Prognostic factors in advanced pancreatic ductal adenocarcinoma patients-receiving second-line treatment: a single institution experience

Background Second-line (2L) treatments for advanced pancreatic ductal adenocarcinoma (PDAC) achieve a modest benefit at the expense of potential toxicity. In the absence of predictive factors of response, the identification of prognostic factors could help in the therapeutic decisions-making. The purpose of this study was to assess the prognostic factors associated with shorter survival in patients with advanced PDAC who received 2L treatment. Methods We conducted a single institution retrospective study, which included all patients with advanced PDAC who received 2L treatment between September 2006 and February 2020 at La Paz University Hospital, Madrid (Spain). Significant variables in the logistic regression model were used to create a prognostic score. Results We included 108 patients. The median overall survival (OS) was 5.10 months (95%CI 4.02–6.17). In the multivariate analysis, time to progression (TTP) shorter than 4 months after first-line treatment (OR 4.53 [95%CI 1.28–16.00] p = 0.01), neutrophil-to-lymphocyte ratio (NLR) greater than 3 at the beginning of 2L (OR 9.07 [95%CI 1.82–45.16] p = 0.01) and CA-19.9 level higher than the upper limit of normal at the beginning of 2L (OR 7.83 [95%CI 1.30–49.97] p = 0.02) were independently associated with OS shorter than 3 months. The prognostic score classified patients into three prognostic groups (good, intermediate and poor) with significant differences in OS (p < 0.001). Conclusions TTP shorter than 4 months after first-line treatment, NLR greater than 3 and CA-19.9 level higher than the upper limit of normal at the beginning of 2L were associated with shorter overall survival. We developed a prognostic score that classifies patients with advanced PDAC into three prognostic groups after progression to the first-line. This score could help in the decision-making for 2L treatment (AU)

Incidence of venous thromboembolic events in cancer patients receiving immunotherapy: a single-institution experience

Background Cancer and cancer therapies have been associated with an increased incidence of venous thromboembolic events (VTE). However, the incidence of VTE in patients on immunotherapy has not been well characterized. The aim of this study was to assess the incidence of VTE in cancer patients receiving immunotherapy and ascertain its prognostic utility. Materials and methods We conducted a single-institution retrospective study, including all cancer patients treated with anti-Programmed cell Death 1 (PD-1), anti-Programmed cell Death Ligand-1 (PD-L1), anti-Cytotoxic T-Lymphocyte-Associated Protein 4 (CTLA4), a combination of anti-PD-1/anti-PD-L1 and anti-CTLA4 or a combination including any of these drugs with chemotherapy, antiangiogenic agents or both between June 2013 and April 2019 at La Paz University Hospital, Madrid (Spain). Results We selected 229 patients. VTE occurred in 16 of 229 patients (7%). VTE occurred more frequently in patients with lung cancer followed by melanoma. Female sex and melanoma were independently associated with an increased risk of VTE. 12 of 16 VTE (75%) were symptomatic. Progressive disease to immunotherapy [HR 31.60 (95% CI 11.44–87.22), p = 0.00], lung cancer [HR 2.55 (95% CI 1.34–4.86), p = 0.00] and melanoma [HR 2.42 (1.20–4.86), p = 0.01] were independently associated with shorter OS. VTE occurrence was not independently associated with shorter OS [HR 1.33 (95% CI 0.63–2.80), p = 0.44]. Conclusions The incidence of VTE in cancer patients receiving immunotherapy in our study appeared to be similar to the incidence previously reported in other series of cancer patients treated with systemic therapies. VTE occurrence did not correlate with the prognosis. Further and prospective studies are needed to derive definitive conclusions (AU)

Prognostic factors in advanced pancreatic ductal adenocarcinoma patients-receiving second-line treatment: a single institution experience.

