A rare case of bifocal, extramedullary and hyposecretory relapse of multiple myeloma.

We present a rare extramedullary, bifocal, and hyposecretory manifestation of relapsed MM that could be mistaken for an infection. We stress the importance of complex evaluation including serum, urine, and bone marrow assessment and whole-body imaging.

18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT effectively contribute to early diagnosis of infection of arteriovenous graft for hemodialysis.

OBJECTIVE: An arteriovenous graft (AVG) is indicated in hemodialysis patients with failed arteriovenous access. Early treatment of AVG infection is important because an advanced prosthetic infection leads to the removal of the prosthesis. The aim of this study was to evaluate the benefits of 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT in early detection of AVG infections. SUBJECTS AND METHODS: Fifty-one AVGs were evaluated. 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT studies were performed at intervals of 10, 20-30, and 40-50 weeks after AVG insertion. Agreement between the imaging methods and reference parameters (i.e. clinical presentation, C-reactive protein and microbiological findings on the hemodialysis cannula extracted after hemodialysis from AVG) was evaluated. RESULTS: The study results showed that focal accumulation of the radiopharmaceuticals can be considered a sign of AVG infection. At 10 weeks after AVG implantation, the focal 18F-FDG findings showed the best agreement with the reference parameters (agreement coefficients AC1 - clinical status: 0.693, CRP: 0.605, cannula microbiology: 0.518, respectively). At 20 to 30 weeks after AVG implantation, the diagnostic value of focal 99mTc-HMPAO-WBC accumulation increased (AC1 coefficients: 0.658, 0.658, 0.408) and was similar to that of focal 18F-FDG uptake (AC1s: 0.656, 0.570, 0.409). Between 40 and 50 weeks since AVG implantation, the diagnostic significance of focal 99mTc-HMPAO-WBC accumulation (AC1 coefficients: 0.771, 0.811, 0.611) slightly exceeded the diagnostic value of focal 18F-FDG accumulation (AC1 coefficients: 0.524, 0.456, 0.569). CONCLUSION: 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT can both serve as important tools contributing to early diagnosis of AVG infection.

Bone marrow metastasis of malignant melanoma in childhood arising within a congenital melanocytic nevus.

BACKGROUND: Malignant melanoma in childhood is infrequent and can arise within congenital melanocytic nevi. Spread of malignant melanoma to the bone marrow, especially in children, is extremely rare. METHODS AND RESULTS: Reported is a case of a 5-year-old boy with a congenital large melanocytic nevus of the head and neck who presented with a short history of low back and leg pain, fever and cervical lymphadenopathy. Despite regular follow-up by a dermatologist and plastic surgeon and repeatedly negative histology of previous partial excisions, diffuse bone marrow infiltration with malignant melanoma was diagnosed. The primary site was identified in the post-excision area. The disease progressed rapidly on ipilimumab immunotherapy and led to death at four months from the diagnosis. CONCLUSION: Surveillance is indispensable in children with a predisposition to melanoma and nonspecific symptoms such as bone pain, gait impairment or cytopenia, should always be taken into account.

Acute pancreatitis as the first manifestation of duodenal MALT lymphoma.

BACKGROUND: Possibly any tumor that can cause mechanical obstruction of the distal bile duct can induce acute pancreatitis. However, acute pancreatitis as the first clinical manifestation of duodenal lymphoma is extremely rare. OBJECTIVE: To report the case of a patient with acute pancreatitis as an extremely rare first manifestation of duodenal MALT lymphoma and possible association with erythema nodosum. METHODS: Case report of a 66-year-old woman who was diagnosed with acute pancreatitis caused by infiltration with duodenal lymphoma. RESULTS: Acute pancreatitis was confirmed by CT imaging. Detailed investigation revealed a duodenal mass causing pancreatic injury. Histological analysis established the diagnosis of MALT lymphoma. The patient's medical history also included erythema nodosum. Complete remission of the malignancy was achieved with chemotherapy. CONCLUSION: This is the first published case report of acute pancreatitis caused by the growth of duodenal MALT lymphoma. An association with erythema nodosum is possible.

2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography examination in patients with chronic lymphocytic leukemia may reveal Richter transformation.

