Treatment patterns and outcomes for Hodgkin Lymphoma patients aged 60 and older: a report from the Brazilian Prospective Hodgkin Lymphoma Registry.

The treatment of older patients with Hodgkin lymphoma (HL) remains a challenge. We sought to identify the treatment patterns and outcomes in older HL patients included in the Brazilian HL registry (NCT02589548). A total of 136 patients with HIV-negative classic HL, aged ≥ 60 years, diagnosed between 2009 and 2018, were analyzed. The median age was 66 years old (60-90), 72% had advanced disease, 62% had a high IPS, and 49% had a nodular sclerosis subtype. Median follow-up was 64 months for alive patients. ABVD was the front-line treatment in 96% of patients. Twenty-one patients (15%) died during front-line treatment. The 5-year PFS and 5-year OS rates were 55% and 59%, respectively. The 5-year OS rates in localized and advanced disease were 81% and 51% (p=0.013). Lung toxicity developed in 11% of the patients treated with ABVD. Bleomycin was administered for > 2 cycles in 65% of patients. Compared with 2009-2014, there was a decrease in the use of bleomycin for > 2 cycles in 2015-2018 (88% × 45%, p<0.0001). The impact of socioeconomic status (SES) on outcomes was studied in patients treated with ABVD. After adjusting for potential confounders, lower SES remained independently associated with poorer survival (HR 2.22 [1.14-4.31] for OS and HR 2.84 [1.48-5.45] for PFS). Treatment outcomes were inferior to those observed in developed countries. These inferior outcomes were due to an excess of deaths during front-line treatment and the excessive use of bleomycin. SES was an independent factor for shorter survival.

Lower socioeconomic status is independently associated with shorter survival in Hodgkin Lymphoma patients-An analysis from the Brazilian Hodgkin Lymphoma Registry.

Socioeconomic status (SES) is a well-known determinant of outcomes in cancer. The purpose of this study was to analyze the impact of the SES on the outcomes of Hodgkin lymphoma (HL) patients from the Brazilian Prospective HL Registry. SES stratification was done using an individual asset/education-based household index. A total of 624 classical HL patients with diagnosis from January/2009 to December/2014, and treated with ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine), were analyzed. The median follow-up was 35.6 months, and 33% were classified as lower SES. The 3-year progression- free survival (PFS) in higher and lower SES were 78 and 64% (p < 0.0001), respectively. The 3-year overall survival (OS) in higher and lower SES were 94 and 82% (p < 0.0001), respectively. Lower SES patients were more likely to be ≥ 60 years (16 vs. 8%, p = 0.003), and to present higher risk International Prognostic score (IPS) (44 vs. 31%, p = 0.004) and advanced disease (71 vs. 58%, p = 0.003). After adjustments for potential confounders, lower SES remained independently associated with poorer survival (HR = 3.12 [1.86-5.22] for OS and HR = 1.66 [1.19-2.32] for PFS). The fatality ratio during treatment was 7.5 and 1.3% for lower and higher SES (p = 0.0001). Infections and treatment toxicity accounted for 81% of these deaths. SES is an independent factor associated with shorter survival in HL in Brazil. Potential underlying mechanisms associated with the impact of SES are delayed diagnosis and poorer education. Educational and socio-economic support interventions must be tested in this vulnerable population.

Treatment outcomes for Hodgkin lymphoma: First report from the Brazilian Prospective Registry.

