Anatomical findings in patients with chronic rhinosinusitis without nasal polyps requiring revision surgery.

OBJECTIVES: For the treatment of chronic rhinosinusitis functional endoscopic sinus surgery is a well-established therapy with high initial success rates. However, a significant proportion of patients have persistent disease requiring revision surgery. To date, studies including data of large patient collectives are missing. In this study, we aimed to identify anatomic factors increasing the need for revision surgery in a large patient collective with chronic rhinosinusitis without nasal polyps. METHODS: Data were collected retrospectively on patients with recurrent or persistent chronic rhinosinusitis without nasal polyps requiring revision surgery. The patients' symptomatology, endoscopic and radiographic findings were analyzed. Preoperatively, patients were evaluated with endoscopic examination of the nose and paranasal sinuses. In all individuals computed tomography of the sinuses was performed. Images were evaluated according to the Lund-Mackay system. Information was also collected intraoperatively. RESULTS: 253 patients were included. The most common anatomic factor was incomplete anterior ethmoidectomy (51%), followed by residual uncinated process (37%), middle turbinate lateralization (25%), incomplete posterior ethmoidectomy (20%), frontal recess scarring (19%), and middle meatal stenosis (9%). Other factors such as persistent sphenoid pathology was less frequent. CONCLUSION: Iatrogenic causes with inadequate resection of obstructing structures seem to be a principal risk factor for recurrent chronic rhinosinusitis and the need for revision sinus surgery. Meticulous attention in the area of the ostiomeatal complex during surgery with ventilation of obstructed anatomy as well as avoidance of scarring and turbinate destabilization may reduce the failure rate after primary endoscopic sinus surgery. LEVEL OF EVIDENCE: 2b.

P2X1 and P2X7 Receptor Overexpression Is a Negative Predictor of Survival in Muscle-Invasive Bladder Cancer.

Bladder cancer is amongst the most common causes of cancer death worldwide. Muscle-invasive bladder cancer (MIBC) bears a particularly poor prognosis. Overexpression of purinergic P2X receptors (P2XRs) has been associated with worse outcome in several malignant tumors. Here, we investigated the role of P2XRs in bladder cancer cell proliferation in vitro and the prognostic value of P2XR expression in MIBC patients. Cell culture experiments with T24, RT4, and non-transformed TRT-HU-1 cells revealed a link between high ATP concentrations in the cell culture supernatants of bladder cell lines and a higher grade of malignancy. Furthermore, proliferation of highly malignant T24 bladder cancer cells depended on autocrine signaling through P2X receptors. P2X1R, P2X4R, and P2X7R expression was immunohistochemically analyzed in tumor specimens from 173 patients with MIBC. High P2X1R expression was associated with pathological parameters of disease progression and reduced survival time. High combined expression of P2X1R and P2X7R increased the risk of distant metastasis and was an independent negative predictor of overall and tumor-specific survival in multivariate analyses. Our results suggest that P2X1R/P2X7R expression scores are powerful negative prognostic markers in MIBC patients and that P2XR-mediated pathways are potential targets for novel therapeutic strategies in bladder cancer.

Characterization of the tumor-infiltrating lymphocyte landscape in sinonasal mucosal melanoma.

BACKGROUND: Tumor-infiltrating lymphocytes (TILs) are important prognostic biomarkers in several types of cancers. The interplay between TIL subgroups and immune checkpoint molecules like programmed cell death ligand 1 (PD-L1) is a promising target for immunotherapy. However, the TIL landscape in sinonasal mucosal melanoma (SNMM) has not been sufficiently characterized yet and the prognostic value of TIL subgroups and PD-L1 expression remains uncertain. Here, we investigated subsets of TILs (CD3+, CD4+, CD8+, CD20+) and PD-L1 expression patterns in SNMM and assessed their prognostic value for recurrence-free and overall survival. METHODS: Immunohistochemical staining for CD3, CD4, CD8, CD20 and PD-L1 was performed on tumor tissue from 27 patients with primary SNMM. Patient history was obtained and associations between TIL subgroups or PD-L1 expression and AJCC tumor stage, overall survival, and recurrence-free survival were retrospectively analyzed. RESULTS: Patients with high CD3+ and CD8+ TILs in the primary tumor survived significantly longer than patients with SNMMs with a low number of CD3+ and CD8+ TILs. High CD3+ and high CD8+ TILs were associated with the lower T3 stage and increased 5-year survival. PD-L1 positivity in tumor cells was associated with advanced tumor stage. CONCLUSION: Our results indicate that high densities of CD3+ and CD8+ TILs are strong positive prognostic biomarkers for survival in SNMM. Prospective studies with larger case numbers are warranted to confirm our findings.

