Treatment options in primary mediastinal B cell lymphoma patients, retrospective multicentric analysis; a Turkish oncology group study.

Introduction and Aim: Primary mediastinal B-cell lymphomas (PMBL) are aggressive B- cell lymphomas. Although the initial treatment models vary in PMBL, appropriate treatment methods are not known. We aim to show real-life data on health outcomes in adult patients with PMBL who received various type of chemoimmunotherapies in Turkey. Method: We analyzed the data of 61 patients who received treatments for PMBL from 2010 to 2020. The overall response rate (ORR), overall survival (OS) and progression-free survival (PFS) of the patients were evaluated. Results: 61 patients were observed in this study. The mean age of the study group was 38.4 ± 13.5 years. From among them, 49.2% of the patients were female (n = 30). For first-line therapy, 33 of them had received rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen (54%). Twenty-five patients had received rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA-EPOCH-R) regimen. The ORR was 77%. The median OS and PFS were as follows: 25 months (95% CI: 20.4-29.4) and 13 months (95% CI: 8.6-17.3), respectively. The OS and PFS at 12 months were 91.3% and 50%, respectively. The OS and PFS at five years were 64.9% and 36.7%, respectively. Median follow-up time period was 20 months (IQR 8.5-38.5). Conclusion: R-CHOP and DA-EPOCH-R showed good results in PMBL. These remain one of the best determined systemic treatment options for first-line therapy. Also, the treatment was associated with good efficacy and tolerability.

Clinical presentation and course of the novel coronavirus disease 2019 in patients with various types of cancer: A retrospective case-control analysis of an experienced cancer center in Turkey.

OBJECTIVE: Cancers have been reported to worsen the clinical course of coronavirus disease 2019 (COVID-19) infection. We aimed to demonstrate the real-life data on health outcomes in COVID-19-infected cancer patients. MATERIALS AND METHODS: We analyzed the data of 43 COVID-19-infected cancer patients in our COVID-19 clinics between March 25, 2020, and May 9, 2020, retrospectively. RESULTS: We determined that 1051 patients were followed up with COVID-19 infection and 43 (4%) of them were cancer patients. The mean age of the patients was 64.3 ± 12.3 years. Lung cancer is the most common cancer type among the patients (23.2%). Dyspnea (51.2%) was the most common symptom in the first admission. Typical ground-glass consolidation or patchy appearance with peribronchial thickening resembling bronchopneumonia on high-resolution computed tomography (HRCT) was present in 29 (67.4%) patients. COVID-19 was diagnosed in 14 (32.5%) patients based on reverse transcriptase-polymerase chain reaction analysis of nose-throat swab samples without any sign of lung involvement on HRCT. Total mortality of the COVID-19 infection was 46.5% (n = 20). Presence of heart disease (hazard ratio [HR]: 3.5; 95% confidence interval [CI]: 1.29-9.4), previous surgeries to the respiratory system (HR: 6.95; 95% CI: 1.29-27.7), and presence of dyspnea at admission (HR: 4; 95% CI: 1.31-12.3) were statistically significantly associated with death (P = 0.01, 0.02, and 0.01, respectively). CONCLUSION: Our practices supported that cancer patients were more affected by COVID-19 disease than the normal population. However, our findings can not be generalized due to being retrospective and single centered study, Also, we did not compare the findings with noncancer patients with COVID19 disease.

Factors Affecting Success of Semi-rigid Ureterorenoscopy in Proximal Ureter Stone Treatment.

OBJECTIVE: To evaluate the factors affecting the success of semi-rigid ureteroscopy in proximal ureter stones. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Urology, Nevsehir State Hospital, Turkey between March 2017 and October 2019. METHODOLOGY: Patients, who underwent a semi-rigid ureteroscopic lithotripsy (URSL) operation for proximal ureteral stones, were evaluated retrospectively in terms of gender, age, stone side, stone size, stone density, the type of lithotripsy, placement of the stone cone, the type of anesthesia and postoperative stone-free rates, which were recorded. The diameter of the ureter with the stones and the distances of the stones to the ureteropelvic junction (UPJ) were measured. Patients who had stone-free status after the URSL were labelled as group I. Patients whose stones were pushed back during URSL were labelled as group II. RESULTS: The distance of the stone to the UPJ was statistically significantly higher in group I (p=0.006). The rate of using stone cone in patients in group I was statistically significantly higher than in patients in group II (p=0.001). The rate of stones in the middle ureter in group I was statistically higher than group II (p<0.001). The rate of using laser lithotriptor in group I was statistically higher than group II (p=0.007). CONCLUSION: Semi-rigid URSL is a useful technique in the proximal ureter stones.  The distance of the stone to the UPJ affects the success; and using laser lithotripsy and stone cone increases the success. Key Words: Ureteral stone, Ureterorenoscopy, Laser lithotriphsy, Pnomotic lithotripsy.

