Feasibility and clinical value of CT-guided 125I brachytherapy for metastatic soft tissue sarcoma after first-line chemotherapy failure.

PURPOSE: To evaluate the feasibility and usefulness of computed tomography (CT)-guided iodine125 (125I) brachytherapy for patients with metastatic soft tissue sarcoma (STS) after first-line chemotherapy failure. METHODS: We recruited 93 patients with metastatic STS who had received first-line chemotherapy 4-6 times but developed progressive disease, from January 2010 to July 2015; 45 patients who had combined 125I brachytherapy and second-line chemotherapy (Group A), and 48 patients who received second-line CT only (Group B). RESULT: In Group A, 49 125I seed implantation procedures were performed in 45 patients with 116 metastatic lesions; the primary success rate was 91.1% (41/45), without life-threatening complications. Local control rates at 3, 6, 12, 24 and 36 months were 71.1%, 62.2%, 46.7%, 28.9% and 11.1% for Group A, and 72.9%, 54.2%, 18.8%, 6.3% and 0% for Group B. Mean progression-free survival differed significantly (Group A: 7.1±1.3 months; Group B: 3.6 ±1.1 months; P<0.001; Cox proportional hazards regression analysis), but overall survival did not significantly differ (Group A: 16.9 ±5.1 months; Group B: 12.1 ± 4.8 months). Group A showed better symptom relief and quality of life than Group B. CONCLUSION: CT-guided 125I brachytherapy is a feasible and valuable treatment for patients with metastatic STS. KEY POINTS: • 125 I brachytherapy is feasible and valuable for treating metastatic soft tissue sarcoma. • 125 I brachytherapy represents a prominent activity in disease control. • 125 I brachytherapy can achieve better symptom relief and quality of life.

Tumor-induced Osteomalacia in a 3-Year-Old With Unresectable Central Giant Cell Lesions.

Tumor-induced osteomalacia (TIO) is a rare cause of hypophosphatemia involving overproduction of fibroblast growth factor 23. TIO has been described largely in adults with small mesenchymal tumors. We report a case of TIO in a child who presented with knee pain and radiographic findings concerning for rickets, and was found to have maxillomandibular giant cell lesions. The patient was treated with oral phosphorus and calcitriol, surgical debulking, and intralesional corticosteroids, which resulted in tumor regression and normalization of serum fibroblast growth factor 23 and phosphorus. This case illustrates the occurrence of this rare paraneoplastic syndrome in children and adds to our knowledge about clinical manifestations and pathologic findings associated with pediatric TIO.

Adjuvant Antiangiogenic Treatment for Aggressive Giant Cell Lesions of the Jaw: A 20-Year Experience at Massachusetts General Hospital.

PURPOSE: To document long-term outcomes using a standardized treatment protocol of enucleation with preservation of vital structures and adjuvant subcutaneous interferon for aggressive giant cell lesions (GCLs) of the jaws. MATERIALS AND METHODS: A retrospective cohort study was designed. We evaluated all patients treated at Massachusetts General Hospital from April 1995 through September 2015 by enucleation with preservation of vital structures and adjuvant daily subcutaneous interferon for aggressive GCLs. The sample included patients with complete medical records consisting of clinical, radiographic, histopathologic, and follow-up data. The exclusion criteria included patients with incomplete records, contraindications to interferon therapy, non-aggressive GCLs, and GCLs associated with syndromes or with hyperparathyroidism. The primary outcome variable was long-term progression-free survival (PFS). The secondary outcome variables were adverse effects and laboratory abnormalities classified by type, frequency, and severity. Predictor variables for recurrence or failure included age, gender, location and features of lesion, type of procedure, duration of interferon treatment, amount of bone fill at end of treatment, and adverse effects. Descriptive statistics, Kaplan-Meier survival analysis, and Cox proportional hazards regression analysis were computed. RESULTS: Of a total of 77 patients, 45 (mean age, 18.8 ± 12.5 years; 29 female patients; 36 in whom the mandible was affected) met the inclusion criteria. The mean duration of interferon therapy was 7.9 ± 2.3 months. After follow-up of 4.8 ± 3.9 years, 6 patients showed progression of the lesion, considered recurrence (13.3% failure rate, 82.6% PFS rate). Most patients had mild (n = 42; 93.3%) and/or moderate (n = 31; 68.8%) side effects, which were readily managed. Adverse effects required stoppage of interferon in 7 patients, whereas no patients had long-term toxicity. No variable was significantly associated with PFS. CONCLUSIONS: The results of this study indicate that enucleation with preservation of vital structures in combination with adjuvant interferon alfa is a reliable treatment for aggressive GCLs of the jaws associated with a low recurrence rate.

