Infradiaphragmatic Nodes Research Articles

Baseline volumetric parameters of PET/CT <sup>18</sup>F-FDG and international prognostic index at patients with diffuse B-cell large cell lymphoma

INTRODUCTION: Metabolic tumor volume (MTV) and Tumor lesion glycolysis (TLG) are used in 18F-fluorodeoxyglucose Positron-Emission Tomography combined with Computed Tomography (18F-FDG PET/CT) as biometric markers in whole tumor. International prognostic index (IPI) has been used during 30 years at patients with diffuse B-cell large cell lymphoma (DLBCL) for prognosis, use MTV and TLG was unknown. Our aims were to determinate the best statistical relationship between MTV, TLG and IPI in patients with DLBCL.OBJECTIVE: Complex study of baseline volumetric parameters PET/CT with 18F-FDG at patients with DLBCL and assessment of their correlation with prognostic groups.MATERIALS AND METHODS: Baseline 18F-FDG PET/CT performed in 31 primary patients with DLBCL and evaluated SUVmax, MTV, TMTV, TLG, TTLG at different involved anatomic zones; correlation between PET biomarkers and prognostic groups of patients.Statistics: The research materials were subjected to statistical processing using the methods of correlation and regression analyses.RESULTS: SUVmax mean level didn’t discerned at patients of low and high-risk groups, but TMTV has been less in favorable prognostic, than in unfavorable groups (152±3.0 sm3 vs 890±178 sm3 p<0,01); the same TTLG (1291±474 g/ml×sm3 vs 7640±2067 g/ml×sm3 , p<0.01) and IMA (6.7±0.7 vs 9.2±0.6; p<0,01). All volumetric parameters have been less at patients with supradiaphragmatic lymph nodes, than infradiaphragmatic lymph nodes and bones too. Significant positive correlation was found between the TMTV u TTLG (p=0.965; p<0,001), between TMTV, TTLG and progressive disease risk (p=0.735; p=0.747; p<0,001). The regression analysis was derived to estimate the connection PET biomarkers and progressive disease risk.DISCUSSION: The 30-year experience of using IPI in assessing the prognosis of patients with DLBCL has shown its insufficient effectiveness in many clinical situations, and the R-IPI prognostic model has been tested on a smaller number of patients and can only be considered additionally. We studied in detail the initial volumetric parameters of patients with DLBCL in different regions of the lesion and their relationship with the level of prognosis according to the IPI criteria. Our data on large values of volumetric parameters in the infradiaphragmatic areas and bones may be related to the worse prognosis in patients with these localizations. Further broader studies of the initial volumetric biomarkers of PET in DLBCL patients will contribute to the development of approximate boundaries of specific volumetric parameters for different tumor localizations.CONCLUSION: The results obtained showed that the baseline volumetric parameters PET/CT at patients with DLBCL have significant connection with prognostic groups of patients and can be additional factors to influence of tactics of therapy.

Dissemination patterns of Hodgkin lymphoma using a probability network model based on [18F]-FDG PET/CT.

The preferred hypothesis for the dissemination patterns of Hodgkin lymphoma (HL) is the contiguity hypothesis. However, this hypothesis is based on studies performed before the advent of [18F]-FDG PET/CT which is now the established reference for HL staging. This study aims to extract the dissemination patterns of HL using [18F]-FDG PET/CT and a probability network model. We retrospectively analyzed [18F]-FDG PET/CT performed for initial staging of patients with classical HL. The HL involvement status (presence of absence) was reported for 19 supra- and infra-diaphragmatic lymph node regions and 4 extranodal regions (lung, spleen, liver, and osteo- medullary). The analysis of HL dissemination was carried out using HL involvement status for all regions through 3 distinct methods: comparison of nearby lymph node regions, correlation assessment between all regions and relationship strength between all regions using Ising network model. A total of 196 patients were included. Our results showed strong relationships between nearby involved lymph node regions (for example between the left pelvic and the abdominal lymph node regions (relationship strength = 0.980)) and between more distant regions (for example between right and left axillary lymph node regions (strength = 0.714)). Furthermore, involvement of the infra-diaphragmatic lymph node regions was significantly correlated with Ann Arbor stage IV (phi = 0.56, p < 0.001). This study confirms the hypothesis of lymphatic dissemination of HL in a contiguous mode, with additional links between more distant regions. These predictable dissemination patterns could be useful for the initial staging assessment of patients with HL using [18F]-FDG PET/CT.

