Fatality in Kikuchi-Fujimoto disease: A rare phenomenon

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is an uncommon condition, typically characterized by lymphadenopathy and fevers. It usually has a benign course; however, it may progress to fatality in extremely rare occasions. The diagnosis is made via lymph node biopsy and histopathology. Our patient was a young female who presented with shortness of breath, fever, and malaise. Physical examination revealed significant cervical and axillary lymphadenopathy. Chest X-ray displayed multilobar pneumonia. She required intubation and mechanical ventilation for progressive respiratory distress. Histopathology of lymph nodes demonstrated variable involvement of patchy areas of necrosis within the paracortex composed of karyorrhectic debris with abundant histiocytes consistent with KFD. After initial stabilization, the patient’s condition quickly deteriorated with acute anemia, thrombocytopenia and elevated prothrombin time, partial prothrombin time, and D-dimer levels. Disseminated intravascular coagulopathy (DIC) ensued resulting in the patient’s fatality. DIC in KFD is not well understood, but it is an important cause of mortality in patients with aggressive disease.

Indolent lung opacity: Ten years follow-up of pulmonary inflammatory pseudo-tumor

Inflammatory pseudotumor (IPT) has always been considered a diagnostic challenge. Its rarity and resemblance to other more common pathological entities imposes that neither clinical nor radiological characteristics can lead to a definitive diagnosis. The surgical excision of the lesion is the ultimate approach for accurate diagnosis and cure. Moreover the true nature of IPT, its origin as a neoplastic entity or an over-reactive inflammatory reaction to an unknown trigger, has been a long debated matter. Surgery remains the treatment of choice. IPT is mostly an indolent disease with minimal morbidity and mortality. Local invasion and metastasis predict a poor prognosis. We hereby present a unique case of pulmonary IPT that was surgically excised, but recurred contralaterally, shortly thereafter. Despite no medical or surgical treatment for ten years, the lesion has remained stable in size, with neither symptoms nor extra-pulmonary manifestations.

Cardiac papillary fibroelastoma: The need for a timely diagnosis

Cardiac papillary fibroelastomas (CPFs) are the second most common primary cardiac tumors and the most common cardiac valvular tumors. Although they are histologically benign and usually asymptomatic, CPFs can lead to serious and life-threatening complications like myocardial infarction, stroke, pulmonary embolus, cardiac arrest etc. CPFs represent a rare entity in clinical medicine and literature regarding their management is limited. We report two cases which illustrate such complications arising from undiagnosed CPFs on the aortic valve. We further stress on the importance of identifying CPFs early so that they can be managed appropriately based on recommendations from the available literature.

Conscience imperative of providing information and knowledge in hepatology: The Portuguese approach

The last 25 years have been a thrilling time for the Portuguese hepatologists. Our national meetings have been providing the forum for the exchange of scientific ideas and the presentation of clinical research in clinical Hepatology, a growing world of knowledge in medical care. Bridging the gaps between technology and clinical daily practice, the latest development and the almost humble bedside care, has been a challenge for the increasing numbers of doctors devoted to the diagnostic and treatment of liver disease. We have been trying to be very persuasive among the Portuguese medical community in demonstrating that cultural vectors may influence the origin and pattern of liver disease among us. Viral hepatitis and alcoholic liver disease are paradigms of this assumption. Chronic liver disease is responsible for 3% of the deaths in Portugal, which accounts for the top ten causes of death in our country. The recognition by public health authorities of this fact along with the national net of hepatology outpatient consultation in public hospitals, has brought liver diseases under the lights of doctors concerns and an increased public awareness of its dimension.

Inverse correlation between CD8+ inflammatory cells and E-cadherin expression in gallbladder cancer: Tissue microarray and imaging analysis

AIM

To investigated the association between the tumor cells’ expression of E-cadherin and the numbers of several types of inflammatory cells infiltrating into the invasive portion of gallbladder cancer (GBC).

METHODS

We analyzed 50 GBC cases for which a sufficient amount of tumor tissues for tissue microarray (TMA) had been saved. Three tissue cores (3.0 mm) of invasive lesion from each case were used for the TMA. The 4-μm cut sections on slides were immunostained using primary antibodies including E-cadherin for cancer cells, leukocyte common antigen for leukocyte, myeloperoxidase for neutrophils, CD3 for T cells, CD4 for helper T cells, CD8 for killer T cells, CD20 for B cells and CD68 for macrophages. The immunostained slides were digitally analyzed by imaging analysis software.

