Original ResearchTo describe clinical features and outcomes of seven patients with pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma in the setting of underlying primary Sjögren's syndrome from a single center, we reviewed medical records of consecutive patients with pulmonary MALT lymphoma evaluated at our facility from January 1, 1999 to December 31, 2015 for clinical features, laboratory, pathologic and radiographic findings, management, and outcomes. Out of 13 patients with pulmonary MALT lymphoma, 7 (54 %) met the criteria for Sjögren's syndrome. The mean age at lymphoma diagnosis was 66 years; male-female ratio was 1:6. One-third of patients were asymptomatic at the time lymphoma was discovered. When symptomatic, patients reported nonspecific pulmonary complaints such as cough and dyspnea. All patients had positive antinuclear antibody and anti-SSA/Ro antibody. Rheumatoid factor was positive in six cases. A monoclonal gammopathy was present in three patients; the remaining four had polyclonal hypergammaglobulinemia. The radiologic, morphologic, and immunohistochemical features of primary Sjögren's syndrome-associated pulmonary MALT lymphomas did not differ significantly from pulmonary MALT lymphoma cases in general. All treatment modalities used resulted in complete and sustained response. One patient died 11 years after initial diagnosis with no lymphoma but of another cause. The remaining six patients are still alive and disease-free to date. The present series confirms the favorable course of pulmonary MALT lymphoma in Sjögren's patients. The overall imaging and pathologic features are in accordance with pulmonary MALT lymphoma not associated with primary Sjögren's syndrome. Further studies should be carried out in order to better understand pulmonary MALT lymphomagenesis, treatment, and outcomes in Sjögren's patients.
The management of locally advanced unresectable head and neck squamous cell cancer (HNSCC) continues to improve. One of the major advances in the treatment of HNSCC was the addition of chemotherapy to radiation in the treatment of non-surgical patients. The majority of the data regarding chemotherapy in HNSCC involve cisplatin chemotherapy with concurrent radiation. However, several new approaches have included targeted therapy against epidermal growth factor receptor and several recent studies have explored the role of induction chemotherapy in the treatment of HNSCC. The purpose of this article is to provide an overview of the role of chemotherapy in the treatment of locally advanced HNSCC.
e15084 Background: Case studies and retrospective chart reviews of health system data have demonstrated an increased risk of nephrotoxicity in patients receiving immune checkpoint inhibitors (CPIs) compared to the incidence of nephrotoxicity reported in clinical trials. The primary objective of this study is to determine the extent to which CPIs may induce nephrotoxicity in a real-world, rural population. The secondary objectives are to identify risk factors for renal dysfunction and describe real-world use of this relatively new class of medications. Methods: This represents a retrospective review of patients receiving at least one dose of a CPI at Marshfield Clinic Health System (MCHS) in Central Wisconsin from May 2013 to November 2019. Baseline serum creatinine, defined as the average of all serum creatinine values obtained within 6 months of the CPI start date, was compared to all serum creatinine measurements during CPI therapy and through 60 days after the last CPI dose. Acute kidney injury (AKI) was defined using the Kidney Disease Improving Global Outcomes definition. Patients developing an AKI of at least three day duration were further assessed to determine the likely cause of AKI. The incidence of potentially CPI-induced AKI was our primary outcome. Chi-square test will be used to compare incidence of AKI among different CPIs. A subdistribution hazard regression will be used to assess the association between the incidence of potentially CPI-induced AKI and patient characteristics (including comorbidities, type of cancer diagnosis, demographics, baseline ECOG score, CPI line in therapy, time lapse between diagnosis and CPI start, and concomitant nephrotoxic medications) while accounting for the competing risk of death. Results: A total of 922 patients received at least one dose of a CPI at MCHS during the study period. After applying exclusion criteria, a total of 920 patients were included in the analysis. The incidence of AKI of any duration and due to any cause was 29.5% (272 of 920 patients). Conclusions: The raw incidence of AKI in our patient population receiving CPIs is higher than previously published studies. However, our data are still being refined and research is in progress.
Case report A 54-year-old male with AIDS based on a CD4 count of 48, and viral load of 71653 IU/ml was admitted to our institution for evaluation of ongoing fevers, chills, night sweats, and pancytopenia. His evaluation included a bone marrow aspiration and biopsy which showed diffuse infiltration by classical Hodgkin lymphoma. He had rapidly progressive cholestatic liver abnormalities with a bilirubin that peaked at 27.8 mg/dl. He underwent a liver biopsy which also showed involvement by classical Hodgkin lymphoma. His mental status deteriorated rapidly and he developed acute kidney injury with a peak creatinine of 2.65 mg/dl. He was not a suitable candidate for conventional chemotherapy with ABVD because of his deteriorating kidney function and abnormal hepatic profile. It was then decided to treat him with carboplatin and gemcitabine which he received on day #1, followed by another dose of gemcitabine on day #14. His total bilirubin improved but eventually plateaued at 6 mg/dl on day 28. With no good therapeutic options, he was given a dose of brentuximab 1.4 mg /m2 on day #34. Following this single dose, his bilirubin improved, his mental status changes resolved and his creatinine stabilized at 1.3 mg/dl. The patient continued to improve clinically during his hospital stay and was eventually discharged home on day #37 Because of persistent cytopenias, he had repeat bone marrow biopsy done on day #54. The bone marrow showed patchy cellularity ranging from 20 to 80%, all normal hematopoietic elements and no evidence of Hodgkin lymphoma by morphology. Eventually his cytopenias started to improve on day # 57. Since his discharge from the hospital, he has received two additional doses of brentuximab (at the dose of 1.4mg/kg) as an outpatient and now on day #150 he continues to do well with normal total bilirubin (o.3 mg/dl), creatinine (1.3 mg /dl), and normal absolute neutrophil count (2.02 k/µl). His viral load is now undetectable and his CD 4 count is 64. His only adverse event is grade 1 peripheral neuropathy involving the toes. Based on our single case experience, we think that brentuximab vedotin could offer an option of therapy for patients with advanced stage Hodgkin lymphoma, severe hyperbilirubinemia from hepatic involvement, and acute kidney injury who cannot be treated with standard therapy due to organ dysfunction. Additionally, our patient with advanced HIV experienced no significant ill effects of Brentuximab administration in terms of response of the HIV disease to ART therapy. He rapidly achieved HIV PCR negativity and his CD 4 count is on the rise from baseline. We think that additional studies should be done to establish the safety and efficacy of this approach in this group of patients with no other good options for therapy as well as in HIV infected patients. Disclosures: Off Label Use: Brentuximab Vedotin is an antibody drug conjugate directed at CD30 and is used in the treatment of refractory Hodgkin lymphoma after failure of at least 2 prior chemotherapy regimens. We describe in our presentation the use of Brentuximab Vedotin in Hodgkin lymphoma after 1 prior therapy.
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