Angiosarcoma of the head and neck: A clinicopathologic study with special emphasis on diagnostic pitfalls

BACKGROUND AND AIMS

Angiosarcoma (AS) is a rare malignant vascular tumor that phenotypically and functionally recapitulate normal endothelium. They constitute approximately 2-4% of soft tissue sarcomas. We present 36 cases of head and neck AS diagnosed for 11 years at a tertiary care hospital in South India to analyze the clinical, pathological, and immunophenotypic profiles with special emphasis on their differential diagnoses and diagnostic pitfalls.

MATERIALS AND METHODS

Head and neck AS diagnosed from January 2006 to December 2017 were included. Clinical characteristics, treatment received, and follow-up data were obtained from electronic medical records. Hematoxylin and eosin (H&E)-stained slides and immunohistochemistry (IHC) slides were reviewed, and the histomorphological features, immunohistochemical staining, and their utility in resolving differential diagnosis were assessed.

RESULTS

Twenty-two females and 14 males were diagnosed with head and neck AS in the study period. Histomorphological patterns observed were mixed vasoformative and solid (n = 22), pure vasoformative (n = 13), and pure solid (n = 1). Neoplastic cells showed epithelioid, spindly, signet cell-like, clear cell, and rhabdoid morphology. CD31 was positive in 100% of cases, and CD34 was positive in 40% of cases. Differential diagnoses included melanoma, rhabdomyosarcoma, and large-cell lymphoma. Surgery, radiotherapy, and chemotherapy were the treatment modalities used. Twelve patients developed local recurrence, and 12 patients developed metastasis on follow-up. Twenty-five patients died of disease, on an average of 24 months after diagnosis.

CONCLUSION

Head and neck AS pose a significant diagnostic challenge due to their broad morphologic spectrum. Proper clinicopathologic correlation is necessary to avoid misdiagnosis.

Ewing's sarcoma in adolescents and adults - 10-year experience from a tertiary cancer center in India

BACKGROUND

Ewing's sarcoma (EWS) is an aggressive small round cell tumor, affecting bone and soft tissues and is mostly seen in childhood and second decade of life. EWS accounts for 10-12% of bone tumors in more than 15 years age group and is even rarer after 40 years of age.

MATERIALS AND METHODS

This retrospective analysis was conducted among patients aged more than 15 years with histologically proven EWS.

RESULTS

Among 240 cases of EWS treated at our center during 2001-2010, 130 (54%) were more than 15 years of age. The median age was 20 years with a male: female ratio of 2.4:1. Ninety percent had skeletal EWS, 10% had extra skeletal EWS, and 37% patients were metastatic at presentation. Eighty-two received curative treatment with chemotherapy (vincristine, doxorubicin, cyclophosphamide, ifosfamide, etoposide (VAC/IE)) along with local treatment, radiotherapy (RT) in 61, surgery alone in seven, and RT plus surgery in 14. Two- and 5-year overall survival (OS) was 43.3% and 25.5%, respectively, for the entire series. The OS for the non-metastatic group was 63.2% at 2 years and 36.5% at 5 years, and the progression free survival was 53.7% at 2 years and 37.8% at 5 years. High lactate dehydrogenase was found to be a significant poor prognostic factor (P = 0.001). Median OS for localized central EWS was 49.2 months and that for peripheral EWS was 24 months. Patients more than 20 years of age with non-metastatic disease had better OS compared to those with 15-20 years of age.

CONCLUSION

Treatment of EWS requires a multidisciplinary approach with radical surgery and/or radiation to control local disease and multiagent chemotherapy to control systemic disease. Long-term follow-up is essential because of disease relapse and treatment-related complications.

Castleman disease: Experience from a single institution

Castleman disease (CD) describes a group of rare heterogeneous lymphoproliferative disorders characterized by enlarged hyperplastic lymph nodes. It is classified into unicentric CD (UCD) and multicentric CD (MCD). The present retrospective study examined the data of 11 patients with CD diagnosed and treated at a tertiary cancer center from 2017 to 2022. The median age of the study group was 41 years (range, 24 to 68 years). There were 8 males and 3 females. In total, 7 patients were diagnosed with UCD and 4 patients with MCD. The hyaline-vascular variant was the most common histology in both UCD and MCD. Among the 7 patients with UCD, 5 patients underwent excision, 1 patient underwent debulking followed by radiotherapy and 1 patient received single agent rituximab. Of the patients with UCD, 6 had a complete response (CR) and 1 patient had a partial response (PR). All 4 patients with MCD received systemic treatment, which included single agent rituximab (2 patients), rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (RCHOP) (1 patient) and CHOP (1 patient). Among the patients with MCD, 1 patient attained a CR, 2 patients had a PR and 1 patient succumbed. The 3-year survival rate for the study population was 91%. In summary, CD is a rare disease occurring in immunodeficient patients. UCD is more common and is associated with better outcomes. Surgery is the mainstay of management in UCD whereas MCD requires combination chemotherapy.

