Ovarian tissue cryopreservation in girls undergoing haematopoietic stem cell transplant: experience of a single centre.

Fertility after childhood haemopoietic stem cell transplant (HSCT) is a major concern. Conditioning regimens before HSCT present a high risk (>80%) of ovarian failure. Since 2000, we have proposed cryopreservation of ovarian tissue to female patients undergoing HSCT at our centre, to preserve future fertility. After clinical and haematological evaluation, the patients underwent ovarian tissue collection by laparoscopy. The tissue was analysed by histologic examination to detect any tumour contamination and then frozen following the slow freezing procedure and cryopreserved in liquid nitrogen. From August 2000 to September 2013, 47 patients planned to receive HSCT, underwent ovarian tissue cryopreservation. The median age at diagnosis was 11.1 years and at the time of procedure it was 13 years, respectively. Twenty-four patients were not pubertal at the time of storage, whereas 23 patients had already experienced menarche. The median time between laparoscopy and HSCT was 25 days. Twenty-six out of 28 evaluable patients (93%) developed hypergonadotropic hypogonadism at a median time of 23.3 months after HSCT. One patient required autologous orthotopic transplantation that resulted in one live birth. Results show a very high rate of iatrogenic hypergonadotropic hypogonadism, highlighting the need for fertility preservation in these patients.

Monitoring of TNFR1, IL-2Rα, HGF, CCL8, IL-8 and IL-12p70 following HSCT and their role as GVHD biomarkers in paediatric patients.

No predictive factors are currently available to establish patient-specific GVHD risk. A panel of six serum cytokines (TNF receptor 1, IL-2 receptor alfa (IL-2Rα), hepatocyte growth factor (HGF), monocyte chemo-attractant protein-2, IL-8, IL-12p70) were monitored at established time points (days -1, +1, +7, +14, +21, +28 and +60) in 170 paediatric hematopoietic SCT (HSCT) recipients. We found that higher concentrations of IL-2Rα on days +14 and +21 together with HGF on days +14 and +21 were significantly associated at a higher probability of both grade II-IV GVHD (on day +14 it was: 60% vs 28%, P=0.007) and grade III-IV (on day +14 it was: 40% vs 15%, P=0.001). The higher IL-8 serum concentration on day +28 was associated with a lower probability of chronic GVHD being 4% vs 29% (P=0.01) for patients with higher vs lower IL-8 serum concentration. These findings were confirmed when the analysis was restricted to the the matched unrelated donor group. In conclusion, even if the serum cytokine levels were related to several variables associated with HSCT, we identified two cytokines as predictors of GVHD II-IV and III-IV, translating into a higher TRM risk (17% vs 3%, P=0.004).

Preoperative risk stratification in patients undergoing elective infrarenal aortic aneurysm surgery: evaluation of five risk scoring methods.

OBJECTIVE: To evaluate five risk scoring methods in predicting the immediate postoperative outcome after elective open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective evaluation of the Eagle score, Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score in a consecutive series of patients. PATIENTS: Two hundred and eighty-six consecutive patients undergoing elective infrarenal aortic aneurysm repair. RESULTS: Nine patients (3.1%) died in hospital and another 35 (12%) experienced severe postoperative complications. For the Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.749 (p=0.01), 0.777 (p=0.008), 0.788 (p=0.006) and 0.794 (p=0.005), respectively. The Eagle risk score was less accurate for predicting in-hospital mortality. The risk-scoring systems did not perform well in predicting post-operative complications, but multivariate analysis showed that the modified Leiden score was an independent predictor of postoperative complications. CONCLUSION: All scoring systems predict, with reasonable accuracy, the risk of in-hospital death in patients undergoing elective open repair of AAA, whereas the accuracy in predicting severe postoperative complications is less.

Successful unrelated cord blood transplantation in two children with severe combined immunodeficiency syndrome.