411 AN UNEXPECTED (AND UNDESIRED) ECHOCARDIOGRAPHIC FINDING IN A PATIENT WITH RIGHT-SIDED CHEST PAIN

Abstract A 71-year-old man, former smoker, without other cardiovascular risk factors nor previously known cardiological history, was admitted to our emergency department for nonproductive cough and right-sided chest pain, worsened by inspiration. ECG documented reduced peripheral QRS voltages. Echocardiography was performed, revealing the presence of an inhomogeneous, hyperechoic neoformation involving the lateral wall of the right ventricle (RV), dislocating the right coronary artery, protruding into the cavity towards the intraventricular septum and reaching the sub-valvular apparatus of the tricuspid valve, without any hemodynamic interference. Pericardial effusion was also documented (maximum 20 mm around the atrioventricular groove), without signs of cardiac tamponade. For better mass characterization, a computed tomography (CT) scan and a cardiac magnetic resonance (CMR) were performed, confirming the presence of a solid neoformation involving the RV and pericardial effusion, also showing right pleural effusion. Furthermore, right hilar and subcarinal lymphadenomegaly with compression of the bronchi was observed. A positron emission tomography (PET) scan showed areas of increased 18-fluorodeoxyglucose (18FDG) uptake in supra- and infra diaphragmatic lymph nodes, adrenal glands, bones, and lungs. Due to the clinical suspicion of a lymphoproliferative neoplasm, corticosteroid therapy was started. Before a diagnostic lymph node biopsy could be performed, the patient had a syncopal episode due to cardiac tamponade, requiring pericardiocentesis. During hospitalization, continuous heart monitoring revealed intermittent third-degree atrioventricular block, so a permanent pacemaker was implanted. Finally, an excisional lymph node biopsy was obtained, and a diagnosis of diffuse large B-cell lymphoma was established. Treatment with Prednisone, Cyclophosphamide, Vincristine, nonpegylated liposomal Doxorubicin, and Rituximab (R-COMP) was promptly started. Seven months later, after five cycles of chemotherapy, complete remission was documented by PET scan, and the cardiac mass was no longer evident at echocardiography. Metastatic involvement of the heart is a relatively frequent event in oncologic patients, with an estimated prevalence of 8% at autopsy. Lymphoproliferive neoplasms have a not negligible rate of heart mestastatization (9,4%). Neoplastic invasion secondary to lymphoma tends to infiltrate the myocardium, typically causing arrhythmias and conduction disturbances. Diagnostic evaluation relies upon echocardiography, CT and CMR. PET/TC is of paramount importance to assess the malignant nature of the mass, to stage the disease and to evaluate the response to chemotherapy. Metastatic cardiac involvement typically occurs as a late manifestation of disseminated lymphoma and the prognosis is usually poor; however, survival is increasing thanks to new chemo-immunotherapy strategies.

A Challenging Case of PTLD-Related Broncho-Esophageal Fistula After Lung Transplantation

<h3>Introduction</h3> Post-transplant lymphoproliferative disease (PTLD) is a complication often encountered after lung transplantation (LTx). We present a case where necrotic subcarinal lymph nodes (LNs) affected by PTLD caused a large broncho-esophageal fistula, for which all treatment options were exhausted. <h3>Case Report</h3> A 64-year-old LTxrecipient presented with a 1.5-month history of fever and general weakness, 11 years after bilateral LTx for IPF and 4 years after redo LTx for BOS. PET/CT revealed hypermetabolic subcarinal, paratracheal, supraclavicular and infra-diaphragmatic LNs (image A). EBV-associated diffuse large B-cell lymphoma (DLBCL)-PTLD was confirmed on supraclavicular LN biopsy. The patient had to be intubated for respiratory failure due to pneumonia, prior to initiating PTLD-specific treatment. An underlying bilateralbroncho-esophageal fistula was diagnosed by chest computed tomography (CT) (image B) and confirmed with esophagoscopy and bronchoscopy. Treatment of the DLBCL consisted of reduction of tacrolimus, discontinuation of mycophenolate mofetil, steroids, rituximab, and cyclophosphamide. Esophagostomyand gastrostomy were performed to prevent airway aspiration. Despite broad-spectrum antibiotics and antifungals, the patient developed neutropenic sepsis due to respiratory infection as well as probable invasive pulmonary aspergillosis. Twenty days after surgical intervention, chest CT (image C) and bronchoscopy (image D) showed that the posterior side of the airway below the carina was completely eroded. No therapeutic options remained, and the patient passed away. <h3>Summary</h3> Management of a broncho-esophageal fistula resulting from PTLD following LTx is challenging. Due to erosion of necrotic subcarinal LNs, surgical intervention was performed to prevent ongoing infection precipitated by PTLD-specific treatment.

Aanhoudende koorts zonder focus met lymfadenopathieën: infectie, inflammatie of maligniteit?

