Clinical considerations about terminally ill cancer patients who died in hospice unit / 대한내과학회지

BACKGROUND: Although physicians state that patients ideally should receive hospice palliative care for 3 months before death, the majority of patients survive less than one month in hospice palliative care. This is too short to do effective hospice palliative care. Therefore, we figured out the problems through the clinical considerations about terminally ill cancer patients who had died in hospice unit. METHODS: From July to December in 2003, 107 patients with terminally ill cancer who had died in Sam Anyang Hospice Unit were enrolled in this study. For getting the informations about patients characteristics, we reviewed the medical records and interviewed the patients on the first visit. RESULTS: There were 70 males (65%) and 37 females (35%), and median age of patients was 60 years (range 23-93). The most common cancer was stomach cancer (18 patients, 17%). Forty seven patients (44%) took analgesics, the others 60 (56%) not. The most common symptom was pain (75 patients, 70%) and the most prevalent reason for admission was also pain (60, 56%). The most prevalent physician specialty who transferred patients or referred to local hospital was other internal medicine (48 patients, 44%), followed by hemato-oncology (38, 36%), surgery (12, 11%) and others (9, 9%). The median duration between the day when the patients were diagnosed as terminally ill cancer patient and the day when they were referred to hospice center is 48 days. The median survival in hospice palliative care is 30 days. The median hospitalization is 19 days. CONCLUSION: We found that lack of recognition about hospice palliative care of physicians, patients and families made the length of hospice palliative care too short. To do effective hospice palliative care, it needs education and promotion for them constantly.

A case of thymic hyperplasia after high-dose chemotherapy in a patient with malignant lymphoma / 대한내과학회지

Thymic hyperplasia results from thymic regrowth after atrophy during a stressful period. Differentiation from recurrent or residual neoplasm may be an important consideration. Thymic hyperplasia is most problematic when it is observed in patients with malignant lymphoma. We report a case of thymic hyperplasia in which thymic enlargement is developed in a malignant lymphoma patient with high-dose chemotherapy and autologous peripheral blood stem cell transplantation and this condition is confirmed by the findings of serial chest computed tomography without chemotherpy.

Total Plasma Exchange in a Patient with HD-MTX-induced Acute Renal Failure: A Case Report / 대한혈액학회지

A 16-year-old male patient was diagnosed as chondroid osteosarcoma of the left humeral shaft. He showed normal serum creatinine level and no complications following the first course of high-dose methotrexate (HD-MTX) chemotherapy with a total dose of 12g/m2. After the 2nd HD-MTX chemotherapy with the same dosage as in the 1st course, plasma MTX levels soared up to 72micromol/L and serum creatinine level increased to 1.39mg/dL. We failed to lower the plasma MTX levels and to recover the renal function by high-dose leucovorin rescue and plasmapheresis. Plasma MTX level was successfully lowered after three consecutive total plasma exchanges and the withdrawal of aceclofenac which was suspected as an aggravating agent. No rebound in plasma MTX level was observed. We report that total plasma exchanges were effective in a patient with renal failure and delayed MTX excretion which occurred after HD-MTX chemotherapy.

BEAM conditioning regimen and autologous peripheral stem cell transplantation in patients with malignant lymphoma / 대한내과학회지