RESULTS

A significant inverse correlation between the number of infiltrating CD8⁺ cells at invasive areas and the expression of E-cadherin by cancer cells was observed (P = 0.0001), although the degree of this correlation was relatively weak (R = 0.32). The number of CD8⁺ cells and the cancer cells’ E-cadherin expression were also significantly correlated with tumor differentiation (well-differentiated vs poorly differentiated) (P = 0.0467 and P = 0.0294, respectively). Inverse correlation of T-stage and the number of CD8⁺ cell infiltration was observed with statistical significance in comparison of T2 and T3 cases (P = 0.0324).

CONCLUSION

Our findings indicate an inverse correlation of CD8⁺ T cell infiltration and cancer cells’ E-cadherin expression at invasive areas of GBC. Further analyses are essential to test these findings.

Local advanced rectal cancer perforation in the midst of preoperative chemoradiotherapy: A case report and literature review

Standard chemoradiotherapy (CRT) for local advanced rectal cancer (LARC) rarely induce rectal perforation. Here we report a rare case of rectal perforation in a patient with LARC in the midst of preoperative CRT. A 56-year-old male was conveyed to our hospital exhibiting general malaise. Colonoscopy and imaging tests resulted in a clinical diagnosis of LARC with direct invasion to adjacent organs and regional lymphadenopathy. Preoperative 5-fluorouracil-based CRT was started. At 25 d after the start of CRT, the patient developed a typical fever. Computed tomography revealed rectal perforation, and he underwent emergency sigmoid colostomy. At 12 d after the surgery, the remaining CRT was completed according to the original plan. The histopathological findings after radical operation revealed a wide field of tumor necrosis and fibrosis without lymph node metastasis. We share this case as important evidence for the treatment of LARC perforation in the midst of preoperative CRT.

Intra-abdominal abscess and intractable sinus - a rare late complication after splenectomy

Intra-abdominal abscess and an intractable abdominal wall sinus forty years after splenectomy is rare, which has not been described previously in the surgical literature. We report the management of a patient who had presented with an intractable sinus on his left hypochondrium forty years after having undergone splenectomy and cholecystectomy, which persisted for more than two years despite repeated surgery and courses of antibiotics and compromised quality of life significantly from pain. A sinogram and computerised tomographic scan followed by exploration and laying open of the sinus delivered multiple silk sutures used for ligation of splenic pedicle, led to complete resolution of the sinus. It is important to avoid using non-absorbable silk sutures during splenectomy when splenectomy is undertaken in a contaminated field. Appropriate imaging and exploration is mandatory for its resolution.

Lymphocytic esophagitis: Report of three cases and review of the literature

Lymphocytic esophagitis (LyE) is a rare condition characterised histologically by high numbers of esophageal intraepithelial lymphocytes without significant granulocytes infiltration, in addition to intercellular edema (“spongiosis”). The clinical significance and natural history of LyE is poorly defined although dysphagia is reportedly the most common symptom. Endoscopic features range from normal appearing esophageal mucosa to features similar to those seen in eosinophilic esophagitis, including esophageal rings, linear furrows, whitish exudates, and esophageal strictures/stenosis. Symptomatic gastroesophageal reflux disease is an inconsistent association. LyE has been associated in paediatric Crohn’s disease, and recently in primary esophageal dysmotility disorder in adults. There are no studies assessing effective treatment strategies for LyE; empirical therapies have included use of proton pump inhibitor and corticosteroids. Esophageal dilatation have been used to manage esophageal strictures. LyE has been reported to run a benign course; however there has been a case of esophageal perforation associated with LyE. Here, we describe the clinical, endoscopic and histopathological features of three patients with lymphocytic esophagitis along with a review of the current literature.

Primary pediatric mid-brain lymphoma: Report of a rare pediatric tumor in a rare location

Primary central nervous system lymphoma (PCNSL) is a rare disease in pediatric age group. A thirteen-year-old male child presented with complaints of headache for six months, vomiting and diplopia for three days. Magnetic resonance imaging of the brain showed a single lesion of 1.7 cm × 1.6 cm × 1.6 cm in the mid brain and tectum. He underwent a gross total resection of the tumor. The histopathological evaluation revealed B cell high grade non Hodgkin lymphoma. The patient was treated with High dose methotrexate and cranio spinal radiation. The patient was alive without disease 12 mo after completion of treatment. This case highlights importance of keeping PCNSL as differential in brain stem lesions of pediatric patients also. Radiation and chemotherapy remains the most important treatment for such patients.

