Martin Fehr

Primary manifestation of small lymphocytic lymphoma in the prostate.

Background: Infiltration of non-haematopoietic organs by small lymphocytic lymphoma/chronic lymphocytic leukaemia (SLL/CLL) is not unusual in late-stage disease and thus quite frequently encountered in post-mortem examinations. However, primary manifestation of SLL/CLL in the prostate is rarely diagnosed. Patients and Methods: We report two cases of primary prostatic SLL/CLL, in one case in combination with prostate carcinoma, and discuss diagnostic pitfalls, pathophysiological mechanisms and therapeutic management, together with an overview of the literature. Conclusions: Lymphocytic infiltration of the prostate associated with obstructive symptoms is rare but can already occur in very early disease. Microscopically, SLL/CLL infiltration can be distinguished from chronic prostatitis by its pattern of infiltration and by immunohistochemistry. As the incidence of both SLL/CLL and prostatic carcinoma increases with age, composite tumours might occur more often in the future.

Metastatic Angiosarcoma Arising From the Right Atrium: Unusual Presentation and Excellent Response to Treatment in a Young Patient

36-year-old male patient presented with rapidly progressive dyspnea over 3 weeks. Computed tomography scan showed a tumor in the right atrium, multiple bilateral pulmonary nodules, and ground-glass infiltrates. Histology obtained by wedge resection of a lung nodule revealed a high-grade epithelial angiosarcoma. Therefore, the patient was diagnosed with angiosarcoma from the right atrium with multiple lung metastases. During the 2 weeks of diagnostic workup, the dyspnea had worsened to New York Heart Association grade IV, and a repeated computed tomography scan showed rapidly progressing pulmonary metastases and infiltrates (Figure 1A). The decision was taken to quickly initiate chemotherapy with doxorubicin (75 mg/m 2 ) and ifosfamide (7500 mg/m 2 ) every 3 weeks. After two cycles of chemotherapy treatment, the patient’s overall condition had markedly improved, and the dyspnea was reduced to New York Heart Association grade I. A partial remission was achieved after six cycles of combination chemotherapy (Figure 1B). Four months later, progression of the primary tumor in the right atrium was diagnosed as well as slightly progressive pulmonary metastases. To avoid the danger of complete obstruction of the right atrium (Figure 2A), we decided to treat the patient with a combination of radiotherapy (22 fractions of 2 Gy) to the right atrium and weekly paclitaxel (80 mg/m 2 weekly). The local response to treatment was good with a marked reduction of the atrial tumor mass (Figure 2B). A few months later, however, there was new evidence of liver metastases. At that point, the patient refused any further treatment. He died 12 months after the initial diagnosis due to an acute intraabdominal hemorrhage most likely deriving from the rapidly progressive liver metastases. DISCUSSION Primary cardiac angiosarcoma (PCA) is an uncommon diagnosis although it is the most frequent primary malignant tumor of the heart. Seventy-five percent of PCA occur in the right heart, especially the right atrium. 1 Complete resection of localized tumors is the treatment of choice in PCA, and there are anecdotal reports of long

Spontaneous Pneumothorax During Chemotherapy: A Case Report

Background: Spontaneous pneumothorax (SP) associated with malignant disease is relatively infrequent but has important diagnostic and therapeutic implications. Case Report: We describe a case of SP that occurred during chemotherapy with ifosfamide and doxorubicin in a patient with an advanced pleomorphic sarcoma. The pneumothorax developed secondary to the rapid regression of peripheral pulmonary metastases presumably resulting in bronchopleural fistula formation. After treatment with chest tube drainage, the patient recovered and chemotherapy could be continued without further complications. Discussion: We discuss different pathophysiological mechanisms and the clinical context of SP in sarcoma patients and give an overview of the literature and different treatment options.

Carboplatin dose based on actual renal function: no excess of acute haematotoxicity in adjuvant treatment in seminoma stage I

Introduction The practice of carboplatin dosing is not concordant among different centres and oncologists. Some clinical guidelines recommend capping of the carboplatin dose at, for example, creatinine-clearance (Crea-Cl) of 125 mL/min because of concerns of excessive toxicity. Clinical data to support such recommendations are lacking, especially in patients with seminoma. Methods This is a retrospective analysis of acute haematotoxicity of patients with stage I seminoma treated with adjuvant carboplatin area under the curve (AUC) 7 in routine practice in two Swiss centres in 2005–2015, and a comparison of incidence and grade (according to Common Terminology Criteria for Adverse Events v4.0) of haematological adverse events (hAEs) in patients with Crea-Cl <125 mL/min vs >125 mL/min without dose capping. Results 74 patients with 229 documented measurements were included (median 3/patient). A total of 151 hAEs occurred. Platelet nadir occurred earlier than median white cell/neutrophil count (median day 15 vs day 22; P<0.0001). The majority of hAEs were mild, with more than 80% being of grade 1. Only two (2.7%) clinically relevant hAEs necessitating subsequent interventions occurred (one patient received platelet transfusion, one patient with febrile neutropaenia). Haematological toxicities were not statistically different in patients dosed with Crea-Cl >125 mL/min versus those with Crea-Cl <125 mL/min. No hAEs other than grade 1 occurred before day 10 and after day 24. Conclusions Toxicity after single-dose carboplatin AUC 7 is generally mild. No excess of toxicity occurs in patients with high Crea-Cl above 125 mL/min, and therefore dose capping is not routinely necessary. In addition, this study provides a rationale for efficient use of healthcare services without compromising patients’ safety.