BACKGROUND: The long-term survival in patients with non-Hodgkin's lymphoma (NHL) after conventional chemotherapy is about 35% and the rest of the patients tend to have relapse. So, in relapsed or refractory NHL, the outcome of patients undergoing high-dose chemotherapy and autologous peripheral stem cell transplantation (APBSCT) was evaluated, and the main prognostic factors were determined. METHODS: 17 patients with relapsed or resistant NHL (5 complete response group, 7 partial response group, 4 primary refractory group, 1 resistant relapse) underwent BEAM (carmustine, etoposide, cytarabine, melphalan) chemotherapy and APBSCT between July 1997 and February 1999. RESULTS: The median follow-up duration was 17 months (range: 4-47). The response rate was 58.3% (complete response 33.3%, partial response 25.0%) in 12 patients in whom complete response group was not included. The 2-year, 3-year overall response rate were 41.2%, 27.5%, respectively. And 2-year progression free survival was 35.3%. The disease status before high-dose chemotherapy was the only significant prognostic factor in determining overall survival (univariate p=.024, multivariate p=.059) and progression free survival (univariate p=.013, multivariate p=.026). Patients with complete response to salvage regimen had better overall survival (p=.021) and progression free survival (p=.008) than patients with refractory response. WBC (> or = 1,000/uL) was recovered at the median 11 days (range; 8-24), and platelet (> or = 50,000/uL) was recovered at the median 18 days (range; 9-44). There was no treatment-related death and no grade 3 and 4 toxicity. Neutropenic infection was in 4 patients (1 Herpes zoster, 1 typhlitis, 1 perianal infection, 1 otitis externa). CONCLUSION: The pre-transplant disease status was the main prognostic factor. Patients with complete response to salvage regimen had the significant benefit in survival from high-dose chemotherapy and APBSCT, but patients with refractory or resistant relapsed NHL did not have any significant benefit.

A case of basophilic crisis in a patient with chronic myelogenous leukemia / 대한내과학회지

Chronic myelogenous leukemia (CML) is a clonal disorder of pluripotent hematopoietic stem cell. Transformation of CML can take place at different stages of stem cell development. The common terminal event in CML is blastic crisis in the majority of cases. Basophilic crisis of CML is very rare event and we experienced a case in 48-year-old patient with philadelphia chromosome positive CML. He had received conservative treatment for 3 years. In the basophilic crisis phase, the WBC count was 64,800 /mm3 with 70 % basophils in the peripheral blood and 43.6% in bone marrow. These basophils had left-shifted maturation. Cytogenetic study revealed the philadelphia chromosome without other abnormalities.

Expression of P53, Bcl-2, Bax, and P-glycoprotein in Relation to Chemotherapeutic Response in Patients with Advanced Non-Small-Cell Lung Cance / 대한암학회지

PURPOSE: To evaluate the relationship between the expressions of p53, bcl-2, bax, and p-glycoprotein and the chemotherapeutic response seen in patients with advanced NSCLC. MATERIALS AND METHODS: Forty-four patients pathologically proven as NSCLC were reviewed. They had undergone at least two cycles of the same chemotherapeutic agents (cisplatin 60 mg/m2 day 1+ vinorelbine 25 mg/m2 day 1, 8, 21-day cycle) and the clinical response was evaluated by WHO criteria. The expressions of p53, bcl-2, bax, and p-glycoprotein were determined by immunohistochemistry. RESULTS: Patients recorded as CR (2/44) and PR (20/44) were classified as the responder group (22/44) and stable (17/44) and progression (5/44) as the non-responder group (22/44). Positive expression of p53, bcl-2, bax, and p-glycoprotein were 84.1%, 65.9%, 88.6%, and 61.4% respectively. The expression score of p53 was significantly higher in the non-responder group than that seen in the responder group (8.59+/-1.89 vs 5.32+/-2.15, p<0.05). However, the expression scores of bcl-2, bax, and p-glycoprotein were not significantly correlated with the clinical response. CONCLUSION: This study suggests that p53 gene mutation plays an important role in the clinical response to chemotherapy including cisplatin and vinorelbine. In future investigations, the correlation with the survival time will be studied.

