Emphysematous Pancreatitis as a Life-Threatening Condition: A Case Report and Review of the Literature

Emphysematous pancreatitis represents the presence of gas within or around the pancreas on the ground of necrotizing pancreatitis due to superinfection with gas-forming bacteria. This entity is diagnosed on clinical grounds and on the basis of radiologic findings. Computed tomography is the preferred imaging modality used to detect this life-threating condition. The management of emphysematous pancreatitis consists of conservative measures, image-guided percutaneous catheter drainage or endoscopic therapy, and surgical intervention, which is delayed as long as possible and undertaken only in patients who continue to deteriorate despite conservative management. Due to its high mortality rate, early and prompt recognition and treatment of emphysematous pancreatitis are crucial and require individualized treatment with the involvement of a multidisciplinary team. Here, we present a case of emphysematous pancreatitis as an unusual occurrence and discuss disease features and treatment options in order to facilitate diagnostics and therapy.

A Rare Case of Isolated Hepatocellular Carcinoma Metastasis in Left Mandibular Region in a Patient with Hepatitis C Virus Liver Cirrhosis Diagnosed after the Onset of COVID-19 Infection

Background and Objectives: Hepatocellular carcinoma (HCC) most frequently metastasizes in the lungs, abdominal lymph nodes and adrenal glands. Metastatic spread to the head and neck area is extremely rare. In the presented case, an uncommon site of solitary metastatic spread of HCC to the mandible confirmed after the core biopsy of the lesion is reported. There have been only about 80 cases of mandibular HCC metastases described in the literature to date. We contribute our experience to the pool of data. Case presentation: A 65-year-old female with HCV-related liver cirrhosis was diagnosed with an HCC that was successfully treated with liver resection. Subsequently, the patient had developed COVID-19 disease, which was associated with a painless swelling in the left jaw. A neck MDCT scan demonstrated an osteolytic soft-tissue mass in the left mandible, with the characteristics consistent for the metastasis of HCC. In order to confirm the diagnosis, a core biopsy of the mandibular mass was performed. The pathohistological evaluation confirmed the presence of a metastatic HCC in the mandible. No other sites of disease dissemination were identified in extensive MDCT scans. Despite considering various treatments, including symptomatic and palliative, the patient's overall prognosis remained poor. Conclusions: Isolated metastases of HCC to the orofacial region are extremely rare; however, it should be considered in patients with known risk factors for HCC development. Early diagnosis is critical, and clinicians should consider this possibility of HCC spread when assessing patients with orofacial swelling, among those patients with risk factors for HCC. The overall prognosis for such patients remains poor, emphasizing the challenges in managing these cases.

The role of acute rehabilitation in COVID-19 patients

BACKGROUND

In the published literature there is scarce data on the importance of acute rehabilitation in patients suffering from COVID-19 disease.

AIM

Evaluation of the feasibility of respiratory and neuromuscular rehabilitation treatment in stable acute COVID-19 inpatients.

DESIGN

The study was designed as an observational prospective investigation of two cohorts respectively identified as Mild/Moderate and Stable Severe COVID-19 disease. All patients received a rehabilitation treatment consisting of breathing exercises, range of motion exercises and strengthening exercises, with the main difference in intensity and progression of treatment, depending on individual capacity of patient.

SETTING

Inpatients with diagnosed mild to moderate, or stable severe COVID-19 infection were included in the study.

POPULATION

Acute COVID-19 inpatients.

METHODS

Patients were divided into two groups depending on the severity of disease: "mild to moderate group" (MMG) and "stable severe group" (SSG). Functional outcomes included the Barthel Index (BI), Six Minute Walk Test (6MWT), Borg Scale for dyspnea, "Time Up and Go" Test (TUG), "Sit To Stand" test (STS), "One Leg Stance Test" (OLST) and Beck Depression Inventory (BDI) were evaluated at baseline and after rehabilitative treatment, on discharge.

RESULTS

We included 147 acute COVID-19 inpatients (75 male and 72 female), mean aged 63.90±13.76 years. There were noticeable statistically significant improvements in all observed measurements in both groups. Comparison between groups showed significant difference in MMG compared to SSG in all functional outcomes: TUG (P<0.001), STS (P<0.001), OLST (P<0.001), BDI (P=0.008), BI (P<0.001), and Borg scale for dyspnea (P<0.001). Despite the significant improvements of BI in SSG, the obtained values showed that the patients were still not functionally independent.

CONCLUSIONS

Acute respiratory and neuromuscular rehabilitation program is a feasibile, but also effective and safe method for improving functional status in patients with COVID-19 infection.

