Eosinophilia is not an uncommon finding on a routine complete blood count (CBC) during a primary care visit. The differential diagnosis is varied including allergic/atopic disease, drug reaction, infection, inflammatory conditions, and malignancy. An 80-year-old male was incidentally found to have leukocytosis on routine labs. White blood cell (WBC) was 27.5 K/ul with eosinophilia 4.3 K/ul (normal range 0-0.6 Kul) and Hemoglobin/Platelet counts were normal. Patient was asymptomatic. Denied history of medication change or allergy. Chest X-Ray (CXR) followed by Computed tomography (CT) showed 5 cm pulmonary mass with mediastinal lymphadenopathy. Patient developed progressively enlarging left neck mass, hoarseness, weight loss and decreased appetite in the next 3 weeks. WBC increased steeply to 65 K/ul with eosinophil count - 18.5 K/ul. CT neck revealed a large heterogeneous mass of the thyroid extending to the trachea, esophagus, and mediastinum. Patient decided not to proceed with further diagnostic workup and management given his age and comorbidities. Eosinophilia can be asymptomatic or present with nonspecific symptoms like cough, fatigue, skin rash or neuropathy. Eosinophilia work up starts with a comprehensive history detailing travel history, exposure to well water/spring water, analysis of past medical history to include asthma, atopy and especially medication history. Physical exam with attention to atopy/eczema and skin rash is vital. Work up may include a CBC, peripheral blood smear, stool test (for ova and parasite), IgE/tryptase levels and evaluation for occult malignancy (CXR is an ideal first step). Further testing with Bone marrow biopsy and CT scans is a consideration if a clear diagnosis is not achieved. Life-threatening complications of untreated hyper-eosinophilia include thromboembolism, endomyocardial fibrosis, cognitive disturbances, and respiratory failure. Incidence of eosinophilia is 1% in malignant tumors. Malignancy encompasses hematological cancers (acute leukemia, chronic myeloid leukemia, systemic mastocytosis, lymphoid neoplasms) and solid tumors (lung, thyroid, breast and gastrointestinal tract cancers). Eosinophilia suggests advanced disease in solid tumors and portends poor prognosis. Paraneoplastic eosinophilia has been reported in thyroid cancer (sclerosing muco-epidermoid) and lung cancer (squamous and adenocarcinoma). Pathophysiology of eosinophilia in solid tumors is related to bone marrow stimulation through cytokines (interleukin-5, granulocyte-macrophage colony-stimulating factor, and interleukin-2). Primary eosinophilia responds to steroids and hydroxyurea. Treating the underlying malignancy is the cornerstone of paraneoplastic eosinophilia management. We present a case of extreme progressive eosinophilia secondary to a malignancy which would be of interest to the primary care clinician.

Diagnosis of two distinct malignant entities existing concurrently and at the same location (synchronous malignancy) by fine-needle aspiration (FNA) is unusual but may occur. Small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) in particular is associated with an increased incidence of secondary tumor, likely due to associated immunodeficiency. Co-occurrence of some carcinomas such as squamous cell carcinoma (SCC), may show especially aggressive behavior. A 57-year-old Caucasian male presented with recurrent upper extremity lymphedema and diffuse lymphadenopathy ofthe axillary and cervical regions. FNA ofa large cervical lymph node was diagnostic for both atypical lymphocytic proliferation and SCC. Flow cytometric analysis showed the atypical lymphocytic proliferation to be positive for CD5, CD23, CD19, CD20, HLA-DR, CD38, and the population was kappa light chain restricted. These cells were negative for CD-10 and FMC-7 antigens, suggesting a phenotype of B-cell SLL/CLL. We report a rare occurrence of metastatic SCC to a lymph node infiltrated by SLL/CLL. The diagnosis was achieved by a combination of cytomorphologic examination of FNA smears, immunohistochemical staining of cell block material, and flow cytometry on the sample obtained by FNA. To the best of our knowledge, only three cases of SCC metastasis to SLL/CLL diagnosed by FNA have been reported in the English literature. Though rare, awareness of such a possibility and careful cytological examination under the appropriate clinical conditions is warranted.