Anatomical findings in patients with chronic rhinosinusitis without nasal polyps requiring revision surgery

Abstract Objectives For the treatment of chronic rhinosinusitis functional endoscopic sinus surgery is a well-established therapy with high initial success rates. However, a significant proportion of patients have persistent disease requiring revision surgery. To date, studies including data of large patient collectives are missing. In this study, we aimed to identify anatomic factors increasing the need for revision surgery in a large patient collective with chronic rhinosinusitis without nasal polyps. Methods Data were collected retrospectively on patients with recurrent or persistent chronic rhinosinusitis without nasal polyps requiring revision surgery. The patients' symptomatology, endoscopic and radiographic findings were analyzed. Preoperatively, patients were evaluated with endoscopic examination of the nose and paranasal sinuses. In all individuals computed tomography of the sinuses was performed. Images were evaluated according to the Lund-Mackay system. Information was also collected intraoperatively. Results 253 patients were included. The most common anatomic factor was incomplete anterior ethmoidectomy (51%), followed by residual uncinated process (37%), middle turbinate lateralization (25%), incomplete posterior ethmoidectomy (20%), frontal recess scarring (19%), and middle meatal stenosis (9%). Other factors such as persistent sphenoid pathology was less frequent. Conclusion Iatrogenic causes with inadequate resection of obstructing structures seem to be a principal risk factor for recurrent chronic rhinosinusitis and the need for revision sinus surgery. Meticulous attention in the area of the ostiomeatal complex during surgery with ventilation of obstructed anatomy as well as avoidance of scarring and turbinate destabilization may reduce the failure rate after primary endoscopic sinus surgery. Level of evidence: 2b.

Tumor-infiltrating lymphocytes predict survival in ≥ pT2 urothelial bladder cancer.

Tumor-infiltrating lymphocytes (TILs) are associated with improved survival in several types of cancers, including genitourinary cancers. However, multiple different scoring methods used to assess TILs complicate the comparison of different studies and are not always suitable for daily practice. In 2014, the International TILs Working Group (ITWG) proposed a simple and robust assessment method for a more standardized evaluation of TILs. Here, we validated this system in muscle-invasive urinary bladder cancer (MIBC). Patient history and histologic specimens from 203 patients with MIBC were retrospectively analyzed. The stromal TIL (sTIL) score was determined using the ITWG system and 3 groups were defined according to the degree of stromal lymphocytic infiltration: low (0-10%), intermediate (10-55%) and high (55-100%). Associations between sTIL score, clinicopathological variables, tumor-specific survival (TSS), overall survival (OS), and disease-free survival (DFS) were analyzed. High stromal lymphocytic infiltration was associated with significantly higher OS, TSS and DFS when compared to low grade sTILs. The survival benefit remained statistically significant in multivariate analyses, confirming that sTILs are a strong independent positive prognostic factor in patients with MIBC. In summary, the degree of sTILs as defined by the ITWG robustly predicts survival in MIBC patients. Prospective studies with larger case numbers are needed to determine whether sTILs should be included in staging guidelines and how they could aid in therapeutic decision making.

Prognostic Value of Tumor-Infiltrating Lymphocytes in Sinonasal Mucosal Melanoma.

