Sites Of Nodal Involvement Research Articles

Pediatric Hodgkin’s lymphoma: experience from a tertiary cancer center in North East India

Background: Hodgkin’s lymphoma is a clonal malignant lymphoid proliferation, which originates from the germinal centers of B cells. This study was conducted to observe the socio-epidemiological profile of Hodgkin’s lymphoma in a tertiary cancer care centre from North East India. Methods: All patients from 0 to 18 years of age group with histopathologically proven diagnosis of HL, presenting to department of medical & pediatric oncology at Dr. Bhubaneswar Borooah cancer Institute during the period January 2012 to December 2019 were included in the study. Clinical parameters assessed included age, sex, locality, occupation, presenting symptoms, performance status, site of lymph node involvement, treatment modality, response to treatment, progression free survival and overall survival. Results: A total of 64 patients with histopathologically confirmed diagnosis of HL were registered in lymphoma joint clinic of BBCI from January 2012 to December 2019. The mean age was 12.68±4.71 years. Out of 64 patients, 54 (84.4%) belonged to rural areas and 10 patients (15.6%) to urban areas. Complete response was observed in 93.5% patient with limited risk disease, 73.24% with intermediate risk and 60% with advance stage. The overall survival and event free survival rates of 91% and 78.1%, respectively, were observed at 4 years. Conclusions: This study provides insight to incidence, demographic profile, overall response rates and survival pattern with other secondary objectives such as complete response rate, compliance rate and toxicity assessment among children with Hodgkin lymphoma belonging to Northeastern India.

18F-FDG PET/CT imaging features of patients with multicentric Castleman disease.

ObjectiveThe aim of this study is to investigate the role of 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) in the evaluation of multicentric Castleman disease (MCD).MethodsThirty-five patients with pathologically confirmed MCD who underwent 18F-FDG PET/CT were retrospectively included. The FDG uptake and CT findings of lymph nodes, pulmonary involvement, spleen, and bone marrow were assessed and the maximum standardized uptake value (SUVmax) of each lesion was measured. The locations of lymph nodes were also evaluated.Results18F-FDG PET/CT showed increased uptake in multiple nodal regions in 34 out of 35 MCD patients. The most frequently involved nodal sites were the cervical, iliac, axillary, and inguinal areas, and the least common was paraaortic and abdominal nodes. The involved lymph nodes were not confluent and presented a relatively symmetric pattern on PET/CT images. The highest SUVmax of lymph nodes per patient ranged from 2 to 19 with a mean value of 5.61 ± 3.12. Pulmonary manifestation including cysts, nodules, and interstitial lung disease were found in 10 patients, eight of whom demonstrated mild to moderate uptake in the lungs. 18F-FDG PET/CT also revealed other findings including hypermetabolic spleen (n = 8) and bone marrow (n = 23), elevated uptake in salivary glands (n = 8). Four patients also underwent follow-up PET/CT scans after therapy, and three of them displayed decreased metabolism.Conclusion18F-FDG PET/CT is a useful tool in the diagnosis, evaluation, and follow-up of MCD by providing systemic manifestations of lymphadenopathy, pulmonary involvement, and hypermetabolic spleen or bone marrow. Furthermore, the lymphadenopathy in MCD presented a predominantly peripheral distribution, relatively symmetric, moderately hypermetabolic, and not confluent pattern on 18F-FDG PET/CT.

Brentuximab Vedotin with Chemotherapy in Frontline Treatment of Classic Hodgkin Lymphoma Nodular Sclerosis Syncytial Variant

