In a comatose patient with acute subdural haematoma, the polytrauma spiral indicated pulmonary metastasising renal carcinoma, which limited therapeutic possibilities. Whole-body positron-emission tomography/computer tomography (PET/CT) was performed with fluorodesoxyglucose. Renal carcinoma with pulmonary, nodal and parotidal metastases was proved. A cerebral metastasis could not be excluded because of perifocal hypermetabolism. There were few therapeutic possibilities. PET/CT is possible and sensible in the unconscious patient to differentiate the results of polytrauma-CT.
Brain Injuries/diagnostic imaging , Carcinoma, Renal Cell/diagnostic imaging , Hematoma, Subdural, Acute/diagnostic imaging , Kidney Neoplasms/diagnostic imaging , Positron Emission Tomography Computed Tomography , Accidents, Traffic , Brain Injuries/etiology , Brain Injuries/therapy , Carcinoma, Renal Cell/secondary , Hematoma, Subdural, Acute/etiology , Hematoma, Subdural, Acute/therapy , Humans , Kidney Neoplasms/pathology , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/secondary , Lung Neoplasms/diagnostic imaging , Lung Neoplasms/secondary , Lymphatic Metastasis/diagnostic imaging , Male , Middle Aged , Parotid Neoplasms/diagnostic imaging , Parotid Neoplasms/secondary , Prognosis , Unconscious, Psychology , Withholding Treatment
To define the role of radiotherapy and intrathecal prophylaxis in extralymphatic craniofacial involvement (ECFI) of aggressive B-cell lymphoma, we analyzed 11 consecutive German High-Grade Non-Hodgkin Lymphoma Study Group trials. ECFI occurred in 290/4155 (7.0%) patients (orbita, 31; paranasal sinuses, 93; main nasal cavity, 38; tongue, 27; remaining oral cavity, 99; salivary glands, 54). In a multivariable analysis adjusted for International Prognostic Index rituximab improved event-free and overall survival both in patients with and without ECFI. Three-year event-free (79% vs 79%; P = .842) and overall survival (86% vs 88%; P = .351) rates were similar in 145 patients receiving and 57 not receiving radiotherapy. Without rituximab, the 2-year cumulative rate of central nervous system (CNS) disease was increased in 205 ECFI patients compared with 2586 non-ECFI patients (4.2% vs 2.8%; P = .038), whereas this was not observed with rituximab (1.6% in 83 ECFI vs 3.4% in 1252 non-ECFI patients; P = .682). In 88 ECFI patients who received intrathecal prophylaxis with methotrexate, the 2-year rate of CNS disease was 4.2% compared with 2.3% in 191 patients who did not (P = .981). In conclusion, rituximab eliminates the increased risk for CNS disease in patients with ECFI. This retrospective analysis does not support intrathecal prophylaxis or radiotherapy to ECFI patients in complete remission/unconfirmed complete remission. These findings should be confirmed in a prospective study.
Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Central Nervous System Neoplasms , Facial Neoplasms , Lymphoma, B-Cell , Radiotherapy , Skull Neoplasms , Adolescent , Adult , Antibodies, Monoclonal, Murine-Derived/administration & dosage , Central Nervous System Neoplasms/mortality , Central Nervous System Neoplasms/prevention & control , Disease-Free Survival , Facial Neoplasms/mortality , Facial Neoplasms/therapy , Female , Germany , Humans , Injections, Spinal , Lymphoma, B-Cell/mortality , Lymphoma, B-Cell/therapy , Male , Methotrexate/administration & dosage , Middle Aged , Rituximab , Skull Neoplasms/mortality , Skull Neoplasms/therapy , Survival Rate
PURPOSE: To study clinical presentation, outcome, and the role of radiotherapy in patients with aggressive B-cell lymphoma and skeletal involvement treated with and without rituximab. PATIENTS AND METHODS: Outcome of patients with skeletal involvement was analyzed in a retrospective study of nine consecutive prospective trials of the German High-Grade Non-Hodgkin lymphoma Study Group. RESULTS: Of 3,840 patients, 292 (7.6%) had skeletal involvement. In the MabThera International Trial (MInT) for young good-prognosis patients and the Rituximab With CHOP Over 60 Years (RICOVER-60) study for elderly patients, the randomized addition of rituximab improved event-free survival (EFS; hazard ratio for MInT [HRMInT] = 0.4, P > 001; hazard ratio for RICOVER-60 [HRRICOVER-60] = 0.6, P > .001) and overall survival (OS; HRMInT = 0.4, P < .001; HRRICOVER-60 = 0.7, P = .002) in patients without skeletal involvement, but failed to improve the outcome of patients with skeletal involvement (EFS: HRMInT = 1.4, P = .444; HRRICOVER-60 = 0.8, P = .449; OS: HRMInT = 0.6, P = .449; HRRICOVER-60 = 1.0, P = .935). Skeletal involvement was associated with a worse outcome after cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus rituximab (HREFS = 1.5, P = .048; HROS = 1.1; P = .828), but not after CHOP without rituximab (HREFS = 0.8, P = .181; HROS = 0.7, P = .083). In contrast to rituximab, additive radiotherapy to sites of skeletal involvement was associated with a decreased risk (HREFS = 0.3, P = .001; HROS = 0.5; P = .111). CONCLUSION: Rituximab failed to improve the outcome of patients with diffuse large B-cell lymphoma with skeletal involvement, although our data suggest a beneficial effect of radiotherapy to sites of skeletal involvement. Whether radiotherapy to sites of skeletal involvement can be spared in cases with a negative positron emission tomography after immunochemotherapy should be addressed in appropriately designed prospective trials.
Antibodies, Monoclonal, Murine-Derived/administration & dosage , Antineoplastic Agents/administration & dosage , Chemoradiotherapy , Lymphoma, B-Cell/drug therapy , Lymphoma, B-Cell/radiotherapy , Adolescent , Adult , Aged , Bone Neoplasms/drug therapy , Bone Neoplasms/radiotherapy , Bone Neoplasms/secondary , Disease-Free Survival , Female , Humans , Lymphoma, B-Cell/mortality , Male , Middle Aged , Randomized Controlled Trials as Topic , Retrospective Studies , Rituximab
