnosis showed multiple remnant gastric polyps that were suggestive of remnant gastric NET.

Conservative surgery for multifocal/multicentric breast cancer

Multifocal (MF) and multicentric (MC) breast cancer is regularly considered a relative contraindication for breast-conserving therapy (BCT). There are two reasons for this wide spread notion: However, we concur that if optimal 'cytoreductive surgery' is achieved this will result in good local control (i.e. in-breast relapse <10% at 10 years). This can only be achieved on the basis of the right imaging, image guidance for non-palpable foci, and tumor free (invasive as well as ductal carcinoma in situ) margins after adequate pathological assessment. Surgery must then be followed by whole breast irradiation and systemic treatments as indicated by primary cancer biology. Careful planning and adaptive application of oncoplastic techniques will result in an optimal cosmetic results. The meticulous work of Roland Holland and coworkers(1) in the early 1980's on whole breast specimen showed invasive foci at more then 2 cm distance from the invasive primary cancer in more then 40% of specimen. Although multiple tumor foci may occur in up to 60% of mastectomy specimens, equivalent survival outcomes were observed in prospective trials comparing BCT and mastectomy for clinically unifocal lesions, suggesting that the majority of these foci are not, or do not become, biologically relevant or clinically significant with appropriate treatment. As diagnostic tools advance, MF and MC tumors are more commonly diagnosed. Cancers that previously would have been classified as unifocal now can be detected as MF or MC. In addition, locoregional treatment modalities have improved significantly over the past decade. More recent studies reflect these advances in diagnosis and treatment. Studies evaluated staging MRI showed that up to 19% of woman with diagnosed breast cancer harbor a second malignant ipsilateral lesion. These findings should only have consequences when additional lesions are proven cancer. Multiple enhancing lesions on MRI are in itself not an indication for a mastectomy. The Z0011 trial and the AMAROS trial demonstrated a similar phenomenon for axillary treatment; less surgery does not necessarily lead to inferior local control or survival outcomes. Recent studies supplement the growing evidence that treatment of patients with MF/MC breast cancer with BCS, radiotherapy, and adjuvant systemic therapy can result in low rates of in-breast recurrence.