Clinicopathological profile of orbital exenteration: 14 years of experience from a tertiary eye care center in South India

This study aims to describe the clinicopathological features and outcomes of patients who underwent orbital exenteration at a tertiary eye care center in south India. Retrospective chart reviews were performed on all patients undergoing orbital exenteration from January 1999 to December 2012. Parameters recorded include demographic data, clinical presentations, past medical or surgical interventions, exenteration notes, histopathological diagnosis, adjunctive treatment, follow-up examination findings, recurrences, complications, and their management. Orbital exenteration was performed on 119 orbits of 119 patients over a 14-year period. The mean age was 48.9 years (range 1-82 years). The indications were malignancies in 90.7 % (108/119), while 9.3 % (11/119) of cases were exenterated for non-malignant indications. Among the malignancies, the commonest tissue of origin was conjunctiva, noted in 45.4 % (49/108), followed by eyelids (25.9 %, 28/108), orbit (19.4 %, 21/108), and intraocular tissues (9.3 %, 10/108). The commonest malignancies noted in this series were an extensive ocular surface squamous neoplasia (OSSN) (44.4 %, 48/108) and sebaceous gland carcinoma of eyelids with an orbital involvement (18.5 %, 20/108). Extensive fungal granuloma (mucormycosis-4, aspergillosis-4) was the commonest (81.8 %, 9/11) indication among the non-malignant group. All complications were wound related, and none had a recurrence at a mean follow-up of 12.8 months. Extensive orbital involvement with OSSN and SGC were the commonest indications for exenteration. There is a need of creating awareness among general ophthalmologists in specific geographical regions regarding early diagnosis, standardized protocols of management, and appropriate referral.

The importance of re-examination with deep biopsies in diagnosing cervical malignancies despite multiple negative pathology reports: A case report

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The role of gynecological examination in diagnosis genital cancer is important as in this case (a woman with stony cervix and frozen pelvis).

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When we have frozen pelvis and fix stony cervix, taking multiple deep biopsies in spite of previous negative pathologic reports, is necessary.

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Reviewing the slides by qualified pathologists can help us to achieve true diagnosis when we the physical exam does not match with histopatologic results.

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Lymphoma should be always in our mind to remind the pathologists.

Introduction

Clinical symptoms of female genital tract lymphoma are often non-specific, and mimic other more common gynecological malignancies. Diagnosis can only be confirmed by histology.

Case presentation

We report the case of a 48-year-old multiparous woman who underwent subtotal hysterectomy because of enlarged myomatous uterus and persistent heavy vaginal bleeding. “2 months later”, postoperative pelvic and abdominal CT scan performed because of flank pain, revealed bilateral hydronephrosis. Pelvic and colposcopic exam and cervical biopsy under anesthesia showed benign histology, as reported by two pathologists. Referral to a third pathologist and immunohistochemical (IHC) exam revealed malignant lymphoproliferative disorder.

Conclusion

Despite multiple negative pathology reports of the cervical biopsies, bimanual pelvic exam with deep biopsies by a gynecologist, allowed accurate final diagnosis of this unusual case.

MR Imaging of Soft-Tissue Tumors of the Upper Extremity

Certain soft-tissue tumors seem to be specific to the upper extremity; most are benign. Knowledge of key magnetic resonance features, with clinical history and epidemiologic knowledge, can assist the radiologist in establishing optimal diagnosis. Indeterminate lesions require biopsy to exclude malignancy.

Significance of caveolin-1 and matrix metalloproteinase 14 gene expression in canine mammary tumours

Canine mammary tumours (CMTs) are the most common neoplasms affecting female dogs. There is an urgent need for molecular biomarkers that can detect early stages of the disease in order to improve accuracy of CMT diagnosis. The aim of this study was to examine whether caveolin-1 (Cav-1) and matrix metalloproteinase 14 (MMP14) are associated with CMT histological malignancy and invasion. Sixty-five benign and malignant CMT samples and six normal canine mammary glands were analysed using quantitative reverse transcription-polymerase chain reaction. Cav-1 and MMP14 genes were highly expressed in CMT tissues compared to normal tissues. Cav-1 especially was overexpressed in malignant and invasive CMT tissues. When a CMT cell line was cultured on fluorescent gelatin-coated coverslips, localisation of Cav-1 was observed at invadopodia-mediated degradation sites of the gelatin matrix. These findings suggest that Cav-1 may be involved in CMT invasion and that the markers may be useful for estimating CMT malignancy.

Characteristics and Risk Factors of Cancer Associated Venous Thromboembolism

INTRODUCTION

The objective of this study was to examine the differences in commonly associated characteristics and risk factors of venous thromboembolism (VTE) between patients with and without cancer in a VTE population.

MATERIALS AND METHODS

Uniform data were collected for patients with a diagnosis of VTE obtaining care at CDC funded Thrombosis Network Centers. Patient characteristics and risk factors were compared in VTE patients with and without cancer. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to assess patient characteristics and thrombotic risk factors more frequently identified among VTE patients with cancer compared to those without cancer.

RESULTS

Between August 2003 and April 2011, 3,115 adult patients with a diagnosis of VTE including 189 (6.1%) patients with active cancer participated in the multi-site thrombosis registry. VTE patients with cancer had a higher prevalence of PE and DVT in unusual sites compared to those without cancer. Thrombophilia was more common among VTE patients without cancer than those with cancer (25.1% vs 10.6%, p<0.001). In adjusted analysis, age group≥45years (OR =5.20, 95% CI, 3.30, 8.18), surgery (OR =1.86, 95% CI, 1.19, 2.91), and hypertension (OR =1.66, 95% CI, 1.15, 2.40) were the VTE risk factors more commonly found among VTE patients with cancer.

CONCLUSION

The study identified several thrombotic risk factors more likely to be found with cancer associated VTE, which may help to characterize at risk cancer patients and to develop prevention and management strategies in this population.

A 7-Years Retrospective Study of Gastrointestinal Cancers Incidence in the Western Iran

INTRODUCTION

In Iran, cancer is the third reason of the death and every year 500,000 new cases were detected, and 14% of all death is related to cancer. The most common system that is affected by cancer (after the skin) is gastrointestinal (GI) system. The purpose of the study is evaluation of the 7 years incidence (2002-2008) of the GI cancers in Ilam province in the west of Iran.

MATERIALS AND METHODS

In this retrospective cross-sectional study, total 307 record health related to the patients affected by the gastro-intestinal system cancer were evaluated after referring to the pathologic centers of the Ilam province and neighboring provinces. Patient's data were recorded from their file based on the standard questionnaire.

RESULT

The mean age ± standard deviation of participants was 63.8+1.5. More than half of participants study was men (58.3%). The prevalence of the esophagus, stomach, small intestine and colorectal cancers was significantly higher in the men than the women (unlike liver cancer) (p<0.001). The most common site of GI cancer were esophagus (38.1%) and stomach (34.2%) but small intestine was allocated the least prevalence (1%) to itself. The most common pathology type of cancer was adenocarcinoma in the GI system (68.1%).

CONCLUSION

According to the high prevalence of the GI cancer and also the ascending incidence of the patient with disease in the Ilam province, special measures should be considered for the reduction of the life and property load resulted from this disease. People by introduction of the warning signs of the gastrointestinal system cancer should be screened for GI cancer.

rAdinbitor, a disintegrin from Agkistrodon halys brevicaudus stejneger, inhibits tumorigenicity of hepatocarcinoma via enhanced anti-angiogenesis and immunocompetence

Adinbitor is a disintegrin previously obtained from Agkistrodon halys brevicaudus stejneger by our group. Here, we investigated the in vitro and in vivo anti-tumor activities of recombinant Adinbitor (rAdinbitor). rAdinbitor stimulation can inhibit the in vitro proliferation, migration and invasion capacities of murine hepatocarcinoma H22 and Hca-F cells. The administrations of rAdinbitor either by gavage or intraperitoneal injection suppress the tumor malignancy and prolong the survival rate and time of H22-transplanted mice. The number and size of formed blood vessels decreased dramatically in tumorous tissues in that the expression levels of vascular endothelial growth factor (VEGF) and cluster of differentiation 34 (CD34) were significantly decreased in responding to rAdinbitor treatment. The protein levels of IL-18 and IgG increased significantly in the serum of H22-transplanted tumor mice with rAdinbitor treatment. rAdinbitor shows in vitro and in vivo anti-tumor effects as an angiogenesis inhibitor and immunocompetence enhancer.

