Occurrence of graft-versus-host disease increases mortality after umbilical cord blood transplantation for acute myeloid leukaemia: a report from Eurocord and the ALWP of the EBMT.

BACKGROUND: The efficacy of umbilical cord blood transplantation (UCBT) as treatment for acute myeloid leukaemia (AML) relies on immune-mediated graft-versus-leukaemia effects. Previous studies have suggested a strong association between graft-versus-host disease (GVHD) occurrence and graft-versus-leukaemia effects after allogeneic hematopoietic cell transplantation. METHODS: Here, we evaluated the kinetics of relapse rate in correlation with GVHD occurrence after UCBT. The kinetics of relapse rate over time in correlation to GVHD occurrence were assessed by calculating the relapse rate per patient-year within sequential 90-day intervals. The impact of GVHD on relapse and mortality was further studied in multivariate Cox models handling GVHD as a time-dependent covariate. RESULTS: The study included data from 1068 patients given single (n = 567) or double (n = 501) UCBT. The proportion of patients with grade II, III and IV acute GVHD was 20%, 7% and 4%, respectively. At 2 years, the cumulative incidence of chronic GVHD was 42%, the cumulative incidence of relapse was 32%, and overall survival was 32% as well. Relapse rates declined gradually over time during the first 30 months after transplantation. There was a possible suggestion that grade II-IV acute (HR = 0.8, P = 0.1) and chronic (HR = 0.65, P = 0.1) GVHD decreased relapse risk. However, grade II-IV acute GVHD significantly increased early (the first 18 months after UCBT) mortality (HR = 1.3, P = 0.02), whilst chronic GVHD increased each early (HR = 2.7, P < 0.001) and late (HR = 4.9, P < 0.001) mortality after UCBT. CONCLUSIONS: The occurrence of grade II-IV acute or chronic GVHD each increases overall mortality after UCBT for AML mitigating the possible graft-versus-leukemia effect of GVHD.

Is leishmaniasis an "unusual suspect" of infection in allogeneic transplantation?

Leishmaniasis is a disease of the immunocompetent population, more often affecting infants and young children. However, the number of leishmaniasis cases associated with immunosuppression has increased over the last 20 years. The visceral form of the disease, visceral leishmaniasis (VL), is identified as an opportunistic infection in immunosuppressed individuals, occurring mainly after solid organ transplantation, especially in renal transplant recipients. Limited data are available about VL after hematopoietic stem cell transplantation (HSCT). We report the cases of 3 patients with late VL after allogeneic HSCT, and review the literature.

Identification of prognostic factors predicting outcome in Hodgkin's lymphoma patients relapsing after autologous stem cell transplantation.

BACKGROUND: High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard of care for patients with relapsed Hodgkin's lymphoma (HL). However, there is currently little information on the predictors of outcome for patients whose disease recurs after ASCT. METHODS: Five hundred and eleven adult patients with relapsed HL after ASCT from EBMT-GITMO databases were reviewed. RESULTS: Treatments administered following ASCT failure included conventional chemotherapy and/or radiotherapy in 294 (64%) patients, second ASCT in 35 (8%), and alloSCT in 133 (29%). After a median follow-up of 49 months, overall survival (OS) was 32% at 5 years. Independent risk factors for OS were early relapse (<6 months) after ASCT, stage IV, bulky disease, poor performance status (PS), and age ≥50 years at relapse. For patients with no risk factors OS at 5 years was 62% compared with 37% and 12% for those having 1 and ≥2 factors, respectively. This score was also predictive for outcome in each group of rescue treatment after ASCT failure. CONCLUSION(S): Early relapse, stage IV, bulky disease, poor PS, and age ≥50 years at ASCT failure are relevant factors for outcome that may help to understand the results of different therapeutic approaches.

Solitary fibrous tumor of the tongue: case report and literature review.

