Clinical observation of soft palate-pharyngoplasty in the treatment of obstructive sleep apnea hypopnea syndrome in children

BACKGROUND

Childhood obstructive sleep apnea hypopnea syndrome (OSAHS) is a common clinical disease that can cause serious complications if not treated in time. The preferred treatment for OSAHS in children is surgery.

AIM

To observe the effects of soft palate-pharyngoplasty on postoperative outcome, pharyngeal formation, and possible complications.

METHODS

A total of 150 children with snoring, hernia, and mouth breathing were selected. A polysomnography test was performed to confirm the diagnosis of OSAHS. The children were randomly divided into experimental and control groups. The experimental group underwent adenoidectomy, tonsillectomy, and soft palate-pharyngoplasty. The control group underwent adenoidectomy and tonsillectomy. The t-test and chi-square test were used to compare conditions such as postoperative fever, postoperative hemorrhage, and pharyngeal reflux. Postoperative efficacy and complications were interrogated and observed in the form of outpatient follow-up and telephone follow-up at 6 mo and 1 year after surgery. The curative effects were divided into two groups: Cure (snoring, snoring symptoms disappeared) and non-cure.

RESULTS

The effective rate of the experimental group was significantly higher than that of the control group, but the difference was not statistically significant (P > 0.05). The incidence of postoperative bleeding was lower in the experimental group. There was no postoperative pharyngeal reflux in either group. In the experimental group, the incidence of hyperthermia (body temperature exceeded 38.5 °C) was lower than that in the control group. The difference in postoperative swallowing pain scores between the experimental and control groups was significant.

CONCLUSION

Soft palate-pharyngoplasty can more effectively enlarge the anteroposterior diameter and transverse diameter of the isthmus faucium. Compared with surgery alone, it can better treat OSAHS in children, improve the curative effect, reduce the risk of perioperative bleeding, close the surgical cavity, reduce the risk of postoperative infection, reduce the proportion of postoperative fever, and accelerate healing. Although this process takes more time, it is simple, safe, and effective.

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND

Sepsis is fatal in patients with gastrointestinal perforation (GIP). However, few studies have focused on this issue.

AIM

To investigate the risk factors for postoperative sepsis in patients with GIP.

METHODS

This was a retrospective study performed at the Department of General Surgery in our treatment center. From January 2016 to December 2018, the medical records of patients with GIP who underwent emergency surgery were reviewed. Patients younger than 17 years or who did not undergo surgical treatment were excluded. The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group. Clinical data for both groups were collected and compared, and the risk factors for postoperative sepsis were investigated. The institutional ethical committee of our hospital approved the study.

RESULTS

Two hundred twenty-six patients were admitted to our department with GIP. Fourteen patients were excluded: Four were under 17 years old, and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members. Two hundred twelve patients were finally enrolled in the study; 161 were men, and 51 were women. The average age was 62.98 ± 15.65 years. Postoperative sepsis occurred in 48 cases. The prevalence of postoperative sepsis was 22.6% [95% confidence interval (CI): 17.0%-28.3%]. Twenty-eight patients (13.21%) died after emergency surgery. Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery [odds ratio (OR) = 1.021, 95%CI: 1.005-1.038, P = 0.006], colonic perforation (OR = 2.761, CI: 1.821–14.776, P = 0.007), perforation diameter (OR = 1.062, 95%CI: 1.007-1.121, P = 0.027), and incidence of malignant tumor-related perforation (OR = 5.384, 95%CI: 1.762-32.844, P = 0.021) were associated with postoperative sepsis.

CONCLUSION

The time interval from abdominal pain to surgery, colonic perforation, diameter of perforation, and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.

Extrapleural solitary fibrous tumor of the thyroid gland: A case report and review of literature

BACKGROUND

Solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm that arises from the pleura. A few SFTs have also been described in extrapleural sites. However, SFT of the thyroid gland is rare. Here, we report a case of extrapleural SFT on the thyroid gland, in addition to a literature review.

CASE SUMMARY

A 59-year-old man visited our hospital in July 2017 complaining of a large mass in his neck. His thyroid function test results, including antibody levels, were within the normal limits. Ultrasonography showed a 4.7 cm × 4.0 cm × 3.2 cm solitary mass of intermediate suspicion in the left thyroid lobe. A fine-needle aspiration biopsy was subsequently performed. The pathologist reported a benign follicular lesion. However, the size of this nodule increased to 5.5 cm × 5.0 cm × 3.4 cm by April 2018. After a multidisciplinary discussion, a left lobectomy was performed in May 2018. The specimen showed a well-demarcated, partly encapsulated, soft nodule of whitish and tan/brown color on the cut surface. Light microscopy revealed high cellularity with moderate cytologic atypia. The mitotic count was 5/10 high-power fields. There was no tumor necrosis or lymphovascular invasion. The tumor was CD34-positive and signal transducer and activator of transcription 6-positive. Neither thyroid transcription factor-1 nor cytokeratin expression was detected. The Ki-67 showed intermediate proliferative activity. The final diagnosis was extrapleural SFT of the thyroid gland with a clear resection margin. The patient was discharged without complication three days after the surgery.

CONCLUSION

In the literature, extrapleural SFT of the thyroid gland has been reported to behave indolently with the capacity for recurrence and rare metastasis, although surgical resection is the treatment of choice. Understanding this disease entity is important for accurate diagnosis and proper management.

Effectiveness of a microabrasion technique using 16% HCL with manual application on fluorotic teeth: A series of studies

BACKGROUND

Dental fluorosis is caused by excessive fluoride ingestion during tooth formation. As a consequence, there is a higher porosity on the enamel surface, which causes an opaque look.

AIM

The aim of this study was to identify a dental intervention to improve the smile in patients with tooth fluorosis. Additional aims were to relate the stain size on fluorotic teeth with the effectiveness of stain removal, enamel loss and procedure time using a manual microabrasion technique with 16% hydrochloric acid (HCL).

METHODS

An experimental study was carried out on 84 fluorotic teeth in 57 adolescent patients, 33 females and 24 males, with moderate to severe fluorosis. The means, standard deviations and percentages were analyzed using nonparametric statistics and ArchiCAD 15 software was used for the variables including stain size and effectiveness of stain removal.

RESULTS

The average enamel loss was 234 µm and was significantly related to the procedure time categorized as 1-4 min and 4.01-6 min, resulting in a P > 0.000. The microabrasion technique using 16% HCL was effective in 90.6% of patients and was applied manually on superficial stains in moderate and severe fluorosis. Procedure time was less than 6 min and enamel loss was within the acceptable range.

CONCLUSION

Microabrasion is a first-line treatment; however, the clinician should measure the average enamel loss to ensure that it is within the approximate range of 250 µm in order to avoid restorative treatment.

Borderline form of empty follicle syndrome treated with a novel dual trigger method combined with delayed oocyte retrieval: A case report

BACKGROUND

Borderline form of empty follicle syndrome is a condition in which only a few mature or immature oocytes are recovered after meticulous follicular aspiration, despite adequate ovarian response to stimulation. It is a rare phenomenon with an unclear cause. Currently, the condition still lacks effective treatment.

CASE SUMMARY

A patient with secondary infertility who had undergone three cycles of assisted reproductive technique (ART) is described. With regard to good follicular response, two oocytes were obtained in the first two ART cycles, but no embryo was formed. In the third ART cycle, which is the subject of this study, ovulation was induced by dual trigger of a supernormal dose of human chorionic gonadotropin (HCG) combined with a delayed oocyte retrieval approach. The method involved administration of gonadotropin-releasing hormone agonist, recombinant HCG, and urinary HCG 39 h before ovum pick-up. Ten oocytes were recovered, two out of three mature eggs were fertilized after intracytoplasmic sperm injection, resulting in two embryos that were subsequently cryopreserved. The case report guidelines have been used herein to present the first case of this novel dual trigger method.

CONCLUSION

This approach provides a new treatment option for patients with a similar condition in the future. This study can also inspire further investigation on the effects of various β-HCG serum levels 36 h after intramuscular HCG administration.

Rescue treatment and follow-up intervention of a left main acute myocardial infarction with typical carina shift under 3D optical coherence tomography: A case report

BACKGROUND

Coronary intervention for bifurcation lesions is still challenging for interventional cardiologists. Left main (LM) bifurcation lesions have a higher risk due to the vast blood supply in this area and treatment choice is difficult. Ostial compromise of the side branch decreases patient prognosis, and its management is still an issue despite the different strategies and devices available.

CASE SUMMARY

A 42-year-old male patient was admitted to hospital due to chest pain and syncope. Coronary angiography showed acute LM occlusion. Following thrombus aspiration, a LM bifurcation lesion remained. Coronary angiography was repeated one week later, and at the same time, 3D optical coherence tomography (OCT) was carried out to better show the geometry of the bifurcation, which confirmed that the stenosis in the ostial left circumflex artery was caused by a long carina. After assessment of the plaque characteristics and the minimum lumen area, the cross-over strategy, kissing balloon inflation and proximal optimization technique were chosen to treat the bifurcation lesion. A “moving” carina was found twice during the intervention. Good stent apposition and expansion were confirmed by OCT after proximal optimization technique. The three-month follow-up showed good recovery and normal cardiac function.