A Prospective Single-Arm Study of Melphalan, Prednisolone and Lenalidomide (MPL) as First Line Treatment in Elderly Patients with Multiple Myeloma – An Institutional Study

Introduction Multiple myeloma in the elderly population is rising in India. Such frail transplant-ineligible patients are less frequently included in clinical trials. Moreover, novel agents are not accessible to everyone. Melphalan-based chemotherapy regimens are frequently used in elderly myeloma patients. Our study revisited the role of melphalan, prednisone, and lenalidomide (MPL) as front-line therapy in this subgroup of patients.

Objective The aim of this study was to determine the response, tolerance, and outcome of MPL in elderly patients with newly diagnosed multiple myeloma.

Materials and Methods This prospective study was conducted at the Department of Medical Oncology at a tertiary cancer center during January 2012 to September 2013. Newly diagnosed patients with multiple myeloma >60 years who were transplant ineligible formed the study subjects. Eligible patients received oral melphalan 0.18 mg/kg from D1 to 4, prednisone 2 mg/kg from D1 to 4, and lenalidomide 10 mg from D1 to 21 q28 days. Patients who achieved complete response/very good partial response (CR/VGPR) after 6 cycles of MPL received maintenance with lenalidomide 10 mg from D1 to 21 q28 days (MPL-L) until progression or 1 year whichever was earlier. Quality of life was assessed using the Eq. 5D questionnaire.

Results Out of 46 patients, 25 were males and 21 were females. Median age was 67 years (range: 60—83 years). Majority had immunoglobulin G myeloma, followed by immunoglobulin A subtype. The median quality of life score at baseline was 50 (range: 30–70). Forty patients completed six cycles of MPL. The main toxicity was grade 1 to 2 hematological. There were no treatment-related deaths. Twenty-two (55%) achieved CR, 5 (13%) achieved VGPR, 4 (10%) achieved partial response, 6 (15%) achieved stable disease, and 3 (7%) had progressive disease. Twenty-seven patients received lenalidomide maintenance. At a median follow-up of 55 months, the 2- and 5-year progression-free survival was 60 and 18%, respectively. The overall survival at 2 and 5 years were 80 and 53%, respectively. The median number of subsequent lines of treatment was 2 (range: 1–4). The quality of life was improved and preserved in all study subjects. At 8 years, three patients had second malignant neoplasms and seven are alive.

Conclusion MPL-L is a well-tolerated and effective regimen in elderly myeloma with good overall response rates.

Histiocytic Sarcoma: Clinical Features and Outcomes of Patients Treated at a Tertiary Cancer Care Center

Histiocytic sarcoma (HS) is an extremely rare histiocytic disorder of unknown etiology. It is not a true sarcoma and is named so, due to the pathological resemblance to mature histiocytes. The clinical presentation of HS is diverse and is related to the involved organs. Due to its aggressive nature, with poor prognosis and lack of a standard treatment regimen of choice, its diagnosis and management pose a challenge to the clinician. Limited literature is available on the management of this entity. Here, we report four patients with HS, diagnosed over 15 years in a tertiary cancer center, with varied clinical presentation, management, and outcomes. The first patient presented with a localized unresectable esophageal mass. He was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) combination chemotherapy and attained complete remission. The second patient had a painless mass of the hand, treated with wide excision and adjuvant Radiotherapy. She is disease-free for the past 12 years. The third patient had presented with an anterior mediastinal mass. He had progressive disease on chemotherapy. The fourth patient had multifocal disease with generalized lymphadenopathy. She was treated with CHOP chemotherapy and is now disease-free at 13 months. To summarize, the patients with the localized resectable disease did well, with surgical excision and adjuvant radiotherapy, while patients with the multifocal disease did well on CHOP chemotherapy. The take-home message from this case series is - CHOP off whenever you can and if not give CHOP to chop off the disease.

