Syndrome of inappropriate antidiuretic hormone secretion in a patient with cryptococcal meningoencephalitis: a hidden mediastinal small cell carcinoma

We report a 59-year-old man with cryptococcal meningoencephalitis who presented with typical features of syndrome of inappropriate antidiuretic hormone secretion (SIADH). There was no evidence of lung disease or drugs causing SIADH. Studies for endocrine functions and tumor markers were normal. The patient's hyponatremia was refractory to treatment (Na 120-125 mmol/L) after resolution of the cryptococcal infection. Three months after completion of antifungal treatment, a radiograph of the chest disclosed widening of the mediastinum. Computed tomography revealed a mediastinal mass. A tentative diagnosis of extrapulmonary cryptococcoma or a tumor was made. Positron emission tomography using F-fluorodeoxy glucose demonstrated an intense uptake mass in the mediastinum without lesions elsewhere in the body. A biopsy of the mass clearly showed small cell carcinoma (SCC) with positive immunoreactivity for arginine vasopressin and atrial natriuretic peptide. The hyponatremia completely resolved and tumor size dramatically decreased after chemotherapy. To the best of our knowledge, this is the first case of mediastinal SCC associated with SIADH. Patients with otherwise unexplained SIADH should be meticulously scrutinized for a possible malignancy.

Thyroid Cancer Presenting as a PET Incidentaloma in a Patient With Concomitant Breast Cancer Metastases to the Thyroid

INTRODUCTION

Metastases to the thyroid gland are considered a rare cause of thyroid tumor. Furthermore, a relationship between breast and thyroid carcinoma has been previously proposed.

CASE DESCRIPTION

We describe the case of a 59-year-old woman who presented with simultaneous papillary and breast carcinoma within the thyroid gland. F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) done for the evaluation of her metastatic breast cancer revealed a thyroid incidentaloma with a high metabolic rate (standardized uptake value [SUV] of 13). She underwent thyroidectomy and the pathology revealed papillary thyroid carcinoma corresponding to the lesion visualized on FDG PET. However, small metastatic implants of breast carcinoma were seen within the opposite thyroid lobe.

CONCLUSION

This is a rare description of a concomitant papillary thyroid carcinoma presenting as an FDG PET incidentaloma alongside breast cancer metastases to the thyroid gland. Thyroid and breast cancer sometimes occur in the same patient. However, no explanation has been found to link these 2 cancers. Although uncommon, FDG PET thyroid incidentalomas seem to harbor a higher rate of malignancy than incidentalomas found on conventional imaging. In the appropriate clinical setting, it is therefore suggested to investigate these lesions thoroughly.

Surgical treatment of complex malignant anterior mediastinal tumors invading the superior vena cava

Determining the appropriate surgery-based treatment for complicated anterior mediastinal malignancies (CAMM), especially those invading the superior vena cava (SVC) and its branches, remains a challenge for general thoracic surgeons. In this report, we summarize our experience and lessons regarding this issue in order to discuss a reasonable strategy for diagnosis and treatment of CAMM. Between January 2001 and April 2003, 15 patients with CAMM invading the SVC and/or its branches with or without invasion of other neighboring organs were surgically treated in our institution by a single surgeon team. We collected clinical data from the medical charts and from surgeons' specific notes for complicated cases, and performed a comprehensive analysis. There were 9 patients with malignant thymoma. Thymic carcinoma, teratoma, embryonal carcinoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma, and mixed teratoma with thymoma were diagnosed in 1 patient each. All procedures were performed via median sternotomy. Some angioplasty techniques were successfully used to resect and reconstruct the SVC. Ten of the 15 patients also underwent pulmonary resection due to involvement of pulmonary parenchyma. Four of the patients underwent perioperative chemotherapy. There were no perioperative deaths. Two patients suffered prolonged ventilation after surgery, and there were no other severe complications related to surgery. One patient died 10 months after surgery. The remaining 14 patients were still living and their progress is still monitored. As of August 2004, the median follow-up duration for all patients was 35 months, and the disease-free survival duration was 10-43 months. CAMM can be safely and completely resected via a median sternotomy, even if it has invaded other mediastinal structures. CAMM should be pathologically identified before initial treatment. A good outcome for patients with CAMM is possible if a suitable strategy combining accurate diagnosis and appropriate treatment, especially surgical resection, is established.

[Uncommon diagnosis in a patient with fever and new-onset cardiac murmur]

HISTORY AND PHYSICAL FINDINGS

A 34-year old man was referred because of persistent low-grade fever and a newly-diagnosed systolic murmur. He complained of atypical chest pain and dyspnoea on exertion for the past few weeks.

STUDIES

Blood analysis revealed an elevated CRP level (67.7 mg/l) along with a hypochromic, microcytic anaemia (Hb 122 g/l). Transthoracic echocardiography showed an extracardiac tumour compressing the right ventricular outflow tract. Computed tomography (CT) localized the tumour in the anterior upper mediastinum. Subsequently, a biopsy was carried out and revealed a non-seminomatous germ-cell tumour.

DIAGNOSIS, TREATMENT AND COURSE

The diagnosis having been made the patient received four cycles of chemotherapy according to the BEP-protocol (bleomycin-etoposide-cisplatin). The remaining tumour was then resected surgically. After additional cycles of chemotherapy two autologous stem cell transplantations were carried out.

CONCLUSION

This patient presented initially with symptoms typical of endocarditis. However, the reason for his newly diagnosed systolic murmur and persistent fever was an extracardiac germ cell tumor compressing the right ventricular outflow tract.

[High-dose chemotherapy with peripheral blood stem cell auto transplantation for an intractable case of mediastinal seminoma]

HDC with PBSCT is effective for some intractable cases with malignant neoplasma. We encountered an intractable case of mediastinal seminoma treated by HDC with PBSCT. The patient was a 25-year-old man with mediastinal seminoma. He had undergone chemo-radiotherapy several times and salvage surgery for the mediastinal tumor and chest wall recurrence since September 2001. He was referred to our clinic for management of recurrent seminoma in the chest wall in January 2004. In our clinic, chemo-radiotherapy consisting of cisplatin and etoposide was performed. The tumor size decreased transiently, but re-growth was observed 2 months after chemo-radiotherapy. We then performed HDC with PBSCT twice without any lethal complication. Now, the patient is well and disease-free 1 year after HDC with PBSCT.