MAGPI under local anaesthesia without catheter as an alternative to standard TIP procedure in distal hypospadias repair.

To evaluate the surgical outcomes of meatal advancement and glanuloplasty incorporation (MAGPI) and tubularised incised plate (TIP) urethroplasty. We retrospectively reviewed the patient records who had hypospadias repairing surgery between March 2017 and March 2020 in terms of age, meatal position, operative and anaesthesia techniques and surgical outcomes. Hypospadias repair was performed in 85 patients. TIP urethroplasty was performed in 17 patients where MAGPI was performed in 63 patients. Preoperative meatal stenosis was present in 10. Coronal glanular and subcoronal hypospadias were present in 65 and 15 patients respectively. Mean operative time was 41.3 ± 28 min. The mean duration of the catheter was 7.56 days. A significant chordee was present in 35 patients where 45 patients had no chordee. The overall success rate was 93.75%. MAGPI ended up with an unfavourable result in 1 and TIP urethroplasty in 4. Postoperative urethral stenosis was seen in 1. Of those who ended up with an unfavourable result, 4 were with subglandular hypospadias. Urethral catheter required in 4 of those who failed, whereas 1 had no catheter following surgery. Therefore, MAGPI is a useful method in selected glandular and subglandular hypospadias repair with favourable surgical outcomes including no stent requirement.

Treating relapsed and refractory metastatic germ cell tumours with high-dose chemotherapy with carboplatin and etoposide and autologous haematopoietic stem cell transplantation.

INTRODUCTION AND AIM: To demonstrate the real-life data about patients who underwent AHSCT due to GCT. METHODS: Between November 2016 and April 2020, 64 patients who received CE as high-dose chemotherapy for AHSCT in the Gulhane Education and Research Hospital were included in the study. Sixty-one patients received one AHSCT with CE chemotherapy regimen. Survival data and clinical characteristics were evaluated retrospectively. RESULTS: The mean age of the patients were 31.9 ± 9 (min-max:18-55). With a median follow-up of 10.7 ± 8.7 months, the 1-year progression-free survival (PFS) rate was 57.8%, and the 1-year overall survival rate was 77.5%. Median overall survival (OS) and progression-free survival (PFS) times were 21.5 ± 1.8 (95% CI: 14.5-33.4) and 20 ± 2 months, respectively. The response rate was 72%. There were three treatment-related deaths. CONCLUSION: This sizeable single-centre study shows that patients with relapsed metastatic GCT are curable by CE as high dose chemotherapy plus AHSCT with reliable toxicity even for a single cycle.

Perioperative Indices Predicting Fever Following Percutaneus Nephrolithotomy.

OBJECTIVE: To investigate 18 independent peroperative parameters that may have an effect on fever after percutaneous nephrolithotomy (PCNL). STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Departments of Urology, Nevsehir State Hospital, and Sultan Abdulhamid Han Education and Research Hospital, Turkey, from January 2016 to June 2019. METHODOLOGY: Two hundred and seventy-six patients, who underwent PCNL between 2016 and 2019 in two institutions, were evaluated retrospectively. Patients were divided as Group I and II, according to the absence or presence of fever after PCNL, then peroperative parameters were compared. RESULTS: There was no statistically significant difference between Group I and II in terms of age, gender, side of stone, ipsilateral open stone surgery or PCNL history, presence of renal anatomic anomaly, preoperative hydronephrosis grade, stone size in computed tomography (CT), stone Houndsfield Unit (HU) value, skin stone distance, duration of operation, postoperative D-J insertion rate and postoperative blood transfusion requirement (p >0.05). Guy' s Stone Score (GSS), number of calyceal access and duration of achieving limpid urine coming out of the nephrostomy tube were significantly higher in Group II (p <0.05). The rate of postoperative fever was statistically significantly higher in patients with middle calyceal (mid-calyceal) access, than patients with inferior calyceal access (p=0.05). CONCLUSION: High GSS, mid-calyceal access, the increase in the amount of mid-calyceal access, the longer duration of achieving limpid urine coming out of the nephrostomy tube were found to be related with fever after PCNL. Key Words: PCNL, Post-PCNL fever, Nephrolithiasis, Guy's stone score.

