Epithelioid angiosarcoma of the pericardium: Case report of the challenges in the management of a rare malignancy with poor prognosis

ABSTRACT

A primary epithelioid angiosarcoma of the pericardium is a rare soft tissue malignancy. This report describes a young adult woman who presented with progressive dyspnea and pericardial effusion. She was found to have pericardial mass on imaging along with extensive myocardial infiltration. The biopsy of the mass revealed epithelioid angiosarcoma, which was CD34 and CD31-immuno-positive. Due to unresectable disease, she was given a trial of immunotherapy followed by conventional chemotherapy. She showed partial response on interim assessment, but progressed soon after the completion of six cycles and succumbed to her rapidly progressive illness within nine months of diagnosis. This report discusses the diagnostic and therapeutic challenges faced while managing this disease of aggressive tumor biology.

Empagliflozin May be a Game Changer in Managing Pulmonary Embolism: A Case Report

Pulmonary Embolism (PE) tolls heavy casualty on human lives because it is often misdiagnosed, and patients have limited access to quality care in resource constraint settings. It usually propagates from deep vein thrombosis of lower limbs. A Bangladeshi old lady suddenly developed symptoms on 19 March 2023. She had predisposing conditions like Type-2 Diabetes mellitus, hypertension and knee replacement surgery that made her bedridden for several years. Finding all the available parameters suggestive of PE, she received standard care but failed to have complete remission. When Empagliflozin was added to her treatment plan, she responded very well and got full recovery off her illness. This is the take away of the story.

To compare neoadjuvant concurrent chemo-radiotherapy followed by surgery and neoadjuvant chemotherapy followed by surgery in carcinoma esophagus patients: A single institutional study in the Indian population

Objective

This single institutional study compared neoadjuvant concurrent chemo-radiotherapy (NACCRT) and neoadjuvant chemotherapy (NACT) followed by surgery in locally advanced middle and lower-1/3 carcinoma esophagus patients in terms of toxicity, clinical response, operative complications, disease downstaging, resection rates, pathological response, recurrence, and survival.

Materials

and

Methods

This randomized prospective comparative study comprised 40 consecutive patients divided equally between two study arms NACCRT (n = 20; 41.4 Gy radiation dose; carboplatin area under the curve (AUC) 2/paclitaxel 50 mg/m2; 5 cycles) and NACT (n = 20; carboplatin AUC 5/paclitaxel 175 mg/m2; 2 cycles) from March 2014 to December 2016. Follow-up was done for 4 years. Chi-square test, Fischer's-exact test were used for comparative analysis and Kaplan-Meier analysis for survival.

Results

Statistically significant esophagitis in NACCRT and peripheral-neuropathy in NACT was observed (P < 0.001). NACCRT recorded more postoperative complications, higher complete resection (R0) rates, and pathologically complete response (pCR). Tumor downstaging was significant in both study groups (n < 0.001). Four-year median disease-free survival (DFS) and overall survival (OS) were 28.50 months and 38 months in NACCRT versus 28 months and 35.5 months in NACT, respectively. In both NACCRT and NACT, pCR cases showed improved median DFS and OS compared to pathological partial response (pPR) (n < 0.001).

Conclusion

This study demonstrated significant activity and tolerable toxicity of taxane-based therapy in NACCRT and NACT. Both groups recorded no survival benefit over each other, although pCR cases resulted in statistically significant survival advantage compared to clinical partial response. NACCRT resulted in lesser toxicity, numerically higher R0-resection, pCRs, median DFS, and OS compared to NACT.

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

Oral Re-hydration Solution is a Silver Lining to Preventing Shock in Covid-19: A Brief Report of Unusual Findings

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Therapeutic audit of patients on warfarin in an anticoagulation clinic of a tertiary care hospital

BACKGROUND

Studies have reported huge variations in the prescribing practice of warfarin. We carried out a clinical audit of warfarin use in an anticoagulation clinic of a tertiary care hospital.

