Linfoma de células B de alto grado de malignidad con morfología blastoide durante el embarazo: reporte de un caso / High-grade malignant B-Cell lymphoma with blastoid during pregnancy: a case report

Resumen ANTECEDENTES: Durante el embarazo es más común el linfoma de Hodking que el no Hodking; afecta, en promedio, a mujeres de 30 años (18-44 años) y más. Suele diagnosticarse alrededor de las 28 semanas de embarazo y está documentado que puede llegarse al término. Los esquemas de tratamiento pueden iniciarse en el posparto inmediato o, incluso, antes. La incidencia mundial del linfoma no Hodking es de 0.8 por cada 100,000 mujeres; se desconoce la supervivencia durante el embarazo. CASO CLINICO: Paciente de 34 años, con antecedentes obstétricos de tres embarazos, una cesárea y un aborto y el embarazo actual en curso de las 29 semanas, referida de la ciudad de Colima debido a un reporte de BI-RADS 3 en el ultrasonido de mama y un nódulo mamario palpable, con evidencia de múltiples tumoraciones en la zona hepática, esplénica y peripancreática. La biopsia tomada de las zonas de la lesión reportó: linfoma de células B de alto grado de malignidad, con morfología blastoide y expresión de C-MYC y BCL2. Además, la paciente se encontró con: anemia, dolor abdominal, múltiples nódulos hepáticos y adenopatías abdominales. Se decidió la interrupción del embrazo a las 30 semanas, con la obtención de un recién nacido, sin complicaciones. Enseguida se inició el tratamiento con rituximab-etopósido-prednisolona-vincristina-ciclofosfamida-doxorrubicina (R-EPOCH) con adecuada adaptación por la paciente. CONCLUSION: Puesto que la información bibliográfica de linfoma y embarazo es escasa el caso aquí reportado es relevante por su aporte. La atención multidisciplinaria favorecerá siempre el pronóstico de las pacientes.

Abstract BACKGROUND: Hodking's lymphoma is more common during pregnancy than non-Hodking's lymphoma; it affects, on average, women aged 30 years (18-44 years) and older. It is usually diagnosed around 28 weeks of pregnancy and is documented to be carried to term. Treatment regimens can be initiated in the immediate postpartum period or even earlier. The worldwide incidence of non-Hodking's lymphoma is 0.8 per 100,000 women; survival during pregnancy is unknown. CLINICAL CASE: 34-year-old patient, with obstetric history of three pregnancies, one cesarean section and one abortion and the current pregnancy in progress at 29 weeks, referred from the city of Colima due to a report of BI-RADS 3 on breast ultrasound and a palpable breast nodule, with evidence of multiple tumors in the hepatic, splenic and peripancreatic area. Biopsy taken from the lesion areas reported: high grade malignant B-cell lymphoma, with blastoid morphology and expression of C-MYC and BCL2. In addition, the patient was found to have: anemia, abdominal pain, multiple hepatic nodules and abdominal adenopathies. It was decided to terminate the pregnancy at 30 weeks, with the delivery of an uncomplicated newborn. Rituximab-Etoposide, Prednisone, Vincristine, Cyclophosphamide, and Doxorubicin (R-EPOCH) therapy was started immediately with adequate adaptation by the patient. CONCLUSION: Since bibliographic information on lymphoma and pregnancy is scarce, the case reported here is relevant for its contribution. Multidisciplinary care will always favor the prognosis of patients.