BACKGROUND: Classic Hodgkin lymphoma (cHL) Nodular Sclerosis (NS) is the most common subtype of cHL and has a good prognosis. However, an uncommon variant of cHL NS, the syncytial variant (cHL NS-SV), represents an entity with a worse clinical outcome with conventional frontline cytotoxic therapy. Nevertheless, in the pivotal phase III study ECHELON-1, Brentuximab Vedotin (BV), doxorubicin, vinblastine, and dacarbazine (BV+AVD) while demonstrating a superior efficacy, unfortunately more febrile neutropenia (FN) and peripheral neuropathy (PN) were observed compared to bleomycin+AVD (ABVD) as frontline treatment of advanced-stage classical Hodgkin's lymphoma (cHL) (Straus et al Blood 2020). It is unknown whether BV combined with chemotherapy would improve the inferior prognosis of cHL NS-SV. METHODS: After obtaining institutional research approval, we retrospectively reviewed the characteristics and outcomes of adult cHL NS-SV patients, treated per physician preference with frontline BV combined with cytotoxic therapy, either as standard of care (SOC) or in a clinical trial (NCT01712490, NCT03646123 and NCT01060904) between 7/2010 and 7/2020. cHL NS-SV diagnosis was based on morphology and Immunophenotype. Bulky disease was defined as mass>10cm or mediastinal mass >1/3 of thoracic diameter at T5-T6. Lymph node regions were defined by the German Hodgkin Study Group (GHSG). Treatment consisted of 0.9 or 1.2 mg/kg of BV and standard dose ABVD or AVD or D, intravenously on days 1 and 15 of each 28-day cycle for up to 6 cycles. All patients received support with pegfilgrastim. Response assessment was based on positron emission tomography/computerized tomography (PET/CT). Follow-up time was calculated from the date of pre-treatment baseline lab measurement to relapse date or death date, whichever happened first. Patients with no event were censored at the last follow-up date. RESULTS: Among the 11 patients included in the analysis, the median age was 29 (range 19-59 years), 27.2% were female, and 90.9% were Caucasian. All patients had Eastern Cooperative Oncology Group (ECOG) 0-1, 72.7% of patients had B-symptoms and 81.9% had stage III or IV disease. The median size of the largest lesion was 9.0 cm, 45.5% of patients had bulky disease, 63.6% had extranodal disease, 72.7% had >3 GHSG involved nodal sites and median International Prognostic Score was 4. Overall, all patients received 6 cycles of therapy, 63.6% received BV+AVD, 27.3% received BV+ABVD and 1 patient received SOC BV with dacarbazine because of previous anthracycline exposure. The interim PET/CT showed response in all patients with Deauville score (DS) of 2-3 in 45.5% and 4 in 54.4%. The end-of-therapy PET/CT showed DS of 1-3 in 90.1% and 4 in 8.9%. The latter patient had the most voluminous bulk of this study. To date, no patient received additional systemic therapy or consolidative radiotherapy after completion induction therapy. With a median follow-up time of 14 months (range 5-82 months), no patient had relapse and all were still alive (Progression-Free Survival and Overall Survival of 100%). CONCLUSIONS: BV combined with cytotoxic therapy such as BV+AVD is a highly effective treatment strategy for patients with cHL NS-SV. Further studies are required to evaluate whether frontline therapy of BV+AVD could improve the outcome of the higher-risk subgroup cHL NS-SV. Table Disclosures Lee: Oncternal Therapeutics:Research Funding;Guidepoint Blogal:Consultancy;Aptitude Health:Speakers Bureau;Takeda:Research Funding;Seattle Genetics:Research Funding;Celgene:Research Funding;Bristol-Myers Squibb:Consultancy, Research Funding.

Tumor long-axis diameter and SUVmax predict long-term responders in 90Y-ibritumomab tiuxetan monotherapy.

90Y-ibritumomab tiuxetan (90Y-IT) is widely used, but the factors responsible for its optimal treatment effects are unknown. We enrolled 34 patients with relapsed indolent lymphoma treated with 90Y-IT monotherapy at Gunma University Hospital between 2003 and 2014 in the present study. Clinical data including computed tomography and 18-Fluoro-deoxyglucose positron emission tomography were retrospectively analyzed. The overall response rate and complete response rate were 91% and 82%, respectively. The median progression-free survival (PFS) and overall survival were 32months and not reached, respectively. In univariate analysis, tumor long-axis diameter ≤ 2.5cm, maximum standardized uptake value (SUVmax) ≤ 6.5, localized disease, normal levels of serum soluble interleukin-2 receptor, and the number of involved nodal sites ≤ 3 immediately prior to 90Y-IT were associated with median PFS greater than 6 years. However, in multivariate analysis, only tumor long-axis diameter ≤ 2.5cm and SUVmax ≤ 6.5 affected PFS [hazard ratio (HR) 0.130, P = 0.0021 and HR 0.283, P = 0.0311, respectively]. Patients with only one prior regimen needed less granulocyte colony-stimulating factor and platelet transfusion. Thus, 90Y-IT treatment should be considered for patients with indolent lymphoma in first relapse who have tumor long-axis diameter ≤ 2.5cm and SUVmax ≤ 6.5.

P166 - Which patients with clinically node prostate cancer benefit from radical prostatectomy? The impact of the size and site of nodal involvement on long-term outcomes

P166 - Which patients with clinically node prostate cancer benefit from radical prostatectomy? The impact of the size and site of nodal involvement on long-term outcomes

Metastatic Involvement of the Prostatic Anterior Fat Pad: Implications for the Pathologist.