METHODS

Patients receiving warfarin for at least 6 months were recruited and the following details were collected: demographics (age, body weight and gender); diagnoses; concomitant drugs. We calcula-ted CHA₂DS₂-VASc, HASBLED and SAMe-TT2R2 scores for each study participant. Statins, proton pump inhibitors, carbamazepine and amiodarone were the concomitant drugs identified with potential drug interaction with warfarin in patients.

RESULTS

Two hundred and three patients were recruited. Almost one-third of the study population had poor anticoagulation status. CHA₂DS₂-VASc and HASBLED scores were the significant predictors of appropriate anticoagulation. Poor anticoagulation status was observed more commonly in the first 6 months following which improvements were seen. Nearly half-of the time abnormal PT-INR was observed to be either between 2 to 2.4 (for patients with heart valve replacements) or 1.5 to 1.9 (for other indications). Significant number of patients without any potentially interacting drugs was observed with higher risk of supra-therapeutic PT-INR.

CONCLUSION

We observed a similar proportion of patients with adequate anticoagulation in our study participants as reported in other populations; and have identified categories at risk for poor anticoagulation. It is the need of the hour to develop in-house algorithm in compliance to international standards for dose titration of warfarin.

Synthesis, Characterization, and Physicochemical Studies Of Orientation-Controlled Multi-Arm PEG Zn(II)/Mg(II) (Aza)Phthalocyanines

Tuning the amphiphilicity of (aza)phthalocyanine hydrophobic cores by introducing multiple polyethylene glycol (PEG) moieties with controlled orientations of their (non)peripheral positions is an innovative approach to fabricating water-soluble macrocyclic materials. Although many water-soluble PEGylated macrocycles have been produced in this way, the ability to generate substances with PEG tails oriented outward from the macrocyclic plane in order to obtain non-aggregated, water soluble forms remains a challenge. In this study, we resolved this issue by developing a methods for the synthesis of four new dual directional PEG containing Zn(II)/Mg(II) amphiphiles (ZnPc-PEG, MgPc-PEG, ZnAzaPc-PEG and MgAzaPc-PEG). In addition, the non-aggregating behaviour, and photophysical and photochemical properties of these PEG-complexes were elucidated.

Carcinoma Penis Manifesting as Upfront Supraclavicular Lymph Node Metastases Detected by 18F-Fluorodeoxyglucose Positron Emission Tomography Scan: Report of an Extremely Rare and Aggressive Case

Carcinoma penis is a rare malignancy accounting 0.5 to 1% cases in the developed countries with a slightly higher incidence in the developing nations. Slow locoregional progression is characteristic of penile carcinoma and distant metastases are very uncommon. We hereby report a case of highly aggressive squamous cell penile carcinoma in a 46-year-old male with fulminant upfront distant dissemination to left supraclavicular lymph nodes without involving the inguinal and pelvic nodes detected by whole-body ¹⁸ F-fluorodeoxyglucose positron emission tomography scan. The scan also detected lytic destructive lesion involving the pelvic and adjacent bones with infiltration of skeletal muscles. He was treated with palliative radiotherapy to the weight-bearing sites followed by systemic chemotherapy. A thorough review of literature reveals that our case may be one of the rarest cases ever reported in world literature where an asymptomatic penile carcinoma presents with upfront supraclavicular lymph node metastasis bypassing the inguinal, pelvic, and retroperitoneal lymph node chains.

Intracardiac device associated interference with tricuspid valve apparatus on echocardiography: What can we learn from pathology?

Funding Acknowledgements

Type of funding sources: None.

Background

 New or worsening tricuspid regurgitation (TR) is associated with right-sided heart failure and worsened outcomes. Cardiac Implantable Electronic Devices (CIEDs), which are being implanted at growing rates worldwide, are increasingly being recognized as associated with TR occurrence related to interference with the tricuspid valve (TV) apparatus. Purpose: We sought to identify echocardiographic features in the right ventricle and TV that differentiate patients who have anatomically demonstrated interference with the TV on direct pathology inspection. 