CLINICAL REHABILITATION IMPACT

Results of the present study implicate that a supervised early rehabilitation program, implemented in the treatment of patients with COVID-19 disease in the acute phasis a feasible way for significant improvement of patient's functional outcomes. Early rehabilitation should be included into clinical protocols for the treatment of patients with COVID-19.

Effect of Percutaneous Biliary Drainage on Enzyme Activity of Serum Matrix Metalloproteinase-9 in Patients with Malignant Hilar Obstructive Hyperbilirubinemia

Background and Objectives. Cholestasis activates complex mechanisms of liver injury and as a result has an increased production of matrix metalloproteinases (MMP). Depending on the stage of liver disease, different matrix metalloproteinases expressions have been detected and could serve as indirect biomarkers as well as therapeutic targets. MMP-9 proteolytic activity has a proven role in both liver regeneration and neoplastic cell invasion in various malignancies. The purpose of this prospective cohort study was to evaluate the effect of external biliary drainage on enzyme activity of MMP-9 in the serum of patients with malignant hilar biliary obstruction. Materials and Methods. Between November 2020 and April 2021, 45 patients with malignant hilar biliary obstruction underwent percutaneous biliary drainage following determination of serum MMP-9 enzyme activity (before treatment and 4 weeks after the treatment) by gelatin zymography. Results. MMP-9 values decreased statistically significantly 4 weeks after percutaneous biliary drainage (p = 0.028) as well as the value of total bilirubin (p < 0.001), values of direct bilirubin (p < 0.001), aspartate aminotransferase (AST) (p < 0.001), alanine transaminase (ALT) (p < 0.001), and gamma-glutamyl transferase (GGT) (p < 0.001). Conclusions. In patients with malignant hilar biliary obstruction treated by external percutaneous biliary drainage for cholestasis resolution, a significant reduction in MMP-9 serum values was noted 4 weeks after the treatment.

3D Imaging Segmentation and 3D Rendering Process for a Precise Puncture Strategy During PCNL – a Pilot Study

Percutaneous nephrolithotomy (PCNL) is frequently used as the first-line treatment of large and complex stones. The key point for successful complex stone removal with minimal risk of complications is to establish the most appropriate access route. Understanding the three-dimensional (3D) relationship of kidney stones and renal collecting systems is crucial for planning and creating an optimal access route. By using a 3D volume segmentation tool a more accurate approach to the renal collecting system and stone treatment could be planned. The objective of this study was assessing the impact of 3D software in getting the desired access.

Low-grade chondrosarcoma of the larynx: A case report

BACKGROUND

Chondrosarcomas of the larynx are malignant tumours that most commonly originate from the hyaline cartilage. Chondrosarcoma of the larynx, the most common type of low-grade tumour, accounts for 1% of all laryngeal neoplasms.

CASE SUMMARY

We present the case of a 60-year-old female patient who developed progressive hoarseness and shortness of breath over a 2-mo period. The patient had undergone resection of a laryngeal tumour 14 years before the aforementioned symptoms occurred, and histopathological analysis indicated that it was a chondroma. During the assessment of the patient, a submucosal, oval-shaped tumour was detected that was predominantly located on the left side of the larynx and was approximately 6 cm in size. The decision to perform left partial vertical laryngectomy was made. A pathohistological diagnosis of low-grade chondrosarcoma was made. Considering the results of pathohistological analysis and the positive margins of the resection, a total laryngectomy was performed. During the 12-mo follow-up, no local relapse or regional or distant metastases was detected.

CONCLUSION

Chondrosarcoma of the larynx must be considered in the differential diagnosis of laryngeal submucosal tumours. It is crucial to carefully sample of tumour tissue, differentiate chondroma and chondrosarcoma, and consider the possibility of malignant changes from chondroma to chondrosarcoma.