Serum Free Light Chain Assay as a Prognostic Marker in Patients with Aggressive B-Cell Non-Hodgkin's Lymphoma: Impact on Survival Outcome

T.M. AnoopBackground  The role of serum free light chain (FLC) as a prognostic biomarker in lymphoproliferative diseases is being increasingly studied. In this study we present the 5-year survival outcome for patients with aggressive B-cell non-Hodgkin's lymphoma (NHL) and their relation to FLC and other known prognostic markers. Materials and Methods  This is a prospective study conducted in patients diagnosed with aggressive B-cell NHL. Serum FLC level and ratio were estimated prior to initiation of treatment. Results  A total of 100 patients were included in the study from December 2013 to December 2015 with a median age of 53 years. Thirty-eight patients (38%) had elevated FLC level of which 26% were polyclonal and 12% were monoclonal elevations. Abnormal FLC ratio was noted in 12% patients. Median follow-up duration of the study was 75 months. Five-year relapse-free survival (RFS) for the study population was 54.4%. Five-year RFS was 64.1% for early stage and 48.2% for advanced stage diseases ( p  = 0.05). The RFS was significantly better in age less than 60 years (59.5% vs 43.8%, p  < 0.001). Five-year overall survival (OS) was 61.3%. OS was significantly better in younger patients (73.6% vs 33.4%, p  < 0.001), with International Prognosis Index score of 0 to 2 (87.4% vs 26.7%, p  < 0.001). Patients with elevated FLC had inferior RFS (50% vs 71.4%, p  = 0.04). Abnormal FLC ratio also strongly corresponded to inferior RFS (54.5% vs 66.2%, p  = 0.001). OS was also significantly inferior in patients with abnormal FLC ratio (72.6% vs 63.6%, p  = 0.001). Conclusion  In patients with newly diagnosed aggressive B-cell NHL, elevated FLC levels and abnormal FLC ratio were significantly associated with inferior survival.

Primary Extranodal Lymphomas: A Five Year Retrospective Study from a Tertiary Care Cancer Centre, Kerala, India

Introduction: Primary Extranodal Lymphomas (pENLs) are defined as lymphomas with dominant extranodal involvement with no or minor involvement of lymph nodes after routine staging procedures. The present study highlights the profile of pENLs in Kerala, South India which is not yet reported in literature. Aim: To study the frequency, distribution and histopathology profile of pENLs diagnosed in a tertiary care cancer centre. Materials and Methods: This was a cross-sectional study done in a tertiary care cancer centre in Kerala, Southern India for a period of five years. All the cases of pENLs diagnosed during this five year period which fulfilled the inclusion criteria were included in this study. These 3,357 cases were reviewed and classified according to the 2017 revised 4th edition World Health Organisation (WHO) classification of Tumours of Haematopoietic and Lymphoid tissues. Data was summarised using descriptive statistics. The frequency, distribution and histopathology features of pENLs were studied. Results: A total number of 3,357 lymphomas were diagnosed at the centre during this period. Non Hodgkin lymphomas (NHLs) constituted 2610 (78%). pENLs constituted 477 cases which included two cases of classical hodgkin lymphomas. Primary extranodal NHL (n=475) constituted 18.2% of NHL. Diffuse large B-cell lymphoma, Not Otherwise Specified (NOS), (DLBCL, NOS) was the most common histologic subtype (173 cases, 36%) followed by Mucosa Associated Lymphoid Tissue (MALT) lymphoma (77cases, 16%). Most common site of presentation were Gastrointestinal Tract (GIT) (117 cases, 24%) and Head and Neck region (HN) (117 cases, 24%). Conclusion: DLBCL, NOS was the most common subtype. GIT and HN region was the most common site of pENLs in present study. The frequency of pENLs in present study was comparable to few other Indian studies but was lower than Far Eastern studies. The frequency of Adult T-cell leukaemia/ Lymphoma (ATLL) was high which was not mentioned in similar studies on pENLs from India.

Hematolymphoid Neoplasms in Serous Effusions: Morphological Spectrum, Distribution, and Role of Ancillary Techniques—A Retrospective Analysis of 75 cases

Introduction Involvement of body fluids can occur at the time of diagnosis or during the disease course of hematolymphoid neoplasms. Cytodiagnosis of malignant effusion is important in effective clinical management.