Early Postoperative FDG-PET-CT Imaging Results in a Relevant Upstaging in the pN2 Subgroup of Stage III Colorectal Cancer Patients

Micro‐Abstract Our institutional approach for follow‐up recommending an early postoperative 18fluor‐deoxy‐glucose (FDG)‐positron emission tomography (PET)‐computed tomography (CT) imaging in stage III colorectal cancer patients with ≥4 locoregional lymph node metastases (pN2) was evaluated. In 7 of 50 patients, the postoperative FDG‐PET‐CT imaging resulted in a relevant change of the therapeutic management because of detection of new malignant disease. The number needed to screen was 7. Therefore, early postoperative FDG‐PET‐CT imaging represents a valuable tool to detect new macrometastases in the subgroup of pN2 cM0 colorectal cancer patients. Introduction Clinical practice guidelines regarding follow‐up in patients after curative resection of colorectal cancer (CRC) vary widely. Current follow‐up recommendations do not include additional postoperative imaging before starting adjuvant treatment in any patients. We evaluated the potential benefit of our institutional approach, recommending 18fluor‐deoxy‐glucose (FDG)‐positron emission tomography (PET)‐computed tomography (CT) imaging in CRC stage III patients with ≥4 locoregional lymph node metastases (pN2). Patients and Methods Our study included all patients from a single center with complete resection of a pT1‐4, pN2, cM0 CRC. All patients were considered free of distant metastases on the basis of preoperative CT imaging of the chest, abdomen, and pelvis. The main objective of the present study was to assess the proportion of patients with changes of therapeutic management (defined as any other treatment than the preplanned adjuvant chemotherapy) because of the results of additional postoperative FDG‐PET‐CT imaging. Results Fifty patients (22 female/28 male) were included; the median age was 64 years (range, 37‐78 years). Previously undiagnosed metastatic disease resulting in a change of the therapeutic management was detected using postoperative FDG‐PET‐CT imaging in 7 patients (14.0%; 95% confidence interval, 5.8%‐26.7%). The number needed to screen to detect new or previously occult metastases was 7 (7 of 50). Conclusion To our knowledge, this is the first study to evaluate the role of an additional postoperative FDG‐PET‐CT scan before adjuvant treatment in patients with completely resected CRC with ≥4 lymph node metastases (pT1‐4, pN2) and without distant metastases on preoperative CT imaging (cM0). Postoperative FDG‐PET‐CT imaging represents a valuable tool for the detection of new macrometastases in the subgroup of pN2 cM0 CRC patients. The low number needed to screen for consequent therapeutic changes is clinically relevant and should be further evaluated.

CXCR4-Antagonist: Plerixafor verbessert die Mobilisierung in der autologen hämatopoetischen Stammzelltransplantation

tischen Stammzelltransplantation (HSZT) bestimmt, kann die Übertragung jedoch nur dann durchgeführt werden, wenn eine ausreichende Menge an CD34+ Zellen aus dem peripheren Blut gewonnen werden kann. Dabei gelten zwei Millionen CD34+ Zellen pro kg Körpergewicht als Minimum für eine erfolgreiche Transplantation, wünschenswert ist jedoch eine Zielzellzahl von fünf Millionen Stammzellen pro kg Körpergewicht. Deshalb galt in der Folge die besondere Aufmerksamkeit möglichen Prädiktoren für eine erfolgreiche Mobilisierung und Strategien, mit denen einer schlechten Mobilisierung begegnet werden kann. Das bisher zur Mobilisierung von Stammzellen in das periphere Blut eingesetzte G-CSF hat den Nachteil, dass der ideale Zeitpunkt für die Apherese sowie die Anzahl der erforderlichen Sitzungen schlecht vorhersagbar sind. Bei einigen Patienten können trotz mehrerer Sitzungen im Verlauf von mehreren Tagen unter G-CSF allein nicht genügend CD34+ Zellen für eine Transplantation gesammelt werden. «Für diese Patienten stehen seit kurzem echte Verbesserungen zur Verfügung», so Chabannon: Eine neue Generation leistungsfähiger Zellseparatoren wurde eingeführt und der CXCR4Antagonist Plerixafor zugelassen.