Accesory and ectopic liver lobe at same patient: Case report

Accessory liver lobes (ALL) are defined as supranumerary liver lobes, composed of normal liver parenchyma in continuity with the liver, in contrast to ectopic liver lobes (ELL) that have no anatomical continuity with the normal liver. Case report: In this article we report on a rare radiological diagnosis of an synchronous accessory and ectopic liver lobe using ultrasonography (US) and computed tomography (CT). A 59-year-old female with no symptoms was admitted to our hospital due to preventive exam. Abdominal ultrasonography revealed a high echoic 6 cm x 5 cm soft tissue area in right anterior subhepatic space with distinct margins, a uniform echo and blood flow and was suspected to be abdominal tumor. An enhanced abdominal computed tomography (CT) showed the irregular 65 mm x 48 mm x 32 mm mass in the right hypochondrium below IV and V liver segment with clear margins, a uniform density, texture and contrast enhancement as normal liver tissue. In same patient CT also showed small 16 mm x 12 mm mass in posterior mediastinum in right retrocrural space so diagnosis of accessory and ectopic liver lobe was confirmed. An accessory liver lobe is adjacent and attached to the liver by its own mesentery, while an ectopic liver lobe is one that is completely detached from the normal liver parenchyma. Conclusion: Ultrasound can show mass in the abdomen, which is most commonly in the subhepatic area, but very rarely can initially diagnose ALL or ELL due to different echogenicity of the liver parenchyma in different acoustic windows. In the case of an atypical CT presentation, an MR examination of the abdomen is indicated but it is very rarely. Fast and accurate radiological diagnosis of ALL and ELL is important in the prevention of unnecessary invasive diagnostic procedures such as laparotomy and thoracotomy which are needed only in cases of complications.

Paraganglioma of the thyroid gland: a case report

INTRODUCTION

Thyroid paraganglioma is a very rare malignant neuroendocrine tumor. Immunohistochemical features of thyroid paraganglioma are helpful for the diagnosis.

CASE REPORT

A 69-year-old female came to hospital with the presence of a growing thyroid nodule of the left lobe. Ultrasonic neck examination showed 5 cm hypoechoic nodule in the left thyroid lobe. Thyroid scintigraphy showed a big cold nodule in the left lobe. Computed tomography (CT) scan showed left lobe thyroid tumor with tracheal deviation on the right site. Extended total thyroidectomy was done. Intraoperative consultation with the pathologist confirmed thyroid cancer. The pathologist diagnosed thyroid paraganglioma on the base of immuohistochemical investigation. This thyroid paraganglioma was positive for neuron-specific enolase, chomogranin A, synaptophysin, and S-100 protein highlighted the sustentacular cells. Tumor cells were negative for thyroglobulin, epithelial membrane antigen, cytokeratin, calcitonin, and carcinoembryonic. After the surgery the patient was treated with chemotherapy, peptide receptor radionuclide therapy, and permanent TSH suppressive therapy. The patient was followed with measurements of thyroid hormone and serum neuron-specific enolase, chromogranin A level, every 6 months. Gastroscopy, colonoscopy, chest and abdomen CT scan as well as further tests (chest xray, ultrasound of the neck, and whole body octreotide scintigraphy) were done. No primary neuroendocrine tumor in digestive sistem or in the chest was found. After more than 3 years the patient has no evidence of the recurrent disease.

CONCLUSION

Radical resection of thyroid paraganglioma, followed by chemotherapy and peptide receptor radionuclide therapy, should be considered the treatment of choice in patients with thyroid gland paraganglioma.

Claudin-1 as a promoter of EMT in hepatocellular carcinoma

Claudins are integral structural and functional components of apical cell adhesions (tight junctions). Loss of such adhesions has been associated with malignant transformation, a process most often accompanied by a concomitant loss of claudin expression. A growing body of evidence reveals the highly contextual upregulation of claudin expression in certain cancer types, and moreover their relevance in promoting cancer cell invasion and metastatic progression. In this issue of Oncogene, Suh et al. reported on claudin-1 expression in hepatocellular carcinoma (HCC), including its role as a promoter of the epithelial-to-mesenchymal transition via the c-Abl/Raf/Ras/ERK signaling pathway. Considering the limited therapeutic options in HCC, evaluation of its role as a target merits further investigation.

Invasive follicular thyroid carcinoma infiltrating trachea

INTRODUCTION

Although follicular thyroid carcinoma is a rare malignant tumor, up to 20% of the patients are threatened by potential complications resulting from infiltrating tumor growth into surrounding tissues.

CASE REPORT

A 66-year-old female came to hospital with the presence of a growing thyroid nodule of the left lobe. Ultrasonic examination showed a 8 cm hypoechoic nodule in the left lobe. Thyroid scintigraphy showed a cold nodule. CT scan and tracheoscopy showed tracheal infiltration without tracheal obstruction. An extended total thyroidectomy was done, with the left jugular vein, strap muscles and tracheal 2 cm long circular resection. The pathologist confirmed invasive follicular thyroid cancer. After the surgery the patient was treated with radioiodine therapy and permanent TSH suppressive therapy. The patient was followed with measurements of the thyroid hormone and serum thyroglobulin level every six months, as well as the further tests (chest xray, ultrasound of the neck and a whole body scintigraphy) were done. After more than three years the patient had no evidence of the recurrent disease.