There is little information regarding the utility of pathologic evaluation of the prostatic anterior fat pad (PAFP) in patients with a low preoperative probability of recurrence. Our study aimed to determine the utility of PAFP pathologic examination, especially for this group of patients. We analyzed a tertiary care academic center's radical prostatectomy (RP) specimens from 2009 to 2017. Of 602 RP specimens, 420(70%) included the PAFP; four of 420 (1%) had lymph node involvement (LNI) in the PAFP. In two of four cases with LNI in the PAFP, this was the only site of LNI. Of these two cases, one occurred in a patient with low probability of recurrence and involved a nonpalpable PAFP lymph node. Pathologic evaluation of the PAFP may be useful even in patients with low probability of recurrence because it may change staging by detecting metastatic involvement of small PAFP lymph nodes.

PRETREATMENT SOLUBLE INTERLEUKIN‐2 RECEPTOR LEVEL WAS A ROBUST PROGNOSTIC FACTOR IN FOLLICULAR LYMPHOMA IN RITUXIMAB ERA

Background: Robust prognostic markers as well as rituximab maintenance has been unknown in follicular lymphoma (FL). Soluble interleukin-2 receptor (sIL-2R) reflects activity, tumor burden, and prognosis of lymphoma. Methods: To aim to investigate whether sIL-2R was prognostic marker equivalent to rituximab maintenance, we retrospectively analyzed 219 patients with FL grade 1–3a, who achieved objective response by R-CHOP or R-CVP. Rituximab maintenance (single infusion for four weeks every six months for maximum of two years) was given to 169 patients (77%) with median duration of 1.6 years. Results: Baseline characteristics are following: aged >60 was 105 (47%), men was 92 (42%), stage III/IV was 174 (79%), nodal lesions > four sites was 118 (54%), grade 3a was 33 (15), bone marrow involvement was 84 (40%), elevated LDH was 36 (16%), hemoglobin <12 g/dl was 27 (12%), bulky disease (tumor diameter > 6 cm) was 43 (20%), β2MG > 2 mg/dl was 83 (37%), and SUVmax > 10 was 48 (22%). FLIPI classified patients into 99 (45%) as low FLIPI, 55 (25%) as intermediate FLIPI, and 66 (30%) as high FLIPI, respectively. FLIPI2 classified patients into 40 (18%) as low FLIPI2, 130 (59%) as intermediate FLIPI2, and 50 (23%) as high FLIPI2, respectively. Pretreatment sIL-2R (median 871 IU/ml, range 115–13700) was significant higher in patients, who experienced a relapse. ROC curve illustrates 1070 IU/ml as adequate cut-off value to predict relapse of FL in this cohort (AUC = 0.7, 95%CI = 0.62–0.78). Elevated LDH, stage III/IV, involved nodal sites >4, bone marrow involvement, bulky disease, elevated β2MG, SUVmax >10 in PET scan, high FLIPI, and high FLIPI2 were statistically associated with high sIL-2R, respectively. At the median follow-up time of 74.2 months, the six-year PFS was 75.1% (95% CI = 66.5–81.8) in the maintenance + group versus 44.1% (95%CI = 28.5–58.6) in the maintenance group (P < 0.0000001) and 84.0% (95%CI = 74.4-90.2) in the low sIL-2R group versus 51.1% (95%CI = 39.8-61.3) in the high sIL-2R groups, respectively (P < 0.000001). The six-year PFS was 84.8%, 78.4%, 58.5%, and 48.1% in the maintenance+/low sIL-2R, maintenance-/low sIL-2R, maintenance+/high sIL-2R, and maintenance-/high sIL-2R groups, respectively (P < 0.000001). Multivariate analysis showed that high sIL-2R (hazard ratio 2.7, 95% confidential interval = 1.3–5.6, P < 0.01) was an independent factor of poor PFS as well as elevated β2MG and no rituximab maintenance. Keywords: cytokines; follicular lymphoma (FL); rituximab.

Prognostic Factors in Metastatic Cutaneous Squamous Cell Carcinoma of the Head and Neck

Metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck poses a significant therapeutic challenge due to its aggressive biologic behavior. We conducted a retrospective study of 71 patients-58 men and 13 women, aged 28 to 88 years (mean: 71)-who had been treated at our university-affiliated tertiary care medical center for metastatic cutaneous SCC over a 15-year period. In addition to demographic data, we compiled and analyzed information on tumor characteristics, the site and extent of metastasis, treatment, follow-up, and outcome. Among the tumor factors, poorly differentiated carcinoma was an independent predictor of poorer disease-free survival, and older age was found to be an independent predictor of poorer overall survival. We found no significant difference in disease-free or disease-specific survival among patients with parotid involvement, neck involvement, or both. In our series, the site of nodal involvement appeared to have no prognostic significance in patients with metastatic cutaneous SCC of the head and neck.

