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Diffuse large cell lymphoma, a different form of presentation
e146
Abstracts
without cardiorespiratory complaints. Repeat CT-scan that reveals increased of conglomerate mediastinal lymphadenopathy (with 6 cm) and the patient was submitted to a mediastinoscopy for biopsy of lymphadenopathy and histological results were inconclusive but with some features of Castleman's disease. For a strong diagnosis it was decided a thoracotomy to removal of conglomerate mediastinal lymphadenopathy. Now the result of immunohistological staining was LF. With this case the authors pretend to highlight the difficulty of diagnosis and the need of long follow-up in these patients because of possible long and painless evolution of these cases.
rapid diagnostic and treatment intervention, ensuring the best clinical prognosis possible. doi:10.1016/j.ejim.2013.08.377
ID: 466 Follicular lymphoma—A hidden diagnosis C. Cabrala, A. Lagesa, A. Gonçalvesa, R. Araújoa, C. Vazb, F. Gonçalvesa a
Internal Medicine Department, Hospital de Braga, Braga, Portugal Radiology Department, Hospital de Braga, Braga, Portugal
b
doi:10.1016/j.ejim.2013.08.376
ID: 465 Diffuse large cell lymphoma, a different form of presentation C. Cabrala, A. Lagesa, A. Gonçalvesa, R. Araújoa, J. Rochab, J. Amorimc, M. Ribeiroc, F. Gonçalvesa a
Internal Medicine Department, Hospital de Braga, Braga, Portugal Neurology Department, Hospital de Braga, Braga, Portugal c Neuroradiology Department, Hospital de Braga, Braga, Portugal b
Aims: To alert clinicians to an unusual presentation form of a relatively common disease. Material and methods: We present the case of a 75-year-old white male, with a past medical history significant for arterial hypertension, type 2 diabetes mellitus, dyslipidemia, ischemic heart disease and chronic gastritis. A month before hospital admission the patient noted diplopia and right hemiface hypoesthesia. Initial cerebral CT scan was unremarkable and he was referred to a Neurology consult at our hospital. Brain MRI showed infiltrative lesions, with replacement of the bone marrow fat of clivus and probably the body of C2, characterised by hypodensity in the sequence T1 and clival isointensity in T2 with enhancement after gadolinium administration. The hypophysis was enlarged and the left cavernous sinus tumescent. An Internal Medicine consult was requested to clarify the etiology of the described alterations. Results: Extensive blood work analysis showed central hypothyroidism with decreased testosterone, cortisol and LH, B2 microglobulin of 3695 ng/ml and normocytic, normochromic anaemia with no changes in liver function tests, LDH, alkaline phosphatase, serum protein electrophoresis, ionized calcium and prostate-specific antigen. Viral serologic testing and autoimmunity panel were negative. CSF analysis revealed mildly elevated protein (0,66 g/dl). Body CT scan was normal, as well as the endoscopic study, with biopsies, of the gastrointestinal tract. Bone marrow aspirate and biopsy were normal. 18-FDG PET scan exposed foci of hypermetabolism in the clivus, C2, D1, D4 and D9 vertebrae; right side pterygoid muscle; lateral aspect of the fourth left costal arch and proximal shaft of diaphysis of the right humerus, with suspicion of neoplastic etiology, although the hypothesis of granulomatous disease could not be excluded. Biopsy of the body of the 9th dorsal vertebra was performed by a interventional neuroradiology team with histology confirming the diagnosis of diffuse lymphoma of large B cells with CD45+, CD3− CD20+ immunohistochemical profile. Discussion and conclusion: Almost 85% of NHLs are of B-cell origin. Although this type of lymphoma usually starts in lymph nodes, they may as well appear as extranodal disease, arising, most often, from the gastrointestinal tract. Primary bone lymphoma with neurologic presenting symptoms is rarely reported in literature. The diagnosis was only possible after the D9 vertebra biopsy, showing the diagnostic challenge often posed by atypical forms of this disease. The patient started chemotherapy with R-CHOP and is currently being followed as an outpatient in our Oncology department, with good clinical response to this date. Multidisciplinary assessment of this patient was essential for a