Results of IVAM chemotherapy in relapsed or refractory non-Hodgkin's Lymphoma / 대한내과학회지

BACKGROUND: Patients with non-Hodgkin's lymphoma who do not respond to first-line chemotherapy or those who relapse after obtaining a complete response have a poor prognosis and are rarely cured with usual salvage chemotherapy. We investigated the treatment responses, toxicities, prognostic factors and mobilization efficacy of peripheral blood stem cells (PBSC) used as salvage chemotherapy. METHODS: 55 patients with refractory (36) or relapsed (19) NHL were treated from Novembr 1997 to October 1999 with IVAM (ifosfamide, etoposide, cytarabine, methotrexate) regimen. Each patients was scheduled to receive one to three cycles of chemotherapy. When the leukocyte count reached 5x109/L after chemotherapy, PBSC collection was performed. The treatment was repeated every 4 weeks. RESULTS: The median age was 48 years (range, 19-76). Median 2.1 cycles of chemotherapy were administered. 15 patients (27.3%) achieved complete response and 29 (52.7%) partial response, with an overall response rate of 80.0%. Myelosuppression was the major toxicity, with 98.2% of grade 3, 4 neutropenia and thrombocytopenia, but there was no serious hemorragic event. Neutropenic fever occurred in 25.5% of the patients with one treatment-related death due to sepsis. Non-hematologic toxicity was modest. PBSC was collected in 36 patients for high dose chemotherapy and autologous stem cell transplantation. The median number of mononuclear cells collected was 9.9x108/kg and the median number of CD34(+) cells collected was 11.9x106/kg. After a median follow-up of 13 months (range, 3-26), median progression free survival were 12 months and median overall survival has not been reached yet. 1-year overall survival and progression free survival were 61.9% and 46.1%, respectively. In univariate analyses, unfavorable prognosis was associated with poor performance status (p=0.001), high LDH (p=0.041), stage III,IV (p=0.04), extralymphatic lesion (p=0.027), B sx (p=0.034), bone marrow involvement (p=0.039) and performing high dose chemotherapy (p=0.005). Multivariate analysis showed that performance status(p=0.0042), B sx(p=0.049) was a significant independent risk factors for death. CONCLUSION: These results suggest that IVAM is an effective salvage chemotherapy for refractory or relapsed NHL and allow effective PBSC collection for high dose chemotherapy and autologous PBSCT.

A Case of High Methotrexate-induced Acute Renal Failure Successfully Treated with Plasma Exchange and Hemodialysis / 대한혈액학회지

We describe the case of a 70-year old female who had developed acute renal failure following high dose methotrexate therapy for malignant lymphoma. Previously, she showed normal renal function and tolerance to high dose methotrexate therapy. Serum methotrexate level reached 9.25 micro mol/L and sustained elevated level for 1 week, although folic acid rescue was intensified to 150 mg intravenously every 3 hours. Therefore, 3 times total plasma exchange and one hemodialysis were performed, and serum methotrexate level returned to normal range. Acute renal failure induced by methotrexate can be complicated by prolonged high serum level of methotrexate, resulting in bone marrow suppression and severe mucositis. To lower the serum methotrexate level, dialysis, plasma exchange, hemoperfusion with charcoal only or combined with hemodialysis and carboxypeptidase-G2 were tried. Successful rescue was obtained by plasma exchange and hemodialysis. No rebound phenomenon was developed.

Hematopoietic Recovery of Peripheral Blood Stem Cells Stored at 4degrees C / 대한암학회지

