Hairy cell leukemia : experience at a tertiary cancer centre in Northern India

Background : The prognosis of Hairy cell leukemia (HCL) has improved markedly following treatment with cladribine (2- CdA), a nucleoside analogue. We reviewed data on patients with HCL treated in our department. Methods . Between 1995 and 2004, 23 patients with hairy cell leukemia (HCL) were diagnosed Patients median age was 48.5 years (range, 32 to 66 years), there were 18 males and 5 females. The common presenting symptoms were: fatigue (82.6%), fever (34.7%), abdominal discomfort (21.7%), arthralgia/bone pains (13%) and bleeding (17.3%). 22 of 23 (95.6%) patients had enlarged spleen, and hepatomegaly (65%). Lymph node enlargement was present in 17% of patients. Investigations revealedmedian Hb of 7.8g% (5.7 to 12.9 g%), thrombocytopenia (median 55000/cmm) and median WBC count of 3500/cmm (range, 600 to 20,200/cmm). Bicytopenia or pancytopenia was present in 87% and bone marrow fibrosis in 75% of cases. Immunophenotyping studies revealed expression of CD11C (60%), CD25 (60%), FMC7(47.8%), CD23(34.8%), CD103 in 39% of cases. 20 of 23 patients received treatment; two received treatment else where and one patient died of liver failure prior to treatment. 17 of 20 patients were treated with 2-CdA, 2 with interferon alfa (IFN-a) and one patient underwent splenectomy alone. Three patients received 2-CdA as second line therapy for treatment of relapse: this includes . one patient each, treated with IFN- α and splenectomy both and one patient received 2-cdA twice in view of relapse. Results . Following treatment with 2CdA . 95% of patients responded; complete-84.2% and partial response in 10.5%. one (5.2%) patient died of toxicity. Two patients relapsed at a mean follow up of 25 months. The common side effects were febrile episodes (n=10) and grade I-II myelosuppression. One patient died of toxicity to 2-CdA. This patient was a known case of multidrug resistant disseminated tuberculosis. He had severe myelosuppression with fungal sepsis with multiorgan failure and BM Aspirate was positive for AFB. Other infections documented were Pulmonary tuberculosis in 2 and herpes zoster in one patient. The patient who underwent Splenectomy achieved remission but relapsed after 3 years and was salvaged with 2-CdA again. Median time for normalization of blood counts after 2-CdA was 28 days and median time to regress spleen was 41.5 days . Conclusion . Present study confirms good outcome with 2-CdA (cladribine) therapy for patients of hairy cell leukemia

2017年の1月から6月へのデラウェア裁判所のM&A訴訟

This paper presents an overview of some of the most important decisions handed down by theDelaware Supreme Court　and the Delaware Court of Chancery from January 2017 to June 2017 inlawsuits arising out of Merger and Acquisition (M&A) transactions

A randomized, prospective open labeled study of oral amoxicillin-clavulanate and levofloxacin with intravenous ceftriaxone and amikacin in chemotherapy induced low risk febrile neutropenia

Background : We compared the efficacy of oral antibiotics with intravenous antibiotics in low risk febrile neutropenia. Design : A prospective, randomized study Methods: Between April 2004 - December 2005, 55 patients with low risk febrile neutropenia (expected neutropenia duration < 7 days with no co-morbid features) between 15 and 75 years of age, were randomized to receive either oral amoxicillin-clavulanate 625mg twice daily and levofloxacin -500mg once daily OR intravenous (i.v.) ceftriaxone 2g and amikacin 15mg/kg once daily. Most patients were treated on out patient basis. The primary end point was response to therapy, defervescence of fever within 72 hours with improvement in any clinical manifestation of infection and no recurrence of fever for 48 hours without use of antipyretics. Use of growth factors was not permitted except in treatment failure. Results: A total of 64 febrile episodes were recorded (mean 1.20 ); 33 in the IV group and 31 in the oral antibiotics group. Both groups were equally matched for age (median 25 years in the IV group and 19 years in the oral group), gender, type of cancer, baseline absolute neutrophil count (median 200/cmm in both arms) and duration of neutropenia (5 days and 4 days in the IV and oral groups, respectively). A focus of infection was identified clinically in 15% of episodes and microbiologically in 11% of episodes; 57% of which were Gram positive organisms and the rest Gram negative. 72% in the IV arm and 77% in the oral arm responded to therapy (p=ns). One patient in IV group had one episode of seizure. Non-responding patients received second line IV antibiotics. There was no mortality in either group. Age > 60 years, neutropenia lasting > 7 days after the onset of fever and positive blood culture were predictors for lack of response to antibiotics on multivariate analysis. Conclusion: Oral antibiotics have comparable efficacy as IV antibiotics in the management of low risk febrile neutropenia