Persistent fever without focus but with lymphadenopathy: infection, inflammation or malignancy? Adult-onset Still’s disease (AOSD) is a rare auto-inflammatory disease in which four cardinal signs have been described: rash, spiking fever, arthritis or arthralgia and hyperleucocytosis with neutrophilia. Nevertheless, diagnosis can be challenging as infectious, other inflammatory or neoplastic diseases need to be ruled out. It affects typically young adults (from 16 to 35 years). The disease can be controlled with non-steroidal anti-inflammatory agents and glucocorticoids. To date, treatments as Il-6, IL-1 or anti-TNFα can be used in glucocorticoid-dependent or refractory patients. We present a case of a 22-year old woman with all four cardinal symptoms in which all cultures and infectious serology resulted negative. Also, auto-immune markers were negative. Because of diffuse bilateral supra- and infradiaphragmatic enlarged lymph nodes up to 1.6 cm in size on computed tomography (CT), additional positron emission tomography-computed tomography imaging (PET-CT-scan) was performed. Besides the multiple enlarged lymph nodes, increased tracer capture was shown in the spleen and bone marrow. All of this was suspicious for high-grade lymphoma. Eventually, an additional bone marrow biopsy with aspiration and lymph node biopsy could rule out a lymphoproliferative process and the diagnosis of AOSD could be made. This case report highlights the importance of a profound diagnostic work-up in fever of unknown origin.

Value of the 18F-choline PET/MR hybrid technique on the therapeutic approach in patients with prostate cancer treated with prostatectomy and elevation of prostate specific antigen levels less than 1 ng/ml

ObjectiveTo assess the detection rate of 18F-Choline PET/MRI and subsequent changes in therapy approach for patients with prostate cancer treated by prostatectomy and with rising levels of PSA <1ng/ml. MethodsProspective study with our first 36 patients with prostatectomy for prostate cancer and rising levels of PSA, who were referred for an 18F-Choline PET/MRI study.A dual-phase study was acquired after intravenous administration of 185±10% MBq of 18F-Choline: (1) early imaging (immediately after tracer administration) of prostate area (emission PET/Multiparametric MRI). (2) Whole-body imaging 1h after tracer injection (emission PET/MRI: T1, T2, STIR, diffusion).The therapy approach for patients was decided upon the Oncology Committee consensus based on 18F-Choline PET/MRI findings. ResultsTwenty out of 36 patients (55.6%) were positive for the 18F-Choline PET/MRI study: 8 (22.2%) within the prostatectomy bed, 7 (19.4%) with infradiaphragmatic lymph nodes, 4 (11.1%) with local recurrence and infradiaphragmatic lymph nodes, and 1 (2.8%) with bone metastasis.Sixteen out of the 36 patients (44.4%) were negative for the 18F-Choline PET/MRI study.18F-Choline PET/MRI findings had an impact on the therapy approach to follow: 15 patients (41.6%) showed oligometastatic disease which was treated by imaging-guided radiotherapy, 5 (13.9%) with multiple metastatic disease were treated by androgen deprivation therapy, 16 (44.4%) negative were under active surveillance. ConclusionHybrid 18F-Choline PET/MRI procedure showed a high detection rate for recurrence in prostate cancer patients treated with prostatectomy and rising PSA levels <1ng/ml, and 18F-Choline PET/MRI findings resulted in a better tailored therapy approach delivered to our patients.

Impacto de la tecnología híbrida PET/RM con 18F-colina en la estrategia terapéutica de los pacientes con cáncer de próstata tratados con prostatectomía que presentan elevación del antígeno prostático específico inferior a 1 ng/ml

ObjectiveTo assess the detection rate of 18F-Choline PET/MRI and subsequent changes in therapy approach for patients with prostate cancer treated by prostatectomy and with rising levels of PSA <1 ng/ml. MethodsProspective study with our first 36 patients with prostatectomy for prostate cancer and rising levels of PSA, who were referred for an 18F-Choline PET/MRI study.A dual-phase study was acquired after intravenous administration of 185±10% MBq of 18F-Choline: 1) early imaging (immediately after tracer administration) of prostate area (emission PET/Multiparametric MRI). 2) whole-body imaging 1 h after tracer injection (emission PET/MRI: T1, T2, STIR, diffusion).The therapy approach for patients was decided upon the Oncology Committee consensus based on 18F-Choline PET/MRI findings. ResultsTwenty out of 36 patients (55.6%) were positive for the 18F-Choline PET/MRI study: 8 (22.2%) within the prostatectomy bed, 7 (19.4%) with infradiaphragmatic lymph nodes, 4 (11.1%) with local recurrence and infradiaphragmatic lymph nodes, and 1 (2.8%) with bone metastasis.Sixteen out of the 36 patients (44.4%) were negative for the 18F-Choline PET/MRI study.18F-Choline PET/MRI findings had an impact on the therapy approach to follow: 15 patients (41.6%) showed oligometastatic disease which was treated by imaging-guided radiotherapy, 5 (13.9%) with multiple metastatic disease were treated by androgen deprivation therapy, 16 (44.4%) negative were under active surveillance. ConclusionHybrid 18F-Choline PET/MRI procedure showed a high detection rate for recurrence in prostate cancer patients treated with prostatectomy and rising PSA levels <1 ng/ml, and 18F-Choline PET/MRI findings resulted in a better tailored therapy approach delivered to our patients.

