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The incidence of posttransplant hepatic arterial stenosis (HAS) has been reported in 5 to 10% of orthotopic liver transplants and, left untreated, can lead to hepatic arterial thrombosis. Most vascular complications develop less than 3 months after initial transplant, with thrombosis representing over half of all complications. There has been a trend toward minimally invasive, endovascular techniques for treating HAS with angioplasty and stenting. In one review of endovascular therapies for HAS, primary technical success was achieved in 95% of the interventions. Complication rates following endovascular repair of HAS have been reported to be between 0 and 23% in the literature. The main risk factors for complications include tortuosity of the hepatic artery and history of a second liver transplant. Other associated risk factors include female gender, age greater than 60 years, prior history of transarterial chemoembolization, and multiple arterial graft anastomoses. The case presented here is representative of a complication of balloon rupture and fragmentation in a patient undergoing hepatic arterial stent placement post–liver transplant.

Highlights • Video-conference platforms (VCPs) have rapidly become utilized in the current COVID-19 pandemic to promote social distancing. • Radiology trainee education, as regulated by the ACGME, necessitates active learning based on image review and VCPs can facilitate and support this. • Patient protected health information and HIPAA requirements must be adhered to even with VCPs and many platforms have the appropriate security measures to comply. • Tools within the VCP permit two-way interaction, screen control/sharing, and annotation features, which enable appropriate education even in a remote setting., Technologic advances have resulted in the expansion of web-based conferencing and education. While historically video-conferencing has been used for didactic educational sessions, we present its novel use in virtual radiology read-outs in the face of the COVID-19 pandemic. Knowledge of key aspects of set-up, implementation, and possible pitfalls of video-conferencing technology in the application of virtual read-outs can help to improve the educational experience of radiology trainees and promote potential future distance learning and collaboration.

The coracoid process of the scapula is in close proximity to major neurovascular structures, including the brachial plexus and the axillary artery and vein. In addition, it serves as a major site of attachment for multiple tendons and ligaments about the shoulder. Isolated coracoid fractures are rare; however, they can be easily overlooked on routine shoulder radiographs. Importantly, when these fractures go undiagnosed, they are at high risk for nonunion. In this paper, we will review the relevant anatomy of the coracoid process, classification schemes for coracoid fractures, mechanisms of injury how these fractures typically present, multimodality imaging findings, and associated injuries. Finally, we will briefly discuss the clinical management of these fractures.

Percutaneous renal transplant biopsy (PRTB) is the gold standard for evaluating allograft rejection after renal transplant. Hemorrhage is the predominant complication. We describe the implementation of a standardized protocol for PRTB at a single institution, with the aim of reducing bleeding complications. Utilizing the plan-do-study-act model for quality improvement, we created and deployed a protocol centered on controlling patient's hypertension, platelet function, and anticoagulation status. The 4-year study encompassed a total of 880 PRTBs, before and after implementation of the protocol. Total complication rate, which was 5.8% in the 2 years leading up to implementation of the protocol, was reduced to 2.9% after the protocol was introduced ( P = .04). A standardized approach to PRTB can potentially lower complication rates; we present a framework for implementating a quality improvement protocol at other institutions.

Extracranial metastasis of glioblastoma multiforme (GBM) is rare, but has recently been reported with increasing frequency. GBM metastases typically present after a biopsy or resection of the primary tumor. An otherwise healthy 54year-old woman presented with recurring pleural effusions originally believed to be from a primary lung malignancy. The patient subsequently experienced a generalized tonic clonic seizure and a right temporal brain mass was discovered. The patient later developed weakness and radiculopathy, and an extramedullary extradural mass spreading from C7 to T6 was discovered. She underwent resection of both central nervous system lesions as well as a lung biopsy, and all pathologic specimens were consistent with GBM. The case presented is unique in that the patient's initial symptoms were related to her metastasis. Furthermore, a purely epidural spread of GBM that respects the leptomeninges and intramedullary parenchyma is highly unusual.