Simultaneous presentation of pulmonary tuberculosis and lung cancer: experience from a regional cancer centre

Background: Prevalence of pulmonary tuberculosis is very high in India. Lung cancer is the most common cancer in males in Delhi and because of close similarity in clinical and radiological features of lung cancer and tuberculosis many of lung cancer patients have had received empirical anti tubercular treatment (ATT) before a diagnosis of lung cancer was established. True incidence of pulmonary tuberculosis in lung cancer is not known. Tuberculosis in lung cancer may get reactivated following chemotherapy and/or radiation therapy. Simultaneous presentation of tuberculosis and lung cancer independent of treatment with immunosuppresants, however, is rare. Material and Methods: At our center we evaluated records of 580 lung cancer patients seen over a period of 5 years to see incidence of pulmonary tuberculosis in lung cancer. Patients who had been worked up for pulmonary tuberculosis like sputum or bronchoalveolar lavage (BAL) for AFB smear or culture were identified. Results: Two hundred and ninety eight of these patients were worked up for pulmonary tuberculosis. Twelve patients in the present study had documented evidence of simultaneous existence of pulmonary tuberculosis (acid fast bacilli positive sputum and or culture positivity) and lung cancer. Radiologically, no separate active tubercular lesion was identified except in one patient who had left upper zone fibro parenchymal lesion. Fibrosis and calcification on chest X-rays (CXR) suggestive of old tuberculosis were evident in 7 patients. Eight patients died of progressive lung cancer within 3 months of diagnosis, 4 patients became acid fast bacilli (AFB) negative after 2 months of anti tubercular therapy. Diagnosis of lung cancer was delayed in 4 patients as they were receiving anti tubercular therapy after detection of AFB in sputum. Conclusion: Recognition of tuberculosis is important not only because it is curable but also due to the fact that its presence interferes with radiological assessment to chemotherapy and radiotherapy. Sputum acid fast smear may be done more frequently in patients of lung cancer in countries where tuberculosis has high prevalence. The true incidence may be still higher and newer techniques e.g. PCR based and others may help in knowing true incidence of co existence of lung cancer and pulmonary tuberculosis

VAD followed by VMCP An alternative regimen for multiple myeloma

In patients with multiple myeloma, a good complete response rate and disease-free survival may be achieved with sequential chemotherapy using VAD and VMCP, which is an alternative effective and less expensive treatment regimen. This regimen thus assumes particular significance in developing nations like India, where the majority of patients with myeloma cannot afford the cost of high-dose chemotherapy with stem cell rescue