Chylothorax: The Unusual Suspect

AbstractA chylothorax results when the lymphatic duct becomes disrupted. It is an uncommon and poorly described complication of both Hodgkin’s and non-Hodgkin’s lymphomas of any histological type and grade. A 62-year-old female presented with dyspnea on exertion and dry cough for 15 days. Chest radiograph showed left-sided effusion. Pleural fluid reports were suggestive of chylothorax. Fluid was drained and CT thorax was performed which revealed multiple supra- and infradiaphragmatic lymphadenopathy. Left supraclavicular lymph node biopsy revealed chronic inflammation. Immunohistochemistry of the same sample was reported as non-Hodgkin’s lymphoma of follicular type grade I/III (2008). Positron emission tomography-computed tomography (PET-CT) showed hypermetabolic areas in supra- and infradiaphragmatic lymph nodes and also in multiple bones (with surrounding regions encasement). Patient has received two cycles of chemotherapy with Bendamustine and Rituximab. She is on regular follow-up with the oncologist and doing fine.

Abstract 2652: Favorable outcome of primary mediastinal large B-cell lymphoma treated by Dose Adjusted EPOCH-Rituximab regimen

Abstract Background Primary Mediastinal Large B-Cell Lymphoma (PMLBCL) is a unique type of B-cell lymphoma probably arising from a putative thymic medulla B-cell. One to 2% of NHL, 7% of all diffuse large B-cell lymphomas (DLBCL), occurring more often in young females. Often presents with superior vena cava syndrome and airway compromise. Treatment is with chemotherapy combined with Rituximab, followed by involved field radiation therapy to mediastinum. PMLBCL has better outcome than others DLBCL. We aimed to develop a more dose-dense/intense regimens that improves the rate of cure with an attempt to avoid mediastinal radiation. Patients and methods A prospective study was conducted in our department from January to December 2015, in 6 patients with untreated primary mediastinal B-cell lymphoma. An infusional dose-adjusted etoposide, doxorubicin, and cyclophosphamide with vincristine, prednisone, and rituximab (DA-EPOCH-R) has been administred according to the protocol Day 1 : Rituximab 375 mg/m2 IV Day 1-4 : Etoposide 50 mg/m2 IV, Doxorubicin 10 mg/m2 AND Vincristine 0.4 mg/m2 Day 5 : Cyclophosphamide 750 mg/m2 Days 1-5 : Prednisone 60 mg/m2 PO BID. Administer G-CSF 5 mcg/kg SQ on day 6 until ANC exceeds nadir Cycles were repeated every 3 weeks for a toal of 6 cycles Results The median age of the patients was 32 years, the male to female ratio : 2:4. Systemic symptoms mainly fever and weight loss, were present in all cases; increased LDH levels were also observed in 50% of cases. Majority of the patients (83%) presented with stage I/II disease, bulky mass with a median tumor diameter 15 cm. Most had features of local extension like pleuro-pericardial effusion. Absence of infradiaphragmatic lymph nodes and no bone marrow involvement at presentation. All patients required biopsy from the mediastinal mass by image guided core biopsy. The patients were treated by RDA-EPOCH, they received 4 to 6 courses, without involved field radiotherapy (only one patient underwent radiotherapy for residual mass). No late morbidity or cardiac toxic effects were found in any patients. After 24 months of follow-up, one patient still received treatment and was not evaluable. 5 patients achieved complete remission and were disease-free at the last visit. Conclusion PMBCL is a specific lymphoma entity seen in the young with good survival. It has a distinct clinical behavior and prognosis, and therefore require a different therapeutic approach. The R/DA-EPOCH regimen need to be confirmed in further prospective study for a large cohort. Note: This abstract was not presented at the meeting. Citation Format: Fatiha Grifi, Soraya Bougherira. Favorable outcome of primary mediastinal large B-cell lymphoma treated by Dose Adjusted EPOCH-Rituximab regimen [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2652. doi:10.1158/1538-7445.AM2017-2652

