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.

Incidence and management of etoposide hypersensitivity in pediatrics

Introduction: Etoposide is widely used in pediatric chemotherapy. At the moment, there is conflicting data in the literature on the incidence of etoposide hypersensitivity. The aim of this study is to assess etoposide hypersensitivity incidence and to evaluate potential risk factors for hypersensitivity in pediatrics.Methods: Retrospective study of pediatric patients treated with etoposide since June 2013 until September 2020. Symptoms of hypersensitivity, grade of hypersensitivity reaction according to the Common Terminology Criteria for Adverse Events guidelines and management of hypersensitivity reaction data were collected.Results: 213 patients were treated with etoposide during the period of the study. The mean age was 6.8 (range 0.2-17 years), 58.7% were male. Doses administered ranged from 100-200 mg/m2 and from 2.5-6 mg/kg, median infusion rate was 55 (2-200) mg/h and median infusion concentration was 0.3 (0.2-0.5) mg/ml. Hypersensitivity reactions occurred in 23 (10.8%) patients, 3 and 20 cases were classified as grade I and II respectively. All hypersensitivity reactions were successfully managed with medication and reduction of the infusion rate. No statistical significant association between the variables collected and the apparition of hypersensitivity reactions was found.Conclusions: The incidence of hypersensitivity reaction was higher than the described in the summary of products characteristics. All reactions were mild being resolved by standard treatment. (AU)

Introducción: Existen datos contradictorios en la literatura sobre la incidencia de hipersensibilidad a etopósido. El objetivo de este estudio fue evaluar la incidencia de hipersensibilidad asociada a etopósido y posibles factores de riesgo asociados en pacientes pediátricos en un hospital de tercer nivel.Métodos: Estudio retrospectivo de pacientes pediátricos tratados con etopósido desde junio de 2013 hasta septiembre de 2020. Se recogieron los datos acerca de síntomas asociados a la reacción de hipersensibilidad, grado de la reacción de hipersensibilidad según la Common Terminology Criteria for Adverse Events Guidelines y el manejo de la reacción de hipersensibilidad.Resultados: Se identificaron 213 pacientes tratados con etopósido. La mediana de edad fue de 6,75 (rango 0,16-17 años), el 58,68% eran hombres. Las dosis administradas variaron entre 100-200 mg/m2 y 2,5-6 mg/kg, las medianas de velocidad de infusión y concentración fueron 55 (2-200) mg/h y 0,3 (0,2-0,5) mg/ml respectivamente. Las reacciones de hipersensibilidad ocurrieron en 23 (10,8%) pacientes, clasificadas como grado I (3) y II (20). Todas las reacciones fueron manejadas con éxito mediante medicación y reducción de la velocidad de infusión. No se encontró asociación estadística entre las variables evaluadas y las reacciones de hipersensibilidad.Conclusiones: La incidencia de reacciones de hipersensibilidad fue superior a la descrita en ficha técnica. Todas las reacciones fueron moderadas y manejadas con tratamiento estándar. (AU)

Carcinoma de células pequeñas en la unión gastroesofágica / Gastroesophageal junction small cell carcinoma

Resumen Los tumores de células pequeñas extrapulmonares pueden aparecer en múltiples órganos y forman una rara afección clínico-patológica de tumores neuroendocrinos, con gran proliferación epitelial y con comportamiento biológico agresivo. El tubo gastrointestinal es la fuente más común de tumores de células pequeñas extrapulmonares. Nuestro caso clínico describe un paciente con carcinoma de células pequeñas en la unión gastroesofágica, que fue diagnosticado en el contexto de sangrado de tubo digestivo alto. Se excluyó un tumor pulmonar primario; el paciente recibió quimioterapia, quimiorradioterapia y radioterapia cerebral profiláctica, con buena evolución clínica. Nuestro caso se trata de una rara afección clínica, lo que evidencia la importancia de diagnosticar enferemedades poco frecuentes. Existe poca evidencia en la bibliografía de cómo deben tratarse estos pacientes.

Abstract Extrapulmonary small cell carcinomas (EPSCC) can arise in multiple organ sites and form a rare clinicopathological entity of high proliferative epithelial neuroendocrine tumors with aggressive biological behavior. Gastrointestinal is the most common source of EPSCC. We report a case of gastroesophageal junction small cell carcinoma, which was diagnosed in the context of upper gastrointestinal bleeding. A primary small cell lung carcinoma was excluded. Chemotherapy, neoadjuvant chemoradiotherapy and prophylactic cranial radiotherapy were given, with good clinical outcome. Our case of a very rare condition highlights the importance of recognizing atypical pathologic diagnoses. More research needs to be conducted with EPSCC patients in order to better characterize disease pathogenesis, and an optimal disease management.