Granulomatous lobular mastitis secondary to Mycobacterium fortuitum

Granulomatous lobular mastitis is a rare inflammatory disease of the breast of unknown etiology. Most present as breast masses in women of child-bearing age. A 29-year-old female presented with a swollen, firm and tender right breast, initially misdiagnosed as mastitis. Core needle biopsy revealed findings consistent with granulomatous lobular mastitis, and cultures were all negative for an infectious etiology. She was started on steroid therapy to which she initially responded well. A few weeks later she deteriorated and was found to have multiple breast abscesses. She underwent operative drainage and cultures grew Mycobacterium fortuitum. Granulomatous lobular mastitis is a rare inflammatory disease of the breast. The definitive diagnose entails a biopsy. Other causes of chronic or granulomatous mastitis should be ruled out, including atypical or rare bacteria such as Mycobacterium fortuitum. This is the first reported case of granulomatous mastitis secondary to Mycobacterium fortuitum. With pathologic confirmation of granulomatous mastitis, an infectious etiology must be ruled out. Atypical bacteria such as Mycobacterium fortuitum may not readily grow on cultures, as with our case. Medical management is appropriate, with surgical excision reserved for refractory cases or for drainage of abscesses.

Rare case of tibial hemimelia, preaxial polydactyly, and club foot

A seven-month old female presented with left tibial hemimelia (or congenital tibial aplasia; Weber type VIIb, Jones et al type 1a), seven-toed preaxial polydactyly, and severe club foot (congenital talipes equinovarus). Definitive amputation surgery disarticulated the lower limb at the knee. This case report describes the anatomical findings of a systematic post-amputation examination of the lower limb’s superficial dissection, X-rays, and computed tomography (CT) scans. From the X-rays and CT scans, we found curved and overlapping preaxial supernumerary toes, hypoplastic first metatarsal, lack of middle and distal phalanges in one supernumerary toe, three tarsal bones, hypoplastic middle phalanx and no distal phalanx for fourth toe, and no middle or distal phalanges for fifth toe. The fibula articulated with the anteromedial calcaneus and the tibia was completely absent. We identified numerous muscles and nerves in the superficial dissection that are described in the results section of the case report. Due to the rarity of this combination of anatomical findings, descriptions of such cases are very infrequent in the literature.

Primary splenic lymphoma: Current diagnostic trends

The primary splenic lymphoma is extremely uncommon, can present with grave complications like hypersplenism and splenic rupture. In view of vague clinical presentation, it is difficult to arrive at the diagnosis. In such circumstances, histopathological diagnosis is very important. A precise diagnosis can only be made on histopathology and confirmed on immunohistochemistry.Emergency splenectomy is preferred as an effective therapeutic and diagnostic tool in cases with giant splenomegaly. Core biopsy is usually not advised due to a high risk of post-core biopsy complications in view of its high vascularity and fragility. Aim behind highlighting the topic is to specify that core biopsy/ fine needle aspiration cytology can be used as an effective diagnostic tool to arrive at correct diagnosis to prevent untoward complications related to disease and treatment. Anticoagulation therapy is vital after splenectomy to avoid portal splenic vein thrombosis.

Paclitaxel-associated reticulate hyperpigmentation: Report and review of chemotherapy-induced reticulate hyperpigmentation

Drug-induced reticulate hyperpigmentation is uncommon. Including the patient described in this report, chemotherapy-associated reticulate hyperpigmentation has only been described in ten individuals. This paper describes the features of a woman with recurrent and metastatic breast cancer who developed paclitaxel-induced reticulate hyperpigmentation and reviews the characteristics of other oncology patients who developed reticulate hyperpigmentation from their antineoplastic treatment. A 55-year-old Taiwanese woman who developed reticulate hyperpigmentation on her abdomen, back and extremities after receiving her initial treatment for metastatic breast cancer with paclitaxel is described. The hyperpigmentation became darker with each subsequent administration of paclitaxel. The drug was discontinued after five courses and the pigment faded within two months. PubMed was searched with the key words: Breast, cancer, chemotherapy, hyperpigmentation, neoplasm, reticulate, tumor, paclitaxel, taxol. The papers generated by the search, and their references, were reviewed. Chemotherapy-induced reticulate hyperpigmentation has been described in four men and six women. Bleomycin, cytoxan, 5-fluorouracil, idarubacin, and paclitaxel caused the hyperpigmentation. The hyperpigmentation faded in 83% of the patients between two to six months after the associated antineoplastic agent was discontinued. In conclusion, chemotherapy-induced reticulate hyperpigmentation is a rare reaction that may occur during treatment with various antineoplastic agents. The hyperpigmentation fades in most individuals once the treatment is discontinued. Therefore, cancer treatment with the associated drug can be continued in patients who experience this cutaneous adverse event.

