Dynamic change of cancer genome profiling in metachronous bilateral breast cancer with BRCA pathogenic variant.

A 61-year-old woman with BRCA2 pathogenic variant had been treated for 20 years and showed dynamic changes in the genomic profile of her metachronous bilateral breast cancer and metastases. She underwent right breast conservation surgery at age 42-Genome 1, lung metastasis and left axillary lymph node metastasis at age 51, partial excision under local anesthesia for left breast cancer at age 53-Genome 2, left axillary lymph node dissection was added 6 month later-Genome 3. Then, olaparib was administered, and subsequently, left mastectomy was performed for the recurrence of left breast cancer at age 59-Genome 4. Genomic profile of the tumor was analyzed at four points (Genome 1-3 were analyzed by in house breast cancer panel, and Genome 4 was analyzed by Foundation One CDx). Two interesting findings emerged from these analyses. First, the genomic profile revealed that the left axillary lymph node metastasis, considered histologically from right breast cancer, was a metastasis from the left breast cancer. The second finding is that as the disease progressed, mutation profile became more diverse. The profile of the left breast cancer removed after olaparib and other treatments showed reversion mutation of BRCA2 and was diagnosed as tumor mutation burden high. Subsequent response to pembrolizumab was favorable.

Unrelated hematopoietic stem cell transplantation for familial platelet disorder/acute myeloid leukemia with germline RUNX1 mutations.

Germline mutations in RUNX1 result in rare autosomal-dominant familial platelet disorder with predisposition to acute myeloid leukemia (FPD/AML). As genetic analysis is becoming increasingly prevalent, the diagnosis rate of FPD/AML is expected to increase. In this report, we present two pedigrees, one diagnosed molecularly and another highly suspected to be FPD/AML, whose members both received allogeneic hematopoietic stem cell transplantation (HSCT). Both pedigrees had a family history of thrombocytopenia, platelet dysfunction, and hematological malignancies. One family inherited a frameshift mutation (p.P240fs) of RUNX1, a known pathogenic variant. Another family inherited a point mutation (p.G168R) in the runt-homology domain, the clinical significance of which is uncertain at this point. As this mutation was completely absent from all population databases and had a relatively high REVEL score of 0.947, we thought that it would be dangerous to ignore its possible pathogenicity. Consequently, we avoided choosing HSCT donors from relatives of both families and performed HSCT from unrelated donors. In conclusion, our experience with two families of FPD/AML highlights the importance of searching for gene mutations associated with germline predisposition and indicates the necessity of developing a donor coordination system for FPD/AML patients, as well as a support system for families.

Successful azacitidine therapy for myelodysplastic syndrome associated with VEXAS syndrome.

VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is caused by UBA1 somatic mutations and is characterized by late-onset systemic autoimmune inflammation and blood abnormalities such as cytopenia, vacuolation of myeloid/erythroblastic cells, and myelodysplastic syndrome (MDS). It is often resistant to immunosuppressive therapy, and no treatment strategy has been established. A 65-year-old man presented with palpable erythema, fever, macrocytic anemia, and arthralgia. He was subsequently diagnosed with MDS complicated by Sweet's disease. Treatment with azacitidine was initiated due to suspected skin invasion by MDS cells and resistance of the skin rash to steroid therapy. Next-generation sequencing of bone marrow samples prior to treatment initiation revealed the presence of UBA1 p.M41L (VAF 0.38) and DNMT3A p.L605fs mutations (VAF 0.184). Based on the findings of systemic inflammation, a diagnosis of VEXAS syndrome was made. The fever and skin rash improved with azacitidine therapy. In conclusion, somatic mutations in UBA1 should be explored in patients with MDS exhibiting systemic autoimmune inflammation. Furthermore, azacitidine may be a good treatment option for systemic autoinflammation in MDS associated with VEXAS syndrome.

Cystic degeneration during neo-adjuvant chemotherapy predicts squamous metaplasia of triple negative breast cancer: report of two cases.

