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Large B cell lymphomas (LBCL) are a heterogeneous group of diseases with variable presentations and prognoses. Rarely, LBCLs arise in the sinonasal tract and are distinct from extranodal NK/T-cell lymphoma which is more typical in this anatomic location. We hypothesized that large B cell lymphoma primary to the sinonasal tract (snLBCL) would be heterogeneous and include high-grade B cell lymphomas (HGBCL) described in the revised 4thedition WHO classification of lymphomas. We retrospectively evaluated cases of snLBCL at our center, and performed additional immunohistochemical and in situ hybridization studies where needed for modern WHO classification. Our cohort consisted of 25 cases, 15 males and 10 female patients, aged 14 to 87 years, with predominantly nasopharyngeal disease (n= 11), Ann Arbor stage IIE (n= 15), and immunocompetence (n= 24). According to revised 2016 WHO criteria, 20 of the 25 cases were DLBCL-NOS (80%, two-thirds germinal center phenotype), 3 were HGBCL-NOS (8%, one with MYCrearrangement without BCL2rearrangement), and 2 were EBV-LBCL (8%). Among DLBCL-NOS, those arising in the nasopharynx all showed a germinal center B cell (GCB) phenotype, whereas both evaluable maxillary sinus tumors showed non-GCB characteristics (p= 0.02). These data show that large B cell lymphoma primary to the sinonasal tract is histopathologically heterogeneous as systemic large B cell lymphoma. The observation that GCB and non-GCB tumors differs in anatomic location suggests that microenvironmental factors in sinonasal anatomic sites may drive lymphoma characteristics.

Adult Christian children have an obligation to provide responsible care for their elderly parents. The factors to consider when deciding to place someone in a nursing home include finances, support services and health-care needs.

ABSTRACT To meet the challenge of internationalizing the nursing profession, professional education programs have developed various learning strategies, including international courses and student and faculty exchange programs. Few studies have [...]

Abstract:During 1918, the “Spanish Flu” took millions of lives worldwide and remains the worst influenza pandemic in history. The worldwide transmission and the number of deaths from this flu were increased due to the conditions of World War I. In September 1918, the first cases of flu in Kentucky appeared at Camp Zachary Taylor, Louisville. At the time, over forty thousand troops were stationed at the camp. Within a week of the first cases being diagnosed, thousands of soldiers were ill, and the base hospital was quickly overwhelmed. By the end of September, 20 percent of the barracks had been converted to emergency hospitals, and urgent appeals went out for additional nurses. During many previous health crises within Kentucky, dating back to the early 1800s, Catholic sisters had volunteered to work as caregivers. A Roman Catholic Army chaplain at the base requested help from various orders of Kentucky nuns, and within days, eighty-eight sisters from seven orders arrived to help, despite knowing they were placing themselves at great personal risk. The majority of the sisters were teachers rather than professional nurses. The care and vigilant observation provided by the sisters was vital to saving many soldiers’ lives, yet they received little recognition for their contribution. In this year of the centenary of the flu pandemic and the end of the war, it is appropriate to acknowledge the work of the sisters who sacrificed to help the stricken soldiers.

According to a study by Skyhook Wireless, 2,300 of the 35,000 iPhone apps available in the App Store are location-aware. Not surprisingly, navigation and travel apps account for more than […]

MYC/BCL2double-hit lymphoma (DHL), defined by conventional cytogenetic or fluorescence in situ hybridization (FISH) analysis, and MYC/BCL2 double-positive lymphoma (DPL), defined by immunohistochemistry, are associated with a poor prognosis. However, DHL and DPL are not concordant, and it is unclear whether MYCand BCL2aberrations have prognostic impact in DPL patients. In a cohort of 135 patients diagnosed with large B-cell lymphoma between 2010 and 2014 in whom MYC/8q24 and BCL2/t(14;18)(q32;q21) statuses were assessed by FISH at diagnosis, we evaluated MYC and BCL2 expression by immunohistochemistry. A total of 54 (40%) cases were positive for MYC and BCL2 supporting DPL. Among them, 19 (35%) had MYCrearrangement including 11 DHLs, 12 (22%) had multiple copies of MYC, 19 had no MYCabnormalities, and in 4 cases FISH analysis failed. BCL2abnormalities were present in 28/54 (52%) cases (20 rearranged and 8 multiple copies). MYCrearrangement correlated with a significantly worse overall survival in DPL (P<0.05), whereas BCL2genetic status did not correlate with survival (P>0.05). MYC and BCL2 expression by immunohistochemistry correlates with gene status by FISH; however, immunohistochemistry is neither specific nor adequately sensitive to be used as a surrogate for MYCand BCL2gene status using any cutoff level. In conclusion, MYCrearrangement identifies a subset of patients with DPL who have a significantly worse prognosis. Although immunohistochemical assessment for MYC and BCL2 may be a helpful initial screen to identify higher-risk patients, FISH analysis for MYCremains important for further risk stratification in patients with DPL.

