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Radiology Case Reports Aug 2024Ovarian dysgerminoma is a rare germ cell tumor accounting for 1%-2% of all malignant ovarian tumors and is generally associated with a good prognosis. The condition is...
Ovarian dysgerminoma is a rare germ cell tumor accounting for 1%-2% of all malignant ovarian tumors and is generally associated with a good prognosis. The condition is more frequent in young women and can arise in dysgenetic gonads that contain gonadoblastomas. Imaging findings, particularly MRI, have a prominent role in the early and correct identification of ovarian dysgerminoma, the most common ovarian malignant germ cell tumor. On CT and MR images, ovarian dysgerminoma often appears as a large, solid mass. The edematous condition of characteristic fibrovascular septa can be well displayed by imaging, which can guide the radiologists to make an accurate diagnosis. This article describes 2 cases of patients with ovarian dysgerminoma who presented with pelvic pain. Imaging showed a right ovarian mass that was surgically and histologically confirmed.
PubMed: 38872745
DOI: 10.1016/j.radcr.2024.04.074 -
Journal of Minimally Invasive Gynecology Jun 2024Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to...
STUDY OBJECTIVE
Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed.
DESIGN
The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM).
SETTING
Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling.
INTERVENTIONS
The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up.
CONCLUSION
Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.
PubMed: 38866099
DOI: 10.1016/j.jmig.2024.06.003 -
International Journal of Surgery Case... Jul 2024The most common cancer among females worldwide and in Saudi Arabia is breast cancer. Lobular breast carcinoma is the second most common subtype of breast cancer. There...
INTRODUCTION AND IMPORTANCE
The most common cancer among females worldwide and in Saudi Arabia is breast cancer. Lobular breast carcinoma is the second most common subtype of breast cancer. There are different patterns of metastasis as ductal breast cancer spreads to the liver, lung, brain, and bone while the lobular subtype metastasizes to the gastrointestinal tract.
CASE PRESENTATION
A 69-year-old Indian pilgrim presented to the ER complaining of abdominal pain, vomiting, and abdominal distention admitted as a case of intestinal obstruction. CT scan demonstrated intestinal obstruction with transition zone at the terminal ileum. The patient underwent exploratory laparotomy where she was found to have a mass at the terminal ileum. Resection of around 8 cm of small bowel and primary anastomosis were done, histopathology revealed metastatic lobular breast carcinoma.
CLINICAL DISCUSSION
Patients with metastatic breast cancer to the gastrointestinal tract often present with nonspecific symptoms, while acute cases present with complications such as perforation. In a retrospective review of metastatic breast cancer, the majority metastasizes to the colon and rectum, while 19 % to the small bowel. Palliative surgery is considered the first-line treatment of complicated patients, while stable cases are referred to medical oncology.
CONCLUSION
Breast cancer is the second most common cancer leading to death and lobular subtype has more propensity to metastasize to the gastrointestinal tract compared to ductal breast cancer. Regarding patients presenting to the emergency bay, treating the emergency complaints is the standard management. For immigrant patients, we highly recommend creating a data system for sending histopathology reports to facilitate follow-up in their countries.
CASE PRESENTATION
A 69-year-old Indian pilgrim patient presented to the ER complaining of abdominal pain for 3 days associated with nausea and vomiting, not passing stool nor flatus was admitted as a case of intestinal obstruction. On examination patient was in pain with tachycardia, abdominal distended with generalized tenderness. Labs revealed metabolic alkalosis with hypokalemia. Abdomen X-ray showed signs of intestinal obstruction with multiple air-fluid levels and dilated small bowel loops. CT scan abdomen and pelvis with IV contrast reported (Figs. 1,2) distended ileum around 5 cm proximal to the transition zone at the terminal ileum with mild free fluid in the abdomen and pelvis. The patient underwent exploratory laparotomy where she was found to have a mass at the terminal ileum with the proximal loop dilated and distal loops collapsed, and further exploration showed enlarged mesenteric lymph nodes. Small bowel resection of around 8 cm and side to side anastomosis was done to relive the intestinal obstruction. Gross pathology showed a solid lesion protruding into the lumen measuring 1.5*1.5*1.5 cm, while the microscopic description consists of small cells with round ovoid nuclei which lack cohesion and appear individually dispersed through a fibrous connective tissue and arranged in single file linear cords that invade the stroma (Fig. 4) concluded as metastatic lobular carcinoma of the breast. Immunohistochemistry reported CK7 + ve, ER + ve, EMA + ve and CKAE1/AE3 + ve. The patient had an uneventful recovery, then she was discharged against medical advice and traveled to her country after two days before the histopathology result and she lost follow-up with us.