Neo-adjuvant chemotherapy (NAC) has become a standard treatment for advanced breast cancer because of the advantage of monitoring drug sensitivity and enabling breast-conserving therapy. The changes during NAC are also important to know the biological characteristics of the tumor. We experienced two cases with cystic degeneration and enhancement of the cyst wall during NAC for triple negative breast cancer (TNBC). They were diagnosed to have breast cancer with squamous metaplasia. In case 1, a 37-year-old woman with right breast cancer diagnosed as TNBC, T3N3M0, Stage 3b was treated with NAC. MRI showed a cystic degeneration with a diameter of 3.5 cm and enhancement of the cyst wall, and the other nodules were extinguished. The histopathological finding of the surgical specimen revealed solid tubular carcinoma with squamous metaplasia. In case 2, a 58-year-old woman with right breast cancer diagnosed as HER2 enriched subtype, T2N0M0 stage 2 was treated with NAC containing trastuzumab. The post-NAC MRI showed extinguishment of the mass in the right breast, but showed a cystic lesion with 24 mm in diameter and enhancement of its wall in the left breast. She underwent breast conserving surgery for bilateral breast cancer, and histopathological finding of the surgical specimen indicated complete remission of right breast cancer and squamous cell carcinoma developed in the left breast. These changes are impressive and remind us that there are metaplastic changes (especially for squamous metaplasia) with resistance to chemotherapy.

Benefit of home parenteral nutrition (HPN) and chemotherapy in patients with invasive lobular carcinoma developed peritoneal metastases.

The benefit of home parenteral nutrition (HPN) for patients with malnutrition due to peritoneal metastasis depends on the type of cancer. During the period 1999-2020, we treated 460 patients with metastatic and stage 4 breast cancer, 23 of whom were invasive lobular carcinoma (ILC). Of the 23 patients with ILC, 13 (57%) developed peritoneal metastasis, and 11 died of progression of peritoneal metastasis. Among these 11 patients, 2 patients who underwent surgery due to bowel obstruction, had no improvement, and died 1-4 months after surgery. The prognosis of the other 7 patients under BSC alone was poor, survival time were ranging from 1 to 5 months. The remaining two patients who were able to continue outpatient chemotherapy under HPN were able to prolong their survival time by 18 months and 26 months, respectively. We need to recognize that HPN and chemotherapy may prolong survival time in patients with peritoneal metastasis of ILC, and determine the indication for HPN based on the non-peritoneal life-threatening metastasis, length of treatment, availability of support for HPN management and outpatient chemotherapy, and the patient's willingness to accept it.

[Durable remission following donor lymphocyte infusion for post-transplant relapse of acute myeloid leukemia developing from secondary myelofibrosis].

Essential thrombocythemia gradually developed into secondary myelofibrosis and progressed to leukemia eight months later in a 53-year-old man. After remission induction therapy, he achieved remission by undergoing allogeneic hematopoietic stem cell transplantation from unrelated patients in non-remission. However, peripheral blood WT-1 mRNA gradually increased, and the disease relapsed three years and six months after transplantation. He was taking prednisolone (7.5 mg) and tacrolimus (5 mg) for chronic pulmonary graft-versus-host disease (GVHD) and was reluctant to reduce or discontinue immunosuppressive drugs; therefore, donor lymphocyte infusion (DLI) was performed for a total of five times. Four months after the fifth DLI, cutaneous GVHD appeared, a slow decrease in WT-1 mRNA was observed, and blasts in the peripheral blood disappeared. One year and three months after the last DLI, he achieved complete remission. Although DLI for post-transplant relapse in patients with secondary myelofibrosis or leukemia is rare, it can be beneficial for post-relapse therapy.

Successful treatment with famciclovir for varicella zoster virus infection resistant to acyclovir.