Methods

 Explanted hearts from 44 consecutive patients undergoing orthotopic heart transplant (55 ±13 yrs, 68% men) with known implanted CIEDs were dissected to assess the presence (n = 18) or absence (n = 26) of CIED interference with the TV (Figure). Echocardiographic measurements performed prior to transplantation, including left and right ventricular (LV, RV) size and performance metrics as well as TR severity, were compared between both groups using non-parametric testing. 

Results

 Echocardiographic features of patients with and without anatomically demonstrated TV interference are shown in the Table. Although overall LV dimensions and volumes were not different between the two groups and LV ejection fraction was severely reduced in both groups, patients demonstrating CIED interference trended towards larger right atrial volumes (Table) and also larger RV and tricuspid annular sizes. Importantly, however, they were more than 4 times likely to have abnormal right ventricular function. Lastly, patients with tricuspid apparatus interference tended to have more significant TR, although these differences have not reached statistical significance (Table). 

Conclusion

 CIED interreference with tricuspid valve apparatus occurs frequently (41%) among patients with CIEDs, who undergo orthotopic heart transplantation. This may be associated with worsening TV function with subsequent changes in right atrial and ventricular geometry and function. In light of prior data showing poor outcomes with CIED associated TR, this study emphasizes the importance of non-invasive assessment of CIED interference with the tricuspid valve, in order to improve device placement and patient outcomes. Abstract Figure  Abstract Table

Beneficial Effect of Low Dose Aspirin in Adult Patients with COVID-19: A Retrospective Observational Study in Bangladesh

Presently Coronavirus disease 2019 is a huge human misery that is almost unstoppable with little remedy on board. The disease is predominantly associated with inflammation and thrombosis. Although aspirin exhibits excellent anti-thrombotic and anti-inflammatory properties, it is yet to be explored in treating Covid-19 patients. In this article we want to bring forth its beneficial effect in Covid-19 case management. It is a retrospective observational study. Adult Covid-19 patients either diagnosed with RT-PCR (reverse transcriptase polymerized chain reaction), or categorized as probable cases (as per World Health Organization case definition protocol) by medical doctors were enrolled as participants. Data were collected from doctors' office records for the period ranging from May 2020 to September 2020 in six districts of Bangladesh. Out of 44 participants 42 were eligible (2 children excluded) for the study. Among them 11 participants took low dose aspirin (75mg daily) during the disease process. All participants in aspirin group became cured without complication or death (RR 2.2, 95% CI 1.5-3.2, p<0.001). On the other hand, no aspirin group suffered complications and deaths. The study findings revealed that complications were significantly low among aspirin users. It documented that low dose aspirin is beneficial for Covid-19 patients. Further study is warranted with larger sample size.

Carcinoma penis manifesting as upfront supraclavicular lymph node metastases detected by 18F-fluorodeoxyglucose positron emission tomography scan: Report of an extremely rare and aggressive case

Carcinoma penis is a rare malignancy accounting 0.5%-1% of cases in the developed countries with a slightly higher incidence in the developing nations. Slow locoregional progression is characteristic of penile carcinoma (PC) and distant metastases are very uncommon. We hereby report a case of highly aggressive squamous cell PC in a 46-year-old male with fulminant upfront distant dissemination to left supraclavicular lymph nodes (LNs) without involving the inguinal and pelvic nodes detected by whole-body ¹⁸F-fluorodeoxyglucose positron-emission tomography scan. The scan also detected lytic destructive lesion involving the pelvic and adjacent bones with infiltration of skeletal muscles. He was treated with palliative radiotherapy to the wight-bearing sites followed by systemic chemotherapy. A thorough review of literature reveals that our case may be one of the rarest cases ever reported in world literature where an asymptomatic PC presents with upfront supraclavicular LN metastasis bypassing the inguinal, pelvic, and retroperitoneal LN chains.