Malignant lymphoma in Hadhramout Sector, Yemen: a retrospective study of 170 cases classified according to the WHO classification

Introduction Malignant lymphoma is a primary neoplasm of lymphoid tissue. It is the third most common cancer in children worldwide. There are two broad categories of malignant lymphomas: non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL). Both have different microscopic features, follow different treatment modalities, and have different prognoses. Aim of the work The aim of the study was to determine the different types of lymphoma in all age groups, and find its relation to sex and site of lymph node involvement in Hadhramout Governorate. Materials and methods This is a retrospective descriptive study of 170 cases of lymphomas retrieved from the archives of the National Oncology Center, Hadhramout, during the period between 2008 and 2013. The diagnosis was assessed with immunohistochemical results and categorized according to the WHO classification of lymphoid neoplasms. Results Out of 170 patients, 116 (68.2%) had NHL and 54 (31.8%) had HL. A male predominance was observed (103/170, 60.6%). B-cell lymphomas were the most frequent type of NHL (95/116, 81.9%) and diffuse large B-cell lymphoma was the most common pattern of NHL (58/95, 61.1%), followed by Burkitt's lymphoma (20/95, 21.1%). The distribution of HL showed predominance of nodular sclerosis classical HL (38/54, 70.4%). The proportion of lymph node involvement of lymphomas was higher than extranodal involvement, being seen in 91/116 cases (78.5%) of all NHLs and 49/54 cases (90.8%) of all HLs. Conclusion NHL is the most common type of malignant lymphoma, and diffuse large B-cell lymphoma is the most common pattern among all NHL types, whereas nodular sclerosis classical HL is the most common type of HL. The nodal involvement of malignant lymphoma is higher than extranodal involvement.

Sentinel lymph node imaging guided IMRT for prostate cancer: Individualized pelvic radiation therapy versus RTOG guidelines

Purpose/ObjectivesCurrent Radiation Therapy Oncology Group (RTOG) guidelines for pelvic radiation therapy are based on general anatomic boundaries. Sentinel lymph node (SLN) imaging can identify potential sites of lymph node involvement. We sought to determine how tailored radiation therapy fields for prostate cancer would compare to standard RTOG-based fields. Such individualized radiation therapy could prioritize the most important areas to irradiate while potentially avoiding coverage in areas where critical structures would be overdosed. Individualized radiation therapy could therefore increase the therapeutic index of pelvic radiation therapy. Methods and materialsTen intermediate or high-risk prostate cancer patients received androgen deprivation therapy with definitive radiation therapy, including an SLN imaging–tailored elective nodal volume (ENV). For dosimetric analyses, the ENV was recontoured using RTOG guidelines (RTOG_ENV) and on SLNs alone (SLN_ENV). Separate intensity modulated radiation therapy (IMRT) plans were optimized using RTOG_ENV and SLN_ENV for each patient. Dosimetric comparisons for these IMRT plans were performed for each patient. Dose differences to targets and critical structures among the different IMRT plans were calculated. Distributions of dose parameters were analyzed using non-parametric methods. ResultsSixty percent of patients had SLNs outside of the RTOG_ENV. The larger volume IMRT plans covering SLN imaging–tailored elective nodal volume exhibited no significant dose differences versus plans covering RTOG_ENV. IMRT plans covering only the SLNs had significantly lower doses to bowel and femoral heads. ConclusionsSLN-guided pelvic radiation therapy can be used to either treat the most critical nodes only or as an addition to RTOG guided pelvic radiation therapy to ensure that the most important nodes are included.

Prevalence of Common Non-Hodgkin Lymphomas and Subtypes of Hodgkin Lymphoma by Nodal Site of Involvement

Non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) represent a heterogeneous group of malignant lymphoid tumors, which have distinct histological and/or biological characteristics with preferential nodal involvement. However, none of the previous studies have assessed the prevalence of common NHL and HL subtypes at each nodal site of involvement.The aim of our study was to determine the prevalence of HL and NHL subtypes depending on their nodal sites of involvement.We conducted a single-center retrospective study of 938 lymphoma cases diagnosed in the Pathology Department of Toulouse Purpan Hospital in France between 2001 and 2008, taking into account the site that corresponded to the diagnostic biopsy.The most frequent sites were cervical lymph nodes (36.8% of all cases), inguinal lymph nodes (16.4%), axillary lymph nodes (11.9%), and supraclavicular lymph nodes (11%). We found an unexpected association between intraparotid nodes and nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) and between inguinal nodes and follicular lymphoma. The risk of having classical Hodgkin lymphoma (CHL) was 15 times greater in patients with mediastinal lymphoma compared to those with other sites of involvement. Regarding HL, nodal and extranodal mediastinal sites and supraclavicular nodes were more likely to be involved by nodular sclerosis Hodgkin lymphoma (NSCHL). In addition, intra-abdominal lymph nodes were more frequently involved by lymphocyte depleted Hodgkin lymphoma compared to inguinal nodes where NLPHL predominated.Our study shows that some lymph node sites have a disproportionate prevalence of specific subtypes of lymphoma. Identifying these sites may aid to diagnose and better elucidate the pathogenesis of these tumors.