Data about Hodgkin lymphoma (HL) in developing countries are scarce and suggest the existence of substantial disparities in healthcare and outcomes in large areas of the world. In 2009, a prospective registry of HL was implemented in Brazil. Web-based data were contributed by 20 institutions across the country participating in the Brazilian Prospective Hodgkin's Lymphoma Registry. The aim of this study was to present the clinical features and outcomes of newly diagnosed patients with HL aged 13 to 90 years. Multivariate Cox regression models were used to estimate progression-free (PFS) and overall survival (OS) by clinical factors. A total of 674 patients with classical HL were analysed, with a median follow-up of 37 months. Median age was 30 years (13-90). The median time from the onset of symptoms to diagnosis was 6 months (0-60). Only 6% of patients had early favourable disease, while 65% had advanced disease. Stage IVB was present in 26% and a high-risk International Prognostic Score in 38%. Doxorubicin, bleomycin, vinblastine, and dacarbazine was used in 93%. The median dose of radiotherapy was 36 Gy for localized disease and 32 Gy for advanced disease. The 3 year PFS in early favourable, early unfavourable, and advanced disease were 95%, 88%, and 66%, respectively. High-risk International Prognostic Score, advanced disease, and age greater than or equal to 60 were independently associated with poorer PFS and OS; performance status greater than or equal to 2 was also associated with a poorer OS. Poor-risk patients predominated. Radiation doses for localized disease appear higher than current recommendations. Outcomes appear inferior in developing countries than in developed countries. Delayed diagnosis is probably a major factor underlying these findings. Scattered reports from developing nations suggest that many aspects of standard care in developed countries remain unmet needs for populations living in developing countries. The present report contributes to this body of data, with a proper description of what is currently achieved in urban areas in Brazil.

Evaluation of C-reactive protein and its prognostic relationship in patients with Hodgkin's Lymphoma.

OBJECTIVES: To assess the prognostic value of C-Reactive Protein (CRP), at diagnosis and during follow-up, of patients with Hodgkin´s Lymphoma treated at the Hematology Service of the Santa Casa de São Paulo Hospital, and to correlate serum CRP levels with disease stage and treatment response. METHODS: A retrospective study involving review of 71 medical records of patients diagnosed with Hodgkin´s Lymphoma between February 2012 and January 2016 was performed. Three patients were subsequently excluded, giving a total of 68 patients for analysis. A level of CRP > 1mg/dl was considered elevated. RESULTS: Patients were predominantly male (61.8%) and mean age was 34 years. Fifty-three (78%) patients had advanced stage and (76.5%) had B symptoms. Elevated baseline CRP was associated with greater likelihood of B symptoms (p= 0.02) and of advanced stage (p= 0.015). Patients with Low CRP level after 5th and 6th cycles of chemotherapy was associated with complete response (p=0.04 and p=0.03, respectively). Treatment-refractory patients had greater risk of death (p=0.002). CONCLUSION: CRP is clinically important for follow-up of patients with Hodgkin´s Lymphoma, where high levels were associated with advanced disease and/or presence of B symptoms. CRP level was considered a predictor of treatment response. Persistence of high CRP values during treatment was associated with refractoriness.

Application of the Central Nervous System International Prognostic Index (CNS-IPI) score in daily practice: a retrospective analysis apart from the clinical trial at two centers in Brazil.

INTRODUCTION: The diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL) and, despite all the progress in this field, central nervous system infiltration (CNSi) still occurs at an incidence of 2-10%. The objective of the present study was to evaluate the Central Nervous System International Prognostic Index (CNS-IPI) score in daily practice regarding the reproducibility in a heterogeneous cohort apart from a clinical trial. METHODS: Primary DLBCL patients were eligible for this study, between January 2007 and January 2017. All patients were treated with rituximab-based chemotherapy, mostly R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). The CNSi was diagnosed by liquor (positive cytology and/or immunophenotype), computerized tomography, magnetic resonance image and/or fluorodeoxy-glucose-positron emission tomography, requested only in symptomatic patients when the CNSi was clinically suspected. The CNS-IPI was assessed by graphical comparison and calibration. RESULTS: After applying the inclusion/exclusion criteria, 322 patients were available for the analysis. The median follow-up was 60 months and the median age was 58 years. Seven patients experienced CNSi, characterizing an incidence of 2.17% (7/322). Comparing groups of patients with and without CNSi, we observed that the lactate dehydrogenase (LDH), number of extranodal sites, IPI, kidney/adrenal and absence of complete response were statistically different. The CNS-IPI model stratified patients in a three-risk group model as low-, intermediate- and high-risk. In our cohort, using the same stratification, we obtained an equivalent the 2-year rate of CNS relapse of 0.0%, 0.8% and 13.8%, respectively. CONCLUSION: Our study reinforces the reproducibility of the CNS-IPI, specifically apart from clinical trials, and suggests the CNS-IPI score as a tool to guide therapy.