Adrenal Mass in Patients who Underwent Abdominal Computed Tomography Examination

BACKGROUND

Adrenal masses are usually discovered incidentally (IAM) during abdominal computed tomography (CT).

AIMS

We aimed to describe the prevalence, management, and outcome of incidentally discovered adrenal mass on radiological investigation.

MATERIALS AND METHODS

A retrospective analysis was conducted to look for IAM identified by abdominal CT performed for other reasons between 2004 and 2008 and were followed for 4 years. IAM patients with known malignancy or clinically evident adrenal disease or overt disease originally missed due to insufficient clinical examination were excluded.

RESULTS

A total of 13,115 patients underwent abdominal CT, of which 136 were identified with adrenal mass (69 males and 67 females). Overall, 84 patients had benign IAM and six had primary adrenal carcinoma (all had tumor size ≥4 cm and five were males). Hormonal evaluation was performed in 80 cases, which revealed hypersecretion in 10 cases (six had Conn's syndrome and four had pheochromocytoma). Males had higher frequency of right-sided IAMs; whereas, left-sided IAM swere more common among females (P = 0.02). Seven patients underwent surgery and all were males (one Conn's syndrome, one pheochromocytoma, three primary adrenal adenocarcinoma, one benign nonfunctional adenoma, and one metastatic tumor). Only one patient died due to brain metastasis.

CONCLUSION

The overall prevalence of adrenal incidentaloma is 1% in Qatar. Unfortunately, hormonal evaluation, surgical referral, and follow-up are not appropriate in this study. Moreover, screening of IAM warrants more attention to rule out malignancy. This work could be of value as a local auditing for the current management.

Quality and Outcomes of Treatment of Hypercalcemia of Malignancy

Using a nationwide database, 4,874 patients with hypercalcemia of malignancy were identified. The in-hospital mortality rate was 6.8%. Overall, 1,971 (40.4%) patients received pamidronate and 1,399 (28.7%) received zoledronic acid during hospitalization. Calcitonin was utilized in 1,337 (27.4%) patients while glucocorticoids were administered to 1,311 (26.9%). Use of contraindicated medications was noted in 136 (2.8%) patients who received thiazide diuretics and 12 (0.2%) who received lithium. Tumor site, presence of bone metastases, and severity of illness were predictors of treatment. There was no association between treatment with bisphosphonates, calcitonin, or glucocorticoids and morbidity or mortality.

Clinico-Epidemiological Study and Treatment Outcome of Multinodular Goitre at A Tertiary Care Hospital

BACKGROUND

Thyroid enlargement has been a common problem encountered in general surgical practice. Thyroid being an endocrine gland, its involvement has a diverse issue from a meagre cosmetic problem to a more concerned malignancy.

AIM

This study was conducted to study the age and sex distribution along with the mode of presentation of Multinodular Goitre (MNG). The incidence of malignancy and the surgical complications in the study population were also studied.

MATERIALS AND METHODS

In this descriptive study, patients diagnosed with MNG from January 2011 to July 2012 were chosen from the in-patient of our teaching hospital. One hundred such patients who qualified to undergo surgery were included in the study after a detailed history and clinical examination. Patients underwent Fine needle aspiration cytology (FNAC) for preoperative pathological diagnosis and the goitre was confirmed to be benign. Patients diagnosed with malignancy were excluded from the study. Following thyroidectomy, the thyroid specimens were subjected to histopathological examination.

RESULTS

Among the 100 cases of MNG, 59% patients belonged to 3rd and 4th decade of life, 90% patients were females, 82% presented before 5yrs. The most common symptom at presentation was swelling (100%). Among the patients 80% were in euthyroid state, 19% were hyperthyroid and 1% hypothyroid. Most of the patients were treated with sub-total thyroidectomy (59%), followed by total (20%), near total (11%), and Hemithyroidectomy (10%). Following surgery complications like stridor and laryngeal oedema (3%), wound infection (2%), hypocalcemia (2%), haemorrhage (1%) and seroma (1%) were noted. On Histopathological examination (HPE) of the surgical specimen, 3% were reported to be malignant.

CONCLUSION

As noted by this study, Multinodular Goitre is more common among females in the third and fourth decades. Patients can present with various complaints. MNG can present as hyperthyroid, hypothyroid but mostly in euthyroid state. The indication for surgery in patients with MNG includes cosmesis, hyperthyroidism, local compressive symptoms and most importantly malignancy. Subtotal thyroidectomy is the preferred surgery, but a trend towards total and near total thyroidectomy is noticeably replacing the old belief in subtotal thyroidectomy.

Spectrum of Oral Lesions in A Tertiary Care Hospital

AIM

The present study was undertaken to study the spectrum and pattern of various oral cavity lesions in a tertiary care hospital in Rohilkhand region of Uttar Pradesh, India.

BACKGROUND

Oral cavity is one of the most common sites for tumour and tumour like lesions especially in males. It has been observed that benign lesions are more common than malignant ones.

MATERIALS AND METHODS

A retrospective study was carried out in a tertiary care hospital during the period of two years from June 2012 to May 2014. The study included 133 cases of oral cavity lesions. The parameters included in the study were age, gender, site of the lesion and histopathological diagnosis. Special stains and Immunohistochemical markers were applied as and when required. Data collected were analysed.

RESULTS

A total of 133 cases were included in the present study. The age ranged from 8 to 80 years. Males were affected more often than females with a Male: Female ratio of 3.3:1. The most common involved site was tongue 39 (29.32%) followed by tonsil in 30 (22.56%), buccal mucosa 27(20.32%), floor of mouth 14 (10.53%), palate 12(9.02%), lower lip 8 (6.02%), upper lip 2(1.50%) and vestibule in 1 (0.75%) cases. Of the 133 cases, 63 cases (47.36%) were malignant, 52 non-neoplastic (39.10%) and 18 cases (13.53%) of benign neoplasias. The various lesions included - Squamous cell carcinoma, Verrucous carcinoma, Carcinoma-in-situ, Leukoplakia, Fibroma, Lipoma, Squamous cell papilloma, Lymphoid hyperplasia, Pseudoepitheliomatous hyperplasia, Haemangioma, Schwannoma, Atypical Pleomor -phic adenoma, Pleomorphic adenoma, Epidermal cyst, Retention cyst, Parasitic infestation, Tubercular pathology, Granulation tissue, Chronic Sialadenitis and Chronic non-specific inflammatory pathology. A larger epidemiopathological study in this region needs to be carried out for detailed statistical analysis.

CONCLUSION

Benign lesions were the predominant pathology. Squamous cell carcinoma was the commonest malignant lesion. Histopathological typing of the lesion is mandatory to confirm or rule out malignancy and is essential for the rational management thus avoiding mutilating surgery.

Giant Cutaneous Horn Overlying A Verruca at an Uncommon Site: Medical Marvel vs Superstitious Dilemma

Cutaneous horn has been a matter of discussion to mankind since time immemorial and a subject of fascination for the layman. There have been instances where certain groups saw it with angst and disgust, with a person having a large cutaneous horn on an exposed area getting a dismal look. We present a case of a 64-year-old man with a giant cutaneous horn over his left gluteal region. Cutaneous horns more commonly present in the sun-exposed areas. In our case it has presented in an uncommon site. The patient had delayed and denied medical treatment due to his superstitious beliefs, after having sought advice from faith healers leading to progression of the disease. This case has been presented for its giant size (rare variety), its location being over the gluteal region (photo-protected site) and its benign histopathology suggestive of wart in spite of the giant size.

Incidence and impact of interstitial lung disease and malignancy in patients with polymyositis, dermatomyositis, and clinically amyopathic dermatomyositis: a retrospective cohort study

The aims of this study were to retrospectively review Japanese consecutive cases of polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM), focusing on interstital lung disease (ILD) and malignancy, and to document any differences in the incidence, clinical features, and impact on prognosis among patients with PM, DM, and CADM.

We retrospectively reviewed 62 consecutive patients diagnosed with PM, DM, and CADM according to Bohan and Peter’s criteria (PM/DM) and Sontheimer’s criteria and Gerami’s criteria (CADM), focusing on ILD and malignancy.