CONCLUSION

3D-OCT can facilitate decision-making for coronary interventions in patients with critical bifurcation lesions.

Risk factors for long-term prognosis of hepatocellular carcinoma patients after anatomic hepatectomy

BACKGROUND

The risk factors for patients with major postoperative complications immediately after liver resection have been identified; however, the intermediate and long-term prognoses for these patients have yet to be determined.

AIM

To evaluate the factors responsible for the long-term recurrence-free survival rate in patients with hepatocellular carcinoma (HCC) following anatomic hepatectomy.

METHODS

We performed a retrospective analysis of 74 patients with HCC who underwent precise anatomic hepatectomy at our institution from January 2013 to December 2015. The observational endpoints for this study were the tumor recurrence or death of the HCC patients. The overall follow-up duration was three years. The recurrence-free survival curves were plotted by the Kaplan-Meier method and were analyzed by the log-rank test. The value of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis.

RESULTS

The 1-year and 3-year recurrence-free survival rates of HCC patients were 68.92% and 55.41%, respectively, following anatomic liver resection. The results showed that the 3-year recurrence-free survival rate in HCC patients was closely related to preoperative cirrhosis, jaundice level, tumor stage, maximal tumor diameter, complications of diabetes mellitus, frequency of intraoperative hypotensive episodes, estimated blood loss (EBL), blood transfusion, fluid infusion, and postoperative infection (P < 0.1). Based on multivariate analysis, preoperative cirrhosis, tumor stage, intraoperative hypotension, and EBL were identified to be predictors of 3-year recurrence-free survival in HCC patients undergoing anatomic hepatectomy (P < 0.05).

CONCLUSION

Tumor stage and preoperative cirrhosis adversely affect the recurrence-free survival rate in HCC patients following anatomic hepatectomy. The long-term recurrence-free survival rate of patients with HCC is closely related to intraoperative hypotension and EBL.

Application of positive behavior management in patients after breast cancer surgery

BACKGROUND

As a radical treatment, breast cancer surgery has a positive psychological impact on most patients. However, some patients do not have a clear understanding of the disease, which requires a more scientific and comprehensive consideration during clinical intervention and are based on cognition. The positive behavior management model is based on this kind of background-derived new interventions, which can better serve the clinical rehabilitation process of patients. The positive behavior management model based on cognitive architecture is a new type of intervention derived from this background, which can better serve the clinical rehabilitation process of patients.

AIM

To analyze the influence of a positive behavior management model based on cognitive framework on the degree of hope and self-efficacy of patients with breast cancer surgery.

METHODS

Eighty-four patients with breast cancer who underwent surgical treatment in our hospital from August 2016 to December 2018 were included in the study. The patients were divided into the experimental group (n = 42) and control group (n = 42) by random number table grouping. The control group received traditional nursing intervention, while the experimental group received a positive behavior management model based on cognitive framework based on the traditional intervention of the control group. General Self-efficacy Scale, Herth Hope Scale, Self-Rating Anxiety Scale, Self-Rating Depression Scale and Cancer Patient Specific Scale were used to evaluate the two groups before and 1 wk after intervention.

RESULTS

After the intervention, self-efficacy and hope level of the experimental group were significantly higher than those of the control group (P < 0.05). The Self-Rating Anxiety Scale and Self-Rating Depression Scale scores in the experimental group were significantly lower than those in the control group (P < 0.05). There was no significant difference in the quality of life scores between the two groups before intervention (P > 0.05). The quality of life scores in all aspects in the experimental group after intervention were significantly higher than those in the control group (P < 0.05).

CONCLUSION

The positive behavior management model based on cognitive framework applied to patients with breast cancer surgery improved hope for treatment and self-efficacy, reduced negative emotion, and improved quality of life.

Using Materialise's interactive medical image control system to reconstruct a model of a patient with rectal cancer and situs inversus totalis: A case report

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital anomaly that refers to a completely reversed location of abdominal and thoracic organs. An extremely small number of patients with this condition, especially those with rectal neoplasms, have been reported. Surgery in these patients is technically challenging. Therefore, we reconstructed a three-dimensional (3D) digital model with the Materialise’s interactive medical image control system (Mimics) as a guide for laparoscopic resection.

CASE SUMMARY

We report the case of a 68-year-old woman with rectal neoplasms and SIT diagnosed by electronic colonoscopy biopsy and enhanced computed tomography (CT), which showed that there was a soft tissue mass protruding into the lumen in the lower rectal segment, a lesion that involved the serosal layer, multiple enlarged peripheral lymph nodes, and visceral situs abnormalities. Based on the CT images, we reconstructed a 3D model with Mimics to assist with our surgical planning. Then, we performed laparoscopy-assisted radical resection of the rectal neoplasms and total excision of the lesion. Adjuvant chemotherapy with the XELOX regimen (oxaliplatin 150 mg, D1 + Xeloda 1.0 g, Bid, D1-14) was initiated 1 mo after the operation. The patient recovered well after surgery, and her physical condition remained stable.

CONCLUSION

Preoperative 3D reconstruction of the imaging results could help reduce the unknown risks during surgery caused by anatomical abnormalities and improve the perioperative safety for patients.

Prevalence and associated factors of suicide among hospitalized schizophrenic patients

BACKGROUND

Previous studies found several factors associated with suicide in schizophrenic patients, such as age, sex, education level, history of suicide attempts, psychotic symptoms, social factors, and substance abuse. However, there might be some additional factors that were not considered in previous studies but may be correlated with a greater likelihood of suicide attempts, such as medication and treatment.

AIM

To investigate the prevalence of suicide attempts and identify the risk of suicidality in hospitalized schizophrenia patients.

METHODS

This is a cross-sectional study of schizophrenic patients admitted to a psychiatric hospital who were 18 years of age or more. The outcomes and possible suicide risk factors in these patients were collated. The current suicide risk was evaluated using the mini-international neuropsychiatric interview module for suicidality and categorized as none (0 points), mild (1-8 points), moderate (9-16 points), or severe (17 or more points). This study used ordinal logistic regression to assess the association of potential risk factors with the current suicide risk in schizophrenic patients.

RESULTS

Of 228 hospitalized schizophrenia patients, 214 (93.9%) were included in this study. The majority (79.0%) of patients were males. Females appeared to have a slightly higher suicidality risk than males, with borderline significance. With regard to the current suicide risk assessed with the mini-international neuropsychiatric interview, 172 (80.4%) schizophrenic patients scored zero, 20 (9.4%) had a mild risk, 8 (3.7%) had a moderate risk, and 14 (6.5%) had a severe risk. The total prevalence of current suicide risk in these schizophrenic patients was 19.6%. Based on multivariable ordinal logistic regression analysis with backward elimination, it was found that younger age, a current major depressive episode, receiving fluoxetine or lithium carbonate in the previous month, or a relatively higher Charlson comorbidity index score were all significantly and independently associated with a higher level of suicide risk.

CONCLUSION

The prevalence rate of suicide attempts in schizophrenia is high. Considering risk factors in routine clinical assessments, environmental manipulations and adequate treatment might prevent or decrease suicide in these patients.

Thyroid metastasis from breast cancer presenting with enlarged lateral cervical lymph nodes: A case report

BACKGROUND

Secondary malignancy of the thyroid occurs infrequently and mainly originates from malignant tumors of the kidney, gastrointestinal tract, lungs, breast, and skin. The correct diagnosis is important but difficult. Importantly, there are major differences in the treatment of primary and metastatic thyroid cancer, which has a significant impact on prognosis and survival. Therefore, how to diagnose thyroid metastasis (TM) correctly before surgery is a major concern for surgeons.

CASE SUMMARY

We report a 38-year-old woman who presented with palpable cervical lymph nodes after breast cancer (BC) surgery 2 years ago. Ultrasonography and computed tomography revealed thyroid nodules with irregular margins and enlarged cervical lymph nodes. Biopsy was performed for the right largest cervical lymph node, and immunohistochemical analysis revealed negativity for thyroglobulin, estrogen receptor, and progestin receptor and positive for human epidermal growth factor receptor 2. The diagnosis was TM from BC with cervical lymph node metastasis. Total thyroidectomy with bilateral central and lateral neck lymph node dissection was performed. After a 5-mo follow-up, no recurrence or novel distant metastasis was identified.

CONCLUSION

TM from BC is a rare secondary malignancy. Broad differential diagnosis by biopsy and immunohistochemical analysis needs to be considered.

Diverticulum of the buccal mucosa: A case report

BACKGROUND

A diverticulum is the medical or biological term for outpouching of a hollow structure in the body. It particularly occurs in the digestive system, but rarely occurs in the oral mucosa.

CASE SUMMARY

This report describes a rare case of diverticulum presenting in the buccal mucosa in a 44-year-old woman that was initially diagnosed in Stomatology Hospital, Wuhan University. We made our diagnosis under the guidance of imaging data, and the patient underwent surgical resection.