CONCLUSION

Radical resection of the tracheal infiltrating thyroid cancer with circular tracheal resection and terminoterminal anastomosis followed by radioiodine therapy should be considered the treatment of choice.

[Abdominal compartment syndrome caused by ruptured abdominal aortic aneurysm in vena cava]

BACKGROUND

Abdominal compartment syndrome (ACS) is a rapid increase in intra-abdominal pressure asssociated with multi-organs dysfunction. It is caused mostly by abdominal bleeding und massive volume compensation.

CASE REPORT

We reported a 76-year-old patient admitted to the hospital with aortic abdominal aneurysm, 13.7 cm in diameter, ruptured in vena cava, which caused intraabdominal hypertension, the liver and kidney dysfunction, as well as circulation, respiration and metabolic disorders. Intraabdominal pressure was measured by bladder manometry. Central venous pressure and systemic arterial pressure were monitored continuously. Clinical signs were thrill and typical abdominal bruit. Aorto-caval fistula was diagnosed by the use of contrast computerized tomography. Caval endoaneurysmatic suture and aortobiiliac bypass with 18 x 9 mm Dacron prothesis were performed. Haemodynamic changes were mostly corrected during the surgery. The complete correction of haemodynamics, liver, kidney, respiration and metabolic changes was established in the next few weeks.

CONCLUSION

The ACS was caused by rupture of abdominal aortic aneurysm in vena cava followed by edema of the abdominal organs, retroperitoneum, abdominal wall and ascites. Caval endoaneurysmatic suture and aortobiiliac bypass with 18 x 9 mm Dacron prothesis solved aortocaval fistula as well as all the organs and metabolic dysfunctions caused by ACS.

[Parathyroid carcinoma]

BACKGROUND

Parathyroid carcinoma is the least frequent malignancy among endocrine tumors. In the most reported series of patients with primary hyperparathyroidism the incidence of carcinoma is less than 1%. Racognition by a surgeon that the parathyroid tumor is malignant, and the performance of an adequate en bloc removal of primary lesion, with histologic diagnosis offer the best treatment of a patient with this unusual malignancy.

CASE REPORT

We reported a 30-year-old patient with parathyroid carcinoma, primary hyperparathyroidism, and recurrent nephrocalcinosis. Marked hypercalcemia, low serum phosphorus, and substantial elevation of serum parathyroid hormone indicated a diagnosis of primary hiperparathyroidism. General symptoms were anorexia, muscle weakness, back pain and depression. Ultrasonography done before the surgery revealed a 2 cm upper left parathyroid gland with solid and cystic areas. The neck exploration was done with en block resection of the tumor. A histopathological evaluation confirmed the diagnosis of parathyroid carcinoma. Over more than a three-year-follow-up, the patient had no evidence of the disease recurrence and his serum PTH and calcium levels remained within the normal.

CONCLUSION

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. Preoperative diagnosis remains a challenge. Radical en bloc resection of the tumor is the treatment of choice for this malignancy.

Epidemiology of breast cancer in the city of Nis, Serbia

PURPOSE

Over the past 10 years, Serbia has been affected by a heavy economic and political crisis that in 1999 even led to war and bombardment. Numerous facts indicate that the crisis has resulted in low-level health protection, increasing mortality, as well as other deteriorating effects over the general health of the population. The aim of the study was to assess mortality trends in female breast cancer in the city of Nis prior to (1986-1993) and following (1995- 1999) the socio-economic crisis peak.

MATERIALS AND METHODS

Population and hospital cancer registry data for the 1986-1999 period were used for analysis, as well as death certificate data for all women who lived and died in the city of Nis in the given period. Survival was calculated according to the Kaplan-Meier method. The rates were calculated per 100,000 inhabitants (1991 census) and were not standardized.

RESULTS

A total of 455 women in the city of Nis died of breast cancer during 1986-1999. The polynomial trend in mortality revealed an increasing (1986-1992) and decreasing (1993-1996) tendency, although the first period showed a lower average mortality (28.7) than did the second one (30.45). Survival rates were calculated for the periods 1986- 1993 and 1995-1998. The 12-month survival rate was 84.7% in the first and 92% in the second period; the 24-month survival rate for the first period was 76.6% and 87.9% for the second; the 36-month survival was 67.7% in the first and 80.5% in the second period; the 4-year survival rate for 1986-1993 was 64.1% and 78.1% for 1995-1999.