Background: Oral fludarabine and intravenous rituximab (FR) was the standard first-line therapy for CLL or small lymphocytic lymphoma (SLL) patients (pts) in BC from 2003-2015. Ibrutinib for relapsed/refractory (R/R) CLL was introduced and publicly funded in 2015. Our aim was to review long term outcomes of all CLL/SLL pts treated with FR in BC, including the impact of 2nd line therapy with ibrutinib versus chemoimmunotherapy and to report the risk of secondary malignancies in this population based cohort. Methods: The BC Provincial CLL Database was used to identify all CLL/SLL pts who received first-line FR from 2003-2017. The BC Cancer Registry was used to identify secondary malignancies occurring after FR. Primary outcomes were overall survival (OS) and treatment free survival (TFS), defined as start of FR to next-line therapy or death/last follow-up. Variables examined for impact on OS/TFS included age at FR, gender, primary diagnosis (CLL vs SLL), B symptoms, advanced stage (Rai stage 3-4 CLL, Ann Arbor 1-2 SLL), baseline hemoglobin, lymphocyte count, platelets, LDH and FISH abnormalities. All variables significant on univariate analyses (P Results: 673 pts were identified as receiving FR as first-line therapy for CLL (86%) or SLL (14%). Median time from CLL/SLL diagnosis to FR was 2.5 years (y) (range 0.1-27.3). Median age at FR was 67 y (range 26-91) with 73% ≥ 60 y and 39% ≥ 70 y. Most pts were male (66.1%), had early stage disease (84.2%) with no B symptoms (89.7%) and normal LDH (81.1%). Of 411 pts with pre-treatment FISH testing, prevalence of FISH abnormalities were: 48.5% del13q, 25.7% trisomy 12, 12.9% del11q, 8.0% del17p. Median number of FR cycles was 6 (range 1-10). Median follow-up of living pts from FR was 6.4 y (range 0.2-12.7). 2 y and 5 y OS were 89.4% (95% CI: 86.8-91.6) and 73% (95% CI: 69.0-76.6) respectively; median OS 11.6 y (95% CI: 4.6-13.7 y). 2 y and 5 y TFS were 72% (95% CI: 68-75%) and 37% (95% CI: 33 - 41) respectively, median TFS 3.8 y (95% CI: 1.78-7.09). Those with del17p had significantly worse OS and TFS compared to those without (median OS 5.7 vs 13.7 y, P During the follow up period, 351 pts (52%) went on to 2nd-line therapy: ibrutinib 87 (including 2 with BR and 1+R), cyclophosphamide-based (CVP/CHOP) +/- R 102, repeat FR 71, FCR 6, F alone 21, bendamustine +/-R 13, chlorambucil+/-R 38, steroids 3, R alone 3, alemtuzumab 2, other chemotherapy 3 and allotransplant 2. Median follow-up after 2nd-line therapy was 2.8 y (range 0.1-10.8). Median OS and TFS from 2nd-line treatment (TFS2) for ibrutinib (n=87) vs. for other treatments (n=264) was: OS not reached vs 5.3 y, P A total of 202 malignancies were recorded after initiation of FR in 166 pts (24.7%), Table 1. The median time from FR to 2nd malignancy was 2.3 y (range 0.1-13.5). Richter's transformation (RT) occurred in 36 pts (5.3%) at median 1.9 y (range 0.1-13.2) from FR. Most frequent 2nd malignancies were: non-melanoma skin cancer (11.7%), lung (2.5%), colon (2.1%), other heme (1.9%), and prostate (1.8%). There were 4 cases of acute myeloid leukemia (AML), 2 of which received alkylator therapy after FR prior to AML diagnosis. Conclusions: In this large, homogeneous cohort of CLL/SLL pts treated with first-line FR, including nearly 40% of pts ≥ age 70, we demonstrate a short median TFS of 3.8 y; however, a long OS of 11.6 y. Rates of 2nd malignancies are low after this non-alkylator based chemoimmunotherapy regimen. Ibrutinib for R/R CLL/SLL after FR resulted in significantly improved survival over alternate therapy, with excellent 2 yr OS 91% and TFS 78%. These data demonstrate the efficacy of FR and the benefit of ibrutinib over chemoimmunotherapy as second-line therapy for CLL/SLL in the real-world. Disclosures Bruyere: Jenssen: Other: Travel Grant; Celgene: Honoraria. Villa:Roche, Abbvie, Celgene, Seattle Genetics, Lundbeck, AstraZeneca, Nanostring, Janssen, Gilead: Consultancy, Honoraria. Scott:Celgene: Consultancy; Roche/Genentech: Research Funding; Janssen: Consultancy, Research Funding; NanoString: Patents & Royalties: Named inventor on a patent licensed to NanoSting [Institution], Research Funding. Savage:BMS, Merck, Novartis, Verastem, Abbvie, Servier, and Seattle Genetics: Consultancy, Honoraria; Seattle Genetics, Inc.: Consultancy, Honoraria, Research Funding. Connors:Takeda Pharmaceuticals: Honoraria; Seattle Genetics: Honoraria, Research Funding; Bristol-Myers Squibb: Consultancy. Sehn:TEVA Pharmaceuticals Industries: Consultancy, Honoraria; Acerta: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; F. Hoffmann-La Roche/Genentech: Consultancy, Honoraria, Research Funding; Seattle Genetics: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Astra Zeneca: Consultancy, Honoraria; F. Hoffmann-La Roche/Genentech: Consultancy, Honoraria, Research Funding; Kite Pharma: Consultancy, Honoraria; Kite Pharma: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; TEVA Pharmaceuticals Industries: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Acerta: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Astra Zeneca: Consultancy, Honoraria. Gerrie:Lundbeck, Seattle Genetics: Consultancy, Honoraria.

Background Lumbar spinal stenosis (LSS) is the most common indication for spine surgery among the geriatric population. Although decompressive surgery is effective, older patients do not benefit as much as younger patients, and they are frequently excluded from studies assessing postoperative physiotherapy. We sought to evaluate the long-term outcomes after surgery when a novel postoperative physiotherapy regimen was included. Methods We performed a retrospective review of patients with LSS greater than 70 years old who underwent lumbar decompressive surgery by the senior author over the past five years. We evaluated patients who participated in a novel postoperative physiotherapy regimen involving four phases of rehabilitation aimed at progressively independent ambulation. The visual analog scale (VAS), lower extremity motor strength, and functional independence measure (FIM) were collected preoperatively and after physiotherapy to measure outcomes. Results Ten consecutive patients with an average age of 83 years (range: 71 - 96) met the inclusion criteria. Nine patients underwent minimally invasive laminotomies at L4-L5 and one underwent a laminotomy at L3-L4. The average follow-up time was 41.9 months. The preoperative mean VAS was 7.35, and at the end of the study, it was 1.7 (p = 0.005). Three of the four patients with preoperative motor deficits improved. The median transfer and locomotion subscores of the FIM were six preoperatively and increased to seven postoperatively. Neither of these improvements was significant. Conclusions Patients older than 70 years undergoing decompressive surgery and a novel postoperative physiotherapy regimen experienced significant reductions in pain. Independence also increased; however, this did not reach statistical significance.