Primary non-metastatic Ewing sarcoma of the jaw in children: results of surgical resection and primary reconstruction.

BACKGROUND AND OBJECTIVE: The rarity of Ewing sarcoma (ES) of the jaw coupled with the technical challenge of resection and associated functional and cosmetic impairment has resulted in deficient data on surgical management of these tumors. The purpose of this study is to describe the results of surgical excision and reconstruction of primary non-metastatic ES of the mandible and maxilla in children. METHODS: Consecutive patients (mandible = 6, maxilla = 5) treated with surgery from August 2005 to January 2013 were selected. All patients received induction chemotherapy and were selected for surgical resection based on the presence of specific criteria for operability. RESULTS: The median age was 11.5 years (range 5-16 years). Free fibular osteocutaneous flap was commonly used for reconstruction. There were no complications related to microvascular anastomosis or flap loss. Five patients had 100% tumor necrosis and did not receive radiotherapy. Teeth alignment, chewing, swallowing, and speech were normal in all and donor site morbidity occurred in one. The 5-year overall, event-free survival, and local control are 87.5%, 72.9%, and 90%, respectively. CONCLUSION: In eligible patients, surgery with contemporary reconstruction results in optimal oncological and functional outcome. Surgery also has the added advantage of identifying patients who may not need radiotherapy.

Case of metastatic clear cell odontogenic carcinoma with response to chemoimmunotherapy.

Our patient initially presented with 6 months of left jaw pain and gingival bleeding, leading to the discovery of a radiolucent left maxillary mass on dental evaluation. A biopsy confirmed clear cell odontogenic carcinoma, and the patient was treated with definitive surgery and radiation for localised disease. Unfortunately, the patient was found to have pulmonary metastases 3 months after initial management and was subsequently treated with a combination of cytotoxic chemotherapy and immunotherapy with a partial response. To our knowledge, this is the first case demonstrating the successful use of chemoimmunotherapy in metastatic clear cell odontogenic carcinoma.

Aseptic meningitis: a rare side effect of cetuximab therapy.

Cetuximab, a chimeric IgG1 monoclonal antibody against the epidermal growth factor receptor, is indicated for the treatment of epidermal growth factor receptor-expressing metastatic colorectal cancer and recurrent or metastatic squamous cell cancer of the head and neck after failure of platinum-based therapy. The commonly reported side effects of cetuximab are infusion-related reactions, skin rash, fatigue, malaise and nausea. We report a case of aseptic meningitis developing as a rare side effect in a patient of stage IVB squamous maxillary cancer treated with cetuximab. To our knowledge, there have been very few cases of cetuximab-induced aseptic meningitis reported in literature. Clinicians should recognize that self-limiting aseptic meningitis can occur with administration of cetuximab. Our case report may serve as an additional reference for clinicians encountered with aseptic meningitis in the setting of using cetuximab.

Primary extranodal B-cell non-Hodgkin lymphoma mimicking an endodontic lesion: report of 2 cases.

Intrabony oral non-Hodgkin lymphoma (NHL) is rare. We report 2 cases of NHL of the maxilla that initially presented as apical abscesses in endodontically treated teeth. Radiographic findings were nondescript, but tissue biopsy revealed diffuse large B-cell NHL in both instances. No other sites of disease were found. Both patients were treated by chemotherapy and radiation with good results. As primary NHL of the maxilla can mimic a dental inflammatory lesion, tissue biopsy is mandatory in cases where symptoms do not resolve after specific treatment.