CONCLUSION

This report is the first confirmed case of buccal mucosal diverticulum. in addition, we elucidated that in general, idiopathic developmental abnormalities caused by succinate muscle defects are responsible for diverticulum development.

Must pilots permanently quit flying career after treatment for colorectal cancer? - Medical waiver for Air Force pilots with colorectal cancer: Three case reports

BACKGROUND

Colorectal cancer (CRC) could seriously threaten the physical and mental health of pilots. Shall they end their flying after treatment of CRC? With this study, we investigated the possibility of a gradual medical waiver for such pilots to fly aircrafts again after treatment of CRC.

CASE SUMMARY

We analyzed the medical waiver and clinical data of 3 pilots with CRC, who had accepted the treatment at the Department of General Surgery, Air Force Medical Center (formerly, Air Force General Hospital) between 2013 and 2018. All 3 cases underwent a series of comprehensive treatment courses, including radical resection of CRC, sequential radiotherapy, and chemotherapy. The follow-up results were satisfactory. After passing through the high-risk period of recurrence and metastasis of CRC, they all were given a medical waiver for flying again. Medical observation showed that their flying operations were safe.

CONCLUSION

The CRC treatment shall follow the guidelines for diagnosis and treatment and should simultaneously protect the combating capabilities of pilots as much as possible. It is safe for pilots with CRC, who are continuously monitored under medical observation after passing through the high-risk period of recurrence and metastasis, to undertake military flight missions again.

Upper esophageal sphincter abnormalities on high-resolution esophageal manometry and treatment response of type II achalasia

BACKGROUND

Little is known about the clinical significance of upper esophageal sphincter (UES) motility disorders and their association with the treatment response of type II achalasia. None of the three versions of the Chicago Classification of Esophageal Motility Disorders has defined UES abnormality metrics or their function. UES abnormalities exist in some patients and indicate a clinically significant problem in patients with achalasia.

AIM

To demonstrate the manometric differentiation on high-resolution esophageal manometry between subjects with abnormal UES and normal UES, and the association between UES type and the treatment response of type II achalasia.

METHODS

In total, 498 consecutive patients referred for high-resolution esophageal manometry were analyzed retrospectively. The patients were divided into two groups, those with normal and abnormal UES function. UES parameters were analyzed after determining lower esophageal sphincter (LES) function. Patients with type II achalasia underwent pneumatic dilation for treatment. Using mixed model analyses, correlations between abnormal UES and treatment response were calculated among subjects with type II achalasia.

RESULTS

Of the 498 consecutive patients, 246 (49.40%) were found to have UES abnormalities. Impaired relaxation alone was the most common UES abnormality (52.85%, n = 130). The incidence rate of type II achalasia was significantly higher in subjects with abnormal UES than those with normal UES (9.77% vs 2.58%, P = 0.01). After pneumatic dilation, LES resting pressure, LES integrated relaxation pressure, and UES residual pressure were significantly decreased (41.91 ± 9.20 vs 26.18 ± 13.08, 38.94 ± 10.28 vs 16.71 ± 5.65, and 11.18 ± 7.93 vs 5.35 ± 4.77, respectively, P < 0.05). According to the Eckardt score, subjects with type II achalasia and abnormal UES presented a significantly poorer treatment response than those with normal UES (83.33% vs 0.00%, P < 0.05).

CONCLUSION

Impaired relaxation alone is the most common UES abnormality. The incidence of type II achalasia is associated with abnormal UES. Type II achalasia with abnormal UES has a poorer treatment response, which is a potentially prognostic indicator of treatment for this disease.

Breast non-mass-like lesions on contrast-enhanced ultrasonography: Feature analysis, breast image reporting and data system classification assessment

BACKGROUND

Breast non-mass-like lesions (NMLs) account for 9.2% of all breast lesions. The specificity of the ultrasound diagnosis of NMLs is low, and it cannot be objectively classified according to the 5^th Edition of the Breast Imaging Reporting and Data System (BI-RADS). Contrast-enhanced ultrasound (CEUS) can help to differentiate and classify breast lesions but there are few studies on NMLs alone.

AIM

To analyze the features of benign and malignant breast NMLs in grayscale ultrasonography (US), color Doppler flow imaging (CDFI) and CEUS, and to explore the efficacy of the combined diagnosis of NMLs and the effect of CEUS on the BI-RADS classification of NMLs.

METHODS

A total of 51 breast NMLs verified by pathology were analyzed in our hospital from January 2017 to April 2019. All lesions were examined by US, CDFI and CEUS, and their features from those examinations were analyzed. With pathology as the gold standard, binary logic regression was used to analyze the independent risk factors for malignant breast NMLs, and a regression equation was established to calculate the efficiency of combined diagnosis. Based on the regression equation, the combined diagnostic efficiency of US combined with CEUS (US + CEUS) was determined. The initial BI-RADS-US classification of NMLs was adjusted according to the independent risk factors identified by CEUS, and the diagnostic efficiency of CEUS combined with BI-RADS (CEUS + BI-RADS) was calculated based on the results. ROC curves were drawn to compare the diagnostic values of the three methods, including US, US + CEUS, and CEUS + BI-RADS, for benign and malignant NMLs.

RESULTS

Microcalcification, enhancement time, enhancement intensity, lesion scope, and peripheral blood vessels were significantly different between benign and malignant NMLs. Among these features, microcalcification, higher enhancement, and lesion scope were identified as independent risk factors for malignant breast NMLs. When US, US + CEUS, and CEUS + BI-RADS were used to identify the benign and malignant breast NMLs, their sensitivity rates were 82.6%, 91.3%, and 87.0%, respectively; their specificity rates were 71.4%, 89.2%, and 92.9%, respectively; their positive predictive values were 70.4%, 87.5%, and 90.9%, respectively; their negative predictive values were 83.3%, 92.6%, and 89.7%, respectively; their accuracy rates were 76.5%, 90.2%, and 90.2%, respectively; and their corresponding areas under ROC curves were 0.752, 0.877 and 0.903, respectively. Z tests showed that the area under the ROC curve of US was statistically smaller than that of US + CEUS and CEUS + BI-RADS, and there was no statistical difference between US + CEUS and CEUS + BI-RADS.

CONCLUSION

US combined with CEUS can improve diagnostic efficiency for NMLs. The adjustment of the BI-RADS classification according to the features of contrast-enhanced US of NMLs enables the diagnostic results to be simple and intuitive, facilitates the management of NMLs, and effectively reduces the incidence of unnecessary biopsy.

Lymphoepithelioma-like carcinoma of the upper urinary tract: A systematic review of case reports

BACKGROUND

Lymphoepithelioma-like carcinomas (LELCs) are rare, malignant epithelial tumors, generally considered a subtype of squamous cell carcinoma. LELCs are undifferentiated and can occur in multiple tissues, although LELCs in the urinary tract are extremely rare. As such, evidence does not provide clinicians with guidelines for the best practices. Even though this is a rare disease, it is associated with high morbidity and mortality. Therefore, we must learn to differentiate LELC types and identify risk factors for early identification.

AIM

To develop an evidence base to guide clinicians treating primary LELCs of the upper urinary tract (UUT-LELC).

METHODS

We performed a systematic review of all reports on UUT-LELC from the first published case in 1998 until October 2019, according to the PRISMA. A database was then developed by extracting data from previously published reports in order to analyze interactions between clinical characteristics, pathological features, interventions and outcomes. Survival was analyzed using Kaplan–Meier estimates, which were compared using log rank tests.

RESULTS

A total of 28 previously published cases were identified for inclusion. The median age was 72 years with a male to female ratio of 4:3. Pure type LELCs were most common with 48.3% (n = 14), followed by 37.9% (n = 11) predominant LELCs and 3.4% (n = 1) focal LELCs. Epstein-Barr virus testing was negative in all cases. Fourteen patients received radical nephroureterectomy (RNU)-based intervention. Twenty-three patients survived with no evidence of further metastasis, although six died before the median 18 mo follow-up point. Survival analysis suggests pure histological subtypes, and patients who receive complete tumor resection have more favorable prognoses. As always in cancer care, early identification generally increases the probability of interventional success.

CONCLUSION

The most effective treatment for UUT-LELC is RNU-based therapy. Since cases are few in number, case reporting must be enhanced and publishing encouraged to both save and prolong lives.

Identification of key genes and pathways in gastric signet ring cell carcinoma based on transcriptome analysis

BACKGROUND

Gastric signet ring cell carcinoma (GSRCC) is one of the most malignant tumors. It has the features of high invasiveness, rapid progression, and resistance to chemotherapy. However, systematic analyses of mRNAs have not yet been performed for GSRCC.

AIM

To identify key mRNAs and signaling pathways in GSRCC.

METHODS

A transcriptome analysis of two GSRCC and two non-GSRCC samples was performed in this study. Differentially expressed mRNAs and pathways were identified based on the KEGG and PANTHER pathway annotations. The interactive relationships among the differential genes were mapped with the STRING database. Quantitative real-time polymerase chain reaction was used to validate the key gene expression in GSRCC.

