Comprehensive Diagnosis and Management of Malignant Bowel Obstruction: A Review.

Malignant bowel obstruction is a common complication of advanced gastrointestinal, gynecologic, and genitourinary tumors. Patients present with nausea, vomiting, abdominal pain, and constipation. Cross-sectional imaging is essential to make a diagnosis of bowel obstruction. Initial management is conservative with fluid replacement, electrolyte replacement, bowel rest and sometimes nasogastric decompression. Numerous advanced options exist for definitive management, though none are overly promising but nevertheless may improve quality and quantity of life. Surgical bypass, endoscopic stenting, and endoscopic decompression are some of the options with variable efficacy and are employed in select patients. Chemotherapy may be utilized if the bowel obstruction resolves to reduce tumor burden in a limited number of patients. Parenteral nutrition is an option and should typically be used in surgical patients with good functional and nutritional status with limited tumor burden or curative intent. Palliative care and hospice should be discussed in patients with advanced malignancy who present with peritoneal carcinomatosis or multiple levels of obstruction. Overall prognosis of malignant bowel obstruction is poor, and median survival ranges from 26 to 192 days.

Severe Thrombocytopenia Associated With Black Seed Oil and Evening Primrose Oil.

We report the case of a 69-year-old female with stage IIIB endometrial adenocarcinoma who developed an acute thrombocytopenia with greater than 90% decrease from her baseline value in platelets one day after a laparoscopic hysterectomy. Subsequently, the patient was found to have bilateral subsegmental pulmonary emboli and a right atrial thrombus. The thrombocytopenia reached a nadir of 31,000/mL3 from a baseline of 410,000/mL3 and resolved without intervention. Prior to the surgery, the patient was taking black seed oil, which is commonly used for its anti-carcinogenic effects, and evening primrose oil daily for approximately one month. A literature review revealed that black seed oil contains thymoquinone, which is a compound related to quinine. Evening primrose oil is also known to reduce platelet aggregation and has anti-thrombotic properties. We believe the patient's thrombocytopenia was caused by a consumptive coagulopathy due to the formation of multiple thrombi and exacerbated by the use of herbal supplements, namely black seed and evening primrose oil.

VERU-111 suppresses tumor growth and metastatic phenotypes of cervical cancer cells through the activation of p53 signaling pathway.

In this study, we investigated the therapeutic efficacy of VERU-111 in vitro and in vivo model systems of cervical cancer. VERU-111 treatment inhibited cell proliferation and, clonogenic potential, induce accumulation of p53 and down regulated the expression of HPV E6/E7 expression in cervical cancer cells. In addition, VERU-111 treatment also decreased the phosphorylation of Jak2(Tyr1007/1008) and STAT3 at Tyr705 and Ser727. VERU-111 treatment arrested cell cycle in the G2/M phase and modulated cell cycle regulatory proteins (cyclin B1, p21, p34cdc2 and pcdk1). Moreover, VERU-111 treatment induced apoptosis and modulated the expression of Bid, Bcl-xl, Survivin, Bax, Bcl2 and cleavage in PARP. In functional assays, VERU-111 markedly reduced the migratory and invasive potential of cervical cancer cells via modulations of MMPs. VERU-111 treatment also showed significant (P < 0.05) inhibition of orthotopic xenograft tumor growth in athymic nude mice. Taken together, our results demonstrate the potent anti-cancer efficacy of VERU-111 in experimental cervical cancer models.Thus, VERU-111 can be explored as a promising therapeutic agent for the treatment of cervical cancer.

Diagnosis and Management of Gastro-pleural Fistula in Metastatic Malignancy.

Gastro-pleural fistula is a rare condition, and the diagnosis can be challenging, as demonstrated in our case. The management is even more complex, with wide gamut of management strategies from more conservative management such as endoscopic closures and minimally invasive video-assisted thoracoscopic surgery (VATS) to open surgical repair. We present the case of a 55-year-old female with metastatic renal cell cancer with prior radiation therapy and cabozantinib treatment who was diagnosed with gastro-pleural fistula after extensive workup. She underwent endoscopic closure and subsequent jejunostomy tube feeding, venting gastrostomy tube, and draining chest tube. Antibiotics and chest tube drainage were primary modalities for treatment of her empyema. Subsequently, she required laparoscopic surgery for fistula repair.

Massive Pneumoperitoneum Presenting as an Incidental Finding.

Pneumoperitoneum is often associated with surgical complications or intra-abdominal sepsis. While commonly deemed a surgical emergency, pneumoperitoneum in a minority of cases does not involve a viscus perforation or require urgent surgical management; these cases of "spontaneous pneumoperitoneum" can stem from a variety of etiologies. We report a case of a 72-year-old African American male with a history of metastatic pancreatic adenocarcinoma who presented with new-onset abdominal distention and an incidentally discovered massive pneumoperitoneum with no clear source of perforation on surveillance imaging. His exam was non-peritonitic, so no surgical intervention was recommended. He was treated with bowel rest, intravenous antibiotics, and hydration. He had a relatively benign clinical course with preserved gastrointestinal function and had complete resolution of his pneumoperitoneum on imaging two months after discharge. This case highlights the importance of considering non-surgical causes of pneumoperitoneum, as well as conservative management, when approaching patients with otherwise benign abdominal exams.

Spontaneous Tumor Lysis Syndrome as Presenting Sign of Metastatic Prostate Cancer.

