Unusual presentation of extranodal diffuse large B-cell lymphoma in a solid-organ recipient during long-term immunosuppressive treatment

INTRODUCTION

Posttransplant lymphoproliferative disorders (PTLDs) refer to a group of diseases, including diffuse large B-cell lymphoma (DLBCL), that develop after solid organ transplantation or hematopoietic stem cell transplantation. Extranodal involvement in PTLDs is common. Reports about exclusive bone marrow involvement are rare.

CASE DESCRIPTION

A 70-year-old woman, who had undergone kidney transplantation in 2018, was diagnosed with exclusively extranodal, Epstein-Barr virus-negative DLBCL, with bone marrow and spleen involvement, during long-term immunosuppression. She achieved complete remission with combined immunochemotherapy and temporary hold of immunosuppression.

CONCLUSIONS

This case shows an uncommon clinical presentation of DLBCL, which was challenging to diagnose, being entirely extranodal. The favorable clinical course relied on timely diagnosis and a multidisciplinary approach. Long-term consequences of posttransplant immunosuppression require a high level of suspicion for an appropriate management, aimed at preserving the graft while eradicating the lymphoproliferative disorder.

Sentinel lymph node biopsy in patients with thick (= 4 mm) melanoma: a single-centre experience

BACKGROUND AND OBJECTIVE

Lymphatic mapping/sentinel lymph node biopsy (LM/SLNB) have become routine techniques for staging the regional lymph nodes in early stage melanoma, yet their role in the management of thick (= 4 mm) melanoma is debated. The aim of the present study is to review our experience with LM/SLNB in a series of patients with thick primary melanoma, to evaluate its utility in this melanoma subset.

PATIENTS AND METHODS

Thirty patients (18 men and 12 women; mean age 70.6 years; median 75 years) with thick primary melanoma underwent LM/SLNB, using both radioisotope and blue dye. The statistical tests were performed by using SAS software for Windows, version 8.2.

RESULTS

The primary tumour sites were head/neck (n = 5; 16.6%), trunk (n = 10; 33.3%), and extremities (n = 15; 50%). Tumour thickness ranged from 4 to 17 mm (mean 5.14 mm; median 4.5 mm). Ulceration was observed in 23 (76.6%) tumours. Eleven patients (36.6%) had at least a positive sentinel lymph node (SLN). The mean follow-up was 27.3 months (median 26 months; range 5-63 months). Patients without SLN metastases had a 5-year disease-free survival rate of 78.9%, vs. 18.2% for patients with SLN metastases (P = 0.0121 by log rank test). The 5-year overall survival rate for patients without SLN metastases was 89.5%, whereas patients with SLN metastases had a 5-year overall survival rate of 36.4% (P = 0.0272 by log rank test).

CONCLUSION

Our retrospective analysis indicates that the SLN status is predictive of recurrence and survival in patients with thick melanoma, and LM/SLNB should be routinely performed in this subset of melanoma patients.

Aspiration needle biopsy refines preoperative diagnosis of thyroid nodules defined at fine needle aspiration as microfollicular nodule

The aim of this paper was to verify the hypothesis that large needle biopsy performed preoperatively can refine preoperative fine needle aspiration (FNA) cytological diagnoses of microfollicular nodules. Since 1980 we have been using FNA and aspiration needle biopsy (ANB) (18 or 16 gauge needles) to select for surgery all euthyroid patients with palpable thyroid nodules referred to our department. From 1980 to 1994, 6,124 patients (12% male, 88% female) with thyroid nodules (71% single, 29% multiple) were examined by FNA; 29% of these patients were also examined preoperatively by ANB histology. Of all the nodule patients examined, 371 received a preoperative FNA diagnosis of microfollicular nodule. Two hundred and fifty-four of these nodules (68%) were also examined preoperatively by ANB. Unsatisfactory ANB specimens constituted 17% of cases; pure microfollicular structure was confirmed by ANB in 36% of the nodules; ANB showed the remaining 47% to contain a macrofollicular component, thus suggesting a benign hyperplastic lesion. Twelve nodules which were found to be microfollicular at FNA cytology and micro-macrofollicular at ANB were excised and were subsequently determined as benign at definitive postoperative histology. These data indicate the utility of ANB in refining the preoperative FNA diagnosis of microfollicular nodule and in preoperatively identifying benign hyperplastic mixed micro-macrofollicular lesions which can be followed by observation.