The significance of positron emission tomography/computed tomography (PET/CT) in chronic lymphocytic leukemia (CLL) has not yet been systematically studied. This prospective study was aimed at assessing the benefit of PET/CT in patients with newly diagnosed or relapsed CLL and Richter transformation (RT). PET/CT examination was performed in 23 patients with newly diagnosed disease, 13 with relapsed disease and eight with suspected or histopathologically confirmed RT. In all patients, the maximum standardized uptake value (SUV(max)) was calculated. The median SUV(max) was 3.4 (range: 1.5-6.3) and 3.1 (range: 1.2-5.9) in newly diagnosed and relapsed patients, respectively. The median SUV(max) of patients with suspected or confirmed RT reached 16.5 (range: 7.2-25.3), a value different from that of the previous groups (p < 0.001). 2-[18F]fluoro- 2-deoxy-D-glucose ((18)F-FDG) PET/CT revealed inflammatory lesions in seven patients (16%) and synchronous tumors in two newly diagnosed patients. (18)F-FDG PET/CT may be a beneficial imaging method when used in individuals with CLL and suspected RT.

Synchronous second primary neoplasms detected by initial staging F-18 FDG PET/CT examination in patients with non-Hodgkin lymphoma.

PURPOSE OF THE REPORT: Cases of synchronous non-Hodgkin lymphoma (NHL) and second primary carcinoma in previously untreated immunocompetent patients are relatively rare. The aim of this part of our prospective study was to a revealed 2-F-18 fluoro-2-deoxy-D-glucose (F-18 FDG) positron emission tomography (PET)-positive lesion in an extranodal organ suggestive of second primary neoplasm in newly diagnosed NHL patients. MATERIALS AND METHODS: A total of 209 patients with NHL underwent initial staging F-18 FDG PET/computed tomography (CT). The finding was assessed by a radiologist, nuclear medicine physician, and hematologist. In 6 suspicious cases (2.9%) of second neoplasm, the decision was made to perform further investigations before lymphoma therapy. RESULTS: Two patients were diagnosed with colorectal carcinoma, 1 with esophageal adenocarcinoma, 1 with invasive ductal breast carcinoma, 1 with medullary thyroid carcinoma, and 1 with squamous cell lung carcinoma. In 5 of the 6 patients, the second solid tumor was completely asymptomatic and revealed only by F-18 FDG PET/CT examination. CONCLUSIONS: We conclude that in patients with NHL, appropriate imaging, clinical, and histologic analysis of organ lesions detected by F-18 FDG PET/CT will occasionally demonstrate significant synchronous neoplasms.

Standardised uptake value of 18F-FDG on staging PET/CT in newly diagnosed patients with different subtypes of non-Hodgkin's lymphoma.

OBJECTIVES: Positron emission tomography using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose ((18) F-FDG) is considered to be the most beneficial imaging method for staging patients with non-Hodgkin's lymphoma (NHL). The intensity of (18) F-FDG accumulation may be determined by calculating the so-called standardised uptake value (SUV). The study aimed at assessing the benefit of SUV(max) determination in staging (18) F-FDG PET/CT in untreated patients with NHL. METHODS: One hundred and forty-nine initial staging (18) F-FDG PET/CT scans performed in patients with NHL between January 2007 and August 2009 were assessed, and the SUV(max) was determined. RESULTS: The highest mean and median values of SUV(max) were observed in patients with diffuse large B-cell lymphoma (DLBCL), the lowest mean and median values were found in small lymphocytic lymphoma. The overlap in SUV(max) < 10 between DLBCL and the other subgroups of NHL was very significant. Statistically, no correlation was found between the lactate dehydrogenase and SUV(max) values. On the other hand, a correlation of the Ki-67 proliferative index of tumour cells and SUV(max) was revealed (r = 0.409, P < 0.001). The geometric mean of SUV(max) in patients with Ki-67 ≤ 60 and those with Ki-67 > 60 was 8.8 and 14.3, respectively (P < 0.001). CONCLUSIONS: The results confirm that SUV(max) is not beneficial for making a more precise diagnosis in most patients with NHL. Correlation of SUV(max) with the Ki-67 values suggests that SUV(max) might have a prognostic values in NHL.

Tc-99m MIBI scintigraphy in multiple myeloma: prognostic value of different Tc-99m MIBI uptake patterns.