CONCLUSION

The socio-economic and political crisis has proved to affect breast cancer patients in Serbia. Overall, the mortality rate increased. Calculated upon division of the whole period into two, mortality shows an upward trend in the first period (1986-1992) and a downward trend in the second. Although 1993-1999 was more difficult for the Serbian and Yugoslavian population (manifested in the therapy of all diseases, including breast cancer), the diagnosis of breast cancer improved and the disease was detected at earlier stages, the result of which were better survival rates in the 1986-1992 period.

Sensitivity, specificity, positive and negative predictive value of serum S-100 beta protein in patients with malignant melanoma

PURPOSE

To establish the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of serum S-100 beta protein (sSB) in patients with malignant melanoma (MM), based on its concentration in the peripheral blood and the likelihood ratio (LR) for the whole group of patients with MM, as well as for each separate clinical stage.

PATIENTS AND METHODS

sSB was determined immunoluminometrically in 172 patients with histologically confirmed MM. Sera from 64 healthy subjects were used as controls.

RESULTS

Increased values of sSB were detected in 65 out of 172 patients with MM, and in 5 cases among healthy subjects. Sensitivity, specificity, PPV and NPV were 38%, 92%, 93% and 35%, respectively. In stage I 1/29 patients had increased values of sSB, in stage II 3/34, in stage III 13/47 and in stage IV 48/62 patients. Sensitivity, specificity, PPV and NPV for stage I were 3%, 92%, 17% and 68%, respectively/ for stage II 9%, 92%, 37% and 65%, respectively; for stage III 28%, 92%, 72% and 63%, respectively; and for stage IV 77%, 92%, 91%, and 81%, respectively. The LR for sSB values of >13 mug/l was 5 for the whole group of patients with MM, 0.4 for stage I, 1 for stage II, 3 for stage III and 10 for stage IV.

CONCLUSION

Based on our results we conclude that sSB is a reliable serum marker for the diagnosis of stage IV MM.

[Characteristics of thyroid carcinoma in Grave's disease Hashimoto's thyroiditis and nodular goiter]

The biology of thyroid cancer represents a spectrum of behavior ranging from well-differentiated lesions with an excellent prognosis to anaplastic carcinoma, which is almost fatal. For this reason, it is important that clinicians have methods at their disposal to asses the characteristics of patient's thyroid malignancy. In this work we discuss the behavior of differentiated thyroid cancer in associated diseases of thyroid as: Graves' disease, chronic lymphocytic thyroiditis--Hashimoto and nodular goiter. This is retrospectively reviewing of 50 patients treated for differentiated thyroid carcinoma at Department of surgery, Clinical Centre of Montenegro in Podgorica from 1998 until 2003. We evaluated occurrence, as well as the role of this diseases in patients with thyroid cancer. We found a more favorable course of thyroid cancer in the presence of chronic lymphocytic thyroiditis and nodular goiter, a contrary Graves' disease. In associated diseases of thyroid, a significantly greater proportion of patients with thyroid cancer, have modular goiter.

Symptomatic physiologic hydronephrosis in pregnancy: incidence, complications and treatment

OBJECTIVE

We present the incidence and results of treatment of symptomatic physiologic hydronephrosis in 3,400 pregnant women.

METHODS

We analyzed 103 consecutive women who presented with clinical signs and symptoms related to the upper urinary system. Renal sonography, urinalysis, serum creatinine levels, white blood cell (WBC) count, and urine culture were done in all patients at first visit and repeated at least once a month until 1 month after delivery. In patients who manifested acute pyelonephritis, urinalysis, WBC count, erythrocyte sedimentation rate and C-reactive protein levels were repeated every 3 days until normalization, and urine culture as well as renal sonography were performed once a week until 1 month after delivery. Conservative measures (positioning, analgesia, antibiotics) were performed in all patients with symptomatic physiologic hydronephrosis. If the patient's condition was refractory to medical management, drainage of the ureter with a double pigtail stent was performed.

RESULTS

Conservative measures were successful in 97 (94%) of 103 patients but 6 (6%) patients had ongoing signs and symptoms of acute pyelonephritis progressing to urosepsis. In all of them, antibiotics were continued and a double pigtail stent was placed resulting in fast regression of symptoms, curing of renal infection and progress of the pregnancies to the term with vaginal delivery.

CONCLUSIONS

Symptomatic hydronephrosis in pregnancy can be treated conservatively. If the patient's condition is refractory to medical management, an internal drainage with double pigtail stent may be necessary.