Objectives (1) The aims of the study were to determine the frequency of distribution of various hematolymphoid neoplasms involving body fluids, (2) to study the morphology of hematolymphoid neoplasms in fluids, and (3) to assess the role of ancillary techniques in the diagnosis.

Materials and Methods In this retrospective study, all cases of hematolymphoid neoplasms involving body fluids diagnosed from January 2016 to December 2018 were evaluated.

Results During the 3-year period, there were 75 cases of hematological malignancies involving body fluids. These included 48 male patients and 27 female patients. Pleural fluid was involved in majority of cases (56 cases; 74.67%), followed by ascitic fluid (17 cases; 22.67%), and pericardial fluid (2 cases; 2.67%). High cellularity, monotonous population of cells, high nuclear-cytoplasmic (N/C) ratio, indentation/irregularity of nuclear membrane, immature chromatin/irregular clumping of chromatin, increased mitosis, and karyorrhexis were the key features which helped to differentiate between reactive and neoplastic processes. There were 35 cases of B-cell neoplasms, 33 cases of T-cell neoplasms, and seven cases of myeloid neoplasms involving body cavity fluids. T-lymphoblastic lymphoma was the most common subtype (29 cases; 38.7%), followed by diffuse large B-cell lymphoma (DLBCL) (12 cases; 16%). In 53 cases, effusion was present in the initial presentation itself. Initial diagnosis was made in effusion cytology in 25 cases (33.33% of the total), with the help of flow cytometry in 20 cases, and immunohistochemistry (IHC) in cell blocks in five cases.

Conclusion Diagnosis of hematolymphoid neoplasms in body fluids based on correlation with clinical details, critical evaluation of cytology findings, and comparison with previous diagnosis along with the judicious use of ancillary techniques helps in deciding an early treatment plan.

Outcome of Treatment in Elderly Myeloma—A Single-Centre Experience

Introduction Multiple myeloma (MM) accounts for approximately 1% of all cancers and 10% of all hematologic malignancies. In our institution, we see around 200 patients with myeloma every year. We present our experience with multiple myeloma in the patients aged more than 60 years.

Objectives This is a retrospective study of 300 newly diagnosed multiple myeloma patients above 60 years of age treated in the Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India, during the period between 2014 and 2017. The medical records of the patients were studied and following data were collected: demographic and clinical details, diagnostic and staging workup, primary treatment, response assessment, relapse, and survival. Survival was estimated using the Kaplan–Meier method.

Results A total of 300 patients were included in the study. The median age was 66 years with a male-to-female ratio of 1.4:1. The common clinical presentations were backache (134), fatigue (49), lower respiratory infection (20), and paraparesis (14). Monoclonal protein was immunoglobulin (Ig)-G in 199 patients (66.6%), IgA in 52 patients (17.4%), IgM in 2 patients, and IgD in 1 patient. Light-chain disease was seen in 42 patients (14%). One hundred and sixty patients (53.5%) had ISS stage III. Only 285 patients received treatment, of which 203 (67.8%) received bortezomib-based regimen, - bortezomib and dexamethasone (BD; 33.4%); bortezomib, lenalidomide, and dexamethasone (BLD; 19.7%); bortezomib, cyclophosphamide, and dexamethasone (VCD; 8.7%); bortezomib, thalidomide, and dexamethasone (BTD; 2.3%); and bortezomib, melphalan, and prednisolone (3.7%). Nonbortezomib-based regimens used were melphalan and prednisolone (MP) alone or with thalidomide or lenalidomide (15%), lenalidomide and dexamethasone (LD; 10.4%), and thalidomide and dexamethasone (TD; 2%). Response assessment was done as per IMWG guidelines. Fifty-seven (26.3%) patients achieved complete response (CR), 94 (43.3%) achieved very good partial response (VGPR), 19 (8.8%) attained partial response (PR), 15 (5.6%) had stable disease, and 46 (15.4%) developed progressive disease. With bortezomib-based regimens, 119 patients (58.3%) achieved CR/VGPR, and with non-bortezomib based regimens, 42 patients (51.2%) achieved CR/VGPR. One hundred and forty-three patients (47.8%) received maintenance therapy of which 79 received maintenance with bortezomib, 49 with lenalidomide, and 15 with thalidomide. The average duration of maintenance was 24 months. Second-line chemotherapy regimens were used in 37 patients. Agents used were MP, LD, TD, and VCD. With second-line treatment, 15 patients achieved VGPR, 10 patients achieved partial response, and 25 patients developed progressive disease. Third-line chemotherapy regimens were used in 22 patients and the regimens used were pomalidomide and dexamethasone, MP, TD, LD, vincristine, doxorubicin, and dexamethasone and carfilzomib and dexamethasone. At a median follow-up of 34 months, the 2-year overall survival (OS) was 68%. The median progression-free survival was 21 months. The 2-year OS for patients receiving initial bortezomib-based regimen was 67.8% and non-bortezomib based regimen was 68% which was similar.