ILD occurrence rates were 48 % (11/23) in patients with PM, 46 % (11/24) in DM, and 100 % (15/15) in CADM. Malignancy occurred during diagnosis or the observation period in 14 patients; 86 % were without ILD, and 64 % were DM without ILD. Multivariate logistic regression analysis showed that the risk of newly diagnosed malignancy was significantly lower in patients with ILD [odds ratio, 0.0688; 95 % confidence interval (CI), 0.00127–0.372; p = 0.00190] and significantly higher in patients with DM (odds ratio, 5.21; 95 % CI, 1.17–23.1; p = 0.0299) than in other patients. Patients with malignancies had shorter survival than those without malignancies; no clinically meaningful difference in survival was observed among the different myositis types and for presence of ILD. In CADM-ILD, 80 % fatal cases died from refractory ILD ≤90 days from the first visit; neither death nor recurrence occurred subsequently.

In conclusion, a positive association between DM and malignancy and a negative association between ILD and malignancy were noted. In the present study, malignancy was a predictor of poor long-term prognosis, but ILD were not. ILD associated with CADM contributed greatly to poor short-term prognosis, but neither death nor recurrence occurred subsequently.

Serum N-glycan profiles in patients with intraductal papillary mucinous neoplasms of the pancreas

BACKGROUND/OBJECTIVES

Diagnosing the invasiveness of intraductal papillary mucinous neoplasms (IPMNs) is difficult, especially by blood test. Alterations in serum glycan profiles have been reported for several cancers, but changes in serum glycan profiles have not been investigated in patients with IPMNs. The objectives of this study were to determine the serum N-glycan profile and to investigate its clinical utility in patients with IPMNs.

METHODS

We measured serum N-glycan profiles in 79 patients with IPMNs, including 13 invasive IPMNs, by performing comprehensive glycome analysis and assessed the relationship between N-glycan changes and clinical parameters.

RESULTS

Seventy glycans were identified and their expression profiles were significantly different depending on the cyst size, the presence of an enhancing solid component, and the histological grade of the IPMN. Nine glycans were highly expressed in patients with invasive IPMNs. The glycan m/z 3195, which is a fucosylated tri-antennary glycan, had the highest diagnostic value for distinguishing invasive IPMNs from non-invasive IPMNs (area under the receiver operating characteristic curve = 0.803). Multivariate analyses revealed high levels of m/z 3195 [odds ratio (OR), 20.5; 95% confidence interval (CI) 2.60-486.4] and the presence of enhancing solid components (OR, 35.8; 95% CI, 5.39-409.6) were significant risk factors for invasive IPMNs.

CONCLUSIONS

We performed a comprehensive evaluation of the changes in serum N-glycan profiles in patients with IPMNs for the first time. We determined that increased expression of fucosylated complex-type glycans, especially m/z 3195, is a potential marker for invasive IPMNs.

Unusual Presentation of Renal Cell Carcinoma in Crossed Ectopic Kidney

INTRODUCTION

Crossed renal ectopia is a rare anomaly and ninety percent of crossed ectopic kidneys are fused to their ipsilateral mate. Based on autopsy findings, the incidence has been estimated to be one in 2000 individuals.

CASE PRESENTATION

We hereby report on a 53-year-old woman with two episodes of painless gross hematuria. Imaging revealed left side fused crossed renal ectopia and filling defect within the pyelocaliceal of crossed kidney.

CONCLUSIONS

The patient underwent surgery applying a midline incision. The left kidney showed a lump pattern embedded in lower pole of the right kidney. Left sided nephrectomy was performed while temporary right renal artery was clamped temporarily. Histopathological evaluation revealed clear cell carcinoma with severe nuclear atypia (Fuhrman grade 4/4). However, local recurrence was not detected during the 18-month follow up after surgery.

Percutaneous unilateral biliary metallic stent placement in patients with malignant obstruction of the biliary hila and contralateral portal vein steno-occlusion

Objective

To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion.

Materials and Methods

Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients.

Results

A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days).

Conclusion

Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.

Predictors of malignancy in pure branch duct type intraductal papillary mucinous neoplasm of the pancreas: A nationwide multicenter study

BACKGROUND/OBJECTIVES

Prediction of malignancy in patients with BD-IPMNs is critical for the management. The aim of this study was to elucidate predictors of malignancy in patients with 'pure' BD-IPMNs who had a main pancreatic duct (MPD) diameter of ≤5 mm according to the most recent international consensus criteria and in whom MPD involvement was excluded on postoperative histology.

METHODS

We identified 177 patients with 'pure' BD-IPMNs based on preoperative imaging and postoperative histology from 15 tertiary referral centers in Korea. BD-IPMNs with low-grade (n = 72) and moderate-grade (n = 66) dysplasia were grouped as benign and BD-IPMNs with high-grade dysplasia (n = 10) and invasive carcinoma (n = 29) were grouped as malignancy.

RESULTS

On univariate analysis, particular symptoms (jaundice and clinical pancreatitis), CT findings (cyst size > 3 cm, the presence of enhancing mural nodules) and EUS features (the presence of mural nodules, the mural nodule size > 5 mm) were significant risk factors predicting malignant BD-IPMNs. Multivariate analysis revealed that the cyst size > 3 cm (odds ratio = 9.9), the presence of enhancing mural nodules on CT (odds ratio = 19.3) and the mural nodule size > 5 mm on EUS (odds ratio = 14.9) were the independent risk factors for the presence of malignancy in BD-IPMNs (p < 0.001).

CONCLUSIONS

The cyst size > 3 cm, the presence of enhancing mural nodules on CT, the mural nodule size > 5 mm on EUS are three independent predictors of malignancy in patients with 'pure' BD-IPMNs.

Choroid Melanoma - A Rare Case Report

Uveal tract encomprise melanomas of the iris, ciliary body and the choroid. The choroid melanomas are more frequent to occur in comparison to iris and ciliary body melanomas. Choroid melanoma though rare, is the most common occurring intraocular malignancy amongst the adults. Incidence of occurrence of choroid melanoma is around 20 per million cases per year globally. The uveal tract pigment producing melanocytes are the origin for the melanoma in the eye. Melanomas tend to commonly arise from sixth decade of age with increasing incidence with progressive age. We present a rare case choroidal melanoma, in a 65-year-old adult, who presented with three months history of headache and gradual dimunision of vision, his investigations revealed clinical diagnosis of choroid melanoma , an enucleation was carried.

Malignant infiltration of the liver presenting as acute liver failure

There have been few reports of acute liver failure (ALF), with encephalopathy and coagulopathy, caused by infiltration of the liver by malignant cells. We describe a case series of 27 patients with ALF caused by malignancy. We examined a large, multicenter ALF registry (1910 patients; mean age, 47.1 ± 13.9 y) and found only 27 cases (1.4%) of ALF attributed to malignancy. Twenty cases (74%) presented with abdominal pain and 11 presented with ascites. The most common malignancies included lymphoma or leukemia (33%), breast cancer, (30%), and colon cancer (7%); 90% of the patients with lymphoma or leukemia had no history of cancer, compared with 25% of patients with breast cancer. Overall, 44% of the patients had evidence of liver masses on imaging. Diagnosis was confirmed by biopsy in 15 cases (55%) and by autopsy for 6 cases. Twenty-four patients (89%) died within 3 weeks of ALF.

Fungal Orbital Infection Mimicking Malignancy in a Girl

Fungal infection of the orbit is rare especially among immunocompetent patients. We present a 9-year-old girl with peri-orbital, eyelid and internal canthus swelling of the left eye. Clinical impression was suggestive of malignant tumor such as rhabdomyosarcoma or lymphoma. Histopathological examination of biopsied tissue revealed necrotizing granulomatous inflammation confirmed as fungal infection. Complete response to antifungal therapy was noted after four months.

Risk Factors Associated with the Malignant Changes of Symptomatic and Asymptomatic Endometrial Polyps in Premenopausal Women

OBJECTIVE

This study aimed to evaluate the prevalence of premalignant and malignant lesions of symptomatic and asymptomatic endometrial polyps among premenopausal women and to verify whether different clinical parameters, and polyp volume and number are associated with a more precise estimate of malignancy.

METHODS

One hundred and fifty women aged 29-52 years and with certain diagnosis of endometrial polyp were enrolled in a prospective observational study. The recruited patients underwent hysteroscopic polypectomy based on saline infusion sonohysterography and diagnostic hysteroscopy. Pathologic report was the main outcome.