[A case of primary choriocarcinoma of the mediastinum in a Japanese woman]

A 32-year-old Japanese woman was referred to our hospital complaining of non-productive cough and dyspnea when in a dorsal position. Physical examination revealed left cervical lymph node swelling. Laboratory data showed HCG 17,700mIU/ml, betaHCG 130ng/ml, CYFRA 104ng/ml, AFP<2.0ng/ml, and LDH 802IU/l. A chest radiograph showed a giant mass shadow in the left hilum and many round mass shadows in both lung fields. Chest CT showed a mass shadow in the anterior mediastinum and many round mass shadows in both lung fields. There was no abnormality on abdominal and pelvic CT. A CT-guided transcutaneous lung biopsy specimen obtained from a mass in the left lower lobe revealed necrotized portions and atypical cells which were positive for HCG. We diagnosed primary choriocarcinoma of the mediastinum. The patient received 4 courses of the standard BEP regimen, resulting in partial response. This is the first reported case of primary choriocarcinoma of the mediastinum in a Japanese woman.

Primary Mediastinal Large B-Cell Lymphoma: A Single-Center Study of Clinicopathologic Characteristics

Primary mediastinal large B-cell lymphoma (PMLBCL) is a subset of LBCL with unique clinicopathologic features. Some studies have raised the question of differences in biological features and clinical course among patients from different parts of the world. We conducted a retrospective clinicopathologic analysis of 24 patients with PMLBCL from a single center in Croatia. We also conducted the first investigation of the frequency of lymphotropic viruses human herpesvirus 6 (HHV-6) and HHV-8 in lymphoid lesions of this disease. The clinical characteristics of the patients were as expected, with high International Prognostic Index scores, elevated serum lactate dehydrogenase (LDH) levels, and bulky disease being adverse prognostic factors. Only 6 patients (25%) showed CD30 expression, and Bcl-6 protein expression was, in our series, prognostically favorable (P = .0401). One patient's tumor had detectable HHV-6 genome sequence, but no HHV-8 sequences were detected in any tumors. Two thirds of the patients received CHOP chemotherapy (cyclophosphamide, hydroxydaunomycin, vincristine, and prednisone) with a relatively low complete remission rate (43.8%; median follow-up, 33.8 months). This study confirmed the moderate preponderance among PMLBCL patients of young females with B symptoms and elevated LDH levels. The CHOP regimen proved effective as first-line therapy only in patients with limited disease. Therefore, other third-generation chemotherapy protocols may be considered for treatment, especially in patients with bulky and advanced disease.

Primary mediastinal germ cell tumor--successful curative resection following chemotherapy--a case report

Primary mediastinal germ cell tumours are relatively rare and account for only a small portion of all the mediastinal tumours. We present a case of a primary mediastinal germ cell tumour in a 14 years old Afghani boy.

[Clinical analysis of reactive thymic hyperplasia following chemotherapy for childhood malignant lymphoma]

BACKGROUND & OBJECTIVE

Reactive thymic hyperplasia following chemotherapy for malignant tumors is likely to be misdiagnosed as tumor residue or relapse, therefore, leads to unnecessary treatment. This study was to analyze the clinical features of reactive thymic hyperplasia following chemotherapy for childhood malignant lymphoma.

METHODS

Clinical data of 13 children with reactive thymic hyperplasia following chemotherapy for malignant lymphoma, treated from Mar. 1999 to Mar. 2004, were retrospectively analyzed. Of the 13 cases, 5 were Hodgkin's disease (HD), and 8 were non-Hodgkin's lymphoma (NHL). All patients received computed tomography (CT) to evaluate the therapeutic effect. When a new thymic mass emerged, positive electron tomography/computed tomography (PET/CT) was performed to identify its quality.

RESULTS

At diagnosis, 10 patients had mediastinal involvement. Reactive thymic hyperplasia occurred following the completion of chemotherapy in 9 cases, or during the maintenance of chemotherapy in 4 cases. CT showed that the longest diameters of the new mediastinal masses were 2.2-6.0 cm (mean 3.7 cm). The interval from last chemotherapy cycle to the occurrence of thymic hyperplasia was 2-12 months (mean 4 months). PET/CT was performed to 5 cases, and showed no vital tumors in the mediastinum. Three cases were misdiagnosed as tumor residue or relapse, and received second-line therapy. All patients were followed-up for 1-6 years (median 4 years), and none suffered tumor relapse.

CONCLUSIONS

Reactive thymic hyperplasia may occur following intensive chemotherapy for childhood malignant lymphoma. It should not be misdiagnosed as malignant tumors and overtreated.

Midline carcinoma with t(15;19) and BRD4-NUT fusion oncogene in a 30-year-old female with response to docetaxel and radiotherapy

BACKGROUND

Poorly differentiated midline carcinoma with a translocation between chromosomes 15 and 19, i.e. t(15;19), has been recognized as a distinct clinical entity for over a decade. This tumor affects young individuals, shows a rapidly fatal clinical course despite intensive therapy. The t(15;19) results in the fusion oncogene BRD4-NUT. Information concerning treatment of this rare disorder is scarce.

CASE PRESENTATION

A 30-year-old woman was admitted with a rapidly progressing tumor in the mediastinum, cervical lymph nodes, vertebral column and the epidural space. Pathological, cytogenetic, FISH and PCR analysis revealed a glycogenated carcinoma rarely expressing cytokeratins and showing t(15;19) and BRD4-NUT gene rearrangement. The patient was initially treated with a Ewing sarcoma chemotherapy regimen, but had rapid progression after two cycles. She then received docetaxel and radiotherapy, which resulted in almost complete disappearance of the tumor.