RESULTS

About 1162 differential genes (using a 2-fold cutoff, P < 0.05) were identified in GSRCC compared with non-GSRCC. The enriched KEGG and PANTHER pathways for the differential genes included immune response pathways, metabolic pathways, and metastasis-associated pathways. Ten genes (MAGEA2, MAGEA2B, MAGEA3, MAGEA4, MAGEA6, MUC13, GUCA2A, FFAR4, REG1A, and REG1B) were identified as hub genes in the protein-protein interaction network. The expression levels of five genes (MAGEA2, MAGEA3, MAGEA4, MAGEA6, and REG1B) showed potential clinical value.

CONCLUSION

We have identified the potential key genes and pathways in GSRCC, and these hub genes and pathways could be diagnostic markers and therapeutic targets for GSRCC.

Mesenteric phlebosclerosis with amyloidosis in association with the long-term use of medicinal liquor: A case report

BACKGROUND

Mesenteric phlebosclerosis (MP) is a rare disease of the colon. The clinical manifestations of this disease are nonspecific and it may easily be misdiagnosed. We report a case of MP with amyloidosis in the colonic vessel walls in a patient with hypertension who had been consuming Chinese medicinal liquor for 10 years. We also review the relevant literature and summarize the characteristics of MP in patients in mainland China.

CASE SUMMARY

A 64-year-old man was referred to our department from his primary hospital because of abdominal pain, diarrhea, and fever for almost 10 d. Computed tomography showed colon wall thickening, with threadlike calcifications in the mesenteric vein in the transverse colon. Colonoscopy revealed purple-blue mucosa with multiple ulcers in the ascending and transverse colon. Biopsy showed thickening and calcification of the vein walls, perivascular and mucosal collagen degeneration, and amyloidosis. The patient had been consuming Chinese medicinal liquor, mainly that made from gardenia fruit, for 10 years. Based on these results, a diagnosis of MP with amyloidosis was made. After conservative treatment, the patient’s discomfort subsided and he was followed closely. The use of Chinese herbal medicine was suspected to play a role in the pathogenesis of MP.

CONCLUSION

The clinical manifestations of MP are nonspecific. Recognition of its typical imaging findings, including multiple calcifications on computed tomography and purple-blue mucosal discoloration on colonoscopy, is vital.

Effectiveness of surgical resection for complicated liver cancer and its influencing factors: A retrospective study

BACKGROUND

Surgical resection is the preferred method for patients with complex liver cancer. But the tumor is in a special position, the surgery is highly risky, postoperative complications can easily occur, and the prognosis is not ideal.

AIM

To investigate the effectiveness of surgical resection for complex liver cancer and its influencing factors.

METHODS

Fifty-seven patients who had complicated liver cancer and underwent surgical resection at our hospital from August 2015 to August 2016 were enrolled in this study. All patients were followed for three years, and their postoperative complications, survival, and factors that impacted their survival were analyzed.

RESULTS

The total incidence of postoperative complications was 45.61%, and the incidence of pleural effusion was the highest at 28.07%. There were no correlations between the 2-year and 3-year survival rates and sex, age, and HbsAg of the patients (P > 0.05). In terms of pathological parameters, the 2-year and 3-year survival rates were significantly different according to the presence of a tumor capsule, degree of liver cirrhosis, satellite or focal lesions, hepatic vein thrombosis, portal vein tumor thrombus, and intraoperative blood loss (P < 0.05).

CONCLUSION

The effectiveness of surgical resection for complex hepatocellular carcinoma may be affected by factors such as the presence of a tumor capsule, cirrhosis degree, satellite or focal lesions, hepatic vein embolization, portal vein tumor thrombus, and intraoperative blood loss. Therefore, these factors should be controlled and prevented during surgery to help improve patient survival after surgery.

Fear can be more harmful than the severe acute respiratory syndrome coronavirus 2 in controlling the corona virus disease 2019 epidemic

The current corona virus disease 2019 outbreak caused by severe acute respiratory syndrome coronavirus 2 started in Wuhan, China in December 2019 and has put the world on alert. To safeguard Chinese citizens and to strengthen global health security, China has made great efforts to control the epidemic. Many in the global community have joined China to limit the epidemic. However, discrimination and prejudice driven by fear or misinformation have been flowing globally, superseding evidence and jeopardizing the anti-severe acute respiratory syndrome coronavirus 2 efforts. We analyze this phenomenon and its underlying causes and suggest practical solutions.

Ligament augmentation reconstruction system artificial ligaments in patellar tendon reconstruction - a chronic patellar tendon rupture after multiple operations: A case report

BACKGROUND

Patellar tendon rupture is a rare disease, and reports regarding patellar tendon reconstruction with ligament augmentation reconstruction system (LARS) ligaments are limited, with only three reports available in the literature. LARS ligaments are made of polyethylene terephthalate and have been certified as a more favorable option than other tendon transplants. To our knowledge, this is the first report of patellar tendon reconstruction with LARS for suture fixation due to poor quality of the tendon after multiple operations to enable early mobilization and quick rehabilitation.

CASE SUMMARY

A 65-year-old woman had limited ability in extending her leg and an inability to perform a straight leg raise after multiple operations due to patella fracture. The patient underwent patellar tendon reconstruction with LARS artificial ligaments. After 12 mo of follow-up, the patient was able to perform a straight leg raise, and the incision healed well without complications. The Lysholm score was 95 and the range of motion of the knee was 0-130°.

CONCLUSION

This study revealed that patellar tendon reconstruction with LARS artificial ligaments is possible in a patient with a patellar tendon rupture who required rapid postoperative recovery.

Delayed right coronary ostial obstruction after J-valve deployment in transcatheter aortic valve implantation: A case report

BACKGROUND

Aortic stenosis is the most common valve disease in adults. Transcatheter aortic valve implantation (TAVI) is being increasingly applied for intermediate- to low-risk patients. Here, we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.

CASE SUMMARY

A 73-year-old woman with a EuroSCORE II of 1.21% underwent transapical TAVI because of severe aortic stenosis. The surgical procedure was uneventful. However, during routine monitoring after valve placement, the patient had a sudden onset of slow heart rate, the systolic blood pressure dropped sharply from 115 to 60 mmHg, and the central venous pressure abruptly increased from 10 to 33 cmH₂O. The patient had a poor response to vasoactive agents. Transesophageal echocardiography revealed poor myocardial contractility, and electrocardiography showed a significant depression of ST-segment. Another angiography was performed immediately, which suggested complete obstruction of the right coronary artery. An emergency protocol was initiated. Cardiopulmonary bypass was established immediately. An aortic biological valve replacement under cardiopulmonary bypass was performed.

CONCLUSION

Perioperative monitoring, early recognition, and diagnosis of obstruction of coronary arteries in TAVI are important. Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation. Emergency protocols should be established during TAVI.

Can cyclin-dependent kinase 4/6 inhibitors convert inoperable breast cancer relapse to operability? A case report

BACKGROUND

Pathological complete response (pCR) is rare in hormone receptor-positive (HR+) HER2-negative breast cancer (BC) treated with either endocrine therapy (ET) or chemotherapy. Radical resection of locoregional relapse, although potentially curative in some cases, is challenging when the tumor invades critical structures. The oral cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with ET has obtained a significant increase in objective response rates and progression-free survival in patients with advanced BC and is now being evaluated in the neoadjuvant setting. We present a clinical case of a patient with an inoperable locoregional relapse of HR+ HER2-negative BC who experienced pCR after treatment with palbociclib.

CASE SUMMARY

We report the clinical case of a 60-year-old patient who presented with an inoperable locoregional relapse of HR+, HER2-negative BC 10 years after the diagnosis of the primary tumor. During a routine follow-up visit, breast magnetic resonance imaging and positron emission tomography/computed tomography revealed a 4-cm lesion in the right subclavicular region, infiltrating the chest wall and extending to the subclavian vessels, but without bone or visceral involvement. Treatment was begun with palbociclib plus letrozole, converting the disease to operability over a period of 6 mo. Surgery was performed and a pCR achieved. Of note, during treatment the patient experienced a very uncommon toxicity characterized by burning tongue and glossodynia associated with dysgeusia, paresthesia, dysesthesia, and xerostomia. A reduction in the dose of palbociclib did not provide relief and treatment with the inhibitor was thus discontinued, resolving the tongue symptoms. Laboratory exams were unremarkable. Given that this was a late relapse, the tumor was classified as endocrine-sensitive, a condition associated with high sensitivity to palbociclib.

CONCLUSION

This case highlights the potential of the cyclin-dependent kinase 4/6 inhibitor plus ET combination to achieve pCR in locoregional relapse of BC, enabling surgical resection of a lesion initially considered inoperable.

Radiation recall dermatitis with dabrafenib and trametinib: A case report

BACKGROUND

Radiation recall dermatitis has been defined as the “recalling” by skin of previous radiation exposure in response to the administration of certain response-inducing drugs. Although the phenomenon is relatively well known in the medical world, an exact cause has not been documented.

CASE SUMMARY

Here, we report the rare occurrence of radiation recall dermatitis after palliative radiotherapy for bone metastases in a metastatic melanoma patient treated with a combination of dabrafenib and trametinib.