Groin pain is a common complaint in the primary care setting. The etiologies of groin pain are multifactorial and include neurological causes, fractures, malignancy, and sacroiliac joint (SI) dysfunction. Differentiating spinal and back pathologies from inguinal etiologies is challenging, but the characteristics, distribution, symptoms, signs, physical exam, and imaging help to appropriately guide the evaluation and subsequent therapy.

BACKGROUND AND METHODS: Elevated serum ferritin is a common clinical finding. The etiology of hyperferritinemia in the Asia-Pacific population is less clear due to a low prevalence of knownHFEmutations such asC282YandH63D, as well as an increased prevalence of viral hepatitis and hereditary anemia. A retrospective case review of 80 patients of Asian ethnicity referred to three subspecialists in tertiary care teaching hospitals between January 1997 and March 2005 for assessment of hyperferritinemia was performed.RESULTS: Only four patients (5%) had iron overload on liver biopsy or quantitative phlebotomy. Forty-nine patients (61%) had secondary causes for their hyperferritinemia, of which 26 had liver disease; 16 of those patients also had viral hepatitis. Thirteen patients fulfilled criteria for the insulin resistance syndrome. Other causes included hematological disorders (n=10), malignancy (n=2) and inflammatory arthritis (n=2). Twenty-seven cases (34%) of unexplained hyperferritinemia were found. Of a total of 22 patients who underwent liver biopsy, significant iron deposition was found in one patient. Fifteen patients underwentC282YandH63Dgenotyping, with two cases ofH63Dheterozygosity. Fourteen patients had first-degree relatives with hyperferritinemia. Three families were identified with more than two members affected, which is suggestive of a possible hereditary hyperferritinemia syndrome.CONCLUSION: Secondary causes of elevated ferritin in the Asian population, particularly liver disease, are common, but primary iron overload syndromes appear to be rare. In a significant proportion of patients, the etiology remains unexplained. The genetic basis for hyperferritinemia in Asians is poorly defined and requires further study.

Recent trials suggest serious toxicity in HIV-associated non-Hodgkin's lymphoma (NHL) with rituximab (R) and chemotherapy (CT), offsetting the benefit of rituximab.We retrospectively reviewed experience with CHOP-R vs. CT in 40 patients with HIV-associated diffuse large B-cell lymphoma (DLBCL) diagnosed between December 1992 and February 2006, all of whom were treated with curative intent.In a univariate analysis, International Prognostic Index (IPI) score, prior AIDS, HAART, and rituximab were significant for overall survival (OS). In a multivariate analysis, IPI 0-1 (p.02), no prior AIDS (p.0002), and receiving CHOP-R (p.01) were significant for improved OS, and HAART use (p.09) retained a trend for improved OS. The hazard ratio (HR) for patients with high IPI receiving CHOP-R was 0.3 (95% CI 0.1-0.8). Patients without prior AIDS receiving CHOP-R had an HR of 0.5 (95% CI 0.1-1.7). The OS at 30 months in patients not receiving HAART was 0%. With HAART, OS was 33% for CT and 86% for CHOP-R; HR for CHOP-R was 0.4 (95% CI 0.1-1.2). Toxic deaths were 3 (33%) for CHOP-R and 6 (25%) for CT (p = ns); all toxic deaths with CHOP-R were in patients not receiving HAART. Rituximab-treated patients had a lower death rate from lymphoma (CHOP-R, 2 [16%] vs. CT, 15 [63%]; p.04), and overall mortality (CHOP-R, 5 [42%] vs. CT, 21 [88%]; p.01).These retrospective data suggest that fatal toxicity of rituximab in HIV-NHL is not increased provided HAART is used, that the addition of rituximab to CT improved outcome, and that further prospective trials investigating this issue are warranted.

Monoclonal B-cell lymphocytosis (MBL) is a clonal lymphoproliferation with the immunophenotype of chronic lymphocytic leukemia (CLL) but a B-lymphocyte count of less than 5 x 10(9)/l and no lymphadenopathy, organomegaly, cytopenias or symptoms. We performed a retrospective analysis of patients with MBL (n = 46), Rai stage 0 CLL (n = 112) and Rai stageor =1 CLL (n = 54). Median follow-up and range was 30 (0.1-120) months for MBL, 60 (0.1-309) months for stage 0 CLL and 54 (0.1-309) months for stageor =1 CLL. None of the MBL patients required treatment compared with 24 of 112 (21%) stage 0 CLL and 28 of 54 (52%) stageor =1 CLL patients (p0.0003). No MBL underwent aggressive transformation compared with 1 of 112 (0.8%) stage 0 CLL and 6 of 54 (11%) stageor =1 CLL patients (p0.0003). Progression-free survival (PFS) appeared improved in MBL compared to stage 0 CLL, although this did not reach statistical significant (p = 0.07) due to the relatively short follow-up in the MBL group; two year PFS was 97.2% for MBL, 93.1% for stage 0 CLL, and 68% for stageor =1 CLL patients (p0.0001 for stageor =1 CLL compared with MBL and stage 0 CLL). This is the first study of outcome in MBL which demonstrates that patients have an improved disease course compared to stage 0 CLL patients. Over a median 2.5 years of follow-up, no MBL patients required treatment or died of CLL-related causes.