Giant idiopathic renal arteriovenous fistula managed by coils and amplatzer device: Case report and literature review

An idiopathic renal arteriovenous (AV) fistula is a rare malformation of the kidney that may present insidiously with heart failure or hematuria. The treatment may be challenging due to large fistula size that may limit endovascular management. The authors report a case of an 85-year-old Caucasian woman who presented with acute heart failure and was found to have a right renal AV fistula. Since she had no prior history of renal intervention or trauma, a diagnosis of idiopathic renal AV fistula was made. She was managed by endoluminal occlusion using multiple stainless steel coils and Amplatzer vascular plug II device. The follow-up computed tomography showed complete occlusion of the fistula. This report highlights the late presentation of this rare disease and presents the utility of the combination of coils and Amplatzer device for management of a large fistula. It also reiterates that even if large, these fistulas can be managed by endovascular occlusion.

Low expression of angiotensinogen and dipeptidyl peptidase 1 in saliva of patients with proliferative verrucous leukoplakia

AIM

To elucidate the profile of the salivary proteome.

METHODS

Unstimulated whole mouth saliva was collected from 30 volunteers [15 proliferative verrucous leukoplakia (PVL) patients and 15 controls] and proteins were submitted for mass spectrometry-based proteomics using the discovery approach, followed by analyses of variance and logistic regression tests.

RESULTS

A total of two hundred and eighty-three proteins were confidently identified in saliva. By combining two low abundance proteins from the PVL group, angiotensinogen (AGT) and dipeptidyl peptidase 1 (DPP1), a model for group differentiation was built with a concordance index of 94.2%, identifying both proteins as potential etiologic biomarkers for PVL.

CONCLUSION

This study suggests that both AGT and DPP1 may be involved in developmental mechanisms of PVL.

Migrating fish bone piercing the common carotid artery, thyroid gland and causing deep neck abscess

Foreign body (FB) ingestion is very common in Malaysian population. The most commonly ingested FB is fish bone. Common presenting symptoms include FB sensation, odynophagia and or sharp pricking pain during swallowing. A careful history and physical examination is very important. Despite negative laryngoscopy and rigid esophagoscopy, persistent symptoms warrants further radiographic imaging studies. The FB can migrate extraluminally and involve other important adjacent structures of the neck and along the digestive tract. We report 3 cases of extraluminal migration of fish bone and their complications, which were successfully managed. One case with vascular complication which involve common carotid artery and the other two cases with neck abscess formation involving thyroid gland, retropharyngeal and parapharyngeal abscess.

Case of severe alcoholic hepatitis treated with granulocytapheresis

Severe alcoholic hepatitis (AH) has a high mortality, and it is associated with encephalopathy, acute renal failure, sepsis, gastrointestinal bleeding, and endotoxemia. The 28-d mortality remains poor (34%-40%), because no effective treatment has been established. Recently, corticosteroids (CS) have been considered effective for significantly improving the prognosis of those with AH, as it prevents the production of pro-inflammatory cytokines. However, CS are not always appropriate as an initial therapeutic option, such as in cases with an infection or resistance to CS. We describe a patient with severe AH complicated by a severe infection caused by the multidrug resistance bacteria (Pseudomonas aeruginosa), and was successfully treated with granulocytapheresis monotherapy without using CS. The experience of this case will provide understanding of the disease and information treating cases without using CS.

Blunt traumatic tension chylothorax: Case report and mini-review of the literature

Tension chylothorax following blunt thoracic trauma is an extremely rare condition. Here we report such a case and review its management. A 31-year-old man was involved in a road traffic collision. The car rolled over and the patient was ejected from the vehicle. On arrival at the Emergency Department the patient was conscious and haemodynamically stable. Clinical examination of the chest and abdomen was normal. The patient had sustained fractures of the sixth cervical vertebra and the tenth thoracic vertebra, left pleural effusion, haematoma around the descending aorta and fracture of the right clavicle. The left pleural effusion continued to increase in size and caused displacement of the trachea and mediastinum to the opposite side. An intercostal chest tube was inserted on the left side on the second day. It drained 1500 mL of milky, blood-stained fluid. We confirmed the diagnosis of chylothorax by a histopathological examination of a cell block prepared from the left pleural effusion using Oil red O stain. The patient was managed conservatively with chest tube drainage and fat free diet. The chylothorax completely resolved on the eighth day after the injury. The patient was discharged home on day 16.