BACKGROUND: Second-line (2L) treatments for advanced pancreatic ductal adenocarcinoma (PDAC) achieve a modest benefit at the expense of potential toxicity. In the absence of predictive factors of response, the identification of prognostic factors could help in the therapeutic decisions-making. The purpose of this study was to assess the prognostic factors associated with shorter survival in patients with advanced PDAC who received 2L treatment. METHODS: We conducted a single institution retrospective study, which included all patients with advanced PDAC who received 2L treatment between September 2006 and February 2020 at La Paz University Hospital, Madrid (Spain). Significant variables in the logistic regression model were used to create a prognostic score. RESULTS: We included 108 patients. The median overall survival (OS) was 5.10 months (95%CI 4.02-6.17). In the multivariate analysis, time to progression (TTP) shorter than 4 months after first-line treatment (OR 4.53 [95%CI 1.28-16.00] p = 0.01), neutrophil-to-lymphocyte ratio (NLR) greater than 3 at the beginning of 2L (OR 9.07 [95%CI 1.82-45.16] p = 0.01) and CA-19.9 level higher than the upper limit of normal at the beginning of 2L (OR 7.83 [95%CI 1.30-49.97] p = 0.02) were independently associated with OS shorter than 3 months. The prognostic score classified patients into three prognostic groups (good, intermediate and poor) with significant differences in OS (p < 0.001). CONCLUSIONS: TTP shorter than 4 months after first-line treatment, NLR greater than 3 and CA-19.9 level higher than the upper limit of normal at the beginning of 2L were associated with shorter overall survival. We developed a prognostic score that classifies patients with advanced PDAC into three prognostic groups after progression to the first-line. This score could help in the decision-making for 2L treatment.

Incidence of venous thromboembolic events in cancer patients receiving immunotherapy: a single-institution experience.

BACKGROUND: Cancer and cancer therapies have been associated with an increased incidence of venous thromboembolic events (VTE). However, the incidence of VTE in patients on immunotherapy has not been well characterized. The aim of this study was to assess the incidence of VTE in cancer patients receiving immunotherapy and ascertain its prognostic utility. MATERIALS AND METHODS: We conducted a single-institution retrospective study, including all cancer patients treated with anti-Programmed cell Death 1 (PD-1), anti-Programmed cell Death Ligand-1 (PD-L1), anti-Cytotoxic T-Lymphocyte-Associated Protein 4 (CTLA4), a combination of anti-PD-1/anti-PD-L1 and anti-CTLA4 or a combination including any of these drugs with chemotherapy, antiangiogenic agents or both between June 2013 and April 2019 at La Paz University Hospital, Madrid (Spain). RESULTS: We selected 229 patients. VTE occurred in 16 of 229 patients (7%). VTE occurred more frequently in patients with lung cancer followed by melanoma. Female sex and melanoma were independently associated with an increased risk of VTE. 12 of 16 VTE (75%) were symptomatic. Progressive disease to immunotherapy [HR 31.60 (95% CI 11.44-87.22), p = 0.00], lung cancer [HR 2.55 (95% CI 1.34-4.86), p = 0.00] and melanoma [HR 2.42 (1.20-4.86), p = 0.01] were independently associated with shorter OS. VTE occurrence was not independently associated with shorter OS [HR 1.33 (95% CI 0.63-2.80), p = 0.44]. CONCLUSIONS: The incidence of VTE in cancer patients receiving immunotherapy in our study appeared to be similar to the incidence previously reported in other series of cancer patients treated with systemic therapies. VTE occurrence did not correlate with the prognosis. Further and prospective studies are needed to derive definitive conclusions.

Dramatic dilatation of the upper airway secondary to a Valsalva manoeuvre in a lateral cephalometric teleradiograph of a child.

Radiographs are routinely used by orthodontists for the planning of treatment for their patients and they can, in some cases, play a decisive role in the early diagnosis of some unexpected medical or surgical disorders. This report presents the case of a substantial dilatation of the upper airway in a 10-year-old girl, which was attributed to a forced Valsalva manoeuvre. The diagnosis was confirmed upon repetition of the teleradiograph with the mouth open.

Queratoquistes maxilares: marsupialización / Keratocysts of the jaw: marsupialization

El queratoquiste odontogénico es una tumoración quística cuya cápsula está formada por un epitelio escamoso derivado de la lámina dental o el epitelio odontogénico primordial. Representa un 10% de todas las lesionesquísticas de los maxilares. Radiológicamente, es raro que presentes reabsorciones radiculares. El diagnóstico está basado en las características histológicas.El diagnóstico diferencial más importante es el quiste folicular que se caracteriza por un revestimiento escamoso de espesor variable. El tratamiento de los queratoquistes odontogénicos es objeto de constante discusión ya que la tasa de recidiva publicada es elevada (en torno al 30%). El tratamiento estándar es la enucleación, pero dado que la cápsula es típicamente fina y friable, se suele fragmentar durante la extirpación. La resección incompleta de la cápsula así como la presencia de microquistes en el tejido conectivocircundante predispone a la recidiva o persistencia de la tumoración. La alternativa es el tratamiento por medio de descompresión y marsupialización

