Biclonal Low-Grade B Cell Lymphoma as Detected by Multiparametric Flow Cytometry in Blood and Marrow

Biclonal B cell lymphomas (BCL) of two different low-grade components are rare. Multiparametric flow cytometry (MFC) is an integral tool in lymphoma diagnosis and very efficient in picking up BCL cases, especially when the associated second component is small. We studied the incidence of BCL in the routine blood and marrow samples sent for immunophenotyping by MFC. A total of 376 cases were analyzed retrospectively. We studied their clinical, immunophenotypic, molecular, and cytogenetic findings with literature review. We found five cases of BCL with two different clonal low-grade B cell components at an incidence of 1.3%. All cases were males with a median age of 68 years. The chronic lymphocytic leukemia (CLL) clone was present in all 5 cases. The other associated component in cases 1 to 5 were lymphoplasmacytic lymphoma, follicular lymphoma, splenic marginal zone lymphoma, hairy cell leukemia, and monoclonal B cell population of non-CLL type respectively. Diagnosing BCL may be challenging and may also go undiagnosed when the second component is petite and overshadowed by the more significant component. It may be critical if the small, unnoticed lymphoma component is of a more aggressive type.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-022-01625-y.

Independent diagnostic utility of CD20, CD200, CD43 and CD45 in chronic lymphocytic leukaemia

Immunophenotyping plays a major role and is essential for establishing the diagnosis of chronic lymphocytic leukemia (CLL). Though CLL has a characteristic phenotype, diagnosis may be challenging due to immunophenotypic overlap with other B cell non-Hodgkin's lymphomas (B-NHL). Markers like CD200, CD43, CD20 and CD45 were found valuable in CLL and we investigated their diagnostic efficiency and accuracy in 174 patients with leukemic B-NHL. On the integration of four markers by a scoring system, 96% (49/51) of CLL cases showed a score of 3 or 4 and 90% (36/40) of non-CLL cases had a score of 0 or 1. This scoring system for CLL diagnosis showed a sensitivity of 98.2% and 96% in the analytical cohort and validation cohort respectively, which was significantly higher than the classical Matutes score. Hence we strongly suggest considering the expression of CD200, CD20, CD43 and CD45 in the diagnosis of B-NHL cases.

Assessment of cognitive function following a course of electroconvulsive therapy

Introduction

ECT is a potentially life-saving treatment for patients with severe or treatment resistant depression. Cognitive function disturbances following ECT are generally transient, but could be of longer duration in some cases

Objectives

To assess the cognitive side effects in patients with affective disorders treated with a course of electroconvulsive therapy (ECT).

Methods

Cognitive functions of patients who undergo ECT was assessed prior to start of treatment, midway of the course of treatment and after end of the course of treatment using Montreal Cognitive Assessment (MoCA). We did a retrospective analysis of MoCA scores of 15 patients who received bilateral ECT in 2017-2018. In order to assess the efficacy of ECT in the treatment of their illness, we did a retrospective analysis of Montgomery Asberg Depression Rating Scale (MADRS) scores of 18 patients who received bilateral ECT in 2017-2018

Results

Only 7% of the patients who underwent ECT in our sample did have significant cognitive decline as per their MoCA scores. 28% of patients achieved complete remission in their depressive symptomes. 22% of patients continued on maintenance treatment. 95% of patients showed significant improvement in their symptoms following treatment with ECT where there symptoms reduced to either mild or minimal depressive symptoms.

Conclusions

Cognitive side effect was not a significant side effect in our sample of patients. We did see an improvement in cognitive function in a significant number of the sample of patients as they progressed with treatment, which coincided with improvement in their affective symptoms.

Leaf open time sinogram (LOTS): a novel approach for patient specific quality assurance of total marrow irradiation