PURPOSE: Cryopreservation has been the standard method of storing hematopoietic cells for the past 20 years, but this prdegrees Cedure is laborious and expensive. So, we evaluated the hematopoietic recovery of stored PBSCs at 4degrees C for a variable storage period MATERIALS AND METHODS: Eight leukapheresis products were kept unprdegrees Cessed at 4degrees C for 96 hours. To evaluate the effect of storage period on the hematopoietic recovery of PBSCs, assays for viability of mononuclear cells (MNCs), CFU-GM colony counts and CD34 cell counts were performed every 24 hours after PBSC collection. We tried to compare hematopoetic recovery of stored PBSCs at 4degrees C with that of cryopreserved PBSCs by using repeated measures ANOVA. RESULTS: Viability of MNCs, CFU-GM colony counts and CD34 cell counts were monitored at 24 hour, 48 hour, 72 hour and 96 hour after PBSC collection. Data are expressed as percentage of baseline value and shown as mean s.d.; MNCs viability (96+/-2%, 94+/-2%, 92+/-2%, 88+/- 3%), CFU-GM colony counts (87+/-10%, 79+/-11%, 65+/-13%, 56+/-15%), and CD34 cell counts (93+/-13%, 93+/-12%, 88+/-14%, 85+/-19%). After storing PBSCs at 4degrees C for 96 hours, viability of MNCs and CFU-GM colony counts were significantly reduced (p0.05). Prdegrees Cedures of controlled-rate freezing and thawing resulted in a notable loss of viability (77+/-9%) and CFU-GM colony count (71+/-29%). CFU-GM colony counts of 72 hour-stored PBSCs at 4degrees C was similar to those of cryopreserved PBSCs. CONCLUSION: If G-CSF mobilized PBSCs are stored at 4degrees C in less than 72 hours after collection, those hematopoietic recovery would be comparable to that of cryopreserved stem cells which are achieved by the rate-control freezer.

A Case of Triple-Alkylating Regimen and Peripheral Blood Stem Cell Transplantation for a Patient with Relapsed Ovarian Carcinoma / 대한암학회지

Despite an aggressive surgical debulking followed by front-line chemotherapy, most patients with advanced ovarian carcinoma die of drug-resistant disease. Drug resistance can be overcome in a subset of patients with hematologic malignancies and lymphoma with high-dose therapy (HDT) and hematopoietic stem cell transplantation, suggesting that this therapy may also be value in ovarian carcinoma. We report the successful outcome of HDT and peripheral blood stem cell transplantation (PBSCT) in a 41-year-old nulliparous woman who initially was diagnosed with advanced ovarian carcicnoma with FIGO stage IIIc. Her disease relapsed after 19 months from initial therapy of definitive surgery and intra- and post-operative chemotherapy. Subsequently, she received optimal debulking surgery and salvage chemotherapy followed by HDT with triple- alkylating regimen, composed of cyclophosphamide (100 mg/kg), thiotepa (500 mg/m2), and melphalan (100 mg/m2). Her pretranplant characteristics were platinum-sensitive and complete response state. She showed rapid hematologic recovery and mild regimen-related toxicity (Bear man's toxicity criteria), stomatitis (grade I), cardiac toxicitiy (grade II). She has been followed up for 36 months after the inital therapy and is doing well without relapse.

Combination Chemotherapy with Cisplatin and Vinorelbine in Patients with Non-Small-Cell Lung Cancer / 대한암학회지

PURPOSE: To determine the therapeutic effect and toxicities of cisplatin and vinorelbine combination chemotherapy in patients with inoperable non-small-cell lung cancer. MATERIALS AND METHODS: Between Jan 1998 and Dec 1999, 28 patients with inoperable non- small-cell lung cancer were treated with cisplatin and vinorelbine combination chemotherapy as induction treatment. A combination of vinorelbine 25 mg/m2 day 1,8 and cisplatin 60 mg/m2 day 1 were given and repeated every 3 weeks. Then we assessed response and toxicity according to WHO grades. RESULTS: According to response criteria, there were 1 complete response, 12 partial response (42.9%), 12 stable disease (42.9%), and 3 progression (10.7%). The median survival was 12 months. According to toxicity grades, 24 grade 3 myelosuppression (24.7%), 12 grade 4 myelo suppression (10.7%), 6 grade 3 and 4 constipation (6.1%), and mild 7 (7.2%) thrombophlebitis were experienced in evaluable 97 cycles. There was no other clinically severe toxicity. CONCLUSION: These results suggest that combination chemotherapy with cisplatin and vinorelbine in patients with inoperable non-small-cell lung cancer was effective and safe.

