Extramedullary Plasmacytoma in a Patient with Aids: Report of a Case and Review of the Literature

Human immunodeficiency virus (HIV) is likely to play a role in the onset of plasma cell tumors (PCT). In fact, HIV could be involved in plasmacytomagenesis in several ways: it has the ability to lessen the immunosurveillance to such a degree as to impair the immune response against tumor cell growth. This decreased immunosurveillance could further facilitate the transforming malignant role of possible Epstein-Barr virus (EBV) infection occurring in this setting. Lastly, a murine retrovirus has been shown to be able to accelerate plasmacytomagenesis in mice, thus indicating that these viruses may be directly involved in the onset of PCT. According to cases previously reported in the literature, the clinical features of this case of HIV-associated PCT were more aggressive and the survival was shorter than expected for PCT cases in the general population. Further, the pattern of alteration of gam-maglobulinemia differed in this setting. These alterations strongly suggest a direct role of HIV in PCT. Further in-depth investigations are therefore warranted to elucidate this issue.

Efficacy and safety of echoguided catheterisation approach in oncological and hematological patients. Report on 843 consecutive patients

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Background: A central venous catheter (CVC) represents the most frequently adopted intravenous line for patients undergoing infusional chemotherapy, bone marrow transplantation (BMT) and parenteral nutrition. The aim of this study was to explore the feasibility and safety of CVC insertion under ultrasound (US) control. US offers the advantage of real-time, multiplanar imaging as well as Doppler analysis. Methods: The echoguided approach allowed us to insert CVC in right supraclavicular site nearby the clavicular head of sternocleidomastoid muscle. Using a 7.5-MHz probe we were able to perform a real time control of the hip of the needle while it was inserted in the last side of internal jugular vein. At the end of the procedure chest Rx was executed to evaluate CVC position and to detect pneumotorax. Mainly Sekalon Seldy, Becketon Dickinson was employed. For PBSC collection, 14-gauge Arrow double lumen revealed to be highly efficacious (46 PBSC collections, no one failure). Results: From November 1999 to December 2006 the echoguided CVC insertion method was applied 1003 times in 843 patients. The procedure was applied 288 times in haematological malignancies, in 698 solid tumors, in 3 neurological autoimmune diseases. Among solid tumors colon carcinoma was the first indication, while gastric carcinoma the second. Among haematological patients: non-Hodgkin lymphoma was the first indication, then acute leukemia. Ten patients underwent allogenic BMT and 92 autologous BMT. Nine in 1003 procedures failed (1%). Failures were caused by: arterial puncture in 3, CVC dislocation in 1, vein collapse in 3 and no efficacious “eco window” in 2. No pneumotorax was registered. The safety of this procedure was confirmed by 35 catheterisations obtained with platelets under 20000/μl, by 7 procedure with prothrombin activity under 50%. In 44 patients catheter was inserted with neutrophil count below 100/μl and in 66 below 500/μl without any increase in infections. Mean time of catheter permanence was 151 days with 1,7 infectious events every 1000 days of permanence. Symptomatic deep veins thrombotic complications were 9 (1%). Conclusions: This procedure is safe, cheap with high accuracy and success rate, and above all US-guidance avoids pneumothorax.

No significant financial relationships to disclose.

Antiviral treatment in Hepatitis C Virus (HCV)- related low grade non-Hodgkin lymphoma: An update of a multicenter study