Rapid implementation of triaging system for assessment of breast referrals from primary care centres during the COVID-19 pandemic

OBJECTIVE

The aim of this study was to establish a triaging system for assessment of breast referrals from primary care to ensure safe and effective breast services without compromising breast cancer management.

BACKGROUND

COVID-19 was officially declared a global pandemic on 11 March 2020, and with no effective treatment available, preventing spread has been paramount. Previously, all referrals from primary care were seen in the rapid-access breast clinic (RABC). Clinic appointments exposed patients and healthcare professionals to risk.

METHOD

Initial triage during the lockdown was in line with national governing body guidance, rejected low risk referrals and streamed remaining patients through a telephone consultation to RABC or discharge. A modified triage pathway streamed all patients through virtual triage to RABC, telephone clinic or discharge with advice and guidance categories. Demographics, reasons for referral and outcomes data were collected and presented as median with range and frequency with percentages.

RESULTS

Initial triage (23 March-23 April 2020) found fewer referrals with a higher percentage of breast cancer diagnoses. Modified triage (22 June-17 July 2020) resulted in a 35.1% (99/282) reduction in RABC attendance. Overall cancer detection rate remained similar at 4.2% of all referrals pre-COVID (18/429) and 4.3% (12/282) during modified triage. After six months follow-up of patients not seen in RABC during the modified triage pathway, 18 patients were re-referred to RABC and none were diagnosed with cancer.

CONCLUSION

A modified triage pathway has the potential to improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic. Further refinement of pathway is feasible in collaboration with primary care.

Synchronous Detection of Extra-Adrenal Paraganglioma in a Follow-Up Case of High-Grade Gastrointestinal Stromal Tumor

Extraadrenal paragalionoma at multiple sites and its association with GIST is a rare finding. Although ¹⁸F-FDG PET-CT is not a modality of choice for primary diagnosis of paraganglioma, and its use is restricted for detection of metastases/multiple sites and disease staging. However, in this case that we describe here, its role in an already-proven/recurrent case of paraganglioma is emphasized by its simultaneous assessment of disease at several different sites.

A 5-year retrospective review of skin adnexal tumours received at a tertiary dermatopathology service: Implications for linked genetic diagnoses

BACKGROUND

Skin adnexal tumours (SATs) comprise a diverse range of neoplasms, which are difficult to diagnose clinically. They present in paediatric and adult populations, and may be indicative of an underlying genetic syndrome. There is a lack of recent data on the presentation of these tumours in clinical practice in European populations.

OBJECTIVE

To characterise the clinical and pathological features of SATs received at a single tertiary centre over a 5-year period.

METHODS

A retrospective health record audit of SATs received at the Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, during the period November 2012 to October 2017.

RESULTS

107144 skin cases were received during the audit period. 1615 cases of SATs from 1359 patients were included; 1570 (97.2%) were benign and 45 (2.8%) were malignant. Overall, the average age at presentation was 55 years (range 11 months - 97 years) and the male to female ratio was 0.77:1. Sweat gland and hair follicle SATs were most frequently excised; in adults the most frequent tumour was hidrocystoma, and in children, pilomatrixoma. Pre-biopsy diagnosis was correct 28% of the time. Benign SATs are often markers of an associated genetic condition, warranting improved discrimination of sporadic from genetically related SATs.

CONCLUSIONS

 SATs are difficult to diagnose clinically, and clinicopathological correlation may help enhance selection of genetically related SATs from sporadic cases. These data have implications for clinical and dermatopathological training provision, the development of reporting standards, and genetic assessment of selected patients.

Tumor thrombi in multiple tributaries of the mesenteric vein in a case of carcinoma rectosigmoid: A rare entity

Treatment for tumor thrombus in multiple blood vessels can be a challenge for management and thus FDG PET CT is a potent tool in evaluation of such cases in differentiating between bland and tumor thrombus and commenting on the extent of the involvement.