CONCLUSION

We present a case of radiation recall dermatitis after completion of palliative radiotherapy while being treated with a combination of dabrafenib and trametinib. This is a very rare toxic event, and there is insufficient data to describe prevention strategies. Increased awareness and reporting of cases will help to better explain the association between targeted therapy and the radiation recall phenomenon.

Clinicopathologic characteristics of prostatic stromal sarcoma with rhabdoid features: A case report

BACKGROUND

Prostatic stromal sarcoma presenting with rhabdoid features is extremely rare, and only four cases have been reported in the English-language literature to date. Accordingly, there is no absolute definition of this group of tumors as yet, and our overall understanding of its morphological features, therapeutic regimen and prognosis is limited.

CASE SUMMARY

A 34-year-old male patient was referred to our hospital to address a 2-mo history of hematuria and progressive dysuria. Pelvic computed tomography scan revealed a 6.0 cm × 5.2 cm × 7.2 cm mass in the prostate, with bladder invasion. The patient underwent transurethral prostatectomy as upfront therapy. He refused further treatment and died of uncontrollable tumor growth 3 mo after surgery. Pathology analysis revealed the stroma to be pleomorphic, with a huge number of atypical spindle cells. Rhabdomyoblastic cells, with abundant eosinophilic cytoplasm, were detected. The spindle cells were positive for vimentin, INI1 and β-catenin, and the rhabdomyoblastic cells were positive for MyoD1, myogenin and INI1. The spindle cells and epithelial cells were sporadically positive for P53.

CONCLUSION

The prostatic stromal sarcoma tumor was immunoreactive for β-catenin, suggesting a role for the Wnt/β-catenin pathway in this tumor type.

Complete response to trastuzumab and chemotherapy in recurrent urothelial bladder carcinoma with HER2 gene amplification: A case report

BACKGROUND

Targeted treatments may greatly affect the natural history of urothelial carcinoma based on their pharmacokinetics. A phase II trial has explored the combination of cytotoxic chemotherapy with the anti-HER-2 monoclonal antibody trastuzumab in selected patients with metastatic bladder cancer, but it failed.

CASE SUMMARY

Here, we report a case of recurrent urothelial bladder carcinoma (UBC) in a patient who has undergone three operations, and further illuminate its diagnosis and treatment. The diagnosis of UBC was rendered according to the pathological indices. Next-generation sequencing on formalin fixed paraffin-embedded (FFPE) tissue was also performed and suggested HER2 gene amplification in the FFPE tissue. Based on HER2 gene amplification in FFPE, the patient was treated with chemotherapy in combination with trastuzumab after his third surgery. Fortunately, the patient got a clinically complete remission to trastuzumab for 34 mo.

CONCLUSION

There is not enough clinical evidence for incorporating trastuzumab in routine treatment of UBC. This case hinted that recurrent UBC patients with HER2 gene amplification may benefit from targeted trastuzumab. Further studies are needed to further investigate the status of HER2 gene and better determine trastuzumab in the management of UBC.

Cytomegalovirus ileo-pancolitis presenting as toxic megacolon in an immunocompetent patient: A case report

BACKGROUND

Cytomegalovirus (CMV) enterocolitis presenting in the form of pancolitis or involving the small and large intestines in an immunocompetent patient is rarely encountered, and CMV enterocolitis presenting with a serious complication, such as toxic megacolon, in an immunocompetent adult has only been reported on a few occasions.

CASE SUMMARY

We describe the case of a 70-year-old male with no history of inflammatory bowel disease or immunodeficiency who presented with toxic megacolon and subsequently developed massive hemorrhage as a complication of CMV ileo-pancolitis. The patient was referred to our institute for abdominal pain and distension. Abdominal X-ray showed marked dilatation of ileum and whole colon without air-fluid level, and sigmoidoscopy with biopsy failed to reveal any specific finding. After 7 d of conservative treatment, massive hematochezia developed, and he was diagnosed to have CMV enterocolitis by colonoscopy with biopsy. Although the diagnosis of CMV enterocolitis was delayed, the patient was treated successfully by repeat colonoscopic decompression and antiviral therapy with intravenous ganciclovir.

CONCLUSION

This report cautions that CMV-induced colitis should be considered as a possible differential diagnosis in a patient with intractable symptoms of enterocolitis or megacolon of unknown cause, even when the patient is non-immunocompromised.

Esophageal tuberculosis complicated with intestinal tuberculosis: A case report

BACKGROUND

Although the overall incidence of tuberculosis in underdeveloped areas has increased in recent years, esophageal tuberculosis (ET) is still rare. Intestinal tuberculosis (ITB) is relatively more common, but there are few reports of ET complicated with ITB. We report a case of secondary ET complicated with ITB in a previously healthy patient.

CASE SUMMARY

A 27-year-old female was hospitalized for progressive dysphagia, retrosternal pain, acid regurgitation, belching, heartburn, and nausea. Upper gastrointestinal endoscopy showed a mid-esophageal ulcerative hyperplastic lesion. Endoscopic ultrasonography showed a homogeneous hypoechoic lesion, with adjacent enlarged lymph nodes. Biopsy histopathology showed inflammatory exudation, exfoliated epithelial cells and interstitial granulation tissue proliferation. Colonoscopy revealed a rat-bite ulcer in the terminal ileum and a superficial ulcer in the ascending colon, near the ileocecal region. The ileum lesion biopsy showed focal granulomas with caseous necrosis. Polymerase chain reaction for Mycobacterium tuberculosis was positive in the esophageal and ileum lesion biopsies. The T-cell spot tuberculosis test was also positive. The patient was diagnosed with secondary ET infiltrated by mediastinal lymphadenopathy and complicated with ITB, possibly from the Mycobacterium tuberculosis-infected esophageal lesion. After 2 mo of anti-tuberculosis therapy, her symptoms improved significantly, and upper gastrointestinal endoscopy showed healing ulcers.

CONCLUSION

When dysphagia or odynophagia occurs in patients at high-risk for tuberculosis, ET should be considered.

Cutaneous nodules and a novel GNAS mutation in a Chinese boy with pseudohypoparathyroidism type Ia: A case report and review of literature

BACKGROUND

Pseudohypoparathyroidism type Ia (PHP Ia) is a rare hereditary syndrome, and patients with early PHP Ia are generally not diagnosed based on the presentation of cutaneous nodules as the main clinical feature. Here, we describe a Chinese boy with PHP Ia in whom the main clinical feature was cutaneous nodules, and the patient exhibited a novel GNAS mutation.

CASE SUMMARY

A 5-year-old boy presented with a 5-year history of cutaneous nodules scattered over his entire body. The patient had a short stature, round face, short neck, and slightly flattened nose; he also had multiple hard papules and cutaneous nodules scattered over his entire body. The patient had a significantly elevated parathyroid hormone level. His serum calcium level was reduced, while his serum phosphorus level was increased and his serum thyroid-stimulating hormone level was elevated. Skin biopsy showed osteoma cutis in subcutaneous tissue. Sanger sequencing revealed a frameshift mutation, c.399delT (p.Ser133Argfs*2) in exon 5 of the GNAS gene. The patient was diagnosed with PHP Ia and subclinical hypothyroidism. He was given 1,25-dihydroxyvitamin D, calcium carbonate, and synthetic L-thyroxine. After 3 months of treatment, the patient’s parathyroid hormone level decreased, and his serum calcium and serum phosphorus levels were normal. Moreover, his thyroid-stimulating hormone level decreased.

CONCLUSION

These findings can help dermatologists to diagnose PHP Ia in patients with cutaneous nodules as the main early clinical feature.

Erdheim-Chester disease with asymmetric talus involvement: A case report

BACKGROUND

Erdheim-Chester disease (ECD) is a rare multi-system or multi-organ histiocytic proliferative disease with diverse clinical manifestations, and the development of the disease is complex, which makes clinical diagnosis and treatment difficult. The characteristic clinical manifestations include multi-organ involvement, especially in the symmetrical diaphysis and metaphysis of the bilateral extremities. ECD with a unilateral talus lesion is extremely rare. Here, we report an unusual case of ECD invading the asymmetric talus and tibia without involving other organs. The patient had good outcome after surgery.

CASE SUMMARY

We report a case of a 67-year-old man who was referred to our outpatient department because of left ankle chronic pain for 5 years, which exacerbated after a foot sprain 6 mo previously. We discovered multiple sclerotic lesions of the tibia and talus on his previous X-ray films, which were initially missed in a local hospital. Therefore, enhanced computer computed tomography (CT) and magnetic resonance imaging were performed. These examinations showed multiple lesions in the bone marrow cavity of the left tibia, and cortical sclerosis and osteonecrosis of the left talus. Specimens were collected via bone puncture from the two lesions, and a final diagnosis of ECD was confirmed by pathological and immunohistochemical examinations. In addition, other auxiliary examinations including head CT, pulmonary CT, spinal CT, abdominal CT, cardiac ultrasound and thyroid ultrasound showed no obvious abnormalities. The patient underwent surgery for the tibia lesion scraping and talus lesion scraping combined with cement casting. The patient started on a progressive rehabilitation at 4 wk, and felt no pain after surgery. During a 2-year follow-up period, the patient exercised normally without pain, and there were no signs of recurrence.

