Accidental discovery of metastasized basal cell carcinoma.

INTRODUCTION: Metastasis of basal cell carcinoma (BCC) is a very rare finding because the disease is mostly discovered early in development and treated immediately. Moreover, the metastasis percentage is less than 0.5%. PATIENT AND METHODS: A 66-year-old man presented to the emergency department after a fall from his bike. He sustained fractures, and a 40-year-old skin lesion was discovered on his back. Histological analysis of a biopsy from the primary lesion, a CT scan, and bone biopsy were performed. RESULTS: The three tests combined confirmed BCC with metastasis to the liver, lung, and bone. We also systematically eliminated the possibility of other skin lesions, such as squamous cell carcinoma, angiosarcoma, cutaneous lymphoma, and melanoma. CONCLUSION: We report an accidental discovery of a rare case of a 40-year-old BCC with multiple distant metastases, resulting in stage IV disease.

Observational Cohort Study on the Use of a Slowly Fully Resorbable Synthetic Mesh (Phasix™) in the Treatment of Complex Abdominal Wall Pathology with Different Grades of Contamination.

PURPOSE: Abdominal wall hernia repair in contaminated cases remains a therapeutic challenge due to the high risk of post-operative surgical site occurrences (SSO). Slowly resorbable synthetic (biosynthetic) meshes have recently been introduced and may offer unique advantages when challenged with bacterial colonization during abdominal wall reconstruction. METHODS: A multicenter single-arm retrospective observational cohort study examined all consecutive patients in whom a poly-4-hydroxybutyrate mesh (Phasix™ or Phasix™ ST; Becton Dickinson, Franklin Lakes, NJ, USA) was used for the repair of an inguinal or ventral/incisional hernia, or to replace an infected synthetic mesh. Patient records were analyzed according to the level of contamination, using the classification score of the Centers for Disease Control and Prevention (CDC). The primary objective was to evaluate short-term postoperative morbidity by assessing SSOs and the need for reoperation or even mesh excision. RESULTS: A total of 47 patients were included. The median age was 68 years (30-87), the male/female ratio was 26/21, and the median BMI was 26.5 kg/m2 (16.4-46.8). There were 17 clean cases, 17 clean-contaminated, 6 contaminated and 7 dirty. Median follow-up time was 48 days. An SSO was seen in 4 clean (23.5%), 7 clean-contaminated (41.2%), 2 contaminated (33.3%) and 5 dirty cases (71.4%). A surgical site occurrence requiring procedural intervention (SSOPI) was seen in 2 clean (11.8%), 3 clean-contaminated (17.6%), 1 contaminated (16.7%) and 2 dirty cases (28.6%). Hernia recurrence was seen in 1 clean (5.9%), 2 clean-contaminated (11.8%) and 3 dirty cases (42.9%). Mesh excision had to be performed in only one case in the contaminated group. CONCLUSION: The Phasix™ mesh shows promising short-term results when used in contaminated hernia-related surgery. Even in contaminated or dirty conditions, with or without infection of the mesh, resection of the mesh only had to be performed once and patients could be managed either conservatively or by relatively minor reoperations. However, further research is needed to fully evaluate the safety and efficacy of these meshes.

Evaluation of a New Elastic Ostomy Appliance to Decrease Skin Complications: Results of a Pilot Study.

Peristomal skin complications due to appliance leakage frequently occur in all types of ostomies, resulting in great emotional, social, and financial impact for patients. PURPOSE: This pilot study was conducted to evaluate the safety and use of a new, reusable, nonadherent, elastic device. METHOD: A convenience sample of nonhospitalized patients with ileostomies and colostomies was recruited through the Dutch ostomy patient association. Participant inclusion criteria stipulated the presence of ileostomy or colostomy, a body mass index (BMI) between 18 and 30, and presence of an osto-my for at least 1 month. Patients with existing prolapse or necrosis of the ostomy, inability to give consent, or concurrent usage of other aids to prevent leakage or skin problems were excluded. Participants were fitted with and asked to wear the appliance continuously for 4 weeks and report experiences in a structured diary. Patient charts were reviewed for baseline demographic characteristics that included age, gender, American Society of Anaesthesiologists classification, and BMI. Study nurses performed structured weekly interviews and inspections of the ostomies and peristomal skin. The primary outcome measure was occurrence of serious adverse events such as ostomy necrosis or perforation. Secondary outcome measures were patient reported incidents of leakage and satisfaction during wear and changing of the appli-ance. Peristomal skin complications also were recorded. Descriptive statistics were used to analyze results. In addition, subgroup analysis of patients with a parastomal hernia was performed because of the potential benefits of the device design in these cases. RESULTS: Participants included 23 patients (16 with colostomies, 7 with ileostomies); 13 participants (57%) were female. Mean age and BMI were 64 years and 28.3, respectively. Six (6) patients had a parastomal hernia. Due to shifting or discomfort while wearing the appliance, 16 participants discontinued use before the end of the study and were excluded from analysis from the point they left the study. Mean duration of participation was 12.8 days. No adverse events occurred. Mean number of incidents of leakage/week decreased from 3.5 ± 4.9 at start of the study to 1.8 ± 1.3 at week 4. The mean number of pouches used/week decreased from 10.5 ± 5.4 to 8 ± 2.6. Peristomal skin reactions present in 15 patients at start of the study decreased to 1 patient at the end of the study. Patient satisfaction did not change over the course of the study. Patients with parastomal hernias had similar results. CONCLUSION: No serious adverse events were reported and leakage and skin irritation were found to improve, but participant dropout rate was high and average usage time was only 12.8 days, which limited interpretation of the results. The data suggest that the appliance may offer an (intermittent) alternative to existing ostomy materials for patients experiencing troublesome leakages, peristomal skin problems, or parastomal hernias, but further research is needed to explore these outcomes.