The value of aspiration needle biopsy in evaluating thyroid nodules

From 1980 to 1990 4,229 consecutive euthyroid patients with thyroid nodule (73% with single and 27% with multiple nodules) were examined by FNA cytology for preoperative selection. One thousand four hundred and eight of these patients (33%) had nodules also suitable for evaluation by large needle biopsy histology (Aspiration Needle Biopsy, ANB). No significant complications occurred following ANB. The proportion of inadequate specimens was 25% for ANB and 15% for FNA, however a definite diagnosis was obtained with ANB in 62 patients with inadequate FNA finding. Diagnostic sensitivity was higher (93%) for FNA than for ANB whereas specificity was better (82%) for ANB diagnoses. Nonetheless ANB contributed to the increase of overall sensitivity as four of all the malignant nodules diagnosed as benign by FNA were correctly identified by ANB. Analysis of the postoperative results of 102 nodules with FNA and ANB finding of benign nodule or of suspected cancer showed that the addition to the same FNA finding (benign nodule or suspected cancer) of a different ANB diagnosis (suspected cancer or benign nodule) greatly changed the probability of finding a malignant nodule at postoperative histology. ANB was also useful in showing a macrofollicular component in 52% of 150 nodules diagnosed by FNA as pure microfollicular nodules.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous injection of ethanol to treat autonomous thyroid nodules

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of sonographically guided percutaneous injection of ethanol for treating autonomous thyroid nodules in order to assess that technique's feasibility as an alternative to traditional ablative (radionuclide and surgical) therapies.

SUBJECTS AND METHODS

Thirty-two patients with autonomous thyroid nodules were included in the study: seven had thyrotoxicosis, and 25 were in the pretoxic clinical phase. Ethanol was injected percutaneously on an outpatient basis once or twice a week for a total of three to 10 injections per nodule, mainly depending on the nodule's size. Scintigrams obtained 3 months after the end of treatment were used to assess response to this therapy. The follow-up period was from 3 to 30 months.

RESULTS

Thyroid scintigraphy 3 months after percutaneous injection of ethanol showed complete recovery of function in extranodular tissue in 26 patients (81%), partial recovery in five patients (16%), and no recovery in one patient (3%). In all patients, the volume of the nodules decreased by more than 50% after treatment. In three of five patients in whom scintigraphy showed only partial recovery of function in extranodular tissue, a second percutaneous injection of ethanol was given after 15 months. The therapy was well tolerated, and after a total of 216 injections, no patient had permanent side effects.

CONCLUSIONS

Our experience shows that percutaneous injection of ethanol is a practical alternative to traditional treatments for autonomous thyroid nodules and that it is an option for treating pretoxic adenoma.

Comparison of the effect of a single oral L-thyroxine dose (150 micrograms) in tablet and in solution on serum thyroxine and TSH concentrations