PURPOSE: Technetium-99m 2 methoxyisobutylisonitrile (Tc-99m MIBI) scintigraphy has been used to identify biologic activity and extent of multiple myeloma (MM) and monoclonal gammopathy of unknown significance (MGUS). The examination could also serve both as a prognostic tool and an examination for monitoring the disease course in MM patients. The purpose of this study was to evaluate the prognostic value of different Tc-99m MIBI uptake patterns. MATERIALS AND METHODS: Ninety-nine consecutive patients with newly diagnosed symptomatic MM and 18 patients with MGUS underwent baseline Tc-99m MIBI scintigraphy before applying any kind of therapy. The Tc-99m MIBI scans were classified as showing normal, diffuse, and focal or combined (diffuse and focal) patterns of tracer uptake. To evaluate the prognostic value of different Tc-99m MIBI uptake patterns, overall survival (OS) was chosen as an end point. Median of follow-up period was 84 months. Survival according to patterns of Tc-99m MIBI uptake was calculated using the Kaplan-Meier plots. RESULTS: Statistically significant correlation between the baseline patterns of Tc-99m MIBI uptake and OS was found (P < 0.0001). Focal or combined patterns of Tc-99m MIBI uptake indicated significantly worse prognosis with shorter OS than normal or diffuse tracer patterns. CONCLUSIONS: Tc-99m MIBI scintigraphy plays the predictive role in the follow-up of patients with MM. Baseline scintigraphic pattern of Tc-99m MIBI uptake seems to be a useful prognostic indicator of OS in MM patients and Tc-99m MIBI scintigraphy could be used as an additional tool for the initial examination in patients with newly diagnosed MM.

Precursor T-lymphoblastic lymphoma as a secondary malignancy in a young patient after successful treatment of acute promyelocytic leukemia.

BACKGROUND: Acute promyelocytic leukemia (APL) is a relatively rare subtype of acute myeloid leukemia. It has become the best curable subtype of acute leukemias in adults due to the inclusion of all-trans-retinoic acid (ATRA) in the treatment. Despite the efficacy of ATRA, chemotherapy must be added in APL patients in order to maintain durable complete remission. However, chemotherapy administration is inevitably related to many complications, including the risk of secondary malignancies. T-lymphoblastic lymphoma (T-LBL) is an infrequent disease that belongs to the group of highly aggressive lymphomas. CASE REPORT: The authors describe the case of a 25-year-old woman who was treated for APL in 2002 and developed precursor T-LBL 5 years later. CONCLUSION: Several cases of secondary acute lymphoblastic leukemias in 'cured' APL patients have been described, but probably no patient with secondary precursor T-LBL. Secondary malignancy has become one of the topics discussed (not only) in APL patients. It is apparently related to the excellent treatment outcomes and long-term survival. Better tailored treatment based on relevant prognostic factors allowing chemotherapy reduction or omission in some patients is needed.

Relapsed follicular lymphoma sequentially treated with rituximab and 90Y-ibritumomab tiuxetan. Case report.

BACKGROUND: Monoclonal antibodies have dramatically changed the treatment possibilities for follicular lymphoma. (90)Y-ibritumomab tiuxetan (Zevalin) is the first radioimmunotherapy agent approved for the treatment of relapsed and resistant follicular lymphoma patients. Long-term benefit was observed especially for patients achieving CR after radioimmunotherapy. METHODS AND RESULTS: A 65-year-old female patient with the second relapse of CD20 positive follicular lymphoma and multiple concomitant diseases was treated with four weekly doses of rituximab (375 mg/m(2)). (18)F-fluoro-deoxyglucose positron emission tomography combined with computed tomography (PET-CT) demonstrated only partial response to therapy with persistent PET scan positivity in enlarged abdominal lymph nodes. Therefore, it was decided to treat her with a 1200-MBq (32-mCi) dose of (90)Y-ibritumomab tiuxetan radioimmunotherapy. No acute complications were noted afterwards. Hematological nadirs were reached 4 weeks later, with a platelet count of 24 x 10(9)/l that normalized within the next 2 weeks. The patient had neither infection nor bleeding complications. Eight weeks after radioimmunotherapy, the PET-CT scans documented only 3 lymph nodes around the abdominal aorta, maximum size 2 x 1 cm. The PET scan analysis proved no accumulation of (18)F-fluoro-deoxy-glucose in any lymph nodes or other organs and tissues. CONCLUSIONS: Sequential treatment with rituximab and (90)Y-ibritumomab tiuxetan may be an interesting alternative in cases of relapsed follicular or other indolent lymphomas in pretreated or older patients with other concomitant diseases.

Combined strategy in AAA elective treatment.

The authors describe surgical treatment for high risk patients with abdominal aortic aneurysms of complicated morphology for standard endovascular repair. This was achieved by combining endovascular stent-grafting for aneurysmal sac exclusion with conventional vascular surgical procedures.