[Purulent peritonitis due to gonococcal infection]. / Purulente peritonitis door een gonokokkeninfectie.

BACKGROUND A Neisseria gonorrhoea infection is one of the most common sexually transmitted diseases and can present both urogenitally and extragenitally. CASE DESCRIPTION A 55-year-old woman presented at the emergency room with general malaise, abdominal pain and fever. Despite extensive surgical, gynaecological and radiological investigations no clear cause could initially be found. She was subsequently admitted to the surgical unit for observation. During the admission period the patient developed diffuse peritonitis and her infection parameters were rising. Diagnostic laparoscopy revealed extensive terminal ileitis with a reactive infiltrate of the uterine fundus and purulent peritonitis. A PCR test of the abdominal exudate was strongly positive for Neisseria gonorrhoeae, but cultures remained negative. Following an 8-day course of antibiotic treatment with intravenous ceftriaxone, the patient recovered from her symptoms. CONCLUSION Terminal ileitis with peritonitis is an unusual extragenital manifestation of a gonococcal infection. In order to make a diagnosis, surgical exploration with cultures is sometimes indicated.

Intrapelvic Retroperitoneal Synovial Sarcoma in a 15-Year-Old Adolescent Girl: A Case Report and Review of the Literature.

Synovial sarcomas are a rare subtype of soft tissue sarcomas mostly located in the lower extremities. The authors report a case of synovial sarcoma in a 15-year-old adolescent girl with several unusual features including age, intrapelvic retroperitoneal location of the primary tumor, and presentation with right abdominal tenderness and compression of the iliac vessels with thrombosis of the right iliac and femoral vein.

Internal herniation of the abdominal wall.

A symptomatic arcuate line hernia should be considered in patients with acute lower abdominal complaints. This rare internal herniation is caused by a sharp ending of the posterior aponeurotic sheath of the rectus muscle, rather than the more common gradual delineation, and can cause strangulation or incarceration of abdominal contents.

Postoperative drug-induced priapism.

We presented a case of a postoperative patient with low-flow priapism, possibly initiated by propofol-based anaesthesia or epidural anaesthesia. The delay in diagnosing priapism resulted in emergency interventions with a partially successful effect and eventually permanent erectile dysfunction. Due to the delay in treatment, erectile dysfunction ensued and was manageable with medication; hence, the patient decided against a penile prosthesis.

Pretargeted radioimmunoscintigraphy in patients with primary colorectal cancer using a bispecific anticarcinoembryonic antigen CEA X anti-di-diethylenetriaminepentaacetic acid F(ab')2 antibody.

BACKGROUND: Antibody-based imaging agents are available commercially, but their success has been limited, mainly because of low contrast and the emergence of 2-fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) scanning. In pretargeting, administration of the radionuclide is separated from the antibody, thereby enhancing image contrast and allowing detection at earlier time points after injection. METHODS: The authors conducted an open-label, single-arm trial that assessed a pretargeting procedure in which an anticarcinoembryonic antigen x (anti-CEA x) anti-diethylenetriaminepentaacetic acid (anti-DTPA)-indum (In) antibody was used in combination with a (111)In-labeled di-DTPA peptide for the diagnostic imaging of CEA-expressing colorectal cancer. Three patients received the (111)In peptide alone to investigate tumor targeting, organ distribution, and clearance of the peptide. Thereafter, 11 patients received the bispecific antibody (bsAb) (5 mg) to pretarget the tumor. After 3 to 5 days, patients were injected with 185 megabecquerels of (111)In-labeled peptide to assess the optimal interval for best image quality. RESULTS: Fourteen patients with primary colorectal cancer were enrolled. One of 3 patients who received (111)In peptide alone had low-level tumor uptake. In 9 of 11 other patients, tumors were observed. In 1 patient, FDG-PET-positive lymph nodes were observed clearly with pretargeted immunoscintigraphy. Peptide pharmacokinetics revealed enhanced circulating levels of (111)In-labeled peptide in patients in the 3-day interval cohort compared with the other cohorts. Tumor-to-background ratios ranged from 3.5 to 6.4 in the 3-day interval group, from 5.1 to 14.2 in the 4-day interval group, and from 3.5 to 3.9 in the 5-day interval group. The best images were acquired with a 4-day interval at 24 hours after injection of the radiolabeled peptide. Grade 1 adverse events were observed in 2 patients. CONCLUSIONS: Imaging of colorectal cancer using a 2-step, pretargeting system produced the best imaging results 24 hours after peptide administration using a 4-day interval between injection of the bsAb and the peptide.