RESULTS

Among women with endometrial polyps, 62 % had asymptomatic polyps. The prevalence of premalignant and malignant polyps comprised 4.6 % of cases (3.3 % hyperplasia with atypia and 1.3 % carcinomatous polyps). The presence of abnormal uterine bleeding was not a predictor of premalignant and malignant changes in the polyp. On logistic regression analysis, the premalignant and malignant lesions were influenced by polycystic ovary syndrome (p < 0.001; OR 4.61; CI 1.9-27), polyp volume >10 ml (p < 0.001; OR 5.83; CI 4.31-9.17), and multiple polyps (p = 0. 01; OR 2.05; CI 1.09-3.76). Notably, the odds ratio of polyp volume >10 ml was 5.83. This additional risk confirms the importance of polyp volume in the detection of malignant transformation rather than associating bleeding in premenopausal women.

CONCLUSION

Polycystic ovary syndrome, polyp volume greater than 10 ml, and increased polyp number represent the markers of risk for premalignant and malignant transformation of endometrial polyps in premenopausal women. Nonetheless, the majority of polyps are asymptomatic, and the risk of malignancy is very low. Therefore, for women with polyp volume ≤10 ml and no risk factors, a more expectant approach may be warranted in order to reduce surgical risks and costs.

Malignancies arising in allograft kidneys, with a first reported translocation RCC post-transplantation: A case series

BACKGROUND

The increased risk of malignancy in the post-renal transplant population has been well documented. Renal carcinoma is more common in this population, usually arising in native kidneys. Rarely, tumors arise in the transplanted kidney. Our case series reports four cases of malignancy in allograft kidneys, one of which is a first reported case of translocation RCC in a transplanted kidney.

METHODS

The renal transplantation database (1584 patients) at St. Michael's Hospital was reviewed for malignancies arising in allograft kidneys: reports and pathology slides were reviewed.

RESULTS

Four cases of malignancies arising in the allograft kidney were identified among our kidney transplant population. One patient developed a high grade urothelial carcinoma in the donor kidney post BK virus infection. The other 3 cases were renal cell carcinomas: one clear cell renal cell carcinoma, one translocation renal cell carcinoma, and one papillary renal cell carcinoma. The translocation renal cell cancer had confirmed TFE3 protein over-expression by immunohistochemistry. Molecular testing of the tumors in all 4 cases identified two separate genetic profiles, favored to represent tumors arising from donor tissues along with infiltrating recipient lymphocytes.

DISCUSSION

Previous reports suggested that epithelial malignancies in allograft kidneys are rare. We identified 4 such tumors in 1584 transplant patients. Further, we identified the first reported case of translocation RCC in an allograft kidney. While the rate of malignancy in allograft kidneys is low, screening of the donor kidneys by ultrasound and/or urine cytology may be of use in detecting these lesions.

Febrile neutropenia in children treated for malignancy

Febrile neutropenia (FN) in children treated for malignancy is a common and direct sequela of chemotherapy. Episodes of FN can be life-threatening, and demand prompt recognition, assessment and treatment with broad spectrum antibiotics. While in the majority of episodes no causal infection is identified, 10-20% are secondary to a bloodstream infection (BSI). A reduction in episodes of BSI could be achieved through robust infection prevention strategies, such as CVL care bundles. Alongside good antimicrobial stewardship, these strategies could reduce the risk of emergent, multi-drug resistant (MDR) infections. Emerging bacterial pathogens in BSI include Viridans Group Streptococci (VGS) and Enterobacteriaceae such as Klebsiella spp. which are known for their ability to carry MDR genes. There is also increased recognition of the role of invasive fungal infection (IFI) in FN, in particular with Aspergillus spp. Novel diagnostics, including multiplex blood and respiratory polymerase chain reaction assays can identify infections early in FN, facilitating targeted therapy, and reducing unnecessary antimicrobial exposure. Given appropriate, and sensitive rapid diagnostics, potential also exists to safely inform the risk assessment of patients with FN, identifying those at low risk of complication, who could be treated in the out-patient setting. Several clinical decision rules (CDR) have now been developed and validated in defined populations, for the risk assessment of children being treated for cancer. Future research is needed to develop a universal CDR to improve the management of children with FN.

Paracrine factors from adipose-mesenchymal stem cells enhance metastatic capacity through Wnt signaling pathway in a colon cancer cell co-culture model

Background

Mesenchymal stem cells (MSCs) in tumors have emerged as progenitors involved in stroma formation and metastasis of cancers, partially owing to their abilities to differentially express paracrine factors related to the proliferation and invasion of cancer cells. In this regard, increasing evidence has shown that MSCs have impacts on the malignancy of colon cancer, however, the underpinning mechanisms by which MSCs promote cancer metastasis remain elusive.

Methods

To investigate the crosstalk between adipose-derived MSCs (AMSCs) isolated from adipose tissues and colon cancer cells, a co-culture transwell model of AMSCs and colon cancer cells was employed, and the activation of Wnt signaling and paracrine factors in colon cancer cells and AMSCs were measured.

Results

The results showed that AMSCs could enhance the metastatic capacity of colon cancer cells with an elevated expression of mesenchymal-epithelial transition (EMT)-associated genes in a contact-dependent manner. Reciprocally, colon cancer cells were able to induce AMSCs to produce metastasis-related factors and cytokines, such as FGF10, VEGFC and matrix metalloproteinases (MMPs) in part through a mechanism of an activation of Wnt signaling, by which these factors in turn activate Wnt signaling of colon cancer cells. Intriguingly, an inhibition of Wnt signaling leads a reduced capacity of invasion and colony formation of colon cancer cells in vitro, and the tumorigenicity of cancer cells in a murine model.

Conclusions

These findings thus suggest that the crosstalk between the Wnt signaling of cancer cells and paracrine factors of AMSCs has an implication in colon cancer malignancy. This study thus uncovers a novel Wnt-paracrine factors mediated-crosstalk between colon cancer cells and AMSCs in cancer malignancy.

Effect of silymarin in the prevention of Cisplatin nephrotoxicity, a clinical trial study

BACKGROUND

Reno-protective effect of Silymarin was studied in some studies mainly on rats. In some of these studies, Silymarin was shown to have positive effects on preventing or decreasing severity of Cisplatin nephrotoxicity.

OBJECTIVE

The aim of this study was to evaluate the protective effect of Silymarin on Cisplatin nephrotoxicity in adult patients with malignancy.

MATERIALS AND METHODS

In this clinical trial study, 60 patients with malignancy, candidate of Cisplatin treatment were randomly enrolled in two equal groups. In patients of case group, Silymarin tablet 140 mg/bid was administrated seven days before Cisplatin administration together with Cisplatin, and in control group, Cisplatin was prescribed. Blood Urea Nitrogen (BUN) and serum Creatinine (Cr) were checked at the same day and 3 and 7 days after administration of Cisplatin.

RESULTS

Mean age of the patients in case and control groups were 51.1±14.3 y and 51.1±13.7 y respectively (p=0.99). There was no significant difference based on BUN and serum Cr in the beginning of study and three days after administration of Cisplatin in two groups of patients; however, after two weeks, BUN and serum Cr were significantly lower in the case group compared to the control group. Also, in the case group, BUN and serum Cr decreased and in the control group, they increased after two weeks after Cisplatin administration.

CONCLUSION

This study showed that Silymarin can decrease Cisplatin nephrotoxicity, so because of safety profile and minor adverse effect of Silymarin, we can use it as prophylaxis against Cisplatin nephrotoxicity in various Cisplatin-contained chemotherapy regimens.

Colorectal cancers in ulcerative colitis from a low-prevalence area for colon cancer

AIM: To determine the incidence and risk factors for colorectal cancer (CRC) in patients with ulcerative colitis from a low prevalence region for CRC.

METHODS: Our prospective database yielded a cohort of 430 patients [age: 44 ± 14.6 years; 248 men (57.7%)] with ulcerative colitis (median disease duration 6, range: 1-39 years) for analysis. Of these, 131 (30.5%) had left-sided colitis and 159 (37%) extensive colitis. Patients with histologically confirmed CRC within the segment with colitis were compared with those without CRC, to determine the risk factors for the development of CRC.