Trend Analysis of Clinical Outcomes in Hodgkin Lymphoma over the Last Three Decades: Report from the Nebraska Lymphoma Study Group

BACKGROUND: With improvements in the treatment of Hodgkin lymphoma (HL) over time, we hypothesized a reduction in disease progression, and an increase in progression-free (PFS) and overall survival (OS) over the past 3 decades. METHODS: This is a retrospective study that included previously untreated HL patients reported to the Nebraska Lymphoma Study Group between 1983 and 2012. To analyze trends in outcomes, we divided the cohort into 3 time periods of 10 years each (1983-1992, 1993-2002, 2003-2012) to represent early (E), middle (M) and late (L) time periods. Patient, disease, and treatment-related factors as well as clinical outcomes (cumulative incidence of progression, PFS and OS) were compared according to time period. Multivariate analyses (MVA) were performed using Cox regression to adjust for significant covariates. RESULTS: In this retrospective review, 528 patients were identified during the study period: E (n=120), M (n=208), L (n=200). Patients in the more recent cohort (L) were more likely to be younger (p=0.008), have better performance score (p&lt;0.001), have more sites of nodal involvement (p=0.05) and were more likely to receive ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) or Stanford V (mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, prednisone) as initial therapy (p&lt;0.0001). In univariate analysis, there was a decrease in the 5-year cumulative incidence rate of disease progression over time (E=27% vs M=22% vs L=21%), and an increase in the 5-year probability of PFS (E=58% vs M=66% vs L=74%, p=0.004) and 5-year OS (E=67% vs M=80% vs L=85%, p=0.001). In MVA, improvement in the cumulative incidence of disease progression, PFS and OS over time was mainly driven by prognostic patient-related (age, sex) and treatment-related factors (type of chemotherapy regimen). Independent predictors of shorter PFS included age ≥45 y and male gender (Hazard Ratio [HR] 2.00 [95% CI 1.52-2.62, p&lt;0.001] and 1.43 [1.09-1.87, p&lt;0.01], respectively), while patients who received ABVD and Stanford V regimens as initial therapy experienced improved PFS (HR 0.39 [0.23-0.65, p&lt;0.001] and 0.42 [0.28-0.64, p&lt;0.001], respectively versus MOPP-like regimens). For OS, patients who were ≥45 y and males were more at risk of death (HR 4.34 [3.08-6.08, p&lt;0.001] and 1.73 [1.26-2.37, p&lt;0.001], respectively) while patients who received ABVD and Stanford V regimens as initial therapy were less likely to die (HR 0.36 [0.19-0.69, p &lt;0.01] and 0.39 [0.23-0.65, p&lt;0.001], respectively compared to MOPP-like regimens). Similarly, in MVA, a decrease in risk of progression was noted for patients who received ABVD and Stanford V regimens (HR 0.36 [0.19-0.69, p&lt;0.01] and 0.39 [0.23-0.65, p&lt;0.001], respectively) compared to MOPP-like regimens, while increased for patients who were ≥45 y and male (HR 4.33 [3.08-6.08, p&lt;0.001] and 1.73 [1.26-3.37, p&lt;0.001], respectively). CONCLUSIONS: Changes in upfront treatment regimens for HL over the last 3 decades have resulted in significant improvement in PFS and OS, and modest improvement in the risk for progression. Disclosures No relevant conflicts of interest to declare.

Inactivation of the CDKN2A Tumor-Suppressor Gene by Deletion or Methylation Is Common at Diagnosis in Follicular Lymphoma and Associated with Poor Clinical Outcome

Follicular lymphoma, the most common indolent lymphoma, is clinically heterogeneous. CDKN2A encodes the tumor suppressors p16(INK4a) and p14(ARF) and frequently suffers deleterious alterations in cancer. We investigated the hypothesis that deletion or hypermethylation of CDKN2A might identify follicular lymphoma cases with distinct clinical or pathologic features potentially amenable to tailored clinical management. Deletion of CDKN2A was detected in pretreatment biopsy specimens using a single nucleotide polymorphism-based approach or endpoint PCR, and methylation of CpG elements in CDKN2A was quantified by methylation-specific PCR. Correlations between CDKN2A status and pathologic or clinical characteristics, including overall survival (OS), were investigated in 106 cases using standard statistical methods. Deletion of CDKN2A was detected in 9 of 111 samples (8%) and methylation was detectable in 22 of 113 (19%). CDKN2A was either deleted or methylated in 29 of 106 cases (27%) and this status was associated with inferior OS especially among patients treated with rituximab (P = 0.004). CDKN2A deletion or methylation was associated with more advanced age (P = 0.012) and normal hemoglobin (P = 0.05) but not with sex, FLIPI score, ECOG stage, LDH, performance status, number of involved nodal sites, B symptoms, histologic grade, the presence of a component of diffuse large B-cell lymphoma, proliferation index, or other pathologic factors. Our results show that deletion or methylation of CDKN2A is relatively common in pretreatment follicular lymphoma biopsy specimens and defines a group of cases associated with reduced survival in the rituximab era presumably on the basis of more aggressive disease biology.