Evaluation of C-reactive protein and its prognostic relationship in patients with Hodgkin's Lymphoma.

OBJECTIVES: To assess the prognostic value of C-Reactive Protein (CRP), at diagnosis and during follow-up, of patients with Hodgkin´s Lymphoma treated at the Hematology Service of the Santa Casa de São Paulo Hospital, and to correlate serum CRP levels with disease stage and treatment response. METHODS: A retrospective study involving review of 71 medical records of patients diagnosed with Hodgkin´s Lymphoma between February 2012 and January 2016 was performed. Three patients were subsequently excluded, giving a total of 68 patients for analysis. A level of CRP > 1 mg/dl was considered elevated. RESULTS: Patients were predominantly male (61.8 %) and mean age was 34 years. Fifty-three (78 %) patients had advanced stage and (76.5 %) had B symptoms. Elevated baseline CRP was associated with greater likelihood of B symptoms (p = 0.02) and of advanced stage (p = 0.015). Patients with Low CRP level after 5th and 6th cycles of chemotherapy was associated with complete response (p = 0.04 and p = 0.03, respectively). Treatment-refractory patients had greater risk of death (p = 0.002). CONCLUSION: CRP is clinically important for follow-up of patients with Hodgkin´s Lymphoma, where high levels were associated with advanced disease and/or presence of B symptoms. CRP level was considered a predictor of treatment response. Persistence of high CRP values during treatment was associated with refractoriness.

Hodgkin lymphoma in Brazil: trends in incidence and mortality over 4 decades.

BACKGROUND: In Brazil, there is lack of studies on the incidence and mortality of this malignancy. The aim of this study was to describe the profile of HL in Brazil for incidence, mortality and trends. METHODS: Data on incidence in Brazil were collected from Population-Based Cancer Registries (1988-2017) and mortality for 1979-2019. Age-standardized incidence and mortality rates were calculated. Average annual percent change was estimated and analyzed in two calendar periods for mortality (1979-1999 and 2000-2019). RESULTS: Trends in the incidence of HL for males in Brazil declined in two state capitals - Belo Horizonte, -3.7% (95% CI, -7.1 to -0.3); and Salvador, -8.5% (95% CI, -13.0 to -3.8) - and remained stable in other cities. For females, two capitals showed a decrease in incidence: Salvador, -9.5% (95% CI, -15.3 to -3.2) and Porto Alegre, -3.9% (95% CI, -7.0 to -0.8). Mortality rates in males were higher than those in females. However, the decrease in mortality was greater in males, -2.2% (95% CI, -2.5 to -1.8). Age incidence distribution across Brazilian capitals showed a higher incidence among younger (15-30 years) individuals yet no clear incidence among older adults (>60 years). CONCLUSION: The incidence trend of HL in Brazil has remained stable. While the mortality rates have decreased for both sexes. Age distribution for mortality at a young age and older ages follows the bimodal pattern for Brazil as a whole. Finally, further studies are necessary to understand age incidence distribution of HL in Brazil.

The Regulatory Complex for Health Care in the Federal District, Brazil and the challenge for integrating levels of health care. / O Complexo Regulador em Saúde do Distrito Federal, Brasil, e o desafio da integração entre os níveis assistenciais.