We describe the successful unrelated cord blood transplantation in two patients affected by a Zap-70 deficiency and an Omenn-like syndrome, respectively. The patients were hospitalised for recurrent infections at the age of 13 and 2 months, respectively. An unrelated cord blood unit was found for each. The conditioning regimen was cyclophosphamide, busulfan and antithymocyte globulin. The total number of infused cells was 15.1 x 10(7)/kg and 17 x 10(7)/kg, respectively. Neutrophil engraftment was achieved on days +15 and +23, and platelet count >50 x 10(9)/l was achieved on days +21 and +52, respectively. One patient presented acute Graft-versus-host disease (GVHD) grade I and the other grade III. Chimerism was mixed and full donor. Normal lymphoproliferative response to mitogens and alloantigens was detectable at 6 months for both. No chronic GVHD was observed in either. The patients are alive and well at 53 and 15 months after transplantation. In conclusion, umbilical cord blood represents a valid alternative source of haemopoietic stem cells.

Role of different medium and growth factors on placental blood stem cell expansion: an in vitro and in vivo study.

Expansion of haemopoietic stem cells from placental blood has been obtained with a combination of flt3 ligand (FL), thrombopoietin (TPO), kit-ligand (KL) with or without interleukin-6 (IL6) in serum-replete medium. For clinical use, cell expansion in the absence of serum is a clear advantage. Therefore, stem cell expansion in serum-free (SF) medium with a combination of three (FL, TPO, KL) or four (FL, TPO, KL, IL6) growth factors was compared with the results obtained using fetal calf serum (FCS) or human serum (HS). Human CD34(+) placental blood cells were cultured in the presence of FL, TPO, KL +/- IL6 with SF medium, HS and FCS for up to 8 weeks. CD34(+), CFC, LTC-IC content was measured at intervals. To determine the in vivo repopulating capacity of expanded cells, CD34(+) expanded cells were transplanted in sublethally irradiated NOD/SCID mice. With the three growth factor combination the CD34(+) cell number increased steadily up to the 8 weeks of culture. CD34(+) cells were expanded 67.5-fold with SF, 11.7 with HS and 49.2 with FCS. However, when CFCs and LTC-ICs were considered, a continuous expansion was observed only with HS and FCS, whereas in SF medium after 6 weeks their number started to decline. The addition of IL-6 did not change the expansion significantly. Cells grown ex vivo for 14 days were transplanted into NOD/SCID mice. The engraftment of human cells in mice was higher for serum-replete than for SF expanded cells. Nevertheless, SF cultured cells were also able to engraft both marrow and spleen in all animals. In addition, engrafted human cells still maintained clonogenic ability. With KL, FL, TPO +/- IL6 it is possible to expand haemopoietic progenitor cells in a SF medium. Compared with serum-replete cultures, the absolute number of clonogenic cells and in vivo repopulating cells is lower. Although the degree of expansion remains significant, a clinical trial still needs to be carried out to address the question of whether this expansion might be useful in reducing post-transplant aplasia.

Carotid artery dissection. Correlation of different diagnostic techniques.

Dissection of the carotid artery is a rare entity, but a frequent cause of cerebrovascular accidents in young adults and can result in severe neurologic consequences that are often irreversible. Carotid dissection can be secondary to trauma, brisk rotation of hyperextension of the neck, as a complication in certain diseases. It may lead to distal embolization, complete occlusion of the vessel, extensive or limited stenosis, aneurysmal form which has the appearance of a berry aneurysm or resolution of the process with complete patency of the dissected vessel. The authors find color-Doppler sonography to be an invaluable tool in the evaluation of such a process, since it is non invasive, readily available, relatively inexpensive and can yield detailed information about the lumen of the vessel, blood flow, mural and intramural structures. Furthermore, in comparison to MRA, color-Doppler sonography is particularly suitable for the early detection of thrombus. Ultrasonographic investigation has some methodologic limitations: occlusion cannot always be demonstrated directly because of its high cervical location and detection of aneurysms localized in the retrostyloid++ space is usually not possible. The combination of ultrasonographic findings and MRA is the method of choice for follow-up on evaluation of carotid dissection and helps make the decision as to whether one should proceed to angiography in this young age group.

Primary orbital angiosarcoma: a case report.

