Inflammatory response following neutrophil recovery postchemotherapy in acute myeloid leukemia cases without evidence of infection: role of homing of neutrophils

A grant from the One-University Open Access Fund at the University of Kansas was used to defray the author’s publication fees in this Open Access journal. The Open Access Fund, administered by librarians from the KU, KU Law, and KUMC libraries, is made possible by contributions from the offices of KU Provost, KU Vice Chancellor for Research & Graduate Studies, and KUMC Vice Chancellor for Research. For more information about the Open Access Fund, please see http://library.kumc.edu/authors-fund.xml.Neutropenic sepsis is a common clinical entity occurring in postchemotherapy patients. Infection may not be the cause of fever in such patients after neutrophil-count recovery. Herein, we present two patients who developed fever during the neutropenic phase of induction chemotherapy and were treated with broad-spectrum antibiotics until they were no longer febrile and had recovered their neutrophil count. Being off antibiotics, they redeveloped fever within 48–72 hours. These fevers seemed to be secondary to postinfectious inflammatory response and not infection, supported by the fact that adequate antibiotic treatment was given and the collected fluid contained neutrophils but the cultures were negative. We hypothesize an explanation for this phenomenon based on the “homing of neutrophils” to bone marrow, which involves chemoattraction of CXC chemokine receptor (CXCR)-4 expressed on neutrophils towards the chemokine stromal cell-derived factor (SDF)-1 (CXCL12) expressed constitutively by bone marrow. Literature has shown that elevation of SDF-1 levels at injured/inflamed sites might create a similar gradient. This gradient results in the migration of neutrophils to the sites of previous injury/inflammation, leading to the formation of sterile abscesses. Based on our cases, we also conclude that antibiotics do not prevent the formation or treat such sterile “abscesses”; however, the drainage of these “abscesses” and treatment with anti-inflammatory agents are useful in such cases

FDG-PET staging and importance of lymph node SUV in head and neck cancer

OBJECTIVES: The role of positron emission tomography (PET) with fluoro-deoxy-glucose (FDG) in the staging of head and neck cancer (HNC) is unclear. The NCCN guidelines do not recommend FDG-PET as a part of standard workup. The purpose of this report is to examine the role of FDG-PET imaging in altering management and providing prognostic information for HNC. METHODS: Retrospective review of HNC patients who had a staging FDG-PET scan performed at either Thomas Jefferson University or University of Kansas Medical Center between the years 2001 and 2007. A total of 212 PET scans were performed in patients who went on to receive radiotherapy. RESULTS: The median follow-up time for all patients was 469 days. The PPV and NPV of PET imaging to correctly identify lymph node status was 94% and 89% respectively. Lymph nodes with extracapsular extension (ECE) had higher SUVs than nodes without ECE, 11.0 vs. 5.0 (p \u3c 0.0007). Maximum SUV for the primary tumor \u3e 8.0 was predictive of worse overall survival (p \u3c 0.045), while the SUV of the lymph nodes was predictive for distant recurrence at one year--with a mean SUV value of 10.4 for patients with distant failure vs. 7.0 without (p \u3c 0.05). CONCLUSIONS: FDG-PET staging in head and neck cancer has good positive and negative predictive values in determining lymph node status. The maximum SUV of the primary tumor is predictive of overall survival. This is the first report to find that the SUV of a lymph node is predictive for ECE and also for distant recurrence

Leiomyosarcoma of the inferior vena cava: a case report and review of the literature

A 68-year-old white female presented with two years of progressively worsening dyspnea. Echocardiography revealed a large right atrial mass and partial obstruction of the inferior vena cava. Further imaging revealed a cystic dense mass in the inferior vena cava and right atrium. Immunohistochemical stains were consistent with leiomyosarcoma. Intraoperatively, the tumor was noted to originate from the posterior aspect of the inferior vena cava. The patient underwent successful resection of the mass. Adjuvant radiation therapy was completed. The patient's dyspnea gradually improved and she continues to remain disease free five years post-resection

Optimizing the diagnostic power with gastric emptying scintigraphy at multiple time points

