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Cutaneous PTCL-NOS is a rare and aggressive variant of cutaneous T-cell lymphoma with unfavourable prognosis. First line treatment includes anthracycline based regimens. However, the disease tends to be refractory to chemotherapy and patients relapse very quickly. We present a case of cutaneous PTCL-NOS, follicular T-helper phenotype, CD30+, successfully treated with brentuximab vedotin after rapid progression under two standard chemotherapy regimens and TSEBT. The baseline PET/CT in May 2020 (prior to cycle 1 of brentuximab) showed metabolically active subcutaneous nodules throughout the body, with muscle involvement in both legs. The patient already had 2 lines of chemotherapy (CHOP) with progressive multiple focal lesions following cycle 4. The treatment was switched to GCVP – 4 cycles completed 15.08.19 – after which she had further progression. The only available treatment options were either gemcitabine/oxaliplatin containing chemotherapy or CEPP regimen (cyclophosphamide, etoposide, procarbazine, prednisolone). Both treatments had a low chance to be beneficial, considering the rapid progression on the previous two chemotherapy lines. In view of the CD30 positivity (more than 30%) we considered treatment with brentuximab vedotin, which we obtained as compassionate use supply. We started treatment in September 2020 and a restaging PET/CT showed partial response after cycle 4 and complete metabolic response after cycle 8. The patient was still free from recurrence after cycle 13. The treatment tolerance was excellent with only G1–G2 peripheral neuropathy. There was one episode of G3 peripheral neuropathy post cycle 10, which improved back to G1 after giving 2 weeks break from treatment. PTCL NOS is characterised by poor overall survival (20–30% at 5 years) and rapid progression. The treatment with brentuximab vedotin has proven to be safe and effective in our patient, with maintained response at 10 months after treatment initiation.

“Mutational signatures” are patterns of mutations that report DNA damage and subsequent repair processes that have occurred. Whole-genome sequencing (WGS) can provide additional information to standard diagnostic techniques and can identify therapeutic targets. A 32-yr-old male with xeroderma pigmentosum developed metastatic angiosarcoma that was unresponsive to three lines of conventional sarcoma therapies. WGS was performed on his primary cancer revealing a hypermutated tumor, including clonal ultraviolet radiation-induced mutational patterns (Signature 7) and subclonal signatures of mutated DNA polymerase epsilon (POLE) (Signature 10). These signatures are associated with response to immune checkpoint blockade. Immunohistochemistry confirmed high PD-L1 expression in metastatic deposits. The anti-PD-1 monoclonal antibody pembrolizumab was commenced off-label given the POLE mutation and high mutational load. After four cycles, there was a significant reduction in his disease with almost complete resolution of the metastatic deposits. This case highlights the importance of WGS in the analysis, interpretation, and treatment of cancers. We anticipate that as WGS becomes integral to the cancer diagnostic pathway, treatments will be stratified to the individual based on their unique genomic and/or transcriptomic profile, enhancing classical approaches of histologically driven treatment decisions.

Strongyloidiasis is associated with Gram-negative bacteremia. Septic portal vein thrombosis or pylephlebitis is a rare but serious complication of intra-abdominal infection, and it is often associated with Bacteroides bacteremia. We present the first report of pylephlebitis with Bacteroides bacteremia associated with underlying Strongyloides stercoralis infection and briefly review the management of septic portal vein thrombosis.

Pulmonary embolism is one of the leading causes of mortality in pregnancy in the Western world. No clinical prediction models have been validated in pregnancy. As a result, any pregnant woman presenting with signs possibly consistent with pulmonary embolism is investigated radiologically. This study investigates whether using clinical prediction models for pulmonary embolism in pregnancy should be pursued in future prospective trials. The aim of this study was to retrospectively evaluate the Wells clinical prediction model and ventilation-perfusion scanning for pulmonary embolism in pregnancy. A retrospective study was performed on consecutive pregnant women who presented with suspected pulmonary emboli and underwent ventilation perfusion scanning at two tertiary institutions from 2007 until 2010. The clinical pretest probability was determined as likely or unlikely by two independent clinicians retrospectively using Wells-modified criteria. Scans were determined as normal, nondiagnostic or high probability for pulmonary emboli independently by two experienced radiologists. Disagreements were resolved by a third assessor independently. In 183 pregnant women, the pretest probability was determined as 'pulmonary emboli likely' in 76 (42%) and 'pulmonary emboli unlikely' in 107 (58%) of women. Scans were of high probability in four (2%), nondiagnostic in six (3%) and normal in 173 (95%) of women. This gives the pretest probability using Wells-modified criteria a sensitivity of 100% [95% confidence interval (CI) 0.4-1.0] and a negative predictive value of 100% (95% CI 0.96-1.0). A structured clinical model such as modified Wells criteria may be useful in pregnancy, but further prospective evaluation is required.

The diagnosis and management of pulmonary embolism in pregnancy is difficult, because diagnostic procedures and the use of anticoagulants potentially can expose mother and fetus to adverse effects. This article reviews evidence for current best practice and emerging novel techniques for the diagnosis of pulmonary embolism in pregnancy and includes clinical prediction models, biomarkers, and diagnostic imaging that may offer improvement in the diagnosis and investigation of pulmonary embolism in pregnancy in the future. The usefulness of new anticoagulant agents (fondaparinux, rivaroxaban, and dabigatran) in managing pulmonary embolism in future pregnancies is also explored.