PubMed: 38865947
DOI: 10.1016/j.ijscr.2024.109855 -
Journal of Surgical Case Reports Jun 2024Colorectal cancer typically metastasizes to the peritoneum, liver, and lungs. However, metastases to the fallopian tube and uterus are uncommon. This case report delves...
Colorectal cancer typically metastasizes to the peritoneum, liver, and lungs. However, metastases to the fallopian tube and uterus are uncommon. This case report delves into this rare occurrence of metastasis and discusses its characteristics, diagnostic methods, and treatments based on an extensive literature review. We present the case of a 61-year-old female patient who underwent her initial hospitalization for da Vinci robotic surgery to address colorectal cancer, stage pT3N0M0. However, during routine postoperative follow-up 6 months later, a localized rectal recurrence was detected. The patient commenced chemoradiotherapy with full response. Subsequently, the patient was readmitted due to pelvic pain again, and a magnetic resonance imaging scan revealed an abnormal mass in the patient's left fallopian tube and uterine corpus, infiltrating the myometrium. Consequently, total hysterectomy with bilateral adnexectomy was performed, along with omentectomy, which confirmed metastatic involvement from rectal cancer upon postoperative pathological examination. This case may inform further diagnosis and treatment of colorectal cancer metastasis to the fallopian tube.
PubMed: 38859968
DOI: 10.1093/jscr/rjae400 -
Chinese Clinical Oncology Jun 2024Neutrophilia is an increase in the number of neutrophils over 7.5×103 /μL. An increase in leukocytes over 50×103 /μL is called a leukemoid reaction; and when it is...
BACKGROUND
Neutrophilia is an increase in the number of neutrophils over 7.5×103 /μL. An increase in leukocytes over 50×103 /μL is called a leukemoid reaction; and when it is associated with a solid tumor, it is considered a paraneoplastic syndrome called paraneoplastic leukemoid reaction (PLR). It is a very rare clinical condition and it is very unusual for it to be associated with carcinosarcoma. We present two cases of a leukemoid reaction observed in the Medical Oncology Department of the University Hospital of Salamanca between May and September 2023. The main objectives of our article are to describe the unusual appearance of paraneoplastic leukocytosis at the diagnosis of carcinosarcoma carcinosarcoma, explain in a detailed way its diagnostic procedure and to show the poor prognosis to which it is associated.
CASE DESCRIPTION
In our presentation, we describe two similar cases: first of all, a 60-year-old woman without relevant medical history. She was referred by her primary physician to the Department of Internal Medicine in August 2023 with asthenia, lumbar pain, and weight loss of 12 kg of 3 months of evolution. The physical examination revealed a palpable hypogastric mass. An abdominal, pelvic, and thoracic computed tomography (CT) scan revealed a heterogenous solid mass with necrotic areas originating in the uterus. The anatomopathological diagnosis was carcinosarcoma. The patient showed a progressive worsening in her renal function associated with hyperviscosity secondary to hyperleukocytosis caused by 170×103 /μL neutrophils. In the second case we describe the diagnosis of a PLR secondary to a kidney carcinosarcoma. When the patient started chemotherapy, he presented 55.08×103 /μL leukocytes, 53.16×103 /μL neutrophils. Eight days after receiving chemotherapy, the patient was admitted as an emergency with oligoanuria and decreased consciousness. He presented creatinine 6.25 mg/dL, phosphate 12.4 mg/dL, leukocytes 1.05×103 /μL, and neutrophils 0.71×103 /μL. The clinical diagnosis was acute exacerbation of multifactorial mixed (renal and prerenal) chronic kidney disease associated with tumor lysis syndrome and grade 3 neutropenia. The patient presented a poor evolution, dying after 2 months.
CONCLUSIONS
PLR is a severe paraneoplastic syndrome associated with different types of solid tumors. Its appearance at the time of diagnosis of a tumor implies a poor vital prognosis.
PubMed: 38859609
DOI: 10.21037/cco-23-146 -
World Neurosurgery Jun 2024The purpose of this study was to explore the impact of central obesity on spinal sagittal balance in adults aged 18 and older by examining correlations between waist...
OBJECTIVE
The purpose of this study was to explore the impact of central obesity on spinal sagittal balance in adults aged 18 and older by examining correlations between waist circumference (WC) and abdominal circumference (AC) and spinopelvic alignment parameters.
METHODS
This prospective cohort study included 350 adults aged 18 and older. Participants underwent whole-body biplanar radiography using the EOS imaging system. Spinal and pelvic parameters were measured and correlated with body mass index, WC, and AC. Statistical analyses included one-way analysis of variance, Wilcoxon rank-sum tests for data with nonhomogeneous variances, and chi-squared tests for categorical data. Intra-rater and inter-rater reliability were assessed using intraclass correlation coefficients, with subsequent analyses to explore correlations between body measurements and spinal parameters.