<p>Abstract</p> <p>Background</p> <p>Gastric Emptying Scintigraphy (GES) at intervals over 4 hours after a standardized radio-labeled meal is commonly regarded as the gold standard for diagnosing gastroparesis. The objectives of this study were: 1) to investigate the best time point and the best combination of multiple time points for diagnosing gastroparesis with repeated GES measures, and 2) to contrast and cross-validate Fisher's Linear Discriminant Analysis (LDA), a rank based Distribution Free (DF) approach, and the Classification And Regression Tree (CART) model.</p> <p>Methods</p> <p>A total of 320 patients with GES measures at 1, 2, 3, and 4 hour (h) after a standard meal using a standardized method were retrospectively collected. Area under the Receiver Operating Characteristic (ROC) curve and the rate of false classification through jackknife cross-validation were used for model comparison.</p> <p>Results</p> <p>Due to strong correlation and an abnormality in data distribution, no substantial improvement in diagnostic power was found with the best linear combination by LDA approach even with data transformation. With DF method, the linear combination of 4-h and 3-h increased the Area Under the Curve (AUC) and decreased the number of false classifications (0.87; 15.0%) over individual time points (0.83, 0.82; 15.6%, 25.3%, for 4-h and 3-h, respectively) at a higher sensitivity level (sensitivity = 0.9). The CART model using 4 hourly GES measurements along with patient's age was the most accurate diagnostic tool (AUC = 0.88, false classification = 13.8%). Patients having a 4-h gastric retention value >10% were 5 times more likely to have gastroparesis (179/207 = 86.5%) than those with ≤10% (18/113 = 15.9%).</p> <p>Conclusions</p> <p>With a mixed group of patients either referred with suspected gastroparesis or investigated for other reasons, the CART model is more robust than the LDA and DF approaches, capable of accommodating covariate effects and can be generalized for cross institutional applications, but could be unstable if sample size is limited.</p

Primary thyroid lymphoma mimicking subacute thyroiditis

To the Editors: Primary thyroid lymphoma (PTL) is rare, accounting for only 1\u965% of all thyroid malignancies.1 It should always be considered in the differential diagnosis in patients with thyroid nodules, goiter and carcinomas, mainly because its prognosis and treatment differ substantially from those of the other disorders. The usual difficulty with fine needle aspiration cytology (FNAC) is to differentiate chronic thyroiditis from malignant lymphoma due to lymphocytic infiltrations.2 PTL initially presenting with the clinical pictures of subacute thyroiditis is rare. Here we report such a case. An 82-year-old woman had a progressively enlarging, tender, right neck mass for 6 months. She denied any history of neck radiation or thyroid disease. The initial FNAC, after 2 passes and immediate staining and examination under a microscope, was interpreted as subacute thyroiditis (Figure 1). However, the mass did not improve after a short course of glucocorticoid therapy; instead, progressive enlargement was noted. Physical examination revealed mild deviation of the laryngeal cartilage. Palpation of the neck revealed asymmetric goiter with predominant enlargement of the right lobe, which had a firm consistency associated with tenderness. No adjacent or distant lymph nodes were palpate

Intravascular large B-cell lymphoma presenting with diffusely increased pulmonary fluorodeoxyglucose uptake without corresponding CT abnormality

A 60-year-old male presented with complaints of dyspnea, intermittent fever, and 40 pounds of weight loss over the previous 9 months and was admitted for acute hypoxemic respiratory failure. Labs demonstrated elevated inflammatory markers, mild anemia, and thrombocytopenia. Fluorodeoxyglucose-positron emission tomography scan demonstrated diffusely increased pulmonary fluorodeoxyglucose uptake without corresponding abnormality on CT images. Excisional lung biopsy demonstrated intravascular large B-cell lymphoma (IV-LBCL). Presentation, imaging findings, and diagnosis of IV-LBCL will be discussed, as well as differential considerations for pulmonary involvement by IV-LBCL. Keywords: Lymphoma, Intravascular large B-cell lymphoma, FDG-PET, CT, Pulmonary uptak