Intravesical electromotive drug administration for non-muscle invasive bladder cancer.

BACKGROUND: Electromotive drug administration (EMDA) is the use of electrical current to improve the delivery of intravesical agents to reduce the risk of recurrence in people with non-muscle invasive bladder cancer (NMIBC). It is unclear how effective this is in comparison to other forms of intravesical therapy. OBJECTIVES: To assess the effects of intravesical EMDA for the treatment of NMIBC. SEARCH METHODS: We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE), two clinical trial registries and a grey literature repository. We searched reference lists of relevant publications and abstract proceedings. We applied no language restrictions. The last search was February 2017. SELECTION CRITERIA: We searched for randomised studies comparing EMDA of any intravesical agent used to reduce bladder cancer recurrence in conjunction with transurethral resection of bladder tumour (TURBT). DATA COLLECTION AND ANALYSIS: Two review authors independently screened the literature, extracted data, assessed risk of bias and rated quality of evidence (QoE) according to GRADE on a per outcome basis. MAIN RESULTS: We included three trials with 672 participants that described five distinct comparisons. The same principal investigator conducted all three trials. All studies used mitomycin C (MMC) as the chemotherapeutic agent for EMDA. 1. Postoperative MMC-EMDA induction versus postoperative Bacillus Calmette-Guérin (BCG) induction: based on one study with 72 participants with carcinoma in situ (CIS) and concurrent pT1 urothelial carcinoma, we are uncertain (very low QoE) about the effect of MMC-EMDA on time to recurrence (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.64 to 1.76; corresponding to 30 more per 1000 participants, 95% CI 180 fewer to 380 more). There was no disease progression in either treatment arm at three months' follow-up. We are uncertain (very low QoE) about serious adverse events (RR 0.75, 95% CI 0.18 to 3.11). 2. Postoperative MMC-EMDA induction versus MMC-passive diffusion (PD) induction: based on one study with 72 participants with CIS and concurrent pT1 urothelial carcinoma, postoperative MMC-EMDA may (low QoE) reduce disease recurrence (RR 0.65, 95% CI 0.44 to 0.98; corresponding to 147 fewer per 1000 participants, 95% CI 235 fewer to 8 fewer). There was no disease progression in either treatment arm at three months' follow-up. We are uncertain (very low QoE) about the effect of MMC-EMDA on serious adverse events (RR 1.50, 95% CI 0.27 to 8.45). 3. Postoperative MMC-EMDA with sequential BCG induction and maintenance versus postoperative BCG induction and maintenance: based on one study with 212 participants with pT1 urothelial carcinoma of the bladder with or without CIS, postoperative MMC-EMDA with sequential BCG may result (low QoE) in a longer time to recurrence (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77; corresponding to 181 fewer per 1000 participants, 95% CI 256 fewer to 79 fewer) and time to progression (HR 0.36, 95% CI 0.17 to 0.75; corresponding to 63 fewer per 1000 participants, 95% CI 82 fewer to 24 fewer). We are uncertain (very low QoE) about the effect of MMC-EMDA on serious adverse events (RR 1.02, 95% CI 0.21 to 4.94). 4. Single-dose, preoperative MMC-EMDA versus single-dose, postoperative MMC-PD: based on one study with 236 participants with primary pTa and pT1 urothelial carcinoma, preoperative MMC-EMDA likely (moderate QoE) results in a longer time to recurrence (HR 0.47, 95% CI 0.32 to 0.69; corresponding to 247 fewer per 1000 participants, 95% CI 341 fewer to 130 fewer) for a median follow-up of 86 months. We are uncertain (very low QoE) about the effect of MMC-EMDA on time to progression (HR 0.81, 95% CI 0.00 to 259.93; corresponding to 34 fewer per 1000 participants, 95% CI 193 fewer to 807 more) and serious adverse events (RR 0.79, 95% CI 0.30 to 2.05). 5. Single-dose, preoperative MMC-EMDA versus TURBT alone: based on one study with 233 participants with primary pTa and pT1 urothelial carcinoma, preoperative MMC-EMDA likely (moderate QoE) results in a longer time to recurrence (HR 0.40, 95% CI 0.28 to 0.57; corresponding to 304 fewer per 1000 participants, 95% CI 390 fewer to 198 fewer) for a median follow-up of 86 months. We are uncertain (very low QoE) about the effect of MMC-EMDA on time to progression (HR 0.74, 95% CI 0.00 to 247.93; corresponding to 49 fewer per 1000 participants, 95% CI 207 fewer to 793 more) or serious adverse events (HR 1.74, 95% CI 0.52 to 5.77). AUTHORS' CONCLUSIONS: While the use of EMDA to administer intravesical MMC may result in a delay in time to recurrence in select patient populations, we are uncertain about its impact on serious adverse events in all settings. Common reasons for downgrading the QoE were study limitations and imprecision. A potential role for EMDA-based administration of MMC may lie in settings where more established agents (such as BCG) are not available. In the setting of low or very low QoE for most comparisons, our confidence in the effect estimates is limited and the true effect sizes may be substantially different from those reported here.