This study introduces the use of multivariate linear regression (MLR) and support vector regression (SVR) models to predict postoperative outcomes in a cohort of patients who underwent surgery for cervical spondylotic myelopathy (CSM). Currently, predicting outcomes after surgery for CSM remains a challenge. We recruited patients who had a diagnosis of CSM and required decompressive surgery with or without fusion. Fine motor function was tested preoperatively and postoperatively with a handgrip-based tracking device that has been previously validated, yielding mean absolute accuracy (MAA) results for two tracking tasks (sinusoidal and step). All patients completed Oswestry disability index (ODI) and modified Japanese Orthopaedic Association questionnaires preoperatively and postoperatively. Preoperative data was utilized in MLR and SVR models to predict postoperative ODI. Predictions were compared to the actual ODI scores with the coefficient of determination ( R 2 ) and mean absolute difference (MAD). From this, 20 patients met the inclusion criteria and completed follow-up at least 3 months after surgery. With the MLR model, a combination of the preoperative ODI score, preoperative MAA (step function), and symptom duration yielded the best prediction of postoperative ODI ( R 2 = 0.452; MAD = 0.0887; p = 1.17 × 10 −3 ). With the SVR model, a combination of preoperative ODI score, preoperative MAA (sinusoidal function), and symptom duration yielded the best prediction of postoperative ODI ( R 2 = 0.932; MAD = 0.0283; p = 5.73 × 10 −12 ). The SVR model was more accurate than the MLR model. The SVR can be used preoperatively in risk/benefit analysis and the decision to operate.

Retrospective case series.Large national inpatient databases estimate that approximately 200,000 lumbar fusions are performed annually in the United States alone. It is common for surgeons to routinely order postoperative hematologic studies to rule out postoperative anemia despite a paucity of data to support routine laboratory utilization.To describe quantitative criteria to guide postoperative utilization of hematologic laboratory assessments.A retrospective analysis of 490 consecutive lumbar fusion procedures performed at a single institution by 3 spine surgeons was performed. Inclusion criteria included instrumented and noninstrumented lumbar fusions performed for any etiology. Data were acquired on preoperative and postoperative hematocrit, platelets, and international normalized ratio as well as age, sex, number of levels undergoing operation, indication for surgery, and intraoperative blood loss. Multivariate logistic regression was performed to determine correlation to postoperative transfusion requirement.A total of 490 patients undergoing lumbar fusion were identified. Twenty-five patients (5.1%) required postoperative transfusion. No patients required readmission for anemia or transfusion. Multivariate logistic regression analysis demonstrated that reduced preoperative hematocrit and increased intraoperative blood loss were independent predictors of postoperative transfusion requirement. Intraoperative blood loss1000 mL had an odds ratio of 8.9 (P=0.013), and preoperative hematocrit35 had an odds ratio of 4.37 (P=0.008) of requiring a postoperative transfusion.Routine postoperative hematologic studies are not necessary in many patients. High intraoperative blood loss and low preoperative hematocrit were independent predictors of postoperative blood transfusion. Our results describe quantitative preoperative and intraoperative criteria to guide data-driven utilization of postoperative hematologic studies following lumbar fusion.

Background: There have been rare reports of intracranial subdural hematoma (SDH) that migrated into the spine. All previous cases have been surgically managed and in this case report, we describe the first case of conservatively managed spinal hematoma secondary to migratory intracranial SDH. Case Description: A 26-year-old male presented with a left tentorial SDH after blunt trauma. He was conservatively managed and discharged home. He presented 8 days later with worsening lower back pain that was found to be secondary to a spinal SDH. Conclusion: Spinal hematomas can be a serious sequelae of migrated intracranial hematomas. Tentorial and other caudally located intracranial hematomas may be more prone to this phenomenon.

Upregulation of tumor necrosis factor-alpha (TNF-alpha) has been implicated in the pathogenesis of several inflammatory conditions, including rheumatoid arthritis. Therapeutic agents such as antibodies or soluble TNF-alpha receptor analogs, which block TNF-alpha activity are a recent addition to the therapeutic armamentarium for the conditions. We describe a patient who developed aplastic anemia complicated by sepsis after receiving etanercept, a TNF-alpha receptor analog, for the treatment of rheumatoid arthritis. Pancytopenia resolved within 3 wk of discontinuing etanercept. To our knowledge, this is the first report of aplastic anemia associated with TNF-alpha blockade.

Clinical trials report that fludarabine and rituximab (FR) as initial therapy for chronic lymphocytic leukemia (CLL) improves progression-free and overall survival (OS) when compared historically to fludarabine alone. To determine whether similar results are achievable with oral FR in a community-based setting, we conducted a population-based analysis of patients treated for CLL or small lymphocytic lymphoma (SLL) in British Columbia, where FR is standard initial therapy. Ninety-eight patients received FR for CLL/SLL from 2004 to 2009. Two- and 4-year OS was 90% and 73%, respectively (median not reached); 2- and 4-year treatment-free survival (TFS) was 69% and 54% (median 4.0 years). Age ≥ 60 years or ≥ 70 years had no effect on OS or TFS. Toxicity led to treatment discontinuation in 13%. FR with oral fludarabine was safely, conveniently and successfully given to community-based patients, irrespective of age, for first-line therapy for CLL/SLL, achieving OS and TFS similar to those in clinical trials.