Varicella zoster virus (VZV) reactivates more frequently in immunocompromised patients than immunocompetent subjects and is a significant cause of morbidity and mortality. Acyclovir is frequently used for treatment against VZV reactivation. However, long-term use of acyclovir can result in the emergence of VZV strain resistant to acyclovir. Here, we report a 67-year-old man with adult T-cell leukemia who suffered from herpes zoster with acyclovir-resistant VZV after long-term prophylaxis. The isolated viruses from his skin lesions were a mixture of acyclovir-resistant and acyclovir-susceptible strains. Sequence analysis showed the presence of thymidine kinase (TK) mutations in the resistant clones. Interestingly, oral administration of famciclovir, a prodrug form of penciclovir, resulted in resolution of his herpes zoster, although most acyclovir-resistant strains of VZV were reported to be resistant to penciclovir. This implied that a certain amount of susceptible VZV with wild-type viral TK gene was present in vivo, and that famciclovir could be phosphorylated intracellularly by the intact viral kinases. As famciclovir is more potent and longer-acting than acyclovir, the susceptible strains might have suppressed the generation and proliferation of the resistant in vivo. Even when VZV is developing resistance to acyclovir, famciclovir might be effective at least in the early resistant phase.

[Successful surgical resection of rectal cancer in a patient with relapsed hairy cell leukemia under interferon-α treatment].

An 83-year-old man was diagnosed with hairy cell leukemia (HCL). He was treated with cladribine and achieved partial remission. However, pancytopenia due to HCL bone marrow involvement progressed slowly. Nine years later, he developed rectal cancer. Prior to the surgery, endoscopy-assisted submucosal ink injection was performed to identify the area of lower intestinal lesions. The following day, he developed septic peritonitis with shock status, perhaps due to his neutropenia and ink injection procedures. Surgical resection of the cancer was presumed unfeasible; therefore, radiation was performed. Several months later, bone marrow examination revealed HCL infiltration with reticulin fibrosis. Chemotherapy regimens with purine nucleoside analogs, which are the standard treatments for HCL, might accentuate the progression of his rectal cancer and enhance the development of severe infections. Therefore, interferon (IFN) -α was administered as an alternative therapy. Three months later, pancytopenia resolved, and bone marrow examination revealed a remarkable improvement in HCL infiltration and marrow fibrosis. With IFN-α therapy, the patient successfully underwent surgical resection of the rectal cancer. Using INF-α, a prompt recovery from pancytopenia might be expected even in a patient with advanced HCL, who requires surgical treatment for a concomitant cancer.

[18F-fluorodeoxyglucose-positron emission tomography imaging before and after treatment of chronic-phase chronic myeloid leukemia with tyrosine kinase inhibitors].

A 64-year-old man presented with abnormal imaging results on 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET), showing moderately increased FDG-uptake in the entire bone marrow. Blood tests revealed leukocytosis, thrombocytosis, and increased lactate dehydrogenase levels. Furthermore, the neutrophil alkaline phosphatase score decreased. Bone marrow examination revealed marked hypercellularity of myeloid and megakaryocytic lineages without an excess of blasts. Cytogenetic analysis of the bone marrow demonstrated Philadelphia chromosome, and fluorescence in situ hybridization analysis was positive for BCR-ABL1 fusion genes. Thus, the patient was diagnosed with chronic myeloid leukemia (CML) in the chronic phase and tyrosine kinase inhibitor therapy with 100 mg of dasatinib daily was initiated. Complete cytogenetic response and a major molecular response were achieved at 3 and 12 months post-treatment, respectively. FDG-uptake values of the bone marrow remarkably decreased along with the remission status of the disease. FDG-PET images at pre- and post-treatment of CML are rarely compared, so we report this case as an important reference.

Follicular lymphoma with plasmacytic differentiation accompanied by monoclonal IgG gammopathy.

A 59-year-old woman presented with high serum total protein, detected on a screening examination. Laboratory tests revealed high plasma levels of M-protein (IgG-λ), and FDG-PET/CT revealed systemic lymph node swelling and a large tumorous mass in the abdominal cavity. Bone marrow aspirates contained 8.4% plasma cells and approximately 30% abnormal small lymphocytes. A biopsy of the left supraclavicular lymph node was initially interpreted as lymphoplasmacytic lymphoma (LPL). However, chromosomal analysis of the lymph node demonstrated an unusual karyotype with t (14;18) (q32;q21). FISH analysis for the IgH-BCL2 fusion gene was positive. Furthermore, the MYD88 L265P mutation was not detected in tumor cells. Based on these findings, this case was determined to be a type of follicular lymphoma with plasmacytic differentiation. We considered that this case was an important example emphasizing the importance of karyotypic examination for lymphoma classification.