A Study of Dose-Adjusted EPOCH Chemotherapy in Diffuse Large B-Cell Lymphoma

Background: Worldwide, diffuse large B-cell lymphoma (DLBCL) represents the most common subtype of non-Hodgkin lymphoma (NHL), accounting for 30%-40% of all newly diagnosed cases. The response rate to currently available chemotherapy in DLBCL is much unsatisfactory. Dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA-EPOCH) was developed in an effort to improve outcome in patients with diffuse large B-cell lymphoma. To assess the efficacy and safety of DA-EPOCH chemotherapy in patients with diffuse large B-cell lymphomas.Material & Methods:This quasi experimental study was conducted in the department of Hematology, DMCH, from January 2016 to December 2017. 20 patients with diffuse large B-cell lymphomas were treated with etoposide, vincristine, and doxorubicin for 96 hours with bolus doses of cyclophosphamide and oral prednisone (DA-EPOCH chemotherapy). The doses of etoposide, doxorubicin and cyclophosphamide were adjusted to achieve a nadir absolute neutrophil count below 0.5× 109/L. Cycles were repeated after 21 days. After 3rd and 6th cycle patients were evaluated for interim analysis and response evaluation respectively. Evaluation was done in aspect of clinical parameter (lymph node size, physical complaint), laboratory parameter (CBC) and radiological imaging (CT scan of chest and abdomen). The median age of the patient was 46.5 years (range, 25-62 years); 20% were older than 50 years; and 25% were at high-intermediate risk according to International Prognostic Index (IPI) criteria. The statistical analyses were done by appropriate methods.Results:There was a complete response in 73.7% of patients and partial response 10.5% of patients, which were evidenced by significant reduction of size of the lymph nodes after chemotherapy. The mean Serum LDH was also significantly lower after chemotherapy in comparison to before chemotherapy in those patients who achieved complete or partial response. Moreover, size of the liver and spleen were significantly lower after chemotherapy in response group patients who had either hepatomegaly or splenomegaly or both. Doses were escalated in 12.50% cycles and toxicity levels were acceptable.Conclusion:DA-EPOCH chemotherapy is an effective regimen for treatment of diffuse large B-cell lymphoma patients.

Efficacy analysis of rituximab combined with CHOP or EPOCH regimen in treatment of diffuse large B-cell lymphoma with newly diagnosed myc/bcl-2 double-expression / 白血病·淋巴瘤

Objective To evaluate the efficacy, safety and the prognosis of rituximab combined with CHOP (R-CHOP) or combined with EPOCH (R-EPOCH) regimen in treatment of newly diagnosed myc/bcl-2 double-expression diffuse large B-cell lymphoma (DLBCL). Methods The clinical efficacy, adverse reactions and survival of 16 DLBCL patients who received R-CHOP regimen with double-expression and 15 DLBCL patients who received R-EPOCH regimen with double-expression between August 2014 and December 2017 in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed, and all patients with double or triple-hit lymphoma were excluded. Results The ratio of the International Prognostic Index (IPI) score ≥3 in R-EPOCH group was higher than that in R-CHOP group [10 cases vs. 5 cases, χ2＝ 3.888, P＝0.049]. There were no statistical differences in other clinical data of both groups. Complete remission (CR) was achieved in 75% (12/16) of R-CHOP group and 67% (10/15) of R-EPOCH group, and there was no statistical difference between the two groups (χ2＝ 0.013, P＝ 0.908). The incidence of grade 3-4 leukopenia and grade 3-4 thrombocytopenia in R-EPOCH group was higher than that in R-CHOP group, and the difference was statistically significant [93% (14/15) vs. 38% (6/16), χ 2＝ 10.542, P＝ 0.01; 73% (11/15) vs. 6% (1/16), χ 2＝ 14.685, P< 0.01]. The 1-year overall survival (OS) rate and progression-free survival (PFS) rate was 86.5% and 81.3% in R-CHOP group, 76.0% and 51.4% in R-EPOCH group. There was no statistical difference in the 1-year OS rate between the two groups (P＞0.05), and the 1-year PFS rate in R-CHOP group was higher than that in R-EPOCH group (P<0.01). The 1-year OS rate and PFS rate was 100.0% and 93.8% in IPI<3 group, 65.5% and 45.0% in IPI≥3 group. The 1-year OS rate and PFS rate in IPI<3 group were superior to those in IPI≥3 group (all P ＞0.01). The 1-year OS rate and PFS rate of the female group were lower than those of the male group (59.6% vs. 100.0%, 44.2% vs. 86.3%), and there were statistical differences (all P<0.01). Cox regression analysis showed that high IPI score was an independent prognostic factor for all patients ( HR＝6.335, 95% CI 0.740-54.261, P＝0.092). Conclusions R-EPOCH and R-CHOP are the ideal treatment methods for the double-expression lymphoma. Both regimens have similarities in the treatment outcome of myc/bcl-2 double-expression DLBCL. The adverse reactions in R-EPOCH group are severer than those in R-CHOP group.