Malignant peripheral nerve sheath tumor of thigh with sphenoid and brain metastases: Extremely rare occurrence with dismal prognosis despite significant response to palliative chemoradiotherapy

Malignant peripheral nerve sheath tumor (MPNST) is a neurogenic tumor arising from peripheral nerves or nerve sheaths. MPNSTs are highly aggressive sarcomas mainly associated with neurofibromatosis type-1 (NF-1) with high rates of local recurrence and distant metastasis carrying a dismal prognosis. Lung is the most common metastatic site. Bone metastasis although documented in the literature is still very rare, while dissemination to brain without the involvement of lungs and that too in a non-NF-1 case is extremely unusual. A 48-year-old female was diagnosed with a case of non-NF-1 MPNST left thigh with bone metastases including sphenoid. Despite showing complete resolution of skeletal and primary lesions postpalliative chemoradiotherapy, she developed brain metastases and succumbed to her disease. This case is discussed to highlight an unusual scenario we encountered, the clinical course of the disease with its management, and overall poor prognosis. To the best of our knowledge, this may be the earliest case of MPNST with sphenoid metastases detected by 18-fluorodeoxyglucose positron-emission computed tomography scan and a sporadic case of brain metastases reported in the world literature.

Inherited pulmonary cylindromas: extending the phenotype of CYLD mutation carriers

Background

Germline mutations in the tumour suppressor gene CYLD are recognized to be associated with the development of multiple cutaneous cylindromas. We encountered such a patient who presented with breathlessness because of multiple pulmonary cylindromas.

Objectives

To search for clinical and radiological features of multiple pulmonary cylindromas in a cohort of 16 patients with CYLD mutations.

Methods

A retrospective case‐note review was carried out in a tertiary dermatogenetics clinic where CYLD mutation carriers are reviewed on an annual basis. In‐depth investigation was carried out for patients with pulmonary tumours.

Results

Four patients had radiological imaging of their lungs, of which two had multiple pulmonary cylindromas that were confirmed histologically. Serial computed tomography monitoring allowed for pre‐emptive endobronchial laser ablation, preventing major airway obstruction and pulmonary collapse.

Conclusions

Pulmonary cylindromas are an unrecognized, but infrequently symptomatic, aspect of the phenotype in these patients that can have implications for patient care. They should be considered in patients with a high tumour burden that present with respiratory symptoms, and where appropriate, monitored with serial imaging.

What's already known about this topic?

Germline mutations in the tumour suppressor gene CYLD are recognized to be associated with the development of multiple cutaneous cylindromas, spiradenomas and trichoepitheliomas.

Beyond the skin, salivary gland tumours are seen in less than approximately 5% of patients, but otherwise the tropism of this disease is recognized as exclusively cutaneous.

What does this study add?

We report multiple pulmonary cylindromas in two patients out of a series of 16 patients, a previously unreported aspect of this genetic disease.

Deep phenotyping with radiological, histological and genetic approaches provides evidence that supports that these tumours are similar to cutaneous cylindromas and share a cytokeratin signature seen in cutaneous cylindroma.

What is the translational message?

Patients with this rare disease should be investigated if they present with new symptoms of respiratory disease.

These data inform the clinical surveillance and management of patients with this rare condition and also inform the longstanding debate on benign metastases.

https://doi.org/10.1111/bjd.17046 available online

https://goo.gl/Uqv3dl

Upfront Skeletal Muscle Metastases from Non-small Cell Lung Carcinoma: Report of an Extremely Rare Occurrence Detected by 18F-Fluorodeoxyglucose Positron Emission Computed Tomography Scan