Doctor Educationis / Background: South Africa has the largest burden of HIV in the world with 7.9 million people living with HIV and 4.4 million registered on antiretroviral therapy (ART) in 2017. KwaZuluNatal is hardest hit by the HIV epidemic with a prevalence of 27% among adults aged 15 to 49 years old. With the widespread ART uptake, the spectrum of HIV related admissions in hospitals has changed over the last decade. Hypertension, diabetes, cardiovascular disease, and renal failure have become significant reasons for inpatient care. Increased life expectancy, rising non-communicable diseases (NCDs) and easier access to ART have played a significant change in the landscape of inpatients as compared to the pre-ART era. To provide integrated healthcare to the patient, it is necessary to understand the prevalence and patterns of HIV comorbidities for efficient and effective service delivery to HIV patients at facility-level. Aim: The current study aimed to describe the prevalence and patterns of HIV-related comorbidities in adult hospital admissions in iLembe, KwaZulu-Natal. Methodology: A retrospective, cross-sectional survey was conducted of all adult HIV-related admissions between 1st October and 31st December 2019. Clinical and demographic characteristics were extracted from admission and discharge records, and laboratory data was collected via the National Health Laboratory Services using Labtrack. Summative and inferential analyses were done using SPSS v 23.

Aims: To elucidate the aetiopathological mechanisms underlying the IIMs, through a combination of genotyping, serotyping and clinical phenotyping in a large cohort of Caucasian idiopathic inflammatory myopathy (IIM) patients. Methods: A cross-sectional study of prevalent IIM cases, ascertained through the Adult Onset Myositis Immunogenetic Collaboration, was performed. Cases were confirmed as possessing myositis according to Bohan and Peter (Bohan and Peter 1975a; Bohan and Peter 1975b). IIM clinical subtypes studied included polymyositis (PM), dermatomyositis (DM) and myositis associated with other connective tissue disease (myositis/CTD-overlap). Genotyping of major histocompatibility complex genes, including HLA-B, -DR, -DQ, tumour necrosis factor alpha (TNF-α), was performed using commercial kits. Serotyping of a comprehensive range of myositis specific/associated antibodies (MSA/MAAs) was undertaken. Results: Clinical subsets are described within the serological groupings, suggesting that the classification of the IIMs appears to be better served by the serotype than by the clinical subgrouping of disease. The IIMs possess HLA class I and II haplotype associations and genetic differences observed between PM and DM are accounted for by serological differences. The TNF-308A association is not independent of HLA class I, due to the strong LD within the MHC, but does form part of a haplotype with these factors. An absence of routinely tested for MSA/MAAs makes cancer associated myositis (CAM) more likely, especially in the DM subgroup. An antibody against a 155 and 140kDa doublet is associated with the development of CAM. Outcome measures in the IIMs show construct validity. HLA-DRB1*07 appears to predict a milder clinical phenotype with less disability. No convincing gene-environmental interaction was found capable of altering disease susceptibility or clinical phenotype. Conclusions: Myositis disease subtypes therefore appear to be defined by specific haplotypes acting as risk factors for the development of various MSAs and MAAs.

Introduction Advanced Kadish stage esthesioneuroblastoma requires more extensive resections and aggressive adjuvant therapy to obtain adequate disease-free control, which can lead to higher complication rates. We describe the case of a patient with Kadish D esthesioneuroblastoma who underwent multiple surgeries for infectious, neurologic, and wound complications, highlighting potential preventative and salvage techniques. Case Presentation A 61-year-old man who presented with a large left-sided esthesioneuroblastoma, extending into the orbit, frontal lobe, and parapharyngeal nodes. He underwent margin-free endoscopic-assisted craniofacial resection with adjuvant craniofacial and cervical radiotherapy and concomitant chemotherapy. He then returned with breakdown of his skull base reconstruction and subsequent frontal infections and ultimately received 10 surgical procedures with surgeries for infection-related issues including craniectomy and abscess evacuation. He also had surgeries for skull base reconstruction and CSF leak, repaired with vascularized and free autologous grafts and flaps, synthetic tissues, and CSF diversion. Discussion Extensive, high Kadish stage tumors necessitate radical surgical resection, radiation, and chemotherapy, which can lead to complications. Ultimately, there are several options available to surgeons, and although precautions should be taken whenever possible, risk of wound breakdown, leak, or infection should not preclude radical surgical resection and aggressive adjuvant therapies in the treatment of esthesioneuroblastoma.