Efficacy observation of DA-EPOCH-R protocol for patients with B-cell non-Hodgkin lymphoma / 白血病·淋巴瘤

Objective To evaluate the efficacy and safety of DA-EPOCH-R protocol for patients with B-cell non-hodgkin lymphoma (NHL). Methods 43 patients with B-cell NHL received DA-EPOCH-R protocol, and their efficacy and adverse reactions were analyzed. Results 43 patients received a total of 203 cycles of chemotherapy and the median chemotherapy cycle was 6 (2ˉ8 cycles). 32 patients (74.4%) achieved complete remission (CR) after 2ˉ4 cycles of chemotherapy. A further analysis found that age ≤60 years and>60 years, stageⅠ/Ⅱand stageⅢ/Ⅳ, germinal center B-cell (GCB), non-GCB, double expression lymphoma (DEL) and non-DEL patients had no significant differences (P> 0.05). With a median follow-up of 40 months (9ˉ62 mouths), the overall survival (OS) rate of 1-year and 3-year was 97.6 % and 92.8 % respectively. The major toxicity of DA-EPOCH-R protocol was hematologic toxicity. Other toxicities were mild, and no treatment-related deaths occurred. At the end of follow-up, no secondary tumors were found. Conclusions DA-EPOCH-R protocol is an effective and safe protocol for patients with NHL. The result shows that the curative effect of patients in stageⅢandⅣis similar to the patients in stageⅠandⅡ.

Histeria, femineidad y locura en los tiempos del otro que no existe / Hysteria, feminity and folly in the epoch of the non existing other

Este trabajo realiza un recorrido por diversas referencias teóricas para intentar situar la especificidad de las llamadas locuras en las mujeres entre histeria y femineidad; así mismo se sitúa cómo la lógica de estas responde a ciertas coordenadas subjetivas estructurales que a su vez están tomadas por los puntales que estructuran la época y sus avatares.

This paper examines various theoretical references to put into place the specificity of so-called follies in women, between hysteria and femininity. It places, as well, how their logic responds to certain subjective structural coordinates, taken in turn by the coordinates that structure our time and its avatars.

Los efectos de la época actual en la tramitación de la crisis de la pubertad, abordaje psicoanalítico de pacientes con patología orgánica en el hospital general / The effects of the current epoch on the processing time of the crisis of puberty. A psychoanalytical approach of patients with organic pathology in the general hospital

En el presente trabajo, nos preguntamos acerca de la aparición de patología orgánica que afecta los órganos reproductores en el momento de la pubertad ­ adolescencia, a partir de la práctica clínica de orientación psicoanalítica desarrollada en el marco del Programa de la Facultad de Psicología en el Hospital de Clínicas que tiene lugar en dicho Hospital y que concierne a las investigaciones PROINPSI "La adolescencia y el déficit en los procesos de simbolización" y "La incidencia de la época actual en el déficit de los recursos subjetivos para la elaboración psíquica en la pubertad" ­en proceso de aprobación-. La maduración biológica que da inicio a la pubertad-adolescencia, implica la posibilidad de la reproducción sexuada que Freud plantea como ligada a la muerte puesto que el viviente se reproduce y muere. En nuestro trabajo realizamos un planteo acerca de cómo se presenta lo real en aquel los casos donde la respuesta frente a la castración es el rechazo, y que tiene como consecuencia, desde la perspectiva psicoanalítica, la enfermedad del órgano facilitado. Se trata de un punto forclusivo que no implica necesariamente el rechazo del significante del Nombre del Padre.

In the present work we wonder about the appearance of organic pathology that affects reproductive organs during puberty ­ adolescence, from the psychoanalytically oriented clinical practice developed under the Program of the School of Psychology of the University of Buenos Aires in the Hospital de Clinicas. This program takes place in this Hospital and it concerns the PROINPSI (Program for the Promotion of Research of the School of Psychology of the University of Buenos Aires) investigation projects: "Adolescence and the deficit in the processes of symbolization" and "The incidence of the current epoch in the deficit of subjective resources for the psychic processing in puberty". The biological maturation which initiates puberty ­ adolescence, implies the possibility of sexual reproduction. Freud says that sexual reproduction is linked to death because the living being reproduces and dies. In this paper, we try to propound how the real is presented in those cases in which the answer to castration is rejection, which, from the psychoanalytic perspective, has the disease of the provided organ as a consequence. It is a foreclusive response which does not necessarily implies the rejection of the Name-of-the-Father signifier.