Adenocarcinoma lung with upfront metastases to skeletal muscle is rarely encountered in clinical practice since skeletal muscles are highly resistant to dissemination from solid organs. Moreover, these muscle metastatic lesions generally present with pain and palpable mass to get detected clinically. However, silent skeletal muscle metastases without any symptoms or signs getting detected by functional imaging with whole body 18F-fluorodeoxyglucose positron emission/computed tomography (18FDG-PET/CT) scan have been scarcely described in literature, while we present such an interesting case in a 45-year-old female. She was diagnosed as a case of biopsy-proven metastatic adenocarcinoma lung after evaluation by 18FDG-PET/CT. Despite treatment with palliative chemoradiotherapy, her disease progressed, and she finally succumbed to her illness. This case is discussed to highlight an unusual scenario we encountered, the clinical course of the disease with its management and overall poor prognosis.

INTERNATIONAL STANDARDS ON FOOD AND ENVIRONMENTAL RADIOACTIVITY MEASUREMENT FOR RADIOLOGICAL PROTECTION: STATUS AND PERSPECTIVES

Radiological protection is a matter of concern for members of the public and thus national authorities are more likely to trust the quality of radioactivity data provided by accredited laboratories using common standards. Normative approach based on international standards aims to ensure the accuracy or validity of the test result through calibrations and measurements traceable to the International System of Units. This approach guarantees that radioactivity test results on the same types of samples are comparable over time and space as well as between different testing laboratories. Today, testing laboratories involved in radioactivity measurement have a set of more than 150 international standards to help them perform their work. Most of them are published by the International Standardization Organization (ISO) and the International Electrotechnical Commission (IEC). This paper reviews the most essential ISO standards that give guidance to testing laboratories at different stages from sampling planning to the transmission of the test report to their customers, summarizes recent activities and achievements and present the perspectives on new standards under development by the ISO Working Groups dealing with radioactivity measurement in connection with radiological protection.

Degradation/oxidation susceptibility of organic photovoltaic cells in aqueous solutions

A criterion of the degradation/oxidation susceptibility of organic photovoltaic (OPV) cells in aqueous solutions was proposed for the first time. The criterion was derived based on calculating the limit of the ratio value of the polarization resistance of an OPV cell in aqueous solution (Rp(s)) to the polarization resistance of the OPV cell in air (Rp(air)). In other words, the criterion lim(Rp(s)/Rp(air)) = 1 was applied to determine the degradation/oxidation of the OPV cell in the aqueous solution when Rp(air) became equal (increased) to Rp(s) as a function of time of the exposure of the OPV cell to the aqueous solution. This criterion was not only used to determine the degradation/oxidation of different OPV cells in a simulated operational environment but also it was used to determine the electrochemical behavior of OPV cells in deionized water and a polluted water with fine particles of sand. The values of Rp(s) were determined by the electrochemical impedance spectroscopy at low frequency. In addition, the criterion can be applied under diverse test conditions with a predetermined period of OPV operations.

Laser guided automated calibrating system for accurate bracket placement

BACKGROUND

The basic premise of preadjusted bracket system is accurate bracket positioning. It is widely recognized that accurate bracket placement is of critical importance in the efficient application of biomechanics and in realizing the full potential of a preadjusted edgewise appliance.

AIM

The purpose of this study was to design a calibrating system to accurately detect a point on a plane as well as to determine the accuracy of the Laser Guided Automated Calibrating (LGAC) System.

MATERIALS AND METHODS

To the lowest order of approximation a plane having two parallel lines is used to verify the accuracy of the system. On prescribing the distance of a point from the line, images of the plane are analyzed from controlled angles, calibrated and the point is identified with a laser marker.

RESULTS

The image was captured and analyzed using MATLAB ver. 7 software (The MathWorks Inc.). Each pixel in the image corresponded to a distance of 1cm/413 (10 mm/413) = 0.0242 mm (L/P). This implies any variations in distance above 0.024 mm can be measured and acted upon, and sets the highest possible accuracy for this system.

CONCLUSION

A new automated system is introduced having an accuracy of 0.024 mm for accurate bracket placement.