OBJECTIVES/HYPOTHESIS: Tumor-infiltrating lymphocytes (TILs) predict better outcome in several types of cancers. However, the prognostic value of TILs in sinonasal mucosal melanoma (SNMM) is uncertain. Here, we investigated whether TILs can be used as a prognostic indicator for survival in SNMM. STUDY DESIGN: Retrospective cohort study. METHODS: Patient history and histologic specimens from 27 patients with primary SNMM were retrospectively analyzed. TIL grade was determined and associations between TILs and AJCC tumor stage, overall survival, and recurrence-free survival were analyzed. RESULTS: Patients with TILs in the primary tumor classified as brisk or non-brisk survived significantly longer than patients with SNMMs lacking lymphocyte infiltrates. Brisk TILs were associated with the lower T3 stage and increased recurrence-free and 5-year survival. CONCLUSION: Our results indicate that TIL density is a strong prognostic factor for better survival in SNMM. Prospective studies with larger case numbers are warranted to determine whether TILs should be included in future AJCC staging guidelines. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1334-1339, 2022.

Evaluation of an image enhancement system for the assessment of nasal and paranasal sinus diseases.

PURPOSE: Dysplasia and cancer of the upper aerodigestive tract are characterized by significant neoangiogenesis. This can be recognized by optical methods like the Storz Professional Image Enhancement System (SPIES). Up to now, there are no reports of using this novel technique for examining nasal diseases. The objective of this study was to evaluate the use of SPIES during sinus surgery to help differentiate various nasal pathologies and determine their extension. METHODS: Patients (n = 27) with different pathologies in the region of the paranasal sinuses were operated via functional endoscopic surgery using a 2D-HD-camera with white light and SPIES. In addition, 10 healthy individuals were examined. The system was evaluated using two different questionnaires. RESULTS: The handling and operation of SPIES was intuitive and easy. Use of SPIES did not prolong the procedure. There was no disturbing image distortion. SPIES seemed to improve the visualization, differentiation and evaluation of vascularization of paranasal pathologies and allowed for precise and accurate surgery. Compared to examination with the 2D-HD-camera and white light alone, SPIES appeared to facilitate the identification of mucosal pathologies. CONCLUSION: SPIES could be a promising adjunct tool to evaluate nasal pathologies intraoperatively. Especially in the case of vascularized tumors the enhanced image endoscopy seemed to be clearly superior to standard white light alone. In our study, the system facilitated the assessment of tumor extension and vascularization as well as the differentiation of healthy mucosa. Future randomized studies will be necessary to prove the potential of integrating this novel technique into the clinical routine for the differentiation of nasal pathologies and the improvement of resection margins during nasal tumor surgery.

Endoscopic endonasal repair of complete bilateral choanal atresia in neonates.

Reported success rates of endoscopic choanal atresia (CA) surgery vary substantially due to a high heterogeneity in and between study groups. Comprehensive data on the unique patient cohort of newborns with bilateral CA are scarce. Our study aimed to close this gap by using narrow inclusion criteria and standardized surgical outcome parameters. A total of ten neonates who were diagnosed with bilateral complete CA and underwent endoscopic surgery at the Department of Otolaryngology, Head and Neck Surgery in the University Hospital of Munich between 2008 and 2017 were included. Preoperative findings, surgical procedures, outcome, and follow-up were analyzed. Standardized criteria were used to assess surgical outcome. Almost all patients (90%) required at least one revision procedure within the first 6 months after initial surgery because of symptomatic partial or complete restenosis. After that, all surviving patients remained asymptomatic until the end of the follow-up period.Conclusion: Endoscopic bilateral CA repair in neonates is a safe procedure with a high long-term success rate. However, compared to other patient groups with choanal obstruction, restenosis occurs frequently, and revision procedures are required in a large number of cases. This should be considered during preoperative planning and parent counseling. What is Known: • Bilateral complete choanal atresia (CA) is a neonatal emergency that requires surgical intervention. • Reported success rates of endoscopic choanal obstruction repair are highly variable and mostly derived from heterogenous study groups that do not reflect the situation in neonates adequately. What is New: • This study focuses exclusively on newborns with complete bilateral CA who underwent endoscopic surgery within the first 28 days of life and uses standardized criteria to assess outcome. • The long-term success rate of endoscopic bilateral CA repair in neonates is high; however, almost all patients require at least one revision procedure within the first 6 months.