There is no ideal detector-phantom combination to perform patient specific quality assurance (PSQA) for Total Marrow (TMI) and Lymphoid (TMLI) Irradiation plan. In this study, 3D dose reconstruction using mega voltage computed tomography detectors measured Leaf Open Time Sinogram (LOTS) was investigated for PSQA of TMI/TMLI patients in helical tomotherapy. The feasibility of this method was first validated for ten non-TMI/TMLI patients, by comparing reconstructed dose with (a) ion-chamber (IC) and helical detector array (ArcCheck) measurement and (b) planned dose distribution using 3Dγ analysis for 3%@3mm and dose to 98% (D_98%) and 2% (D_2%) of PTVs. Same comparison was extended for ten treatment plans from five TMI/TMLI patients. In all non-TMI/TMLI patients, reconstructed absolute dose was within ± 1.80% of planned and IC measurement. The planned dose distribution agreed with reconstructed and ArcCheck measured dose with mean (SD) 3Dγ of 98.70% (1.57%) and 2Dγ of 99.48% (0.81%). The deviation in D_98% and D_2% were within 1.71% and 4.10% respectively. In all 25 measurement locations from TMI/TMLI patients, planned and IC measured absolute dose agreed within ± 1.20%. Although sectorial fluence verification using ArcCHECK measurement for PTVs chest from the five upper body TMI/TMLI plans showed mean ± SD 2Dγ of 97.82% ± 1.27%, the reconstruction method resulted poor mean (SD) 3Dγ of 92.00% (± 5.83%), 64.80% (± 28.28%), 69.20% (± 30.46%), 60.80% (± 19.37%) and 73.2% (± 20.36%) for PTVs brain, chest, torso, limb and upper body respectively. The corresponding deviation in median D_98% and D_2% of all PTVs were < 3.80% and 9.50%. Re-optimization of all upper body TMI/TMLI plans with new pitch and modulation factor of 0.3 and 3 leads significant improvement with 3Dγ of 100% for all PTVs and median D_98% and D_2% < 1.6%. LOTS based PSQA for TMI/TMLI is accurate, robust and efficient. A field width, pitch and modulation factor of 5 cm, 0.3 and 3 for upper body TMI/TMLI plan is suggested for better dosimetric outcome and PSQA results.

Total marrow and lymphoid irradiation with helical tomotherapy: a practical implementation report

Purpose

To standardize the technique; evaluate resources requirements and analyze our early experience of total marrow and lymphoid irradiation (TMLI) as part of the conditioning regimen before allogenic bone marrow transplantation using helical tomotherapy.

Materials and Methods

Computed tomography (CT) scanning and treatment were performed in head first supine (HFS) and feet first supine (FFS) orientations with an overlap at mid-thigh. Patients along with the immobilization device were manually rotated by 180° to change the orientation after the delivery of HFS plan. The dose at the junction was contributed by a complementary dose gradient from each of the plans. Plan was to deliver 95% of 12 Gy to 98% of clinical target volume with dose heterogeneity <10% and pre-specified organs-at-risk dose constraints. Megavoltage-CT was used for position verification before each fraction. Patient specific quality assurance and in vivo film dosimetry to verify junction dose were performed in all patients.

Results

Treatment was delivered in two daily fractions of 2 Gy each for 3 days with at least 8-hour gap between each fraction. The target coverage goals were met in all the patients. The average person-hours per patient were 16.5, 21.5, and 25.75 for radiation oncologist, radiation therapist, and medical physicist, respectively. Average in-room time per patient was 9.25 hours with an average beam-on time of 3.32 hours for all the 6 fractions.

Conclusion

This report comprehensively describes technique and resource requirements for TMLI and would serve as a practical guide for departments keen to start this service. Despite being time and labor intensive, it can be implemented safely and robustly.

A Prospective Observational Multi-institutional Study on Invasive Fungal Infections Following Chemotherapy for Acute Myeloid Leukemia (MISFIC Study): A Real World Scenario from India

We performed a prospective multi-centre observational study to understand the incidence of IFI in patients with AML in India with use of anti-fungal prophylaxis. All patients with AML receiving either induction chemotherapy or salvage chemotherapy between November 2014 and February 2016 were included in this prospective observational study from 10 Indian centres. IFI was defined as per the revised EORTC-MSG criteria. Data on type of chemotherapy used, type of anti-fungal prophylaxis used, time to neutrophil recovery, incidence of IFI and survival were collected. Two hundred patients (118 male and 82 females) with a median age of 35 years (range: 2-66) were recruited. One hundred and eighty-six (93%) had newly diagnosed acute myeloid leukemia (AML) while 14 (7%) had relapsed disease. IFI occurred in 53 patients (26.5%) with proven or probable IFI occurring in 17 (8.5%). Use of posaconazole prophylaxis (p = 0.027) was the only factor found to be associated with a reduced incidence of IFI. The overall survival (OS) at 6 weeks and 3 months respectively was similar among patients who had IFI (83.0 ± 5.2%; 81.0 ± 5.4%) as compared to those without IFI (84.4 + 3.0%; 81.4 ± 3.2%). This prospective study reveals a high incidence of IFI in patients undergoing chemotherapy for AML in India. The use of posaconazole prophylaxis was associated with a significantly lower incidence of IFI. Optimal strategies to prevent IFI need to be studied.