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Background: HCV is largely diffuse in North-western Europe and U.S.A. It has been shown to play a role both in hepatocellular carcinoma and in B-cell non-Hodgkin lymphoma (B-NHL). Up to now the exact biological mechanisms that could explain the lymphomagenic role of the virus are under study. Methods: We have previously published a series of 13 patients, affected by low grade B-cell NHL and characterized by an indolent course (i.e. doubling time less than 1 year, no bulky disease), who underwent antiviral treatment only with peghilated interferon and ribavirin (peghilated interferon 50–70 microgram weekly, ribavirin 1000–1200 mg daily). Now we report the second update of this study. Up to now 17 patients are evaluable with a mean follow up of 12.1 ± 8 months (range 2–31 months). Results: Eight patients experienced complete or good partial haematological response that has lasted up to now with a mean follow up of 19,5 months, among them 3 splenic marginal lymphomas, 2 nodal marginal, 1 follicular lymphoma, 1 plasmocytoid and 1 marginal extranodal lymphoma. Three other patients achieved a long lasting partial response. The only one relapse (marginal nodal lymphoma) occurred about one year after the end of treatment, hematological relapse happened together with viral relapse, the lymphoma reappeared as highly chemo resistant high grade lymphoma, and two months later the patient died. Interestingly complete and good partial responses were more likely to be seen in viral genotype 2 (p = 0.04) and were strictly related to the decrease of viral load under treatment (p = 0.005). Toxicity causes the stop of the treatment in 3 patients; however one of them was able to achieve complete hematological response. Time to achieve hematological response was quite long (mean 8 ± 4.5 months). Conclusions: This kind of experience strongly provides a role for antiviral treatment in patients affected by HCV related low grade B-cell NHL. Especially viral genotype 2 infection may be considered a good prognostic marker for hematological response as well as decrease of viral load under treatment. Toxicity in our hands was however significant and further experiences are warranted in order to better modulate antiviral therapy doses.

No significant financial relationships to disclose.

Oncologic Emergencies Secondary to Advanced Colorectal Cancer Successfully Treated with Oxaliplatin/5-Fluorouracil/Leucovorin: Report of Three Cases

Metastatic/advanced colorectal cancer is considered a resistant disease and oncologic emergencies secondary to advanced disease may be regarded with a nihilistic attitude. The objective of this report is to emphasize the efficacy of the oxaliplatin/5-fluorouracil/leucovorin regimen (FOLFOX-4) in three patients presenting oncologic emergencies secondary to advanced colon cancer. The first case was a 40-year-old man with severe respiratory insufficiency due to massive carcinomatous lymphangitis; subsequently a cecal adenocarcinoma was diagnosed. The patient's conditions became life-threatening and he was admitted to the intensive care unit. The second case was a 41-year-old woman presenting with fever, abdominal mass and pain. Ultrasound and CT-scan revealed two hepatic masses (13 x 15 and 15 x 20 cm), diagnosed as liver metastases from colon cancer. The patient's condition deteriorated with intestinal obstruction secondary to the large left liver mass. The third case was a 58-year-old woman presenting with hepatic mass, fever and weight loss. Ultrasound and CT-scan showed a liver lesion occupying the right lobe (12 x 14 cm). Ultrasonically-guided biopsy and colonoscopy showed liver metastases from cecal cancer. A 5-fluorouracil/leucovorin regimen failed to improve her clinical condition and she had disease progression, inferior vena cava neoplastic thrombosis and right hydronephrosis. All three patients rapidly improved after a few cycles of oxaliplatin-containing chemotherapy. These cases demonstrate that even patients with advanced colorectal cancer presenting with oncologic emergencies and life-threatening conditions can be successfully treated with the FOLFOX-4 regimen.

Focal liver lesions in non-Hodgkin's lymphoma: investigation of their prevalence, clinical significance and the role of Hepatitis C virus infection