Spontaneous tumor lysis syndrome is an exceedingly rare manifestation of metastatic prostate cancer. It can masquerade as thrombotic thrombocytopenic purpura (TTP) or complement-mediated hemolytic uremic syndrome (HUS). These entities present with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure, and improve with the initiation of plasma exchange and steroids. In situations where the laboratory data does not wholly validate the presumed diagnosis and clinical and laboratory deterioration occurs in spite of appropriate treatment, it is necessary to expand the differential diagnosis and investigation. In this case, worsening renal function, cytopenias, lactate dehydrogenase, and uric acid in the setting of proper treatment for TTP and complement-mediated HUS prompted additional analysis. This workup revealed bone marrow infiltration by metastatic prostate cancer complicated by tumor lysis syndrome.

Hyperkalemia from Dietary Supplements.

Hyperkalemia is a common electrolyte problem in patients with chronic kidney disease. It is typically caused by medications in patients with poor kidney function. Patients with comorbodities such as heart failure and diabetes are predisposed to electrolyte problems. Salt substitutes and dietary supplements are uncommon causes of hyperkalemia, but we propose that they are under-recognized and underdiagnosed causes in patients with chronic kidney disease. Our case report and literature review illustrates that a careful dietary history is essential in patients presenting with electrolyte disorders, especially hyperkalemia.

From suspected Creutzfeldt-Jakob disease to confirmed histoplasma meningitis.

A 77-year-old man with chronic obstructive lung disease who was on steroids, presented to the hospital after a fall with subacute headaches and ataxia. During the patient's hospital course, his clinical condition deteriorated with myoclonic jerks, fevers and severe encephalopathy. An extensive workup, including EEG, brain MRI and lumbar puncture, revealed possible Creutzfeldt-Jakob disease. Unfortunately, the patient failed to improve and died 12 days after admission. A brain-only autopsy revealed he had acute histoplasma meningitis with patchy superficial cerebritis.

Bilateral cellulitis.

We present a case of bilateral lesions in a 50-year-old man, which were on first impression mistaken for and initially treated as bilateral cellulitis. We propose that bilateral cellulitis, as opposed to unilateral, is rare and that other aetiologies should be considered in evaluating a patient with bilateral lesions. The differential diagnosis includes stasis-dermatitis, lipodermatosclerosis, lymphoedema and vascular lesions such as Kaposi sarcoma, as was identified in this case. Early consultation with dermatology and biopsy in unclear cases mitigates the unnecessary use of prolonged antibiotics, antibiotic resistance and Clostridium difficile infections. HIV testing is an essential screening test in all adults who present with non-specific viral symptoms and rash.

Anesthesia for hemicolectomy in a known porphyric with cecal malignancy.

Intraoperative management of a known acute intermittent porphyria patient is a challenge requiring awareness of factors, which trigger an acute crisis, clinical features of a porphyric attack, knowledge of safe pharmacologic intervention, and preparedness for reintubation and ventilatory support. The classical signs of a porphyric crisis such as pain abdomen, vomiting and neuropsychiatric symptoms are masked under general anesthesia and can be confused with postoperative pain and vomiting and postoperative cognitive dysfunction, especially for intra-abdominal surgeries. Eternal vigilance for onset of an acute crisis is imperative. After a crisis of acute intermittent porphyria, residual paresis may persist for years in the absence of further attacks.

Target definition for malignant gliomas: no difference in radiation treatment volumes between 1.5T and 3T magnetic resonance imaging.

PURPOSE: Currently, most high-grade glioma patients undergo a 1.5T brain magnetic resonance (MR) for radiation treatment planning. We hypothesized that 3T MR imaging (MRI) scanning is superior to 1.5T due to higher signal-to-noise ratio (SNR), and thus will result in more accurate quantification of tumor volumes. The purpose of this prospective study was to determine differences in radiation planning volumes for high-grade gliomas when scanned on 3T MR versus 1.5T MR. METHODS AND MATERIALS: In this prospective controlled trial, 23 patients with high-grade gliomas underwent brain MRI scanning in both 1.5T and 3T field strengths within a 24-hour period; no steroids or treatment changes were made in-between scans. After 3 investigators contoured the T2 fast low-angle inversion recovery (FLAIR) abnormality (gross tumor volumes or [GTV]) for all patients, clinical target volume (CTV) and planning treatment volumes (PTV) were defined. Calculations by an independent investigator included volumes, standard deviations, SNRs, and contrast-to-noise ratios (CNRs); statistical analysis was performed on raw data. RESULTS: Planning treatment volume ratios (3T:1.5T) for each investigator were 0.95 ± 0.12 (range, 0.64-1.10), 0.98 ± 0.10 (range, 0.64-1.16), and 0.99 ± 0.06 (range, 0.86-1.13). By paired 2-tailed t test, these volumes were not statistically different (P = .051), although there is a trend to 3T producing smaller volumes than 1.5T. Dice similarity coefficients were 0.90 ± 0.05, 0.90 ± 0.06, and 0.91 ± 0.05 for the investigators. CONCLUSIONS: Planning target volumes for high-grade gliomas were similar at 3T and 1.5T MR using our standard imaging protocols. However, in some patients, the 3T MR may reveal substantially smaller tumor volume due to inferior conspicuity of the lesion. These findings imply that while overall the radiation target volumes are comparable, there are differences in CNR and SNR that lead to differences in individual patients. The 1.5T may be better for gaining conspicuity of the tumor.