Conclusion In this study, CR/VGPR rates and 2-year OS in patients treated with bortezomib and non-bortezomib based regimens were not statistically significant.

Early Normalization of Free Light Chains Predicts Better Outcomes in Patients with Multiple Myeloma

Background: The half-life of free light chain is short and can be used as an early marker for tumor response in patients with multiple myeloma [MM]. This prospective study is aimed at evaluating whether early light chain response can predict response to treatment in patients with MM.

Materials and Methods: Thirty six patients with a diagnosis of MM and with an abnormal to normal light chain ratio of > 10 were included in this study.

Results: The median age at presentation was 56 years. Fourteen patients had lambda light chain disease, whereas 22 patients had kappa light chain disease. Twenty-four patients [66.6%] had reduction of abnormal to normal light chain ratio to < 10 after 2 cycles, of whom 15 [62.5%] achieved a CR or VGPR after 6 cycles. Among 12 patients who did not have reduction of abnormal to normal light chain ratio to < 10, only 1 patient achieved CR while 11 patients [91.6%] achieved a PR or less[Fishers exact p=0.004]. Median follow-up was 13 months. Median progression-free survival for the entire cohort was 15 months. One-year Progression-Free Survival was 77% vs 57.1%, [p= 0.008], respectively for patients with early normalization and those who did not show early normalization.

Conclusion: Early light chain response after 2 cycles of chemotherapy is a good predictor for treatment response in patients with MM treated with bortezomib based chemotherapy. Treatment intensification based on early light chain response merits further evaluation in a prospective trial

Hypereosinophilia: A rare presentation of acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) presenting as peripheral blood hypereosinophilia is very rare and the incidence is <1%. The characteristic feature of patients with ALL and hypereosinophilia is the absence of blasts in peripheral blood, and this might lead to misdiagnosis of ALL. It is important for clinicians and pathologists to be aware of this uncommon initial presentation of ALL to avoid delay in diagnosis. We report a 37-year-old man who presented with fever and respiratory symptoms and was found to have hypereosinophilia in peripheral blood. His bone marrow and lymph node biopsies were diagnostic of ALL.

Isolated Intracranial Myeloid Sarcoma Occurring as Relapse in Acute Myeloid Leukemia

Myeloid sarcoma (MS) or chloroma is a rare extramedullary tumor composed of extramedullary proliferation of blasts of granulocytic, monocytic, erythroid, or megakaryocytic lineage occurring at sites outside the bone marrow. MS occurs in 2%-8% of patients with acute myeloid leukemia (AML), sometimes it occurs as the presenting manifestation of relapse in a patient in remission. We describe the case of a young male with AML in remission for 6 years presenting with central nervous system symptoms. Magnetic resonance imaging showed an extra-axial altered intensity lesion in the parasagittal parietal region, infiltrating anterosuperiorly into anterior falx, and posterosuperior aspect of the superior sagittal sinus. A biopsy from the lesion was diagnostic of MS which was positive for myeloperoxidase. He did not have any other sites of disease. He has received chemotherapy with FLAG (Fludarabine, Cytosine arabinoside) followed by cranial irradiation and is in complete remission.