Imaging techniques like ultrasonography (US) or computed tomography (CT) allow full liver scanning and the accurate detection of focal lesions of the liver parenchyma. The occurrence of such lesions in concomitance with non-Hodgkin's lymphoma (NHL), both at the onset of the disease and during follow-up, is of great significance, because it affects staging, prognosis and therapeutic choices. Moreover, the occurrence of focal liver lesions in the setting of a lymphoma is generally considered to be a marker of liver involvement. Nonetheless, data on the prevalence and clinical significance of focal liver lesions occurring in these clinical conditions are limited. Therefore, we retrospectively evaluated the prevalence, nature and clinical significance of focal liver lesions diagnosed by imaging techniques (US and CT) in 414 consecutive NHL patients. The nature of the lesions was established either by US-guided biopsy or by evaluation of the response to chemotherapy for the underlying disease and confirmed by clinical and US follow-up. Subtype of NHL (aggressive or indolent) and Hepatitis C virus (HCV) status were also considered. We detected 129 focal liver lesions (76 at onset and 53 during the follow-up). Hepatic involvement by NHL was found in 69 cases (53%). We observed 7 cases of Hepatocellular Carcinoma (HCC) and 3 cases of metastasis. At onset, only 39% of the detected lesions were due to lymphoma and 58% were benign. Conversely, 74% of the liver lesions detected during the follow-up were due to NHL while 15% to a malignancy other than NHL. All HCC cases occurred in HCV-positive patients with chronic liver disease. We concluded that the focal liver lesions detected at onset in NHL patients are frequently benign and unrelated to the underlying disease. Conversely, most focal liver lesions detected during the follow-up period are malignant and the possibility of HCC occurrence in HCV-positive patients should always be considered. Therefore, these lesions should undergo a full diagnostic work-up, including US-guided biopsy.

Ultrasound-guided fine needle biopsy of the spleen: high clinical efficacy and low risk in a multicenter Italian study

The aim of this study was to evaluate the clinical efficacy and safety of the ultrasound-guided fine needle biopsy (UG-FNB) of the spleen in a large population of patients. We collected retrospectively the findings concerning the application of UG-FNB of the spleen from eight Italian clinical centers that utilized this technique for at least ten years. A data schedule was sent to all centers to collect information about techniques, results, and complications of UG-FNB of the spleen. We analyzed 398 biopsy procedures both on focal lesions (257 cases) and on splenic parenchyma (141 cases). The overall accuracy was 90.9% for the series as a whole, 84.9% for cytological sampling, 88.3% for microhistological sampling, and 90.3% for both cytological and histological sampling (double biopsy). Tissue core biopsy yielded better overall accuracy in patients with suspected splenic involvement by lymphoma (90.9% vs. 68.5% for cytology). The complication rate was low (no death cases, less than 1% for major complications, and 5.2% for all complications). No predictive factors were able to detect high-risk situations. The operator's skill (higher number of performed procedures) was significantly related to better overall accuracy. Conversely, the complication rate was not affected. UG-FNB of the spleen is a very effective diagnostic procedure with low risk for the patient. Aspiration cytology and core needle biopsy showed similar diagnostic yields, except for the diagnosis of splenic lymphoma, in which core needle biopsy obtained better results.

Image-aided estimate of tumor burden in Hodgkin's disease: evidence of its primary prognostic importance

PURPOSE

To explore a more direct method for evaluating tumor burden (TB) in Hodgkin's disease (HD) and to verify its prognostic importance.

PATIENTS AND METHODS

The volume of TB at diagnosis was directly and retrospectively measured in 121 HD patients through images of the lesions recorded by computed tomographic (CT) scan of the thorax, abdomen, and pelvis for all deep sites of involvement and many superficial ones, and by ultrasonography (US) for the remaining superficial lesions.

RESULTS

The TB, which was obtained from the sum of the volumes of all the lesions measured on CT scans and US and normalized to body-surface area (relative TB [rTB]), showed a median value of 102.6 cm(3)/m(2) (range, 2.2 to 582.8). At multivariate analysis for prognostic value, rTB was the parameter that statistically correlated best with time to treatment failure (P = 2.2 x 10(-6)), followed by erythrocyte sedimentation rate (ESR) (P =.0003), and serum fibrinogen (P =.0112). The prognostic discrimination allowed by rTB alone proved to be clearly superior to that obtained with the score of the International Prognostic Factor Project. The rTB was found to be correlated with many clinical staging parameters (bulky disease, number of involved lymph node regions, serum lactate dehydrogenase, ESR, hemoglobin, Karnofsky index), but its predictability from these variables was low (R(2) =.668).

CONCLUSION

Relative TB is emerging as a strong prognostic factor in HD, more powerful than and largely independent of those hitherto known and used. Further studies are needed to confirm these results and exploit their clinical value, particularly the relationship among rTB, drug doses, and response.