RESULTS
The study found significant correlations between increased WC and AC and changes in spinopelvic parameters. However, obesity did not uniformly influence all sagittal alignment parameters. Significant variations in spinal measurements indicate that central obesity plays a role in altering spinal stability and alignment.
CONCLUSIONS
The findings highlight the impact of central obesity on spinal alignment and emphasize the importance of considering central obesity in clinical assessments of spinal pathologies. Further research is essential to better understand the relationship between obesity, spinal sagittal balance, and related health conditions.
PubMed: 38857870
DOI: 10.1016/j.wneu.2024.06.005 -
PloS One 2024Neuromuscular electrical stimulation (NMES) can improve physical function in different populations. NMES-related outcomes may be influenced by muscle length (i.e., joint...
Effect of muscle length on maximum evoked torque, discomfort, contraction fatigue, and strength adaptations during electrical stimulation in adult populations: A systematic review.
Neuromuscular electrical stimulation (NMES) can improve physical function in different populations. NMES-related outcomes may be influenced by muscle length (i.e., joint angle), a modulator of the force generation capacity of muscle fibers. Nevertheless, to date, there is no comprehensive synthesis of the available scientific evidence regarding the optimal joint angle for maximizing the effectiveness of NMES. We performed a systematic review to investigate the effect of muscle length on NMES-induced torque, discomfort, contraction fatigue, and strength training adaptations in healthy and clinical adult populations (PROSPERO: CRD42022332965). We conducted searches across seven electronic databases: PUBMED, Web of Science, EMBASE, PEDro, BIREME, SCIELO, and Cochrane, over the period from June 2022 to October 2023, without restricting the publication year. We included cross-sectional and longitudinal studies that used NMES as an intervention or assessment tool for comparing muscle lengths in adult populations. We excluded studies on vocalization, respiratory, or pelvic floor muscles. Data extraction was performed via a standardized form to gather information on participants, interventions, and outcomes. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for cross-over trials and the Physiotherapy Evidence Database scale. Out of the 1185 articles retrieved through our search strategy, we included 36 studies in our analysis, that included 448 healthy young participants (age: 19-40 years) in order to investigate maximum evoked torque (n = 268), contraction fatigability (n = 87), discomfort (n = 82), and muscle strengthening (n = 22), as well as six participants with spinal cord injuries, and 15 healthy older participants. Meta-analyses were possible for comparing maximal evoked torque according to quadriceps muscle length through knee joint angle. At optimal muscle length 50° - 70° of knee flexion, where 0° is full extension), there was greater evoked torque during nerve stimulation compared to very short (0 - 30°) (p<0.001, CI 95%: -2.03, -1.15 for muscle belly stimulation, and -3.54, -1.16 for femoral nerve stimulation), short (31° - 49°) (p = 0.007, CI 95%: -1.58, -0.25), and long (71° - 90°) (p<0.001, CI 95%: 0.29, 1.02) muscle lengths. At long muscle lengths, NMES evoked greater torque than very short (p<0.001, CI 95%: -2.50, -0.67) and short (p = 0.04, CI 95%: -2.22, -0.06) lengths. The shortest quadriceps length generated the highest perceived discomfort for a given current amplitude. The amount of contraction fatigability was greater when muscle length allowed greater torque generation in the pre-fatigue condition. Strength gains were greater for a protocol at the optimal muscle length than for short muscle length. The quality of evidence was very high for most comparisons for evoked torque. However, further studies are necessary to achieve certainty for the other outcomes. Optimal muscle length should be considered the primary choice during NMES interventions, as it promotes higher levels of force production and may facilitate the preservation/gain in muscle force and mass, with reduced discomfort. However, a longer than optimal muscle length may also be used, due to possible muscle lengthening at high evoked tension. Thorough understanding of these physiological principles is imperative for the appropriate prescription of NMES for healthy and clinical populations.
Topics: Humans; Torque; Adult; Muscle Fatigue; Muscle, Skeletal; Muscle Contraction; Electric Stimulation; Muscle Strength; Adaptation, Physiological; Electric Stimulation Therapy
PubMed: 38857245
DOI: 10.1371/journal.pone.0304205 -
Cureus May 2024Idiopathic intracranial hypertension (IIH) or benign intracranial hypertension affects the neuro-ophthalmological system and leads to elevated intracranial pressure....
