Acral lentiginous melanoma with multiple bone metastasis: case report.

Acral lentiginous melanoma (ALM) is a type of melanoma that is traditionally seen on the soles of the feet, palms of the hand, and under the fingernails or toenails. It is the least frequently diagnosed melanoma among the four histologic subtypes of cutaneous melanoma, accounting for less than 5% of all cases. ALM is frequently diagnosed at late stages and has higher incidences in non-white populations in relation to the other forms of cutaneous malignant melanoma. The most common sites of metastases in melanoma are the skin and subcutaneous tissue followed by lung, liver, brain, and bone. Bone metastases from malignant melanoma usually occur in patients who already have widespread metastases. We present this paper as a unique case study of ALM lesion in an 84-year-old African American male presenting originally in the base of right fifth toe plantar aspect then found multiple bone metastases without any other organ involved.

HTLV-1-Associated Lymphoma Presented as Massive Lymphadenopathy.

Adult T-cell leukemia/lymphoma is an aggressive T-cell malignancy caused by the long-term infection of human T-cell lymphotropic virus type 1 (HTLV-1). Our understanding of clinical features still largely relies on the Shimoyama classification developed 30 years ago, which described the 4 clinical subtypes (the smoldering, chronic, lymphoma, and acute types) based on the manifestations of lymphocytosis, elevated lactate dehydrogenase, hypercalcemia, lymphadenopathy, and involvement of the skin, lung, liver, spleen, central nervous system, bone, ascites, pleural effusion, and gastrointestinal tract. HTLV-1-associated lymphoma has a variety of presentations but the presentation of massive lymphadenopathy and compression symptoms is rare and has not been emphasized in the literature. In this article, we describe 2 cases of adult T-cell leukemia/lymphomas that presented with massive cervical nodes or mediastinal nodes with compressing symptoms as the major presenting clinical features. Clinicians should remain aware of this type of presentation by HTLV-1-associated lymphoma, especially in patients who came from endemic areas, even if not all clinical features are present and particularly with hypercalcemia and lytic bone lesions.

Gamma-delta (γδ) T-cell lymphoma - another case unclassifiable by World Health Organization classification: a case report.

BACKGROUND: We present a case of gamma-delta T-cell lymphoma that does not fit the current World Health Organization classifications. CASE PRESENTATION: A 74-year-old Caribbean-American woman presented with lymphocytosis, pruritus, and non-drenching night sweats. Bone marrow and peripheral blood analyses both confirmed the diagnosis of gamma-delta T-cell lymphoma. An axillary lymph node biopsy was negative for lymphoma. Clinically absent hepatosplenomegaly and skin lesions with biopsy-proven gamma-delta T-cell lymphoma suggest that she is unclassifiable within the current classification system. CONCLUSIONS: We believe this is a case of not otherwise specified gamma-delta T-cell lymphoma. Accumulation of these rare not otherwise specified cases will be important for future classification which further defines the biology of this disease.

A Case Report of Primary Nasal Natural Killer (NK)/T-Cell Lymphoma in an African American Patient Presenting with Hemophagocytic Syndrome.

BACKGROUND Extranodal natural killer/T-cell lymphoma, nasal type (ENKTCL) is generally an aggressive and rare non-Hodgkin lymphoma. It is most common in East Asians, Native Americans, and South Americans, but is rarely reported in blacks. CASE REPORT A 55-year-old African American male born in Grenada presented with a left nostril mass with facial swelling and biopsy subsequently confirmed a diagnosis of extranodal NK/T-cell lymphoma, nasal type (ENKTCL). Immunochemistry was positive for CD2, cytoplasmic CD3, CD7, CD 43, CD 56, granzyme B, and TIA-1. In situ hybridization was positive for Epstein-Barr virus encoded ribonucleic acid (EBERs). Bone marrow aspiration did not show lymphoma involvement. The patient had progressive neutropenia upon presentation, with further investigations showing hepatomegaly, hyperferritinemia, and hemophagocytosis in the bone marrow. We reached a diagnosis of hemophagocytic syndrome. He was treated with a high-dose combination chemotherapy and radiation therapy; the neutropenia improved significantly with steroids as treatment for immune activation in the setting of hemophagocytic syndrome. CONCLUSIONS To the best of our knowledge, this is the only second report of extranodal NK/T-cell lymphoma, nasal type in a black patient, and it raises the awareness of early recognition of rare manifestations of NK/T-cell lymphoma such as hemophagocytic syndrome.

Hepatitis B Reactivation After Ifosfamide Therapy for Retroperitoneal Sarcoma.