Solitary fibrous tumor (SFT) is an uncommon spindle cell neoplasm with unpredictable behavior. It was originally described in the pleura, but is now known to occur in various locations. SFT of the tongue is rare, with only four cases on record. An SFT of the anterolateral part of the left side of the tongue, which occurred in a 48 year-old man is recorded. The tumor was resected and the patient remains free of recurrence 3 years postoperatively.

Bisphosphonate-induced avascular osteonecrosis of the jaws: a clinical report of 11 cases.

Bisphosphonates are compounds used in the treatment of various metabolic and malignant bone diseases. In the last 2 years there has been a significant increase in referrals to the Department of Oral and Maxillofacial Surgery of patients with exposed necrotic jaw bone, diagnosed elsewhere as chronic refractory osteomyelitis of jaws, mostly after several teeth extractions. The only clinical feature in common for all the patients was the use of bisphosphonates in the treatment of bone diseases. A retrospective study was performed of 11 patients with necrotic bone lesions of the jaws of various extents referred to this Department from July 2003 to November 2004. The management of the patients included cessation of bisphosphonate therapy for 2-8 months and various surgical restorative procedures thereafter. Four patients (36%) presented with maxillary bone involvement, 6 (55%) had mandibular bone necrosis and 1 (9%) presented with necrosis at 3 quadrants. All patients had received bisphosphonate therapy for 6 months to 5 years. Biopsies from the necrotic lesions revealed no metastatic disease. One patient who was removed from bisphosphonate therapy for 8 months recovered completely, one other who was not removed from bisphosphonate therapy relapsed and for all the others, with cessation of bisphosphonate therapy for 2-6 months, the results were inconsistent. A new complication of bisphosphonate therapy administration, i.e. osteonecrosis of jaws, seems to be developing. The improved results after cessation of the medication should make clinicians reconsider the merits of the rampant use of bisphosphonates, while further investigation is needed to completely elucidate this complication.

Comparison of outcomes after unrelated cord blood and unmanipulated haploidentical stem cell transplantation in adults with acute leukemia.

Outcomes after unmanipulated haploidentical stem cell transplantation (Haplo) and after unrelated cord blood transplantation (UCBT) are encouraging and have become alternative options to treat patients with high-risk acute leukemia without human leukocyte antigen (HLA) matched donor. We compared outcomes after UCBT and Haplo in adults with de novo acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Median follow-up was 24 months. Analysis was performed separately for patients with AML, n=918 (Haplo=360, UCBT=558) and ALL, n=528 (Haplo=158 and UCBT=370). UCBT was associated with delayed engraftment and higher graft failure in both AML and ALL recipients. In multivariate analysis, UCBT was associated with lower incidence of chronic graft-vs-host disease both in the AML group (hazard ratio (HR)=0.63, P=0.008) and in the ALL group (HR=0.58, P=0.01). Not statistically significant differences were observed between Haplo and UCBT for relapse incidence (HR=0.95, P=0.76 for AML and HR=0.82, P=0.31 for ALL), non-relapse mortality (HR=1.16, P=0.47 for AML and HR=1.23, P=0.23 for ALL) and leukemia-free survival (HR 0.78, P=0.78 for AML and HR=1.00, P=0.84 for ALL). There were no statistically differences on main outcomes after unmanipulated Haplo and UCBT, and both approaches are valid for acute leukemia patients lacking a HLA matched donor. Both strategies expand the donor pool for patients in need.

Treatment of early clinically staged Hodgkin's disease with a combination of ABVD chemotherapy plus limited field radiotherapy.