CONCLUSION

Docetaxel may be considered for initial chemotherapy in young patients presenting with a midline carcinoma with bone marrow involvement and cytogenetic and molecular genetic finding of a t(15;19)/BRD4-NUT-rearrangement. We herein describe, in detail, the laboratory methods by which the BRD4-NUT -rearrangement can be detected.

Continuous Murmur Due to a Mediastinal Tumor

Despite the lengthy differential diagnosis of causes of cardiac murmurs, the association of a mediastinal mass and a continuous murmur is very rare. We report herein a case of a mediastinal tumor and continuous murmur where transthoracic echocardiography provided clear differential diagnosis and demonstrated the cause of murmur.

Refractoriness to rituximab monotherapy in a child with relapsed/refractory Burkitt non-Hodgkin lymphoma

The authors describe a 6-year-old boy diagnosed with mediastinal Burkitt lymphoma with tumor invasion into bone marrow and both kidneys. After receiving chemotherapy according to NHL BFM-95 protocol for the high-risk disseminated lymphoma, the patient reached complete remission. He relapsed in the mediastinum at 5 months from the diagnosis. He underwent thoracotomy and tumor mass was removed by inferior lobectomy of right lung. Residual tumor progressed rapidly. Autologous stem cell transplantation could not be performed because of unresponsiveness to cytoreductive chemotherapy. Twenty-three days after the last chemotherapy course, he received rituximab at a dose of 375 mg/m2 by intravenous infusion weekly, for a total of 8 dose. However, multiple intra-abdominal metastatic lesions were detected at the end of the therapy. Palliative radiotherapy was applied to these sites. He died because of disease progression, 11 months after the diagnosis.

[A case of primary mediastinal choriocarcinoma]

A 30-year-old man presented with cough and bloody sputum. He brought a chest radiogram showing abnormal findings. His chest computed tomography revealed a large mediastinal mass and multiple nodular shadows in both lungs. The serum beta-HCG level was remarkably elevated, and physical examination revealed bilateral gynecomastia and right supraclavicular lymph node swelling. His lymph node was biopsied and choriocarcinoma was diagnosed. After 3 cycles of BEP therapy (cisplatin, etoposide, bleomycin), the tumors regressed and the serum beta-HCG level decreased. Although there were residual tumors and serum beta-HCG was mildly elevated, he refused additional therapy. The choriocarcinoma progessed rapidly again and he died seven months after his first visit. Primary mediastinal germ cell tumors are rare, and in particular the pure type of choriocarcinoma arising in the mediastinum is even rarer. Patients with mediastinal choriocarcinoma are mostly young men. The prognosis of primary mediastinal choriocarcinoma is still very poor despite the introduction of combination chemotheraphy including cisplatin. We report a case of primary mediastinum pure choriocarcinoma. Chemotherapy was effective for the patient, but he died because of recurrence after refusal of future treatment. Establishment of more effective treatment is necessary.

Giant posterior mediastinal liposarcoma invading the esophagus: a case report

Giant liposarcoma is an unusual variant of mediastinal tumors. The case of a 73-year-old woman is reported. She presented with a posterior mediastinal tumor invading the third middle tract of the thoracic esophagus and the adventitia of the descending aorta, close to the posterior pericardium; a neoplastic thrombus 2cm in size was located in the upper left pulmonary vein. The tumor was completely excised by left thoracotomy, in extracorporeal circulation. The postoperative course was uneventful and the patient received adjuvant chemotherapy. She is currently alive after 8 months, disease-free. The natural history, pathology, and prognosis of the disease are reviewed and management of such lesions is discussed.

Favorable outcome of primary mediastinal large B-cell lymphoma in a single institution: the British Columbia experience

BACKGROUND

Primary mediastinal large B-cell lymphoma (PMBCL) is a distinct clinico-pathological subtype of diffuse large B-cell lymphoma (DLBCL). The optimal treatment is unknown, with some studies suggesting a superior outcome with dose-intensive chemotherapy regimens, and the role of radiotherapy remains ill-defined.

PATIENTS AND METHODS

The British Columbia Cancer Agency lymphoma database was searched and records reviewed to identify those patients presenting with a prominent mediastinal mass and considered to be PMBCL based on the current REAL/WHO classifications. Patients were treated based on era-specific BCCA guidelines (1980-1992 MACOPB/VACOPB; 1992-2001 CHOP-type; 2001-present CHOP-R). Beginning in January 1998 involved-field radiotherapy was recommended to be routinely administered following chemotherapy. Prior to this, use of radiotherapy was individualized in advanced disease.

RESULTS

In total, 153 patients with newly diagnosed PMBCL were identified between 28 July 1980 and 30 June 2003. The median age was 37 years (range 13-82) and the majority had stage I/II (74%), bulky mediastinal disease (75%). Overall (OS) and progression-free (PFS) survival at 5 years for the entire cohort were 75% and 69%, respectively. In direct comparison with a cohort of patients with DLBCL (n = 1273), OS (P = 10(-4)) and PFS (P = 0.0001) favored PMBCL. The age-adjusted International Prognostic Index (aaIPI) was not predictive of survival (P = 0.18). Five-year OS in patients < 65 years old treated with MACOPB/VACOPB, CHOP-R and CHOP-type was 87%, 81% and 71% respectively (P = 0.048). In pair-wise survival comparisons, only MACOPB/VACOPB and CHOP-type treated patients were significantly different (P = 0.016). In Cox multiple regression analysis, poor performance status remained the only predictor of survival, with treatment received demonstrating a trend to worse outcome for patients treated with CHOP-type regimens (P = 0.09). In an intention-to-treat analysis comparing the era before radiotherapy was routinely administered with after, there was no significant difference in 5-year PFS (74% versus 62%; P = 0.09) or OS (78% versus 69%; P = 0.14).

CONCLUSIONS

In this single institution, population-based retrospective study, we found that PMBCL patients have excellent survival rates and a distinct plateau is observed in PFS, in striking comparison to DLBCL. The aaIPI was not predictive of survival in this population, suggesting that other prognostic models may be better suited for risk stratification. Dose-intensified chemotherapy with MACOPB or VACOPB demonstrated a trend to superior outcome over CHOP-type chemotherapy. However, further randomized studies are needed and the impact of rituximab on these comparisons must be considered. Finally, the routine addition of radiotherapy does not improve survival.