Maxillary solitary recurrent plasmacytoma: a case report.

Solitary plasmacytoma is a very rare form of neoplasia, part of the monoclonal gammopathies. It represents a tumoral proliferation of plasma cells in the form of a solitary mass which can be located in the bone marrow or extramedullary.Initial symptoms are vague and nonspecific. Being such a rare affliction, there is little information in the literature. Early diagnosis is difficult but very important due to therapy outcome.A high risk of progression towards a multiple myeloma has been reported. We present a rare case of a 52-year-old patient diagnosed with multiple solitary plasmacytomas. The tumours were separated from one another in time, over a 14 years period. The various medullograms did not show any sign of medullary plasma cell infiltrate. Initially, the affliction responded to chemotherapy, but later the haematologist recommended surgical resections followed by reconstruction.The maxillary localization required excision of the tumour with the preservation of the eye bulb despite the destruction of the orbital floor and with the regain of ocular functionality as well as aesthetic rehabilitation. This evolution highlights the benefits of surgical treatment in conjunction with chemotherapy in the treatment of this entity.

Keratocystic odontogenic tumors and Carnoy's solution: results and complications assessment.

OBJECTIVE: Keratocystic odontogenic tumors (KOTs) can be treated with Carnoy's solution, although this treatment modality is not free from complications. It is important to verify the incidence of complications after the use of Carnoy's solution and compare these with the literature. MATERIALS AND METHODS: This study verified the effects of a complementary treatment for KOTs and assessed the incidence of such complications as recurrence, infection, sequestrum formation, mandibular fracture, dehiscence, and neuropathy. RESULTS: Twenty-two KOTs treated with Carnoy's solution combined with peripheral ostectomy were included, and the follow-up period varied from 12 to 78months with a mean of 42.9months. Complications included recurrence (4.5%), dehiscence (22.7%), infection (4.5%), and paresthesia (18.2%). No difference was found among lesions associated (9.1%) or not (0%) with nevoid basal cell carcinoma syndrome (P>0.05). Dehiscence was influenced by marsupialization (P<0.05), and paresthesia was observed exclusively in cases of mandibular canal fenestration (P<0.01). CONCLUSIONS: Complementary treatment with Carnoy's solution and peripheral ostectomy appear to provide efficient treatment for KOTs. Complications originating from the use of the solution are less frequent and less serious than complications associated with cryotherapy. Neuropathy seems to be related to direct contact between the solution and the epineurium.

Outcomes of patients with maxillofacial osteosarcoma: a review of 15 cases.

PURPOSE: To assess clinical behavior, response to treatment, and factors affecting survival in maxillofacial osteosarcoma treated at a tertiary referral center. PATIENTS AND METHODS: Ethics-approved retrospective review of clinical and pathological records was undertaken for 15 patients managed by the Royal Melbourne Hospital Head and Neck Oncology Tumor Stream. RESULTS: Treatment was a combination of surgery and chemotherapy. Chemotherapy was given as adjuvant, neoadjuvant, or in combination. The overall 2-, 5-, and 15-year disease-free survival rates in this study were 92%, 74%, and 74%, respectively. Using Kaplan-Meier analysis with log rank tests, increasing T stage (P = .01) and positive margins (P = .003) were found to affect survival significantly. Neoadjuvant chemotherapy was not significantly associated with tumor necrosis or improved survival. CONCLUSIONS: Tumor size and adequacy of local control were found to be the most important predictors of outcome.

Maxillary sinus squamous cell carcinoma with concurrent prolonged foreign body impaction.

Several elements in the maxillary sinus are reported to be carcinogenic. Also, foreign body reaction can cause cancer in any part of the body. We report a case of squamous cell carcinoma at the site in the maxillary sinus where a bullet splinter, analyzed as iron afterward, was inserted during the Korean War, approximately 60 years earlier.

HIV-associated oral plasmablastic lymphoma and role of adherence to highly active antiretroviral therapy.