The integration among levels of care is a continuous challenge even in consolidated and high performance health systems. The reform of public health system of Distrito Federal, based on the strengthening of primary health care associated to the reconfiguration of specialized attention (ambulatory and hospital) and of its of urgency and emergence network brought, as a challenge, the need for integration between these levels. Thus, became necessary to create an instrumentto perform the role of gatekeeper, leading to equanimous, transparent and safe access to specialized and hospital care. Thus, the Regulatory Complex in Health of Distrito Federal (CRDF) and its Regulatory Centers (CR) were created to carry out the regulatory process of access to care services, such as hospitalization, ambulatory care (procedures and specialized consultations), elective surgeries, complex procedures, sanitary transport, urgencies and transplants of patients of the Federal District and outside it. This article describes the process of the CRDF implementation and its CRs, aiming to reflect on the potential and challenges of its role as an instrument of integration among the levels of care.

A integração entre os níveis de atenção é um desafio contínuo mesmo em sistemas de saúde consolidados e de alta performance. A reestruturação do sistema público de saúde do Distrito Federal, baseado no fortalecimento da Atenção Primária à Saúde (APS), na reconfiguração da atenção especializada (ambulatorial e hospitalar) e de sua rede de urgência e emergência, trouxe como desafio a necessidade de integração entre esses níveis. Fez-se necessária a criação de um dispositivo que desempenhasse o papel de "gatekeeper" conduzindo o acesso equânime, transparente e seguro para a atenção especializada e hospitalar. Neste sentido, foi estruturado o Complexo Regulador em Saúde do Distrito Federal (CRDF) e suas Centrais de Regulação (CR), orientados para a execução de um processo regulatório de acesso para os serviços de internação hospitalar, ambulatorial (procedimentos e consultas especializadas), cirurgias eletivas, alta complexidade, transporte sanitário, urgências e transplantes de pacientes do Distrito Federal e de fora dele. Este artigo descreve o processo de implantação e de implementação do CRDF e de suas CR, de forma a refletir sobre as potencialidades e desafios de seu papel enquanto instrumento de integração entre os níveis assistenciais de saúde.

Fluorodeoxyglucose-positron emission tomography staging can replace bone marrow biopsy in Hodgkin's lymphoma. Results from Brazilian Hodgkin's Lymphoma Study Group.

OBJECTIVE: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-d-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. METHODS: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-d-glucose marrow uptake that resolved following chemotherapy. RESULTS: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. CONCLUSION: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management.

O Complexo Regulador em Saúde do Distrito Federal, Brasil, e o desafio da integração entre os níveis assistenciais / The Regulatory Complex for Health Care in the Federal District, Brazil and the challenge for integrating levels of health care

Resumo A integração entre os níveis de atenção é um desafio contínuo mesmo em sistemas de saúde consolidados e de alta performance. A reestruturação do sistema público de saúde do Distrito Federal, baseado no fortalecimento da Atenção Primária à Saúde (APS), na reconfiguração da atenção especializada (ambulatorial e hospitalar) e de sua rede de urgência e emergência, trouxe como desafio a necessidade de integração entre esses níveis. Fez-se necessária a criação de um dispositivo que desempenhasse o papel de "gatekeeper" conduzindo o acesso equânime, transparente e seguro para a atenção especializada e hospitalar. Neste sentido, foi estruturado o Complexo Regulador em Saúde do Distrito Federal (CRDF) e suas Centrais de Regulação (CR), orientados para a execução de um processo regulatório de acesso para os serviços de internação hospitalar, ambulatorial (procedimentos e consultas especializadas), cirurgias eletivas, alta complexidade, transporte sanitário, urgências e transplantes de pacientes do Distrito Federal e de fora dele. Este artigo descreve o processo de implantação e de implementação do CRDF e de suas CR, de forma a refletir sobre as potencialidades e desafios de seu papel enquanto instrumento de integração entre os níveis assistenciais de saúde.