Histone chaperone HIRA dictate proliferation vs differentiation of chronic myeloid leukemia cells

Abnormal proliferation and disrupted differentiation of hematopoietic progenitors mark leukemia. Histone cell cycle regulator A (HIRA), a histone chaperone, regulates hemogenic to hematopoietic transition involved in normal hematopoiesis. But, its role remains unexplored in leukemia, a case of dysregulated hematopoiesis. Here, the Cancer Cell Line Encyclopedia database analysis showed enhanced HIRA mRNA expression in cells of hematopoietic and lymphoid origin with maximal expression in the chronic myeloid leukemia (CML) cell line, K562. This observation was further endorsed by the induced expression of HIRA in CML patient samples compared to healthy individuals and Acute Myeloid Leukemia patients. Downregulation of HIRA in K562 cells displayed cell cycle arrest, loss in proliferation, presence of polyploidy with significant increase in CD41+ population thereby limiting proliferation but inducing differentiation of leukemia cells to megakaryocyte fate. Induced megakaryocyte differentiation of mouse Hira-knockout hematopoietic progenitors in vivo further confirmed the in vitro findings in leukemia cells. Molecular analysis showed the involvement of MKL1/GATA2/H3.3 axis in dictating differentiation of CML cells to megakaryocytes. Thus, HIRA could be exploited for differentiation induction therapy in CML and in chronic pathological conditions involving low platelet counts.

Cytomegalovirus Retinitis Occurring as a Complication of HyperCVAD Chemotherapy: Report of Two Cases

Cytomegalovirus (CMV) retinitis is usually diagnosed in patients with acquired immunodeficiency syndrome and in solid organ and hematopoietic stem cell transplant recipients. It produces a characteristic necrotizing retinitis which is a sight-threatening condition in these patients. CMV retinitis occurs rarely in patients undergoing only chemotherapy, and very few cases have been reported during the maintenance phase of acute lymphoblastic leukemia (ALL) in children. We report two patients, one with ALL and the other with Burkitt’s lymphoma on HyperCVAD chemotherapy developing CMV retinitis during the course of treatment. Both patients were treated with intravenous ganciclovir, oral valganciclovir and intravitreal ganciclovir. Both patients are alive in remission at 60 and 40 months, respectively, with preservation of normal vision.

Ewing's sarcoma of the trachea in an adolescent girl

Primitive neuroectodermal tumors (PNET) are aggressive neoplasms of neuroectodermal origin. Although they are known to arise in a host of locations, involvement of the trachea has rarely been reported. We describe an adolescent girl who presented with stridor and was diagnosed with PNET of the trachea. She is in remission following treatment with combination chemotherapy and local radiotherapy.

Subcutaneous panniculitis-like T-cell lymphoma

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare form of skin lymphoma that is localized primarily to the subcutaneous adipose tissue without involvement of the lymph nodes. Clinically, the skin lesions mimic lipomas, while histologically they resemble panniculitis. We report a case of a young woman with SPTCL. She achieved complete remission after combination chemotherapy.

Blood group change in acute myeloid leukemia

Blood group antigens are either sugars or proteins found attached to the red blood cell membrane. ABO blood group antigens are the most clinically important antigens because they are the most immunogenic. As red blood cell antigens are inherited traits, they are usually not altered throughout the life of an individual. There have been occasional case reports of ABO blood group antigen change in malignant conditions. We report two such cases of ABO antigen alteration associated with acute myeloid leukemia. These patients had suppression of their blood group antigens during their leukemic phase, and the antigens were reexpressed when the patients attained remission.

Primitive neuroectodermal tumors of the kidney

Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET) rarely occurs as a primary renal tumor. The disease affects young adults and children and has an aggressive course. The clinical presentation and imaging of these tumors are nonspecific, and they often present at an advanced stage. We present the clinical features, imaging, diagnosis, and treatment of 7 cases of renal PNET (4 men, 3 women; median age, 32 years). Common presenting symptoms were flank or abdominal pain and a mass in the abdomen. On imaging, a large heterogenous infiltrating renal mass with areas of calcification, hemorrhage, and necrosis and tumor thrombus can give a clue to the diagnosis of renal PNET. Immunohistochemistry and molecular studies are essential to confirm the diagnosis. The prognosis of renal ES/PNET is generally poor. Radical nephrectomy combined with chemotherapy and radiotherapy is the standard treatment for renal PNET. An early and accurate diagnosis is crucial for the proper management of these aggressive tumors.

