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Invasive fungal infections in children with acute lymphoblastic leukemia have been a major cause of mortality. Recent reports have described increasing incidence of invasive non-Aspergillus mold infections in patients with hematological malignancies. It is always challenging to treat invasive fungal infection and underlying hematological malignancies successfully. Here we report a girl with high-risk acute lymphoblastic leukemia who developed disseminated Cunninghamella bertholletiae infection during induction chemotherapy. This case illustrates the difficulties of diagnosis and treatment of invasive C. bertholletiae infection. It also highlights the necessity for physicians to keep high suspicion and awareness for this infrequent fungal infection.

We sought to investigate the clinical utility of F-18 fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) in Taiwanese patients with cancer of unknown primary site (CUP) and cervical nodal metastases. We also aimed to study the impact of F-18 FDG PET/CT on clinical treatment priority in this patient group. Between September 2006 and May 2014, patients with CUP and cervical nodal metastases who underwent F-18 FDG PET/CT imaging study were retrospectively identified. The clinicopathological risk factors and PET parameters were analyzed in relation to 2-year overall survival (OS) rates using univariate and multivariate analyses. Two-year OS curves were plotted with the Kaplan-Meier method. Of the eligible patients (n = 54), 12 (22.2%) had distant metastases (DM) at presentation. A total of 13 (24.1%) and 15 (27.8%) primary tumors were identified by FDG PET/CT imaging and an additional triple biopsy, respectively. The results of multivariate analysis identified smoking [p = 0.033, 95% confidence interval (CI) = 1.197-40.342], a maximum standardized uptake value (SUVmax) of cervical nodes ≥ 14.2 (p = 0.035, 95% CI = 1.134-28.029), and DM at presentation (p = 0.031, 95% CI = 1.257-114.854) as independent predictors of 2-year OS. Specifically, patients who carried ≥ 2 risk factors showed poorer outcomes (70.3% vs. 11.8%, p < 0.001). Fifteen study patients (27.8%) had their treatment modified by FDG PET/CT findings. We conclude that FDG PET/CT is clinically useful in CUP patients not only for tumor staging, but also for modifying treatment regimens.

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