BACKGROUND: Patients receiving cancer treatment are at risk for hepatitis B virus (HBV) reactivation. Ifosfamide is an alkylating agent and is considered to be one of the important drugs for the treatment of metastatic sarcoma. No association of ifosfamide and HBV reactivation has been reported so far. CASE REPORT: We report a case of a 61-year-old Asian man with metastatic retroperitoneal liposarcoma who was HBcAb positive and was treated with ifosfamide and dacarbazine, developed HBV reactivation secondary to ifosfamide requiring treatment with tenofovir. To the best of our knowledge, this is the first report describing HBV reactivation in a patient with positive HBcAb who was treated with ifosfamide. CONCLUSIONS: We recommend close surveillance of possible HBV reactivation while employing ifosfamide chemotherapy.

Nuclear protein in testis midline carcinoma of larynx: An underdiagnosed entity.

BACKGROUND: Nuclear protein in testis (NUT) carcinomas are very rare and have a very poor survival rate. The most common sites of involvement include the nasal cavity, sinus, and mediastinum. Laryngeal NUT midline carcinoma is extremely rare, with only 2 cases reported thus far. Here, we are describing another case of NUT laryngeal carcinoma. METHODS AND RESULTS: The patient was a light smoker and nondrinker who presented with upper respiratory tract obstruction. Imaging and laryngoscopic evaluation revealed a large intraluminal laryngeal mass. Biopsy demonstrated poorly differentiated carcinoma with intact mucosa and only focal coexpression of CK5/6 and p40. NUT protein immune-stain positivity conclusively established the diagnosis of NUT midline carcinoma. CONCLUSION: Absence of well-known risk factors, pathologic finding of lack of mucosal involvement and lack of squamous differentiation with poorly differentiated carcinoma, should prompt clinicians to consider this rare entity as a possible diagnosis. © 2016 Wiley Periodicals, Inc. Head Neck 38:E2471-E2474, 2016.

Effect of smoking on age at the time of coronary artery bypass graft surgery; baseline data results from the ROSETTA-CABG registry.

BACKGROUND: Coronary artery disease (CAD) is a leading cause of death. The aetiology of this disease is not known, but many important risk factors have been recognised. OBJECTIVE: To evaluate the effect of smoking on age at the time of coronary artery bypass graft surgery (CABG), and to examine this finding in the light of medical literature. METHODS: The authors recruited patients immediately after CABG in a prospective, study in 16 centres and enrolled 408 patients, of which 395 were ultimately analysed. RESULTS: Among the 395 patients analysed, there were 60 smokers and 335 non-smokers. The smokers were 8.4 years younger than non-smokers at the time of index CABG. The average age of smokers was 55.79.0 years, and that of non-smokers was 64.1±9.9 years (p<0.001). Hyperlipidaemia was present in 76.7% of smokers and 74.6% of non-smokers (p-NS). Hypertension was present in 58.3% of smokers and 63.9% of non-smokers (p-NS). Diabetes mellitus was present in 21.3% of smokers and 29.3% of non smokers (p-NS). Left ventricular ejection fraction was 53.0±10.5% in smokers and 53.3 ±13.8% in non-smokers (p-NS). Myocardial infarction had occurred in 41.7% of smokers and 35.5% of non-smokers (p-NS). CONCLUSION: Smoking accelerates atherosclerosis and coronary thrombosis resulting in severe form of CAD that cannot be managed by medications or PCI, and requires coronary artery bypass graft surgery (CABG) 8.4 years earlier than non-smokers.

Alveolar soft-part sarcoma of the tongue in a 17-month-old.

Alveolar soft-part sarcoma (ASPS) is a rare and often fatal tumor. Overall survival rates have been reported to be 62% after 5 years, 42% after 10 years, and 18% after 20 years. ASPS accounts for 5% of all pediatric soft-tissue sarcomas other than rhabdomyosarcomas. In children, ASPS rarely occurs in the oral cavity, and to the best of our knowledge, only 12 cases of ASPS of the tongue occurring during the first decade of life have been previously reported in the literature. Because of the rarity of lingual ASPS in children, no specific treatment protocols have been developed, which makes its management difficult. We report a new case of lingual ASPS in a young child. Our patient was a 17-month-old girl whose tumor was located at the base of the tongue. She was successfully treated with surgical excision without adjuvant radiation or chemotherapy. Postoperatively, she has remained disease-free during 4 years of follow-up.

Impact of functional testing results on prescription patterns of anti-anginal medication after coronary artery bypass graft surgery: results from the ROSETTA-CABG Registry.