Sequential HLA-haploidentical transplantation utilizing post-transplantation cyclophosphamide for GvHD prophylaxis in high-risk and relapsed/refractory AML/MDS.

This study evaluates the role of sequential therapy in HLA-haploidentical transplantation (haplo-HSCT) of high-risk, relapsed/refractory AML/MDS. We analyzed the course of 33 adults with active disease at time of transplantation (AML n = 30; MDS n = 3; median age 58 years, range: 32-71). Sequential therapy consisted of cytoreductive chemotherapy (FLAMSA n = 21; clofarabine n = 12) applied shortly prior to reduced intensity conditioning for T-cell-replete haplo-HSCT using post-transplantation cyclophosphamide as GvHD prophylaxis. No graft rejection was observed. Complete remission at day +30 was achieved in 97% of patients. CI of acute GvHD grade II-IV and chronic GvHD was 24% (no grade IV) and 23%, respectively. NRM at 1 and 3 years was 15%, each. Severe regimen-related toxicities (grade III-IV) were observed in 58%, predominantly involving the gastrointestinal tract (diarrhea 48%, mucositis 15%, transient elevation of transaminases 18%). Probability of relapse at 1 and 3 years was 28% and 35%. At a median follow-up of 36 months, the estimated 1- and 3-year overall survival was 56% and 48%. Disease-free survival was 49% and 40%, respectively. At 3 years, GvHD and relapse-free survival (GRFS) was 24% while chronic GvHD and relapse-free survival (CRFS) was 29%. Thus, our results indicate that sequential haplo-HSCT is an effective salvage treatment providing high anti-leukemic activity, favorable tolerance, and acceptable toxicity in patients suffering from advanced AML/MDS.

Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years.

PURPOSE: Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging. METHODS: In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded. RESULTS: Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof-especially in the cribriform plate-and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary. CONCLUSIONS: Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary.

Cochlear Implant Surgery and the Risk of Falls in an Adult Population.

OBJECTIVE: To determine the effect of cochlear implant surgery on the balance and risk of falls in an adult patient population using a mobile posturograph. DESIGN: Prospective clinical pilot study. SETTING: Cochlear implant center at a tertiary referral hospital. SUBJECTS AND METHODS: Twenty adult patients undergoing cochlear implant surgery were tested using a mobile posturograph (VertiGuard). The standard balancing deficit test, or the geriatric standard balancing deficit test protocol (for patients older than 60 yr), was performed both 1 day before and 3 to 5 days after surgery. OUTCOME MEASURES: The risk of falls (%) was calculated from the body sway both forward-to-backward and side-to-side in degrees per second. RESULTS: The mean preoperative risk of falls in the whole study population was 51% (24-max. 86%) and was thus already higher than that in a normal healthy population (norm 0-40%). Comparison of the postoperative risk of falls to the preoperative risk for all 20 patients revealed a mean increased risk of falls of 1.25% after CI surgery. This is not a statistically significant increase. There was also no statistically significant increase when comparing the fall risk calculated using either the standard balancing deficit test protocol or the geriatric standard balancing deficit test protocol alone. CONCLUSION: Postural control in cochlear implant candidates is already decreased before surgery compared with a healthy population. However Comparison of pre- and postoperative body sway measurements did not reveal a significant increase in fall risk as a result of cochlea implant surgery. Therefore in this study population, cochlear implant surgery did not influence balance and risk of falls. Further testing with a larger study population would be necessary to determine the development of falls risk over time after cochlear implant surgery.

In vivo imaging of the internal nasal valve during different conditions using optical coherence tomography.