Can antibody galactosylation be used to improve radioimmunotherapy of induced peritoneal carcinomatosis of colonic origin in the rat?

In radioimmunotherapy (RIT), hematologic toxicity is the dose-limiting toxicity due to the long circulatory half-life of the antibody. Although intraperitoneal (i.p.) RIT results in high uptake of i.p. growing tumors, the radiolabeled antibody enters the circulation, resulting in bone marrow toxicity. Carbohydrate modification of antibodies could induce accelerated clearance of the antibody via the hepatic asialoglycoprotein receptor, thereby reducing exposure to normal tissues. In this study, we investigated whether galactosylation of an antibody in a model of peritoneal carcinomatosis (PC) of colonic origin could be used to improve targeting of i.p. growing tumors. Therefore, the biodistribution of the galactosylated and nongalactosylated anti-CC531 antibody, MG1, after i.p. injection was determined in a model of peritoneal carcinomatosis of CC-531 colon tumors in Wag/Rij rats. Uptake of the radiolabeled antibodies in the tumor and relevant organs was determined at 2, 4, 24, and 48 hours after injection. Galactosylation of the antibody did not affect the binding affinity of MG1. Remarkably, the uptake of Gal-MG1 in tumors was higher than that of MG1 at 2 and 4 hours after injection. After 24 and 48 hours, uptake of Gal-MG1 in tumor tissue was lower than that of MG1. Gal-MG1 cleared from the blood within hours after administration. At 2-24 hours after administration, tumor-to-blood ratios obtained with Gal-MG1 were significantly higher than those obtained with unmodified MG1. Antibody galactosylation resulted in improved tumor-non-tumor ratios after i.p. injection in a model of PC. This could improve the efficiency of RIT, especially in combination with short-lived nonresidualizing radionuclides.

Animal models for liver metastases of colorectal cancer: research review of preclinical studies in rodents.

Liver metastases of colorectal carcinoma occur in about 50-60% of patients. To improve survival of these patients, there is an urgent need for new treatment strategies. For this purpose, the availability of a preclinical model to develop and test such treatments is mandatory. An ideal animal model for studying liver metastases of colorectal origin should mimic all aspects of the metastatic development in humans and be practical, predictable, and optimal in terms of ethical considerations. Thus far, no model has been developed which satisfies all these conditions. As a consequence, choosing an animal model for the study of liver metastases requires compromises and choices about the necessary characteristics that depend on the purpose of the intended experiments. This overview addresses the advantages and disadvantages of different animal models used for research on experimental liver metastases of colorectal origin. Based on data available in literature, we conclude that heterotopic injection of undifferentiated syngeneic tumor cells in immunocompetent rodents covers most of the desired characteristics. Both subcapsular as well as intraportal injection will yield suitable models and the eventual choice will depend on the aim of the study.

Hyperthermia and fibrinolytic therapy do not improve the beneficial effect of radioimmunotherapy following cytoreductive surgery in rats with peritoneal carcinomatosis of colorectal origin.

BACKGROUND AND OBJECTIVE: Cytoreductive surgery (CS) and heated intraperitoneal chemotherapy (HIPEC) are standard treatment for peritoneal carcinomatosis (PC) of colorectal cancer. Previously, we demonstrated that preclinical radioimmunotherapy (RIT) adjuvant to surgery in PC is a good alternative for HIPEC. Now we aimed to improve the effectiveness of RIT by combining it with whole-body hyperthermia (WBH) or fibrinolytic therapy. METHODS: Rats were inoculated intraperitoneally with colon carcinoma cells. Animals underwent CS, CS + WBH (40 degrees C, 3 hours), CS + RIT (74 MBq 177Lu-labeled MG1), or CS + WBH + RIT. In the second experiment, rats underwent CS, CS + RIT, CS + recombinant tissue plasminogen activator (rtPA, twice daily, 3 days), or CS + RIT + rtPA. RESULTS: Median survival after CS and CS + WBH was 34 and 37 days. Median survival after CS + RIT or CS + RIT + WBH was 63 and 86 days (p < 0.0003, p < 0.0006 compared to CS + WBH). Median survival after CS and CS + rtPA was 50 and 42 days (p = 0.1). Median survival was 106 days after CS + RIT and 103 days after CS + RIT + rtPA (p < 0.0001 compared to CS + rtPA). No difference was found between CS + RIT and CS + RIT + rtPA (p = 0.83). CONCLUSIONS: The application of WBH or rtPA in combination with adjuvant RIT after CS for the treatment of PC of colonic was feasible but did not significantly potentiate the efficacy of RIT.