[Yolk sac tumor of the anterior mediastinum and pulmonary metastases; report of a case]

A 31-year-old female was clinically diagnosed as having a anterior mediastinal yolk sac tumor because of the elevation of the AFP (17,500 ng/ml), a large mass lesion (9 x 5 cm) in the anterior mediastinum and bilateral lung metastases. After 4 courses of chemotherapy with cisplatin (CDDP), etoposide (VP-16) and bleomycin hydrochloride (BLM), the mediastinal mass reduced in size significantly and the serum AFP level reached within normal range. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed a weak uptake in the mediastinum, accordingly the operation was performed. The tumor was completely removed and there were no viable foci of the tumor in part of the tumor. After the operation, 4 courses of chemotherapy with carboplatin (CBDCA), VP-16 and ifosfamide (IFM) were performed. She is alive without evidence of recurrence in 5 months after operation. It was noticed that the serum AFP is a useful indicator for determing the chance of operation after chemotherapy.

Salvage high-dose chemotherapy for children with extragonadal germ-cell tumours

We reviewed the European Group for Blood and Marrow Transplantation (EBMT) experience with salvage high-dose chemotherapy (HDC) in paediatric patients with extragonadal germ-cell tumour (GCT). A total of 23 children with extragonadal GCT, median age 12 years (range 1–20), were treated with salvage HDC with haematopoietic progenitor cell support. The GCT primary location was intracranial site in nine cases, sacrococcyx in eight, retroperitoneum in four, and mediastinum in two. In all, 22 patients had a nongerminomatous GCT and one germinoma. Nine patients received HDC in first- and 14 in second- or third-relapse situation. No toxic deaths occurred. Overall, 16 of 23 patients (70%) achieved a complete remission. With a median follow-up of 66 months (range 31–173 months), 10 (43%) are continuously disease-free. Of six patients who had a disease recurrence after HDC, one achieved a disease-free status with surgical resection followed by chemotherapy and radiotherapy. In total, 11 patients (48%) are currently disease-free. Eight of 14 patients (57%) with extracranial primary and three of nine patients (33%) with intracranial primary GCT are currently disease-free. HDC induced impressive long-term remissions as salvage treatment in children with extragonadal extracranial GCTs. Salvage HDC should be investigated in prospective trials in these patients.

Is intensity-modulated radiotherapy better than conventional radiation treatment and three-dimensional conformal radiotherapy for mediastinal masses in patients with Hodgkin's disease, and is there a role for beam orientation optimization and dose constraints assigned to virtual volumes?

PURPOSE

To evaluate the role of beam orientation optimization and the role of virtual volumes (VVs) aimed at protecting adjacent organs at risk (OARs), and to compare various intensity-modulated radiotherapy (IMRT) setups with conventional treatment with anterior and posterior fields and three-dimensional conformal radiotherapy (3D-CRT).

METHODS AND MATERIALS

Patients with mediastinal masses in Hodgkin's disease were treated with combined modality therapy (three to six cycles of adriamycin, bleomycin, vinblastine, and dacarbazine [ABVD] before radiation treatment). Contouring and treatment planning were performed with Somavision and CadPlan Helios (Varian Systems, Palo Alto, CA). The gross tumor volume was determined according to the prechemotherapy length and the postchemotherapy width of the mediastinal tumor mass. A 10-mm isotropic margin was added for the planning target volume (PTV). Because dose constraints assigned to OARs led to unsatisfactory PTV coverage, VVs were designed for each patient to protect adjacent OARs. The prescribed dose was 40 Gy to the PTV, delivered according to guidelines from International Commission on Radiation Units and Measurements Report No. 50. Five different IMRT treatment plans were compared with conventional treatment and 3D-CRT.

RESULTS

Beam orientation was important with respect to the amount of irradiated normal tissues. The best compromise in terms of PTV coverage and protection of normal tissues was obtained with five equally spaced beams (5FEQ IMRT plan) using dose constraints assigned to VVs. When IMRT treatment plans were compared with conventional treatment and 3D-CRT, dose conformation with IMRT was significantly better, with greater protection of the heart, coronary arteries, esophagus, and spinal cord. The lungs and breasts in women received a slightly higher radiation dose with IMRT compared with conventional treatments. The greater volume of normal tissue receiving low radiation doses could be a cause for concern.

CONCLUSIONS

The 5FEQ IMRT plan with dose constraints assigned to the PTV and VV allows better dose conformation than conventional treatment and 3D-CRT, notably with better protection of the heart and coronary arteries. Of concern is the "spreading out" of low doses to the rest of the patient's body.

Primary Germ Cell Tumors of the Mediastinum: 10 Years of Experience in a Tertiary Teaching Hospital

Germ cell tumors occur mostly in the gonad. Extragonadal germ cell tumors are rare, and most occur in the retroperitoneum and mediastinum. Primary mediastinal germ cell tumors are often found in the anterior portion of the mediastinum and include teratomas and non-teratomatous tumors. Non-teratomatous tumors include seminomas and malignant non-seminomatous germ cell tumors (MNSGCTs). MNSGCTs include yolk sac tumors, choriocarcinomas, embryonal carcinomas, and mixed type germ cell tumors. Teratomas are the most common germ cell tumors of the mediastinum, and seminomas are the most common non-teratomatous germ cell tumors of the mediastinum. Cases of primary mediastinal MNSGCT reported in the literature are rare. In this report, we review all primary mediastinal germ cell tumors from a 10-year period at the Chung-Ho Memorial Hospital of Kaohsiung Medical University. A total of 14 cases were reviewed, including 11 patients with mature teratomas, two with yolk sac tumors, and one with seminoma. We discuss the differences in clinical presentation, histopathologic characteristics, treatment, and prognosis.