Plasmablastic lymphoma (PBL) is an HIV-associated non-Hodgkin's lymphoma that primarily affects the oral cavity. We describe the case of an HIV patient with a lesion in the maxilla that lasted four months. He was diagnosed with PBL and received highly active antiretroviral therapy as well as chemotherapy and local radiotherapy. The lesion regressed after the third cycle of chemotherapy. The patient interrupted antiretroviral treatment and the lesion recurred. The immune reconstitution secondary to the use of antiretroviral therapy seems to participate in the regression of PBL and maintains the remission of the tumour, but it might not be enough to prevent the development of PBL.

Non-resolving periapical inflammation: a malignant deception.

AIM: To report a case of oral non-Hodgkin's lymphoma with a delayed diagnosis. SUMMARY: Non-Hodgkin's lymphoma of the oral cavity is an uncommon but important condition. Early diagnosis is complicated when the presenting signs and symptoms are similar to those of odontogenic infections. This report describes the case of a 38-year-old female patient who presented to her dentist complaining of pain in her upper jaw. Subsequent dental treatment, including extraction, root canal treatment and apicectomy including biopsy were carried out by the patient's dentist and local dental hospital. Nine months elapsed before a more extensive surgical exploration established a diagnosis of lymphoma.

The use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions.

Various techniques have been used to repair maxillary defects. The aim of this study was to evaluate the suitability of pedicled temporal musculoperiosteal flap (PTMF) and free calvarial bone graft for the reconstruction of maxillary defects. In this retrospective series, 34 patients operated on from 1995 to 2006 at Turku University Central Hospital because of defects of maxilla reconstructed using PTMF with or without free calvarial bone graft were evaluated. The diagnosis, the indication for surgery, the location and staging of the tumours, and the type of radiotherapy used were reviewed. The classification of the maxillary defects was performed according to the classification of Brown (Br J Oral Maxillofac Surg 40:183-190, 2002) and the success rates of the reconstructions were evaluated. Of the patients, 32 had been operated on due to a malignant tumour, one due to a benign tumour and one due to posttraumatic palatal defect. Preoperative radiotherapy (n = 14), preoperative chemoradiotherapy (n = 2) or postoperative radiotherapy (n = 11) had been used in the tumour group. As a reconstructive method, PTMF had been used with (n = 21) or without (n = 13) free calvarial bone graft. The use of free calvarial bone graft did not have a significant effect on flap survival. At 1-month follow-up, the flap survival in the 32 patients was 71.9%, whereas 28.1% of the patients suffered from partial flap loss, but there was no total flap loss. At 6-month follow-up, the flap survival in 26 patients was 76.9%, whereas 7.7% of the patients suffered from partial flap loss, and there were four (15.4%) total flap losses. If unilateral alveolar maxillectomy had been performed (Brown classification a), at 1-month follow-up, the flap survival was 82.6%, 17.4% of the patients suffered from partial flap loss, and there was no total flap loss. At 6-month follow-up, the flap survival was 89.5%, while 10.5% of the patients suffered from partial flap loss, and there was no total flap loss. The application of PTMF with or without free calvarial bone graft for reconstruction of limited palatal and maxillary defects appears to be feasible.

[Granulocytic sarcoma in the mandibular gingiva of an HIV+ patient]. / Sarcome granulocytique gingival mandibulaire chez un patient VIH positif.

INTRODUCTION: The association between malignant tumors and HIV infection is well known. We report a rare case of gingival granulocytic sarcoma (GS) associated to HIV infection. OBSERVATION: A 31 year-old HIV patient consulted for left maxillary tumefaction. His viral load was high (40,112 copies/ml) and CD4 count low (287cells/mm(3)). After biopsy-exeresis, histology and an immunohistochemical study confirmed the diagnosis of GS. Chemotherapy similar to that of acute myeloid leukemia (AML) completed the treatment. The remission was complete at 5 years. DISCUSSION: Only one case of intra-oral GS associated to HIV infection has been reported so far. The clinical and radiological presentation is unspecific. Histology proves the diagnosis. The treatment is comparable to that of AML. The prognosis is usually bad.