Prognostic importance of metabolic tumor parameters on initial FDG-PET/CT in patients with isolated infradiaphragmatic Hodgkin’s lymphoma

Background/Aim. Isolated infradiaphragmatic lymph node involvement is not common and makes up 5?13% of stage I-II Hodgkin?s lymphoma. Important subjects about prognostic factors and optimal treatment of isolated infradiaphragmatic Hodgkin?s lymphoma (II HL) have not been clearly defined. We aimed to evaluate the prognostic value of metabolic tumor indices on initial 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) through quantitative PET/CT parameters together with the classical predefined risk factors for patients with II HL. Methods. This retrospective cohort study conducted between 2004 and 2015 included 21 patients for whom FDG-PET/CT were requested for primary staging. Quantitative PET/CT parameters (maximum standardized uptake value ? SUV max) average standardized uptake value ? SUV mean, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were used to estimate disease-free survival and overall survival. Results. Univariate Cox regression analysis was performed for all potential risk factors impacting metastasis/recurrence of the disease. Factors which had values of p &lt; 0.2 after univariate analysis (sex, age, stage, bulky disease, SUV max, SUV mean, MTV, TLG) were processed with the multivariate model. Sex, TLG and bulky disease were found to be statistically significant risk factors for prognosis of outcome in patients with IIHL after multivariate analysis. Conclusion. The existence of bulky disease at the diagnosis and high TLG values on primary staging by FDG-PET/CT are potential risk factors for both disease-free survival and overall survival in Hodgkin?s lymphoma with isolated infradiaphragmatic lymph node involvement.

AB0452 Sarcoidosis: An underestimated and potentially dramatic side effect of anti-TNF-α

BackgroundA 41-year-old woman native from Senegal has a 22-year history of rheumatoid arthritis (RA). The past medical history was marked by a left upper tubercular pneumopathy. In the absence of...

PET-TAC con 18F-FDG en el seguimiento de pacientes con linfoma: detección de recidivas asintomáticas

AimTo assess the diagnostic accuracy of 18F-FDG-PET/CT in detecting asymptomatic recurrences in patients with lymphoma. To define uptake patterns of recurrence indicative of recurrence. Material and methodsThose patients with lymphoma who fulfilled the following inclusion criteria of clinical complete remission and negative PET/CT study were included retrospectively and longitudinally. Conventional surveillance of these patients was performed only by 18F-FDG PET/CT following a standardized procedure. Pathologic locations (supra- and infradiaphragmatic) and their character (single or multiple) were analyzed in order to determine reliable metabolic patterns of recurrence. The final diagnosis was established by histopathological analysis or clinical follow-up greater than 8 months. ResultsA total of 199 explorations belonging to 106 patients with lymphoma were included. Of these patients, 59 had Hodgkin's lymphoma and 47 non-Hodgkin's lymphoma. There was suspicion of relapse from the metabolic point of view in 27 of the PET/CT scans. Of these, 14 (10 patients) were false positive (FP), and 13 (8 patients) true positive. The remaining studies were true negative, no false negatives being detected. The pattern most frequently related to recurrence was infradiaphragmatic lymph node involvement while most of the FP had isolated supradiaphragmatic involvement. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of PET/CT parameters for the study were 100%, 92%, 48%, 100% and 93%, respectively. Conclusion18F-FDG-PET/CT is a sensitive technique in the detection of asymptomatic recurrences in patients with lymphoma during their follow-up. Multiple character and infradiaphragmatic locations were the patterns that best correlated to the diagnosis of recurrence.

18F-FDG-PET/CT in the surveillance of patients with lymphoma: Detection of asymptomatic recurrences

AimTo assess the diagnostic accuracy of 18F-FDG-PET/CT in detecting asymptomatic recurrences in patients with lymphoma. To define uptake patterns of recurrence indicative of recurrence. Material and methodsThose patients with lymphoma who fulfilled the following inclusion criteria of clinical complete remission and negative PET/CT study were included retrospectively and longitudinally. Conventional surveillance of these patients was performed only by 18F-FDG PET/CT following a standardized procedure. Pathologic locations (supra- and infradiaphragmatic) and their character (single or multiple) were analyzed in order to determine reliable metabolic patterns of recurrence. The final diagnosis was established by histopathological analysis or clinical follow-up greater than 8 months. ResultsA total of 199 explorations belonging to 106 patients with lymphoma were included. Of these patients, 59 had Hodgkin's lymphoma and 47 non-Hodgkin's lymphoma. There was suspicion of relapse from the metabolic point of view in 27 of the PET/CT scans. Of these, 14 (10 patients) were false positive (FP), and 13 (8 patients) true positive. The remaining studies were true negative, no false negatives being detected. The pattern most frequently related to recurrence was infradiaphragmatic lymph node involvement while most of the FP had isolated supradiaphragmatic involvement. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of PET/CT parameters for the study were 100%, 92%, 48%, 100% and 93%, respectively. Conclusion18F-FDG-PET/CT is a sensitive technique in the detection of asymptomatic recurrences in patients with lymphoma during their follow-up. Multiple character and infradiaphragmatic locations were the patterns that best correlated to the diagnosis of recurrence.

