Outcomes in Refractory Diffuse Large B-Cell Lymphoma: Results from Two Prospective Korean Cohorts / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Diffuse large B-cell lymphoma (DLBCL) is the most common hematologic malignancy worldwide. Although substantial improvement has been achieved by the frontline rituximab-based chemoimmunotherapy, up to 40%-50% of patients will eventually have relapsed or refractory disease, whose prognosis is extremely dismal. @*Materials and Methods@#We have carried out two prospective cohort studies that include over 1,500 DLBCL patients treated with rituximab plus CHOP (#NCT01202448 and #NCT02474550). In the current report, we describe the outcomes of refractory DLBCL patients. Patients were defined to have refractory DLBCL if they met one of the followings, not achieving at least partial response after 4 or more cycles of R-CHOP; not achieving at least partial response after 2 or more cycles of salvage therapy; progressive disease within 12 months after autologous stem cell transplantation. @*Results@#Among 1,581 patients, a total of 260 patients met the criteria for the refractory disease after a median time to progression of 9.1 months. The objective response rate of salvage treatment was 26.4%, and the complete response rate was 9.6%. The median overall survival (OS) was 7.5 months (95% confidence interval, 6.4 to 8.6), and the 2-year survival rate was 22.1%±2.8%. The median OS for each refractory category was not significantly different (p=0.529). @*Conclusion@#In line with the previous studies, the outcomes of refractory DLBCL patients were extremely poor, which necessitates novel approaches for this population.

A Case Report of Axillary Hibernoma: US, CT, MR, and Histopathologic Findings

Hibernoma is a rare benign tumor of brown adipose tissue. Herein, we report a case of axillary hibernoma in a 53-year-old female and discuss the various radiologic findings. The US revealed a 4.5-cm well-defined oval heterogenous hyperechoic mass in the right axilla with anterior displacement of the axillary vessels. Non-enhanced chest CT showed a 5.0-cm well defined, oval, and low-attenuated mass. MRI demonstrated a 5.5-cm mass with heterogeneous intermediate-to-high signal intensity on T1-and T2-weighted images and irregular enhancement at the peripheral portion. The patient underwent an US-guided core needle biopsy and the final diagnosis was hibernoma.

Pulmonary Leukocytoclastic Vasculitis as an Initial Presentation of Myelodysplastic Syndrome / 결핵및호흡기질환

Systemic vasculitis involving the lung is a rare manifestation of myelodysplastic syndrome (MDS), and secondary vasculitis is considered to have poor prognosis. A 44-year-old man presented with fever and dyspnea of 1 month duration. A chest radiograph revealed bilateral multiple wedge shaped consolidations. In addition, the results of a percutaneous needle biopsy for non-resolving pneumonia were compatible with pulmonary vasculitis. Bone marrow biopsy was performed due to the persistence of unexplained anemia and the patient was diagnosed with MDS. We reported a case of secondary vasculitis presenting as non-resolving pneumonia, later diagnosed as paraneoplastic syndrome of undiagnosed MDS. The cytopenia and vasculitis improved after a short course of glucocorticoid treatment, and there was no recurrence despite the progression of underlying MDS.

Four Cases of Acquired Aplastic Anemia Affecting an Entire Family after Ingesting Ganoderma lucidum / 대한내과학회지

We report four cases of Ganoderma lucidum-induced aplastic anemia involving members of the same family. A 33-year-old man and three family members were admitted to the hospital due to fever and pancytopenia. The illness arose after ingesting herbal wine containing G. lucidum 2 weeks earlier. A bone-marrow biopsy showed hypocellularity in three of the four family members (the exception was the one who died). They were treated with supportive management, including transfusions, granulocyte colony stimulating factor, and empirical antibiotics for neutropenic fever. The pancytopenia improved 4-5 weeks after the symptoms first appeared.

A Case of Metastatic Low-Grade Endometrial Stromal Sarcoma Treated with Letrozole after Ovarian Ablation by Radiotherapy / Journal of the Korean Cancer Association, 대한암학회지

A 50-year-old woman was admitted to our hospital due to multiple lung nodules detected incidentally on a chest X-ray. A video-assisted thoracoscopic lung biopsy revealed low-grade endometrial stromal sarcoma (LG-ESS). She had undergone a simple hysterectomy 1 year earlier owing to a diagnosis of adenomyosis. A review of her previous hysterectomy specimen showed not endometriosis but LG-ESS. According to the patient's levels of serum follicle stimulating hormone and estradiol, she was in the premenopausal state with retained and normally functioning ovaries. She then underwent ovarian ablation by radiotherapy, after which she was administered 2.5 mg of letrozole once per day. Three months later, the size of the metastatic nodules in both lungs had decreased. The patient was followed up for 24 months while continuing on letrozole, and maintained a partial remission. We report herein on a case of metastatic LG-ESS treated with letrozole after ovarian ablation by radiotherapy.