PURPOSE: The pathogenesis, natural history, histopathology, and recommended treatment for orbital angiosarcoma are illustrated and reviewed. METHODS: Case report. RESULTS: A 71-year-old white male presented with bluish discoloration and swelling of the left medial canthal area. A fine needle aspiration and excisional biopsy with histopathologic examination was performed, which showed angiosarcoma. Pattern of growth was demonstrated radiographically and histopathologically, confirming primary orbital angiosarcoma. Subsequent wide surgical resection was carried out, with substantial reconstruction of the left orbital and periorbital area. The patient responded well to the surgery, and was free of tumor after six years of follow-up. CONCLUSION: Angiosarcoma is a rare and highly malignant tumor of epithelial origin. The aggressive nature of this tumor usually results in a high mortality rate despite treatment. However, early diagnosis and wide surgical excision has resulted in successful treatment of these tumors.

The role of thalidomide in the treatment of refractory chronic graft-versus-host disease following bone marrow transplantation in children.

Chronic graft-versus-host disease (cGVHD) is a frequent complication of allogeneic bone marrow transplantation (BMT). Thalidomide was found to have immunosuppressive properties and it has been used in a limited number of children with cGVHD. We report our experience with refractory and/or high-risk cGVHD in 14 children. Six children showed complete clinical response to thalidomide in a median time of 2 months. Four children had partial responses and four failed. Side-effects were usually mild (somnolence, constipation) and only two patients developed sensory peripheral neuropathy. An increased incidence of infectious complications attributable to thalidomide was not observed. Nine out of 10 responding patients are alive 49-111 months post-BMT. Thalidomide can be effective particularly in children with prevailing mucocutaneous cGVHD. All patients should be carefully monitored to detect peripheral neuropathy early.

Feasibility of high-dose chemotherapy and autologous peripheral blood stem cell transplantation in children with high grade osteosarcoma.

An Italian-Scandinavian treatment and research protocol with high-dose chemotherapy and double peripheral blood stem cell (PBSC) transplantation has been designed in an attempt to improve overall results of children with metastatic osteosarcoma (OST). Six patients, aged 12-17 years, underwent PBSC mobilization with CY 4 g/m2 and VP-16 600 mg/m2 followed by G-CSF (n = 4 with recurrent disease) or ifosfamide 15 g/m2 plus G-CSF (n = 2 with synchronous metastases). The target dose of CD34+ cells for two transplant procedures was 8 x 10(6)/kg or more; conditioning regimen for both the grafts consisted of carboplatin 375 mg/m2/day for 4 days and VP16 450 mg/m2/day for 4 days. The first transplant was planned 2-4 weeks after the mobilization, the second transplant 4-6 weeks after the first graft. In three patients a single course of CY-VP16 mobilised a total number of CD34+ sufficient for two transplants; in the patient who did not obtain the target dose of CD34+ cells a bone marrow harvest was added. In the two other children high-dose ifosfamide failed to achieve the required CD34+ number: one patient underwent a single transplant procedure, one patient was successfully mobilized with doxorubicin 90 mg/m2 plus G-CSF. Patients underwent a median of two collections (range 2-4). Leukapheresis resulted in the collection of a median of 8.9 CD34+ cells/kg (range 1.3-14.8). The median time to granulocyte count recovery to more than 0.5 x 10(9)/l was 10 days (range 9-14 days) after the first graft and 11 days (range 10-12 days) after the second graft, respectively. Platelets recovered to 50 x 10(9)/l at a median of 11 (range 10-30 days) and 13 days (range 10-28) respectively after the first and the second graft. Conditioning regimen was well tolerated in all patients with mild extra haematological toxicity, also following the second transplant. Two patients grafted with metastases at diagnosis are alive and disease free 3 and 7 months from the transplant. One of the four patients transplanted for recurrent disease developed pulmonary metastases 2 months after the procedure; one patient is alive with significant reduction of tumor mass 1 month after the first transplant, one patient is alive without evidence of disease 9 months from the second transplant and one after a complete metastasectomy (tumor necrosis >90%) which followed the second transplant. With the limits of the small number of cases and the short follow-up, these preliminary results show that this approach may be promising for the treatment of patients with metastatic OST who currently are not cured by conventional-dose regimens.