Abstract The integration among levels of care is a continuous challenge even in consolidated and high performance health systems. The reform of public health system of Distrito Federal, based on the strengthening of primary health care associated to the reconfiguration of specialized attention (ambulatory and hospital) and of its of urgency and emergence network brought, as a challenge, the need for integration between these levels. Thus, became necessary to create an instrumentto perform the role of gatekeeper, leading to equanimous, transparent and safe access to specialized and hospital care. Thus, the Regulatory Complex in Health of Distrito Federal (CRDF) and its Regulatory Centers (CR) were created to carry out the regulatory process of access to care services, such as hospitalization, ambulatory care (procedures and specialized consultations), elective surgeries, complex procedures, sanitary transport, urgencies and transplants of patients of the Federal District and outside it. This article describes the process of the CRDF implementation and its CRs, aiming to reflect on the potential and challenges of its role as an instrument of integration among the levels of care.

New treatment approaches for relapsing/refractory Hodgkin's lymphoma: An overview of the Brazilian scenario / Novas abordagens de tratamento para o linfoma de Hodgkin recidivante/refratário: uma revisão

Hodgkin's lymphoma (HL) is a B-cell malignancy with a classical bimodal distribution with incidence peaking in the third and sixth decades of life. The purpose of this review is to describe the current unmet medical need for relapsing/refractory HL and the main data of emerging treatments, including brentuximab vedotin, the immune checkpoint inhibitors nivolumab and pembrolizumab, as well as other compounds in development. Available guidelines for relapsing/refractory HL are discussed.

O linfoma de Hodgkin (LH) é uma neoplasia de células B com distribuição bimodal clássica com pico de incidência na terceira e sexta décadas de vida. O objetivo desta revisão é descrever as atuais necessidades médicas não atendidas dos pacientes com LH recidivante/refratário e os dados principais dos tratamentos emergentes, incluindo brentuximabe vedotina, os inibidores do ponto de verificação imunológico, nivolumabe e pembrolizumabe, bem como outros compostos em desenvolvimento. Além disso, discutem-se as diretrizes disponíveis para LH recidivante/refratário.

Hodgkin's lymphoma unmet medical needs in Brazil: experts' perspective / Necessidades médicas não atendidas no tratamento de linfoma de Hodgkin no Brasil: perspectiva de médicos

Background: In 2016, Hodgkin's Lymphoma (HL) was responsible for 2,470 new cases in Brazil and, despite recent scientific advances, there are unmet medical needs that affects patients' outcome. Therefore, we aimed to explore the unmet medical needs in the management of HL patients in Brazil, based on experts' perspective. Methods: A questionnaire was developed to address the unmet medical needs including barriers for the diagnosis and treatment of HL in Brazil. The questionnaire results were presented in a panel discussion to validate participants' responses and to collect additional data. Main results: Eight experts participated in the panel. On both healthcare systems, public and private, a slight majority of patients was women and most of them were under 60 yearsold. In addition, the majority of patients were referred from another specialty on both systems. The time from onco-hematologist appointment to diagnosis was different between public and private sector (median of 30 and 12.5 days, respectively). Most patients in the public sector were on stage III (33%) and IV (33%); in the private sector, most patients were on stages II (36%) and III (24%). The most common barriers were the delayed diagnosis and the unavailability of diagnostic procedures and treatment options. Conclusion: According to participants, issues related to infrastructure and healthcare resource allocation affects the management of HL. Improvements in the infrastructure and educational measures for physicians and patients may contribute to minimize the barriers.