La propensión al principio de placer en la época actual y sus efectos en la salida de la adolescencia / The propensity to the pleasure principle in the current epoch and its effects on the exit from adolescence

Partiendo de un caso clínico, y haciendo una lectura del mismo desde los trabajos de Sigmund Freud y Jacques Lacan, los autores presentan a la adolescencia como un momento del ciclo vital en donde se ponen en juego para el sujeto operaciones simbólicas que determinarán su posibilidad de advenir adulto. Para esto se consideran las particularidades que presenta la época actual en lo concerniente a los modos de satisfacción y los ideales propuestos. La operatividad de la metáfora paterna se torna crucial para ligar al adolescente, en tanto sujeto adulto a advenir, a la comunidad en el amor y el trabajo.

Utilizing a clinical case, and reading it with a base on Sigmund Freud and Jacques Lacan's work, the authors present adolescence as a moment in the life cycle where the symbolic operations brought into play will determine the subject's ability to become an adult. For this purpose, the peculiarities of the current epoch regarding the ways to satisfaction and the ideals proposed are to be considered. The operativeness of the paternal metaphor becomes crucial to bind the adolescent, as an adult subject to be, to the community within love and work.

Perspective research of preliminarily diagnosed angioimmunoblastic T-cell lymphoma with dose-adjusted EPOCH regimen / 中国肿瘤临床

Objective:The effect and side effect of the dose-adjusted EPOCH regimen were evaluated perspectively for the pre-liminarily diagnosed angioimmunoblastic T-cell lymphoma. Methods: Nine cases of untreated angioimmunoblastic T-cell lymphoma were diagnosed and enrolled in our department from September 2008 to September 2012. All patients received dose-adjusted EPOCH regimen as first-line chemotherapy. Results: The median age of 9 patients was 54 years. The male-to-female ratio was 2∶1. About 88.9%of all patients were at Ann Arbor stageⅢ/Ⅳ, and 77.8%presented with B symptoms. Anemia was found in 66.7%of 9 patients, and lactate dehydrogenase elevated in 55.6%of patients. After an average of 4.7 cycles of chemotherapy of dose-adjusted EPOCH regi-men, the complete remission rate was 22.2%, and the total response rate was 66.7%. With a median follow-up of 20 months, the 4-year progression-free survival rate was 11.1%, and the overall survival rate was 33.3%. The median survival time was 19 months. The most common adverse events of EPOCH chemotherapy were hematologic toxicity. Grades 3-4 neutropenia and thrombocytopenia were re-ported in 77.8%and 33.3%of patients. Febrile neutropenia was observed in 44.4%of patients. Non-treatment-related mortality was al-so noted. Conclusion: The results of our research showed no clear benefit of treating preliminarily diagnosed angioimmunoblastic T-cell lymphoma with dose-adjusted EPOCH regimen. The main adverse events were hematologic toxicity and could be tolerated.

Role of epoch length on daily locomotive and non-locomotive physical activity using a triaxial accelerometer and relationships with obesity in adults / 体力科学

The aims of the present study were to examine the role of epoch length (time sampling interval) on locomotive and non-locomotive physical activity (PA) estimates and the relationships with obesity in healthy adults in each sex. Subjects were 308 Japanese women and 183 men aged 20-to-64years old. Time in locomotive and non-locomotive light PA (2.0 ~ 2.9METs; metabolic equivalents) and moderate-to-vigorous PA (MVPA, 3 METs or more) and step counts were assessed using a triaxial accelerometer (Active style Pro HJA-350IT, Omron Healthcare Co., Ltd) presented in 60s and 10s epochs. Body mass index (BMI) by height and body weight was calculated. There were significant differences between results by epoch lengths in both locomotive and non-locomotive PA. In particular, the difference was remarkable for non-locomotive PA. Time in each MVPA for women and men when presented in 10s epochs were significantly higher. Time in total MVPA was different by nearly 30min for women and nearly 20min for men. Moreover, time in non-locomotive light PA when presented as 60s epochs was significantly higher in both women and men than that when presented as 10s epochs, and time in total light PA showed an obvious difference of nearly 50min higher in 60s epochs for women. Conversely, the relationships between PA with 60sec and 10sec estimates and BMI were weak, even though over half of PA variables showed significant correlations. These findings suggest that non-locomotive PA evaluated by the triaxial accelerometer was obviously affected by epoch length. The finding also showed gender differences.