CONCLUSION

This study shows that surgery treatment may also achieve good results for ECD patients with only bone involvement.

Novel zinc alloys for biodegradable surgical staples

BACKGROUND

The development of biodegradable surgical staples is desirable as non-biodegradable Ti alloy staples reside in the human body long after wound healing, which can cause allergic/foreign-body reactions, adhesion, or other adverse effects. In order to develop a biodegradable alloy suitable for the fabrication of surgical staples, we hypothesized that Zn, a known biodegradable metal, could be alloyed with various elements to improve the mechanical properties while retaining biodegradability and biocompatibility. Considering their biocompatibility, Mg, Ca, Mn, and Cu were selected as candidate alloying elements, alongside Ti, the main material of clinically available surgical staples.

AIM

To investigate the in vitro mechanical properties and degradation behavior and in vivo safety and feasibility of biodegradable Zn alloy staples.

METHODS

Tensile and bending tests were conducted to evaluate the mechanical properties of binary Zn alloys with 0.1–6 wt.% Mg, Ca, Mn, Cu, or Ti. Based on the results, three promising Zn alloy compositions were devised for staple applications (wt.%): Zn-1.0Cu-0.2Mn-0.1Ti (Zn alloy 1), Zn-1.0Mn-0.1Ti (Zn alloy 2), and Zn-1.0Cu-0.1Ti (Zn alloy 3). Immersion tests were performed at 37 °C for 4 wk using fed-state simulated intestinal fluid (FeSSIF) and Hank's balanced salt solution (HBSS). The corrosion rate was estimated from the weight loss of staples during immersion. Nine rabbits were subjected to gastric resection using each Zn alloy staple, and a clinically available Ti staple was used for another group of nine rabbits. Three in each group were sacrificed at 1, 4, and 12 wk post-operation.

RESULTS

Additions of ≤1 wt.% Mn or Cu and 0.1 wt.% Ti improved the yield strength without excessive deterioration of elongation or bendability. Immersion tests revealed no gas evolution or staple fracture in any of the Zn alloy staples. The corrosion rates of Zn alloy staples 1, 2, and 3 were 0.02 mm/year in HBSS and 0.12, 0.11, and 0.13 mm/year, respectively, in FeSSIF. These degradation times are sufficient for wound healing. The degradation rate is notably increased under low pH conditions. Scanning electron microscopy and energy dispersive spectrometry surface analyses of the staples after immersion indicated that the component elements eluted as ions in FeSSIF, whereas corrosion products were produced in HBSS, inhibiting Zn dissolution. In the animal study, none of the Zn alloy staples caused technical failure, and all rabbits survived without complications. Histopathological analysis revealed no severe inflammatory reaction around the Zn alloy staples.

CONCLUSION

Staples made of Zn-1.0Cu-0.2Mn-0.1Ti, Zn-1.0Mn-0.1Ti, and Zn-1.0Cu-0.1Ti exhibit acceptable in vitro mechanical properties, proper degradation behavior, and in vivo safety and feasibility. They are promising candidates for biodegradable staples.

Boarding issue in a commercial flight for patients with cavitary pulmonary tuberculosis: A case report

BACKGROUND

Several studies have demonstrated that airborne transmission of Mycobacterium tuberculosis bacteria from patients with active pulmonary tuberculosis (TB) to other passengers or crew members can occur during long flights. As such, non-infectious TB patients are usually allowed to undertake air travel after taking the appropriate anti-TB drugs. However, the global guidelines for air travel for patients with TB are inconsistent and insufficiently detailed with respect to cavitary pulmonary TB (CPTB).

CASE SUMMARY

Here, we report a case in which a patient with multiple CPTB was permitted air travel, following negative sputum acid-fast bacilli smear tests after administration of proper anti-TB medication. The patient’s culture results were pending.

CONCLUSION

This case revealed that more specific guidelines regulating air travel for patients with CPTB are necessary.

Ruptured splenic peliosis in a patient with no comorbidity: A case report

BACKGROUND

Splenic peliosis is a disease characterized by widespread blood-filled cystic cavities within the parenchyma. Patients with this disease are usually asymptomatic; therefore, spontaneous or trauma-related rupture of the hemorrhagic cysts can occasionally cause life-threatening hemorrhagic shock.

CASE SUMMARY

A 51-year-old male patient with abdominal pain visited our emergency medical center two times with an interval of 2 mo. The patient was discharged from the hospital without treatment at his first visit; however, at the time of second admission, the hemoperitoneum with multiple cystic lesions of the spleen was found incidentally on the abdomen computed tomography scan. Since the patient was stable hemodynamically, a scheduled surgery was performed. The operative findings were consistent with splenic peliosis, and laparoscopic splenectomy was performed to prevent recurrent rupture of the hemorrhagic cysts.

CONCLUSION

Splenic peliosis is extremely rare, and we suggest splenectomy is necessarily required as a definite treatment for ruptured splenic peliosis to rescue patients with hemodynamic instability and to prevent recurrent rupture of hemorrhagic cysts in patients with stable hemodynamics.

Camrelizumab (SHR-1210) leading to reactive capillary hemangioma in the gingiva: A case report

BACKGROUND

Oncologic immunotherapy is attracting attention as an effective strategy for cancer treatment. Currently, there are two kinds of inhibitors: Anti-PD-1 antibodies and anti-PD-L1 antibodies. These inhibitors have shown significant implications in improving the outcomes of certain cancer types in recent years. However, along with its effectiveness, adverse events cannot be ignored. As an anti-PD-1 antibody, camrelizumab (SHR-1210) has some side effects in tumor immunotherapy. The most common adverse event is reactive capillary hemangioma. While it is widely reported to occur in the skin, gingival reactive capillary hemangioma is rarely reported.

CASE SUMMARY

A 54-year-old man complained of gingival overgrowth on the anterior aspect of the maxilla and mandible for more than 6 mo. He had been placed on SHR-1210 for lung cancer for 7 mo. A gingival mass extending from canine to canine was noted on the lingual surfaces of the mandible. Gingival enlargement was noted in the front teeth. A clinical diagnosis of gingival reactive capillary hemangioma and chronic periodontitis was made. The treatment involved a complex local treatment (repeated local applications of an antibiotic paste, scaling and root planning, and surgery). The excised tissue was sent for histopathological examination, which confirmed the diagnosis of capillary hemangioma. After the operation, most of the gingival enlargement was reduced. At the 2-mo follow-up, it was noted that the gingival overgrowth was immediately reduced after the replacement of the anti-PD-1 agent with an anti-PD-L1 agent.

CONCLUSION

As the prescription for SHR-1210 has increased considerably in recent years, the occurrence of its possible side effects, including gingival reactive capillary hemangioma, has increased. It is recommended that regular oral examinations be performed before and during the treatment of tumors with SHR-1210.

Successful treatment of adult-onset still disease caused by pulmonary infection-associated hemophagocytic lymphohistiocytosis: A case report

BACKGROUND

Adult-onset still disease (AOSD) and hemophagocytic syndrome (HPS) are two inflammatory diseases with very similar clinical manifestations. HPS is one of the most serious complications of AOSD and its risk of death is very high. It is difficult to identify HPS early in patients with AOSD, but early identification and proper treatment directly affects the prognosis.

CASE SUMMARY

A 39-year-old male showed a high spiking fever and myalgia. Laboratory data revealed elevated white blood cell, serum ferritin, and neutrophil percentage. However, his fever failed to relieve after a clear diagnosis of AOSD caused by pulmonary infection and treatment by antibiotics and corticosteroids; further laboratory data showed elevated serum ferritin, C-reactive protein, erythrocyte sedimentation rate and triglyceride, as well as liver abnormalities. Bone marrow smear showed hemophagocytosis. Secondary HPS was definitely diagnosed. The high fever disappeared and the laboratory findings returned to normal values after treatment by high-dose intravenous methylprednisolone and methotrexate.

CONCLUSION

For AOSD patients with high suspicion of HPS, active examination needs to be considered for early diagnosis, and timely using of adequate amount of corticosteroids is the key to reducing risk of HPS death.

Isolated vaginal metastasis from stage I colon cancer: A case report

BACKGROUND

Distant metastasis occasionally occurs in patients who have been diagnosed with colorectal cancer (CRC), but it occurs in a few patients with stage I CRC. The vagina as a metastasis site has also been reported, albeit rarely. Most reported cases of vaginal metastasis (VM) report their origin from advanced CRC. We encountered a patient who was diagnosed with isolated VM originating from stage I colon cancer (T2N0) and herein present the case of this patient.

CASE SUMMARY

A 63-year-old woman visited the outpatient clinic because of a positive result from a stool occult blood test. She underwent laparoscopic anterior resection and was pathologically diagnosed with stage I (T2N0) sigmoid colon cancer. Neither lymphovascular invasion nor perineural invasion was observed. Ten months following the surgery, isolated vaginal metastases were detected on gynecologic examination. The examination was performed due to vaginal spotting. A transvaginal wide excision was performed, and no other adjuvant treatment was provided after discussion with a multidisciplinary team and the patient. Subsequently, a new VM was discovered after 33 mo. An additional transvaginal excision was performed. To date, there has been no evidence of further disease progression. From the time of diagnosis of VM, the patient’s overall survival has been 54 mo.

