Chronic graft-versus-host disease after liver transplantation: a case report

Graft-versus-host disease (GVHD) after orthotopic liver transplantation (OLT) is a rare but significant complication, occuring in 1%-2% of cases with a mortality rate of 85%- 90%. It occurs when donor passenger lymphocytes mount an alloreactive response against the host's histocompatibility antigens. It presents as fever, rash, and diarrhea with or without pancytopenia. Between March 2002 and September 2011, among 656 OLT patients 1 (0.15%) had acute GVHD. A biopsy at the 7th posttransplantation month revealed chronic GVHD. Consequently, in the cases that had fever, rash, and/or desquamation of the any part of body after liver transplantation, GVHD must be considered and skin biopsies must be planned for the diagnosis.     

Acute thrombotic thrombocytopenic purpura following orthopedic surgery: case report and review of the literature

Thrombotic thrombocytopenic purpura (TTP) is an uncommon cause of hematological and renal abnormalities in the postoperative period. An association between TTP and orthopedic surgery, a rare entity, has been reported in the literature. It has the strong possibility of being fatal and therefore should be treated immediately, mostly by plasmapheresis. We report a 15-year-old girl of TTP following a high tibial valgus osteotomy (HTO).     

Analysis of metastatic ovarian tumors from extragenital primary sites

AIMS AND BACKGROUND: The aim of this study was to evaluate patients with metastatic ovarian tumors from extragenital primary sites. METHODS: The medical records of 75 patients were reviewed retrospectively for age at diagnosis, presenting symptoms, preoperative tumor marker levels, preoperative diagnostic workup, operative technique, intraoperative evaluation, frozen-section and pathology results, laterality of metastasis, and primary tumor site. The specific impact of metastasis from colorectal and gastric primary sites on laterality, gross features and dimensions of ovarian mass, volume of ascites and tumor marker levels was investigated. RESULTS: Primary sites were stomach (37.3%), colorectal region (28%), lymphoma (12%), breast (6.7%), biliary system (2.7%), appendix (1.3%) and small intestine (1.3%). It was not possible to identify the primary tumor site in 8 (10.7%) patients. Bilateral metastasis was found in 86.4% patients; 42.7% of the metastatic ovarian tumors were Krukenberg tumors; 50.7% of the ovarian masses were solid. Frozen section was confirmed by postoperative pathological results in 98% of the patients. The mean preoperative serum levels of tumor markers were 298.7 U/mL, 178 U/mL and 113.3 U/mL for CA 125, CA 19-9 and CA 15-3, respectively. CA 125 levels were above 35 U/mL in 81.3% of the patients. The presence of ascites was more frequent in ovarian tumors originating from colorectal and gastric primaries. CONCLUSIONS: Surgery is essential for the diagnosis of the primary tumor and necessary for relief of symptoms. The identification of the primary site is required to plan adequate treatment.     

High dose sequential chemotherapy and autologous stem cell transplantation in patients with relapsed/refractory lymphoma

Although high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) has become the standard approach for patients with relapsed/refractory Hodgkin's disease (HD) or non-Hodgkin's lymphoma (NHL), more than 50% of patients will experience relapse following ASCT. High-dose sequential chemotherapy (HDSC) can intensify the conventional salvage treatment and improve the outcome of ASCT by maximal debulking of the tumor load with the use of non-cross resistant drugs, each at their maximal tolerated doses. We conducted a phase II study in 40 patients with relapsed/refractory HD (n = 18) and NHL (n = 22) using HDSC followed by ASCT. Only patients sensitive to salvage chemotherapy were eligible for the protocol, consisting of three phases. Phase I consisted of cyclophosphamide (4.5 g/m²) followed by G-CSF and peripheral blood stem cell (PBSC) collection. Phase II consisted of etoposide (2 g/m²). The transplant phase consisted of mitoxantrone (60 mg/m²) and melphalan (180 mg/m²) followed by PBSC infusion. Eleven out of nineteen patients with B-cell lymphoma received rituximab. Prior to HDSC, 45% of the patients were in complete remission (CR) and 55% were in partial remission (PR). After completion of all phases of the protocol, 35 out of 39 evaluable patients achieved CR (90%) and this was durable in 30 (75%) patients with a projected progression-free survival (PFS) rate at 4 years of 71.7%. Treatment-related mortality rate at day +100 was 2.5% (n = 1). At a median follow-up of 32 months (range, 3 - 61), nine patients relapsed/progressed and eleven patients died. The estimated 4-year PFS and overall survival (OS) were 72.2% and 47.6% in HD patients and 70.3% and 69.4% in NHL patients, respectively. Factors predicting OS were response to conventional salvage therapy and stage prior to salvage therapy. When compared to patients achieving PR, patients who attained CR prior to HDSC had a significantly higher probability of 4-year OS (78.4% vs 31.3%, p = 0.02). Three prognostic subgroups were defined according to the score determined by stage prior to initiation of salvage chemotherapy, remission duration prior to salvage (refractory/early relapse vs. late relapse) and response to salvage. Prognostic score was found to predict OS, PFS and event free survival (EFS). In conclusion, HDSC followed by ASCT is an effective salvage therapy with acceptable toxicity, allowing further consolidation of response attained by conventional salvage therapy.     

Resolution in partially accomodative esotropia during occlusion treatment for amblyopia

PURPOSE: To evaluate alignment changes in partially accommodative esotropia during occlusion treatment for amblyopia. METHOD: Changes at the deviation angles of 63 partially accommodative esotropia patients, who had occlusion treatment for amblyopia, were evaluated retrospectively. RESULTS: Mean deviation angle at the start of therapy without glasses was 45 PD (10-90 PD) and became 27 PD (5-70 PD) after at least 2 months with glasses. During 12 (2-36) months of occlusion period, mean manifest deviation angle with glasses decreased to 11 PD (0-50) (P < 0.001) and amblyopia resolved in 71.5% of the cases. After termination of amblyopia treatment 24 (38%) cases had surgery for the residual deviation but if we had planned surgery before amblyopia treatment, 81% of the patients would have had surgery. DISCUSSION: Should amblyopia be treated initially or should we operate first in patients with strabismus and amblyopia together? Our research suggests that we should not hurry to operate in high hypermetropic partially accommodative cases, which have amblyopia and a long-term history of strabismus. Initial amblyopia treatment in these cases allows time for resolution of the nonaccomodative component in strabismus and can significantly decrease the necessity for surgery.     

Evaluation of P-POSSUM and CR-POSSUM Scores in Patients with Colorectal Cancer Undergoing Resection

Introduction The aim of this study was to evaluate the predictive accuracy of P-POSSUM and CR-POSSUM models on patients undergoing colorectal resection. Methods P-POSSUM and CR-POSSUM predictor equations for mortality were applied retrospectively to 321 patients who had undergone colorectal resection for cancer. P-POSSUM and CR-POSSUM scores were validated by assessing their calibration and discrimination. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic (ROC) curve analysis. Results Overall, 22 deaths were observed. CR-POSSUM predicted 25 deaths (χ² = 12.20, P = 0.13), and P-POSSUM predicted 29 deaths (χ² =18.85, P = 0.002). ROC curves analysis revealed that CR-POSSUM has reasonable discriminatory power for mortality. Conclusions These data suggest that CR-POSSUM may provide a better estimate of the risk of mortality for patients who undergoing colorectal resection.