OBJECTIVE: Previously, we proposed long-range optical coherence tomography (LR-OCT) to be an effective method for the quantitative evaluation of the nasal valve geometry. Here, the objective was to quantify the reduction in the internal nasal valve angle and cross-sectional area that results in subjective nasal airway obstruction and to evaluate the dynamic behavior of the valve during respiration using LR-OCT. METHODS: For 16 healthy individuals, LR-OCT was performed in each naris during: 1) normal respiration, 2) peak forced inspiration, 3) lateral nasal wall depression (to the onset of obstructive symptoms), and 4) after application of a topical decongestant. The angle and the cross-sectional area of the valve were measured. RESULTS: A reduction of the valve angle from 18.3° to 14.1° (11° in Caucasians and 17° in Asians) and a decrease of the cross-sectional area from 0.65 cm2 to 0.55 cm2 led to subjective nasal obstruction. Forceful breathing did not significantly change the internal nasal valve area in healthy individuals. Application of nasal decongestant resulted in increased values. CONCLUSION: LR-OCT proved to be a fast and readily performed method for the evaluation of the dynamic behavior of the nasal valve. The values of the angle and the cross-sectional area of the valve were reproducible, and changes in size could be accurately delineated. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:E105-E110, 2018.

Intraoperative assessment of laryngeal pathologies with optical coherence tomography integrated into a surgical microscope.

OBJECTIVE: Endoscopic examination followed by tissue biopsy is the gold standard in the evaluation of lesions of the upper aerodigestive tract. However, it can be difficult to distinguish between healthy mucosa, dysplasia, and invasive carcinoma. Optical coherence tomography (OCT) is a non-invasive technique which acquires high-resolution, cross-sectional images of tissue in vivo. Integrated into a surgical microscope, it allows the intraoperative evaluation of lesions simultaneously with microscopic visualization. STUDY DESIGN: In a prospective case series, we evaluated the use of OCT integrated into a surgical microscope during microlaryngoscopy to help differentiating various laryngeal pathologies. METHODS: 33 patients with laryngeal pathologies were examined with an OCT- microscope (OPMedT iOCT-camera, HS Hi-R 1000G-microscope, Haag-Streit Surgical GmbH, Wedel, Germany) during microlaryngoscopy. The suspected intraoperative diagnoses were compared to the histopathological reports of subsequent tissue biopsies. RESULTS: Hands-free non-contact OCT revealed high-resolution images of the larynx with a varying penetration depth of up to 1.2 mm and an average of 0.6 mm. Picture quality was variable. OCT showed disorders of horizontal tissue layering in dysplasias with a disruption of the basement membrane in carcinomas. When comparing the suspected diagnosis during OCT-supported microlaryngoscopy with histology, 79% of the laryngeal lesions could be correctly identified. Premalignant lesions were difficult to diagnose and falsely classified as carcinoma. CONCLUSION: OCT integrated into a surgical microscope seems to be a promising adjunct tool to discriminate pathologies of the upper aerodigestive tract intraoperatively. However, picture quality and penetration depth were variable. Although premalignant lesions were difficult to diagnose, the system proved overall helpful for the intraoperative discrimination of benign and malignant tumors. Further studies will be necessary to define its value in the future. Lasers Surg. Med. 49:490-497, 2017. © 2017 Wiley Periodicals, Inc.

Occurrence, risk factors and outcome of adenovirus infection in adult recipients of allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Adenovirus (ADV) infections can have a high mortality in immunocompromised patients and are difficult to treat. OBJECTIVES AND STUDY DESIGN: We retrospectively analyzed occurrence and risk factors of ADV infection in 399 adults with hematological disorders undergoing hematopoietic stem cell transplantation (allo-HSCT), focusing on alternative donor transplantation (ADT) and disseminated disease. RESULTS: ADV infection occurred in 42 patients (10.5%). Disease was localized in 18 and disseminated in 6 patients. ADV infection was observed in 15% after ADT, performed in 29% of all recipients, and was less frequent (6%) in T-cell-replete (TCR) haploidentical transplantation using post-transplantation cyclophosphamide (PTCY) than in other ADT protocols. Lower age, the use of alternative donor grafts and acute graft-versus-host disease (GvHD)≥grade II were risk factors for ADV infection. After failure of standard antiviral treatment, three patients with disseminated ADV disease received one dose of ADV-specific T cells, resulting in virological response in 2/3 patients, clearance of ADV viremia in 2/2 patients, and survival of 1/3 patients; both patients with pneumonia died. CONCLUSIONS: ADV infection was of moderate occurrence in our adult recipients of allo-HSCT despite a high proportion of potential high-risk patients receiving ADT. TCR strategies using PTCY might limit ADV complications in haploidentical transplantation. Despite feasible adoptive therapy strategies, outcome of disseminated disease remains dismal.