Aims: To establish the necessity of a holistic view of the patient, affirming the essence of Internal Medicine specialty. Material and methods: We present the case of a 63-year-old white female, with a known history of obesity, hypertension and dyslipidemia, who was admitted to our Emergency Room (ER) for an episode of pre-syncope after sudden epigastric pain without other signs or symptoms. After careful medical history, we assessed that she had been feeling dyspnea for about 10 weeks, as well as mild chest and abdominal discomfort. Physical examination revealed no significant changes and she had no palpable lymph nodes. Results: According to the symptoms and signs presented in the ER, chest roentgenogram, electrocardiogram (ECG) and blood work were performed, that showed no alterations. A CT angiogram of the thorax was requested which unveiled no signs of acute pulmonary thromboembolism, a globular heart by a slight hypertrophy of the left ventricle and a homogeneous splenomegaly. Due to this last finding, a CT scan of the abdomen was performed unmasking an adenopathic retroperitoneal conglomerate with numerous para-aortic nodes, compatible with a lymphoproliferative disease. The patient was admitted to our medical ward for further study. Extensive blood work analysis revealed no changes. Upper and lower gastrointestinal endoscopies were normal. Eco-guided fine-needle aspiration cytology of a mesenteric lymph node was performed, showing adipose tissue infiltrated by lymphoid cells in a diffuse nodular arrangement, with immunocytochemistry expression for CD20, CD10, bcl2 and bcl6, compatible with follicular lymphoma grade I. Discussion and conclusion: Non-Hodgkin Lymphoma can be divided into two major groups indolent and aggressive. The low-grade or indolent lymphomas (Follicular, Mantle cell, Splenic marginal zone, MALT, Waldenstrom's macroglobulinaemia, Chronic lymphocytic leukaemia) are those that present a slow progression with non-painful lymphadenopathy, splenomegaly and frequent involvement of the bone marrow only in later stages of the disease, resulting in delayed diagnosis. In this case, unspecific complaints led to the occasional finding of a follicular lymphoma in its early stages. The patient was referred to an oncology consult, where she awaits treatment options. In our every day practice as Internal Medicine doctors we must aim to look at the patient as a whole, rather than just a body system, integrating and pursuing relevant information in order to avoid unnecessary exams, allowing our patients the finest medical care possible. doi:10.1016/j.ejim.2013.08.378
ID: 471 Synergistic cytotoxic and apoptotic effects of paclitaxel/ (-)- gossypol (AT-101) combination in breast cancer cell line K. Masarogullaria, B. Karacab, C. Gokalpc, A. Kisimd, U. Ali Sanlib a
Internal Medicine-Nephrology, Near East University, Nicosia, Cyprus Oncology, Ege University, Izmir, Turkey
b
Abstracts
without cardiorespiratory complaints. Repeat CT-scan that reveals increased of conglomerate mediastinal lymphadenopathy (with 6 cm) and the patient was submitted to a mediastinoscopy for biopsy of lymphadenopathy and histological results were inconclusive but with some features of Castleman's disease. For a strong diagnosis it was decided a thoracotomy to removal of conglomerate mediastinal lymphadenopathy. Now the result of immunohistological staining was LF. With this case the authors pretend to highlight the difficulty of diagnosis and the need of long follow-up in these patients because of possible long and painless evolution of these cases.
rapid diagnostic and treatment intervention, ensuring the best clinical prognosis possible. doi:10.1016/j.ejim.2013.08.377
ID: 466 Follicular lymphoma—A hidden diagnosis C. Cabrala, A. Lagesa, A. Gonçalvesa, R. Araújoa, C. Vazb, F. Gonçalvesa a
Internal Medicine Department, Hospital de Braga, Braga, Portugal Radiology Department, Hospital de Braga, Braga, Portugal
b
doi:10.1016/j.ejim.2013.08.376
ID: 465 Diffuse large cell lymphoma, a different form of presentation C. Cabrala, A. Lagesa, A. Gonçalvesa, R. Araújoa, J. Rochab, J. Amorimc, M. Ribeiroc, F. Gonçalvesa a
Internal Medicine Department, Hospital de Braga, Braga, Portugal Neurology Department, Hospital de Braga, Braga, Portugal c Neuroradiology Department, Hospital de Braga, Braga, Portugal b
Aims: To alert clinicians to an unusual presentation form of a relatively common disease. Material and methods: We present the case of a 75-year-old white male, with a past medical history significant for arterial hypertension, type 2 diabetes mellitus, dyslipidemia, ischemic heart disease and chronic gastritis. A month before hospital admission the patient noted diplopia and right hemiface hypoesthesia. Initial cerebral CT scan was unremarkable and he was referred to a Neurology consult at our hospital. Brain MRI showed infiltrative lesions, with replacement of the bone marrow fat of clivus and probably the body of C2, characterised by hypodensity in the sequence T1 and clival isointensity in T2 with enhancement after gadolinium administration. The hypophysis was enlarged and the left cavernous sinus tumescent. An Internal Medicine consult was requested to clarify the etiology of the described alterations. Results: Extensive blood work analysis showed central hypothyroidism with decreased testosterone, cortisol and LH, B2 microglobulin of 3695 ng/ml and normocytic, normochromic anaemia with no changes in liver function tests, LDH, alkaline phosphatase, serum protein electrophoresis, ionized calcium and prostate-specific antigen. Viral serologic testing and autoimmunity panel were negative. CSF analysis revealed mildly elevated protein (0,66 g/dl). Body CT scan was normal, as well as the endoscopic study, with biopsies, of the gastrointestinal tract. Bone marrow aspirate and biopsy were normal. 