Neoadjuvant Immunotherapy in the Treatment of Renal Cell Carcinoma: A Case Series.

Renal cell carcinoma is a type of urologic cancer that has a poor prognosis, with the majority of these being clear cell renal carcinoma. This subset has a tendency to cause disruptions in the cell cycle, making immune checkpoint inhibitors for adjuvant treatment of renal cell carcinoma the predominant pharmacological approach. Despite this, the use of immune checkpoint inhibitors in this setting is still an area of much research. In the following three different cases, we demonstrate the role and benefit of treatment with neoadjuvant immune checkpoint inhibitors in patients that have an extensive tumor burden at diagnosis, making them ineligible for operative treatment. Our hope is that these cases serve as a foreshadowing of the potential neoadjuvant treatments have in this oncological setting.

Too Hot to Handle: A Case of Fever of Unknown Origin.

Fever of unknown origin (FUO) is defined as a fever higher than 38.3ºC for at least three weeks. It remains a difficult diagnostic challenge and it carries well over 200 differential diagnoses, including infectious, rheumatologic and malignant etiologies. A methodological approach with clinical deductive reasoning and value-based investigative work-up can establish the diagnosis. This case is about a 76-year-old male with a past medical history of atrial fibrillation, bladder cancer treated with chemotherapy (now in remission) and hydronephrosis with recent ureteropelvic junction stent placement. He presented to the emergency department (ED) for worsening shortness of breath (SOB), weakness, and fevers. His initial workup was notable for a urinary tract infection which was treated with ceftriaxone. However, there was only a limited improvement in the fever. Diagnostic imaging was negative on initial review. He was evaluated by consultants of different specialities including infectious disease, rheumatology, and hematology. Ultimately, the decision was made to discharge the patient home on steroids with further outpatient workup. He returned four weeks later with worsening fever and was found to have new-onset mediastinal lymphadenopathy. A biopsy of an inguinal lymph node was obtained which showed high grade-B cell lymphoma. The patient was continued on prednisone and started on chemotherapeutic agents which included vincristine, rituximab and cyclophosphamide. Shortly after starting treatment, the patient and family elected for hospice. This case demonstrates the importance of continuously questioning the diagnosis at hand and of keeping an open mind when evaluating a patient with FUO.

Utilization of Emicizumab in Acquired Factor VIII Deficiency.

BACKGROUND Acquired hemophilia A (AHA) is a rare autoimmune disease caused by immunoglobulins that bind and inactive factor VIII, thereby predisposing to life-threatening bleeding. Bleeding is typically stabilized by utilizing bypassing agents, such as recombinant factor VIIa (rVIIa). Select case reports have demonstrated the success of alternative prophylaxis for clearance of factor VIII inhibitors through the use of emicizumab, a current FDA approved medication for treatment of congenital hemophilia A. In this case report we present the efficacy of utilizing emicizumab as a prophylactic agent in a patient that was unable to tolerate first-line therapy for prophylaxis. CASE REPORT A 91-year-old male presented for ongoing hematuria for 5 weeks with prior workup unrevealing. He was given a day's course of recombinant factor VIIa to stabilize his bleeding and was started on cyclophosphamide and prednisone after a revealing hematological workup including activated partial thromboplastin time (aPTT) >100 seconds and factor VIII inhibitor level of 44 BU/mL. He continued to require VIIa infusions to control his bleeding and was started on emicizumab once stabilized. His bleeding remained controlled and his inhibitor decreased after 6 months of therapy with repeat factor VIII inhibitor level of 1.9 BU/mL. CONCLUSIONS The success of utilizing emicizumab for bleeding prophylaxis in AHA is demonstrated by this patient's resolution of bleeding. The high frequency of dosing and higher risk for thrombosis with factor VIIa, in conjunction with our patient's medical history and ease of administration, make emicizumab an ideal agent for bleeding prophylaxis while awaiting clearance of factor VIII inhibitors.

Comparison of In-Plane Stress Development in Sol-Gel- and Nanoparticle-Derived Mesoporous Metal Oxide Thin Films.

By using an evaporation-induced self-assembly (EISA) process, mesoporous metal oxide thin films are prepared via molecular precursors undergoing a sol-gel transition or by using nanoparticle dispersions as the starting materials. Both methods are employed together with PIB50-b-PEO45 as the structure-directing agent to produce porous TiO2 and ZrO2 thin films with spherical mesopores of around 14 nm in diameter. These nanoparticle- and sol-gel-derived films were investigated in terms of the intrinsic in-plane stress development during the heat treatment up to 500 °C to evaluate the impact of solvent evaporation, template decomposition and crystallization on the mechanical state of the film. The investigation revealed the lowest intrinsic stress for the nanoparticle-derived mesoporous film, which is assigned to the combination of the relaxing effects of the utilized diblock copolymer and the interparticular gaps between the precrystalline nanoparticles. Furthermore, the residual in-plane stress was studied after annealing steps ranging from 300 to 1000 °C and cooling down to room temperature. Here, TiO2 nanoparticle-derived mesoporous films possess a lower residual stress than the sol-gel-derived mesoporous films, while in the case of ZrO2 films, sol-gel-derived coatings reveal the smallest residual stress. The latter is based on the lower thermal expansion coefficient of the dominant monoclinic crystal phase compared to that of the silicon substrate. Hence, the present crystal structure has a strong influence on the mechanical state. The observation in this study helps to further understand the stress-related mechanical properties and the formation of mesoporous metal oxides.

Detection of trabecular bone microdamage by micro-computed tomography.

Microdamage is an important component of bone quality and affects bone remodeling. Improved techniques to assess microdamage without the need for histological sectioning would provide insight into the role of microdamage in trabecular bone strength by allowing the spatial distribution of damage within the trabecular microstructure to be measured. Nineteen cylindrical trabecular bone specimens were prepared and assigned to two groups. The specimens in group I were damaged to 3% compressive strain and labeled with BaSO(4). Group II was not loaded, but was labeled with BaSO(4). Micro-computed tomography (Micro-CT) images of the specimens were obtained at 10 microm resolution. The median intensity of the treated bone tissue was compared between groups. Thresholding was also used to measure the damaged area fraction in the micro-CT scans. The histologically measured damaged area fraction, the median CT intensity, and the micro-CT measured damaged area fraction were all higher in the loaded group than in the unloaded group, indicating that the micro-CT images could differentiate the damaged specimen group from the unloaded specimens. The histologically measured damaged area fraction was positively correlated with the micro-CT measured damaged area fraction and with the median CT intensity of the bone, indicating that the micro-CT images can detect microdamage in trabecular bone with sufficient accuracy to differentiate damage levels between samples. This technique provides a means to non-invasively assess the three-dimensional distribution of microdamage within trabecular bone test specimens and could be used to gain insight into the role of trabecular architecture in microdamage formation.