Predictors of prostate cancer in ultrasound-guided transperineal saturation biopsy in Turkish men with multiple prior negative biopsies.

BACKGROUND: Transperineal prostate biopsy (STPB) is associated with an improved cancer detection rate and an increase in anterior and apical prostate cancers compared to standard transrectal biopsy. PATIENTS AND METHODS: A total of 48 men with at least two sets of prior prostate biopsies underwent transrectal ultrasound-guided STPB. Prostate rebiopsy indications were serum prostate-specific antigen (PSA) levels greater than 2.5 ng/mL and/or abnormal digital rectal examination and/or presence of high-grade prostatic intraepithelial neoplasia (HGPIN; ≥2 cores) or atypical small acinar proliferation (ASAP) at previous biopsies. The procedure was performed at dorsal lithotomy position under general anesthesia using a perineal 0.5 cm brachytherapy template attached to the transrectal ultrasound probe. Specimens from each zone were sent separately for pathological examination. RESULTS: Mean PSA level at STPB was 15.9 ng/mL (range 4.03 to 59.57). An average of 54.5 cores was obtained. Prostate adenocarcinoma was detected in 15 of 48 (31%) patients. Mean percentage of malignant cores was 11.9%. Multivariate logistic regression analysis revealed that age and presence of ASAP or HGPIN at previous biopsies were independent predictors of prostate cancer (p<0.05). No major complications, including sepsis and severe urinary or rectal bleeding, were observed in any of the patients. Five patients (10%) developed acute urinary retention after the procedure requiring urethral catheterization. CONCLUSIONS: Considerable number of patients with negative multiple biopsies were diagnosed with prostate cancer. STPB is a well-tolerated procedure with minimal morbidity, which can be considered for the diagnosis of prostate cancer in patients with previous negative biopsies.

Active surveillance of renal masses: an analysis of growth kinetics and clinical outcomes stratified by radiological characteristics at diagnosis.