RESULTS: Twelve patients (2.8%) developed CRC. The overall incidence density was 3.56/1000 patient-years of disease - 3/1000 in the first 10 years, 3.3/1000 at 10 to 20 years, and 7/1000 at > 20 years. Three of our 12 patients developed CRC within 8 years of disease onset. On univariate analysis, extensive colitis, longer duration of disease, and poor control of disease were associated with development of CRC. On multivariate analysis, duration of disease and extent of colitis remained significant.

CONCLUSION: CRC occurred in 2.8% of patients with ulcerative colitis in our population - an incidence density similar to that in Western countries in spite of a low overall prevalence of colon cancer in our population. The risk increased with extent and duration of disease.

Role of bronchoscopy in evaluation of cases with sputum smear negative pulmonary tuberculosis, interstitial lung disease and lung malignancy: A retrospective study of 712 cases

BACKGROUND

The introduction of flexible bronchoscope has revolutionized the field of pulmonary medicine and is a standard instrument used for diagnostic purpose. A retrospective analysis of the clinico-radiological profile, indication, biopsy procedure and complications, for patients undergoing bronchoscopy at one of the respiratory unit at a tertiary care center in India.

METHODS

Retrospective analysis of 712 bronchoscopies was done in regard to demographic profile, clinical and radiological presentation and diagnostic indication. The results were analyzed on basis of bronchoscopy inspection and histopathological specimen obtained from transbronchial (TBLB), endobronchial biopsy (EBLB) and cytology specimen by transbronchial needle aspiration (TBNA). Furthermore, diagnostic yield of each biopsy procedure and their combination was evaluated.

RESULTS

Of 712 patients undergoing bronchoscopy, the pathological diagnosis was achieved in 384 (53.93%). Of 384 diagnosed cases, the clinic-radio-pathological diagnosis of pulmonary tuberculosis in 88 (22.19%), interstitial lung disease (ILDs) in 226 (58.85%), and lung cancer in 70 (18.22%) cases. Of 116 sputum smear negative tuberculosis patients, 88 (75.86%) were diagnosed to be pulmonary tuberculosis; the contribution of BAL being 71.59%. Of 226 ILDs, sarcoidosis was most common 148/226 (65.48%). Among 70 lung cancer diagnosed cases, squamous cell carcinoma was most common (54.28%).

CONCLUSION

The results from current study reemphasizes on the diagnostic utility as well as safety of the bronchoscopy procedure.

Malignant transformation in sacrococcygeal teratoma and in presacral teratoma associated with Currarino syndrome: a comparative study

BACKGROUND/PURPOSE

The risk of malignant transformation of sacrococcygeal teratoma (SCT) and of presacral teratoma in Currarino syndrome (CS) may differ despite the similar position and appearance.

METHODS

Malignant transformation and teratoma recurrence were assessed in a national retrospective comparative analysis of 205 SCT and 16 CS patients treated in one of the six pediatric surgical centers in the Netherlands between January 1981 and December 2010.

RESULTS

The malignancy free survival of patients with SCT was lower than for patients with a presacral teratoma associated with CS (80% and 58% after one and two years in SCT versus 100% after two years in CS, p=0.017) CONCLUSIONS: In SCT, malignancy and recurrence risk are high. Therefore, early and complete resection is mandatory. Our data show that the risk of malignant transformation of a presacral teratoma in CS is small.

Keystone flap: versatile flap for reconstruction of limb defects

BACKGROUND

There is always a constant search for a new solution to tackle defects in the limbs. The technique has to be simple, easily reproducible and performed within a short duration. The answer is keystone island flap keystone flap is a simple, less time consuming, durable and easily reproducible option to reconstruct most of the limb defects.

AIM

The aim of this article is to study the usefulness of keystone flap in reconstruction of various upper and lower limb defects.

MATERIALS AND METHODS

This retrospective review involves study of 20 patients undergoing keystone flap reconstruction for various defects from 2012 to 2014. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications and follow-up were evaluated and are presented as uncontrolled case series.

RESULTS

Ages of the patients were ranging from 18 to 65 y with an average of 38.75y. Among the defects, 10 were following trauma (50%), 5 were due to tumour resection (25%), 3 followed debridement of abscess (15%) and another 2 defects were due to surgical wound dehiscence (10%). The largest defect covered by this flap in our study measured 45 x 18 cm and the smallest defect was 8 x4 cm. The average intra-operative time was 45.5 min (range 20-90 min). Fourteen flaps were done to cover lower limb defects (70%), 4 for upper limb defects and 2 were for defects in the axilla. Partial flap necrosis was observed in one case. The average duration of hospital stay of patients was 3.45 d. All patients were followed until they achieved stable, healed wound.The overall success rate was 95%.

CONCLUSION

Keystone flap can be safely used to cover various limb defects with minimal pain, a sensate cover and excellent cosmetic outcome, minimizing the need for microsurgical techniques or prolonged operative time.

Correlation of liver and pancreas endoscopic ultrasonography-guided fine-needle aspiration biopsy in patients with a primary pancreatic lesion

BACKGROUND

Endoscopic ultrasonography (EUS) is commonly used in the evaluation of pancreas masses, and when a liver lesion is visualized, it can undergo a fine-needle aspiration (FNA). This can provide diagnostic and staging information. The purpose of the study was to correlate the findings of patients who underwent EUS FNA biopsy of a pancreas lesion and a liver lesion during the same procedure.

MATERIALS AND METHODS

The pathology database at Washington University Medical Center was searched for EUS FNA biopsy cases where biopsy of both the pancreas and liver were performed over a consecutive 10-year period (2003-2013). All pathology reports were reviewed, and clinical information and diagnostic results were recorded.

RESULTS

A total of 102 cases were identified. For pancreas cases, 79.4% were malignant and for liver cases, 58.8% were malignant. In pancreas lesions categorized as suspicious for malignancy (9%), the liver biopsy provided a diagnosis of malignancy in 67% of cases. A malignant pancreatic cohort demonstrated a 62.9% liver malignancy. A malignant liver cohort corresponded to a malignant pancreas diagnosis in 86.6% of cases and a suspicious-malignant group of 98.3%.

CONCLUSIONS

The 102 cases with concomitant EUS FNA biopsy of the pancreas and liver demonstrated the ability to provide a diagnosis of pancreas malignancy and correlate regional metastatic malignancy in the liver. In patients with a pancreas mass and in the appropriate clinical setting, a liver EUS FNA biopsy has the ability to provide a diagnosis of malignancy and demonstrate a high positive predictive value of malignancy in the pancreas (98.3%).

Tumor necrosis factor, tumor necrosis factor inhibition, and cancer risk

OBJECTIVE

Tumor necrosis factor (TNF) is a highly pleiotropic cytokine with multiple activities other than its originally discovered role of tumor necrosis in rodents. TNF is now understood to play a contextual role in driving either tumor elimination or promotion. Using both animal and human data, this review examines the role of TNF in cancer development and the effect of TNF and TNF inhibitors (TNFis) on malignancy risk.

RESEARCH DESIGN

A literature review was performed using relevant search terms for TNF and malignancy.

RESULTS

Although administration of TNF can cause tumor regression in specific rodent tumor models, human expression polymorphisms suggest that TNF can be a tumor-promoting cytokine, whereas blocking the TNF pathway in a variety of tumor models inhibits tumor growth. In addition to direct effects of TNF on tumors, TNF can variously affect immunity and the tumor microenvironment. Whereas TNF can promote immune surveillance designed to eliminate tumors, it can also drive chronic inflammation, autoimmunity, angiogenesis, and other processes that promote tumor initiation, growth, and spread. Key players in TNF signaling that shape this response include NF-κB and JNK, and malignant-inflammatory cell interactions, each of which may have different responses to TNF signaling. Focusing on rheumatoid arthritis (RA) patients, where clinical experience is most extensive, a review of the clinical literature shows no increased risk of overall malignancy or solid tumors such as breast and lung cancers with exposure to TNFis. Lymphoma rates are not increased with use of TNFis. Conflicting data exist regarding the risks of melanoma and nonmelanoma skin cancer. Data regarding the risk of recurrent malignancy are limited.