Lomustine and melphalan cannot be replaced by cyclophosphamide and etoposide without reducing efficacy in MOPPEBVCAD chemotherapy for advanced Hodgkin's disease

BACKGROUND AND OBJECTIVES

To evaluate the feasibility, toxicity and preliminary results of a potentially less toxic variant of the MOPPEBVCAD chemotherapy regimen for advanced Hodgkin's disease: MOPPEBVCyED, in which cyclophosphamide and etoposide replace lomustine and melphalan, respectively, with the remaining components being unaltered.

DESIGN AND METHODS

The study was multicenter, prospective and randomized, and enrolled 67 patients with newly diagnosed stage IIB, III, IV Hodgkin's disease (62 were expected on the grounds of statistical considerations). Radiotherapy was restricted to sites of bulky involvement or to areas that responded incompletely to chemotherapy. Median follow-up was 48 months.

RESULTS

Comparing MOPPEBVCAD vs. MOPPEBVCyED, the results were as follows: complete remissions 35/35 vs. 30/32 (plus one partial remission and one disease progression); relapses 5 vs. 8; deaths 2 (one of myelodysplasia) vs. 2; delivered mean dose intensity (DI): lomustine 0.79+/-0.67 vs. cyclophosphamide 0.82+/-0.32; melphalan 0.80+/-0.13 vs. etoposide 0.86+/-0.18; average DI of the 7 drugs common to both regimens 0.73+/-0.10 vs. 0.83+/-0.11; all 9 drugs 0.75+/-0.13 vs. 0.84+/-0.09 (p=0.002); projected 5-year failure-free survival 0.79 vs 0.62; second cancers, two myelodysplasias vs. one carcinoma of the kidney. Toxicities were not statistically different except for heavier thrombocytopenia being recorded with MOPPEBVCAD.

INTERPRETATION AND CONCLUSIONS

The higher cumulative and single drug DI recorded with MOPPEBVCyED may reflect better short-term tolerability, but it does not lead to better disease control. Its late toxicity may be expected to be lower in the future but at present it does not seem to be a sufficient reason to substitute MOPPEBVCyED for MOPPEBVCAD.

The role of surgery in the treatment of gastrointestinal lymphomas other than low-grade MALT lymphomas

BACKGROUND AND OBJECTIVE

A bias in clinical investigations on gastrointestinal lymphomas is the lack of testing the intention to treat as to resection, emergency conditions at presentation and selection brought about by the evaluation of feasibility of surgery.

DESIGN AND METHODS

A prospective study involved 154 patients with gastrointestinal nodular or high-grade MALT lymphomas, 111 with a gastric and 43 with an intestinal presentation. The decision to resect or treat conservatively was left to clinicians, on condition that it was previously defined for each patient.

RESULTS

Failure-free survival was significantly higher in the 106 resected patients than in the 48 unresected ones but did not differ according to either primary intention to treat or emergency surgery/elective treatment. Survival was similar in patients operated on by choice and in those because of an emergency. Intentionally unresected patients had a significantly better survival than those not undergoing surgery despite the initial intention, for a number of clinical reasons. Patients with gastric lymphoma survived longer than those with intestinal disease and prognostic factors were analyzed separately in the two groups. The best predictors of prognosis were performance status and serum lactic dehydrogenase level in gastric lymphomas, resection alone in intestinal ones.

INTERPRETATION AND CONCLUSIONS

The prognosis of gastric lymphomas depends on lymphoma-related factors and not on surgical treatment. The prognosis of intestinal ones is exclusively related to surgery. These data support the appropriateness of different clinical approaches to gastric and intestinal lymphomas.