18-FDG PET scan exposed foci of hypermetabolism in the clivus, C2, D1, D4 and D9 vertebrae; right side pterygoid muscle; lateral aspect of the fourth left costal arch and proximal shaft of diaphysis of the right humerus, with suspicion of neoplastic etiology, although the hypothesis of granulomatous disease could not be excluded. Biopsy of the body of the 9th dorsal vertebra was performed by a interventional neuroradiology team with histology confirming the diagnosis of diffuse lymphoma of large B cells with CD45+, CD3− CD20+ immunohistochemical profile. Discussion and conclusion: Almost 85% of NHLs are of B-cell origin. Although this type of lymphoma usually starts in lymph nodes, they may as well appear as extranodal disease, arising, most often, from the gastrointestinal tract. Primary bone lymphoma with neurologic presenting symptoms is rarely reported in literature. The diagnosis was only possible after the D9 vertebra biopsy, showing the diagnostic challenge often posed by atypical forms of this disease. The patient started chemotherapy with R-CHOP and is currently being followed as an outpatient in our Oncology department, with good clinical response to this date. Multidisciplinary assessment of this patient was essential for a
Aims: To establish the necessity of a holistic view of the patient, affirming the essence of Internal Medicine specialty. Material and methods: We present the case of a 63-year-old white female, with a known history of obesity, hypertension and dyslipidemia, who was admitted to our Emergency Room (ER) for an episode of pre-syncope after sudden epigastric pain without other signs or symptoms. After careful medical history, we assessed that she had been feeling dyspnea for about 10 weeks, as well as mild chest and abdominal discomfort. Physical examination revealed no significant changes and she had no palpable lymph nodes. Results: According to the symptoms and signs presented in the ER, chest roentgenogram, electrocardiogram (ECG) and blood work were performed, that showed no alterations. A CT angiogram of the thorax was requested which unveiled no signs of acute pulmonary thromboembolism, a globular heart by a slight hypertrophy of the left ventricle and a homogeneous splenomegaly. Due to this last finding, a CT scan of the abdomen was performed unmasking an adenopathic retroperitoneal conglomerate with numerous para-aortic nodes, compatible with a lymphoproliferative disease. The patient was admitted to our medical ward for further study. Extensive blood work analysis revealed no changes. Upper and lower gastrointestinal endoscopies were normal. Eco-guided fine-needle aspiration cytology of a mesenteric lymph node was performed, showing adipose tissue infiltrated by lymphoid cells in a diffuse nodular arrangement, with immunocytochemistry expression for CD20, CD10, bcl2 and bcl6, compatible with follicular lymphoma grade I. Discussion and conclusion: Non-Hodgkin Lymphoma can be divided into two major groups indolent and aggressive. The low-grade or indolent lymphomas (Follicular, Mantle cell, Splenic marginal zone, MALT, Waldenstrom's macroglobulinaemia, Chronic lymphocytic leukaemia) are those that present a slow progression with non-painful lymphadenopathy, splenomegaly and frequent involvement of the bone marrow only in later stages of the disease, resulting in delayed diagnosis. In this case, unspecific complaints led to the occasional finding of a follicular lymphoma in its early stages. The patient was referred to an oncology consult, where she awaits treatment options. In our every day practice as Internal Medicine doctors we must aim to look at the patient as a whole, rather than just a body system, integrating and pursuing relevant information in order to avoid unnecessary exams, allowing our patients the finest medical care possible. doi:10.1016/j.ejim.2013.08.378
ID: 471 Synergistic cytotoxic and apoptotic effects of paclitaxel/ (-)- gossypol (AT-101) combination in breast cancer cell line K. Masarogullaria, B. Karacab, C. Gokalpc, A. Kisimd, U. Ali Sanlib a
Internal Medicine-Nephrology, Near East University, Nicosia, Cyprus Oncology, Ege University, Izmir, Turkey
b