Intramedullary Spinal Cord Metastasis From Rectal Cancer

Intramedullary spinal cord metastasis (ISCM) is an uncommon condition of the central nervous system (CNS) cause by systemic malignant tumors. Most ISCM cases are known to occur in patients with lung cancer and breast cancer; however, ISCM also very rarely occurs in patients with colorectal cancer. For the first time in Korea, we experienced a case of ISCM arising from rectal cancer, where a 75-year-old man presented with an abruptly-developed left-foot drop and numbness in both legs. The patient had lung metastases from rectal cancer that had been treated with chemotherapy. Magnetic resonance imaging revealed an intramedullary nodular lesion at the T12 level. ISCM was diagnosed and treated with steroids and radiotherapy. The patient's neurological symptoms were relieved for a while after treatment, but his condition deteriorated progressively. He died 4 months after ISCM had been diagnosed.

Thrombolytic Therapy Using Urokinase for Management of Central Venous Catheter Thrombosis

PURPOSE: The management of central venous catheters (CVCs) and catheter thrombosis vary among centers, and the efficacy of the methods of management of catheter thrombosis in CVCs is rarely reported. We investigated the efficacy of bedside thrombolysis with urokinase for the management of catheter thrombosis. MATERIALS AND METHODS: We retrospectively reviewed data from patients who had undergone CVC insertion by a single surgeon in a single center between April 2012 and June 2014. We used a protocol for the management of CVCs and when catheter thrombosis was confirmed, 5,000 U urokinase was infused into the catheter. RESULTS: A total of 137 CVCs were inserted in 126 patients. The most common catheter-related complication was thrombosis (12, 8.8%) followed by infection (8, 5.8%). Nine of the 12 patients (75%) with catheter thrombosis were recanalized successfully with urokinase. The rate of CVC recanalization was higher in the peripherally inserted central catheter (PICC) group (87.5%) than the chemoport group (50%). Reintervention for catheter-related thrombosis was needed in only 2.2% of patients when thrombolytic therapy using urokinase was applied. Age <60 years (P=0.035), PICC group (P=0.037) and location of the catheter tip above the superior vena cava (P=0.044) were confirmed as independent risk factors for catheter thrombosis. CONCLUSION: Thrombolysis therapy using urokinase could successfully manage CVC thrombosis. Reintervention was rarely needed when a protocol using urokinase was applied for the management of CVC thromboses.

Delivering bad news to a patient: a survey of residents and fellows on attitude and awareness / 한국의학교육

PURPOSE: Delivering bad news (DBN) to a patient or patient's family is one of the most difficult tasks for physicians. As a complicated task, DBN requires better than average communication skills. This study investigated trainee's attitude and awareness of DBN based on a self-assessment of their experiences and performance in practice. Survey subjects were also asked to assess their perception and the need for education in conducting DBN. METHODS: A survey was carried out on their experiences with DBN, how they currently deal such situations, how they perceive such situations and the need for education and training programs. A SPIKES protocol was used to assess how they currently deal with DBN. RESULTS: One hundred one residents and fellows being trained in a teaching hospital participated in the survey. Around 30% had bad experiences due to improperly delivered bad news to a patient. In terms of self-assessment of how to do DBN, over 80% of trainees assessed that they were doing DBN properly to patients, using a SPIKE protocol. As for how they perceived DBN, 90% of trainees felt more than the average level of stress when they do DBN. About 80% of trainees believed that education and training is much needed during their residency program for adequate skill development regarding DBN. CONCLUSION: We suggest that education and training on DBN may be needed for trainees during the residency program, so that they could avoid unnecessary conflict with patients and reduce stress from DBN.

Evaluation of Prescribing Medications for Terminal Cancer Patients near Death: Essential or Futile / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission. MATERIALS AND METHODS: We conducted a retrospective review of the medical charts of terminally ill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated. RESULTS: A total of 196 patients were included. Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile. CONCLUSION: Our data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.