Cryptococcal meningitis following a thrombotic microangiopathy in an unrelated donor bone marrow transplant recipient.

In patients undergoing bone marrow transplantation cryptococcosis is rarely encountered. We report a fatal case of Cryptococcus meningitis in a 12-year-old girl with acute lymphoblastic leukemia (ALL) in second remission who had a transplant from a human leukocyte antigen (HLA)-identical unrelated bone marrow donor. The conditioning regimen was thiotepa, cyclophosphamide, and total body irradiation (TBI); graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A, methotrexate, and antilymphocyte globulin (ALG). The patient experienced stage III GVHD responsive to high-dose corticosteroids. On day +54 a thrombotic microangiopathy occurred. On day +64 neurological status worsened; a brain computed tomographic (CT) scan showed hyperdense lesions suggesting fungal infection. Detection of cryptococcal antigen by latex agglutination was positive but India ink stain and culture were negative. Despite treatment with amphotericin B, 5-flucytosine, and granulocyte-macrophage colony-stimulating factor, the patient died 13 days after the diagnosis.

Long-term persistence of hemopoietic chimerism following sex-mismatched bone marrow transplantation.

Fifty-eight samples of bone marrow (31), whole peripheral blood (8) and separated fractions of circulating mononuclear (11) and polymorphonuclear (8) cells from 18 male patients, transplanted for hematological diseases from related (14) or unrelated (4) female donors were analyzed for chimerism at subsequent intervals (range, 1-72 months) following bone marrow transplantation, by means of PCR amplification of the Y-chromosome-specific DYS14 sequence, revealed by a radiolabelled hybridization probe (dot blot technique, 0.01% sensitivity). Detection of male cells was positive in all but two of 52 samples collected within the third year after transplantation and negative in six samples collected from three patients after the third year. In the first year after transplantation, mixed chimerism was found in all patients, apparently with no correlation with graft-versus-host disease. Comparable results were found in fractions of mononuclear and polymorphonuclear cells, when analyzed separately. The persistence of very low levels of recipient cells in patients in continuous complete remission until the third year after transplantation, suggests the persistence of normal host hemopoiesis for a long period of time after the so-called myeloablative regimen. The progressive negativization, occurring in our patients between the second and the fourth year after transplantation, could signify the disappearance of residual host hemopoiesis or its decrease to below the detection level of this highly sensitive method.

Management of paralytic lagophthalmos with a modified gold-weight implantation technique.

A modified gold-weight implantation technique was used to treat paralytic lagophthalmos in 15 patients. Three patients had suffered extrusions of previously placed gold-weight implants, two had other complications necessitating reoperation, and 10 had no previous surgery. The surgical modifications were intended to reduce the incidence of implant extrusion, postoperative ptosis, and implant visibility beneath the skin. The important changes in the surgical technique included (a) advancing the levator aponeurosis over the implant and (b) adjusting the final eyelid height intraoperatively with levator myotomies. Follow-up ranged from 6 to 11 months. None of the patients in this study had postoperative problems associated with ptosis, implant extrusion, or implant visibility. Mild, prolonged, postoperative edema was noted in several patients. This resolved spontaneously. Mild eyelid retraction and lagophthalmos were seen postoperatively in two patients. This was caused by a failure to perform marginal myotomies at the time of the initial surgeries.

Clinical performance of low-profile bioprostheses: results at 10 years.

