Lateral Temporal Bone Resection in Advanced Cutaneous Squamous Cell Carcinoma: Report of 35 Patients

Objective To evaluate lateral temporal bone resection (LTBR) in the management of advanced cutaneous squamous cell carcinoma (SCC) with temporal bone invasion and patterns of failure.Methods This is a retrospective study of 35 patients undergoing lateral temporal bone resection for advanced cutaneous SCC at a tertiary care center between 1995 and 2006.Results The Pittsburgh tumor stage was T4 in 18 patients (51%), T3 in 5 (14%), T2 in 9 (26%), and T1 in 3 (9%). Clear margins were reported in 22 (63%) patients. Resection of the mandible and/or temporomandibular joint (TMJ) was required in 11 (31%) patients. Facial nerve involvement was seen in 10 (29%) patients. Survival outcomes at 2 and 5 years for overall survival were 72% and 49%; disease-free survival, 68% and 59%; and disease-specific survival, 79% and 62%, respectively. Pittsburgh T stage correlated significantly with disease-specific survival (p = 0.015) and margin status was significant for both disease-free survival (p = 0.0015) and disease-specific survival (p < 0.001).Conclusions Surgery with curative intent is justified for cutaneous SCC invading the temporal bone with extended LTBR. Margin status was a significant predictor of outcome. Surgeons should plan preoperatively to achieve clear margins by extending the LTBR with possible nerve resection.     

Acute Pancreas Allograft Rejection Is Associated With Increased Risk of Graft Failure in Pancreas Transplantation

The effect of acute allograft rejection (AR) on long‐term pancreas allograft function is unclear. We retrospectively studied 227 consecutive pancreas transplants performed at our institution between January 1, 998 and December 31, 2009 including: 56 simultaneous pancreas and kidney (SPK), 69 pancreas transplantation alone (PTA); and 102 pancreas after kidney (PAK) transplants. With a median follow‐up of 6.1 (IQR 3–9) years, 57 patients developed 79 episodes of AR, and 19 experienced more than one episode. The cumulative incidence for AR was 14.7%, 19.7%, 26.6% and 29.1% at 1, 2, 5 and 10 years. PTA transplant (hazards ratio [HR] = 2.28, p = 0.001) and donor age (per 10 years) (HR = 1.34, p = 0.006) were associated with higher risk for AR. The first AR episode after 3 months post PT was associated with increased risk for complete loss (CL) (HR 3.79, p < 0.001), and the first AR episode occurring during 3‐ to 12‐month and 12‐ to 24‐month periods after PT were associated with significantly increased risk for at least partial loss (PL) (HR 2.84, p = 0.014; and HR 6.25, p < 0.001, respectively). We conclude that AR is associated with increased risk for CL and at least PL. The time that the first AR is observed may influence subsequent graft failure.     

ADAMTS13 reduces vascular inflammation and the development of early atherosclerosis in mice

ADAMTS13, a metalloprotease, plays a pivotal role in preventing spontaneous microvascular thrombosis by cleaving hyperactive ultra large von Willebrand factor multimers into smaller, less active multimers. Reduced ADAMTS13 activity in plasma has been described in many diseases associated with systemic inflammation. It remains uncertain, however, whether ADAMTS13 contributes to disease pathogenesis or rather simply serves as an inflammation-associated marker. We hypothesized that, by decreasing vascular inflammation, ADAMTS13 reduces the development of early atherosclerotic plaques. Using intravital fluorescence microscopy, we observed excessive leukocyte adhesion and accelerated atherosclerotic plaque formation at the carotid sinus of Adamts13(-/-)/ApoE(-/-) mice compared with ApoE(-/-) mice fed a high-fat Western diet. At 4 months of age, there was a significant increase in atherosclerosis in the aorta and aortic sinus of Adamts13(-/-)/ApoE(-/-) mice compared with ApoE(-/-) mice. Interestingly, we detected a 2-fold increase in macrophage recruitment to the atherosclerotic plaque of the Adamts13(-/-)/ApoE(-/-) mice compared with ApoE(-/-) mice, suggesting that the atherosclerotic lesions in these mice were not only larger but also more inflammatory. These findings reveal a new functional role for the antithrombotic enzyme ADAMTS13 in reducing excessive vascular inflammation and plaque formation during early atherosclerosis.     

