Single-agent rituximab in treatment-refractory or poor prognosis patients with chronic lymphocytic leukemia.

OBJECTIVE: Rituximab in combination with fludarabine and cyclophosphamide has significantly improved outcomes for patients with chronic lymphocytic leukemia (CLL) and an improvement in overall survival has recently been shown for the first time in the history of CLL treatment. However, the chemotherapy portion of this regimen may be unsuitable for elderly patients or those with significant comorbidities. We investigated the safety and tolerability of single-agent rituximab in 23 consecutive patients presenting with CLL at a single institution. RESEARCH DESIGN AND METHODS: Patients received eight cycles of weekly rituximab (375 mg/m(2) initially). Patients progressing on rituximab treatment could receive up to five further courses of single-agent rituximab in escalating doses up to 3 gm/m(2) per dose. Previously untreated and previously treated patients, including those refractory to fludarabine, were eligible for the study. RESULTS: Single-agent rituximab was efficacious, even in patients with treatment-refractory or poor-prognosis CLL. The overall response rate was 90.9% with a CR rate of 63.6%. The median PFS was 28.5 months, and median duration of response was 26 months. Responses were seen regardless of prior treatment including in patients refractory to fludarabine. Especially encouraging results were seen in patients receiving rituximab maintenance therapy who had a median duration of response substantially longer than those who did not receive maintenance (35 months vs. 14 months, respectively). CONCLUSIONS: Rituximab was well tolerated with no unexpected adverse events even at the highest dose. These results indicate that single-agent rituximab is effective and has a place in the treatment of CLL.

Recurrent cerebral embolism associated with indwelling catheter in the presence of anomalous neck venous structures.

Persistent left superior vena cava (PLSVC) is the most common central venous anomaly in the thorax, which may remain asymptomatic throughout life. Indwelling catheters that are increasingly used in oncology practice may result in complications in the presence of PLSVC. The authors report an unusual case of recurrent ischemic attacks each time a portacath was accessed in a patient with breast cancer and PLSVC. This case highlights the importance of suspecting this condition in the presence of clinical and radiographic clues to prevent complications.

Abdominal aortitis after use of granulocyte colony-stimulating factor.

Granulocyte colony-stimulating factor (G-CSF) is a recombinant human glycoprotein that promotes proliferation and differentiation of granulocytic-committed progenitors. It is commonly used to treat neutropenia and is generally well tolerated. Occurrences of rare but serious adverse events in association with the use of G-CSF have been described. We report the case of a 54-year-old male with squamous cell carcinoma of the lung who developed abdominal aortitis following the use of G-CSF. Other possible aetiological conditions were excluded based on laboratory and radiological evaluations. To our knowledge, this represents the second case report demonstrating an association between aortitis and the use of G-CSF.

Renal tubular defects from antidepressant use in an older adult: An uncommon but reversible adverse drug effect.

Adverse drug reactions are common and contribute to significant mortality and morbidity. We report a case study of an elderly woman who manifested with uncommon reversible renal tubular defects following the use of escitalopram. She was initially seen for worsening symptoms of depression and started on escitalopram in addition to her regular medications, which included donepezil, hydrochlorothiazide and mirtazapine. Three weeks later, she became increasingly confused and manifested recurrent falls. Laboratory evaluation showed hyponatraemia and evidence of renal tubular absorption defects. The patient's symptoms and laboratory abnormalities improved upon discontinuation of escitalopram as well as of mirtazapine and hydrochlorthiazide. This case illustrates the possibility of rare but reversible renal tubular defects associated with the use of antidepressant medications.

Gastrostomy, esophagitis, and gastrointestinal bleeding in older adults.

INTRODUCTION: Percutaneous endoscopic gastrostomy tubes (PEG) are commonly used in older adults with dysphagia and poor nutrition. The association of PEG with upper gastrointestinal bleeding (UGIB) and role of gastroesophageal reflux disease (GERD) in relation to UGIB in patients with PEG are not well known. METHODS: We conducted a retrospective analysis of older patients with PEG, hospitalized for UGIB, during a 1-year period between 1997 and 1998. The study was performed in a university teaching hospital involving residents from long-term care facilities (LTCF) of the Bronx. RESULTS: A total of 38 patients with PEG were admitted for UGIB; 28 were evaluated with upper endoscopy. The mean age of the group who underwent endoscopy was 83.4 +/- 9.2 years, with 18 females and 10 males. In the same group, 13 patients were on H2 blockers and 4 patients used nonsteroidal antiinflammatory drugs before hospitalization. None of the residents were on proton pump inhibitors. The most common upper endoscopic findings were esophagitis, either alone (11 patients) or in association with other lesions (10 patients). Esophagitis predominantly involved the lower third of the esophagus. Other significant findings on endoscopy were gastric and duodenal ulcers, gastritis, and gastric erosions either alone or in combinations. CONCLUSIONS: Esophagitis is a common occurrence and a significant contributor for UGIB in patients with PEG. Use of H2 blockers does not appear to be an effective preventive measure for UGIB in these patients.

Partially successful treatment of a patient with chronic lymphocytic leukemia and Hodgkin's disease: case report and literature review.

Chronic lymphocytic leukemia (CLL) is rarely associated with Hodgkin's disease (HD). We report a case of nodular sclerosis HD in a patient previously diagnosed with CLL. Reed-Sternberg cells were CD15(+) and CD30(+). He was treated with dose-escalated CHOP and at relapse, mitoxantrone, vinblastine, and CCNU (MVC) with partial response to the former and complete response to the latter, although the patient died 15 months later. Data from 88 other similar cases published in the English language were analyzed. Based on the histological and clinical features at the time of transformation, these patients were divided into distinct categories for analysis. Prognosis was found to be poorer in patients with continued active CLL when compared with those with CLL in remission at the time of transformation to HD. It is suggested that these two presentations may derive from different pathogenic mechanisms.