Primary mediastinal large B-cell lymphoma: optimal therapy and prognostic factor analysis in 141 consecutive patients treated at memorial Sloan Kettering from 1980 to 1999

Primary mediastinal large B-cell lymphoma (PMLBL) is a distinct clinicopathological entity with unclear prognostic factors and optimal treatment approach. To elucidate an optimal treatment and identify predictive factors, a retrospective analysis of 141 consecutive patients was undertaken. Patients received cyclophosphamide, hydroxydaunomycin, Oncovin, prednisone (CHOP)-like therapy, the non-Hodgkin lymphoma (NHL)-15 regimen or upfront autologous stem cell transplantation (ASCT) on Institutional Review Board approved trials or according to the institutional guidelines. Evaluation included lactate dehydrogenase, International Prognostic Index (IPI) assessment, computed tomography scan and gallium imaging. With a median follow-up of 10.9 years, event-free survival (EFS) and overall survival (OS) was 50% and 66% respectively. EFS/OS for CHOP/CHOP-like, NHL-15 and upfront ASCT was 34/51%, 60/84% and 60/78% respectively. CHOP/CHOP-like regimens had inferior EFS and OS versus NHL-15 or upfront ASCT (P < 0.001). A total of 23% of patients received radiotherapy. Multivariate analysis revealed the following outcome predictors: for EFS, greater than or equal to two extranodal sites and initial therapy received (NHL-15 or upfront ASCT); for OS, only initial therapy with NHL-15. We conclude: (i) dose-dense chemotherapy with NHL-15 may be superior to CHOP for PMLBL; (ii) The impact of consolidative radiotherapy requires randomised controlled trials; (iii) The age-adjusted IPI did not predict survival in this analysis; (iv) high-dose chemotherapy/ASCT should be reserved for upfront anthracycline-based therapy failure or in clinical trials for high-risk patients.

Pneumomediastinum as a complication to treatment of mediastinal (thymic) large B-cell lymphoma

Mediastinal (thymic) large B-cell lymphoma (Med-DLBCL) is a subtype of diffuse large B-cell lymphomas (DLBCL) with a typical radiological appearance of bulky anterior mediastinal mass, often with areas of necrosis. We report a case of Med-DLBCL with unusual radiological findings and clinical development. Computed tomography (CT) obtained at presentation revealed a huge anterior mediastinal tumor with an axial diameter of 180 mm. Nineteen days after the first cycle of chemotherapy, chest radiography and CT revealed large areas of tumor necrosis and pneumomediastinum with air-fluid levels. To our knowledge, air-fluid levels inside Med-DLBCL have not been previously described. This finding, in combination with necrotic sputum, may indicate communication between the tracheobronchial tree and the tumor.

Overproduction of an amino-terminal form of PTH distinct from human PTH(1-84) in a case of severe primary hyperparathyroidism: influence of medical treatment and surgery

OBJECTIVE

Rare patients with severe primary hyperparathyroidism present with large parathyroid tumours, severe hypercalcaemia, very high PTH levels and osteitis fibrosa cystica. Some of these patients display a large amount of C-PTH fragments in circulation and present with a higher C-PTH/I-PTH ratio than seen in less severe cases of primary hyperparathyroidism. We wanted to determine how PTH levels and circulating PTH high-performance liquid chromatography (HPLC) profiles analysed with PTH assays having different epitopes could be affected by medical and surgical treatment in such patients.

DESIGN

A 55-year-old man with severe hypercalcaemia (Ca(2+): 2.01 mmol/l), very high PTH levels (CA-PTH 82.1 and T-PTH 72 pmol/l) caused by a large parathyroid tumour (7.35 g) and accompanied by significant bone involvement (alkaline phosphatase of 185 UI/l and subperiostal bone resorption of hands) was referred to us. Blood was obtained at various time points during his medical treatment, before and after surgery, to measure parameters of calcium and phosphorus metabolism, and of bone turnover. HPLC separations of circulating PTH molecular forms were performed and analysed with PTH assays having 1-4 (CA), 12-18 (T), 26-32 (E) and 65-84 (C) epitopes.

RESULTS

Before surgery, serum Ca2+ was nearly normalized with hydratation, intravenous (IV) pamidronate and oral vitamin D administration. Despite a decrease in Ca2+ to 1.31 mmol/l, CA-PTH and T-PTH levels decreased by half in relation to a threefold increase in basal 1,25-dihydroxyvitamin D [1,25(OH)2D] level (94 to 337 pmol/l). After this initial positive response, hypercalcaemia and elevated CA- and T-PTH levels recurred even if 1,25(OH)2D levels remained elevated. The tumour was removed surgically and proved to be poorly differentiated with nuclear atypia and mitosis. After surgery, the Ca2+ level and PTH secretion normalized. The higher CA-PTH level relative to the T-PTH level observed before surgery in this patient was related to the oversecretion of an amino-terminal (N) form of PTH recognized by PTH assays with (1-4) or (26-32) epitopes but not by the T-PTH assay with a (12-18) epitope. This molecular form represented 50% of CA-PTH measured in this patient, but only 7% in less severe cases of primary hyperparathyroidism. It was unaffected by medical therapy and disappeared after surgery.

CONCLUSION

The relationship between the overexpression of this N-PTH molecular form and severe primary hyperparathyroidism remains unclear. Further studies will be required in these rare patients to see whether N-PTH is a marker of less well differentiated parathyroid tumours and/or relates to the overproduction of C-PTH fragments in the presence of severe hypercalcaemia.

[A case of recurrent esophageal cancer successfully treated with weekly paclitaxel in combination with radiotherapy]

A 48-year-old man underwent subtotal esophagectomy for pStage III (pT 3 pN 3) thoracic esophageal carcinoma on June 20, 2002, in combination with chemotherapy (5-FU 500 mg/day day 1-14, CDDP 10 mg/day day 1-14, VDS 3 mg on days 1 and 8) before and after the operation. Recurrence was seen 7 months after the operation in right pleura and lower mediastinum. Chemo (same regimen)-radiotherapy (50 Gy) was then performed but without effect. Thereafter, lung and upper mediastinal metastases were found, and weekly administration of paclitaxel (70 mg/m2, day 1, 8, 15, q 4w) was initiated in combination with radiotherapy (40 Gy). Two cycles of treatment resulted in PR, and CR was achieved after the 8th cycle was completed. Although treatment was terminated after the 12 th cycle due to development of peripheral neuropathy (grade 2), CR was still maintained 8 months after the completion of treatment. These results suggested the effectiveness of the treatment in cases that show resistance to conventional 5-FU-based chemotherapy.