AIMS: To determine the growth rate of renal masses (RMs) under active surveillance (AS), and to describe the clinical outcome of AS patients. MATERIALS AND METHODS: We conducted a retrospective review of an AS database to obtain demographics, radiological and pathologic characteristics and RM size of patients. RMs were followed at 6-12 month intervals for ≥1 year with computed tomography (CT), magnetic resonance imaging (MRI), or renal ultrasound. Kaplan-Meier analysis determined the annual likelihood of intervention. RMs were divided into 3 radiographic subcategories (solid, cystic, and angiomyolipoma). A linear regression model determined RM growth rates. RESULTS: 131 RMs in 114 patients were included. Median age, Charlson Comorbidity Index score and mean follow-up were 69.1 years, 4.0 and 4.2±2.6 years, respectively. Maximal tumor diameter (MTD) at diagnosis was 2.1 ± 1.3 cm. 49 RMs exhibited negative or zero net growth. Mean MTD growth rate for all RMs was 0.72±3.2 (95% CI: 0.16-1.28) mm/year. When stratified by MTD at diagnosis, mean RM growth rates were 0.84, 0.84, 0.44, 0.74 and 0.71 mm/year for RMs ≤1 cm, 1-≤2cm, 2-≤ 3cm, 3-≤ 4cm and ≥4cm, respectively (p≤0.01). The 5 and 10-year freedom from intervention rates were 93.1% and 88.5%, respectively. There was a single case of suspected metastases, but no deaths related to kidney cancer. CONCLUSIONS: RMs under AS grew slowly, and had a low incidence of requiring surgical intervention and progression. Solid enhancing masses grew slowly, and were more likely to trigger intervention. AS should be considered for selected patients with small RMs.

Active surveillance of renal masses: an analysis of growth kinetics and clinical outcomes stratified by radiological characteristics at diagnosis

AIMS To determine the growth rate of renal masses (RMs) under active surveillance (AS), and to describe the clinical outcome of AS patients. Materials and Methods We conducted a retrospective review of an AS database to obtain demographics, radiological and pathologic characteristics and RM size of patients. RMs were followed at 6-12 month intervals for ≥1 year with computed tomography (CT), magnetic resonance imaging (MRI), or renal ultrasound. Kaplan-Meier analysis determined the annual likelihood of intervention. RMs were divided into 3 radiographic subcategories (solid, cystic, and angiomyolipoma). A linear regression model determined RM growth rates. Results 131 RMs in 114 patients were included. Median age, Charlson Comorbidity Index score and mean follow-up were 69.1 years, 4.0 and 4.2±2.6 years, respectively. Maximal tumor diameter (MTD) at diagnosis was 2.1±1.3 cm. 49 RMs exhibited negative or zero net growth. Mean MTD growth rate for all RMs was 0.72±3.2 (95% CI: 0.16-1.28) mm/year. When stratified by MTD at diagnosis, mean RM growth rates were 0.84, 0.84, 0.44, 0.74 and 0.71 mm/year for RMs <1 cm, 1-<2cm, 2-<3cm, 3-<4cm and ≥4cm, respectively (p<0.01). The 5 and 10-year freedom from intervention rates were 93.1% and 88.5%, respectively. There was a single case of suspected metastases, but no deaths related to kidney cancer. Conclusions RMs under AS grew slowly, and had a low incidence of requiring surgical intervention and progression. Solid enhancing masses grew slowly, and were more likely to trigger intervention. AS should be considered for selected patients with small RMs. .

Prognostic indices of perioperative outcome following transperitoneal laparoscopic adrenalectomy.

OBJECTIVES: We sought to identify preoperative patient and tumor characteristics that may be useful prognostic indicators of postsurgical outcome in patients undergoing laparoscopic adrenalectomy (LA). SUBJECTS AND METHODS: Data from 92 patients who underwent 93 transabdominal LA procedures between 2006-2012 were retrieved. Patients were stratified based on estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Interdependencies between surgical outcome and patient demographics, tumor characteristics, comorbidities, and Charlson Comorbidity Index (CCI) were statistically analyzed. The predictive capacity of each index was assessed using receiver operating characteristic curves. RESULTS: Neither age, gender, tumor laterality, body mass index, American Society of Anesthesiologists (ASA) score, nor CCI predicted the occurrence of perioperative complications. EBL was significantly associated with increased age, tumor size, ASA score, and CCI, whereas prolonged LOS was associated with higher ASA score. Tumor size was related, although not significantly, to LOS and perioperative complications. Tumors ≥7.5 cm in diameter were significantly associated with worse perioperative outcomes. CONCLUSIONS: LA for adrenal lesions demonstrated reasonable complication rates and perioperative outcomes. Tumor size, CCI, and ASA score are predictive of increased EBL and LOS.

Predictors of postoperative decline in estimated glomerular filtration rate in patients undergoing robotic partial nephrectomy.