A Rare Case of Adult Autoimmune Neutropenia Successfully Treated with Prednisolone.

Autoimmune neutropenia (AIN) is a rare disorder that may cause life-threatening infections. In adults, most cases are secondary to other pathological conditions, and primary AIN is extremely rare. We herein report a case involving a 57-year-old woman diagnosed with AIN. A granulocyte immunofluorescence test detected autoantibodies against human neutrophil antigens in her serum, while various examinations revealed no other causes of neutropenia, suggesting her AIN was primary. She was refractory to granulocyte-colony-stimulating factor but responded to prednisolone. Her neutrophil count remained normal after gradual discontinuation of prednisolone. Diagnostic procedures and optimal treatments for this disorder need to be established.

Persistence of a t(11;14)-positive clone in a patient with mantle cell lymphoma for 20 years.

We report here a patient with extremely indolent mantle cell lymphoma (MCL) who had progressed and required immunochemotherapy 20 years after diagnostic splenectomy. Non-nodal, indolent MCL patients may progress after such an extraordinary long indolent phase, and we recommend lifelong follow up for such cases.

Granulocytic sarcoma of the pancreas on 18F-FDG PET/CT: A case report.

RATIONALE: Granulocytic sarcoma (GS) is defined as leukemia infiltration in any organ other than the bone marrow. GS rarely occurs in the pancreas. Here, we present the first report of GS in the pancreas on F-fluorodexyglucose positron emission tomography/computed tomography (F-FDG PET/CT). PATIENT CONCERNS: A 19-year-old male patient with acute myeloid leukemia received a human leukocyte antigen-haploidentical stem cell transplant as a second transplant while in second complete remission. INTERVENTIONS: After a second stem cell transplant, obstructive pancreatitis accompanied by a mass in the pancreatic head was observed. FDG-PET/CT revealed abnormal activity in the head of the pancreas and the skin in the patient's left breast area. DIAGNOSES: Pathological examination demonstrated relapsed acute myeloid leukemia in both the lesions. OUTCOMES: This is the first report showing the F-FDG PET/CT findings of GS in the pancreas. LESSONS: F-FDG PET/CT may help determine the stage of GS.

Effects of induction immunosuppression regimen on acute rejection, bronchiolitis obliterans, and survival after lung transplantation.

OBJECTIVE: Effects of daclizumab and antithymocyte globulin induction on acute rejection, bronchiolitis obliterans syndrome, and survival after lung transplantation are unknown. We hypothesized that daclizumab results in less acute rejection and bronchiolitis obliterans and better survival than antithymocyte globulin. METHODS: Consecutive adult lung transplants (n = 163) at the University of Virginia from January 1998 to May 2006 were reviewed. Antithymocyte globulin induction was routinely performed before January 2002 (65 patients), after which all patients received daclizumab (98 patients). Estimates of cumulative event rate of acute rejection, bronchiolitis obliterans, and death were calculated by Kaplan-Meier method and between-group differences compared by log-rank test. Cox proportional hazards models were fitted to assess treatment effects adjusted for covariates. RESULTS: Groups were similar in demographics and preoperative and intraoperative risk factors. Maintenance immunosuppression changed during the study, and mycophenolate mofetil was more commonly given to patients receiving daclizumab. By Kaplan-Meier method, daclizumab was associated with significantly less acute rejection (P = .002), less bronchiolitis obliterans (P = .02), and improved overall survival (P = .04). Induction agent was highly associated with acute rejection (P = .002), bronchiolitis obliterans (P = .02), and mortality (P = .05); antimetabolite agent was associated only with acute rejection (P = .01). Adjusting for covariates, induction agent remained significantly predictive for acute rejection (P = .02) and bronchiolitis obliterans (P = .05), approaching significance for survival (P = .07). CONCLUSION: Lung transplant recipients receiving daclizumab for induction had significantly less acute rejection and bronchiolitis obliterans than those receiving antithymocyte globulin, with possibly improved survival. Improvements in acute rejection may have been confounded by the use of mycophenolate mofetil.