Primary hepatic non-Hodgkin's lymphoma (NHL) is a rare disease that presents unique diagnostic and therapeutic challenges. Secondary liver involvement by lymphoma is common and can complicate treatment decisions. A review of the published case reports and the few larger series suggests that primary hepatic NHL represents a heterogeneous mixture of disparate diseases rather than a single entity. Presentations vary from the incidental discovery of hepatic abnormalities in an otherwise asymptomatic patient to that of fulminant hepatic failure with rapid progression of encephalopathy to coma and death. The clinical, laboratory, and radiographic characteristics are nonspecific, which means the diagnosis is often not suspected until histopathologic examination of liver tissue. There appears to be a strong association between primary hepatic NHL and the hepatitis C virus. Hepatosplenic T-cell lymphoma has attained its own status as a unique disease, whereas case reports suggest that the spectrum of hepatic lymphoma includes many histologies. Involvement of the liver by lymphoma can compound the difficulty of pursuing aggressive chemotherapy in patients who have a life-threatening illness and impaired metabolism of the most effective drugs. Therapy should be tailored to the individual clinical situation, with consideration of the underlying histology and degree of hepatic insufficiency.

Kashishian: Gilead Sciences: Employment. Lannutti:Gilead Sciences Inc: Employment.

Molecular and cytogenetic testing is critical in diagnosis and management of hematologic malignancies. These tests are expensive, complex, and frequently inappropriately ordered. There are no comprehensive guidelines to assist in the disease- and patient-specific selection of these tests. Traditionally, most tests are ordered before morphologic evaluation of the specimen, which could help guide test selection. We hypothesize that this leads to significant over-ordering of tests unnecessary for diagnosis or monitoring, as well as under-ordering of necessary tests. As part of the hematopathology diagnostic management team (DMT) effort, we evaluated this hypothesis by establishing evidence-based rules for molecular and cytogenetic test ordering that are applied by the pathologist after review of clinical history and bone marrow aspirate smears.Using published evidence and best clinical practices, a team of clinical hematologists and hematopathologists developed rules, termed standard operating procedures (SOPs), for selecting cytogenetic and molecular tests on bone marrow biopsies from adult patients performed for myelodysplastic syndrome/acute myeloid leukemia (MDS/AML), plasma cell myeloma, lymphoma, myeloproliferative neoplasms, lymphoblastic leukemia, and bone marrow failure. The rules specify testing in five clinical scenarios: diagnosis or follow-up with morphologically overt disease, bone marrow staging (for lymphoma), routine follow-up without overt disease, evaluation prior to stem cell transplant (pre-SCT), and follow-up after stem cell transplant (post-SCT). To determine the effect that application of these SOPs would have had on test ordering and results, bone marrow biopsies from adults (>18 years) were evaluated retrospectively over a six-month time period. Each test was ruled concordant or discordant with the corresponding SOP. Omitted tests, those recommended by the SOPs, but not performed, were also identified. Statistical analysis of concordant and discordant tests was performed using the Chi-square test.A total of 3,007 tests (769 karyotypes, 1,790 FISH, and 448 molecular tests) were performed on 804 adult bone marrows. Of these, 1,080 (36%) were discordant with the SOPs. Discordant tests were most frequent in myeloma (471), MDS/AML (231), and lymphoma (215). The most common clinical settings for discordant tests were routine follow-up (403) and post-SCT (417). To determine if these tests were necessary, we determined the positive rate of both concordant and discordant tests. The positive rate was significantly higher in the concordant (490/1,929; 25%) than the discordant tests (38/1,078; 4%) (P<0.001). Of the 38 positive discordant tests, 15 were redundant, i.e., a more sensitive test for the abnormality was positive on the same sample. An additional 13 discordant tests were only weakly positive. Of these, most were negative at diagnosis or at subsequent bone marrow testing, suggesting that they may represent false positive results. Thus, only 10/1,080 (<1%) discordant tests had potential clinical significance. In 145 of the marrows (18%), there were 308 omitted tests. By eliminating the discordant tests and including the omitted tests, we estimate that institution of these SOPs would reduce the total number of cytogenetic and molecular tests by 26%, from 3,007 to 2,235.Retrospective analysis of cytogenetic and molecular test ordering demonstrates that more than one-third of cytogenetic or molecular tests ordered on bone marrow specimens at a large tertiary care institution were discordant with rules (SOPs) based on published literature and best clinical practices. Furthermore, the vast majority (>99%) of these discordant tests were negative for any abnormality, redundant, or potential false positives, suggesting that the exclusion of these tests would have little negative clinical impact. In addition, there were a large number of omitted tests, seen in 18% of all marrows. This analysis predicts that institution of rules-based morphology-influenced test ordering would decrease uninformative testing, while increasing appropriate informative tests, leading to more cost-effective, accurate, and complete diagnosis and monitoring of hematolymphoid malignancies. We have therefore instituted a rules-based, morphology-directed approach at our institution.No relevant conflicts of interest to declare.