OBJECTIVES Acute leukemia, particularly acute myeloid leukemia, occurs more frequently in the elderly, a growing segment of the North American population. To evaluate our progress in the diagnosis, treatment and outcome of this condition, we reviewed our experience of all patients > or =60 years of age diagnosed with acute leukemia over a 20-year period at Saint Paul's Hospital, a university-based hospital in Vancouver, Canada. METHODS A retrospective chart review was performed of 103 patients > or =60 years of age diagnosed with acute leukemia (acute myeloid leukemia-81; acute lymphoid leukemia-15; acute leukemia not otherwise specified-7). RESULTS Median age was 72 (range 60-88) years. Bone marrow aspirate yielded cytogenetic information on 57 patients and 18 (31.6%) had an unfavourable karyotype. Fifty-three (51%) patients received induction chemotherapy (treated) and 50 (49%) were palliated (untreated). Treated patients were younger [median 67 years (range 60-79)] than untreated patients [76 years (61-88)], (P < 0.0001). Of the treated patients, 33 (62%) achieved a complete remission. The median overall survival for the group was 104 (1-2689) days, and for treated versus untreated patients-219 (1-2689) and 39 (2-1229) days, respectively (P = 0.0021). Univariate variables predictive of prolonged survival included induction chemotherapy (P = 0.0027), de novo leukemia (P = 0.0420), and younger age, with a relative increase in death in older subgroups (60-69, 70-79, 80+), (P = 0.0311). Induction chemotherapy was the only predictor of prolonged survival in multivariate analysis (P = 0.0027). CONCLUSIONS The prognosis of acute leukemia in older patients remains poor, and even though induction chemotherapy seem to prolong survival in patients able to receive treatment, most ultimately die of leukemia.

To address concerns about regional physician shortages within British Columbia, the University of British Columbia began distributing its undergraduate medical curriculum across multiple campuses (ie, urban Vancouver, small urban Victoria, and rural Prince George) in 2005. The distribution of the pathology curriculum required meeting 3 specific challenges: (i) implementation of high-quality technologies to facilitate distribution; (ii) recruitment of pathologists to teach; and (iii) creation of an electronic pathology learning center. Technological needs were met by a state-of-the-art audiovisual system allowing simultaneous interactive didactic sessions across all 3 sites, and by the use of a digital "virtual slide" system. Recruitment of pathologist educators proved challenging owing to comparatively limited staffing levels at the rural site. A physical and virtual pathology learning center was developed to assist students in self-directed study. Student performance on pathology examinations has proven to be essentially identical pre- and post-distribution, and is equivalent across all 3 sites. Quantitative and qualitative student survey data show that distributed pathology instruction is overwhelmingly well received by medical students at all sites, that pathologists' expertise is very important to students, and that pathology is one of the most popular components of the distributed curriculum. Pathology education continues to be a vital part of a distributed undergraduate medical program, and student grades and feedback demonstrate the value of the teaching and the technologies we have used. To be implemented successfully, the distribution of pathology education requires considerable financial and infrastructure investment, and ongoing commitment from pathologists and university administrators.

Plasmablastic lymphoma (PBL) is a recently described type of non-Hodgkin's lymphoma (NHL) that occurs in up to 3% of patients with HIV infection. Although the clinical-pathological features of several patients with HIV-associated plasmablastic lymphoma are documented, detailed description of clinical outcome is limited to isolated case reports. Generally, the response to lymphoma therapy is poor and survival is short. Response to highly active anti-retroviral therapy (HAART), however, has also been described. In this report, we describe the clinical course of two patients diagnosed with HIV-associated PBL in the era of HAART. One patient had a complete response to HAART, with a response-duration of 14 months, followed by relapse in the gastrointestinal tract several months after an anti-retroviral holiday. He is currently in complete remission (CR) eight months from diagnosis of relapse after receiving a full course of combination chemotherapy with modified CHOP, and 25 months from initial diagnosis. A second patient responded to brief chemotherapy in conjunction with HAART and is in clinical CR ten months from diagnosis. These cases illustrate that immunologic and virologic control with HAART may be beneficial for treating PBL and may possibly maintain continued CR. We advocate a high index of suspicion for primary PBL or its recurrence in patients with HIV infection, a history of low CD4 counts or high viral load, and oral or gastrointestinal symptoms.

Background: Postoperative wound infection is a preventable risk that can lead to significant adverse outcomes and increased cost of care. Minimally invasive surgeries (MIS) have been found to have lower rates of postoperative infection compared with the traditional approach. To assess if the reported difference is related to intraoperative contamination or to other factors, we assessed the surgical field for sterility. Methods: We compared 10 MIS versus 10 traditional microdiscectomies. Swabs of the operating field were obtained before and after the procedure from multiple sites in the operating room. Positive and negative controls were taken of the skin immediately before and after preparation of the incision site. All swabs were plated out on Columbia blood agar plates and grown for 48 hours. Colony counting was performed to determine growth. Results: There was no statistically significant difference in the colony counts of swab sites in traditional microdiscectomies compared with MIS microdiscectomies. There was no significant contamination of the operating field using either approach. Conclusions: In this prospective study, we found that there was no significant difference in bacterial counts in swabs of operative sites in either traditional or MIS microdiscectomies, suggesting that the decreased rate of postoperative infection in the reported literature for MIS cases may be related to other factors, such as patient selection and/or postoperative care.