Summary of the Highlights of 2019 ASTCT Meeting by iNDUS BMT Group at Chennai, India

This article summarises the main highlights of the abstracts presented at the annual meeting of American Society of Transplantation and Cellular Therapy (ASTCT). The highlights of ASTCT meeting were organised by iNDUS BMT group in Chennai, India. The purpose of the highlight meeting was to educate the students about the latest research in the field of hematopoietic stem cell transplantation and its applicability for the developing country perspective.

Retrospective Study of Nephrotoxicity Rate among Adult Patients Receiving Colistin Compared to β-lactam Antibiotics

Purpose

Patients receiving colistin for carbapenem-resistant gram-negative bacteria (CR-GNB) infections generally have multiple risk factors for nephrotoxicity, so it might be possible that colistin may be erroneously blamed for the nephrotoxicity.

Materials and methods

We retrospectively analyzed case records of patients who received colistin and those who received antibiotics other than colistin [carbapenem or β-lactam–β-lactamases inhibitors (βL–βLI)] for gram-negative bacteremia. Those patients with preexisting renal failure and those who received antibiotics for <72 hours were excluded from the study. Nephrotoxicity was assessed using the risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, end-stage kidney disease (RIFLE) criteria.

Results

Out of the 222 patients, the colistin arm had 118 and the noncolistin arm had 104 patients. Even though the colistin arm had significantly higher number of sicker patients with neutropenia (40.7% vs 14.4%, p = 0.0001), mechanical ventilation (0.0001), having lines (0.0001), on inotropes (0.003), receiving other nephrotoxic drugs (0.0001), and higher Pitt score (p = 0.0001), there was no significant difference in the nephrotoxicity between the two arms (10.2% vs 9.6%, p = 0.89). Logistical regression showed a higher Pitt bacteremia score (p = 0.03) and a higher Charlson comorbidity index (p = 0.02), but not colistin administration (p = 0.32), were independently associated with nephrotoxicity.

Conclusion

Administration of colistin was not associated with higher rates of nephrotoxicity than carbapenems or βL–βLI agents.

How to cite this article

Ghafur A, Bansal N, Devarajan V, Raja T, Easow J, Raja MA, et al. Retrospective Study of Nephrotoxicity Rate among Adult Patients Receiving Colistin Compared to β-lactam Antibiotics. IJCCM 2019;23(11):518–522.

Spectrum of bacteremia in posthematopoietic stem cell transplant patients from an Indian center

BACKGROUND

Despite the relatively low prevalence of Gram-positive bacteremic infections in Indian oncology patients, glycopeptides are extensively used for empirical management of febrile neutropenia. Our aim was to analyze the spectrum of bacteremia in posthematopoietic stem cell transplant (HSCT) recipients in our center and make a recommendation on glycopeptide use in this patient population.

MATERIALS AND METHODS

Retrospective analysis of bacteremic data from HSCT recipients in a tertiary care oncology and transplant center from South India, between 2011 and 2013.

RESULTS

In 217 patients, 52 bacteremic episodes were identified. The majority of the isolates were Gram-negatives (88.4%) with very few Gram-positives (7.69%).

CONCLUSION

Glycopeptides need not be included in the empirical antibiotic regimen in post-HSCT settings with very low Gram-positive infection rates.

Monotherapy versus combination therapy against carbapenem-resistant Gram-negative bacteria: A retrospective observational study

BACKGROUND

Colistin-based combination therapy (CCT) is extensively used to treat infections due to carbapenem-resistant Gram-negative bacteria (CRGNB). There are no data available from India on the usefulness of combination therapy, especially in the oncology setup. The aim of this study was to analyze the clinical effectiveness of CCT over monotherapy in patients with CRGNB.

MATERIALS AND METHODS

We conducted a retrospective, observational study of patients with CRGNB bloodstream infections in our oncology and bone marrow transplant center.