PURPOSE: To identify prognostic indicators of estimated glomerular filtration rate (eGFR) following robotic partial nephrectomy (RPN). MATERIALS AND METHODS: In a retrospective study of RPN patients, we examined data describing age, gender, eGFR, body mass index (BMI), tumor size (TS), length of stay, and estimated blood loss (EBL). Changes in eGFR (i.e., renal function trajectory [RFT]) and chronic kidney disease (CKD) stage shift were analyzed with mixed model linear and logistic regression analyses, Chi-squared, and t-tests. RESULTS: Changes in eGFR (RFT) were determined in 122 patients at baseline and at 6- and 12-month follow-up visits. Mean age, TS, and Charlson comorbidity index (CCI) were 62±11 years, 3±1.2 cm, and 4.8±1.8, respectively. The pre- and postoperative eGFR was lower in patients >60 years. Preoperative eGFR was unrelated to gender, BMI>30 kg/m(2), histopathology, nuclear grade, and TS. Univariate analyses determined that age, BMI>30, EBL>200 mL, CCI>5, and TS were associated with greater declines in eGFR. Reduced eGFR was also associated with warm ischemia time ≥22 minutes, while age was associated with a ≥1 worsening of British CKD classification. Using multivariate analysis, only age was significantly associated with a decline in eGFR, which was greater in patients with a normal preoperative eGFR. CONCLUSIONS: Patient age, BMI>30, EBL>200 mL, CCI>5, and TS were predictors of greater postoperative declines in eGFR. Although a decline in eGFR was proportionally greater in low stage CKD, postoperative changes are associated with advancing age.

The impact of body mass index on perioperative outcomes in robot-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: Obese patients undergoing surgical procedures are at increased risk for perioperative morbidity. The purpose of this study is to determine whether there is an association with body mass index (BMI), clinicopathologic features, and perioperative outcomes and complications in patients undergoing robot-assisted laparoscopic partial nephrectomy (RPN). PATIENTS AND METHODS: Medical records of 283 patients who underwent RPN between 2007 and 2012 were reviewed from an Institutional Review Board approved database. We analyzed the association of perioperative outcomes and complications of the surgery with BMI and clinicopathologic features using analysis of variance, Kruskal-Wallis test, t test and chi-square-test. Eventually, independent factors associated with perioperative outcomes and complications were studied using univariate and multivariate regression analysis. RESULTS: Perioperative outcomes including estimated blood loss (EBL), length of hospital stay (LOS) and operative time (OT) were significantly associated with BMI (P=0.002, P=0.009 and P=0.002, respectively). Warm ischemia time (WIT), perioperative complications, and change in glomerular filtration rate (GFR) before and after surgery were not associated with BMI (P=0.459, P=0.86 and P=0.773). In multivariate analysis, BMI, tumor size≥4 cm, and collecting system invasion were independently associated with EBL and OT. Increased LOS was independently associated with BMI and tumor size ≥4 cm. CONCLUSIONS: Increasing BMI was not associated with a significant increase in perioperative complications, WIT, or change in GFR in patients undergoing RPN at a high-volume tertiary medical center. Collecting system invasion or tumor size ≥4 cm and BMI were independently associated with higher EBL, LOS, and OT, however.

Primary osteosarcoma of the urinary bladder following cyclophosphamide therapy for systemic lupus erythematosus: a case report.

INTRODUCTION: The association of systemic lupus erythematosus with malignancies is an uncommon occurrence. We present the case of an osteosarcoma of the urinary bladder developing in a patient with a prolonged history of active systemic lupus erythematosus. This is a previously unreported association. Primary osteosarcoma is an extremely rare disease in the urinary bladder. CASE PRESENTATION: A 24-year-old Caucasian woman with a 13-year history of systemic lupus erythematosus, who had been treated with high dose immunosuppressive agents, presented with pain and hematuria. A deeply invasive high-grade tumor was detected in the urinary bladder and the patient underwent radical surgery. A diagnosis of osteosarcoma was made based on the characteristic histology. CONCLUSION: Predisposing factors for primary sarcomas in the urinary bladder are mostly unknown; however, in our case, long-term administration of immunosuppressive agents, as well as long standing systemic lupus erythematosus, may both be of significance.