Potentials of Fractionated Infusions of Low-dose Peripheral Blood Stem Cells (PBSCs) to Overcome the Hematologic Toxocities after Combination Chemotherapy / 대한암학회지

PURPOSE: We tried to evaluate the clinical usefullness of fractionated low-dose infusions of peripheral blood stem cells (PBSCs) as a supportive care. MATERIALS AND METHODS: Four patients were entered onto this study who were diagnosed to have gastric lymphoma (n=1) and advanced ovarian carcinomas (n=3). To overcome the hematologic toxicities, G-CSF-mobilized PBSCs were collected early in disease course. Harvested products were cryopreserved in aliquotes and then infused after each cycle. Planned therapeutic schedules should be performed without changes of dose and interval regardless of hematologic toxicities. RESULTS: 20 cycles of chemotherapies were performed and data of infused cell doses were as follows: median number of PBSCs infusions, 4.5 (3~5); median MNCs, CFU-GM colony counts per infusion of low-dose PBSCs, 1.7 108/kg (1.0~2.4), 3.2 104/kg (2.1~11.8). Among 20 cycles, delayed recovery of thrombocytopenia was shown on 10 cycles. Leukopenia (III/IV) and thrombocytopenia (III/IV) were shown on 8/6 cycles and 8/2 cycles. In spite of myelosuppression, they were successfully treated with planned dose-intensity. Especially incomplete platelet recovery was successfully rescuced by using fractionated infusions of low-dose PBSCs. CONCLUSION: These data warrant further clinical trials to evaluate the potentials of fractionated low-dose infusions of PBSCs collected early in disease course for overcoming accumulated hematologic toxicities, especially thrombocytopenia complicated by repeated chemotherapies.

A Case with Disseminated Macrophage-related Histiocytic Sarcoma Diagnosed by Positive Histiocytic Markers / 대한혈액학회지

Malignant histiocytosis (MH) is characterized by an invasive, progressive proliferation of neoplastic histiocytes associated with jaundice, lymphadenopathy, refractory anemia, leukopenia, and often hepatic and splenic enlargement. As lymphoblastic leukemia and lymphoma are regarded as neoplasms of lymphoid cells, MH is thought to represent a malignant transformation of the macrophage and dendritic cells. A classification of malignant histiocytic disorders was oriented by cell lineage in the Histiocyte Society's 1987 version. So dendritic cell-related histiocytic sarcoma (localized or disseminated) and macrophage-related histiocytic sarcoma (localized or disseminated) are the recommended nosology. To establish the correct diagnosis, the major challenge seems to distinguish lymphoid from histiocytic cells. M-CSF receptor, lysozyme, Ki-M8, and S-100 protein, etc are useful markers for histiocytes and T-cell and B-cell lineage markers, such as CD3, CD20, and CD79, etc, for lymphocytes. We have experienced a patient with disseminated histiocytic sarcoma diagnosed by positive istiocytic markers, such as lysozyme, S-100 protein, and CD68.

A Case of Multiple Myeloma Presented with a Bulky Cranial Plasmacytoma Invading Cerebrum / 대한혈액학회지

Although neurologic complications of multiple myeloma are common, brain-involvement is rare, despite the high frequency of the cranial lesions. The cranial plasmacytoma grows only from bone, dura mater or adjacent mucous membrane and cerebral structures are affected secondarily. It is less likely that a solitary cranial plasmacytoma exists, and patients who harbor these neoplasms should undergo complete evaluations to exclude multiple myeloma. Solitary plasmacytoma is radiosensitive and the definite treatment for the cranial plasmacytoma usually consists of complete surgical resection with adjacent radiation therapy. However, the treatment and prognosis of the cranial plasmacytoma depends on whether this neoplasm is primary or secondary. Most of patients develop cranial plasmacytoma as the presenting form of multiple myeloma and the treamtment of in these speical cases is usually unsatisfatory. We report a case of multiple myeloma presented with the motor weakness of both upper and lower extremities by a bulky cranial plasmacytoma invading cerebrum treated with surgery, radiation therapy and chemotherapy.