Primary adrenal non-Hodgkin's lymphoma associated with autoimmune hemolytic anemia: a case diagnosed by ultrasound-guided fine needle biopsy

Primary localized adrenal non-Hodgkin's lymphomas are extremely rare. Only 28 observations have been reported so far, all with a very poor prognosis: a median survival of 12.5 weeks. The authors report the case of a 78-year-old male with primary non-Hodgkin's lymphoma of the right adrenal gland. Disease onset was characterized by severe autoimmune hemolytic anemia, and diagnosis was made by echo-guided biopsy. The patient was admitted to our Department with severe autoimmune hemolytic anemia; the hemoglobin value was 6.5 g/dL and both indirect and direct Coombs' tests were positive. Steroid treatment with methylprednisolone 2 mg/kg/day did not improve the hemolytic process. Abdominal ultrasound examination disclosed a right hypoechogenic suprarenal mass of 10 x 9 cm; imaging techniques such as computed tomography and magnetic resonance imaging were not useful in the etiologic diagnosis of the right suprarenal mass; fine needle aspiration and tissue-core biopsy revealed low-grade non-Hodgkin's lymphoma. Staging procedures, including clinical examination, total body computed tomography scan, bone-marrow biopsy, gallium scan, abdominal magnetic resonance imaging, did not disclose other sites of involvement and strongly supported a diagnosis of primary non-Hodgkin's lymphoma of the right adrenal gland. Hormone assays were within normal limits. The patient was treated with chemotherapy, cyclophosphamide-vincristine-prednisone regimen, with good regression of the adrenal mass after 6 courses, and normalization of hemoglobin level and negativity of Coombs' tests. The importance of this case lies in the very rare occurrence of this disease, its association with autoimmune hemolytic anemia, the diagnosis made by ultrasound-guided biopsy, and good response to treatment with respect to cases reported in the literature. The patient remains in clinical remission 12 months after onset of the disease.

Association between hepatitis C virus and non-Hodgkin's lymphoma, and effects of viral infection on histologic subtype and clinical course

PURPOSE

Because an etiologic role for hepatitis C virus in non-Hodgkin's B-cell lymphoma has been suggested by several reports, we assessed the prevalence of hepatitis C virus infection in patients with non-Hodgkin's B lymphoma and in controls, and evaluated the influence of viral infection on histologic and clinical features of the lymphoma patients.

PATIENTS AND METHODS

We prospectively investigated 175 consecutive patients with non-Hodgkin's lymphoma and 350 controls for serologic and molecular markers of hepatitis C virus infection. Controls were selected from inpatients (n = 175) and outpatients (n = 175) cared for at our hospital. Patients with lymphoma who had hepatitis C virus infection were tested for mixed cryoglobulinemia. Aminotransferase levels were measured in all lymphoma patients at baseline and during and after chemotherapy.

RESULTS

Hepatitis C virus prevalence in patients with non-Hodgkin's lymphoma was significantly greater than in control subjects (37% vs 9%, P = 0.0001). Among patients with lymphoma, viral infection was associated with older mean (+/-standard deviation) age (67 +/- 14 vs 61 +/- 8 years, P = 0.001), and women (41 of 87, 47%) were more likely than men (24 of 88, 27%) to have evidence of hepatitis C infection (P = 0.006). Thirteen of the 20 cases of immunocytoma were associated with hepatitis C virus infection, which was also more common in patients with orbital and conjunctival localization of lymphoma. Patients with mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach were less likely to have evidence of hepatitis C infection. Mixed cryoglobulinemia was much more common in patients with hepatitis C virus infection (14 of 65 vs 1 of 110, P = 0.0001); it was not associated with the histologic type of lymphoma. Patients with and without hepatitis C virus infection underwent similar chemotherapy regimens and had no differences in response to chemotherapy or in overall and disease-free survival. Hepatic toxicity from chemotherapy was seen only in patients with hepatitis C virus infection, although all but one of these patients were able to complete their planned treatment.

CONCLUSION

These findings suggest that the hepatitis C virus may have a role as an etiologic agent in non-Hodgkin's B-cell lymphoma. Some clinical and pathologic features of the disease are associated with hepatitis C virus infection, but the virus does not seem to affect prognosis.