Lesion presenting with a “blue amber” pattern

Atypical fibroxanthoma (AFX) is a spindle cell neoplasm with low metastatic potential but high tendency to recur after surgery. Because of the rarity of this lesion and its aspecific clinical features, AFX could be easily misdiagnosed and undertreated by many clinicians who encounter them. Dermoscopy represents a valuable tool for easily assessing skin lesions, even though histological examination is required for final diagnosis. We report a case of a cheek lesion with dermoscopic “blue amber pattern”, easily recognisable and not observed in others skin tumours, which could represent an additional feature useful in differentiating this tumour from other skin neoplasms.

Efficacy of Japanese traditional (Kampo) medicine for treating chemotherapy-induced peripheral neuropathy: A retrospective case series study

AIM

To investigate Japanese traditional (Kampo) medicine’s effectiveness on cancer chemotherapy-induced peripheral neuropathy (CIPN), we carried out this retrospective study.

METHODS

By searching our outpatient database of 3154 patients who consulted our outpatient clinic of Japanese-Oriental (Kampo) Medicine at Chiba University Hospital from November 2005 to December 2010, a total of 281 patients diagnosed with cancer were identified. Twenty-four patients out of the 281 patients identified met the following three conditions and were eligible for further investigation of the effectiveness of Kampo treatment: At least one course of cancer chemotherapy had been administered; numbness and pain appeared after the chemotherapy; and CIPN was diagnosed before they were given Kampo treatment.

RESULTS

The 24 patients included 6 males and 18 females and ranged in age from 39 to 86 (mean 61.2 ± 11.5) years old. Kampo formulas were individually chosen by Kampo expert doctors based on Kampo-specific diagnostics. Beneficial outcomes were obtained by Kampo treatment in 20 out of the 24 cases (83.3%). Nine out 20 cases had a major response (the numbness and pain showed improvement or reduction by 50% or more), with 7 of 9 cases showing a more than 70% symptom reduction. Eleven out of 20 cases showed a minor response (less than 50% symptom reduction), and 4 out of the 24 cases had no beneficial response. The most frequently used formula was goshajinkigan (GJG), followed by hachimijiogan (HJG) and keishibukuryogan. Thirteen of the 24 cases (54.2%) were prescribed aconite root-containing formulas including GJG and HJG. Aconite root has “warming” effects and ameliorates pain and numbness; 21 out of 24 cases (87.5%) in total used warming formulas such as aconite root-containing formulas to reduce CIPN.

CONCLUSION

Our current study suggested that Kampo formulas chosen based on Kampo-specific diagnostics could be for treating CIPN that is refractory to conventional medicine.

Greater occipital nerve blocks in the treatment of refractory chronic migraine: An observational report of nine cases

AIM

To report the effects of greater occipital nerve (GON) blocks on refractory chronic migraine headache.

METHODS

Nine patients who were receiving the conventionally accepted preventive therapies underwent treatment with repeated GON block to control chronic migraine resistant to other treatments. GON blocking with lidocaine and normal saline mixture was administered by the same physician at hospital once a month (for three times in total). Patients were assessed before the injection and every month thereafter for pain frequency and severity, number of times analgesics were used and any appearant side effects during a 6 mo follow-up.

RESULTS

Eight of nine patients reported a marked decrease in frequency and severity of migraine attacks in comparison to their baseline symptoms; one reported no significant change (not more than 50%) from baseline and did not accept the second injection. GON block resulted in considerable reduction in pain frequency and severity and need to use analgesics up to three months after the injection in the present cases. The patients did not report any adverse effects.

CONCLUSION

Hereby we noticed a remarkable success with refractory chronic migraine patients. We believe that this intervention can result in rapid relief of pain with the effects lasting for perhaps several weeks or even months. Further controlled clinical trials are warranted to evaluate the effect of GON block in the treatment of refractory migraine cases.

Factors associated with recurrence of clubfoot treated by the Ponseti method

AIM

To assess several associated factors on the recurrence of clubfoot after successful correction by the Ponseti method.

