Difficulty in Diagnosing Rare Cardiac Tumors: A Case Series.

Primary cardiac tumors are rare because metastatic lesions from distant sites account for most masses. We are reporting two cases of malignant intracardiac masses with their diagnostic dilemma. Our first patient is a 72-year-old male with a pertinent history of desmoplastic and spindle cell melanoma who presented after his surveillance positron emission tomography (PET) scan showed a hypermetabolic lesion in the inferior pericardium. The initial impression for this mass is recurrent malignant melanoma. After an initial negative endometrial biopsy, the patient underwent debulking surgery, and pathology revealed high-grade spindle cell sarcoma. The patient underwent chemotherapy but had a disease progression and ultimately elected hospice care. Our second patient is a 75-year-old male with a history of stage IB adenocarcinoma of the lung who presented with progressive dyspnea. An echocardiogram revealed a moderate-sized left ventricular mass. Initial assessment based on tumor morphology and location suggested possible cardiac sarcoma. However, the patient's subsequent cardiac biopsy revealed small cell carcinoma, likely of primary cardiac origin, as no other primary nidus of the tumor was seen. Based on this result, the patient has been started on carboplatin, etoposide, and atezolizumab and responded well as of the writing of this manuscript. Given the rarity of malignant primary cardiac tumors and their variable clinical presentation, intracardiac masses are often diagnosed incidentally. In addition, given the high risk of biopsy for intracardiac masses, a presumptive diagnosis is rendered via imaging techniques. However, most of these tumors have no pathognomonic imaging findings, and their diagnosis relies heavily on physician interpretation and experience. Our case series illustrated the unpredictable nature of noninvasive methods and that even endometrial biopsy can return a false negative. Therefore, it is essential to be persistent in obtaining a pathological diagnosis, especially if the clinical picture is unclear. While these more invasive methods present the challenge of identifying whether the procedure is truly needed and locating a skilled operator, it could change the diagnosis entirely and open the patient up to new therapies.

DIRAS3 enhances RNF19B-mediated RAC1 ubiquitination and degradation in non-small-cell lung cancer cells.

Distant metastasis remains the leading cause of high mortality in patients with non-small-cell lung cancer (NSCLC). DIRAS3 is a candidate tumor suppressor protein that is decreased in various tumors. However, the regulatory mechanism of DIRAS3 on metastasis of NSCLC remains unclear. Here, we found that DIRAS3 suppressed the migration of NSCLC cells. Besides, DIRAS3 stimulated the polyubiquitination of RAC1 and suppressed its protein expression. Furthermore, RNF19B, a member of the RBR E3 ubiquitin ligase family, was observed to be the E3 ligase involved in the DIRAS3-induced polyubiquitination of RAC1. DIRAS3 could promote the binding of RAC1 and RNF19B, thus enhancing the degradation of RAC1 by the ubiquitin-proteasome pathway. Finally, the DIRAS3-RNF19B-RAC1 axis was confirmed to be associated with the malignant progression of NSCLC. These findings may be beneficial for developing potential prognostic markers of NSCLC and may provide an effective treatment strategy.

Diagnosing Intravascular Large B-Cell Lymphoma: A Tale of Hide and Seek.

We are reporting the first documented case of intravascular large B-cell lymphoma (IVLBCL) manifesting in the endomysial and perimysial capillaries with its associated diagnostic dilemma. Our patient presented with progressive paraplegia. Initial laboratories were remarkable for hyponatremia, hypochloremia, lactic acidosis, elevated C-reactive protein, and lactate dehydrogenase. The bone marrow biopsy was unrevealing. However, a subsequent muscle biopsy confirmed the diagnosis of IVLBCL. As hyponatremia, endocrinopathies, connective tissue disease, rheumatological disorders, and occult cancer could all present similarly, our patient is a unique diagnostic dilemma. Randomized skin biopsy remains the best way to diagnose this disease, and rituximab-based chemotherapy with high-dose intrathecal methotrexate has proven to be a safe and effective regimen. With this initial evidence of IVLBCL involving the endomysial and perimysial capillary, we believe that muscle biopsy could be of value in diagnosing IVLBCL patients with neuromuscular symptoms.