Second-line high-dose chemotherapy in patients with mediastinal and retroperitoneal primary non-seminomatous germ cell tumors: the EBMT experience

BACKGROUND

Results of second-line chemotherapy in patients with extragonadal non-seminomatous germ cell tumor (NSGCT) appear inferior to results in testicular NSGCT. Patients with retroperitoneal NSGCT achieve a comparable long-term survival rate of 30%, but the salvage rates of patients with mediastinal primary are less than 10%. We conducted a retrospective analysis on patients with mediastinal and retroperitoneal NSGCT treated with second-line high-dose chemotherapy (HDCT) registered with the European Group for Blood and Marrow Transplantation (EBMT).

PATIENTS AND METHODS

Between 1987 and 1999, 59 registered patients with retroperitoneal (n=37) and mediastinal (n=22) primary NSGCT, median age 28 years (range 18-60), were treated with second-line HDCT. All had received cisplatin-containing chemotherapy as first-line treatment.

RESULTS

Toxic death occurred in three cases (5%). With a median follow-up of 58 months (range 14-114), 18/59 patients (30%) continue to be disease-free. Of three patients who had a disease recurrence after HDCT, one patient achieved a disease-free status with further chemotherapy and surgery. In total, 19 patients (32%) are currently disease-free. Sixteen of 37 patients (43%) with retroperitoneal NSGCT, and three of 22 patients (14%) with mediastinal NSGCT are currently alive and disease-free.

CONCLUSIONS

Second-line HDCT might represent a possible option for patients with retroperitoneal primary NSGCT. New salvage strategies are needed for patients with mediastinal NSGCT.

Primary mediastinal B-cell lymphoma with sclerosis: report of 11 cases treated with intensified-CHOP plus radiotherapy

Primary mediastinal B-cell lymphoma (PMBCL) is a clinicopathological entity with aggressive behavior. Retrospective evaluation suggests the need for intensive chemotherapy programs. From 1997 to February 2003, a total of 11 cases of previously untreated PMBCL with sclerosis were treated at our institution with 5 courses of intensified CHOP (ICHOP) regimen and mediastinal irradiation. Three patients were submitted to high-dose chemotherapy with peripheral-blood stem-cell support, followed by radiotherapy, because of intermediate-risk age-adjusted International Prognostic Index at diagnosis. After a median follow up of 30 months, all patients but one are in continuous complete remission (CR), and overall survival is 100%.

Primary mediastinal large B-cell lymphoma in an HIV-infected patient

HIV-related non-Hodgkin lymphoma is well documented in the literature. We report a case of an HIV-infected patient who presents with primary mediastinal large B-cell lymphoma. On review of the literature, this appears to be the first documented case of this subtype of large B-cell non-Hodgkin lymphoma seen in an HIV-infected patient. Our patient received CHOP (cyclophosphamide, hydroxydaunomycin, Oncovin, prednisone) chemotherapy with granulocyte colony-stimulating factor support but unfortunately died a few days later.

Successful treatment of mediastinal lymphomatoid granulomatosis with rituximab monotherapy

Lymphomatoid granulomatosis is a rare Epstein-Barr virus (EBV)-positive-B-cell lymphoproliferative disorder. Treatment options include corticosteroids, antiviral therapy, interferon-alpha and chemotherapy. However, long-term prognosis is poor and no therapeutic standard has been established yet. In a 21-year-old woman, a biopsy of mediastinal mass revealed lymphomatoid granulomatosis. Combined therapy with valganciclovir and interferon-alpha proved ineffective. In view of the CD20 expression of the tumor cells, monotherapy with rituximab was intiated. After 3 months a complete remission was achieved. Rituximab was continued for another 6 months with subsequent consolidation radiotherapy. This is the first report of an enduring complete remission (20 months) of a non-CNS lymphomatoid granulomatosis treated with rituximab.

Life-threatening airway obstruction caused by mediastinal germinoma in a 9-year-old girl

The authors report a case of a 9-year-old girl with a mediastinal germinoma that required emergent surgical extirpation because of tracheal compression and asphyxia. The tumor was successfully debulked under general anesthesia with the capability of extracorporeal circulation immediately available. Postoperatively, the tumor responded to adjuvant chemotherapy and irradiation and the patient survived without evidence of recurrence.

[Two cases of testicular tumors with high alpha-fetoprotein levels: a case report]

Two patients with testicular tumors whose serum alpha-fetoprotein (AFP) persisted to show an abnormally high concentration are reported. Case 1 : A 42-year-old male who had been suffering from chronic hepatitis, underwent left high orchiectomy for a left testicular tumor in 1998. Diagnosis was an authentic stage I seminoma. In 2002, chemotherapy was performed for a metastatic seminoma revealed as a solitary mass in the mediastinum by radiographic studies, and histologically confirmed to be a metastatic seminoma. Although lymph nodes were gradually reduced in size, the serum AFP and transaminase levels remained at an abnormally high concentration. The subfraction profile with lens culinaris hemagglutinin (LCA) revealed elevation of only peak 1 which implied that the chronic hepatitis was due to liver dysfunction. After a 10-month follow-up the levels of both AFP and transaminase decreased, and the patient was disease-free. Case 2: In 2002, a 30-year-old male underwent left high orchiectomy for a left testicular tumor, and histological examination revealed seminoma, immature and mature teratoma, embryonal carcinoma. The serum AFP was elevated to 45 ng/ml. Diagnosis was authentic stage I. After 2 courses of chemotherapy, the serum AFP remained at an abnormally high concentration. However, there were no new lesions. The serum AFP level was not elevated in any of the family members. The subfraction profile with LCA revealed elevation of only peak 1, which implied that there were no viable lesions. After a 24-month follow-up AFP was about 20 ng/ml and the patient was disease-free.