Endoscopic treatment of paraesophageal abscess in eosinophilic esophagitis after chest trauma

A 19-year-old man was admitted with dysphagia, retrosternal pain, and fever after he was hit on the breastbone during an assault 10 days before. He experienced progressive chest pain despite treatment with a proton pump inhibitor. Laboratory test analyses showed signs of inflammation, with a leucocyte count of 11,400/mm3 (normal 4.0-10.0 mm3) and C-reactive protein level of 201.8 mg/L (normal < 8 mg/L). CT revealed a 12-cm, paraesophageal abscess, with enlarged mediastinal and infradiaphragmatic lymph nodes and mediastinitis (Fig.

Longitudinal Evaluation of Quality of Life and Fatigue In Hodgkin Lymphoma Patients

AbstractAbstract 935 Background:Long term impairment of quality of life (QoL) and elevated fatigue levels in Hodgkin Lymphoma (HL) survivors have been reported. However, few longitudinal data and no conclusive knowledge on components and determinants of QoL exist so far. Therefore, the German Hodgkin Study Group (GHSG) assessed the patients' QoL within the prospectively randomized studies HD10-12 for a detailed longitudinal evaluation of QoL and fatigue. Methods:QoL was assessed with a psychometrically proven questionnaire (QLQ-S) which contains the EORTC QLQ-C30 among other scales and items. Patients answered the questionnaires before, during, and at the end of therapy and at regular follow-up visits. For all QLQ-C30 functional scales and fatigue, longitudinal courses up to 27 months from diagnosis are given with means and 95%-confidence intervals. Reference values from a German control population were used for interpretation of the results. Components and determinants of QoL were analyzed with special modeling software (MPlus) which allows for full information maximum likelihood estimation of multivariate longitudinal models in the presence of missing data. The predictive value of fatigue at baseline for progression free survival and overall survival was tested in Cox proportional hazards analyses together with other known risk factors. Results:4,160 patients were included in HD10-12, and 3,208 are evaluable for this analysis (total of 15,722 assessments). Before therapy, HL patients had clearly poorer mean scores in each QoL scale when compared to the German reference population. All scales at baseline were negatively influenced by gender (females) and more advanced disease. Before therapy age ≥50 years was negatively related to physical functioning and cognitive functioning, but positively to social functioning. After a decrease of QoL during chemotherapy, all scales showed considerable improvement. However, usually long term QoL remained below normal reference values and this was most pronounced in patients ≥50 years of age and advanced stages. A QoL model with three factors (physical, mental, and social) showed very good fit (RMSEA<.05) and high stability of QoL already 12 months after diagnosis. No relevant effect of the type of treatment could be detected. Overall, 44.7% of patients never experienced severe fatigue ≥50 (relative scale from 0–100), and 17.4% had fatigue only temporarily during treatment, and 15.1% had severe fatigue before therapy which vanished after therapy. In addition, 6.8% of patients developed severe long term fatigue without being severely fatigued before, and 6% had permanently severe fatigue. Cox regression for overall survival revealed that severe fatigue at baseline is a significant, strong and independent risk factor for death from any cause (p<.05, HR= 1.5). Other significant risk factors for OS included age, infradiaphragmatic nodes, and large mediastinal mass. In contrast, gender, high ESR, extranodal involvement, B-symptoms, intermediate stages, advanced stages were not significant. Conclusion:This is the first detailed QoL and fatigue analysis in HL patients covering all stages of the disease before, during, and after therapy. QoL domains are clearly impaired before the onset of chemotherapy, but improve over time substantially. Baseline QoL is affected in considerable degree by tumor- and patient-specific characteristics. Importantly, type and intensity of HL treatment have no relevant negative impact on long term QoL or fatigue. The strong impact of severe fatigue at baseline on overall survival is currently analyzed in more detail and results will be presented. Disclosures:No relevant conflicts of interest to declare.