The current management of early stage Hodgkin's disease (HD) is usually based on clinical staging, combined modality therapy and the use of less toxic chemotherapy regimens. This approach entails high cure rates, while ensures less long term toxicity with avoidance of laparotomy. The aim of this study was to assess the efficacy of a brief course of Adriamycin, Bleomycin, Vinblastine, Dacarbazine (ABVD) chemotherapy followed by limited field radiotherapy (RT) in favorable clinical stage (CS) I and IIA HD. Forty patients, aged 17-68 (median 34) years, with favorable CS I and IIA HD, without bulky mediastinal disease, have been treated with 4-6 (median 4) cycles of ABVD plus limited field RT. Twenty seven (67%) patients received 4 cycles of chemotherapy, while 13 received 5-6 cycles. Thirty five (87%) patients received limited field RT with dose 24-36 Gy and five (13%) received extended field with 36-46 Gy. All patients responded completely to chemotherapy. One patient experienced a relapse two months after the end of therapy. All patients are alive; 39 in continuous complete remission. With a median follow-up period of 44 months (range 18-101) the actuarial overall and progress free survival was 100 and 97% at 5 years. We did not observe any case of secondary leukemia or solid tumor. Pulmonary toxicity was mild in cases of mediastinal irradiation. Considering the short follow-up time and the small number of patients, the combination of a brief course of ABVD plus regional RT is a very efficacious treatment of favorable CS I and IIA HD with mild toxicity. However, long term survival data are needed, which could give confident answers regarding the risk of late therapy related complications, particularly second malignancies.

Aging changes in the articular disk of the temporomandibular joint in the guinea pig.

The development of cartilage cells was investigated in the articular disks of the temporomandibular joint (TMJ disk) from two groups of guinea pigs age 1 month and 2 years old. There is strong evidence that the presence of chondrocytes in the TMJ disks of the older group of guinea pigs is the result of a biological aging phenomenon and is not related to pathologically induced changes.

Extractions in the presence of acute infections.

Of 1,376 extractions performed in the presence of acute infection, 327 were performed in the presence of a coexisting fascial space abscess. No serious complications were observed. It seems that the relation of dental operations to the intracranial infections has been overestimated. The extraction of teeth in cases of acute suppurative infection treats the primary dentoalveolar infection and prevents the development of fascial space abscesses.

Treatment of squamous cell carcinoma of the anterior faucial pillar-retromolar trigone.

Cancer of the anterior faucial pillar-retromolar trigone is an uncommon head and neck tumor, which has historically been shown to be associated with poor prognosis. In this retrospective study, we reviewed our experience with primary surgery followed by postoperative radiation therapy in order to determine the impact of our treatment protocols on patients' outcome. Between January 1994 and December 1998, 31 patients with histologically proven squamous cell carcinoma (SCC) of the anterior faucial pillar-retromolar trigone were treated in our department. Surgical excision of the primary lesion and ipsilateral neck dissection were performed in all patients. Reconstruction was accomplished using masseter muscle flap or tongue flap. Postoperatively, most patients (90%) received radiation therapy (51-58 Gy) to the primary side and neck. Adjuvant chemotherapy was offered if histologic signs of aggressive behavior were identified. Four out of 31 patients were initially seen at stage I or II and 27 patients at stage III or IV of the disease. Metastatic disease was demonstrated in 78% of ipsilateral neck nodes. Occult metastases were found in 64% of clinically N0 necks. The 3-year loco-regional recurrence rates were 44.8%. SCC of retromolar trigone is considered as an aggressive and insidious tumor. The reconstruction of the deficit of the anterior faucial pillar-retromolar area with masseter muscle flap is a reliable, safe and absolutely functional method.

Extra-articular ankylosis of the coronoid processes to the base of the skull. A case report.

Extra-articular temporomandibular bony ankylosis between the coronoid process and the base of the skull is quite uncommon. In this paper we present a case of fusion of the right coronoid to the maxilla and sphenoid bone in an 18-year-old male. This bony ankylosis was the result of surgical removal of an odontogenic tumour from the right mandibular ramus when the patient was 4 years old. The ankylosis of the right coronoid resulted in hypoplasia of the mandible and fibrous fusion between the left coronoid and the base of the skull. The patient was treated by bilateral operation. Postoperative recurrent dislocation of the left condyle was attributed mainly to unbalanced muscle activity and to the flattening of the articular eminence of the left temporomandibular joint which had developed during the long duration of the ankylosis. This was successfully treated by left condylectomy.