Critical stenosis of aortic and mitral valves after mediastinal irradiation

Radiotherapy is used widely in cancer treatment. Mediastinal irradiation is associated with valvular regurgitation; however, stenosis is rare. We present a patient with critical aortic and mitral valve stenosis after mediastinal irradiation and discuss the natural history, treatment, and prognosis of radiation-associated valvular heart disease.

Extended resection of mediastinal undifferentiated carcinoma after chemosensitivity test-guided induction treatment: report of a case

We performed extended resection of primary mediastinal undifferentiated carcinoma, together with the superior vena cava and the upper lobe of the right lung, after effective induction chemoradiation therapy based on the results of a chemosensitivity test. Pathological examination of the resected specimen revealed that almost all of the tumor cells had died. The patient received adjuvant chemotherapy and has remained free from disease progression for 27 months since his operation. Our experience supports the effectiveness of an aggressive approach, in the form of chemosensitivity test-guided induction therapy, to treat this high-grade malignant disease, despite the risk of cancer dissemination.

Paclitaxel plus ifosfamide and cisplatin in second-line treatment of germ cell tumors: a phase II study

The aim of this study was to determine efficacy and toxicity of TIP combination (paclitaxel, ifosfamid, cisplatin) as first salvage treatment in patients with relapsed germ cell tumours (GCTs). Excellent results were achieved from TIP combination with a dose 250 mg/m(2) of paclitaxel [5]. Our hypothesis was that comparable efficacy with less toxicity could be achieved even with a lower dose of 175 mg/m(2) paclitaxel in TIP. In 17 consecutive patients with failed standard 1st line treatment, we used four to six courses of paclitaxel 175 mg/m(2) on day 1 and ifosfamide 1,200 mg/m(2) plus cisplatin 20 mg/m(2), both on day 1 through 5, every 3 weeks. Eleven patients achieved favorable response (65%; 95% confidence interval, 42 to 87%) with 7 complete responses (41%). Estimated 2-year disease free survival is 47% (95% CI, 23-71%). Treatment combination was well tolerated and myelosupression was major toxicity. Granulocytopenia Gr3-4 was observed in 8% and febrile neutropenia in 7% of the courses. No case of severe neurotoxicity or treatment-related death was observed. In our study, TIP combination had good toxicity profile. The results however, did not show expected treatment efficacy and we raise the idea of paclitaxel dosage relevance in TIP.

[Efficacy of different chemotherapy programs, indications for surgery and radiotherapy in primary mediastinal B-cell lymphosarcoma]

AIM

To evaluate efficacy of treatment of primary mediastinal B-cell lymphosarcoma (PMBLS).

MATERIAL AND METHODS

Fifty nine patients with PMBLD were divided into three groups. Group 1 (n = 15) received 8 courses of CHOP, prevention of neuroleukemia and radiotherapy (RT). Group 2 (n = 8)--4 courses of ProMACE-CytaBOM or 1 course of MACOP-B, prevention of neuroleukemia and RT. Group 3 (n = 36)--2 courses of CHOP and 2-3 courses of ESHAP or 3 courses of DexaBEAM, surgical removal of residual mediastinal tumor (RMT), RT.

RESULTS

The number of complete remissions in group 1 and 2 was the same (26 and 25%, respectively). Overall 5-year and event-free survivals in groups 1 and 2 were 52 +/- 5 and 13 +/- 5; 62 +/- 5 and 38 +/- 8%, respectively. In group 3 a complete remission was observed in 89% patients (p = 0.01), overall 5-year and event-free survival reached 88 +/- 8 and 85 +/- 7%, respectively. Removal of RMT in time of tumor size stabilization and partial remission (in 12 of 15 cases) led to a complete remission but in progression of the disease (in 3 cases) appeared ineffective. RT resulted in complete remission in 39 of 53 cases, stabilization of tumor growth was in 3 cases, progression--in 10, recurrence--in 1. RT was ineffective in all 4 cases of partial remission. RT use in stabilization of tumor size induced complete remission only in 1 of 7 cases.

CONCLUSION

CHOP program is ineffective in PMBLS. Program ProMACE-CytaBOM or MACOP-B is insignificantly more effective than CHOP. Combined therapy is most effective. Surgery is justified in partial remission and tumor growth arrest. RT is indicated in complete remission to achieve its consolidation.

Secondary leukemia after first-line high-dose chemotherapy for patients with advanced germ cell cancer

PURPOSE

We investigated the incidence of secondary leukemia in patients treated with first-line high-dose chemotherapy (HDCT) plus autologous stem cell transplantation (PBSCT) for advanced testicular cancer.

METHODS

Three hundred and twenty-three patients who were entered into two consecutive prospective Phase-II studies of the German Testicular Cancer Study Group were analyzed. A total of 221 patients had received HD-VIP containing cisplatin, ifosfamide, and etoposide and 102 patients were treated with Tax-HD-VIP containing cisplatin, ifosfamide, etoposide, and paclitaxel, each cycle supported by autologous PBSCT.

RESULTS

Patients had received a median cumulative etoposide dose of 4.9 g/m(2) (range, 2.2-9.4 g/m(2)). The median follow-up duration for all patients was 36 months (range, 0-128) with a median follow up time of 50 months (range, 0-128) for patients surviving at least 1 year after therapy. One patient developed a secondary acute myeloid leukemia (s-AML) involving a chromosomal translocation t(11;19)(q23;p13.3) 24 months after the start of chemotherapy resulting in a cumulative incidence of 0.48% [95% confidence interval (CI) 0-1.42]. Additionally, two patients with primary mediastinal germ cell cancer developed a myelodysplastic syndrome. No solid tumors had occurred.

CONCLUSIONS

HDCT including high-dose etoposide with autologous PBSCT as first-line therapy for advanced testicular cancer was associated with an acceptably low risk of developing secondary leukemia.