The odontogenic keratocyst is a tumor-like cystic with acapsule that is formed of squamous epithelium originating from dental lamina or from primordial odontogenic epithelium. Radiologically,radicular resorption is rare. The most important differential diagnosis is the follicular cyst that has a characteristic squamous coating of a variable thickness. Treatment for odontogenic keratocysts is the object of constant discussion as the rate of recurrencepublished is high (around 30%). The standard treatment isenucleation, but given that the capsule is very fine and friable, it tends to break into fragments during extraction. Incomplete resection of the capsule, as well as the presence of microcysts in the surrounding connective tissue, makes recurrence or tumor persistencemore likely. The alternative is treatment by means of decompression and marsupialization (AU)

Queratoquistes maxilares: marsupialización

El queratoquiste odontogénico es una tumoración quística cuya cápsula está formada por un epitelio escamoso derivado de la lámina dental o el epitelio odontogénico primordial. Representa un 10% de todas las lesiones quísticas de los maxilares. Radiológicamente, es raro que presentes reabsorciones radiculares. El diagnóstico está basado en las características histológicas. El diagnóstico diferencial más importante es el quiste folicular que se caracteriza por un revestimiento escamoso de espesor variable. El tratamiento de los queratoquistes odontogénicos es objeto de constante discusión ya que la tasa de recidiva publicada es elevada (en torno al 30%). El tratamiento estándar es la enucleación, pero dado que la cápsula es típicamente fina y friable, se suele fragmentar durante la extirpación. La resección incompleta de la cápsula así como la presencia de microquistes en el tejido conectivo circundante predispone a la recidiva o persistencia de la tumoración. La alternativa es el tratamiento por medio de descompresión y marsupialización.

Toxina botulínica y su empleo en la patología oral y maxilofacial / Botulinum toxin and its use in oral and maxillofacial pathology

Las toxinas botulínicas son exotoxinas de la bacteria formadora de esporas Clostridim botulinum y los agentes causantes del botulismo. Cuando se inyecta en el músculo produce una parálisis flácida. El efecto clínico está directamente relacionado con la dosis y debe ajustarse para cada caso concreto. La Toxina botulínica ha demostrado en los más de veinte años en que se está utilizando que es un fármaco seguro. Las indicaciones de la toxina botulínica en la actualidad incluyen todas aquellas patologías que resultan de la hiperfunción muscular y la disfunción autonómica (AU)

Preparing a hemimandibulectomy patient for delayed reconstructive surgery.

A rehabilitation device was designed and used before a reconstructive orthognathic procedure in an adult patient with a severe facial asymmetry. The asymmetry developed as a result of a left hemimandibulectomy in childhood. With this prototype device, the remaining hemimandible was gradually brought into its natural position and dynamics in order to accommodate a graft. The goals were to improve esthetics and function, reduce the chance of the remaining hemimandible not adapting to the graft, and reduce the risk of secondary TMJ pathosis after the mandibular reconstruction.

The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results.

This is an assessment of one surgeon's 15-year experience (1981-1995) using the Millard rotation-advancement principle for repair of unilateral complete cleft lip and nasal deformity. All infants underwent a prior labio-nasal adhesion. Since 1991, dentofacial orthopedics with a pin-retained (Latham) appliance was used for infants with a cleft of the lip and palate. Technical variations are described, including modifications in sequence of closure. A high rotation and releasing incision in the columella lengthens the medial labial element and produces a symmetric prolabium with minimal transgression of the upper philtral column by the advancement flap. Orbicularis oris muscle is everted, from caudad to cephalad, to form the philtral ridge. A minor variation of unilimb Z-plasty is used to level the cleft side of Cupid's bow handle, and cutaneous closure proceeds superiorly from this junction. The dislocated alar cartilage is visualized though a nostril rim incision and suspended to the ipsilateral upper lateral cartilage. Symmetry of the alar base is addressed in three dimensions, including maneuvers to position the deviated anterior-caudal septum, configure the sill, and efface the lateral vestibular web. Secondary procedures were analyzed in 105 consecutive patients, both revised (n = 30) and unrevised (n = .75). The possible need for revision in the latter group was determined by panel assessment of six indicators of nasolabial asymmetry, documented by frontal and submental photographs. In the entire study period, a total of 80 percent of children required or will need nasal revision, and a total of 42 percent required or will require labial revision. In the last 5 years, as compared with the earlier decade, there was a significantly diminished incidence of patients requiring labial revision (54 percent to 21 percent) and alar suspension (63 percent to 32 percent). These improvements are attributable to technical refinements and experience, although dentofacial orthopedics may also have played a role.

Gold chloride technique to study articular innervation. A protocol validated through computer-assisted colorimetry.