CONCLUSION

VM can occur as a result of early-stage colorectal cancer. Surgeons should consider the possibility of VM following complaints of gynecologic symptoms following surgery.

Peutz-Jeghers syndrome with mesenteric fibromatosis: A case report and review of literature

BACKGROUND

Peutz-Jeghers syndrome (PJS) and mesenteric fibromatosis (MF) are rare diseases, and PJS accompanying MF has not been previously reported. Here, we report a case of a 36-year-old man with both PJS and MF, who underwent total colectomy and MF surgical excision without regular follow-up. Two years later, he sought treatment for recurrent acute abdominal pain. Emergency computed tomography showed multiple soft tissue masses in the abdominal and pelvic cavity, and adhesions in the small bowel and peritoneum. Partial intestinal resection and excision of the recurrent MF were performed to relieve the symptoms.

CASE SUMMARY

A 36-year-old male patient underwent total colectomy for PJS with MF. No regular reexamination was performed after the operation. Two years later, due to intestinal obstruction caused by MF enveloping part of the small intestine and peritoneum, the patient came to our hospital for treatment. Extensive recurrence was observed in the abdomen and pelvic cavity. The MF had invaded the small intestine and could not be relieved intraoperatively. Finally, partial bowel resection, proximal stoma, and intravenous nutrition were performed to maintain life.

CONCLUSION

Regular detection is the primary way to prevent deterioration from PJS. Although MF is a benign tumor, it has characteristics of invasive growth and ready recurrence. Therefore, close follow-up of both the history of MF and gastrointestinal surgery are advisable. Early detection and early treatment are the main means of improving patient prognosis.

Comprehensive review into the challenges of gastrointestinal tumors in the Gulf and Levant countries

Although gastrointestinal stromal tumors (GISTs) are rare, with an incidence of 1/100000 per year, they are the most common sarcomas in the peritoneal cavity. Despite considerable progress in the diagnosis and treatment of GIST, about half of all patients are estimated to experience recurrence. With only two drugs, sunitinib and regorafenib, approved by the Food and Drug Administration, selecting treatment options after imatinib failure and coordinating multidisciplinary care remain challenging. In addition, physicians across the Middle East face some additional and unique challenges such as lack of published local data from clinical trials, national disease registries and regional scientific research, limited access to treatment, lack of standardization of care, and limited access to mutational analysis. Although global guidelines set a framework for the management of GIST, there are no standard local guidelines to guide clinical practice in a resource-limited environment. Therefore, a group of 11 experienced medical oncologists from across the Gulf and Levant region, part of the Rare Tumors Gastrointestinal Group, met over a period of one year to conduct a narrative review of the management of GIST and to describe regional challenges and gaps in patient management as an essential step to proposing local clinical practice recommendations.

Sternal Hodgkin’s lymphoma: A case report and review of literature

BACKGROUND

Sternal tumors are difficult to diagnose, and usually need to be differentiated from other diseases such as tuberculosis, osteosarcoma, intrathoracic thyroid and thymoma. The sternum is a rare site of Hodgkin’s lymphoma, which is often misdiagnosed as tuberculosis on routine histopathology.

CASE SUMMARY

We reported a 47-year-old female patient with chest pain in the upper sternum for 1 mo. Chest computed tomography found a mass in the upper sternum. Pathology and immunohistochemistry of the biopsy confirmed the diagnosis of typical Hodgkin’s lymphoma (mixed cellularity subtype). Patient was diagnosed with primary sternal Hodgkin’s lymphoma and administered 6 cycles of adriamycin, bleomycin, vinblastine, and dacarbazine chemotherapy. Patient had no tumor recurrence and progression at a follow-up visit 2 years later.

CONCLUSION

This study highlights the rarity of primary sternal Hodgkin’s lymphoma and the challenges of its diagnosis. A PubMed and Web of Science search revealed 10 reported cases of sternal involvement in Hodgkin’s lymphoma.

Successful kidney transplantation from an expanded criteria donor with long-term extracorporeal membrane oxygenation treatment: A case report

BACKGROUND

Due to a shortage of donor kidneys, many centers have utilized graft kidneys from brain-dead donors with expanded criteria. Kidney transplantation (KT) from donors on extracorporeal membrane oxygenation (ECMO) has been identified as a successful way of expanding donor pools. However, there are currently no guidelines or recommendations that guarantee successful KT from donors undergoing ECMO treatment. Therefore, acceptance of appropriate allografts from those donors is solely based on clinician decision.

CASE SUMMARY

We report a case of successful KT from a brain-dead donor supported by ECMO for the longest duration to date. A 69-year-old male received a KT from a 63-year-old brain-dead donor who had been on therapeutic ECMO treatment for the previous three weeks. The recipient experienced slow recovery of graft function after surgery but was discharged home on post-operative day 17 free from hemodialysis. Allograft function gradually improved thereafter and was comparatively acceptable up to the 12 mo follow-up, with serum creatinine level of 1.67 mg/dL.

CONCLUSION

This case suggests that donation even after long-term ECMO treatment could provide successful KT to suitable candidates.

Combined surgical and interventional treatment of tandem carotid artery and middle cerebral artery embolus: A case report

BACKGROUND

The 2018 American Heart Association/American Stroke Association guidelines for early management of acute ischemic stroke recommend the use of retrievable stents for mechanical thrombectomy in patients with acute internal carotid artery or middle cerebral artery M1 occlusion that can be treated within 6 h from onset. For cases of carotid artery with ipsilateral middle cerebral artery tandem embolization, the operation is more complicated and challenging. We here report a case of a tandem embolism, and the anatomy of the aortic arch was complex. Direct carotid artery incision and thrombectomy can not only prevent the escape of the carotid embolus but also save time during establishment of the thrombectomy access.

CASE SUMMARY

The patient was a 70-year-old man. He was admitted to hospital due to sudden inability to speak and inability to move his right limb for 3 h. Imaging confirmed a diagnosis of a tandem embolism in the left carotid artery with left M1 occlusion. Carotid artery incision thrombectomy combined with stent thrombectomy was performed. The operation was successful, and 24 h later the patient was conscious and mentally competent but had motor aphasia. His bilateral limb muscle strength level was 5, and his neurologic severity scores score was 2.

CONCLUSION

Carotid artery incision thrombectomy combined with stenting for carotid artery plus cerebral artery tandem embolization is clinically feasible. For patients with a complicated aortic arch and an extremely tortuous carotid artery, carotid artery incision can be chosen to establish the interventional path.

Complex liver retransplantation to treat graft loss due to long-term biliary tract complication after liver transplantation: A case report

BACKGROUND

Loss of graft function after liver transplantation (LT) inevitably requires liver retransplant. Retransplantation of the liver (ReLT) remains controversial because of inferior outcomes compared with the primary orthotopic LT (OLT). Meanwhile, if accompanied by vascular complications such as arterial and portal vein (PV) stenosis or thrombosis, it will increase difficulties of surgery. We hereby introduce our center's experience in ReLT through a complicated case of ReLT.

CASE SUMMARY

We report a patient who suffered from hepatitis B-associated cirrhosis and underwent LT in December 2012. Early postoperative recovery was uneventful. Four months after LT, the patient’s bilirubin increased significantly and he was diagnosed with an ischemic-type biliary lesion caused by hepatic artery occlusion. The patient underwent percutaneous transhepatic cholangial drainage and repeatedly replaced intrahepatic biliary drainage tube regularly for 5 years. The patient developed progressive deterioration of liver function and underwent liver re-transplant in January 2019. The operation was performed in a classic OLT manner without venous bypass. Both the hepatic artery and PV were occluded and could not be used for anastomosis. The donor PV was anastomosed with the recipient’s left renal vein. The donor hepatic artery was connected to the recipient’s abdominal aorta. The bile duct reconstruction was performed in an end-to-end manner. The postoperative process was very uneventful and the patient was discharged 1 mo after retransplantation.

CONCLUSION

With the development of surgical techniques, portal thrombosis and arterial occlusion are no longer contraindications for ReLT.

Large cutaneous epithelioid angiomatous nodules in a patient with nephrotic syndrome: A case report

BACKGROUND

Cutaneous epithelioid angiomatous nodules (CEAN) are rare, benign, vascular lesions characterized by benign proliferation of endothelial cells with prominent epithelioid features, which can be easily confused with benign and malignant vascular tumors. However, the etiology of CEAN remains unclear, and no association with infection, trauma, or immunosuppression has been described. This case study indicated that CEAN is closely related to the patient’s impaired immune status and may be induced by cyclosporine.

CASE SUMMARY

A 19-year-old boy with nephrotic syndrome (NS) developed large CEAN on the left foot during treatment for NS. He had repeated relapses of edema in the past 6 years and different types of immunosuppressants were administered including methylprednisolone, mycophenolate mofetil, tacrolimus and cyclosporine; the dosages of these drugs were frequently adjusted. The patient had been receiving cyclosporine and methylprednisolone for 7 mo before he developed CEAN. Cyclosporine was discontinued due to its side effects on skin. After cessation of cyclosporine and 16 mo follow-up, the nodules gradually disappeared without any other treatment for the CEAN.