Angiomatoid Fibrous Histiocytoma as a Second Tumor in a Young Adult with Testicular Cancer / Journal of the Korean Cancer Association, 대한암학회지

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumor, with a low-grade malignant potential, occurring predominantly in children and young adults. Association between AFH and other malignancies has been rarely reported. A 27-year-old man who presented with a palpable abdominal mass was diagnosed as having testicular cancer with multiple liver and lung metastases. At 16 months after chemotherapy, a follow-up computed tomographic scan revealed a supraclavicular mass measuring 3 cm in size, which was suspected to be a recurrence. The patient underwent surgical excision, and the mass was pathologically diagnosed as a AFH. The patient has had no local recurrence and no distant metastasis for 12 months after resection. To the best of our knowledge, this is the first case report of AFH as a second tumor in a patient with testicular cancer.

Renal Insufficiency Secondary to Leukemic Infiltration in Chronic Lymphocytic Leukemia: A Case Report / 대한내과학회지

Renal infiltration is common in chronic lymphocytic leukemia (CLL), but renal impairment caused by leukemic infiltration is rare. This report describes the case of a 38-year-old man with CLL who required no medical treatment for 1 year and was admitted with nonoliguric renal insufficiency (proteinuria > 2,000 mg/day). A renal biopsy subsequently revealed leukemic infiltration by CLL. Treatment with fludarabine plus cyclophosphamide resulted in the improvement of renal function. Leukemic infiltration should be considered in the differential diagnosis of a patient with CLL and impaired renal function because renal impairment often responds well to chemotherapy.

Splenic infarction in a patient with autoimmune hemolytic anemia and protein C deficiency / 대한혈액학회지

Splenic infarction is most commonly caused by cardiovascular thromboembolism; however, splenic infarction can also occur in hematologic diseases, including sickle cell disease, hereditary spherocytosis, chronic myeloproliferative disease, leukemia, and lymphoma. Although 10% of splenic infarction is caused by hematologic diseases, it seldom accompanies autoimmune hemolytic anemia (AIHA). We report a case of a 47-year-old woman with iron deficiency anemia who presented with pain in the left upper abdominal quadrant, and was diagnosed with AIHA and splenic infarction. Protein C activity and antigen decreased to 44.0% (60-140%) and 42.0% (65-140%), respectively. Laboratory testing confirmed no clinical cause for protein C deficiency, such as disseminated intravascular coagulation, sepsis, hepatic dysfunction, or acute respiratory distress syndrome. Protein C deficiency with splenic infarction has been reported in patients with viral infection, hereditary spherocytosis, and leukemia. This is a rare case of splenic infarction and transient protein C deficiency in a patient with AIHA.

Quantifing the Circulating Epstein-Barr Virus (EBV) DNA to Monitor a Case of Aggressive Natural Killer Cell Leukemia / 대한혈액학회지

Epstein-Barr virus (EBV) infection is associated with various lymphoproliferative diseases, including Hodgkin lymphoma, extranodal NK/T cell lymphoma, aggressive NK cell leukemia, Burkitt lymphoma and post-transplant lymphoproliferative disorder. In the recent studies, the plasma EBV-DNA levels in patients with EBV-associated lymphoproliferative disease appeared to be correlated with the therapeutic response. Aggressive NK cell leukemia (ANKL) is a fatal disease that's characterized by high fever, lymphadenopathy, hepatosplenomegaly and frequent hemophagocytosis. No serological tumor marker for this malignancy has yet been identified for monitoring the disease and predicting the outcome. We experienced a case of aggressive natural killer cell leukemia in a 48-year-old man, and we serially monitored the plasma EBV DNA load by performing real time quantitative PCR assay. Serial measurements of the plasma EBV DNA level during therapy showed a close correlation between the clinical response and the changes in the plasma EBV DNA titers.

Orbital Infiltration as the First Site of Relapse of Primary Testicular T-cell Lymphoma / Journal of the Korean Cancer Association, 대한암학회지

A 43-year-old male presented with a painless left testicular mass. The pathologic diagnosis of the radical orchiectomy specimen was peripheral T-cell lymphoma, unspecified (PTCL-u). According to the Ann Arbor staging system, his initial stage was III because of the right nasopharyngeal involvement. After first-line chemotherapy with four courses of the CHOP regimen and this was followed by involved-field radiotherapy, he achieved complete remission. Two months later, disease recurred to the left ciliary body of the left eye without evidence of involvement at other sites. Although the patient received intensive chemotherapy with autologous hema-topoietic stem cell transplantation, he ultimately died of leptomeningeal seeding. Because both the central nervous system (CNS) and the orbit are sanctuary sites for chemotherapy, orbital infiltration of lymphoma should prompt physicians to evaluate involvement of the CNS and to consider performing prophylactic intrathecal chemotherapy as a treatment option.