We studied variations in gold chloride techniques to elicit neural elements within articular samples, after "in toto" staining. These techniques attempt the differentiation of neural and vascular structures. Major changes in differential staining were observed when the gold chloride concentration was empirically modified. After the rest of the technique was standardized, we selected three gold chloride solutions to perform quantitative color experiments: 1%, 0.75%, and 0.5%. Significant sections of the same thickness were acquired with a digital camera to perform computer-assisted colorimetry. Color was measured through RGB (red-green-blue) channels in vessels, nerves, and background connective tissue as an internal control. By means of multivariate regression analysis, we compared differences in color measurements after 1%, 0.75% and 0.5% gold chloride preparation. Statistically significant coefficients confirmed that red color signals in vessels after the 0.75% and the 0.5% solution were both less intense than after the 1% preparation. Green and blue signals in vessels were also significantly less intense after the 0.5% protocol than after using the 1% solution. Red color signals in nerves between the 1% and the 0.75% preparation protocols were more intense and not significantly different, while the 0.5% preparation produced significantly less intense red signals in nerves. Non-significant differences were observed in green or blue signals from nerves after any protocol. We concluded that the 0.75% gold chloride solution protocol produced more intense red signals in nerves and less intense red signals in vessels. This was the most discriminant protocol in our series, based on color signals.

[Pharyngeal chordoma]. / Cordoma faríngeo.

Chordoma is a neoplasm arising from embryonal notochord remnants. It is infrequent and rarely located at the cervical level. The diagnosis is histological and immunohistochemical tests are required to differentiate it from other neoplasms. We report a case of pharyngeal chordoma treated with a transmandibular approach. The diagnosis, treatment, and prognosis of these tumors are reviewed.

Jugular foraminal stenosis in Crouzon syndrome.

We describe a 4-year-old boy with Crouzon syndrome, with associated acanthosis nigricans and Chiari-I malformation, who developed increased intracranial pressure necessitating posterior cranial expansion. Postoperatively, an arteriovenous fistula appeared over the mastoid region. Cerebral angiography demonstrated bilateral atresia of the jugular veins and occlusion of the left sigmoid and right transverse sinuses. We propose that increased intracranial venous pressure, secondary to bilateral jugular foraminal stenosis, caused hydrocephaly and venous dilation in the scalp vasculature. The latter set the stage for a traumatic arteriovenous fistula of the scalp, probably resulting from laceration of an adjacent artery and vein. Jugular atresia is a basilar malformation common to achondroplasia and certain eponymous syndromic craniosynostoses. Our patient has a mutation in fibroblast growth factor receptor 3, a different locus in the same gene mutated in achondroplasia.

Langerhans cell histiocytosis: an uncommon disease commonly manifesting in the craniofacial skeleton.

Langerhans cell histiocytosis is an infrequent and enigmatic proliferative disorder that commonly presents in the head and neck region. This is an analysis of 77 patients with Langerhans cell histiocytosis treated at Children's Hospital and Dana Farber Cancer Institute from 1974 through 1993. The study focused on clinical findings, anatomic location and extent of disease, therapy, and outcome. The patients were, on average, under 5 years of age at initial presentation. Over 62 percent of the patients had signs and symptoms referred to the craniofacial skeleton. Osteolytic lesions of the cranium were the most common, followed, in frequency, by scalp rash, osteolytic mandibular tumor(s), enlarged nodes, and gingival swelling or ulceration. Single bony lesions usually were treated with curettage or radiotherapy. Chemotherapy was used commonly for advanced disease with multifocal or disseminated presentation. Initial therapy included moderate doses of single agents; other agents were added if no response was achieved. The natural history of Langerhans cell histiocytosis varied from an acute fulminant course, a waxing and waning chronic disease, to spontaneous regression. Young age at presentation and organ dysfunction predicted a poor prognosis. Statistical analysis showed that there was no significant relationship between outcome and extent of skeletal involvement when controlling for age or organ dysfunction.

Not all hemangiomas look like strawberries: uncommon presentations of the most common tumor of infancy.

The typical appearance of cutaneous hemangiomas of infancy is well known. We studied unusual manifestations of this common tumor. We reviewed over 500 hemangiomas in the registry of the Vascular Anomalies Program at Boston Children's Hospital. We found four uncommon morphologic variations: deep hemangiomas with normal overlying skin (n = 12); macular hemangiomas with a port-wine stainlike appearance (n = 6); bossed hemangiomas with telangiectasia and peripheral pallor (n = 5); and hemangiomas with persistent fast flow (n = 3). Deep and superficial (macular) varieties regressed at a normal rate. Telangiectatic (bossed) hemangiomas, however, involuted rapidly, usually before 1 year of age. Hemangiomas with persistent fast flow required either resection or sclerotherapy for complications in early childhood.