Abstract 2363 Poster Board II-340 Background: Clinical trials report that FR as initial therapy in symptomatic CLL produces an overall response rate of 90% and significantly improves progression-free survival (PFS) and overall survival (OS) compared retrospectively to F alone [Byrd Blood 2003, 2005] and that FCR (F, cyclophosphamide and R) improves response rates and PFS compared to FC alone [Hallek ASH 2008]. FR has been the standard initial therapy for CLL/SLL in British Columbia (BC) (population = 4.2 × 106) since 2004. We wished to determine if, in an unselected community based population, the same results could be achieved with FR therapy as those seen in highly selected clinical trial populations. Patients and Methods: The BC Cancer Agency (BCCA) Lymphoid Cancer Database was searched to identify pts who received FR as initial therapy for CLL/SLL as per BCCA guidelines (F 40mg/m2/day orally D1-5 or 25mg/m2/day IV D1-5 [adjusted for renal function] and R 375mg/m2 IV D1, q 28 days for 4-8 cycles). Pts were excluded if they had more than one hematologic malignancy (n=2). OS was calculated from date of FR to date of death or last follow-up. Treatment-free survival (TFS) was calculated from date of FR to date of next treatment or death from toxicity. Factors present at initiation of treatment were analyzed for impact on outcomes. Results: 98 pts were identified who received FR from 2004-2009 as initial therapy for CLL (83%) or SLL (17%). Median age at FR was 62 y (range, 42 – 86 y). 36% had Rai stage 3 or 4 and 13% had ECOG performance status 2-3. Median lymphocyte count was 30 × 109/L (range 0.6-282 × 109/L) and LDH was elevated in 34% (29/86 with available levels). Nearly half of all pts tested were positive for CD38 (34 of 69 pts, 49%) and ZAP 70 expression (10 of 22 pts, 45%). FISH was performed in 35 pts: 13q deletion, 21 (60%); 11q deletion, 5 (14%); 17p deletion, 10 (29%); trisomy 12, 11 (31%). Most pts (65%) were observed prior to FR for a median of 28 months (range, 3 – 172 mos). Common indications for treatment included symptomatic lymphadenopathy (n=36), cytopenias (n=28), fatigue (n=23), and constitutional symptoms (n=19). Pts underwent a median of 6 cycles of FR (range, 1-8). Treatment was discontinued due to toxicity in 13 pts (13%) (cytopenias, 5; febrile neutropenia, 3; infection, 2; pulmonary disease, 1; ITP, 1; AIHA, 1) and due to progression in 4 pts (4%). Hospitalization during therapy was required in 13 pts (13%) (febrile neutropenia, 5; documented infection, 2; elective splenectomy, 2; pulmonary disease, 2; ITP, 1; rituximab administration, 1). At a median follow up of living pts of 2.4 y, 31 pts (32%) have received additional therapy after FR including CVP in 11 pts (+R, 8); chlorambucil, 7 (+ R, 1; +prednisone, 1); FR, 5; cyclophosphamide, 5 (+prednisone, 3; +vincristine, 1); CHOP, 3 (+R, 2). At time of analysis (June 2009), 86 pts were alive; 14 died, 12 from progressive CLL and 2 from toxicity of FR (severe infection, 1; interstitial lung disease, 1). For the entire 98 pts, the 2 and 4 y OS were 90% and 72%, respectively (median not reached); 2 and 4 y TFS were 69% and 54%, respectively (median 4.0 y). Factors at treatment contributing to OS in univariate analysis included elevated LDH (P=0.004), Hb 15% of CD19+ cells) by immunophenotyping (P=0.04). TFS was significantly worse in those with Hb 150 × 109/L (P=0.0013) while cytogenetic abnormalities and immunophenotyping had no effect on TFS. Age ≥ 60 y (n=60) or age ≥ 70 y (n=26) had no effect on either OS or TFS. Conclusions: In this non-selected community based population of pts with CLL/SLL, including many over 60 y (61%) and 70 y (27%) of age, our results show that initial treatment with FR leads to excellent OS and TFS, consistent with clinical trial results: 2 y OS, this study 90%; FR Byrd [Blood 2005] 93%; FCR Hallek [ASH 2008] 91%; 2 y TFS, this study 69%; FR Byrd, 2 y PFS 67%; FCR Hallek 2 y PFS 77%. FR can be safely and successfully given to community based pts, irrespective of age, for first-line therapy for CLL/SLL with OS and TFS similar to that achieved in clinical trial settings. Disclosures: Connors: Roche Canada: Research Funding.

Background and Methods. Isolated hyperferritinemia is a common clinical finding. However, known HFE mutations C282Y and H63D have not been well-described in the Asian population. As well, evaluation of hyperferritinemia in the Asian population is confounded by chronic hepatitis B infection. We performed a retrospective case review of 79 patients of Southeast Asian ethnicity referred to three subspecialists in a tertiary care teaching hospital from January 1997 until July 2006 for assessment of hyperferritinemia. A subset of patients may represent a novel syndrome of isolated hereditary hyperferritinemia. Results. 35 patients had identifiable secondary causes for their hyperferritinemia. 4 had clinical or biopsy proven iron overload consistent with hemochromatosis. 40 had isolated hyperferritinemia. Of the 35 patients with secondary causes, 26 had liver disease; 16 with viral hepatitis. Other causes included hematologic disorders (10), malignancy (2) and inflammatory arthritis (2). On liver biopsy, 8 patients showed no increase in stainable iron while 10 showed mild-moderate increase. 7 patients were negative for C282Y and H63D mutations. Of the 40 cases of isolated hyperferritinemia, 38 had normal liver enzymes. 2 had liver biopsies showing mild increase in stainable iron. 9 patients underwent C282Y and H63D genotyping with 1 patient being H63D heterozygous. 8 index patients had first-degree relatives with hyperferritinemia. 3 families were identified with more than 2 members affected, suggestive of a possible hereditary hyperferritinemia syndrome. Conclusion. Hyperferritinemia appears to be relatively common in Asians but classic hemochromatosis is not. Liver disease is a frequent cause of hyperferritinemia in the Asian population. We have, however, discovered a small group of healthy patients with no evidence of liver disease and isolated hyperferritinemia that in some cases appears to be familial. This has not been previously reported.