Efficacy of Docetaxel as a Second-Line Chemotherapy for Thymic Carcinoma

Thymic carcinoma is a rare and aggressive tumor, and the efficacy of second-line chemotherapy is still unclear. Here, we reported a case of thymic carcinoma that responded well to the administration of docetaxel alone as a second-line chemotherapy. A 64-year-old woman was diagnosed with thymic carcinoma (squamous cell type) with bone metastasis, and she, therefore, received nedaplatin combined with etoposide and ifosfamide. She responded partially, after which she received irradiation for bone metastasis. Two months after chemotherapy, the thymic carcinoma exhibited gradual regrowth and she experienced shoulder pain. We treated this with docetaxel alone (60 mg/m2 every 4 weeks). After three courses of docetaxel, we observed a partial response and her shoulder pain disappeared. This case demonstrated that docetaxel is effective as a second-line chemotherapy for thymic carcinoma.

[Treatment of primary mediastinal large B-cell lymphomas]

INTRODUCTION

Primary mediastinal large B-cell non-Hodgkin's lymphoma is a relatively rare disease with specific clinical symptoms. This tumour originates from a subset of B-cells of the thymus and at the time of the diagnosis the disease is predominantly localised in the mediastinum. The tumor grows rapidly and frequently involves other thoracic structures. The majority of the patients are young females. There are no histologic features that reliably distinguish these tumors from other diffuse large B-cell lymphomas. This is the only lymphoma subtype which can only be defined by the combination of clinical and pathologic features. Analysis with DNA microarrays verified that primary mediastinal and diffuse large B-cell lymphomas are different diseases.

AIMS

Comparing the effectiveness of two types of anthracycline-based standard chemotherapy regimens and the evaluation of the prognostic markers which are applied in large B-cell lymphomas.

METHODS

27 patients with primary mediastinal lymphoma were treated by the authors with anthracycline-based polychemotherapy with complementary radiotherapy from January 1995 to December 2002.

RESULTS

Complete remission was obtained in 15 patients (56%) and no relapse was observed in this group. 9 additional patients (33%) achieved partial remission, while in 3 cases (11%) the treatment was ineffective. The patients who failed to achieve complete remission were subsequently treated with more intensive chemotherapy. Afterwards, those patients who were chemosensitive, underwent high-dose chemotherapy with autologous peripheral blood stem-cell transplantation. The chemoresistant patients received palliative chemotherapy. The 5-year overall survival rate of the 27 patients was 62.11%.

CONCLUSION

The authors found that the procarbazine, prednisolone, adriamycin, cyclophosphamide, etoposide, cytosine-arabinoside, bleomycin, vincristine, methotrexate treatment was more effective than the cyclophosphamide, adriamycin, vincristine, prednisolone combination. The expected 5-year overall survival rates were 83.57% vs. 33.33%, respectively. This difference was significant (p = 0.017). No prognostic value of age adjusted international prognostic index, LDH- and b2-microglobulin levels were found. The results with the new standard of combined immuno-chemotherapy (rituximab--cyclophosphamide, adriamycin, vincristine, prednisolone) seem to be hopeful and more effective than earlier treatments.

Intestinal complications in children undergoing chemotherapy for mediastinal non-Hodgkin's lymphoma

Toxicities involving gastrointestinal tract are common in patients undergoing aggressive chemotherapy for cancer. However, it is uncommon to develop severe ulceration or perforation of the small intestine in absence of direct involvement of the bowel with the malignancy. The authors describe two children who developed severe gastrointestinal complications requiring surgical intervention following initial chemotherapy for non-Hodgkin's lymphoma. Both patients had no evidence of small bowel involvement by lymphoma on clinical staging.

[A young man with rapidly progressing dyspnoea and a mediastinal mass]

An 18-year-old male presented with a 2-week history of rapid progressive dyspnoea and dry cough due to a large mediastinal mass with compression of the trachea. Based on the raised serum values of the tumour markers chorionogonadotrophin and alphafoetoprotein the diagnosis of germ-cell tumour was made. Because of the severity of his symptoms chemotherapy with bleomycin, etoposide and cisplatin was begun on the same day and before the results of the histology investigations were known. The next day the symptoms were diminished and after completing four courses of chemotherapy there was complete remission. The differential diagnosis of a rapid progressive mediastinal mass is limited and mainly relates to malignant lymphoma and germ-cell tumours. In emergency situations if tumour markers are raised then anti-tumour therapy may be begun before any histological confirmation is available.

[Malignant germinal tumours of the mediastinum: diagnosis and treatment]

Mediastinal germinal tumours are composed of tissues resembling those that follow one another during embryo development, by differentiation of the primordial and extraembryonic layers. Such practice separates the mature teratomas (benign), seminomas and non-seminomatous germinal tumours (NSGT). Platin-based chemotherapy has shattered the prognosis of such tumours.

Residual tumor resection after high-dose chemotherapy in patients with relapsed or refractory germ cell cancer

PURPOSE

To assess the role of residual tumor resection performed after high-dose chemotherapy (HDCT) in patients with relapsed or refractory germ cell tumors (GCT).

PATIENTS AND METHODS

Between July 1987 and October 1999, postchemotherapy resections of residual tumors were performed in 57 patients who had been treated with HDCT for relapsed or refractory GCT and who had achieved a partial remission to this treatment.

RESULTS

Complete resections of residual masses were achieved in 52 (91%) of 57 patients who were rendered disease free; in five (9%) of 57 patients, the resections were incomplete. Resection of a single site was performed in 39 (68%) of 57 patients, and the remaining 18 (32%) of 57 patients required interventions at two or more residual tumor sites. Necrosis was found in 22 (38%) of 57 patients, mature teratoma with or without necrosis was found in nine (16%) of 57 patients, and viable cancer with or without additional necrosis or mature teratoma was found in 26 (46%) of 57 patients. Viable cancer consisted either of residual germ cell or undifferentiated cancer in 22 (85%) of 26 patients, with additional non-GCT histologies in the remaining four patients. Patients with viable cancer had a significantly inferior outcome after surgery compared with patients with necrosis and/or mature teratoma even if all cancer was completely resected. Pulmonary lesions with a diameter of more than 2 cm were the only predictive variable for viable cancer in univariate analysis.

CONCLUSION

Resections of all residual tumors should be attempted in patients with relapsed or refractory GCT and partial remissions after HDCT.