Abducent nerve palsy following transverse fracture of the middle cranial fossa.

Transverse sphenoidal fractures may be associated with a variety of skull base injuries and neural deficits. Among those nerve injuries, oculomotor palsies and particularly sixth cranial nerve palsy, are quite common. Blows on the side of the head in the squamous temporal region may run across the floor of the middle cranial fossa through the greater wing of the sphenoid in the transverse cranial axis. We report three cases of patients who had sustained craniofacial injury which included a transverse fracture of the middle cranial fossa through the sphenoid sinus, extending to the petrous apex and producing abducent, facial, and eighth nerve dysfunction. Spontaneous recovery from diplopia occurred in all cases within 4 months. The management of the patients and the patterns of transverse cranial base fractures and their associated clinical features are discussed.

Sagittal fracture of the maxilla.

Although sagittal fractures of the maxilla are not common, they can be observed in some cases following severe trauma to the facial skeleton. 18 of the 23 cases reported had combined mandibular and midfacial fractures. Sometimes in severe cases they may demonstrate instability with conventional methods of treatment; thus for adequate stabilization they may need a palatal splint, direct wiring (internal fixation in the buttresses), intermaxillary fixation and cranial suspension.

Posterior dislocation of mandibular condyle into external auditory canal. A case report.

A case is reported of a 49-year-old edentulous patient who suffered a posterior dislocation of the right fractured mandibular condyle causing a fracture of the tympanic plate. This was associated with a right transverse fracture of the petrous bone and an intact tympanic membrane. Some of the problems related to this condition are discussed.

The Gardner syndrome.

The Gardner syndrome is characterized by polyposis coli and multiple hard and soft tissue tumors. A case of a 17-year-old male is presented who complained of painless and hard swellings on the angle of the mandible bilateraly. The patient presented the original triad of lesions of the Gardner syndrome. On the panoramic X-ray, characteristic radio-opaque lesions (exostoses and enostoses) on the jaws were shown and a compound odontoma was detected in the left side of the mandible.

Benign cysts of the parotid gland.

Benign cysts of the parotid gland are not frequently diagnosed. They occur in any portion of the parotid gland and may be difficult to diagnose. They present with considerable histological variation in their linings. Three cases are presented of unilocular benign cystic lesions of the parotid gland that have been treated by superficial parotidectomy. Two of them were lined by a single or pseudostratified layer of cuboidal epithelium and were diagnosed as retention cysts. The third was a lympho-epithelial cyst and was lined by stratified squamous and partially by pseudostratified ciliated columnar epithelium. A review of the relevant literature is also presented.

Metastatic adenocarcinoma to the mandible: report of case.

A 40-year-old woman who had undergone a mastectomy of the right breast two years before was admitted in our department with metastatic malignant tumor of the mandible. The biopsy revealed the presence of the metastatic adenocarcinoma.

Totally submerged deciduous maxillary molars. Case reports.

The total reimpaction or submersion of deciduous teeth is a very uncommon phenomenon and few cases have been reported in the literature. The condition affects the mandibular second deciduous molar most often and the maxillary first deciduous molar least often. Two cases of totally reimpacted maxillary deciduous molars are reported.

Bifid mandibular condyle resulting from a sagittal fracture of the condylar head.

Sagittal or vertical fractures of the mandibular condyle and chip fractures of the medial part of the condylar head are very rare entities and their identification is difficult with conventional radiographs. We report a case of a unilateral bifid mandibular condyle which resulted following a sagittal condylar fracture. This was associated with a chip fracture of the medial part of the condylar head on the contralateral side. These types of condylar fracture do not require any surgical treatment, but early mobilization is indicated.

Congenital hemifacial hyperplasia.

A case of true hemifacial hyperplasia is described. This is an unusual condition which produces facial asymmetry by a marked, unilateral, localised overgrowth of all the tissues in the affected area, including, the facial soft tissues, bones and teeth. The patient is an eight-year-old Caucasian girl with congenital hemihyperplasia of the right side of her face.