Lymphoblastic lymphoma of the palate

Lymphoblastic lymphomas are neoplasms of immature or precursor lymphoid cells with no or limited bone marrow involvement, whose clinical presentation varies according to the immunophenotype. While mediastinal involvement is predominant in T-lymphoblastic lymphomas, B-lymphoblastic lymphomas frequently involve nodal sites. Extranodal presentation of B-lymphoblastic lymphomas is extremely rare. We present the case of a 49-year-old man with B-lymphoblastic lymphoma of the hard palate. The patient was treated with the R-Hyper CVAD regimen and is on maintenance chemotherapy. This is the first reported case of B-lymphoblastic lymphoma arising in the hard palate.

B-lymphoblastic lymphoma of the rectum

Lymphoblastic lymphoma is a neoplasm of immature cells committed to the B-cell or T-cell lineage. B-lymphoblastic lymphoma usually involves lymph nodes and extranodal sites, such as the skin, bone, and soft tissue. The rectum is a very rare site of involvement in B-lymphoblastic lymphoma. We describe a 26-year-old man who presented with bleeding per rectum and fecal incontinence. Endoscopy showed a large nodular friable lesion narrowing the entire rectal lumen. Biopsy was diagnostic of B-lymphoblastic lymphoma. He was started on chemotherapy with the Berlin-Frankfurt-Münster protocol and achieved complete remission after induction chemotherapy. This is the first report of B-lymphoblastic lymphoma presenting as a rectal lesion in the world literature.

Mixed phenotypic acute leukemia with leukemia cutis and neuroleukemiosis

Leukemia cutis and neuroleukemiosis are two rare extramedullary manifestations of acute leukemia. We report a 32-year-old woman with multiple skin lesions and painful peripheral neuropathy. Bone marrow biopsy and skin biopsy confirmed the diagnosis of mixed phenotypic acute leukemia. After induction chemotherapy, she attained marrow remission, her skin lesion resolved completely, and her neurologic symptoms significantly improved.

Lymphoblastic Lymphoma Presenting as Bilateral Ovarian Mass in an Adolescent Girl

BACKGROUND

Lymphomas rarely involve the genital tract and non-Hodgkin lymphoma (NHL) presenting as ovarian tumor is rare. Precursor B-cell lymphoblastic lymphoma arising from the ovary is extremely rare and to our knowledge, only 5 cases have been reported in the literature.

CASE

A 15-year-old girl presented with bilateral ovarian masses, which, on biopsy proved to be precursor B-cell lymphoblastic lymphoma. She was treated with a Berlin-Frankfurt-Munster 90 protocol and she is alive in complete remission for more than 10 years.

SUMMARY AND CONCLUSION

NHL of the ovary should also be considered as a differential diagnosis in adolescent and young adults with ovarian masses. Attempt to make a preoperative diagnosis is crucial because ovarian NHL responds well to chemotherapy and has a good prognosis.

Isodicentric Philadelphia Chromosome: A Rare Chromosomal Aberration in Imatinib-Resistant Chronic Myelogenous Leukemia Patients - Case Report with Review of the Literature

The BCR-ABL1 fusion gene derived from the Philadelphia chromosome, resulting from a classical translocation event t(9;22)(q34.13;q11.23), is responsible for the pathogenesis of chronic myeloid leukemia (CML) in more than 90% of the patients. The isoderivative chromosome 22, ider(22), and relative amplification or duplication of the BCR-ABL1 gene have been considered as one of the major reasons associated with the resistance to chemotherapy with imatinib mesylate, but the data remain unclear. GTG-banding together with FISH were performed to identify the presence of the ider(22) chromosome. Reverse transcription-polymerase chain reaction (RT-PCR) for the detection of BCR-ABL1 fusion transcripts and BCR-ABL1 kinase domain mutation analysis were carried out in this study. Conventional and molecular cytogenetic analysis on metaphase chromosomes confirmed the presence of ider(22) chromosomes in both patients. Molecular characterization revealed the presence of a 210-kDa BCR-ABL1 type b3a2 and lack of mutations at the kinase domain region on the fusion product in both patients. The occurrence of the ider(22) chromosome could be considered as an important marker correlated with the aggressive progression of CML as well as the emergence of drug-resistant cell clones.

Ewing's Sarcoma of the Cranial Vault

Primary Ewing's sarcoma (EWS) arising from cranial bones is rare and accounts for only 1%–4% of all EWS. We report the case of a 15-year-old girl with EWS of the frontoparietal region of the skull. She underwent excision following which she received combination chemotherapy with vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide, and VP16 and local radiation of 45 Gy. She is alive in complete remission at 40 months.