付記する学位プログラム名: 充実した健康長寿社会を築く総合医療開発リーダー育成プログラム / 京都大学 / 0048 / 新制・課程博士 / 博士(薬科学) / 甲第22400号 / 薬科博第122号 / 新制||薬科||13(附属図書館) / 京都大学大学院薬学研究科医薬創成情報科学専攻 / (主査)教授 掛谷 秀昭, 教授 二木 史朗, 教授 土居 雅夫 / 学位規則第4条第1項該当 / Doctor of Pharmaceutical Sciences / Kyoto University / DFAM

Les phéochromocytomes (PCC) et les paragangliomes (PGL) sont des tumeurs neuroendocrines rares, pour lesquelles le déterminisme génétique est très important, avec 16 gènes de prédisposition identifiés à ce jour. Au cours de ce travail de thèse, je me suis plus particulièrement intéressée aux conséquences des mutations du gène SDHB, car il avait été préalablement démontré qu’elles constituaient un facteur de risque de mauvais pronostic, associé à un phénotype métastatique et à une réduction de la survie des patients. Grâce à l’analyse du transcriptome d’une large cohorte de 188 échantillons de PCC/PGL humains, j’ai pu mettre en évidence que la voie de la transition épithélio-mésenchymateuse (EMT) était spécifiquement activée dans les tumeurs métastatiques SDHB-dépendantes. En effet, j’ai observé, dans ce sous-groupe de tumeurs, une surexpression de facteurs de transcription et de régulateurs précoces de l’EMT, comme TWIST1, TFC3, ou LOXL2 ; une perte d’expression de marqueurs de jonctions cellulaires, comme CDH2 et KRT19 ; ou encore une induction de gènes codant pour des enzymes pro-invasives, comme MMP1 et MMP2. Dans ces tumeurs, j’ai par ailleurs validé l’induction transcriptionnelle de l’EMT en mettant en évidence la rétention nucléaire de la protéine SNAIL (un facteur de transcription clé de l’EMT) sur des coupes de tissus. Dans cette même cohorte, l’analyse des données de méthylation globale de l’ADN nous a permis d’observer un phénotype hyperméthylateur dans les tumeurs SDHx, qui est expliqué par une inhibition de déméthylases de l’ADN et des histones par le succinate, qui s’accumule dans ces tumeurs où la succinate déshydrogénase est inactivée. Nous avons ainsi pu démontrer que le succinate est un oncométabolite qui induit des modifications épigénétiques impliquées dans l’extinction de nombreux gènes, et en particulier des gènes associés à l’EMT, comme le gène KRT19 (l’un des plus hyperméthylés dans les tumeurs SDHB-malignes, comparativement aux autres). J’ai ensuite caractérisé le premier modèle cellulaire de PCC/PGL porteur d’une inactivation complète du gène Sdhb, dans lequel j’ai confirmé l’activation de l’EMT, au niveau transcriptionnel et au niveau protéique. La caractérisation fonctionnelle de ces cellules m’a ensuite permis de mettre en évidence des propriétés migratoires, invasives, et adhésives spécifiques des cellules chromaffines Sdhb -/-. J’ai par la suite focalisé mon étude sur le gène Krt19, qui code pour une protéine du cytosquelette, la kératine 19 et qui est éteint dans les tumeurs et dans les cellules Sdhb -/-. La réintroduction de ce gène dans les cellules Sdhb -/- et son inhibition dans les cellules sauvages m’ont permis de conclure à l’implication de la kératine 19 dans les processus d’adhésion, de migration et d’invasion. Cependant je n’ai pas pu expliquer l’ensemble du phénotype par la seule modulation de ce gène, ce qui démontre l’implication d’autres acteurs dans la mise en place du phénotype invasif décrit. Mes travaux de thèse ont ainsi permis de démontrer que l’activation de l’EMT est responsable du caractère métastatique et invasif observé dans les tumeurs porteuses d'une mutation sur le gène SDHB et que cette activation est notamment secondaire aux modifications épigénétiques induites par l’inactivation de la succinate déshydrogénase. / Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors for which there is a major impact of genetic determinism with 16 identified predisposition genes to date. During this PhD training, I was particularly interested in the consequences of SDHB gene mutations because it was previously demonstrated that they constitute a high risk factor of poor prognosis, associated with metastatic phenotype and reduced survival. During my thesis, thanks to the analysis of transcriptomic data of a large cohort of 188 human PCC/PGL samples, I identified epithelial to mesenchymal transition (EMT) as activated in SDHB-metastatic tumors. Indeed, I observed a transcriptional induction of TWIST1, TCF3 and LOXL2, which are transcription factors or early regulators of EMT; a loss of expression of cellular junction components such as CDH2 and KRT19; and an up regulation of genes encoding pro-invasive proteases, such as MMP1 and MMP2. In these tumors, I validated the transcriptional induction of EMT by showing a nuclear retention of SNAIL protein, the master EMT transcription factor. In the same cohort, global DNA methylation data allowed us to describe a hypermethylator phenotype in SDHx related tumors, explained by the inhibition of DNA and histones déméthylases by succinate, which accumulates massively in cells inactivated for succinate dehydrogenase. We thus demonstrated that succinate is an oncometabolite responsible for epigenetic modifications implicated in gene extinction, including EMT-related genes such as KRT19 (one of the most hypermethylated genes in SDHB-metastatic samples). Following these observations, I characterized the first PCC/PGL cellular model displaying a complete Sdhb inactivation, in which I confirmed EMT activation, at transcriptional and protein levels. Functional characterization of these cells allowed me to show Sdhb-specific migratory, invasive and adhesive properties. I thus focused my study on Krt19, which encodes keratin 19, a cytoskeleton protein, lost in Sdhb -/- cells and in human SDHB-related tumors. Krt19 rescue in Sdhb -/- cells or Krt19 inhibition in wild-type cells allowed me to conclude that keratin 19 is implicated in adhesion, migration and invasion. However I was not able to explain the whole phenotype observed, demonstrating the implication of other actors in the establishment of the invasive phenotype. The main result of my PhD work is the discovery that EMT is a molecular pathway responsible for the metastatic and invasive phenotype observed in SDHB-mutated tumors as a result of epigenetic alterations due to succinate dehydrogenase inactivation.

