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

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

Continuing Medical Education Announcement Harvard Medical School RSS 3081: Monthly BOTSOGO Tumor Board; 2017-2018 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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64yoF with non-productive cough Early 2017 - 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

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

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

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.

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

Botswana-MGH Pathology Collaboration Dr. Aliyah Sohani

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

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

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)

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

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

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

Botswana flow lab

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.