Tratamiento de pacientes con linfomas no Hodgkin asociados a SIDA: experiencia del Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán / Treatment of non-Hodgkin's lymphoma associated with acquired immnodeficiency syndrome (AIDS) at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán

Antecedentes: La supervivencia de los pacientes con linfomas no Hodgkin asociados al Síndrome de Inmunodeficiencia Adquirida (SIDA) ha mejorado con el uso de antirretrovirales y de quimioterapia menos tóxica. Material y métodos: El objetivo del estudio fue mostrar los resultados del tratamiento de los pacientes con linfomas no Hodgkin y SIDA. Se estudiaron nueve pacientes de manera retrospectiva. Se analizó la supervivencia global y libre de enfermedad mediante curvas de Kaplan-Meier; además de sus características generales. Resultados: El tratamiento recibido fue a base de etopósido, prednisona, vincristina, doxorrubicina y ciclofosfamida (DA-EPOCH). Los pacientes tuvieron supervivencia global de 18 meses, una supervivencia libre de enfermedad de 13 meses, una mediana de seguimiento de 16 meses con respuestas completas en ocho de nueve pacientes. Conclusiones: Se observó una adecuada repuesta a tratamiento en este grupo de enfermos reflejada en una mayor supervivencia global.

BACKGROUND: Survival in patients with acquired immunodeficiency syndrome (AIDS) related non-Hodgkin's Lymphoma has improved with the use of High Active Antiretroviral Therapy (HAART) and less toxic chemotherapy. MATERIAL AND METHODS: Clinical characteristics and outcome among patients treated for AIDS related non-Hodgkin's Lymphoma are described. Nine patients were studied retrospectively. Overall survival (OS) and Free Disease Survival (FDS) using a Kaplan-Meier model were analyzed. RESULTS: Patients received (DA-EPOCH) etoposide, prednisone, vincristine, doxorubicin and cyclophosphamide. The overall Survival was 18 months and 13 month Free Disease Survival with a median follow-up of 16 months showing full response in 8/9 patients was observed. CONCLUSIONS: A very satisfactory treatment response in this group of patients expressed as an increased Overall Survival was noted.

A Phase 2 Trial of EPOCH (Etoposide, Vincristine, Doxorubicin, Cyclophophamide and Prednisolone) Chemotherapy for Previously Treated Non - Hodgkin's Lymphoma / 대한암학회지

PURPOSE: As a new strategy to modulate drug resistance in the treatment of relapsed or refractory non-Hodgkin's lymphoma(NHL), continuos infusion of drugs has been incorporated into the chemotherapy. We conducted a phase II study to determine the activity and safety of EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, prednisolone) chemotherapy, in which the natursl products are administered as a continuous infusion, for previously treated NHL's of intermediate grade. MATERIALS AND METHODS: EPOCH chemotherapy (etoposide 50 mg/m2/day 24 hour- continuous infusion, days 1~4, vincristine 0.4 mg/m2/day 24 hour-continuous infusion, days 1~4, doxorubicin 10 mg/m2/day 24 hour-continuous infusion, days 1~4, cyclophosphamide 750 mg/m2 i.v., day 5, prednisolone 60 mg/m2/day p.o. days 1-5) was given to eligible patients every 3 weeks and we assessed response and toxicity of the regimen. RESULTS: Between June 1993 and December 1995, total 56 patients entered this trial and 49 were evaluable. The complete response rate was 41%(95% C.I.: 27-55%). After follow up of 9~50(median 38) months, progression free survival was 0~39+(median 7) months and the overall survival was 1~44+(median 14) months. The prognostic factor analyses showed that B symtoms and serum LDH level before treatment and response to previous treatment affected complete response rate, and patients' performance status and response to previous treatment affected progression free survival and overall survival. Toxicities of EPOCH regimen were leukopenia, stomatitis, nausea/vomiting and neurotoxicity, but they were tolerable. There was 1 case of treatment-related death due to sepsis. CONDUSION: EPOCH chemotherapy was safe and effective for the patients with relapsed NHL. However, the results of patients with NHL refractory to previous treatment were so poor that more intensive, novel treatment would be needed for this category of patients.