CONCLUSION

Impaired immune status is proposed to be a risk factor for CEAN, which may be induced by cyclosporine.

Durable response to pulsatile icotinib for central nervous system metastases from EGFR-mutated non-small cell lung cancer: A case report

BACKGROUND

Central nervous system (CNS) metastases are a catastrophic complication of non-small cell lung cancer (NSCLC), including brain and leptomeningeal carcinomatosis, and are always accompanied by a poor prognosis. Despite the continuous development of existing treatments, the therapy of CNS metastases remains challenging.

CASE SUMMARY

We report a patient who was definitively diagnosed with brain and leptomeningeal metastases from NSCLC with a targeted mutation in epidermal growth factor receptor (EGFR). A standard dosage of icotinib (125 mg three times daily) was implemented but ineffective. CNS lesions developed despite stable systemic control, so pulsatile icotinib (1125 mg every 3 d) was administered. This new strategy for administration has lasted 25 mo so far, and resulted in complete remission of neurological symptoms, almost vanished lesions, and longer survival with no notable side effects.

CONCLUSION

This is the first successful example of pulsatile icotinib for treating isolated CNS progression from EGFR mutation-positive NSCLC, providing a new alternative for the local treatment of CNS metastases.

Myocarditis presenting as typical acute myocardial infarction: A case report and review of the literature

BACKGROUND

Myocarditis refers to a variety of myocardial inflammatory lesions. A variety of factors such as infection and physical and chemical factors can cause myocarditis. Depending on the severity of myocardial damage, myocarditis patients can manifest heart failure, cardiogenic shock, and even sudden death. Here we present a case of viral myocarditis that mimicked acute coronary syndrome.

CASE SUMMARY

A middle-aged male patient presented with chest pain and elevated troponin I after a flu-like infection. This patient had a history of hypertension and a habit of alcohol and tobacco use. Electrocardiography showed typical changes in acute myocardial infarction, with the T-wave increasing. Coronary angiogram revealed no stenosis. Cardiac magnetic resonance imaging revealed edema of the middle and apical septal and apical anterior walls on T2-weighted images and the T1 mapping. Late gadolinium enhancement of the middle and apical septal and apical anterior walls could be found. Rubella virus immunoglobulin G and immunoglobulin M antibodies were abnormally elevated. The patient was given antiviral and antibiotic treatments, and serum biomarkers and electrocardiograph returned to normal after 5 d of treatment. After one-year follow-up, the patient showed no symptoms, and cardiac magnetic resonance showed that myocardial thickness was significantly thinner than before, and fibrosis was less than before.

CONCLUSION

This case illustrates the utility of cardiac magnetic resonance for diagnosis of infarction-like myocarditis when the angiogram is normal.

Risk factors for adverse cardiac events in adults with fulminant myocarditis during hospitalization

BACKGROUND

Fulminant myocarditis is the critical form of myocarditis that is often associated with heart failure, malignant arrhythmia, and circulatory failure. Patients with fulminant myocarditis who end up with severe multiple organic failure and death are not rare.

AIM

To analyze the predictors of in-hospital major adverse cardiovascular events (MACE) in patients diagnosed with fulminant myocarditis.

METHODS

We included a cohort of adult patients diagnosed with fulminant myocarditis who were admitted to Beijing Anzhen Hospital from January 2007 to December 2017. The primary endpoint was defined as in-hospital MACE, including death, cardiac arrest, cardiac shock, and ventricular fibrillation. Baseline demographics, clinical history, characteristics of electrocardiograph and ultrasonic cardiogram, laboratory examination, and treatment were recorded. Multivariable logistic regression was used to examine risk factors for in-hospital MACE, and the variables were subsequently assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

The rate of in-hospital MACE was 40%. Multivariable logistic regression analysis revealed that baseline QRS duration > 120 ms was the independent risk factor for in-hospital MACE (odds ratio = 4.57, 95%CI: 1.23-16.94, P = 0.023). The AUC of QRS duration > 120 ms for predicting in-hospital MACE was 0.683 (95%CI: 0.532-0.833, P = 0.03).

CONCLUSION

Patients with fulminant myocarditis has a poor outcome. Baseline QRS duration is the independent risk factor for poor outcome in those patients.

Catheter ablation of premature ventricular complexes associated with false tendons: A case report

BACKGROUND

False tendon is a common intraventricular anatomical variation. It refers to a fibroid or fibromuscular structure that exists in the ventricle besides the normal connection of papillary muscle and mitral or tricuspid valve. A large number of clinical studies have suggested that there is a significant correlation between false tendons and premature ventricular complexes. However, few studies have verified this correlation during radiofrequency catheter ablation of premature ventricular complexes.

CASE SUMMARY

A 45-year-old male was admitted to receive radiofrequency ablation for symptomatic premature ventricular complexes. A three-dimensional model of the left ventricle was established by intracardiac echocardiography using the CartoSound^TM mapping system. In addition to the left anterior papillary muscle, the posterior papillary muscle was mapped. False tendons were found at the base of the interventricular septum, and the other end was connected to the left ventricular free wall near the apex. An irrigated touch force catheter was advanced into the left ventricle via the retrograde approach. The earliest activation site was marked at the interventricular septum attachment of the false tendons and was successfully ablated.

CONCLUSION

This case verified that false tendons can cause premature ventricular complexes and may be cured by radiofrequency ablation guided by intracardiac echocardiography with the CartoSound^TM system.

Excellent response of severe aplastic anemia to treatment of gut inflammation: A case report and review of the literature

BACKGROUND

Cumulative evidence suggests that the aberrant immune responses in acquired aplastic anemia (AA) are sustained by active chronic infections in genetically susceptible individuals. Recently, the constant source to trigger and sustain the pathophysiology has been proposed to come from the altered gut microbiota and chronic intestinal inflammation. In this case, our serendipitous finding provides convincing evidence that the persistently dysregulated autoimmunity may be generated, at least in a significant proposition of AA patients, by the altered gut microbiota and compromised intestinal epithelium.

CASE SUMMARY

A 30-year-old Chinese male patient with refractory severe AA experienced a 3-month-long febrile episode, and his fever was refractory to many kinds of injected broad-spectrum antibiotics. When presenting with abdominal cramps, he was prescribed oral mannitol and gentamycin to get rid of the gut infection. This treatment resulted in a quick resolution of the fever. Unanticipatedly, it also produced an excellent hematological response. He had undergone three episodes of recurrence within the one-year treatment, with each recurrence occurring 7-8 wk from the gastrointestinal inflammation eliminating preparations. However, subsequent treatments were able to produce subsequent remissions and consecutive treatments were successful in achieving durative hematological improvements, strongly indicating an etiological association between chronic gut inflammation and the development of AA. Interestingly, comorbid diseases superimposed on this patient (namely, psychiatric disorders, hypertension, insulin resistance, and renal dysfunction) were ameliorated together with the hematological improvements.

CONCLUSION

Chronic gut inflammation may be responsible for AA pathogenesis. The comorbidities and AA may share a common etiological association.

Japanese encephalitis following liver transplantation: A rare case report

BACKGROUND

Japanese encephalitis (JE) is a serious public health concern with a high mortality rate in many Asian countries. For many years, JE virus (JEV) was considered the major cause of viral encephalitis in Asia. Although most JE cases are asymptomatic, the case fatality rate approaches 30%, and approximately 30%–50% of survivors have long-term neurological sequelae. To the best of our knowledge, JEV infection has never been reported following liver transplantation.

CASE SUMMARY

We report a case of a woman who underwent liver transplantation for autoimmune liver disease but presented with fever and neurological symptoms 13 d after transplantation. Magnetic resonance imaging revealed JEV infection, and positive immunoglobulin M antibody to JEV in blood and cerebrospinal fluid confirmed JE. The patient was treated with antiviral agents, immune regulation, and organ function support. No neurological sequelae were present after 1 year of follow-up.

CONCLUSION

Imaging and lumbar puncture examination should be performed as soon as possible in patients with fever and central nervous system symptoms after liver transplantation, and the possibility of atypical infection should be considered, which is helpful for early diagnosis and improved prognosis.

Eye metastasis in lung adenocarcinoma mimicking anterior scleritis: A case report

BACKGROUND

The eye is a rare site for lung cancer metastasis. Indeed, ocular metastasis is one of the greatest challenges to quality of life in a cancer patient. Here we present a patient with lung adenocarcinoma and ocular metastasis.

CASE SUMMARY

The patient was a 70-year-old man diagnosed with lung adenocarcinoma who developed eye metastasis mimicking anterior scleritis. Brain magnetic resonance imaging showed an abnormal signal in the right eye. Based on next generation sequencing of the surgical specimen, the patient was shown to have a KRAS point mutation (p.G12D).

CONCLUSION

Multidiscipline expertise collaboration is needed to make the early diagnosis and determine the prompt treatment in patients. We hope to increase the awareness of the possibility of lung cancer metastasizing to the eye.