Higher rate of central nervous system involvement by flow cytometry than morphology in acute lymphoblastic leukemia.

INTRODUCTION: Central nervous system (CNS) involvement in acute lymphoblastic leukemia (ALL) is diagnosed traditionally by cytopathology (CP) of the cerebrospinal fluid (CSF). Role of flow cytometry (FC) to diagnose CNS involvement has not been extensively investigated. METHODS: We aimed to detect CNS involvement in 42 ALL patients (33 B-ALL, nine T-ALL) at diagnosis by FC and comparing it with CP and to correlate it with known risk factors for CNS disease like Lactate dehydrogenase (LDH). A receiver operating characteristic curve was used to determine the cutoff of LDH to predict CSF involvement. For the analysis of categorical/quantitative variables, Fisher's exact test was used. For the analysis of continuous variables, Mann-Whitney test was used. A P value of <.05 was taken as significant. RESULTS: CP and FC were positive in five (11.9%) and 11 patients (26.14%) respectively with FC detecting a significantly higher level of involvement (P=.001). All CP-positive cases were FC positive. A LDH value of >472 U/L had a sensitivity of 61% and specificity of 62.5% for diagnosis of CSF involvement by FC. CONCLUSIONS: CSF FC detects CNS disease in ALL patients at diagnosis at a rate double than CP alone and is statistically associated with an elevated LDH level. It should be incorporated in the evaluation of CSF to detect CNS involvement.

Clinico-hematological profile and outcome of acute promyelocytic leukemia patients at a tertiary care center in North India.

OBJECTIVES: Acute promyelocytic leukemia (APL) is the only acute leukemia amenable to targeted therapy. However, there is limited Indian data on APL. We aimed to analyze data of APL patients treated with all trans retinoic acid (ATRA) and anthracycline based chemotherapy. MATERIALS AND METHODS: A total of 34 cases of APL were treated at our center over 4 years. Induction chemotherapy consisted of a combination of ATRA and daunorubicin. RESULTS: Most of our patients were intermediate risk (50%) followed by high risk (41.17%). Induction mortality was 14.7%. We observed a high incidence of febrile neutropenia (91%) and 50% of our patients developed ATRA syndrome. Four patients (11.76%) relapsed during follow-up (median - 15 months, range: 13-33 months). There was no correlation between risk status and death or relapse or ATRA syndrome. Median event free survival (EFS) duration was not reached however mean duration was 38.45 ± 3.84 months. Median overall survival (OS) duration was also not reached at 53 months of follow-up. The 4 year OS and EFS were 75.45% and 64.5% respectively. On multivariate analysis, only disseminated intravascular coagulation (DIC) significantly correlated with a poor OS and EFS. DISCUSSION: Our data reflects that APL remains a highly curable malignancy with good response to ATRA plus anthracycline based chemotherapy even with a greater number of high and intermediate risk patients. Only DIC during induction chemotherapy bore an impact on survival in our patients.

Iliac conduits for endovascular repair of aortic pathologies.

OBJECTIVES: Challenging iliac access during thoracic endovascular aortic repair (TEVAR) is associated with a higher risk of access site complications such as injury or rupture of the iliac vessels. As a result, the use of iliac conduits is frequently used to facilitate access during TEVAR. This report evaluates the effect of iliac conduits on TEVAR outcomes. METHODS: The 2005-2010 American College of Surgeons Surgical Quality Improvement Program database was queried to identify vascular patients undergoing elective TEVAR. Patients without conduit (Group A) were compared to patients who underwent TEVAR with conduit (Group B). RESULTS: We identified 1037 patients (90%) in Group A (69 ± 12.7 years, 42% female) and 117 patients (10%) in Group B (70 ± 12.6 years, 68% female). Women received conduits more often than men (Male:5.8%, Female:15.7%, p < 0.001). There was no significant difference in the rate of non-surgical (A:19%,B:25%,p = 0.121), pulmonary (A:11%,B:16%, p = 0.115), renal (A:3.1%, B:1.7%, p = 0.4) and cardiovascular complications (A:8%, B:12%, p = 0.143) between groups. However, any complication (A:24%, B:33%. p = 0.025), surgical complications (A:10%, B:16%, p = 0.035) and mortality (A:4.5%, B:12%. p = 0.001) were significantly higher in Group B. In multivariate analysis, use of conduit was associated with a 3.8 times higher risk of death compared with no conduit after controlling for confounders. Length of in-hospital stay was similar for both groups (A:6.6 ± 8.8, B:7.6 ± 8 days, p = 0.247). The use of conduits had a declining rate over time from 17.9% in 2006 down to 6.5% in 2010. CONCLUSIONS: Female patients more frequently require iliac conduits during TEVAR compared to men. Conduits were associated with a higher rate of surgical complications and mortality. The incidence of conduit use has decreased threefold in the last five years. Safer access for TEVAR by use of a conduit should not be abandoned based on these results, but there should be a heightened awareness for the higher rate of mortality in these patients.

Pathologic splenic rupture in a patient with follicular lymphoma.

A middle aged man presented with abdominal pain and fever, with progressive dyspnea for the past one week. He had generalized lymphadenopathy with hepatosplenomegaly and a left sided pleural effusion on admission. Further evaluation revealed that he had lymphocytosis on peripheral blood. He then developed increasing abdominal pain and fall in hemoglobin which was confirmed on imaging to be due to a splenic rupture and he underwent a splenectomy. The diagnosis on lymph node biopsy and peripheral blood immunophenotyping was grade 1 follicular lymphoma. He has completed his 6 cycles of chemotherapy (R-CVP) and is on maintenance rituximab and doing well. The case highlights the fact that splenic rupture can even be caused by indolent lymphomas.

A pilot study on CD4 & CD8 cell counts in healthy HIV seronegative pregnant women.

CD4 and CD8 counts are widely used prognostic markers to assess the degree of immune impairment in HIV seropositive individuals and to monitor anti-retroviral therapy (ART). Pregnancy is considered as a physiologically immunocompromised state, hence alterations in T lymphocyte subsets may occur during pregnancy. There is a need to establish base-line values of these counts, especially in healthy pregnant women. One hundred healthy HIV seronegative pregnant women (mean age 22.5 +/- 2.99 yr) in their third trimester of pregnancy and 30 non-pregnant women (mean age 22.7 +/- 3.01 yr) were tested for their CD4 and CDS counts. In pregnant women, the CD4 and CD8 cell counts/microl were 764 +/- 249 and 547 +/- 196 and the CD4 and CD8 per cent were 56.49 +/- 8.3 and 38.03 +/- 7.2 respectively. In the non-pregnant women CD4 and CD8 counts/microl were 965 +/- 267 and 639 +/- 211 whereas the CD4 and CD8 per cent were 55.27 +/- 5.99 and 36.17 +/- 6.44 respectively. Absolute counts were significantly lower (P < 0.05) in the pregnant group as compared to the controls. A wide variation was seen in the CD4 and CD8 counts in both the groups. However, the variations in the mean CD4 and CD8 per cent were much smaller. Thus CD4 and CD8 per cent may be considered as a useful indicator of immune function rather than absolute counts, in pregnant women.