18F-FDG PET/CT in a case of intravascular large B-cell lymphoma

Intravascular large B-cell lymphoma (IVLBCL) is a rare systemic disease characterized by proliferation of lymphoid cells within the lumina of small arteries, veins and capillaries [1]. Due to its rarity and heterogeneous symptoms in close relationship with the involved organs such as skin, liver, lung, bone marrow, kidney or brain, the early diagnosis is difficult and often made post-mortem [2, 3]. However, treatment of IVLBCL is possible when diagnosed early. Herein, we report a case of a 61-year-old woman with IVLBCL who presented with fever and weakness. Her routine laboratory findings were uneventful except elevated serum lactate dehydrogenase (LDH) levels and sedimentation values. Imaging studies such as abdominal ultrasonography, chest and abdominal CT and echocardiography studies revealed neither evidence of tumoural lesions nor the origin of fever. Subsequently, 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) demonstrated an increased FDG uptake in multiple organs such as bilateral kidneys and adrenal glands, uterus, supra- and infradiaphragmatic lymph nodes, and multiple sites of bone marrow. The diagnosis of IVLBCL was established with kidney biopsy performed due to bilateral diffuse intense uptake of renal cortex. Histopathological examination of the renal biopsy demonstrated large atypical lymphoid cells occupying the intravascular space on haematoxylin and eosin staining. Based on the findings of the present case, we believe PET/ CT may be used for detecting locations that are involved with IVLBCL. Moreover, as mentioned in the literature, FDG PET may also have a role in monitoring response to chemotherapy.

Asymptomatic Inguinal Micropapules in a Patient Treated With Chemotherapy

The patient was a 32-year-old woman diagnosed 18 months earlier with nodular sclerosing Hodgkin lymphoma, Ann Arbor stage IIIA (supradiaphragmatic and infradiaphragmatic lymph node involvement and absence of B symptoms). She had initially been treated with 6 cycles of ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). On recurrence of the lymphoma, she was treated with 2 cycles of c-MOPP (cyclophosphamide, vincristine, prednisone, and procarbazine), which was substituted by GPD (gemcitabine, cisplatin, and dexamethasone) due to neurological toxicity (paraesthesias). It was then decided to perform autologous peripheral blood hematopoietic stem cell transplantation after conditioning with melphalan and whole-body irradiation. On day 5 after transplantation, asymptomatic skin lesions developed in both inguinal regions, initially diagnosed as candidal intertrigo. Ten days later, due to persistence of the lesions despite systemic antifungal treatment, the patient was referred to dermatology.

Severe rhabdomyolysis associated with pemetrexed-based chemotherapy

Pemetrexed is an antifolate metabolite that inhibits several enzymes involved in the folate pathway. It has activity against various solid tumours, and has been approved for treatment of malignant pleural mesothelioma on the basis of fi ndings from a randomised phase III trial. The main toxic eff ects noted for pemetrexed have been rash, myelosuppression, diarrhoea, mucositis, and reversible elevation of liver enzymes—eff ects that are preventable partly by vitamin supplementation. A 68-year-old man with malignant pleural mesothelioma had extrapleural pneumonectomy followed by external mediastinal radiotherapy (50 Gy total dose, completed in March, 2003). Because of distant disease progression involving supradiaphragmatic and infradiaphragmatic lymph nodes and a biopsy-confi rmed metastatic nodule in the mammary gland, he received 500 mg/m2 pemetrexed, given as an intravenous infusion over 10 min followed at least 45 min later by carboplatin (AUC [area under the curve] 5, given as an intravenous infusion over 60 min) in the setting of an expanded access trial in January, 2004. As requested per protocol, he was given full vitamin supplementation (ie, 400 μg folic acid a day orally and 1 mg vitamin B12 as one intramuscular injection every 9 weeks), starting 14 days before fi rst trial treatment. The patient was given 4 mg dexamethasone twice a day intramuscularly on the day before chemotherapy and the day after chemo therapy; on the day of chemotherapy, he received 16 mg dexamethasone, 50 mg ranitidine, and 8 mg ondansetron intravenously. No acute toxic eff ects were reported. On day 2 after chemotherapy, he developed severe and gradually worsening myalgias, weakness of the arms and legs, and abdominal tenderness. On day 4 after chemotherapy, he was therefore admitted to the accident and emergency department. Physical examination showed a severely ill patient with weakness in both arms and both legs. Laboratory tests on admission showed substantially increased serum concentrations of creatine kinase (21 530 U/L), myoglobin (3000 μg/L), aspartate aminotransferase (453 U/L), and alanine aminotransferase (159 U/L); serum electrolytes and renal-function tests were normal. The patient was diagnosed with rhabdomyolysis. The patient was treated with vigorous fl uid replacement with the addition of sodium bicarbonate, methylprednisolone, and furosemide. On the third day in hospital, concentration of creatine kinase decreased to 1835 U/L, and the weakness improved slowly during the following weeks. However, the patient was unable to do his normal daily activities, and 1 month later he was transferred to a long-term hospital clinic for muscular rehabilitation, at which stage serum concentrations of creatine kinase and transaminases were normal. Drug-induced rhabdomyolysis is a fairly common and potentially life-threatening syndrome associated with several drugs, including chemotherapeutic agents. In patients with cancer, rhabdomyolysis has been reported in association with exposure to high-dose interferon alfa, vancomycin after high-dose chemotherapy with peripheralblood stem-cell transplantation, and the combination of cyproterone and statins. To our knowledge, this is the fi rst report of severe and life-threatening rhabdomyolysis during pemetrexed-based chemotherapy. Moreover, to our knowledge, no cases of rhabdomyolysis have been reported as a consequence of exposure to other structurally related drugs such as methotrexate and raltitrexed. The causal association of rhabdomyolysis with pemetrexed in our patient is suggested by a temporal relation and by the absence of concomitant exposure to any other drugs potentially involved with this clinical syndrome, including statins. Although to our knowledge no cases of rhabdomyolysis have been reported with carboplatin-based regimens, with the exception of a patient with a testicular germ-cell tumour given high-dose ifosfamide, carboplatin, and etoposide and peripheralblood stem-cell transplantation, we cannot presently rule out its involvement in the pathogenesis of this particular patient. Nevertheless, we think that clinicians should be aware of this possible, although rare, complication of pemetrexed-based treatment to recognise promptly and treat successfully the potentially life-threatening disorder of rhabdomyolysis.

