Question

14. In 2017, Kim Jong Nam, a North Korean man traveling at Malaysia's Kuala Lumpur's airport was attacked and received a lethal exposure to VX (a very potent acetylcholinesterase inhibitor) to his face. Based on what you've learned already of the pathophysiology of the nervous system signal transmission, describe how this toxic substance (which is oily and easily penetrates skin) could be responsible for this man's death based on the pathophysiologic effects, signs and symptoms would be expected from this type of exposure. Who was this man, how old was he and why is this now considered to have been an assassination? 15. Case Study Question: Mr. H is a 30-year-old man who reported to his physician that he has recently lost weight, always seems tired, and has experienced night sweats. A few months ago, he noticed a small firm lump on his neck that was painless and not tender, so he ignored it. Closer physical examination revealed a swelling of several lymph nodes in the neck and throat region. A blood test indicated a decreased lymphocyte count and a lymph node biopsy revealed the presence of Reed-Sternberg cells, confirming the diagnosis of Hodgkin's lymphoma. Briefly describe: i. The four stages of the disease based on the Ann Arbor staging system, and ii. Briefly describe the prognosis, imaging techniques that might be valuable and ii. According to the article in The Oncologist for your reading, how might PET determine which stage the patient is probably in current, standard of care, treatments for this condition. imaging he effectivelv nsed in this case

Answer 1

I	Involvement of a single lymphatic site (i.e., nodal region, Waldeyer's ring, thymus, or spleen) (I); or localized involvement of a single extralymphatic organ or site in the absence of any lymph node involvement (IE).
II	Involvement of two or more lymph node regions on the same side of the diaphragm (II); or localized involvement of a single extralymphatic organ or site in association with regional lymph node involvement with or without involvement of other lymph node regions on the same side of the diaphragm (IIE).
III	Involvement of lymph node regions on both sides of the diaphragm (III), which also may be accompanied by extralymphatic extension in association with adjacent lymph node involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE,S).
IV	Diffuse or disseminated involvement of one or more extralymphatic organs, with or without associated lymph node involvement; or isolated extralymphatic organ involvement in the absence of adjacent regional lymph node involvement, but in conjunction with disease in distant site(s). Stage IV includes any involvement of the liver or bone marrow, lungs (other than by direct extension from another site), or cerebrospinal fluid.
Designations applicable to any stage
A	No symptoms.
B	Fever (temperature >38ºC), drenching night sweats, unexplained loss of >10% of body weight within the preceding 6 months.
E	Involvement of a single extranodal site that is contiguous or proximal to the known nodal site.
S	Splenic involvement. Most probably the patient will be in the second stage. Radiation therapy and chemotherapy alone or in combination have been proposed as the main treatment approaches for patients at an early or advanced stage of Hodgkin lymphoma. In some cases, these therapies have resulted in complete response and prolonged survival (1). Evaluating how a patient may respond to treatment is important, but difficult, especially in patients with residual radiological abnormalities. Imaging techniques represent a significant and effective method by which therapeutic strategies for patients with Hodgkin disease can be managed. Gallium-67 citrate uptake is transferrin receptor-dependent, and it can be used to reveal an active metabolic process and also to predict disease activity in residual mediastinal mass following therapy. This tracer is not absorbed in fibrotic or necrotic tissue; however, it is absorbed by avid and viable HL ( Hodgkin Lymphoma) tissue. As such, 67Ga is proposed as an indicator of tumor viability (2). Whole-body 67gallium (67Ga) scintigraphy is a valuable and sensitive imaging tool, not only for the diagnostic purposes of lymphoma, but also for evaluating the response to treatment including complete remission, partial remission, and recurrence of the disease. Although the 67Ga scintigraphy procedure is able to predict how patients with Hodgkin lymphoma may respond to treatment, physiological accumulation of gallium in the intestine limits the efficacy of this imaging tool in abdominal parts of the body (3). As such, a gallium scan is more sensitive for lesions that are located above the diaphragm than it is for abdominal and pelvic diseases (4). The 99mTc-MIBI (99mTc-methoxyisobutylisonitrile) imaging procedure is recognized to have a prognostic factor regarding response to chemotherapy in various types of malignancies including lung cancer (5), malignant lesions (6), Hodgkin’s and non-Hodgkin’s lymphoma, etc. (7-9). The effectiveness and utility of 99mTc-MIBI scintigraphy has also been investigated in some types of lymphomas. However, these studies have typically employed different methodologies and obtained different results. This systematic review studied the results described in various articles that focused on the prognostic value of conventional imaging techniques that employed Ga67 and 99mTc-MIBI. The inclusion criteria were all articles that studied the prognostic value and sensitivity of gallium scintigraphy and Technetium-99m-sestamibi in predicting response treatment and disease outcome. According to the included studies, response to treatment was reported as complete remission, partial remission, and relapse of the disease. The procedures can be performed before initiating the therapy, during the treatment, or after the treatment. Only English-language articles were included in this systematic review. No limitations regarding date of publication were applied. The exclusion criteria were all the non-English articles that studied patients with lymphomas except Hodgkin and any articles that investigated the diagnostic sensitivity or staging accuracy of the mentioned imaging strategies. 18-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) is currently the most valuable imaging technique in Hodgkin lymphoma. Since its first use in lymphomas in the 1990s, it has become the gold standard in the staging and end-of-treatment remission assessment in patients with Hodgkin lymphoma. The possibility of using early (interim) PET during first-line therapy to evaluate chemosensitivity and thus personalize treatment at this stage holds great promise, and much attention is now being directed toward this goal. With high probability, it is believed that in the near future, the result of interim PET-CT would serve as a compass to optimize treatment. Also the role of PET in pre-transplant assessment is currently evolving. Much controversy surrounds the possibility of detecting relapse after completed treatment with the use of PET in surveillance in the absence of symptoms suggestive of recurrence and the results of published studies are rather discouraging because of low positive predictive value. This review presents current knowledge about the role of 18-FDG-PET/CT imaging at each point of management of patients with Hodgkin lymphoma