Response to ifosfamide, carboplatin, etoposide (ICE) vs. dexamethasone, cytarabine cisplatin (DHAP) as salvage chemotherapy in patients with relapsed/refractory lymphoma

Background

Non-Hodgkin's lymphomas are the eighth-most prevalent malignancy in females and the eleventh in males. No research has been conducted comparing dexamethasone, cytarabine cisplatin (DHAP) vs. ifosfamide, carboplatin, etoposide (ICE) as salvage chemotherapy regimens for relapsed or refractory lymphomas in Pakistan. This study aims to compare the response of ICE vs. DHAP as salvage chemotherapy in patients with relapsed/refractory lymphomas.

Methods

A prospective follow-up study was conducted at the tertiary care hospital in Karachi, Pakistan, from 2019 to 2020. A total of 58 lymphoma patients after first-line chemotherapy were included in the study. The treatment response was evaluated after two cycles of salvage chemotherapy using WHO assessment criteria, and Cox regression was used to determine the hazard ratios considering the P value ≤0.05 significant.

Results

Of 58 patients, 19 (32.8%) patients achieved complete response (CR), and 8 (13.8%) patients achieved partial response (PR), with an overall response rate of overall response rate of 46.6%. In the ICE group, the response was assessed in 19 patients. Overall response was 42.1%, CR was 31.6% and PR was 10.5%. In the DHAP group, response was evaluated in 39 patients, the overall response rate was 48.7%, CR was 33.3% and PR was 15.4%. The hazard ratio for survival in patients with relapsed/refractory lymphomas who received DHAP was 1.40 times (95% CI: 1.27-3.63, P=0.001) compared to patients who received ICE as salvage chemotherapy.

Conclusion

DHAP seems to have a marginally better overall response rate than the ICE regimen in patients with refractory or relapsed lymphoma. However, the toxicity profile of patients in both groups was similar.

COVID-19 and thrombotic thrombocytopenic purpura: A case report

The clinical presentation of COVID-19 varies from being asymptomatic to developing acute respiratory distress syndrome and multi-organ dysfunction. The diffuse microvascular thrombi in multiple organs seen in the autopsy of COVID-19 patients are similar to that of thrombotic microangiopathy (TMA). TMA is characterised by thrombus formation in the microvasculature with laboratory findings of microangiopathic haemolytic anaemia (MAHA) and thrombocytopenia. A 49-year-old male presented to the Aga Khan University Hospital, Karachi. with fever, diarrhoea, altered level of consciousness, and a positive nasopharyngeal swab for SARS-CoV-2. He developed severe thrombocytopenia, MAHA with 5.8% schistocytes, and worsening renal function on the sixth day of admission. Diagnosis of thrombotic thrombocytopenic purpura (TTP) was established based on PLASMIC score, and he was successfully treated with intravenous (IV) Methylprednisolone, therapeutic plasma exchange and IV Rituximab. The case emphasises the need to keep TTP in the differential diagnosis when a patient with COVID-19 develops severe thrombocytopenia, acute renal failure, or impaired level of consciousness, since prompt diagnosis and treatment is necessary to gain favourable outcome.

Outcomes of patients with double/triple expressor diffuse large B-cell lymphoma (DLBCL) treated with R-DA-EPOCH/R-CHOP: A single-center experience

In Pakistan 76.4% of all NHLs to be diagnosed as DLBCLs. The survival of R-CHOP is better compared to the DA-REPOCH treatment regimen. A prospective follow-up study was conducted with 113 patients to study the outcomes of treatment. Multivariable cox-proportional hazard model was used to estimate the hazard ratios in patients receiving these treatment regimens considering p-value ≤0.05 significant. The survival rate among double/triple expressor lymphoma patients received R-DA-EPOCH was 82.8%, and 83.3% received R-CHOP. For double/triple expressor lymphoma patients received R-DA-EPOCH. The findings of our study demonstrated that the survival rate in both R-CHOP and R-DA-EPOCH is mostly similar.

Outcome of adult patients with acute lymphoblastic leukaemia receiving the MRC UKALL XII protocol: a tertiary care centre experience

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) is a heterogeneous group of lymphoid neoplasm resulting from the proliferation of malignant lymphoid cells. We aimed to study the outcome of adult patients with ALL receiving the Medical Research Council UKALL XII protocol.

METHODS

This was a retrospective study conducted at Aga Khan University Hospital from January 2001 to December 2008. The medical records of all adult patients were reviewed and analysed for clinical, morphological and immunological features at presentation and impact on treatment outcomes. Multivariate analysis and survival studies were performed using Kaplan-Meier statistics.

RESULTS

The total number of patients was 54, with a male to female ratio of 3.4:1 and a median age of 28 years. Common presenting symptoms were fever (n is 49) and bleeding (n is 14). 38 patients had haemoglobin less than 10 gms/dl, 21 had white blood cell (WBC) count of 50 × 10E9/L or more, and 35 had lactate dehyrogenase more than 1,000 IU. Morphologically, FAB-L2 was the commonest subtype, with 38 patients with B-ALL and eight with T-ALL. Multivariate analysis showed that age above 30 years, male gender, WBC count above 50 × 10E9/L and T-ALL subtype were independent risk factors for poor survival. 46 (85 percent) patients achieved complete remission. The median survival was 12.3 months. At the end of five years, 16 patients were alive, two were alive with disease and 14 were in complete remission.

CONCLUSION

Overall survival and relapse rates in our study were comparable to those reported internationally.

Transabdominal gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices

Fifty consecutive unselected patients presenting with acute haematemesis and melaena from endoscopically confirmed bleeding oesophageal varices were treated by one-stage transabdominal oesophageal transection with gastro-oesophageal devascularization and splenectomy. According to Child's classification, 15 were Grade A, 29 Grade B and six Grade C. The mortality rate was 10 per cent. Postoperative complications included gastric fundal leak (4 per cent), pleural effusion (4 per cent), subphrenic abscess (2 per cent), atelectasis (2 per cent) and pneumothorax (2 per cent). Although five patients (10 per cent) complained of transient dysphagia during follow-up, only one (2 per cent) presented evidence of stricture at the site of oesophageal transection. Clinical encephalopathy was not present in the surviving patients in the postoperative period. No recurrence of bleeding has been recorded in the surviving patients over a follow-up period of 2-3 years.

Histiocytosis X of the thyroid masquerading as thyroid carcinoma

The case of a 28-year-old woman with histiocytosis X confined to the thyroid is described. A partial thyroidectomy specimen from this patient was at first interpreted as showing poorly differentiated thyroid carcinoma. Subsequent investigations, including electron microscopy, revealed the true nature of the lesion. Even on retrospective examination, the two conditions can simulate each other very closely and may be easily confused.

Appendicitis and schistosomiasis

A retrospective clinical and pathological study of 15 cases associated with schistosomiasis drawn from 1920 patients undergoing appendicectomy is discussed. The average age of the patients was 31.6 years with a 12:3 male predominance. Hepatomegaly, past or present jaundice, or splenomegaly were not observed. One patient had a previous history of similar right lower quadrant pain for several days. Eighty per cent of the cases showed an inflammatory reaction on pathological examination. In the remaining 20 per cent no inflammation was seen, but there was severe congestion mainly involving the subserosal blood vessels. Schistosoma haematobium was present in 80 per cent of the cases.