Introdução: Em 2016, o Linfoma de Hodgkin (LH) foi responsável por 2.470 novos casos no Brasil e, apesar dos recentes avanços científicos, há necessidades médicas não atendidas que afetam os pacientes. Portanto, o estudo teve como objetivo explorar as necessidades médicas não atendidas no manejo de pacientes com LH no Brasil, com base na perspectiva de especialistas. Métodos: Um questionário foi desenvolvido para abordar as necessidades médicas não atendidas, incluindo as barreiras para o diagnóstico e tratamento do LH no Brasil. Os resultados do questionário foram apresentados em um painel de discussão para validar as respostas dos participantes e coletar dados adicionais. Principais resultados: Oito especialistas participaram do painel. De acordo com os especialistas, em ambos os sistemas de saúde público e privado, uma pequena maioria dos pacientes era mulher e a maioria tinha menos de 60 anos. Além disso, a maioria dos pacientes foi encaminhada por outra especialidade em ambos os sistemas. O tempo entre a consulta com o onco-hematologista até o diagnóstico foi diferente entre o setor público e privado (mediana de 30 e 12,5 dias, respectivamente). A maioria dos pacientes do setor público apresenta estádios III (33%) e IV (33%); no setor privado, a maioria dos pacientes apresenta estádios II (36%) e III (24%). As barreiras mais comuns foram o atraso no diagnóstico e a indisponibilidade de procedimentos diagnósticos, e opções de tratamento. Conclusão: De acordo com os participantes, as questões relacionadas à infraestrutura e à alocação de recursos de saúde afetam o gerenciamento do LH. Melhorias na infraestrutura e medidas educacionais para médicos e pacientes podem contribuir para minimizar as barreiras.

Treatment patterns of Hodgkin's lymphoma in Brazil: experts' perspective / Padrões de tratamento do linfoma de Hodgkin no Brasil: a perspectiva dos especialistas

Background: Hodgkin's Lymphoma (HL) is a curable type of cancer, with a wide variety of therapies, especially for refractory/relapsing cases. Therefore, the study aims to explore the treatment patterns used in the management of HL patients in Brazil. Methods: A survey was developed to explore the treatment patterns in Brazil, addressing topics such as clinical characteristics, lines of therapy, transplant information and cure rates. Then, results were presented in a panel discussion to validate participants' responses and gain additional insights. Main results: The eight experts reported that most patients are women and under 60 years old. In both private and public healthcare systems, ABVD was the most commonly used first-line therapy for patients of all stages. The median cure rates for patients in stages I and II were 80% and 87.5%, and for stages III and IV 60% and 67.5%, respectively, in public and private sectors. For the subsequent lines of therapy, different regimens such as DHAP, GVD, GEV, ICE and allogeneic transplant are used, among others. Brentuximab vedotin was present mainly in the private sector. In the public sector, 70% of the patients are eligible for autologous stem cell transplant; of them, 75% actually receive the transplant. In the private sector, 80% of the patients are eligible, and 100% of them receive the transplant. Conclusion: Similarities were found between the public and private sectors in first-line therapy and cure rates. However, barriers for subsequent lines of therapy are more evident in the public system.

Introdução: O linfoma de Hodgkin (LH) é um tipo de câncer curável, com ampla variedade de terapias, especialmente para casos refratários/recidivantes. Portanto, o estudo visa explorar os padrões de tratamento utilizados no manejo de pacientes com LH no Brasil. Métodos: Uma pesquisa foi desenvolvida para explorar os padrões de tratamento no Brasil, abordando tópicos como: características clínicas, linhas de terapia, informações sobre transplantes e taxas de cura. Em seguida, os resultados foram apresentados em um painel de discussão para validar as respostas dos participantes e coletar os insights adicionais. Principais resultados: Os oito especialistas relataram que maioria dos pacientes é composta por mulheres com idade menor de 60 anos. Em ambos os sistemas de saúde, privado e público, ABVD foi a terapia de primeira linha mais comumente usada para pacientes de todos os estágios. As medianas das taxas de cura para pacientes nos estágios I e II foram de 80% e 87,5%, e para os estádios III e IV, de 60% e 67,5%, nos setores público e privado, respectivamente. Para as linhas subsequentes de terapia, diferentes regimes como DHAP, GVD, GEV, ICE e transplante alogênico são utilizados, entre outros. Brentuximabe vedotina estava presente principalmente no setor privado. No setor público, 70% dos pacientes são elegíveis para transplante autólogo de células-tronco; deles, 75% recebem o transplante. No setor privado, 80% dos pacientes são elegíveis e 100% recebem o transplante. Conclusão: Foram encontradas semelhanças entre o setor público e privado na terapia de primeira linha, bem como nas taxas de cura. No entanto, as barreiras para as linhas subsequentes de terapia são mais evidentes no sistema público.