Grâce au progrès de la chimiothérapie systémique, la prise en charge de la carcinose péritonéale a connu une révolution avec le développement de la chirurgie de cytoréduction. L'association d'une chirurgie de cytoréduction à une chimiothérapie systémique et intra-péritonéale a permis de proposer à certains patients sélectionnés un traitement à visée curative et représente le traitement de référence pour la plupart des carcinoses d'origine non gynécologique. Toutes les carcinoses et tous les patients sont différents, c'est pourquoi de nombreux travaux ont permis de préciser les facteurs permettant la sélection des patients pouvant bénéficier d'un tel traitement. Le principal facteur pour proposer un traitement curatif d'une carcinose péritonéale est la possibilité de réaliser une résection complète. Malgré ces progrès dans le traitement et la sélection des patients, les résultats restent insuffisants et trop peu de patients présentent une maladie résécable accessible à un traitement curatif. L'apparition des biothérapies et notamment les anti-VEGF offre une nouvelle voie de recherche. Le bevacizumab, anticorps anti-VEGF, a montré une efficacité significative dans le traitement des maladies métastatiques. Il augmente l'efficacité du traitement par chimiothérapie systémique. Le VEGF semble également présenter un rôle important dans le développement et l'agressivité des carcinoses péritonéales. Pour permettre d'augmenter l'efficacité du traitement curatif des carcinoses péritonéales, se discute d'associer du bevacizumab. Cependant, administré par voie systémique il peut majorer la morbidité faisant contre-indiquer son association avec une chirurgie abdominale lourde déjà grevée d'une morbidité importante. L'hypothèse qui a justifié ce travail est que l'administration intra-péritonéale de bevacizumab pourrait augmenter la résécablité et la survie des patients atteints par une carcinose péritonéale d'origine non gynécologique en limitant la morbidité. Le but de ce travail est au travers d'études cliniques et expérimentales d'évaluer la faisabilité et l'efficacité d'un traitement par bevacizumab intra-péritonéale en association au traitement chirurgical de référence pour la prise en charge des CP d'origine non gynécologique / Advances in systemic chemotherapy permitted revolution in the management of peritoneal carcinomatosis with the development of cytoreductive surgery. The combination of cytoreductive surgery with systemic and intraperitoneal chemotherapy offer to selected patients a hope of cure and is considered as the treatment of choice for most carcinomatosis of non-gynecological origin. All carcinomatosis and all patients are different and numerous studies tried to determine factors for selecting patients eligible for such treatment. The mains prognostic factor for curative treatment is the ability to perform a complete cytoreduction. Despite these advances in the treatment and selection of patients, the results are still insufficient and few patients have resectable disease accessible to a cure. The development of biotherapies including anti -VEGF provides a new way of research. Bevacizumab, anti - VEGF antibody, showed significant efficacy in the treatment of metastatic diseases. It increases the efficiency of treatment by systemic chemotherapy. VEGF appears to have an important role in the development and aggressiveness of peritoneal carcinomatosis. To increase the effectiveness of curative treatment of peritoneal carcinomatosis, the combination of bevacizumab to the current standard treatment can be proposed. The bevacizumab administered intravenously may increase morbidity prohibiting its association with major abdominal surgery already burdened with significant morbidity. The hypothesis of this work is that the intraperitoneal administration of bevacizumab may increase resectability and survival of patients with peritoneal carcinomatosis of non- gynecologic origin and limit the morbidity. The aim is through clinical and experimental studies to evaluate the feasibility and the efficacy of treatment with intraperitoneal bevacizumab in combination with standard surgical treatment of peritoneal surface malignancy

