Rituximab (anti-CD20 monoclonal antibody) for the treatment of patients with clonal lymphoproliferative disorders after orthotopic liver transplantation: a report of three cases.

BACKGROUND/AIMS: Post-transplant lymphoproliferative disorders (PT-LPD) are a well-known complication of organ transplantation. Their incidence after liver transplantation in adults ranges from 1.8 to 4%. Reduction of immunosuppression led to remission in a few cases. Other treatments include chemotherapy, interferon alpha therapy and/or intravenous-immunoglobulins, or antiviral drugs. However, monoclonal antibodies directed against B-cell specific antigens have rarely been used in those patients. Our aim was to study the feasibility and efficacy of Rituximab, a new, promising human chimeric antibody that recognizes the CD20 antigen, for the treatment of patients with clonal lymphoproliferative disorders after orthotopic liver transplantation. METHODS: Rituximab (IDEC-C2HB8; Roche Laboratories, Neuilly-sur-Seine, France) was administered at a 375 mg/m2 dose on days 1, 8, 15, and 22, in an outpatient setting, in three patients with PT-LPD. The tumor was classified as polymorphic PT-LPD in two cases and PT-LPD with features of large cell lymphoma in one case. All the tumors expressed the CD20 antigen and were EBV-related, and the clonality was confirmed in all three cases. The 4 injections of the anti-CD20 monoclonal antibody were associated with reduced immunosuppression in the three patient. RESULTS: The treatment with Rituximab was well tolerated without any side effects. The two patients with polymorphic PT-LPDs underwent rapid complete remission, whereas the treatment modalities were ineffective in the patient with the large-cell non-Hodgkin-lymphoma. CONCLUSION: These results must be confirmed in a larger cohort of liver transplant recipients suffering from lymphoproliferation. However, they indicate rapid efficiency of Rituximab in association with reduced immunosuppression in these disorders.

Magnetic resonance evaluation of idiopathic scoliosis: a prospective study.

The objective of the present study was to determine the incidence of unsuspected intraspinal pathology and to assess the value of atypical clinical features as predictors of these intraspinal pathologies, in patients with idiopathic scoliosis. Twenty-five consecutive patients (13 boys, 12 girls) with idiopathic scoliosis were prospectively evaluated with MRI. Magnetic resonance imaging detected intraspinal pathology in seven patients (28%), which included syringohydromyelia with Chiari I malformation (n = 5), and syringomyelia and dumb-bell neurofibromas in one patient each, respectively. Dural ectasia was also present in five patients. Atypical features, described in the literature as pointers to intraspinal pathologies such as the age < 11 years at presentation, presence of pain, hyperkyphosis, severe curves and the presence of the left thoracic or thoracolumbar curves, were seen to be equally distributed between the two groups (those with and without intraspinal pathologies), thus raising doubts about the importance of these features.

A study of the safety and clinical efficacy of flexible sigmoidoscopy and colonoscopy after recent colonic surgery in 52 patients.

OBJECTIVE: Our objective was to evaluate the safety of lower endoscopy after colonic surgery, which has been unstudied and unknown. Endoscopy could promote suture breakdown at sites of colonic anastomoses, ostia, or repair by colonic abrasion or stretch from endoscopic intubation, torque, and insufflation. METHODS: Risks versus benefits of lower endoscopy performed within 3 wk of colonic surgery were retrospectively analyzed at five medical centers in 36 patients undergoing sigmoidoscopy and 72 age-and-sex-matched controls, and in 16 patients undergoing colonoscopy and 32 age-and-sex-matched controls. RESULTS: Sigmoidoscopy indications included rectal bleeding in 14, distal colonic obstruction in 12, and other in 10. Sigmoidoscopy provided the diagnosis in 18 (54%) of 33 cases (excluding three therapeutic sigmoidoscopies, control rate = 30%, p < 0.01, X2, including colon cancer in six and benign stricture in five. Sigmoidoscopy led to colonic surgery in nine and medical therapy changes in four. Colonoscopy indications included colonic bleeding in seven, colonic obstruction in five, and other in four. Colonoscopy provided the diagnosis in nine (56%, control rate = 56%, NS, X2). Colonoscopy led to colonic surgery in three and chemotherapy in one. Two endoscopic complications, unrelated to suture breakdown, occurred: An acutely ill patient developed hypotension during sigmoidoscopy which resolved with intravenous fluid resuscitation. A contained sigmoid diverticular perforation became a free perforation (requiring laparotomy) after colonoscopy. Both control groups had no endoscopic complications (NS, Fisher's exact test). CONCLUSION: In this study, the benefits outweighed the risks of postoperative sigmoidoscopy and colonoscopy. Clinicians should use discretion and perform colonoscopy or sigmoidoscopy after colonic surgery, particularly bowel anastomosis, only for clinically important indications. Endoscopy is contraindicated when colonic wound dehiscence or bowel perforation is suspected.