CONCLUSIONS

Overall, the available data indicate that elevated TNF is a risk factor for cancer, whereas its inhibition in RA patients is not generally associated with an increased cancer risk. In particular, TNF inhibition is not associated with cancers linked to immune suppression. A better understanding of the tumor microenvironment, molecular events underlying specific tumors, and epidemiologic studies of malignancies within specific disease indications should enable more focused pharmacovigilance studies and a better understanding of the potential risks of TNFis.

Cardiac biomarkers indicate a need for sensitive cardiac imaging among long-term childhood cancer survivors exposed to anthracyclines

AIM

The role that plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponins T (cTnT) and I (cTnI) play in supplementing imaging to screen for cardiac late effects remains controversial and the impact of high-sensitivity cTnT and troponin-specific autoantibodies (cTnAAbs) remains unexplored. We studied the role of cardiac biomarkers as indicators of the late effects of anthracyclines among childhood cancer survivors.

METHODS

We measured NT-proBNP, cTnT, high-sensitivity cTnT, cTnI and cTnAAbs in 76 childhood cancer survivors at a median of 9 years after primary diagnosis. The survivors underwent conventional and real-time three-dimensional echocardiography and 62 underwent cardiac magnetic resonance imaging (MRI).

RESULTS

Of the survivors, four (5.3%) without risk factors for cardiotoxicity were cTnAAb-positive with an impaired cardiac function in MRI. Another four (5.3%) had an abnormal NT-proBNP level associated with an abnormal cardiac function and risk factors for cardiotoxicity. None showed measurable cardiac troponins, determined by the three different methods, with even the high-sensitivity cTnT-levels remaining normal.

CONCLUSION

Elevated plasma NT-proBNP or cTnAAbs indicated that childhood cancer survivors benefitted from being evaluated with modern imaging, despite normal function in conventional echocardiography. However, troponins did not seem to provide additional information on the late cardiotoxicity of anthracyclines.

Malignancy associated with ovarian teratomas: frequency, histotypes, and diagnostic accuracy of intraoperative consultation

Mature cystic teratomas are common ovarian germ cell tumors that rarely undergo malignant transformation, and intraoperative consultation is generally not warranted. The aims of this study were to review a large number of ovarian teratomas (OTs), to document the rate and histotypes of associated malignancy, and to identify parameters that may be associated with malignancy. In this study, a retrospective medical record review of patients diagnosed as having OTs from 2002 to 2011 was performed. Patient age, tumor size, type, and laterality were obtained from pathology reports and operative notes. A total of 956 OTs that ranged in size from 0.3 to 45 cm were identified. Intraoperative consultation was requested in a total of 316 (33.1%) of 956. Intraoperative gross evaluation only was performed on 211 (66.8%) of 316, of which 4 cases were malignant on final diagnosis. Frozen section was performed on 105 (33.2%) of 316, of which 12 were malignant on final diagnosis. The final diagnoses of all OT cases were as follows: 26 (2.7%) of 956 were associated with malignant tumors. The latter were larger than benign cases (average sizes, 11.2 cm vs 6.5 cm; P < .001), and patients with malignant tumors were significantly older than those with benign mature cystic teratoma (48.7 years vs 38.8 years, P < .001). The sensitivity and positive predictive value of frozen section examination during the intraoperative consultation for the detection of malignancy in OTs are 80% and 100%, respectively. In conclusion, patient age and large tumor size were associated with malignancy in this data set. Mucinous and serous borderline tumors were more common than squamous cell carcinoma in our cohort.

Anorectal Melanoma: A Case Report and an Update of a Rare Malignancy

Anal melanoma is an aggressive but rare malignancy. Patients commonly present with very advanced or even metastatic disease. Risk factors for anal melanoma are family history and an activating mutation of C-KIT. Surgical excision remains the mainstay of therapy. The presence of activating mutations of C-KIT has prompted use of C-KIT inhibitors such as imatinib and sunitini. Early diagnosis and treatment remain crucial. Abdominal perineal resection (APR) offers a higher rate of local control whereas wide local excision (WLE) can yield superior long-term survival.

Metabolomics specificity of tuberculosis plasma revealed by (1)H NMR spectroscopy

Tuberculosis (TB) is a communicable disease of major global importance and causes metabolic disorder of the patients. In a previous study, we found that the plasma metabolite profile of TB patients differs from that of healthy control subjects based on nuclear magnetic resonance (NMR) spectroscopy. In order to evaluate the TB specificity of the metabolite profile, a total of 110 patients, including 40 with diabetes, 40 with malignancy, and 30 with community-acquired pneumonia (CAP), assessed by NMR spectroscopy, and compared to those of patients with TB. Based on the orthogonal partial least-squares discriminant analysis (OPLS-DA), the metabolic profiles of these diseases were significant different, as compared to the healthy controls and TB patients, respectively. The score plots of the OPLS-DA model demonstrated that TB was easily distinguishable from diabetes, CAP and malignancy. Plasma levels of ketone bodies, lactate, and pyruvate were increased in TB patient compared to healthy control, but lower than CAP and malignancy. We conclude that the metabolic profiles were TB-specific and reflected MTB infection. Our results strongly support the NMR spectroscopy-based metabolomics could contribute to an improved understanding of disease mechanisms and may offer clues to new TB clinic diagnosis and therapies.

Acquisition of doxorubicin resistance facilitates migrating and invasive potentials of gastric cancer MKN45 cells through up-regulating aldo-keto reductase 1B10

Continuous exposure to doxorubicin (DOX) accelerates hyposensitivity to the drug-elicited lethality of gastric cells, with increased risks of the recurrence and serious cardiovascular side effects. However, the detailed mechanisms underlying the reduction of DOX sensitivity remain unclear. In this study, we generated a DOX-resistant variant upon continuously treating human gastric cancer MKN45 cells with incremental concentrations of the drug, and investigated whether the gain of DOX resistance influences gene expression of four aldo-keto reductases (AKRs: 1B10, 1C1, 1C2 and 1C3). RT-PCR analysis revealed that among the enzymes AKR1B10 is most highly up-regulated during the chemoresistance induction. The up-regulation of AKR1B10 was confirmed by analyses of Western blotting and enzyme activity. The DOX sensitivity of MKN45 cells was reduced and elevated by overexpression and inhibition of AKR1B10, respectively. Compared to the parental MKN45 cells, the DOX-resistant cells had higher migrating and invasive abilities, which were significantly suppressed by addition of AKR1B10 inhibitors. Zymographic and real-time PCR analyses also revealed significant increases in secretion and expression of matrix metalloproteinase (MMP) 2 associated with DOX resistance. Moreover, the overexpression of AKR1B10 in the parental cells remarkably facilitated malignant progression (elevation of migrating and invasive potentials) and MMP2 secretion, which were lowered by the AKR1B10 inhibitors. These results suggest that AKR1B10 is a DOX-resistance gene in the gastric cancer cells, and is responsible for elevating the migrating and invasive potentials of the cells through induction of MMP2.

Pseudomonas aeruginosa causing inflammatory mass of the nasopharynx in an immunocompromised HIV infected patient: A mimic of malignancy

Head and neck manifestations of acquired immunodeficiency syndrome are among the most common complications of this disease. The sinonasal and oral manifestations are more common that the otologic and range from malignancies to infectious processes caused by both opportunistic and nonopportunistic organisms. We report the case of a nasopharyngeal mass of infectious etiology in a severely immunocompromised HIV infected patient. The patient was admitted with a presumptive diagnosis of infectious gastroenteritis and was found to have a nasopharyngeal mass. The mass was extending into the oropharynx and paravertebral soft tissues and was associated with extensive secretions causing near complete occlusion of the oropharynx. CT scan findings favored malignant verses infectious etiology. The surgical biopsy performed twice ruled out malignancy and the bacterial culture proved to be a pure growth of Pseudomonas aeruginosa. Pseudomonas can inhabit the nasopharynx and lower digestive tract, and is only occasionally associated with causing disease in non-susceptible patients but is a common infection in immunocompromised patients. To the best of our knowledge, and after considering the current literature, we believe this case is unique. We discuss this rare entity and its management. Clinicians should be aware of this potential life threatening condition in the HIV population and add P. aeruginosa infection to the differential diagnosis of an acute inflammatory nasopharyngeal mass.