Abstract Approximately 1.5 million people are diagnosed with cancer each year. Most of these people will experience pain at some point during or after their treatment. Areas of knowledge that nurses have been shown to have deficits in include assessment and pharmacological management. These types of issues can affect the treatment given to their patients. The purpose of this study is to evaluate the level of knowledge of cancer pain management in oncology and non-oncology nurses and how they compare with each other. To study these variables, two instruments, the Pain Management Knowledge Test and a demographic survey, were distributed to all nurses during two nursing association meetings. Sixty nurses (30 from each association) chose to participate. Descriptive statistics from demographic data were used to analyze the current knowledge of oncology and non-oncology nurses while a t-test was used to determine if there was a significant difference in oncology verses non-oncology nurses knowledge of cancer pain management. The oncology sample consisted of mostly baccalaureate degree nurses with a mean age of 49 with an average of 22 years experience and mostly worked as hospital bedside nurses. The non-oncology group consisted of an equal number of diploma/associate degree nurses and baccalaureate nurses with a mean age of 51 and an average of 25 years experience. Test scores showed that oncology nurses scored significantly higher on the Pain Management and Knowledge Test overall between the two groups (t=2.1, p=0.04). While the oncology nurses have significantly better knowledge of cancer pain management, the overall scores were low for both groups. It is evident that nurses would benefit from additional education in cancer-related pain management in both continuing education programs as well as in schools of nursing as part of their curriculum.

Background Long-term side effects associated with the treatment of Hodgkin’s lymphoma (HL) have frequently been reported during the last decades. Studies have shown increased mortality in HL survivors. Following Hodgkin’s lymphoma, second malignancies (SM) and cardiovascular disease (CVD) are the most common causes of death in individuals treated for HL. This study investigates the incidence of side effects such as SM, CVD and infections in a cohort diagnosed with HL in Sweden between 1965 and 1995. In addition, this study identifies covariate risk factors for late side effects in order to develop strategies that prevent morbidity and mortality in HL survivors. Methods Using the Swedish Cancer Registry (SCR) at the National Board of Health and Welfare and the Multi-Generation Registry at Statistics (MGR) Sweden, we identified 6946 individuals diagnosed with HL between the years 1965 and 1995, and their first degree relatives (FDR) (n=17 858). In addition we identified the malignancies and inpatient care for CVD and infections for the HL cohort and their FDR. The standard incidence ratio (SIR) was calculated for the risk of SM, CVD and infections. For SM and CVD the risk also was stratified and calculated for family history of disease. The Swedish Hodgkin Intervention and Prevention study (SHIP), a prospective study, invited 702 individuals treated for HL at the age of 45 years or younger and who were treated in the region of Skåne, Uppsala or Umeå. The participants completed a questionnaire and were invited to an out-patient visit to an oncologist with clinical examination and blood tests. Any pathological findings were referred for further investigation. Results An increased risk for SM in HL long-term survivors was observed and seems to increase with the number of FDRs with cancer. There was also an increased risk for inpatient care due to congestive heart failure (CHF) and coronary artery disease (CAD). A family history of CHF and CAD further increased the risk for these diseases. The risk for inpatient care due to infections was increased and remained increased after 20 years or longer. The risk for infections was associated with splenectomy and hypothyroidism. Radiotherapy was an independent risk factor for cardiovascular disease in the cohort of the prospective study. ConclusionLong-term survivors from HL have an increased risk for developing late side effects such as SM, CVD and infections. Since many HL patients are young and the cure rate from the disease is high, it is of great importance to offer focused surveillance programs to selected individuals who are at high risk, e.g. individuals who received radiotherapy as part of their treatment and who have other known risk factors for cardiovascular disease such as hypertension, hypercholesterolemia, family history and smoking.