Imaging of the internal nasal valve using long-range Fourier domain optical coherence tomography.

OBJECTIVES/HYPOTHESIS: To evaluate for the first time the feasibility and methodology of long-range Fourier domain optical coherence tomography (LR-OCT) imaging of the internal nasal valve (INV) area in healthy individuals. STUDY DESIGN: Prospective individual cohort study. METHODS: For 16 individuals, OCT was performed in each nare. The angle and the cross-sectional area of the INV were measured. OCT images were compared to corresponding digital pictures recorded with a flexible endoscope. RESULTS: INV angle measured by OCT was found to be 18.3° ± 3.1° (mean ± standard deviation). The cross-sectional area was 0.65 ± 0.23 cm(2) . The INV angle measured by endoscopy was 18.8° ± 6.9°. There was no statistically significant difference between endoscopy and OCT concerning the mean INV angle (P = .778), but there was a significant difference in test precision (coefficient of variance 50% vs. 15%; P < .001). CONCLUSIONS: LR-OCT proved to be a fast and easily performed method. OCT could accurately quantify the INV area. The values of the angle and the cross-sectional area of the INV were reproducible and correlated well with the data seen with other methods. Changes in size could be reliably delineated. Endoscopy showed similar values but was significantly less precise. LEVEL OF EVIDENCE: 2b. Laryngoscope, 126:E97-E102, 2016.

Isolated Nasal Tip Metastasis from Esophageal Squamous Cell Carcinoma: Case Report and Literature Review.

Objectives. Cutaneous metastases can be the first sign of a malignant disease and have an unfavorable prognostic significance. The external nose is rarely affected. The uncommon clinical presentation of these cutaneous metastases may lead to the wrong diagnosis and treatment. Methods. We present the case of a 59-year-old patient with a small indolent tumor on the tip of the nose that turned out to be the first sign of an extended esophageal cancer. Conclusion. The differential diagnosis of tumors of the facial skin and the nasal tip includes metastases from an unknown primary tumor. In rare cases, squamous cell carcinoma of the esophagus needs to be considered.

Virus infection in HLA-haploidentical hematopoietic stem cell transplantation: incidence in the context of immune recovery in two different transplantation settings.

We retrospectively compared the incidence of virus infections and outcome in the context of immune reconstitution in two different HLA-haploidentical transplantation (haplo-HSCT) settings. The first was a combined T-cell-replete and T-cell-deplete approach using antithymocyte globulin (ATG) prior to transplantation in patients with hematological diseases (cTCR/TCD group, 28 patients; median age 31 years). The second was a T-cell-replete (TCR) approach using high-dose posttransplantation cyclophosphamide (TCR/PTCY group, 27 patients; median age 43 years). The incidence of herpesvirus infection was markedly lower in the TCR/PTCY (22 %) than in the cTCR/TCD group (93 %). Recovery of CD4+ T cells on day +100 was faster in the TCR/PTCY group. CMV reactivation was 30 % in the TCR/PTCY compared to 57 % in the cTCR/TCD group, and control with antiviral treatment was superior after TCR/PTCY transplantation (100 vs 50 % cTCR/TCD). Twenty-five percent of the patients in the cTCR/TCD group but no patient in the TCR/PTCY group developed PTLD. While 1-year OS was not different (TCR/PTCY 59 % vs cTCR/TCD 39 %; p = 0.28), virus infection-related mortality (VIRM) was significantly lower after TCR/PTCY transplantation (1-year VIRM, 0 % TCR/PTCY vs 29 % cTCR/TCD; p = 0.009). On day +100, predictors of better OS were lymphocytes >300/µl, CD3+ T cells >200/µl, and CD4+ T cells >150/µl, whereas the application of steroids >1 mg/kg was correlated with worse outcome. Our results suggest that by presumably preserving antiviral immunity and allowing fast immune recovery of CD4+ T cells, the TCR approach using posttransplantation cyclophosphamide is well suited to handle the important issue of herpesvirus infection after haplo-HSCT.