POEMS syndrome: experience with fourteen cases

The POEMS syndrome, also known as Crow-Fukase disease, is a rare multisystem disorder, which may take several years to evolve fully. The combination of symptoms and signs is highly complex and some of the features are detected at sub-clinical level requiring high level of suspicion. The clinical data on POEMS is still evolving with only a few case reports from India. Herein, we report a series of 14 cases with POEMS syndrome at our centre over the past 8 years, which were analysed retrospectively for their clinical features, response to therapy and treatment outcome. Presence of plasma cell dyscrasia (PCD) was essential for inclusion in this study. Confirmation of PCD was done by positive "M" spike in serum and/or urine, bone marrow plasmacytosis or presence of plasmacytoma on biopsy. In addition, the diagnosis of POEMS syndrome needed the presence of at least two of the following features: polyneuropathy, organomegaly, endocrinopathy and/or skin changes. Patients were excluded from study if there was a secondary cause of polyneuropathy like amyloidosis, drugs like vincristine, nerve root or spinal cord compression. Two patients had complete form (all five features) of the syndrome, whereas 12 had incomplete form. Median age was 48 years (range 32-65). Peripheral neuropathy was seen in 13 (92.85%) cases, organomegaly 10 (71.42%), endocrinal involvement 7 (50%) and skin changes 9 (64.28%). An association with Castleman's disease and vasculitis was also noted. With different chemotherapy protocols, all treated patients <formula>(<italic>n</italic>=12),</formula> had significant symptomatic improvement with or without objective improvement at median follow up of 48 months (range 6-120). In conclusion, high level of suspicion is required to detect this rare entity

Response to imatinib mesylate in chronic myeloid leukemia patients with variant BCR-ABL fusion transcripts

Chronic myeloid leukemia patients with different BCR-ABL transcripts might respond differently to Imatinib mesylate. This prompted us to study BCR-ABL transcripts in chronic myeloid leukemia (CML) patients and their correlation with response to Imatinib. Eighty-seven chronic phase CML patients (median age, 35 years; range, 13-62 years; M/F, 59:28) were included in this study; 57 patients had received interferon-α and/or hydroxyurea, and 30 were previously untreated. All patients received Imatinib mesylate (Gleevec) 400 mg daily. Complete hematological remission rate and major cytogenetic response (CGR) rates were 99% and 72%, respectively. B3a2 transcript was present in 53% of patients, b2a2 in 39%, and both transcripts in 8% of patients. Twenty of 34(59%) patients with b2a2 type achieved complete CGR compared to 15 of 53 (28%) patients with b3a2, p = 0.04. Among 24 patients with minor or no CGR, six (25%) had b2a2 compared to 18 (75%) b3a2 type, p = 0.04. Expression of BCR-ABL/ABL% was higher in b3a2 patients compared to b2a2, p = 0.120. Pre-treatment characteristics-mean spleen size (6.6 vs. 6.4 cm, p = 0.868), mean hemoglobin (G/dl; 12.0 vs. 11.8, p = 0.690), mean WBC count (83 × 109 vs. 77 × 109/L, p = 0.923), and mean platelets counts (360× 109 vs. 340 × 109/L, p = 0.712)-were not significantly different in the b3a2 vs. b2a2 transcripts groups. Our preliminary findings suggest that CML patients with b2a2 BCR-ABL transcript might have higher CGRs to Imatinib mesylate (Gleevec)

Role of sudarshan kriya and pranayam on lipid profile and blood cell parameters during exam stress: A randomized controlled trial

Background: Yoga is a science practiced in India over thousands of years. It produces constituent physiological changes and has sound scientific basis. Aim: Since exam stress modifies lipid profile and hematological parameters, we conducted an investigation on the effect of sudarshan kriya (SK and P) program on these parameters. Materials and Methods: Blood samples of 43 engineering students were collected at four intervals namely baseline (BL), exam stress (ES), three and six weeks practice of SK and P during exam stress. Lipid profile and hematological parameters were measured at all four intervals. Results: ES elevated total cholesterol (TC), triglycerides (TGL) and very low density lipoprotein (VLDL) levels. Hematological parameters affected by ES included neutrophil, lymphocytes, platelet count, packed cell volume (PCV) and mean cell volume (MCV). Three and six weeks practice of SK and P reduced the elevated lipid profile, hematological parameters and improved lymphocyte levels. Conclusion: Our study indicates that SK and P practice has the potential to overcome ES by improving lipid profile and hematological parameters

Fine needle aspiration of extramedullary myeloid cell tumor in myelodysplastic syndrome

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