Immune profiling and cancer post transplantation

Half of all long-term (> 10 year) australian kidney transplant recipients (KTR) will develop squamous cell carcinoma (SCC) or solid organ cancer (SOC), making cancer the leading cause of death with a functioning graft. At least 30% of KTR with a history of SCC or SOC will develop a subsequent SCC or SOC lesion. Pharmacological immunosuppression is a major contributor of the increased risk of cancer for KTR, with the cancer lesions themselves further adding to systemic immunosuppression and could explain, in part, these phenomena. Immune profiling includes; measuring immunosuppressive drug levels and pharmacokinetics, enumerating leucocytes and leucocyte subsets as well as testing leucocyte function in either an antigen specific or non-specific manner. Outputs can vary from assay to assay according to methods used. In this review we define the rationale behind post-transplant immune monitoring assays and focus on assays that associate and/or have the ability to predict cancer and rejection in the KTR. We find that immune monitoring can identify those KTR of developing multiple SCC lesions and provide evidence they may benefit from pharmacological immunosuppressive drug dose reductions. In these KTR risk of rejection needs to be assessed to determine if reduction of immunosuppression will not harm the graft.

HIV and cancer: a comparative retrospective study of Brazilian and U.S. clinical cohorts

BACKGROUND

With successful antiretroviral therapy, non-communicable diseases, including malignancies, are increasingly contributing to morbidity and mortality among HIV-infected persons. The epidemiology of AIDS-defining cancers (ADCs) and non-AIDS-defining cancers (NADCs) in HIV-infected populations in Brazil has not been well described. It is not known if cancer trends in HIV-infected populations in Brazil are similar to those of other countries where antiretroviral therapy is also widely available.

METHODS

We performed a retrospective analysis of clinical cohorts at Instituto Nacional de Infectologia Evandro Chagas (INI) in Rio de Janeiro and Vanderbilt Comprehensive Care Clinic (VCCC) in Nashville from 1998 to 2010. We used Poisson regression and standardized incidence ratios (SIRs) to examine incidence trends. Clinical and demographic predictors of ADCs and NADCs were examined using Cox proportional hazards models.

RESULTS

This study included 2,925 patients at INI and 3,927 patients at VCCC. There were 57 ADCs at INI (65% Kaposi sarcoma), 47 at VCCC (40% Kaposi sarcoma), 45 NADCs at INI, and 82 at VCCC. From 1998 to 2004, incidence of ADCs remained statistically unchanged at both sites. From 2005 to 2010, ADC incidence decreased in both cohorts (INI incidence rate ratio per year = 0.74, p < 0.01; VCCC = 0.75, p < 0.01). Overall Kaposi sarcoma incidence was greater at INI than VCCC (3.0 vs. 1.2 cases per 1,000 person-years, p < 0.01). Incidence of NADCs remained constant throughout the study period (overall INI incidence 3.6 per 1,000 person-years and VCCC incidence 5.3 per 1,000 person-years). Compared to general populations, overall risk of NADCs was increased at both sites (INI SIR = 1.4 [95% CI 1.1-1.9] and VCCC SIR = 1.3 [1.0-1.7]). After non-melanoma skin cancers, the most frequent NADCs were anal cancer at INI (n = 7) and lung cancer at VCCC (n = 11). In multivariate models, risk of ADC was associated with male sex and immunosuppression. Risk of NADC was associated with increased age.

CONCLUSIONS

In both cohorts, ADCs have decreased over time, though incidence of KS was higher at INI than VCCC. Rates of NADCs remained constant over time at both sites.

Portal vein thrombosis

Portal vein thrombosis (PVT) is a rare event in the general medical setting that commonly complicates cirrhosis with portal hypertension, and can also occur with liver tumors. The diagnosis is often incidental when a thrombus is found in the portal vein on imaging tests. However, PVT may also present with clinical symptoms and can progress to life-threatening complications of ischemic hepatitis, liver failure, and/or small intestinal infarction. This article reviews the pathophysiology of this disorder, with a major focus on PVT in patients with cirrhosis, and presents detailed guidelines on optimal diagnostic and therapeutic strategies.

Diagnosis of Peritoneal Metastases with Abdominal Malignancies: Role of ADC Measurement on Diffusion Weighted MRI

OBJECTIVE

The purpose of our study was to evaluate the utility of the apparent diffusion coefficient (ADC) value measurement in the diagnosis of peritoneal metastases on diffusion weighted magnetic resonance imaging.

MATERIALS AND METHODS

Diffusion weighted imaging with conventional magnetic resonance imaging sequences was performed on twenty consecutive oncology patients (group I) with peritoneal metastases. The ADC values of the metastases, the peritoneal fat around the metastases (group I) and the peritoneal fat in patients with no malignancy (group II) at b(0-100), b(0-600), and (b 0-1000) s/mm(2) gradients were measured and compared.

RESULTS

The apparent diffusion coefficient values of three gradients in peritoneal metastases (2.27±0.4; 1.67±0.7 and 1.09±0.4×10(-3) mm(2)/s at b 100, 600 and 1000 gradients, respectively) were significantly lower than the ADC values of the peritoneal fat around metastases (3.07±0.4; 2.07±0.4; 1.33±0.3×10(-3) mm(2)/s at b 100, 600 and 1000 gradients, respectively) (p<0.05). There was no significant difference between the ADC values of peritoneal fat in the patients of group I and group II at the 3 diffusion gradients (p>0.05).

CONCLUSION

The measurement of ADC values may be used as a complementary diagnostic method in differentiating peritoneal metastases from peritoneal fat on Diffusion Weighted MRI (DWMRI DWMRI).

The association of deep vein thrombosis with cancer treatment modality: chemotherapy or surgery?

Background:

Deep vein thrombosis (DVT) is a well-recognized complication in patients with cancer. Chemotherapy and cancer surgery increase the risk of DVT in these patients. There are a few reports about the prevalence of DVT in patients with cancer regarding different managing modalities.

Objectives:

This study aimed to assess the prevalence of DVT in patients with cancer, who were hospitalized in teaching hospitals, according to their treatment intervention.

Patients and Methods:

A cross-sectional retrospective study was conducted on 602 patients with cancer in Kerman, Iran, during years 2006-2007. Among the subjects, 301 had been operated and the rest had received chemotherapy. The prevalence of DVT was determined based on patients’ variables, cancer factors, and therapeutic modalities.

Results:

Totally, 349 subjects (58%) were male. DVT incidence was 19.9%, most of the cases were over 40 years of age (82.2%), and 21.2% of males and 18.2% of females had developed DVT. The prevalence of DVT in chemotherapy group was higher than that in surgery group (21.9% and 17.9%, respectively); however, this difference was statistically insignificant. DVT developed more frequently in lung cancer (42%) with small cell carcinoma being the most common pathologic finding (42.9%) in those with lung cancer (P = 0.0001).

Conclusions:

DVT occurs frequently in patients with malignancies. In this study, there was no association between DVT prevalence and age as well as sex; nonetheless, the prevalence was significantly higher in some sites and in patients with certain pathologies. Although DVT prevalence was higher in chemotherapy than in surgery, the difference was insignificant. Informing patients with cancer about symptoms of DVT and prophylactic interventions are warranted.

Qualitative elastography can replace thyroid nodule fine-needle aspiration in patients with soft thyroid nodules. A systematic review and meta-analysis

CONTEXT

Only a minority of thyroid nodules is malignant; nevertheless, many invasive diagnostic procedures are performed to distinguish between benign and malignant nodules. Qualitative ultrasound elastography is a non-invasive technique to evaluate thyroid nodules.

OBJECTIVE

To investigate the diagnostic value of qualitative elastography in distinguishing benign from malignant thyroid nodules in patients referred for fine-needle aspiration (FNA).

DATA SOURCES

A systematic literature search (PubMed, Embase and Cochrane Library) was performed.

STUDY SELECTION

Included studies reported thyroid nodule elastography color scores and the related cytologic or histologic findings in patients with a thyroid nodule referred for FNA.

DATA EXTRACTION

Two independent reviewers extracted study data and assessed study quality. Pooled sensitivities and specificities of different populations were calculated using a bivariate Bayesian framework.

DATA SYNTHESIS

Twenty studies including thyroid nodules were analyzed. Pooled results of elastography indicate a summary sensitivity of 85% (95% confidence interval [CI], 79-90%) and specificity of 80% (95% CI, 73-86%). The respective pooled negative predictive and positive predictive values were 97% (95% CI, 94-98%) and 40% (95% CI, 34-48%). The pretest probability of a benign nodule was 82%. Only 3.7% of the false-negative nodules was a follicular thyroid carcinoma. A pooled negative predictive value of 99% (95% CI, 97-100%) was found when only complete soft nodules (Asteria elastography 1) were classified as benign, which included 14% of the studied population.