Idiopathic intracranial hypertension (IIH) or benign intracranial hypertension affects the neuro-ophthalmological system and leads to elevated intracranial pressure. Elevated opening pressure during lumbar puncture is diagnostic of IIH. Here in, we present an interesting case of a 15-year-old girl, recently immigrated and with a high BMI, presenting with recurrent fever, abdominal issues, weight loss, and other symptoms, leading to a diagnosis of pelvic inflammatory disease (PID) and HIV infection. After treatment with antibiotics (doxycycline) and antiretroviral therapy, she developed IIH, manifesting as sudden-onset headache and vision problems. MRI and lumbar puncture confirmed the diagnosis. She responded well to acetazolamide and was discharged with continued medication and follow-up appointments. This case underscores the complexity of IIH development, especially in the setting of acute HIV infection and antibiotic treatment, highlighting the need for a comprehensive diagnostic approach and multidisciplinary management.
PubMed: 38854218
DOI: 10.7759/cureus.60001 -
Translational Oncology Aug 2024Neoadjuvant chemotherapy (NACT) is routinely used to treat patients with advanced gastric cancer (AGC). However, the identification of reliable markers to determine...
BACKGROUND
Neoadjuvant chemotherapy (NACT) is routinely used to treat patients with advanced gastric cancer (AGC). However, the identification of reliable markers to determine which AGC patients would benefit from NACT remains challenging.
METHODS
A systematic screening of plasma proteins between NACT-sensitive and NACT-resistant AGC patients was performed by a mass spectrometer (n = 6). The effect of the most differential plasma protein was validated in two independent cohorts with AGC patients undergoing NACT (ELISA cohort: n = 155; Validated cohort: n = 203). The expression of this candidate was examined in a cohort of AGC tissues using immunohistochemistry (n = 34). The mechanism of this candidate on 5-Fluorouracil (5-FU) resistance was explored by cell-biology experiments in vitro and vivo.
RESULTS
A series of differential plasma proteins between NACT-sensitive and NACT-resistant AGC patients was identified. Among them, plasma HIST1H2BK was validated as a significant biomarker for predicting NACT response and prognosis. Moreover, HIST1H2BK was over-expression in NACT-resistant tissues compared to NACT-sensitive tissues in AGC. Mechanistically, HIST1H2BK inhibited 5-FU-induced apoptosis by upregulating A2M transcription and then activating LRP/PI3K/Akt pathway, thereby promoting 5-FU resistance in GC cells. Intriguingly, HIST1H2BK-overexpressing 5-FU-resistant GC cells propagated resistance to 5-FU-sensitive GC cells through the secretion of HIST1H2BK.
CONCLUSION
This study highlights significant differences in plasma protein profiles between NACT-resistant and NACT-sensitive AGC patients. Plasma HIST1H2BK emerged as an effective biomarker for achieving more accurate NACT in AGC. The mechanism of intracellular and secreted HIST1H2BK on 5-FU resistance provided a novel insight into chemoresistance in AGC.
PubMed: 38852277
DOI: 10.1016/j.tranon.2024.102017 -
International Journal of Surgery Case... Jul 2024Urethral Prolapse (UP), first described by Solinger in 1732, is a rare condition characterized by the circular protrusion of the distal urethral mucosa through the...
BACKGROUND AND IMPORTANCE
Urethral Prolapse (UP), first described by Solinger in 1732, is a rare condition characterized by the circular protrusion of the distal urethral mucosa through the external meatus, forming a hemorrhagic, sensitive vulvar mass. This condition is most commonly observed in prepubertal black females. This case report details the clinical manifestations and surgical management of UP in three young girls.
CASES PRESENTATION
Three girls, aged 4, 5, and 6 years, were admitted with symptoms of vaginal blood spotting. Physical examinations revealed moderate bleeding and a red ring of congested, edematous tissue prolapsing through the urethral meatus. Diagnostic procedures confirmed UP, and surgical management was undertaken. The surgical approach involved the complete excision of the prolapsed tissue and mucosal-to-mucosal anastomosis under general anaesthesia. Postoperative follow-up over a mean period of 11 years showed no recurrence or urethral stricture.
CLINICAL DISCUSSION
UP is a rare benign condition primarily affecting the female urethra, with several hypothesized etiologies, including weak pelvic floor structures and increased intraabdominal pressure. The typical presentation includes vaginal bleeding and a doughnut-shaped mass around the urethral meatus. Conservative management may be considered for mild cases, but surgical excision is recommended for severe cases, offering a safe and effective solution with low recurrence rates.
CONCLUSIONS
UP in children, although rare, should be considered in cases of unexplained vaginal bleeding. Diagnosis is primarily clinical, and surgical resection provides a definitive and cost-effective treatment.
PubMed: 38851072
DOI: 10.1016/j.ijscr.2024.109879