RESULTS

Over a 3-year study period (2011-2014), we could identify 91 patients satisfying study criteria. There was no statistically significant difference in the 28-day mortality between monotherapy and combination therapy arms (mono n = 26, mortality 10 (38.5%); combination n = 65, mortality 28 (40%); P = 0.886). Neutropenic patients with Enterobacteriaceae bloodstream infections performed better with combination therapy (mono n = 7, mortality 6 (85.7%); combination therapy n = 22, mortality 8 (36.4%); P = 0.035). There was no significant difference in the 28-day mortality between the two treatment arms in other subgroups.

CONCLUSION

Our study did not find CCT superior to colistin monotherapy in patients with CRGNB blood stream infections; except in the subgroup of neutropenic patients with Enterobacteriaceae bloodstream infections, where combination therapy performed better.

Monotherapy versus Combination Therapy against Nonbacteremic Carbapenem-resistant Gram-negative Infections: A Retrospective Observational Study

Background:

Superiority of colistin–carbapenem combination therapy (CCCT) over colistin monotherapy (CMT) against carbapenem-resistant Gram-negative bacterial (CRGNB) infections is not conclusively proven.

Aim:

The aim of the current study was to analyze the effectiveness of both strategies against CRGNB nonbacteremic infections.

Design:

This was a retrospective observational cohort study.

Subjects and Methods:

Case record analysis of patients who had CRGNB nonbacteremic infections identified over a period of 4 years (January 2012–December 2015) was done by medical record review at a tertiary care center in India.

Statistical Analysis:

P < 0.05 was considered as significant. Multivariate analysis was performed using Cox regression.

Results:

Out of 153 patients (pneumonia 115, urinary tract infection 17, complicated skin and soft-tissue infection 18, intra-abdominal infection 1, and meningitis 2), 92 patients received CCCT and 61 received CMT. Univariate analysis revealed higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, pneumonia as the diagnosis, and Klebsiella as the causative organism to be the risk factors for higher 28-day mortality (P = 0.036, 0.006, 0.016, respectively). Combination therapy had no significant impact on mortality (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.327–2.535, P = 0.857). Multivariate analysis revealed that higher APACHE II score and infection due to Klebsiella were found to be independent risk factors for higher mortality (OR = 3.16 and 4.9, 95% CI = 1.34–7.4 and 2.19–11.2, P = 0.008 and 0.0001, respectively).

Conclusions:

In our retrospective single-center series of CRGNB nonbacteremic infections, CCCT was not superior to CMT. Multicenter large observational studies or prospective randomized clinical trials are the need of the hour.

Colistin Nephrotoxicity in Adults: Single Centre Large Series from India

Context:

Limited Indian data are available on the rate of colistin nephrotoxicity and other risk factors contributing to the development of this important side effect.

Aim:

This study aims to generate data on colistin nephrotoxicity from a large cohort of Indian patients.

Design:

Retrospective cohort study.

Materials and Methods:

Case record analysis of patients who received colistin, in an oncology center in India, between January 2011 and December 2015. Nephrotoxicity was assessed using risk, injury, failure, loss, and end-stage (RIFLE) criteria.

Statistical Analysis:

P < 0.05 was considered as statistically significant.

Results:

Out of the 229 patients, 13.1% (30/229) developed abnormal RIFLE. Abnormal RIFLE group (n = 30), in comparison to the normal renal function group (n = 199), had higher number of patients in intensive care unit (ICU) (96% vs. 79%, P = 0.02), higher Acute Physiology and Chronic Health Evaluation (APACHE II) score (23 vs. 19 P = 0.0001), Charlson score (5.9 vs. 4.3, P = 0.001), mechanical ventilation (90% vs. 67%, P = 0.016), 28 days mortality (63% vs. 25%, P = 0.0001), and abnormal baseline creatinine (36% vs. 8%, P = 0.001). Coadministration of vancomycin had higher rates of nephrotoxicity (P = 0.039). There was no significant difference in nephrotoxicity between 6 and 9 MU/day dosing pattern (8.8% vs. 13.8%, P = 0.058).

Conclusion:

Nephrotoxicity rate in our retrospective single center large series of patients receiving colistin was 13.1%. Patients with abnormal baseline creatinine, ICU stay, and higher disease severity are at higher risk of nephrotoxicity while on colistin. A daily dose of 9 million does not significantly increase nephrotoxicity compared to the 6 million. Concomitant administration of vancomycin with colistin increases the risk of nephrotoxicity.