CONCLUSIONS

Elastography has a fair specificity and sensitivity for diagnostic accuracy. Its major strength entails the detection of benignity, especially when only completely soft nodules are qualified as benign. The outcomes of our analysis show that FNA could safely be omitted in patients referred for analysis of their thyroid nodule when elastography shows it to be completely soft (Asteria elastography 1). This could prevent unnecessary invasive diagnostic procedures in a substantial portion of patients.

Rare case of intussusception in an adult with acute myeloid leukemia

Intussusception is rarely reported in adult patients with acute leukemia. We report a case of intussusception in a 29-year-old woman with acute myeloid leukemia (AML). She developed right lower quadrant pain, fever, and vomiting on day 16 of induction chemotherapy. Physical examination showed tenderness and guarding at the right lower quadrant of the abdomen. Abdominal computed tomography (CT) showed distension of the cecum and ascending colon, which were filled with loops of small bowel, and herniation of the ileocecal valve into the cecum. We proceeded to laparotomy and revealed ileocecal intussusception with the ileocecal valve as the leading point. The terminal ileum was thickened and invaginated into the cecum, which showed gangrenous changes. Right hemicolectomy was performed and microscopic examination of the colonic tissue showed infiltration of leukemic cells. The patient recovered after the operation and was subsequently able to continue treatment for AML. This case demonstrates that the diagnosis of intussusception is difficult because the presenting symptoms can be non-specific, but abdominal CT can be informative for preoperative diagnosis. Resection of the involved bowel is recommended when malignancy is suspected or confirmed. Intussusception should be considered in any leukemia patients presenting with acute abdomen. A high index of clinical suspicion is important for early diagnosis.

Life-threatening complications and outcomes in patients with malignancies and severe pulmonary embolism

BACKGROUND

Data are scarce about ICU patients with malignancy and severe pulmonary embolism. Here, our main objective was to identify risk factors for life-threatening complications, organ failures, and death in ICU patients with severe pulmonary embolism, with special attention to the impact of malignancy. We also described the clinical features of PE in patients with and without malignancies.

METHODS

Data from consecutive adults admitted to our ICU in 2002-2011 with severe pulmonary embolism were collected retrospectively. Multivariate analysis was performed to look for factors associated with death, organ failures, or life-threatening complications (major bleeding, recurrent PE, and cardiac arrest).

RESULTS

Of 119 included patients (42 [35%] with bilateral pulmonary embolism), 41 had solid malignancies, 27 hematological malignancies, and 51 no malignancies. The most common symptoms were syncope (40%) and hemoptysis (18%) in patients with solid and hematological malignancies, respectively. Life-threatening complications occurred in 23 (19%) patients; risk factors were obesity (OR, 13.22; 1.93-90.70), disseminated intravascular coagulation/ischemic hepatitis (OR, 27.06; 5.14-142.46), fluid load ≥1000 mL/24 h (OR, 6.42; 1.60-25.76), and solid malignancy (OR, 5.45; 1.15-25.89). Inhospital mortality was 27/119 (23%) and respiratory or circulatory failure developed in 36 (30%) patients. Risk factors for these adverse outcomes were older age (OR, 1.04/year; 1.01-1.07), higher oxygen flow rate (OR, 1.28/L; 1.13-1.45); and renal failure (OR, 8.08; 2.50-26.11); whereas chest pain was protective (OR, 0.13; 0.04-0.48).

CONCLUSION

In this study, solid malignancy was a risk factor for life-threatening complications but not for death.

Association between height and malignancy among children in the north of Iran

BACKGROUND

This study aim to determine the association between height and cancer in the children aged 14 years at the time of diagnosis in Rasht, Iran.

MATERIALS AND METHODS

In this cross-sectional study, height of patients with a malignancy (≤14) at the time of diagnosis measured in the standard charts of United States National Center for the Health Statistics (NCHS). Data were reported by descriptive statistics and analyzed by Regression tests in SPSS version 19.

RESULTS

Overall, 78 male (38.6%) and 124 female (61.4%) patients with various kinds of malignancies were evaluated for their heights. Leukemia was the most common type of cancer. The median height of the patients was more than 20(th) percentile and under 50(th) percentile of the NCHS. No significant association was found between height and leukemia.

CONCLUSION

Previously, the median height of Iranian girls and boys (≤15) reported under 20(th) percentile of the NCHS. In this study, the median height of the patients at the time of diagnosis was more than 20(th) percentile of the NCHS. There was a correlation between height and cancer among our patients, although, this correlation can be assessed by further cohort study.

Clinical Characteristics of Bowel Obstruction in Southern Iran; Results of a Single Center Experience

OBJECTIVE

To determine the epidemiological, clinical, laboratory characteristics as well as outcome of 411 patients with bowel obstruction in Southern Iran.

METHODS

This was a cross-sectional study being performed in Shahid Faghihi hospital of Shiraz between 2006 and 2012. We reviewed the medical charts of the 411 patients with initial diagnosis of bowel obstruction who were admitted to our center during the study period. The patients' demographic, clinical and laboratory findings as well as their management and outcome was recorded in data gathering forms. The data were then analyzed according to the outcome and clinical characteristics.

RESULTS

Among the 411 patients with initial diagnosis of bowel obstruction, 253 (61.5%) were men and 158 (38.5%) were women. The mean age of the patients was 48.2±19.7 years. Besides, 73.6% were observed and 26.4% were operated. Those who were operated had those who underwent operation had significantly lower frequency of obstipation (28.1% vs. 71.9%; p=0.045) and abdominal distention (32.3% vs. 67.7%; p=0.007). Intraoperative findings included adhesion band formation in 50 (48.1%), mass 18 (17.3%), and hernia 7 (6.7%). We found that the frequency of malignancy was significantly higher in those who were managed conservatively compared to those undergoing operation (64.3% vs. 35.7%; p=0.042). The mean hospital stay was significantly higher in those who underwent operation (8.1±7.5 vs. 2.6±2.2 days; p=0.035).

CONCLUSION

The results of this study demonstrates although some signs and symptoms, such as abdominal pain, vomiting, abdominal tenderness, abdominal distention, and obstipation, were more common among the patients with bowel obstruction, they were not sensitive and specific enough for definite diagnosis. Due to the lack of positive predictive value of clinical signs and symptoms in diagnosis of bowel obstruction, a reasonable and logical modality is needed for bowel obstruction diagnosis with better accuracy.

Interventions to increase influenza vaccination rates in children with high-risk conditions--a systematic review

BACKGROUND

Influenza is a common cause of morbidity and mortality, especially among the elderly and those with certain chronic diseases. Annual influenza vaccination is recommended for individuals in at-risk groups, but rates of vaccination are particularly low in children with high-risk conditions (HRCs).

OBJECTIVE

To conduct a systematic review of studies that have examined interventions aimed at improving influenza vaccination in children with HRCs.

METHODS

Two databases - PubMed and SCOPUS - were searched (with no time or language restrictions) using a combination of keywords - Influenza AND vaccination OR immunization OR children AND asthma OR malignancy OR high-risk AND reminder. Duplicates were removed, and abstracts of relevant articles were screened using specific inclusion/exclusion criteria. Thirteen articles were selected, and five additional studies were identified following a review of the reference lists of the initial thirteen articles, bringing the total number to eighteen.

RESULTS

Most studies were conducted in the United States. Among the 18 studies, there was one systematic review of a specific intervention in asthmatic children, seven randomized controlled trials (RCTs), six before-and-after studies, one non-randomized controlled trial, one retrospective cohort study, one quasi-experimental post-test study, and one letter to editors. Interventions reported include multi-component strategies, letter reminders, telephone recall, letters plus telephone calls, an asthma education tool and year-round scheduling for influenza vaccination, amongst others.

CONCLUSION

There is good evidence that reminder letters will improve influenza vaccination uptake in children with HRCs, but the evidence that telephone recall or a combination of letter reminder and telephone recall will improve uptake is weak. It is not known if multiple reminder letters are more effective than single letters or if multi-component strategies are more effective than single or dual component strategies. There is a need for further research of these interventions, possibly outside the United States.