Clinical experiences with emergency ultrasound guided diagnostic and therapeutic procedures in a department of internal medicine

In some particular clinical emergencies, it is mandatory to obtain a pathological diagnosis as soon as possible and to start therapy quickly. This can be often done by means of ultrasound guided fine needle biopsy. The cases of emergency ultrasound guided fine needle biopsies and drainages performed in our Ultrasound Laboratory over the past 5 years represent 1.6% of all procedures performed on deeply located lesions. Diagnostic accuracy of emergency ultrasound guided fine needle biopsies was comparable to that obtained in routine situations. In 11/12 patients, this diagnostic procedure allowed the immediate start of proper therapy. Emergency ultrasound guided percutaneous drainage was performed in 6 patients and all of them had a successful outcome. We conclude that emergency ultrasound guided diagnostic and therapeutic procedures, although rarely necessary, can be very useful in some clinical situations. The high efficacy of these techniques is not impaired in an emergency.

Linfadenectomia laparoscopica e Mini-lap: Attualità, limiti ed indicazioni

The authors, according to their preliminary experience with laparoscopic lymphadenectomy and Mini-lap performed for the staging of 15 patients with prostatic carcinoma, have compared the morbidity, the diagnostic accuracy rate and costs of these two techniques, referring critically to international literature and evaluating the real efficacy of a delayed laparoscopic pelvic lymphadenectomy prior to radical prostatectomy. Moreover they have tested the general applicability of the equation by Roach et al., which was empirically derived from a nomogram reported by Partin et al., to predict the risk of lymph node metastasis, applying it to a selected group of patients who underwent radical prostatectomy from 1992 to 1994 in order to maximize the utility of lymphadenectomy for prostatic cancer staging.

Relazione su: “La prostatectomia radicale oggi: Problematiche attuali e nuove terapie alternative”

The Authors present a report about 107 patients treated by radical retropubic prostatectomy over a period of 6 years in the Urologic Department of Gorizia Hospital. They compare their data with those given in the latest scientific articles, results being similar. Noticing that many cases are still understaged, they emphasize the opportunity of a joint contribution by surgeon and oncologist in fighting the disease.

La progressione di malattia dopo prostatectomia radicale: Quale strategia terapeutica?

Cancer progression, following radical prostatectomy, is distinguished by its biological or clinical aspects and is a controversial subject. As adjuvant therapy there is hormonal treatment and radiation therapy or a combination of both. The lack of standardization of the main pathological features of prostate cancer does not allow an accurate valuation of the results from the most important studies. A real efficacy in local or distant control seems to be certain, while the influence on disease-free survival is more uncertain. After a review of the most common options of treatment, the Authors present their results from 107 radical prostatectomies carried out between 1989 and 1994.

Quail sono i limiti attuali dell'indicazione alla prostatectomia radicale?

Progressive improvement in surgical techniques has considerably reduced complications subsequent to radical prostatectomy, which has been considered first choice treatment for about a decade. At the same time two lines of thought have been established regarding the more or less extended indication for surgery. Today's greater knowledge concerning the biological behaviour of the neoplasm and the significance of the prognostic factors should stimulate reflection about the selection of patients for more effective surgery.

Primary lymphoma of the spleen. Report of a case with diagnosis by fine-needle guided biopsy

Primary splenic lymphoma is a relatively infrequent disease; the diagnosis of this entity is currently made with splenectomy. In a 52-year-old female with left upper quadrant abdominal pain, ultrasound showed a normal-sized spleen with an internal hypoechoic focal lesion. Ultrasonically-guided fine-needle aspiration and tissue core biopsy of the splenic lesion showed non-Hodgkin's lymphoma (NHL). At the time of presentation there was no evidence of involvement of lymph nodes, bone marrow or any other organ. A diagnosis of primary splenic non-Hodgkin's lymphoma was made and the patient underwent laparotomy with splenectomy. Histologic examination of the spleen confirmed the diagnosis: low-grade NHL confined to the spleen. The patient is well and in complete remission seven months after diagnosis. The purpose of this paper is to report a rare occurrence of primary splenic lymphoma and to demonstrate the possibility of making this diagnosis by percutaneous guided biopsy.

[Bladder leiomyoma. Presentation of a case]

After a brief review of the literature a case of leiomyoma of the bladder accidentally identified during endoscopy for prostatic adenomatosis is presented.