A Case of Tsutsugamushi Disease Complicated with Adult Respiratory Distress Syndrome and Disseminated Intravascular Coagulopathy / 감염

Tsutsugamushi disease is an acute febrile illness caused by Orientia tsutsugamushi. It is characterized by fever, myalgia, lymphadenopathy, and rash. And it can be easily diagnosed by characteristic eschar and serologic testing. Nearly all of the patients with tsutsugamushi disease improve with antibiotics such as doxycycline. However, the fatality rate of untreated cases is seven to ten percent. The well-known causes of mortality are respiratory failure associated with pulmonary edema or adult respiratory distress syndrome. We report a case of tsutsugamushi disease complicated with acute respiratory distress syndrome and disseminated intravascular coagulopathy, despite of doxycycline treatment. A 78-year old woman was admitted to the hospital because of fever. Twelve days before admission she had suffered myalgia and some days later she developed a rash. Despite of management at a local clinic, her condition deteriorated and she was transferred to our hospital. On admission she presented with altered consciousness and two eschars on her right arm and right thigh. Under the initial diagnosis of scrub typhus, doxycycline was administered. Her fever subsided with the initiation of doxycycline. However, her hypoxia worsened progressively and she died on the fifth hospital day.

Behenoyl cytarabine-associated reversible encephalopathy in a patient with acute myelogenous leukemia

We report a case of reversible encephalopathy syndrome in a 16-year-old girl with acute myelogenous leukemia (AML), who is undergoing during consolidation chemotherapy composed of BH-AC (N4-behenoyl-1-beta-D-arabinofuranosyl cytosine) and idarubicin. On the 6th day of chemotherapy, she was in a drowsy state following generalized tonic clonic seizure lasting 20 minutes. MR images revealed extensive cortical and subcortical white matter brain edema. Alertness returned over the 24 hr following by the discontinuation of BH-AC and intravenous administration of diphenylhydantoin, although she complained of intermittent headaches and visual disturbance. She gradually recovered from these symptoms during subsequent 7 days. Previously noted abnormal signal intensities have nearly disappreared on follow-up MRI obtained on the 22nd day after the first seizure. She was discharged without any neurologic sequela. This case suggests that BH-AC, a derivative of cytosine arabinoside (1-beta-D-arabinofuranosylcytosine) could be a cause of reversible encephalopathy syndrome.

Intrapleural chemotherapy with cisplatin and cytarabine in the management of malignant pleural effusion / 대한내과학회지

BACKGROUND: Maligant pleural effusions are common and significant problems in patient with advanced malignancies. In comparison with traditional sclerosing agent, intrapleural chemotherapy has a potential advantage of treating the underlying malignancy in addition to providing local control of th effusion. This study evaluated efficacy of intrapleural chemotherapy with cisplatin and cytarabine in the management of malignant pleural effusion from lung cancer and others. METHODS: 29 patients with pathology-proven malignant pleural effusion were prospectively analyzed to estimate the effect of intrapleural chemotherapy. A single dose of cisplatin 100mg/m plus cytarabine 1200mg/m in the 250ml normal saline were instilled into the pleural space via a chest tube and drained 4 hours later. Patients were evaluated for toxicity and response at 24hours, 1st, 2nd, 3rd week, and monthly interval. No recurrence of the effusion was considered a complete response(CR). Partial responses (PR) was defined as a 75% or greater decrease in the amount of effusion on serial chest radiographs. RESULTS: The overall response rate(CR plus PR) was 93.1% (27 of 29 patients). The median length of response was 7.5 months. Among 17 patients who were assessable until they died, 14 patients(82%) maintained complete response at the last follow-up. One patient experienced reversible grade 4 myelosuppression, 3 patients had grade 3 nausea & vomiting. 2 patients had empyema, and 2 patients had wound infection. CONCLUSIONS: The outcome of this trial indicated that the intrapleural chemotherapy with cisplatin and cytarabine with little treatment related mortality and morbidity.