[Effectiveness of simultaneous combination therapy using S-1 and nedaplatin/radiation (SN therapy) for 4 cases of maxillary cancer].

There are a variety of reports on radiotherapy, combined chemotherapy with radiation (including arterial injection), block resection via surgery, and fractional resection for maxillary cancer, and currently various differences among facilities. In our department, we provide treatment with the aim of preserving the organs and functions in cases of head and neck malignant tumors. We herein report the effectiveness of treatment in 4 cases of maxillary cancer, using S-1, nedaplatin/radiation (SN) therapy at our department from January 2005 to December 2008. The cases comprised 4 patients, including 3 cases of T4N0M0 and 1 case of T2N0M0. All patients were males between 29 to 67 years old, wherein the mean was 52.3 years old. All cases resulted in survival without cancer after the application of the treatment policy of our department, wherein all functions were preserved. It is believed that the performance of SN therapy made it possible to minimize the scope of surgery and preserve the organs and functions. It will be necessary to increase the number of cases in order to examine the effectiveness of the organ and function preservation as well as the survival rate for maxillary cancer after SN therapy.

[Cheek paresthesia by an osteosarcoma]. / Paresthesie van de wang door een osteosarcoom.

A 21-year-old woman was referred by the dental practitioner to an oral surgeon concerning a hard elastic swelling of the left cheek in combination with local paresthesia. Histopathologic and radiographic examination revealed an osteosarcoma in the left segment of the maxilla. Subsequently, the patient was referred to a medical centre for head and neck oncology. The treatment consisted of 3 courses neoadjuvant chemotherapy, followed by radical surgical resection of the tumor, and 3 courses adjuvant chemotherapy. One year after treatment, there was no sign of local tumor recurrence or metastases. An osteosarcoma is a malignant tumor of bone forming cells. About 10% of osteosarcomas are appearing in the head and neck region, primarily in the mandible and the maxilla. The treatment of choice is adequate surgical removal. Treatment with (neo)adjuvant chemotherapy seems to have additional benefit, but this needs further research.

Implication of bevacizumab in fatal arterial thromboembolic incidents.

Bevacizumab, a humanized monoclonal antibody against vascular endothelial factor (VEGF), is approved for the treatment of metastatic colon cancer, but it has also shown efficacy in first line therapy of non-squamous-cell non-smallcell lung cancer, breast cancer and clear-cell renal cancer. Antiangiogenic therapy severe toxic effects such as stroke, myocardial infraction, angina, arterial thromboembolism, pulmonary embolism or haemorrhage, gastrointestinal perforation, heart failure should be taken into account during treatment with bevacizumab. We describe and discuss two cases of cancer patients who developed fatal arterial thromboembolic episodes after administration of bevacizumab. Due to the recent launch of antiangiogenic agents and the limited experience with their use in clinical practice, their adverse effects and pharmacological toxicities, sometimes fatal, are not well-established and a detailed registration of them is needed.

[Influence of chemotherapy regimen on antioxidant level in patients with locally-advanced tumors of the maxilla, nasal and paranasal sinuses].

The study dealt with effect of chemoradiotherapy on the oxidant/antioxidant system in 57 patients with locally-advanced tumors (stage III-IV) of the maxilla, nasal and paranasal sinuses. Therapy modalities ranged from systemic chemoradiotherapy (22), intraarterial chemoradiotherapy + UHF-hyperthermia (20) and intraarterial chemotherapy + radiotherapy (15). The most frequent regimen of chemotherapy involved cisplatin 15 mg/ m2, total dose of 100 mg; fluorouracil 600 mg/m2, total dose of 2,000-3,000 mg, and doxorubicin 15 mg/m2, total dose of 40-60 mg. As far as telegammatherapy is concerned, all patients received STD of 3 Gy and TTD of 40-60 Gy. Unlike systemic chemoradiotherapy, continuous intraarterial chemoradiotherapy with UHF-hyperthermia or without it was followed by lower incidence of enhanced oxidative reaction response and tumor-related endotoxicosis.