The purpose of this retrospective study is to evaluate the long-term performance of the Liotta minimally intrusive bioprosthesis (MIB) and to identify its most important risk factors. From January 1980 to March 1982, 73 patients (30 males and 43 females; mean age 45.5 years +/- 11.7 standard deviation; range 11 to 64) underwent operation for heart valve replacement with an MIB. Fifty-two mitral valve replacements (MVR), 16 aortic valve replacements (AVR), 4 mitral and aortic valve replacements (MAVR), and 1 mitral and tricuspid valve replacement (MTVR) have been performed (78 MIBs implanted). Global operative mortality has been 8.2% (6/73): 9.6% (5/52) for MVR and 6.2% (1/16) for AVR. The 10-year follow-up reaches 519 patient-years and 581 valve-years, and is 96.5% and 93.9% complete, respectively. Actuarial freedom from any patient- or valve-related event has been calculated at one time with its hazard function and its incidence normalized per 100 patient- and/or valve-years; statistical significance of difference between curves has been assessed. In this report, overall actuarial survival at 10 years is 79.4% +/- 5.3% SEM (standard error of the mean), including operative deaths (incidence = 2.6% per patient-year). Two patients experienced periprosthetic leakage (PL) at 4 and 9 years, respectively (incidence = 0.4% per valve-year). One patient underwent reoperation because of otherwise untreatable prosthetic valve endocarditis (PVE) at 5 years (0.2% per valve-year).(ABSTRACT TRUNCATED AT 250 WORDS)

Flap reconstruction techniques in conjunctivorhinostomy.

Dacryocystorhinostomy is usually the standard approach to treat epiphora caused by lower lacrimal tract obstruction. When the pathologic condition lies in the upper lacrimal passage, however, alternate bypass or reconstructive options must be considered. Conjunctivodacryocystorhinostomy, using the Jones tube, can effectively bypass the upper tract, but the technique may be complicated by granulation tissue formation, infection from unapposed mucosal flaps, and inefficient passage of tears through scar as a result of healing by secondary intention. Canaliculodacryocystorhinostomy affords the advantages of a physiologic reconstruction, but is limited by availability of sufficient canaliculus, requires a lengthy and tedious dissection, and must be performed using a microsurgical approach. We describe an alternate technique of conjunctivorhinostomy that provides total lacrimal bypass and has the advantages of bipedicled mucosal flap apposition, temporary stenting, and symptomatic improvement of epiphora. Several case examples illustrate the indications, advantages, and disadvantages of this technique.

A comparison of motility: autogenous dermis-fat vs synthetic spherical implants.

The socket and prosthesis motility and the forniceal depths in a group of 47 patients who had undergone enucleation and implantation of synthetic spherical implants were compared with those in a group of 34 patients who had undergone enucleation and implantation of autogenous dermis-fat orbital implants. The primary autogenous dermis-fat orbital implants provided greater socket movement and deeper fornices than the synthetic spherical implants. Prosthesis motility, however, was the same in the two groups.

Surgical correction of enophthalmos and diplopia. A report of 38 cases.

Enophthalmos, hypophthalmos, and diplopia are complications of orbital injury. This article reviews the causes of these sequelae, describes a method of strategic implantation of bone grafts to the orbit (and malar bone), and reports the long-term (six months to eight years) results in 38 cases. As a result of bone grafting, all but two patients had a correction of the enophthalmos to within 1 to 2 mm of the opposite eye. Of the 20 patients with diplopia, 15 had correction, and an additional four had an improvement of diplopia so it occurred in only one field of gaze. Of the 22 patients with grafts to the malar bone, 16 were thought to have good to excellent results; however, six developed some degree of reabsorption at the graft site. No patients had any decrease in vision. The advantages and disadvantages of the surgical procedure are described and compared with other methods.

Ocular syphilis 1986. Prevalence of FTA-ABS reactivity and cerebrospinal fluid findings.

Serum FTA-ABS tests were obtained for 247 consecutive patients undergoing ambulatory oculoplastic surgery over a 5-month period. The incidence of FTA-ABS reactivity was 52.8%. Cerebrospinal fluid (CSF) from 50 patients with ocular signs of late syphilis and reactive serum FTA-ABS tests was examined. Only 12 (24%) of these patients had reactive serum VDRLs. Thirty patients (60%) had a lymphocytic pleocytosis, elevated protein, or both, in their CSF. No patients had reactive CSF VDRLs. It was concluded that FTA-ABS reactivity is common, serum VDRL tests are inadequate for diagnosing ocular syphilis, and a significant percentage of patients with ocular syphilis have abnormal CSF. More aggressive diagnosis and treatment of ocular syphilis is suggested.