The survival outcome and patterns of failure in node positive endometrial cancer patients treated with surgery and adjuvant radiotherapy with curative intent.

ObjectiveThe purpose of this study was to evaluate the patterns of failure, overall survival (OS), disease-free survival (DFS) and factors influencing outcome in endometrial cancer patients who presented with metastatic lymph nodes and were treated with curative intent.MethodsOne hundred and twenty-six patients treated between January 1996 to December 2008 with surgery and adjuvant radiotherapy were identified from our service's prospective database. Radiotherapy consisted of 45 Gy in 1.8 Gy fractions to the whole pelvis. The involved nodal sites were boosted to a total dose of 50.4 to 54 Gy.ResultsThe 5-year OS rate was 61% and the 5-year DFS rate was 59%. Grade 3 endometrioid, serous, and clear cell histologies and involvement of upper para-aortic nodes had lower OS and DFS. The number of positive nodes did not influence survival. Among the histological groups, serous histology had the worst survival. Among the 54 patients relapsed, only three (6%) failed exclusively in the pelvis and the rest of the 94% failed in extrapelvic nodal or distant sites. Patients with grade 3 endometrioid, serous and clear cell histologies did not influence pelvic failure but had significant extrapelvic failures (p<0.001).ConclusionMajority of node positive endometrial cancer patients fail at extrapelvic sites. The most important factors influencing survival and extrapelvic failure are grade 3 endometrioid, clear cell and serous histologies and involvement of upper para-aortic nodes.

Outcomes in Adolescents and Young Adults with Hodgkin Lymphoma Treated with and without Radiation Therapy On CCG 5942: A Report From the Children's Oncology Group

AbstractAbstract 3659 BackgroundCombined modality therapy with chemotherapy and radiation (RT) has resulted in excellent cure rates for Hodgkin Lymphoma (HL) but is associated with significant late effects. Modern therapeutic protocols attempt to limit cumulative doses of chemotherapy and minimize radiation therapy where possible. There is also growing attention to the optimal management of specific patient populations, including the adolescent and young adult (AYA) population. The CCG trial 5942 provides an opportunity to assess the role of RT in disease control for the AYA population (15–21 years of age) compared with a younger cohort (<15 years of age). MethodologyThe CCG 5942 study included 826 eligible patients (339 AYA) accrued during the years 1995–1998. Patients were assigned to risk-adapted chemotherapy based on stage and presence or absence of unfavourable risk factors (B symptoms, bulk disease, hilar lymphadenopathy, number of involved nodal sites). Disease response was assessed at the completion of chemotherapy and patients in CR were eligible for randomization to receive 21 Gy IFRT or no further therapy. We conducted a retrospective analysis of the CCG 5942 data to compare demographics, treatment response and survival outcomes of children and AYA. ResultsPatient demographics are shown in Table 1. The AYA patients were more likely to present with nodular sclerosing histology (NS), B symptoms, mediastinal bulk disease, and higher stage. The CR rates for children and AYA were 393/487 (80.7%) and 243/339 (71.7%) (p=.003). Of the 636 patients in CR, 498 (181 AYA) participated in the randomization. The AYA patients were less likely to be compliant with randomization to no further therapy (2/165 children vs 5/84 AYA, p=.045). The 8y EFS and OS for all children compared to AYA were 85.7% vs 80.2% (p=.052) and 94.3% vs 90.7% (p=.060) respectively. The 8y EFS and OS for all randomized children compared to AYA were 89.8 vs 81.3 (p=.011) and 97.2% vs 95.1% (p=0.30). A Cox model adjusting for both age group and histology (NS vs. lymphocyte predominant (LP) and mixed cellularity (MC)) demonstrated age to be an insignificant predictor (p=0.30) and NS histology to be a significant predictor (p=.001, HR 2.6) of worse EFS. EFS for all randomized patients with NS histology by age group and treatment received are shown in Figure 1. There is a significant difference among the groups in the overall comparison (p=0.018). There was no difference in OS with all pairwise comparisons p>0.5. ConclusionsThe AYA were more likely to present with higher risk disease and less likely to enter CR compared to younger children on the CCG 5942 trial. Among randomized patients with NS histology, both young and AYA populations show an EFS advantage with RT, though this advantage does not reach statistical significance for the AYA group. There was no difference in OS for randomized patients with NS histology in either age group. This analysis is limited by the retrospective methodology but supports further study of therapy assignment of the AYA population. Elimination of RT from AYA with NS histology may prove more challenging than for younger children. Analysis of current protocols using a uniform chemotherapy backbone and early disease response assessment with PET/CT will be particularly informative.Table 1:Patient characteristicsAll patients (n=826)Randomized patients (n=498)<15 yrs15–21 yrsp-value<15 yrs15–21yrsp-valueN%n%n%n%Gender<0.0010.005male29460%16047%19261%8648%female19340%17953%12539%9552%Histology<0.001<0.001LP6514%185%4514%106%NS32268%29088%20666%15084%MC8518%206%5819%169%LD30.6%20.6%20.6%21%Unknown12963Stage<0.0010.001I10421%319%7925%2011%II23147%20059%15047%11161%III7115%4914%4615%2614%IV8117%5917%4213%2413%B-sym0.0160.002present10922%10130%5417%5229%absent37878%23870%26383%12971%Mediastinal Mass<0.0010.002>=1/310421%10130%5818%4022%<1/318137%15245%11737%8949%no20241%8625%14245%5229%Clinical Group0.0030.017119139%9528%14646%6134%221444%18354%12941%9653%38217%6118%4213%2413% [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Nuclear medicine imaging in tuberculosis using commercially available radiopharmaceuticals

