A 64yo female with tuberculous empyema not improving on treatment: A tribute and farewell to Dr. Alphonse Kayembe

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1 A 64yo female with tuberculous empyema not improving on treatment: A tribute and farewell to Dr. Alphonse Kayembe

2 Continuing Medical Education Announcement Harvard Medical School RSS 3081: Monthly BOTSOGO Tumor Board; Academic Year Today s Objectives: Describe the need for timely cancer case presentation and referral to treatment Formulate a multi-disciplinary plan for the care of common and complex oncologic cases Adopt successful, sustainable strategies to mitigate barriers to quality cancer care common in resource constrained environments Target Audience: Oncologists, internists, surgeons, radiation oncologists, infectious disease specialists, nurses, physicists, therapists, technicians, research staff, administrators, policy makers.

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4 Statements Accreditation Statement The Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians Credit Designation Statement The Harvard Medical School designates this live activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity This activity meets the criteria of the Massachusetts Board of Registration in Medicine for 1.0 credits of Risk Management Study Disclosure Statement In accord with the disclosure policy of the Medical School as well as standards set forth by the Accreditation Council for Continuing Medical Education, course planners, speakers, and content reviewers have been asked to disclose any relevant relationship they, or their spouse or partner, have to companies producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients.

5 Claim your CME credits! To claim your CME credit for attendance at this session of the BOTSOGO Tumor Board, please fill out our survey after the Tumor Board. You can do this at your convenience on your personal or work computer by navigating to Click What We Do Click Tumor Board Click the link under the section Continuing Education Credits, and complete and submit the survey Or follow the link that was ed to our MGH BOTSOGO list:

6 64yoF with non-productive cough Early Started with cough, non-productive - Became more persistent and with SOB - Weight loss and subjective fevers History/exposures - Longstanding hypertension on HCTZ and nifedipine - HIV negative and retested negative - No household TB exposures - No tobacco use or alcohol - Cousin with breast cancer - No personal income but no food insecurity, indoor toilet; lives with 5 family members

7 64yoF with non-productive cough Presumptive TB diagnosis - Exam and whether any diagnostics done not documented No clinical improvement - Progression of dyspnea, continued cough - ~2mo after initial presentation, thoracentesis done with improvement in SOB - However, symptoms recurred - Continued taking TB therapy

8 64yoF with non-productive cough Presented to a military clinic/hospital (5mo after initial presentation) - CXR with space occupying lesion in L apex, and large left pleural effusion - Clinician concerned for possibility of malignancy, repeat thoracentesis - Cytology with inflammatory cells, and suspicious for malignancy - AFB negative Brief admission at SLH - Booked for CT chest, but next available was 4 mo later

9 64yoF with non-productive cough Patient stuck in a diagnostic and treatment impasse - TB seems unlikely no improvement, no known exposure to MDR, HIV uninfected, cytology not consistent - No obvious cutaneous malignancy that could be biopsied - Biopsy of lung mass in public sector and would need CT imaging (>4mo wait for scan and 1-2mo for read/films) - Presumptive treatment for possible lung malignancy with large risk of causing harm A diagnostic procedure was done.

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15 64yoF with non-productive cough Second opinion review of pleural fluid cytology - Report appended to state: adenocarcinoma Admitted to oncology - Staged T3 Nx M1 - TB treatment stopped - Started on palliative carboplatin/docetaxel Ongoing therapy - Received 4 cycles of planned 6, continues to have symptomatic improvement, no SOB - Reports good quality of life

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21 Botswana-MGH Pathology Collaboration Dr. Aliyah Sohani

22 Advancing the diagnosis and treatment of lymphomas in Botswana Two of the aims of this study funded by the Paul Allen Foundation, with Bruce Chabner as PI, involved pathology capacity building Dr. A. Sohani and Dr. A. Kayembe worked together to enhance pathologic subtyping of lymphomas by immunohistochemistry 2 MGH visits by Dr. Kayembe for training and data analysis Identified areas of focus for consultation and additional testing to enhance lymphoma subclassification

23 Drs. Musimar, Sohani, Kayembe at the New England Lymphoma Rounds

24 Summary of Lymphoma Classification 70 cases reviewed and characterized at MGH Hodgkin s Lymphoma: 20/70 cases (29%) Non-Hodgkin s Lymphoma: 47/70 cases (67%) Other (n=3) 2 cases requiring additional clinical correlation Multiple myeloma (vs. plasmablastic lymphoma) Drug reaction (vs. cutaneous T-cell lymphoma) 1 poorly differentiated malignant neoplasm (originally called Hodgkin s lymphoma) Overall reclassification rate: 27% (19/70 cases)

25 Classical Hodgkin s Lymphoma (CHL) Subtypes (20 cases) 11 mixed cellularity 6 nodular sclerosis 2 lymphocyte rich 1 lymphocyte depleted Most EBV+ (83%) All were originally diagnosed as Hodgkin s lymphoma in Botswana EBV

26 Non-Hodgkin s Lymphoma (NHL) Aggressive B-cell lymphomas (n=37) Diffuse large B-cell lymphoma (DLBCL): 28 cases 5 originally called CHL and 1 plasmablastic lymphoma Plasmablastic lymphoma (PBL): 5 cases 3 originally called DLBCL Probable Burkitt lymphoma: 3 cases All originally called DLBCL Mantle cell lymphoma (MCL): 1 case Indolent B-cell lymphomas (n=6) 4 small lymphocytic lymphoma (SLL) 1 originally called DLBCL and 1 MCL 2 low-grade follicular lymphoma 1 originally called CHL Peripheral T-cell lymphomas (n=4) 2 ALK-negative anaplastic large cell lymphoma 1 originally called CHL 2 peripheral T-cell lymphoma, NOS 1 originally called DLBCL and 1 reactive lymphoid hyperplasia DLBCL PBL SLL ALCL

27 Capacity building in flow cytometry Specimen types sent for assessment: Cerebral Spinal Fluid Peripheral blood Lymph Node Fine Needle Aspirate Lymph Node Biopsy Bone Marrow Non-Hodgkin s Lymphoma/Hematologic Malignancies: Chronic Lymphocytic Leukemia Mantle Cell Lymphoma Burkitt s Lymphoma Follicular Lymphoma Marginal Zone Lymphoma Splenic Marginal Zone Lymphoma Plasmablastic Lymphoma Cutaneous T-cell Lymphoma/Sezary/Mycosis Fungoides LGL Leukemia Waldenstroms Macroglobulinemia NK-cell tumors 4-color BD FACSCalibur flow cytometer

28 Botswana flow lab

29 Other pathology connections Dr. D. J. Roberts has visited the National Health Laboratory in Botswana three times for projects and capacity building. She has worked with Dr. Kayembe on improving turn around time and in house immunohistochemistry services.

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