150 micrograms of L-thyroxine were administered to each of 14 euthyroid goitrous patients orally between 7:30 and 8:30 a.m. after fasting overnight. The L-T4 dose given was one and half tablets of the drug "Eutirox" (L-T4 tablet of 100 micrograms distributed by Bracco, Milan, Italy) or one and half ml of the solution "Tiroxen" (solution containing 100 micrograms/ml of L-T4 distributed by Laboratori Baldacci, Pisa, Italy). Two studies (one with tablet and one with solution) were performed on each patient. The tablet or the liquid form of L-T4 were administered in random order. In each study a blood sample for serum hormone determination was drawn immediately before L-T4 administration, then 30 minutes later and every hour up to the fifth hour after. The second study was performed in similar fashion later. The mean serum TT4 concentration value at any time was very similar in the two studies, thus showing the same time course after the administration of solution and the tablet formulation. The mean basal TT4 value (9.07 +/- 0.56 and 8.90 +/- 0.73 micrograms/dl respectively) increased significantly at the first and second hours. The highest value was reached at the second and at the third hour after the solution (11.15 +/- 0.58 micrograms/dl) and the tablet (11.81 +/- 0.78 micrograms/dl) respectively. Subsequently, the mean TT4 values remained significantly higher than basally over the entire 5 hours. The FT4 mean serum concentration at all times were very similar in the two studies and showed the same time course.(ABSTRACT TRUNCATED AT 250 WORDS)

Long term therapy with a new liquid L-thyroxine preparation: bioequivalence with L-T4 tablets

Seventy-four euthyroid patients with nodular goiter (55) or primary hypothyroidism (19) were selected for long term treatment with a new preparation containing L-T4 in solution (Tiroxen, Laboratori Baldacci, Pisa, Italy). Each patient underwent, before or after receiving the L-T4 in solution, long term treatment with L-T4 in tablet form at the same dose. The serum concentrations of TSH, TT4, TT3, FT4 and FT3 were measured basally and during therapy with each of the two L-T4 preparations (liquid and tablet). In the golter group, mean serum TSH concentration was 1.4 microUI/ml basally, while it was 0.47 microUI/ml following both L-T4 tablet therapy and L-T4 solution administration. Mean basal TSH value was significantly different from the two values on the therapy (p < 0.001 in each instance). Mean basal serum TT4 concentration was 8.2 +/- 0.25 microgram/dl basally while it was 9.9 +/- 0.28 microgram/dl (p < 0.001) on L-T4 tablet therapy and 9.7 +/- 0.26 (p < 0.001) on L-T4 solution administration. Mean basal serum concentration of TT3, FT4, FT3 was not significantly different from the value on the therapy, either with L-T4 tablet or with L-T4 solution. In the hypothyroid patients the high mean basal serum TSH concentration (23.6 microUI/ml) returned to normal similar values on L-T4 tablet therapy (0.96 microUI/ml; p < 0.01) and on L-T4 solution administration (1.24 microUI/ml; p < 0.01). The serum TSH concentration value during L-T4 therapy varied from unmeasurable level to 3.5 microUI/ml during the tablet administration and to 4.8 microUI/ml during the solution administration.(ABSTRACT TRUNCATED AT 250 WORDS)

[SPECT in the study of pathology of the temporomandibular joint. The authors' personal experience]

Symptomatic temporomandibular joint dysfunctions may affect about 25% of the adult population, with a smaller though significant percentage of patients experiencing severe impairment. From 1986 through 1991, 107 patients with severe temporomandibular joint symptoms and with various temporomandibular joint disorders were evaluated with conventional radiology and with closed/open-mouth temporomandibular joint tomograms. Single-photon emission-computed tomography (SPECT) and planar imaging were performed on 32 patients using a rotating gamma camera equipped with a general purpose collimator. Transaxial, coronal and sagittal tomoscintigrams were reconstructed. Increased radiotracer uptake in the temporomandibular joint was regarded as a positive finding, and the intensity of temporomandibular joint activity was compared with that of adjacent calvarium using regions of interest. In the 32 patients submitted to scintigraphy, conventional radiology showed no pathologic patterns, while SPECT showed pathologic findings in 31 patients (97% of cases). The patient with normal temporomandibular joint findings on SPECT exhibited abnormal maxillary isotope uptake, ipsilateral to the symptoms. Our results indicate that SPECT is a simple, noninvasive, inexpensive and very sensitive screening test relative to the internal derangement of the temporomandibular joint. Moreover, it provides information which is not available by means of routine bone scans or X-ray studies. Thus, SPECT appears to be the modality of choice for patients whose clinical findings are equivocal or whose symptoms are unclear, and it can guide treatment strategies and be useful in the follow-up.