Acompanhamento farmacoterapêutico de pacientes com câncer de pulmão, em tratamento no HCI/INCA

...Muitos pacientes com doenças que ameaçam a vida, como o câncer, não selimitam ao tratamento prescrito pelo médico assistente e, na esperança da cura, buscam tratamentos alternativos cujos resultados são de difícil avaliação (Beijnen e Schellens, 2004). No anseio da cura ou mesmo do alívio de sintomas, se automedicam por repetição de prescrições anteriores ou por indicação de parentes ou amigos (Arrais et al., 1997) e usam substâncias de efeito indeterminado como fitoterápicos e produtos naturais (Turolla e nascimento, 2006). Esse cenário, apesarde presumido, não pode ser avaliado precisamente, uma vez que freqüentemente não é relatado pelo paciente ao seu médico assistente (Rockwell et al., 2005).Assim, pouco se sabe sobre a prevalência de uso de produtos alternativos e do risco da ocorrência de reações adversas decorrentes de interações medicamentosas (Elmer et al., 2007). Na vigência da quimioterapia antineoplásica, devido à estreitamargem terapêutica, a possibilidade dessas associações cria um quadro maior de incertezas, pela possibilidade de potencialização de toxicidades, elevando-as a graus inaceitáveis (Oates, 2006; Rockwell et al., 2005).Dentro desse contexto, a intervenção do farmacêutico pode representarrecurso poderoso na identificação dessas interações (Weideman,1999; Batlle, 2002; ASPH, 1995; Ikeda et al., 2005, Chumney e Robinson, 2006), as quais pioram a qualidade de vida do paciente, interferem no tratamento e podem ser fatais (Mcleod, 1998). Em nosso estudo, o farmacêutico se colocou em contato direto com o paciente em tratamento quimioterápico antineoplásico, para identificação do uso de medicamentos prescritos e não prescritos, incluindo medicamentos alopáticos e fitoterápicos e de produtos naturais e para caracterização da ocorrência de reações adversas clinicamente significativas, buscando a proposição de uma prática quecontribua para melhoria da assistência ao paciente, com relação a prevenção emanejo das reações adversas.

Patients with lung cancer demand special care not only because of the symptoms and complications due to the progression of the disease, but also because of agerelated comorbidities, continuous use of drugs and use of non-authorized products for intended therapeutical purposes. Because of the narrow safety range of chemotherapy agents, these drug associations may lead to increased toxicities. The main objective of our study was to evaluate the safety of the chemotherapy treatment used for patients with lung cancer in HCI/INCA, in order to improve the quality of the oncologic care. We developed a methodology of pharmacotherapeutic follow-up in order to characterize the frequency and the severity of clinically significant adverse events and to identify the use of prescribed and non-prescribed products, including conventional drugs, phytotherapy and non-authorized therapeutical products. The strategy of pharmacotherapeutic follow-up was based on patient interviews, consults to the patient’s clinical records and laboratory exams and consults to the clinical staff, with no intervention on the definition of clinical conducts. We evaluated 62 patients who were treated exclusively with chemotherapy protocols combining cisplatin or carboplatin to etoposide. The patients had median age of 61years-old (95%CI 59-64), with previous history of tobbacco use (85%) and presence of comorbidities (61%), hypertension being the most frequent (40%). Most patients had advanced disease, with non-small cell lung cancer being predominant (84%) and adenocarcinoma the most frequent hystologic type (56%). Comparing the protocols with carboplatin or cisplatin, we found significant difference on the frequency of emesis, which was more frequent in the group treated with cisplatin, and thrombocitopenia, which was more frequent in the group treated with carboplatin. However, the protocols did not differ on the risk of severe toxicities (grades III or IV). Therefore, we evaluated the global risk of the chemotherapy treatment, regardless of the platinum agent used. We found increased relative risk of hematological toxicities (neutropenia, febrile neutropenia, anemia and thrombocitopenia), gastrointestinal toxicities (constipation, nausea, emesis, mucositis, abdominal pain and diarrhea) and dermatological toxicities (alopecia, itching e desquamation). There was also increased risk of severe toxicities (grades III or IV) for neutropenia (68%), febrile neutropenia (27%) and constipation (34%). The drugs used previously to the chemotherapy treatment included: analgesics (42%), opioid analgesics (40%), anti-hypertensives (40%), antiulcer e antacids (39%). Non-prescribed drugs were reported by 24% of the patients, laxatives being the most frequently used (14%). During the chemotherapy treatment, there was a significant increase in the use of the following agents: antiemetic (100%), propellant (64%), anti-ulcer and antacid drugs (43.5%), antimicrobial agents (39%), axatives (37%), opioid analgesics (21%) and anxyolitics (21%). We also found increase on the use of non-prescribed drugs (24%), laxatives presenting the higher increase (17%). Taken together, these results suggest that the pharmacological support to adverse events should be improved, particularly with relation to the revention of febrile neutropenia and to the prevention and treatment of constipation. The methodology developed here may contribute for implantation of the practice of pharmaceutical care in HCI/INCA.