Aberrant expression of the cell surface marker CD30 in systemic B-cell HIV-related NHL other than anaplastic large cell lymphoma (ALCL) has been reported. CD30 is a member of the tumor necrosis factor (TNF) family of receptors, and activation of CD30 mediates cell cycle regulation in preclinical models. The outcome of AIDS-related lymphoma (ARL) patients (pts) has improved dramatically in recent years with good control of HIV infection and the ability to intensify chemotherapy appropriate to the lymphoma. To determine whether CD30+ systemic ARL might have different clinical outcome and require a tailored approach to therapy, we performed a retrospective clinical-pathological correlation in pts seen at St. Paul’s Hospital in Vancouver, Canada (SPH) and focused on 39 B-cell lymphoma (BCL) pts since 1992. Clinical and HIV-related data were abstracted by chart review and from the CFE data-base. Stored biopsy material diagnostic of BCL was sectioned and stained for CD30 expression by immunohistochemistry. Median age was 41 (range 20–64) years and 37 pts were male. 16 pts had diffuse large B-cell lymphoma (DLBCL), 17 other B-cell NHL excluding ALCL, and 6 Hodgkin’s Lymphoma (HL); 29 were advanced stage. HIV risk was sexual in 31 and injection drug use (IDU) in 8. Median CD4 at diagnosis was 140 (10–770) cells/ul and 20 pts received HAART. Lymphoma therapy was administered according to era and histology: CHOP-like ± Rituximab (R) n=28; ABVD-like n= 6; CODOX-M/IVAC-R n=1; HAART alone n=1; resection n=1; declined therapy n= 2. 8 pts received added R and 4 added radiation therapy. 20 were CD30+ and 19 CD30−; the only baseline characteristic that differed significantly according to CD30 status was histology p

EBV infection of B-lymphocytes is known to promote cell proliferation and survival. In contrast to NHL in HIV-negative patients (pts), in whom ≤5% are EBV-positive (EBV+), up to 50% are EBV+ in systemic HIV-related NHL. Highly active antiretroviral therapy (HAART) has improved the outcome of AIDS-related lymphoma (ARL) pts and allows intensification of lymphoma therapy. To determine whether EBV+ systemic ARL might behave more aggressively and require intensification of therapy, we performed a retrospective clinical-pathological correlation in pts seen at St. Paul’s Hospital in Vancouver, Canada, and focused on 39 B-cell lymphoma (BCL) since 1992. Clinical and HIV-related data were abstracted by chart review and from the CFE data-base. Stored biopsy material diagnostic of BCL was sectioned and stained for EBV by EBER. Median age was 40 (range 20–64) years and 37 pts were male. 16 pts had diffuse large B-cell lymphoma (DLBCL), 17 other B-cell NHL and 6 Hodgkin’s Lymphoma (HL); 29 were advanced stage. HIV risk was sexual in 25 and injection drug use (IDU) in 14. Median CD4 count at diagnosis was 140 (10–770) cells/ul and 23 pts received HAART. Lymphoma therapy was administered according to era and histology: CHOP-like ± Rituximab (R) n=28; ABVD-like n=6; CODOX-M/IVAC-R n=1; HAART alone n=1; resection n=1; declined therapy n=2. 9 pts received added R and 3 added radiation therapy. 11 received therapy directed against other herpes viruses (HVT) at some point in ARL treatment. 25 were EBV+ and 14 EBV−; no baseline HIV or lymphoma related characteristics differed significantly according to EBV status nor did receipt of HVT. In a Kaplan-Meier analysis, EBV expression was significant for overall survival (OS); median survival (MS) for pts with EBV+ ARL was 38 (2.5–74.3) months (mo) vs. 6.1 (0–18.5) mo for EBV− (p

Prognostic factors to predict an aggressive clinical course in chronic lymphocytic leukemia (CLL) such as CD38, ZAP-70 and IgH mutation status have been well described, however, readily available presenting features predictive of long-term stability are less well defined. We performed a retrospective analysis of 335 consecutive patients with CLL seen at St. Paul’s Hospital from January 1969 to July 2005. Patients were identified from the practice data-base and clinical and pathological data abstracted by chart review. Long-term stability was defined as no requirement for treatment for at least 6 years (n=66, group A). Characteristics of group A were compared to all other pts (group B, n=269), and, to avoid follow-up bias, to pts followed for ≥6 y who required treatment (group C, n=62). 65 pts in group A were B-cell in phenotype and 1 was T-cell; group B 268 pts B-cell, 1 T-cell; group C all 62 B-cell. Median age at diagnosis for groups A, B and C were 59.5 (range 33–80) y; 68 (30–94) y; and 60 (30–82) y, respectively (p Characteristic OS @ 120 mo (%) Lymphocyte count at Dx (X109/L) Group A (stable ≥ 72 mo, n=66) Group B (all others, n=269) Group C (not stable, ≥72 f/u mo, n=62) All pts 93 64 64 ≤10 100 100 100 >10 91 64 64 ≤20 93 38 38 >20 0 of 2 0 of 5 0 of 5 p (log rank) A vs. B p In conclusion, in this series of 335 patients with CLL, lower lymphocyte count at diagnosis predicted for long-term stability, decreased requirement for treatment and improved OS.