Treatment possibility for AAA of the visceral branches region.

The authors describe a promising abdominal aortic aneurysm treatment--a combined endovascular/surgical approach--used in two cases of aneurysm taking the aortic visceral branches region.

Femoral - internal iliac bypass in aortoiliac aneurysms endovascular repair.

The authors describe femoral - internal iliac bypass creation to remove ischemic complications in aortoiliac aneurysm endovascular repair. Based on a good experience with bypass in 6 patients they recommend its preventive indication when both internal iliac arteries are overstented.

Endovascular treatment of abdominal aortic aneurysms--6 years of experience with Ella stent-graft system.

PURPOSE: Evaluation of 6-year results of abdominal aortic aneurysm (AAA) treatment by Ella stent-grafts with regard to safety and effectivity in relation to morphology of the aneurysm. METHODS: From a group of 172 patients with AAA, in whom elective endovascular treatment was considered, 120 of them (69.8%) were found to be suitable for this type of therapy. The bifurcated type of stent-graft was implanted in 97 patients, uniiliacal type in 19 patients and only four patients were found to be suitable for tubular type of stent-graft. Additional necessary procedures (internal iliac artery occlusion or contralateral common iliac artery occlusion in a group of patients with uniiliacal type of stent-graft) were performed surgically during the stent-graft implantation. CT and US controls were performed at 3, 6 and 12 months after implantation, later every 12 months. RESULTS: Primary technical success was achieved in 109 of the 120 patients (91%). Primary endoleak was recorded in 11 patients (primary endoleak type Ia in seven patients, type Ib in three patients and type IIIa in one patient). Assisted technical success after reintervention or spontaneous seal was 98.3%. Surgical conversion was indicated in two patients (1.7%). Perioperative mortality rate was 3.3%. Total average follow-up period was 20.7 months (range from 2 to 60 months). In nine patients (7.5%) secondary endoleak type II was found at control CT or US, in three patients partial thrombosis of the stent-graft was found. There was no aneurysm rupture during follow-up. CONCLUSION: Treatment of AAA with Ella stent-graft system is effective and safe. Bifurcated stent-graft is the most frequently used type. Uniiliacal type of stent-graft is used by us only in cases of complicated morphology.

Banding in aortic stent-graft fixation in EVAR.

The authors describe the method of surgical aortic banding for better stent-graft fixation in cases of problematic aortic neck in the endovascular infrarenal aneurysms repair.

Iliac-renal bypass in EVAR of AAA with renal arteries arising from aneurysmal sac.

The authors describe treatment possibility for AAA with renal arteries arising from aneurysmal sac in high operating risk patients. They combined endovascular stent-grafting for aneurysmal sac exclusion and classical vascular surgical iliacrenal bypass for revascularisation of excluded renal arteries.

AAA elective treatment indication tactics in EVAR era.

The authors describe their indication tactics for AAA elective treatment. Based on one-month morbidity and mortality they evaluate the results obtained in the past six years and compare the methods of open surgery, endovascular repair and combined strategy in AAAs elective repair.

Endovascular treatment of central venous stenoses in patients with dialysis shunts.

OBJECTIVE: Evaluation of long-term results of percutaneous treatment of central vein stenoses or occlusions in patients with haemodialysis shunt. MATERIALS AND METHODS: In 26 patients with haemodialysis shunts and confirmed central vein stenosis or occlusion, 28 primary percutaneous transluminal angioplasties (PTA) and 5 repeated PTAs (re-PTA) were performed; in three patients a stent was implanted - primary in one patient and due to early restenosis after PTA in two patients. To maintain stent patency, 10 re-PTA were performed. RESULTS: The technical success rate of primary interventions was 96 % (100 % in stenoses and 50 % in occlusions). Primary post-PTA patency rate was 70 % at 3 months, 60 % at 6 months and 30 % at 12 months. CONCLUSION: PTA with possible stent implantation is a first-choice method in the treatment of stenoses and occlusions of the central venous system. Despite the relatively frequent re-interventions, endovascular treatment is capable to preserve long-term function of the dialysis shunt.

Venous hypertension following average arterious-venous fistula for haemodialysis.

The authors emphasize the need for the investigation of the central venous system prior to the insertion of an avfistula, this they consider to be of utmost importance in patients with anamnesis of central vessel access. After the av-fistula is inserted, an unrecognized obstacle (stenosis or thrombosis) may result in the occurrence of venous hypertension and hypofunction, this may lead to av-fistula malfunction.