METHODS

A total of 115 children with 196 clubfeet deformities, treated by the Ponseti method, were evaluated. Demographic data, family history of clubfoot in first-degree relatives, maternal educational level and brace compliance were enquired. Based on their medical files, the characteristics of the patients at the time of presentation such as age, possible associated neuromuscular disease or especial syndrome, severity of the deformity according to the Dimeglio grade and Pirani score, residual deformity after previous Ponseti method and number of casts needed for the correction were recorded.

RESULTS

There were 83 boys (72.2%) and 32 girls (27.8%) with a male to female ratio of 2.6. The mean age at the initiation of treatment was 5.4 d (range: 1 to 60 d). The average number of casts applied to achieve complete correction of all clubfoot deformities was 4.2. Follow-up range was 11 to 60 mo. In total, 39 feet had recurrence with a minimum Dimeglio grade of 1 or Pirani score of 0.5 at the follow-up visit. More recurrence was observed in non-idiopathic clubfoot deformities (P = 0.001), non-compliance to wear braces (P < 0.001), low educational level of mother (P = 0.033), increased number of casts (P < 0.001), and more follow-up periods (P < 0.001). No increase in the possibility of recurrence was observed when the previous unsuccessful casting was further treated using the Ponseti method (P = 0.091). Also, no significant correlation was found for variables of age (P = 0.763), Dimeglio grade (P = 0.875), and Pirani score (P = 0.624) obtaining at the beginning of the serial casting.

CONCLUSION

Using the Ponseti method, non-idiopathic clubfoot, non-compliance to wear braces, low educational level of mother, increased number of casts and more follow-up periods had more association to possible increase in recurrence rate after correction of clubfoot deformity.

Surgeon-performed point-of-care ultrasound in severe eye trauma: Report of two cases

The indications of point-of-care ultrasound (POCUS) in the management of multiple trauma patients have been expanding. Although computed tomography (CT) scan of the orbit remains the gold standard for imaging orbital trauma, ultrasound is a quick, safe, and portable tool that can be performed bedside. Here we report two patients who had severe eye injuries with major visual impairment where surgeon-performed POCUS was very useful. One had a foreign body injury while the other had blunt trauma. POCUS was done using a linear probe under sterile conditions with minimum pressure on the eyes. Ultrasound showed a foreign body at the back of the left eye globe touching the eye globe in the first patient, and was normal in the second patient. Workup using CT scan, fundsocopy, optical coherence tomography, and magnetic resonance imaging of the orbits confirmed these findings. The first patient had vitreous and sub retinal haemorrhage and a full thickness macular hole of the left eye, while the second had traumatic optic neuropathy. POCUS gave accurate information concerning severe eye injuries. Trauma surgeons and emergency physicians should be trained in performing ocular ultrasound for eye injuries.

Increasing access to kidney transplantation for sensitized recipient through three-way kidney paired donation with desensitization: The first Indian report

The combination of kidney paired donation (KPD) with desensitization represents a promising method of increasing the rate of living donor kidney transplantation (LDKT) in immunologically challenging patients. Patients who are difficult to match and desensitize due to strong donor specific antibody are may be transplanted by a combination of desensitization and KPD protocol with more immunologically favorable donor. We present our experience of combination of desensitization protocol with three-way KPD which contributed to successful LDKT in highly sensitized end stage renal disease patient. All recipients were discharged with normal and stable allograft function at 24 mo follow up. We believe that this is first report from India where three-way KPD exchange was performed with the combination of KPD and desensitization. The combination of desensitization protocol with KPD improves access and outcomes of LDKT.

Long-term stabilization of stage 4 colon cancer using sodium dichloroacetate therapy

Oral dichloroacetate sodium (DCA) has been investigated as a novel metabolic therapy for various cancers since 2007, based on data from Bonnet et al that DCA can trigger apoptosis of human lung, breast and brain cancer cells. Response to therapy in human studies is measured by standard RECIST definitions, which define “response” by the degree of tumour reduction, or tumour disappearance on imaging. However, Blackburn et al have demonstrated that DCA can also act as a cytostatic agent in vitro and in vivo, without causing apoptosis (programmed cell death). A case is presented in which oral DCA therapy resulted in tumour stabilization of stage 4 colon cancer in a 57 years old female for a period of nearly 4 years, with no serious toxicity. Since the natural history of stage 4 colon cancer consists of steady progression leading to disability and death, this case highlights a novel use of DCA as a cytostatic agent with a potential to maintain long-term stability of advanced-stage cancer.