In this paper, data available on nuclear medicine imaging using commercially available radiopharmaceuticals for the differentiation, staging, and prediction or assessment of the response to treatment in tuberculosis (TB) are reviewed. Limited available studies suggest that single photon emission computed tomography (SPECT) using either 201Tl, 99mTc-sestamibi, or 99mTc-tetrofosmin is accurate (≥85%) and has a high negative predictive value (≥90%) for the differentiation of TB from carcinoma in patients presenting with a solitary pulmonary nodule (SPN). The criteria for detection of TB on 201Tl SPECT are nondepiction of the suspicious lesion in the delayed image or a negative retention index [washout on the delayed images (3–4 h postinjection) vs. the early image (5–15 min postinjection)] and a comparable-to-background uptake on 99mTc-sestamibi or 99mTc-tetrofosmin SPECT. Another SPECT tracer of potential interest for the differentiation of TB from malignant SPN that warrants further exploration, is N-isopropyl-p-[123I]iodoamphetamine (123I-IMP). In contrast, 18F-fluorodeoxyglucose (18F-FDG) PET is unable to differentiate malignancy from TB and thus cannot be used as a tool to reduce futile biopsy/thoracotomy in these patients. A limited number of studies have reported on the potential of nuclear medicine imaging in assessment of the extent of disease in patients with extrapulmonary TB using 67Ga-citrate SPECT and 18F-FDG PET, respectively. 67Ga-citrate SPECT was shown to be as sensitive as bone scintigraphy for the detection of bone infection and was found to be complementary to computed tomography (CT) imaging. 18F-FDG PET was found to be significantly more efficient when compared with CT, respectively, in over half of patients for the identification of sites of lymph node involvement that were missed by CT and often the only sites of extrapulmonary TB identified. Unfortunately, 18F-FDG PET findings did not lead to alterations in treatment planning in any of the patients under study. Additional studies confirming these findings are urgently required. Similar to the setting of SPN, 18F-FDG PET cannot differentiate malignant lymph node involvement from lymph node involvement by TB. These results and the recent findings of Demura and colleagues using 18F-FDG PET further suggest that nuclear medicine imaging techniques could be used for the evaluation of therapeutic response. Prospective studies, focusing on specific subgroups of patients in whom such an imaging approach might be clinically relevant, for example in multidrug-resistant TB patients, are warranted. In acquired immunodeficiency syndrome patients, 67Ga scintigraphy proved to be a reliable and sensitive method for the primary detection and follow-up of opportunistic pneumonias, including TB. Combining 201Tl scintigraphy with 67Ga scintigraphy was shown to increase the specificity for both pulmonary and extrapulmonary TB, which is a 67Ga(+) and 201Tl(-) mismatch pattern in acquired immunodeficiency syndrome patients that is specific for mycobacterial infections. Finally, the results obtained using both SPECT and PET indicate that nuclear medicine could be an important noninvasive method for the determination of disease activity, detection of extrapulmonary TB, and determination of response to therapy.