Lessons learned from a nightclub fire: institutional disaster preparedness.

BACKGROUND: On February 20, 2003, a nightclub fire caused a multiple casualty disaster, with 215 victims requiring treatment at area hospitals. In this report, we describe the events, the surgical response at our trauma center, and the lessons learned in institutional disaster preparedness. METHODS: Information regarding the fire was obtained from public access media and state governmental and hospital reports. Patient information was obtained through review of our trauma registry, patient records, and questionnaires sent to regional hospitals. RESULTS: Four hundred thirty-nine patrons were in the building at the time of the fire, of whom 96 died at the scene. One hundred people ultimately died. Two hundred fifteen patients were evaluated at area hospitals: 64 at our trauma center and 151 at 15 other area facilities. Seventy-nine patients were admitted: 47 to our center and 32 to other hospitals. Eight patients were transferred from Rhode Island Hospital (RIH) to other Level I trauma centers. Twenty-eight (60%) of the patients admitted to RIH were intubated for inhalation injury. For patients admitted to RIH, the extent of the total body surface burn was less than 20% in 33 patients (70%), 21% to 40% in 12 patients (26%), and greater than 40% in 2 patients (4%). The average age was 31 years (range, 18-43 years). Previous disaster planning drills facilitated a quick institutional response directed by a surgeon. The trauma floor of the hospital, which normally consists of a 10-bed trauma intensive care unit (ICU), an 11-bed step-down unit, and a 22-bed medical-surgical floor, was cleared of patients and converted into a 21-bed burn ICU and a 34-bed acute burn ward. Surgical residents were mobilized into teams assigned to the emergency department, ICUs, and surgical floors. In addition to the in-house trauma attending already present, four additional surgical staff members were called in to help man the emergency department and burn wards. Two operating rooms became dedicated burn rooms where 23 cases were performed the first week. In total, 43 operative procedures and 9 bedside tracheostomies were performed over 8 weeks. Over the first 4 weeks, 132 bronchoscopies were performed for diagnostic purposes and pulmonary toilet. There were no deaths. CONCLUSION: Disaster planning as well as personnel and institutional commitment resulted in an optimal response to a multiple casualty incident. Still, lessons were learned that will further improve readiness for future disasters.

Splenic embolization revisited: a multicenter review.

BACKGROUND: Splenic embolization can increase nonoperative salvage. However, complications are not clearly defined. A retrospective multicenter review was performed to delineate the risks and benefits of splenic embolization. METHODS: A retrospective chart review of all patients undergoing splenic embolization from 1997 to 2002 at four separate Level I trauma centers was performed. Reviewed results included patient demographics, admission and follow-up computed tomographic scan results, angiographic technique, and patient outcomes including splenic salvage rate and procedural complications. RESULTS: A total of 140 patients were reviewed. The majority were young male patients involved in motor vehicle crashes. These patients had high abdominal computed tomographic grades of splenic injury and moderate Injury Severity Scores. The splenic salvage rate was 87%, which decreased with increasing injury grade. However, over 80% of splenic injury grades 4 and 5 were successfully managed nonoperatively. Significant hemoperitoneum did not affect success, but the presence of arteriovenous fistula was associated with a high failure rate, even with embolization. Salvage rates were similar between main coil and subselective embolization groups. Patients over 55 years of age did no worse than younger patients. Major complications included bleeding in 16 patients; 6 splenic abscesses, with 5 patients requiring splenectomy; and 1 episode of arterial injury requiring operative repair. CONCLUSION: Splenic embolization remains a valuable technique in splenic salvage, especially in higher grade injuries. Complications are common but do not seem to affect outcome.