Laparoscopic Resection of a Left Upper Quadrant Mass Leading to a Surprise Diagnosis.

Background. Resplenectomy is most commonly done for the treatment of recurrent idiopathic thrombocytopenic purpura (ITP) refractory to medical management due to the regrowth of a missed accessory spleen. Case Report. A 66-year-old male had undergone open splenectomy for traumatic rupture 40 years ago. He presented with a leiomyosarcoma of his leg, which was surgically removed. When he developed metastatic disease, chemotherapy was started. He developed left upper quadrant pain, and on CT scan, a 5 cm mass compatible with a sarcoma was found between the tail of the pancreas and the left adrenal gland. During laparoscopy, dense adhesion of the omentum to the abdominal wall and the stomach from his previous splenectomy was divided. The lesser sac was opened through the gastrocolic ligament, and the splenic flexure was taken down. Superior and dorsal to the tail of the pancreas next to the left adrenal gland, the mass was identified and carefully dissected out. The vascular pedicle, which originated from a side branch of the splenic vessels at the tail of the pancreas, was stapled. The gastric fundus showed multiple nodules, and therefore, a modified sleeve gastrectomy was done; also, a 2 cm nodule in segment 5 of the liver and an omental nodule were removed. The tumors and gastrectomy specimen were placed in an endobag and removed through a periumbilical mini-incision. The patient recovered without any complications from the procedure and his LUQ pain resolved. Pathology revealed no sarcoma metastases but accessory spleens in all specimens. Discussion. Splenosis with multiple implants within the abdomen after splenectomy for trauma is a rare condition. In our patient, this seems to have been triggered by chemotherapy for his sarcoma resulting in extramedullary hemopoiesis. Laparoscopic removal of accessory spleens can be safely done.

A rare case of anti-Hu paraneoplastic neurologic syndrome in association with cervical cancer.

Anti-Hu antibodies, also known as ANNA-1, are well characterized in paraneoplastic neuropathies. We present here the first known case of anti-Hu seropositivity, cerebellar ataxia, and sensory neuropathy in association with cervical cancer.

Therapeutic in situ autovaccination against solid cancers with intratumoral poly-ICLC: case report, hypothesis, and clinical trial.

Pathogen-associated molecular patterns (PAMP) are stand-alone innate and adaptive immunomodulators and critical vaccine components. We present a strategy of sequential intratumoral (i.t.) and intramuscular (i.m.) injections of the stabilized dsRNA viral mimic and PAMP, polyinosinic-polycytidylic acid-polylysine-carboxymethylcellulose (poly-ICLC, Hiltonol; Oncovir). We report the first treated patient, a young man with an exceptionally advanced facial embryonal rhabdomyosarcoma with extension to the brain. After treatment, the patient showed tumor inflammation consistent with immunotherapy, followed by gradual, marked tumor regression, with extended survival. Sequential i.t. and i.m. poly-ICLC injections mimicking a viral infection can induce an effective, in situ, personalized systemic therapeutic "autovaccination" against tumor antigens of a patient. We postulate a three-step immunomodulatory process: (i) innate-immune local tumor killing induced by i.t. poly-ICLC; (ii) activation of dendritic cells with Th1 cell- and CTL-weighted priming against the released tumor antigens; and (iii) i.m. poly-ICLC maintenance of the systemic antitumor immune response via chemokine induction, facilitation of CTL killing through the induction of costimulators such as OX40, inflammasome activation, and increase in the T-effector/Treg ratio. These results support the use of certain simple and inexpensive i.t. PAMPs to favorably stimulate effective immunity against solid cancers. A phase II clinical trial testing the hypothesis presented has begun accrual (clinicaltrials.gov, NCT01984892).

Metastatic Renal Cell Cancer and a Gastric Mass: An Unusual Finding.

Renal cell cancer (RCC) accounts for approximately 3% of all adult malignancies. RCC has a metastasis rate of approximately 25%, which is most commonly to the lungs (>50%). On the contrary, RCC metastasis to the gastrointestinal tract (excluding the liver) is very uncommon and ranges from 0.2 to 0.7%. Thus, a gastric cancer in a patient with known metastatic RCC would most likely be secondary to metastasis. We present the first reported case of a metastatic RCC coexisting with a new-onset primary gastric cancer and a review of management using guidelines from metastatic RCC to the stomach. An 82-year-old African American male with papillary RCC status post left nephrectomy with recurrence of liver metastasis presented with failure to thrive shortly after his third cycle of chemotherapy despite stable disease by imaging studies. He had received 7 chemotherapy cycles of Gemzar, Nexavar, and Avastin prior to admission. He subsequently had a drop in his hemoglobin and was found to have hemoccult positive stool in the setting of recent Avastin. Endoscopic evaluation showed a 3 cm ulcerated mass in the cardia which was biopsied. The biopsy showed invasive and poorly differentiated gastric adenocarcinoma unrelated to his RCC. The patient subsequently underwent partial gastrectomy with loop gastrojejunostomy for resection of his stage 1 primary gastric adenocarcioma. The surgery also facilitated future chemotherapy (Avastin), which could not be given prior to surgery due to its side effect of bleeding. The patient did not receive adjuvant chemoradiation for his gastric cancer due to his comorbidities at the time and was doing well at a one month follow-up. Metastatic RCC and primary gastric cancer can coexist, especially when there is an overlap of risk factors such as smoking or nitrosamines. The management of a gastric cancer in the setting of metastatic RCC is similar to the management of solitary primary gastric carcinoma. Treatment of the primary gastric cancer can facilitate future chemotherapy such as Avastin, which has been recently approved for the treatment of metastatic RCC.