Effect of a single oral dose of L-thyroxine (150 micrograms) on serum thyroid hormone and TSH concentrations in clinically euthyroid goitrous patients

Serum TT4, FT4, TT3, FT3 and TSH, concentrations were measured before and 0.5, 1, 2, 3, 4, 5 hours after a single oral dose of L-T4 (150 micrograms) in 21 clinically euthyroid goitrous patients on a long-term therapy program. The mean basal TT4 concentration, 8.85 +/- 0.52 micrograms/dl (mean +/- se), increased significantly at the second hour (10.04 +/- 0.52 micrograms/dl, p < 0.001) and reached the highest value at the third hour (10.35 +/- 0.55 microgram/dl, p < 0.001). Subsequently the mean serum TT4 concentration remained elevated until the fifth hour (10.20 + 0.60 microgram/dl, p < 0.001). The mean basal value of FT4 concentration, 8.66 +/- 0.40 pg/ml, increased significantly at 30 minutes (9.19 +/- 0.40 pg/ml, p < 0.01) and reached the highest value at the third hour (11.81 +/- 0.56 pg/ml, p < 0.001). The mean basal serum FT3 concentration, 3.56 +/- 0.10 pg/ml, increased significantly 30 minutes (3.72 +/- 0.11 pg/ml p < 0.05) after L-T4 administration; the mean serum FT3 concentration was significantly higher than the basal level and 1 and 2 hours as well, and reached the highest value at the third hour (3.86 +/- 0.09 pg/ml). The mean serum TT3 concentration did not show any significant change at any time. The mean basal TSH value (2.73 +/- 0.42 microUI/ml) declined progressively. At 30 minutes it decreased significantly (2.29 +/- 0.38 microUI/ml, p < 0.01) and reached the lowest value at the fifth hour (1.39 +/- 0.26 microUI/ml, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Basal and stimulated TSH serum concentrations in euthyroid thyroid nodule patients

Serum TSH concentrations were determined by a sensitive second generation immunoradiometric (IRMA) assay, basally and 20 min after i.v. injection of 200 micrograms of TRH, in 630 consecutive ambulatory clinically and biochemically euthyroid patients with palpable thyroid nodules. The TSH response was defined as normal when the stimulated TSH values was higher than the basal one by at least 2 microU/ml, as suppressed when the difference between the two TSH values was less than 1 microU/ml and as blunted when this difference was between 1 and 2 microU/ml. The TSH response was normal in 511 patients (81.1%), suppressed in 78 (12.4%) and blunted in 41 cases (6.5%). Nodule patients with suppressed responses showed significantly higher mean age (52.7 vs 45.8 years; p < 0.05) and mean serum concentrations of TT4 (9.32 vs 8.71 micrograms/dl; p < 0.05), TT3 (161 vs 137 ng/dl; p < 0.01) and fT3 (4.94 vs 3.86 pg/ml; p < 0.01) than those with normal TSH secretion. Analysis of the distribution of the different TSH responses in the patients grouped according to basal TSH concentration values showed that 50% of the patient group with basal TSH concentration between > 0.2 and 0.3 microU/ml had normal TSH response to TRH. A normal response occurred in 86.5% of patients with basal TSH between > 0.4 and 0.5 microU/ml and in 95.3% of those with basal TSH between > 0.7 and 0.8 microU/ml. The proportion of normal responses in the patients with basal TSH up to 0.1 microU/ml was 15.7% and that of abnormal responses in those with basal TSH > 1.5 microU/ml was 2.7%.(ABSTRACT TRUNCATED AT 250 WORDS)