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG): Classen J, Schmidberger H, Meisner C, Winkler C, Dunst J, Souchon R, Weissbach L, Budach V, Alberti W, Bamberg M, Department of Radiation Oncology, Universitatsklinikum, Tubingen, Germany.

A prospective nonrandomised trial was performed in order to evaluate tumour control and toxicity of low-dose adjuvant radiotherapy in stage I seminoma with treatment portals confined to the para-aortic lymph nodes. Between April 1991 and March 1994, 721 patients were enrolled for the trial by 48 centres in Germany. Patients with pure seminoma and no evidence of lymph node involvement or distant metastases received 26 Gy prophylactic limited para-aortic radiotherapy. Disease-free survival at 5 years was the primary end point. With a median follow-up of 61 months, 675 patients with follow-up investigations were evaluable for this analysis. Kaplan-Meier estimates of disease-free and disease-specific survival were 95.8% (95% CI: 94.2–97.4) and 99.6% (95% CI: 99.2–100%) at 5 years and 94.9% (95% CI: 92.5–97.4%) and 99.6% (95% CI: 99.2–100%) at 8 years, respectively. A total of 26 patients relapsed. All except two were salvaged from relapse. In all, 21 recurrences were located in infradiaphragmatic lymph nodes without any ‘in-field’ relapse. Nausea and diarrhoea grade 3 were observed in 4.0 and 1.0% of the patients, respectively. Grade 3 late effects have not been observed so far. The results of our trial lend further support to the concept of limited para-aortic irradiation as the recently defined new standard of radiotherapy in stage I seminoma. There is no obvious compromise in disease-specific or disease-free survival compared to more extensive hockey-stick portals, which were used as standard portals at the time this study was initiated.

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG)

A prospective nonrandomised trial was performed in order to evaluate tumour control and toxicity of low-dose adjuvant radiotherapy in stage I seminoma with treatment portals confined to the para-aortic lymph nodes. Between April 1991 and March 1994, 721 patients were enrolled for the trial by 48 centres in Germany. Patients with pure seminoma and no evidence of lymph node involvement or distant metastases received 26 Gy prophylactic limited para-aortic radiotherapy. Disease-free survival at 5 years was the primary end point. With a median follow-up of 61 months, 675 patients with follow-up investigations were evaluable for this analysis. Kaplan–Meier estimates of disease-free and disease-specific survival were 95.8% (95% CI: 94.2–97.4) and 99.6% (95% CI: 99.2–100%) at 5 years and 94.9% (95% CI: 92.5–97.4%) and 99.6% (95% CI: 99.2–100%) at 8 years, respectively. A total of 26 patients relapsed. All except two were salvaged from relapse. In all, 21 recurrences were located in infradiaphragmatic lymph nodes without any ‘in-field’ relapse. Nausea and diarrhoea grade 3 were observed in 4.0 and 1.0% of the patients, respectively. Grade 3 late effects have not been observed so far. The results of our trial lend further support to the concept of limited para-aortic irradiation as the recently defined new standard of radiotherapy in stage I seminoma. There is no obvious compromise in disease-specific or disease-free survival compared to more extensive hockey-stick portals, which were used as standard portals at the time this study was initiated.