The relationship between cisplatin-induced apoptosis and p53, bcl-2 and bax expression in human lung cancer cells

OBJECTIVES: Given the roles of bcl-2, bax and p53 in apoptosis, we investigated the effect of their expression on the response to cisplatin in order to understand the molecular events of cisplatin-resistance in lung cancers. METHODS: Three parental human lung cancer cell lines (PC9, PC14 and H69) and their in vitro selected cisplatin-resistant sublines were examined. Cells treated with cisplatin were processed for acridine orange and ethidium bromide staining and DNA gel electrophoresis for the morphologic detection of apoptosis. The endogenous levels of bcl-2, bax and p53 protein expression in lung cancer cells were assessed by Western blot analysis and DNA of polymerase chain reaction-amplified exon 5 to 8 of p53 gene was directly sequenced. RESULTS: H69, which had bcl-2 expression, p53 mutation and decreased expression of p53 and bax, was relatively resistant to cisplatin and delayed and reduced apoptosis. Although apoptosis was markedly reduced in cisplatin-resistant sublines compared to their parental cells, there were no significant differences in the expression of p53, bcl-2 and bax. CONCLUSIONS: Cisplatin-resistance was associated with the reduced cellular susceptibility to apoptosis. Cancer cells with the natural expression of bcl-2 and p53 mutation may be more resistant to cisplatin and less susceptible to apoptosis.

Retrospective Analysis of Prognostic Factors in Aggressive Malignant Lymphomas / 대한혈액학회지

BACKGROUND: We analyzed retrospectively the clinical features and treatment-related parameters of the aggressive non-Hodgkin's lymphomas (NHL) treated with combination chemotherapy containing doxorubicin to determine the prognostic factors for the response to the treatment and overall survival. METHODS: Adult patients with aggressive NHL who were treated between 1984 to 1993 were evaluated retrospectively for clinical features and treatment-related parameters predictive of the response to the treatment and overall survival, respectively. RESULTS: At 2 years, relapse-free survival and overall survival were 62.2% and 82.6%, respectively, with a median follow-up time of 23.5 months. Significant independent prognostic factors for overall survival were serum LDH level and the complete response (CR) time-interval. For relapse-free survival, the CR time-interval was a significant independent prognostic factor. CONCLUSION: The rapid induction of complete response has a significant implication in the prognosis of aggressive NHL. Appropriate selection of treatment according to the CR time-interval as well as the clinical features of aggressive NHL will improve the overall survival in aggressive NHL.

A Case of Multiple Splenic Infarction in Polycythemia Vera treated with Phlebotomy alone / 대한내과학회지

Polycythemia vera (PV) is a chronic myeloproliferative disease characterized by an increase in the total mass of red cells. Leukocyte and platelet counts are often elevated as well. The most common complication is thrombosis, which usually involves brain, heart, gastrointestinal tract, and kidneys, but rarely involves spleen. The cornerstone of therapy for this disease is phlebotomy and it is associated with an increased risk of thrombosis, especially for patients older than 70 years, those with a history of thrombosis, and those requiring an increased frequency of phlebotomy. Concurrent treatment with myelosuppressive agents decreases the risk of thrombotic complications.Recently we experienced a case of multiple splenic infarction in PV treated phlebotomy alone in a 42-year old woman who had complained of massive splenomegaly, left upper quadrant abdominal pain and fever. CT scan of abdomen showed multiple hypodense areas suggesting splenic infarction. She was managed with hydroxyurea and salicylate instead of phlebotomy and showed a clinical improvement with lowering the platelet count and reducing splenomegaly. PV with a assive splenomegaly is prone to thrombosis and phlebotomy in such patients may contribute to the thrombotic complications by increasing platelet counts. When it is necessary to lower the platelet count or reduce splenomegaly, hydroxyurea may be more useful than phlebotomy.