A review and update on cholangiocarcinoma.

Cholangiocarcinoma is a malignant neoplasm arising from the biliary epithelium that was first described by Durand-Fardel in 1840. Today, it continues to defy diagnosis and treatment. It is difficult to diagnose in part because of its relative rarity, and because it is clinically silent until it becomes advanced disease with obstructive symptoms. The worldwide incidence of cholangiocarcinoma has risen over the past three decades. There is marked geographic variability in the prevalence of this disease, due in large part to regional environmental risk factors. Surgical resection remains the only curative treatment, and high priorities are improving diagnostic methods, and clinical staging for resection once the disease is suspected. A recent trend towards aggressive surgical management has improved outcomes. Chemotherapy, palliative stenting, and radiation are reserved for patients who are not resectable, those with recurrence after surgery, and those who decline surgical intervention. Recent trials using combination systemic chemotherapy and neoadjuvant chemoradiation are promising, but require further study. Over the past five years, several important studies have yielded new insights into the molecular mechanisms of cholangiocarcinoma tumorigenesis. In this review we discuss epidemiology, etiologic factors, molecular pathogenesis, diagnosis, staging, and treatment of cholangiocarcinoma. Particular focus is on recent studies into the cellular and molecular pathogenesis of the disease, recent chemotherapy trials, and newer methods of staging and screening for this devastating malignancy.

Early detection and successful treatment of drug-induced pneumonitis with corticosteroids.

A 69-year-old patient with non-small cell lung cancer developed pneumonitis with the use of the chemotherapeutic drugs gemcitabine, paclitaxel, and vinorelbine. He developed progressively worsening dyspnea, fevers, chills, and night sweats three weeks after initiation of chemotherapy treatment with no improvement with antibiotics. Bronchoscopic lung biopsy and endotracheal cultures were negative. Four weeks after the onset of symptoms, chest computed tomography scan showed a ground glass appearance of the lung parenchyma bilaterally consistent with pneumonitis. Gemcitabine is a nucleoside analog with activity against solid tumors, including breast and non-small cell lung cancers. Pneumonitis is a rare and potentially deadly complication of gemcitabine. Early treatment with corticosteroids leads to a complete resolution of this patients pneumonitis. Gemcitabine was discontinued and his chemotherapeutic regimen was changed to include paclitaxel, vinorelbine, and topotecan with no recurrence of pneumonitis. Pneumonitis should be included in the differential diagnosis of dyspnea in patients undergoing gemcitabine-based chemotherapy.

ANNA-2: an antibody associated with paraneoplastic opsoclonus in a patient with large-cell carcinoma of the lung with neuroendocrine features--correlation of clinical improvement with tumor response.

This report describes a case of large-cell lung carcinoma with neuroendocrine features, presenting with the full clinical picture of paraneoplastic opsoclonus-myoclonus syndrome. The patient had an unexpectedly dramatic resolution of the neurologic dysfunction after receiving antineoplastic treatment. Symptom improvement paralleled a progressive decline of serum ANNA-2 antibody titers to undetectable levels.

Efeitos da inoculação de endotoxina produzida por Escherichia coli, na morfologia tímica e no desenvolvimento ponderal de camundongos jovens / Effects of inoculation of endotoxin produced by Escherichia coli on thymic morphology and weight development in young mice

Este estudo descreve o efeito da injeção única, intraperitoneal de dose subletal de endotoxina, produzida por Escherichia coli na morfologia tímica e no desenvolvimento ponderal de camundongos jovens. Os animais foram separados em grupos de doze, sacrificados a cada 24 horas durante cinco dias e ao final de cada experimen.to, um grupo controle recebeu injeção intraperitoneal de solução salina. Observou-se, neste experimento, nítida redução de peso corpóreo nas primeiras 48 horas, com recuperação após esta fase e redução no peso dos timos, assim como alterações histológicas importantes. Um outro grupo, formado por oito camundongos, teve seu desenvolvimento ponderal acompanhado durante dois meses. Neste experimento foram constatados sinais de recuperação após as primeiras horas, mas cujo desenvolvimento não chegou a alcançar níveis normais como os controles (AU).