BACKGROUND: Although coronary artery bypass graft surgery (CABG) is known to reduce angina, previous studies have suggested that anti-anginal medication use is not significantly reduced after CABG. However, it is unclear how functional testing results have an impact on anti-anginal medication prescription patterns. OBJECTIVES: To determine whether post-CABG functional testing results impact prescription patterns of anti-anginal medication during the 12 months after CABG. METHODS: The Routine versus Selective Exercise Treadmill Testing after Coronary Artery Bypass Graft Surgery (ROSETTA-CABG) Registry is a prospective, multicenter study. We examined anti-anginal medication use (beta blockers, calcium channel blockers and nitrates) at discharge and at 12 months post-CABG with respect to functional testing results among 392 patients. RESULTS: Among the 392 patients, 146 had at least one functional test over the 12-month follow up period. Among the 146 patients, 17% had positive functional tests, 69% had negative tests, and 14% had indeterminate tests. Both beta blocker and calcium channel blocker use did not increase from discharge to 12 months following a positive test (N = 25) (84% vs. 80%; p = NS; 16% vs. 16%; p = NS), while nitrate use increased seven-fold (4% vs. 28%; p = 0.03). However, following a negative test (N = 100), beta blocker use only decreased modestly (85% vs. 70%; p = 0.01), while both calcium channel blocker and nitrate use were unchanged (30% vs. 20%; p = NS; 4% vs. 6%; p = NS, respectively). Following an indeterminate test (N = 21), anti-anginal medication use was unchanged (p = NS for all 3 classes of medication). CONCLUSION: The use of anti-anginal medication is only modestly reduced after CABG, and functional testing results during the first year post-CABG do not have a strong impact on prescription patterns of anti-anginal agents.

Lack of benefit for routine functional testing early after coronary artery bypass graft surgery: results from the ROSETTA-CABG Registry.

BACKGROUND: There is little consensus regarding the use of functional testing after coronary artery bypass graft surgery (CABG). Some physicians opt for a routine functional testing strategy, while others employ a symptom-driven strategy. OBJECTIVE: To examine the effects of routine post-CABG functional testing on the use of follow-up cardiac procedures and clinical events. METHODS: The Routine versus Selective Exercise Treadmill Testing after Coronary Artery Bypass Graft Surgery (ROSETTA-CABG) Registry is a prospective, multicenter cohort study examining the use of functional testing after CABG among 408 patients. The frequencies of functional testing, cardiac procedures, and clinical events were examined during the first 12 months following a successful CABG. RESULTS: Patients were predominantly male (80%) with a mean age of 63 +/- 10 years. During the 12-month follow up, 111 patients were observed to undergo a routine functional testing strategy, while 284 patients underwent a selective strategy. Patients undergoing routine functional testing underwent fewer follow-up cardiac catheterizations, but similar numbers of revascularization procedures (cardiac catheterizations = 0.9% vs. 8.1%; p = 0.027; percutaneous coronary intervention [PCI] = 0.9% vs. 4.6%; p = NS; repeat CABG = 0.0% vs. 0.0%; p = NS, respectively). However, clinical events were less common among patients who underwent routine functional testing including unstable angina (0.0% vs. 6.4%; p = NS), myocardial infarction (MI) (0.0% vs. 2.1%; p = NS), and death (0.9% vs. 1.4%; p = NS). The majority of clinical and procedural events occurred in the selective group who had a positive functional test (clinical events = 33%; procedural events = 40%). In contrast, no events occurred in patients in the routine group with a positive or indeterminate test, while those with a negative test had more events (6.3%) and procedures (6.3%). CONCLUSIONS: Because routine functional testing 1 year after CABG is associated with extremely low event rates, this strategy does not appear to be warranted.

Use of stress testing early after coronary artery bypass graft surgery.

The American College of Cardiology/American Heart Association guidelines for exercise testing do not take a position regarding the utility of routine stress testing after coronary artery bypass grafting (CABG). Our purposes were (1) to document the patterns of use of stress testing after CABG and (2) to establish whether the choice of stress testing strategy is associated with clinical characteristics of patients. The Routine versus Selective Exercise Treadmill Testing after Coronary Artery Bypass Graft Surgery (ROSETTA-CABG) Registry is a prospective multicenter study that examined the use of stress testing after CABG among 395 patients at 16 clinical centers in 6 countries. During the 12 months after CABG, 37% of patients underwent stress testing (range across centers 0% to 100%). Among patients who underwent stress testing, 24% had a clinical indication and 76% had it as a routine follow-up. A total of 65% of stress tests involved exercise treadmill testing alone, 17% involved stress nuclear perfusion imaging, 13% involved stress echocardiographic imaging, and 5% involved other types of stress tests, such as positron emission tomographic scans. The first stress test was performed at a median of 13 weeks after CABG, with 20% of patients having second tests at a median of 28 weeks and 6% having additional tests at a median of 34 weeks. Univariate and multivariate analyses demonstrated that the chief determinant of using routine stress testing was the clinical center. In conclusion, these results suggest that there is little consensus on the appropriate use of stress testing soon after CABG. Practice patterns vary widely; poorly diagnostic tests are used routinely; and the clinical center at which the procedure is performed, rather than the clinical characteristics of the patient, determines the use of stress testing after CABG.