Fluorodeoxyglucose-positron emission tomography staging can replace bone marrow biopsy in Hodgkin's lymphoma. Results from Brazilian Hodgkin's Lymphoma Study Group

ABSTRACT Objective: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-D-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. Methods: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-D-glucose marrow uptake that resolved following chemotherapy. Results: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. Conclusion: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management.

Morbimortalidade em doença falciforme / Morbidity-mortality in sickle cell disease

A alta morbimortalidade referida na doença falciforme (DF) levou-nos a estudar o perfil epidemiológico e respectivas intercorrências clínicas dos pacientes atendidos no Hemocentro Regional (HR) e Hospital de Clínicas da Universidade (HC-U), de 1998 a 2007. Estudo retrospectivo de 151 pacientes, avaliados quanto a: idade, gênero, cor da pele, procedência, diagnóstico, causa de atendimento no HR, causa e tempo de internação no HC-U e a causa e a idade em caso de óbito. Foi realizada análise estatística descritiva simples. A média de idade foi de 17,7 anos, 52,4 por cento eram do gênero feminino, 58,2 por cento procediam da cidade de Uberaba e em 92,2 por cento dos prontuários não foram encontrados relatos sobre a cor da pele. A anemia falciforme representou 82,5 por cento dos casos. Dos 910 atendimentos no HR e 589 internações no HC-U, a crise dolorosa afebril foi a causa mais frequente em ambas as instituições (61,9 por cento e 25,3 por cento, respectivamente). A idade média dos 11 óbitos foi de 33,5 anos, sendo apenas um em menor de 10 anos e a falência de múltiplos órgãos a causa mais frequente. O perfil epidemiológico mostra predomínio de crianças e adultos jovens, sexo feminino e genótipo SS. As taxas de internação no HC-U, de atendimento no HR e a baixa média de idade ao óbito confirmam a alta morbidade e mortalidade da DF. Contudo, o grande número de crianças sem intercorrências e/ou internações reflete a eficácia das medidas preventivas propiciadas pelo diagnóstico precoce implantado nos últimos 10 anos.

The high morbidity-mortality rates in sickle cell disease (SCD) led us to study the epidemiological profile and respective clinical complications of patients seen at a Regional Blood Center (HR) and a University Clinical Hospital (HC-U) between 1998 and 2007. In a retrospective study, 151 patients were evaluated regarding age, gender, skin color, origin, diagnosis, reason of visit to HR or reason and length of stay in the HC-U, and cause and age in cases of death. Simple descriptive statistical analysis was performed. The mean age was 17.7 years, 52.4 percent of the patients were female, 58.2 percent were from the city and no information regarding skin color was available in 92.2 percent of the records. Sickle cell anemia was present in 82.5 percent of cases. The most frequent reason for the 910 visits to HR and 589 hospitalizations in HC-U were afebrile pain episodes (61.9 percent and 25.3 percent, respectively). The mean age of the 11 patients who died was 33.5 years with one patient being younger than 10 years old, and multiple organ failure was the most frequent cause. The epidemiological profile shows a predominance of children and young adults, women, and the SS genotype. The rates of hospitalization in HC-U and of visits to HR and the low mean age at death confirm the high morbidity and mortality related to SCD. However, a large number of children do not present with complications or require hospitalization which reflects the efficacy of preventive measures provided by the early diagnosis implemented over the last 10 years.