Extranodal Rosai-Dorfman disease presenting as an isolated glenoid lesion in a high school athlete

Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy (SHML), was first described as a clinical entity by Rosai and Dorfman in 1969. The first description of the disease reported a rare nonneoplastic disorder involving the proliferation of histiocytes predominantly involving the lymph nodes. ‘‘Sinus histiocytosis’’refers to histiocytosis that occurs in thedistended sinuses of lymph nodes, but since its initial description, RDD has been reported to involve a wide variety of organ systems and has been found in numerous locations throughout the body. RDD most commonly presents in young patients in the second or third decade of life, with an increased prevalence in men. RDD generally presents as bilateral, nontender, painless adenopathy in the neck, which may be accompanied by fever, elevated erythrocyte sedimentation rate, weight loss, and immunologic abnormalities such as leukocytosis and polyclonal hypergammaglobulinemia. Less frequently involved nodal sites are mediastinal, hilar, retroperitoneal, axillary, and inguinal. Extranodal RDDoccurs in 42% of patients, with 23% having isolated extranodal disease. Of the nearly 1000 patients with documented RDD, less than 3% have presented with isolated osseous involvement. In the 423 RDD cases presented by Foucar et al, 7.8% had osseous involvement, 2% had osseous involvement without lymphadenopathy, and 0.5% had isolated osseous

Lymph Node Metastasis of Squamous Cell Carcinoma from an Unknown Primary in the Upper and Middle Neck: Impact of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography

The purpose of this study was to assess the potential of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) imaging for detection of the primary tumor and its impact on treatment planning in patients presenting with cancer of unknown primary and squamous cell carcinoma (SCC)-positive cervical lymph nodes of the upper and middle neck. The study population consisted of 18 consecutive patients with biopsy-proven SCC involving lymph nodes of the upper and middle neck region and negative conventional diagnostic procedures with regard to the location of the primary. All patients underwent FDG-PET/CT according to a standard procedure in search for the primary, unidentified tumor. In none of the patients FDG-PET/CT was able to indicate a primary tumor localization. Although FDG-PET/CT did identify all sites of known lymph node involvement, neither additional sites of lymph node involvement nor sites of distant metastases were identified. Accordingly, FDG-PET/CT did not impact patient treatment planning. In this series, including patients suffering from lymph node metastases by an SCC of unknown primary in the upper and middle neck, FDG-PET/CT was unable to identify a primary tumor. In addition, FDG-PET/CT did not modify the treatment planning in any of the patients studied.

Hodgkin lymphoma: Clinicopathologic features in Benin City, Nigeria and update on its biology and classification

To review the age incidence, common pathohistologic subtypes, and anatomical nodal sites of lymph nodes involvement for histology. A 25 (May 1985-June 2010) years retrospective study of all patients who had lymph node biopsy. Department of Pathology and Haematology, University of Benin Teaching Hospital, Benin City, Nigeria. Of 821 lymph node biopsies encountered, 56 (6.8%) cases biopsied were for Hodgkin lymphoma (HL). There was a bimodal peak incidence of age interval of 11-15 years and 21-25 years and the relationship between the age and sex distribution was statistically significant (P = 0.03). The overall median age was 23 years with a mean age of 25.6 ± 2.0 (SEM). Pathological re-appraisal of these 56 cases in the study indicates that mixed cellularity HL constituting 36 cases (64.3%) was the predominant subtype. This was followed by lymphocyte depleted HL with a total of 11 cases (19.6%). The major site of lymph node involvement where biopsy was taken for histological diagnosis was the cervical group of lymph nodes constituting 78.6%. Staging classification of the disease indicates low frequency of early stage disease (I-II) with 19 cases (33.9%) and high frequency of late stage (III-IV) with 37 cases (66.1%). Patients are predominantly males, children and young adults presenting with cervical lymphadenopathy at late stage of the disease, and a dominance of mixed cellularity and lymphocyte depleted histological subtypes were observed.

Lymphoscintigraphy Defines New Lymphatic Pathways from Cutaneous Melanoma Site: Clinical Implications and Surgical Management

Sentinel lymph node biopsy is commonly applied as staging procedure of regional lymph nodes in patients with cutaneous melanoma. Dynamic lymphoscintigraphy defines the lymphatic pathways from a primary melanoma site and allows to identify the node receiving lymphatic drainage from the primary tumor, which is the sentinel lymph node. In rare cases, lymphoscintigraphy shows sites of lymphatic drainage in nonclassical basins never described in the past when lymphatic drainage was considered only according to the anatomical proximity of the tumor primary site. These peculiar sentinel nodes, so-called “uncommon/interval” nodes, must be surgically removed because they may contain micrometastatic disease and may be the only site of nodal involvement.