Monoclonal Lymphocytosis of Undetermined Significance (MLUS) is a clonal lymphoproliferation, usually of B-cells. MLUS has the immunophenotype of Chronic Lymphocytic Leukemia (CLL) but an absolute lymphocyte count of 10 X 109/L or less and no lymphadenopathy, organomegaly, cytopenias, or symptoms attributable to the lymphoproliferation. There is little published information as to whether the clinical course of MLUS differs significantly from that of CLL. We performed a retrospective analysis of 335 consecutive patients with clonal lymphocytosis seen at St. Paul’s Hospital diagnosed between January 1969 and July 2005. Patients were identified by a search of the practice database and clinical and pathological data were abstracted by chart review. MLUS was present in 106 patients and CLL in 229. All MLUS were of B-cell phenotype and 227 patients had B-CLL. Median age at diagnosis was 64.5 (range 33–86) y for MLUS and 65 (30–94) y for CLL (p50 X 109/L) occurred in 14% of MLUS and 11% of CLL (p Characteristic OS at 10 years (%) P (log-rank) MLUS CLL Age ≤65 68 81 0.07 >65 59 45 0.59 Gender M 38 68 0.47 F 100 76 0.02 LDT ≤12 mo 47 74 0.10 >12 mo 80 47 0.93 CD38 negative 90 73 0.60 (positive ≥ 30% of cells) 3 of 3 0 of 2 0.32 Transformation events n=1 n=15 0.025 In conclusion, in this series of 335 patients with clonal lymphoproliferation, MLUS pts had significantly better OS than did pts with CLL, a difference which was seen in female MLUS pts in particular. Significantly fewer MLUS pts required treatment over their course than did pts with CLL. In CLL pts, there appeared to be an increased rate of transformation to aggressive non-Hodgkin's lymphoma or PLL.

Acute leukemia, especially acute myeloid leukemia (AML), occurs more frequently in the elderly population. Treatment outcomes for this condition have traditionally been poor and very few patients survive for prolonged periods following diagnosis. We performed a retrospective chart review of all patients sixty years of age and older diagnosed with acute leukemia at St. Paul’s hospital, Vancouver, Canada, from June 1984 to July 2004. One hundred and three patients were diagnosed with acute leukemia [AML- 81; ALL- 15; ALN (acute leukemia not otherwise specified)- 7]. The median age was 72 (range 60–88) years. Fifty-seven (55%) and 46 (45%) patients had de novo and secondary leukemia, respectively. Sixteen patients (28%) had an unfavourable karyotype. Fifty-three patients (51%) received induction chemotherapy (treated) and 50 (49%) were provided with supportive care only (untreated). Treated patients were younger [67 years (60–79)] than untreated patients [76 years (61–88)], (p/= 80 years were treated (n=17). Of the treated patients, 33 (62%) achieved a complete remission (CR), 10 (19%) had resistant disease and 10 (19%) died from complications related to treatment. The median overall survival for the entire group was 103 (1–1229) days, and for treated versus untreated patients was 216 (1–1213) and 38 (2–1229) days, respectively (p=0.0021). The disease free survival in treated patients achieving a CR (n=33) was 262 days (9–722). Less than 5% of patients were alive at 4 years from diagnosis. Univariate variables predictive of prolonged survival included receiving induction chemotherapy (p=0.0027), de novo as opposed to secondary leukemia (p=0.0420), and younger age, with a relative increase in death in older subgroups (60–69, 70–79, 80+), (p=0.0311). Induction chemotherapy was the only independent predictor of prolonged survival in multivariate analysis (p=0.0027). There was no statistically significant difference in the number of treated patients and treatment outcomes between 1984–1993 and 1994–2004. In conclusion, this single-institution series of 103 patients aged sixty years and older with acute leukemia, shows that the prognosis of this disease in older patients is extremely poor. Even though induction chemotherapy seems to prolong survival in patients who are fit to receive treatment, the prognosis remains grim and most patients ultimately die of leukemia, supporting a role for investigational regimens focusing solely on this age group. It is no longer appropriate to follow regimens that have remained largely unsuccessful and unchanged over 20 years.

BCL-2 expression in diffuse large B cell lymphoma (DLBCL) in HIV-negative patients (pts) is associated with inferior outcome, an effect at least partially overcome by the addition of rituximab (R) to multi-agent chemotherapy (MA-CT). The effect of BCL-2 expression on DLBCL outcome in HIV-positive pts is less well defined. We performed a retrospective clinical-pathological correlation in 141 pts with systemic HIV-associated lymphoma seen at St. Paul’s Hospital between 1982 and 2004; this analysis includes 36 DLBCL since 1992. Clinical DLBCL data were obtained by chart review; HIV-associated data from the data-base of the BC Centre For Excellence in HIV/AIDS. Stored biopsy material diagnostic of DLBCL was sectioned and stained for BCL-2 expression. Median age at DLBCL diagnosis (dx) was 42 (range 20–64)y, DLBCL stage advanced 27; ECOG PS >1 n=11; median LDH ratio 1.4 (0.5–8.6); IPI >2 n=11; CD4 at DLBCL dx >100 n=21; prior AIDS dx n=18; hepatitis B and/or C n=9; on highly active anti-retroviral therapy (HAART) at DLBCL dx n=11; BCL-2+ n=11. HAART with DLBCL treatment (tx) n=17; received CHOP-R n=9, CHOP or ACOP n=18; G-CSF n=10; herpes virus tx n=10; PCP prophylaxis n=35. Significant factors for inferior overall survival (OS) included prior AIDS, median OS (MS) 3.2 vs. 7.4 mo with no AIDS; no HAART use, MS 2.6 vs. 5.2 mo with HAART; BCL-2+, MS 3.2 vs. 5.2 mo for BCL-2 negative; and receiving MA-CT without R, MS 3.8 vs. 7.6 mo for MA-CT + R (p