Intracavitary radioimmunotherapy to treat solid tumors.

Radioimmunotherapy (RIT) potentially is an attractive treatment for radiosensitive early-stage solid tumors and as an adjuvant to cytoreductive surgery. Topical administration of RIT may improve the efficacy because higher local concentrations are achieved. We reviewed the results of locally applied radiolabeled monoclonal antibodies for the treatment of solid tumors. Intracavitary RIT in patients with ovarian cancer and glioma showed improved targeting after local administration, as compared to the intravenous administration. In addition, various studies showed the feasibility of locally applied RIT in these patients. In studies that included patients with small-volume disease, adjuvant RIT in ovarian cancer and glioma showed to be at least as effective as standard therapy. The information about RIT for peritoneal carcinomatosis of colorectal origin is scarce, while results from preclinical data are promising. RIT may be applied for other, relatively unexplored indications. Studies on the application of radiolabeled antibodies in early urothelial cell cancer have been performed, showing that intracavitary RIT may hold a promise. Moreover, in patients with malignant pleural mesothelioma or malignant pleural effusion, RIT may play a role in the palliative treatment. Intracavitary RIT limits toxicity and improves tumor targeting. RIT is more effective in patients with small-volume disease of solid cancers. RIT may have potential for palliation in patients with malignant pleural mesothelioma or malignant pleural effusion. The future of RIT may, therefore, not only be in the inclusion in contemporary multimodality treatment, but also in the expansion to palliative treatment.

Timing of adjuvant radioimmunotherapy after cytoreductive surgery in experimental peritoneal carcinomatosis of colorectal origin.

BACKGROUND: Treatment of patients with peritoneal carcinomatosis (PC) of colorectal cancer (CRC) includes cytoreductive surgery (CS) in combination with (hyperthermic) intraperitoneal chemotherapy (HIPEC), resulting in a limited survival benefit with high morbidity and mortality rates. Radioimmunotherapy (RIT) as adjuvant therapy after CS of CRC has been shown to prolong survival in preclinical studies. However, the optimal setting of RIT remains to be determined. METHODS: PC was induced by intraperitoneal inoculation of CC-531 colon carcinoma cells in Wag/Rij rats. Animals were subjected to exploratory laparotomy (Sham), CS only or CS + RIT at different time points after surgery. RIT consisted of 55 MBq lutetium-177-labelled anti-CC531 antibody MG1 (183 mug). The primary endpoint was survival. RESULTS: Cytoreductive surgery with or without RIT was well tolerated. Median survival of animals in the Sham and CS group was 29 days and 39 days, respectively (P < 0.04). Compared to CS alone, median survival of rats after adjuvant RIT was 77 days (P < 0.0001), 52 days (P < 0.0001) and 45 days (P < 0.0001) when given directly, 4 and 14 days after surgery, respectively. CONCLUSION: The efficacy of adjuvant RIT after CS for the treatment of PC of colonic origin decreases when the administration of the radiolabelled MAbs is postponed. This study shows that adjuvant RIT should be given as early as possible after surgery.

Antibody-guided radiation therapy of cancer.

Radioimmunotherapy (RIT) using radiolabeled monoclonal antibodies (MAbs) directed against tumor-associated antigens has evolved from an appealing concept to one of the standard treatment options for patients with non-Hodgkin's lymphoma (NHL). Inefficient localization of radiolabeled MAbs to nonhematological cancers due to various tumor-related factors, however, has refrained RIT from outgrowing the experimental stage in solid tumors. Still, small volume or minimal residual disease has been recognized as a potentially suitable target for radiolabeled antibodies. Several strategies are being explored aimed at improving the targeting of radiolabeled MAbs to solid tumors thus improving their therapeutic efficacy. In this review, a historical overview of the application of RIT is given and various aspects of the application of radiolabeled MAbs as anti-cancer agents are discussed. Finally, the clinical results of RIT of NHL, colorectal cancer, ovarian cancer, breast cancer, and renal cell cancer are reviewed.