Intensive chemotherapy with thiotepa, busulfan and cyclophosphamide and hematopoietic stem cell rescue in relapsed or refractory primary central nervous system lymphoma and intraocular lymphoma: a retrospective study of 79 cases

Background

Relapsing primary central nervous system lymphoma carries a poor prognosis when treated with conventional chemotherapy with a one-year overall survival of 25-40%. Encouraging results have been shown with intensive chemotherapy followed by autologous hematopoietic stem cell rescue. We report the results of a large multicenter retrospective analysis of intensive chemotherapy followed by hematopoietic stem cell rescue in immunocompetent adult patients with primary central nervous system lymphoma or intraocular lymphoma after the failure of high-dose methotrexate-based treatment.

Design and Methods

Patients were included if they received intensive chemotherapy with a combination of thiotepa, busulfan and cyclophosphamide. Seventy-nine patients (median age 52.4 years, range 23-67 years) were identified. All of the patients except 5 received a salvage treatment after the failure of high-dose methotrexate. After salvage treatment and just before intensive chemotherapy followed by hematopoietic stem cell rescue, 32 patients were in complete response, 26 patients were in partial response, 2 patients had stable disease and 19 patients had progressive disease.

Results

With a median follow up of 56 months, the 5-year overall survival probability was 51% in the whole population and 62% among patients who were chemosensitive to the salvage treatment. The 5-year event-free survival probability was 37.8% in the whole population and 43.7% in the chemosensitive subpopulation. Neurocognitive assessments in a subset of patients suggest no evidence of intensive chemotherapy-induced neurocognitive decline.

Conclusions

Thiotepa, busulfan and cyclophosphamide-based intensive chemotherapy is an effective treatment for refractory and recurrent primary central nervous system lymphoma in chemosensitive patients up to 65 years of age. The role of intensive chemotherapy followed by hematopoietic stem cell rescue in chemorefractory patients needs to be more accurately defined.Key words: thiotepa, busulfan, cyclophosphamide, hematopoietic stem cell, central nervous system, intraocular, lymphoma     

Percutaneous Closure of a Left Ventricular Pseudoaneurysm in a High-Risk Surgical Candidate

Few cases of percutaneous device closure of a left ventricular pseudoaneurysm have been reported. We describe the case of a 67-year-old man with a history of coronary artery disease who presented with shortness of breath and chest pain. Computed tomographic angiography showed a left ventricular pseudoaneurysm that was filling from a small leak in the anterolateral aspect of the ventricle. The patient had undergone 3 previous sternotomies and was a high-risk candidate for surgical treatment of the pseudoaneurysm. Despite technical challenges, we closed the pseudoaneurysm percutaneously with use of a 6-mm AMPLATZER muscular ventricular septal defect occluder. The patient was released from the hospital the next day and was asymptomatic a year later.To our knowledge, this is the first report of the percutaneous closure of a left ventricular pseudoaneurysm via the femoral vein. We show that this manner of closure can be feasible in patients who have undergone multiple sternotomies and who are at high surgical risk.Key words: Aneurysm, false/complications/therapy; heart catheterization/instrumentation; heart ventricles; risk factors; septal occluder device; surgical procedures, minimally invasive; treatment outcome; ventricular dysfunction, left/complications/therapyA left ventricular (LV) pseudoaneurysm is a small channel that connects the LV to a large aneurysmal sac that contains blood and thrombus.¹ Complications of a pseudoaneurysm include rupture into the pericardium, peripheral embolization, and severe mitral regurgitation.² Emergent surgical repair is the preferred method of closing a pseudoaneurysm³; however, patients who have previously undergone cardiac surgery have a higher risk of morbidity and death after reoperation.^4,5 We describe the percutaneous closure of a pseudoaneurysm of the LV in a high-risk surgical candidate.