Pembrolizumab-Associated Seronegative Myasthenia Gravis in a Patient With Metastatic Renal Cell Carcinoma.

Seronegative myasthenia gravis is a rare, but potential adverse effect of immune checkpoint inhibition. There have been few but increasing number of cases reported in recent years, and early recognition is important for prompt diagnosis and management. Here, we describe the case of a 65-year-old male with metastatic renal cell carcinoma on pembrolizumab diagnosed with new-onset seronegative myasthenia gravis and review literature on its management.

When the Tumor Lyses: A Case Report on Spontaneous Tumor Lysis Syndrome.

Tumor lysis syndrome (TLS) is an oncological emergency characterized by severe electrolyte disturbance that typically occurs when hematologic cancer patients have been started on systemic chemotherapy. We present an uncommon case of spontaneous TLS (STLS) occurring in a patient with cholangiocarcinoma. The patient was a 59-year-old male with newly diagnosed differentiated carcinoma of unknown origin who presented with weakness, fatigue, and lightheadedness. Initial imaging revealed cholangiocarcinoma with innumerable pulmonary and hepatic metastases. The laboratory values showed leukocytosis, hypercalcemia, and lactic acidosis. He was diagnosed and treated for sepsis of pulmonary origin. Over the next 3 days, the patient's clinical condition steadily worsened despite aggressive treatment, with new-onset hypoxic respiratory failure, acute kidney injury, and septic shock. Chemotherapy was administered, with new laboratory values showing hyperuricemia and hyperkalemia, consistent with STLS. The patient was transferred to the ICU and emergently started on dialysis but expired a day later from multi-organ failure. To our knowledge, this is the second case of STLS in cholangiocarcinoma. Our patient was unique in that he presented with hypercalcemia and normal phosphorus levels, instead of the typical hyperphosphatemia and secondary consumptive hypocalcemia. While the exact pathophysiology of STLS is still elusive, we believe that the patient's initial sepsis-induced hypotension, aggressively enlarging tumor, and extent of metastasis all contributed to his rapid decline. Given the high mortality rate with TLS and its vague presentation, particularly in a chemotherapy-naïve solid tumor, a high level of clinical suspicion is needed to improve patients' outcome.

Potential Savings from Visit Reduction of Continuous Intraocular Pressure Monitoring.

INTRODUCTION: A continuous method of measuring intraocular pressures (IOP) could be advantageous in the management of glaucoma. This report aims to analyze the potential savings from visit reduction of continuous IOP measurements obtained with an intraocular device. MATERIALS AND METHODS: We constructed a model adapted from a prior study based on the number of glaucoma patients among 5% of the Medicare population. RESULTS: We found that the implementation of a device that continuously measures IOP can result in a reduction of 23.21% in yearly costs from glaucoma outpatient visits. CONCLUSION: Continuous IOP monitoring has the potential to alleviate the economic burden of the current management structure of patients with glaucoma. CLINICAL SIGNIFICANCE: In an era of elevated healthcare costs, continuous IOP monitoring offers an option to improve the care of glaucoma patients through visit reduction, also resulting in a 23.21% reduction in yearly expenses related to glaucoma clinical visits.How to cite this article: Dong J, Syed ZA, Fan K, Yahya AF, Melki SA. Potential Savings from Visit Reduction of Continuous Intraocular Pressure Monitoring. J Curr Glaucoma Pract 2018;12(2):59-63.

Encapsulated Bifidobacteria reduced bacterial translocation in rats following hemorrhagic shock and resuscitation.

OBJECTIVE: The aim of the present study was to determine the effects of peroral encapsulated Bifidobacteria on intestinal microflora, bacterial translocation (BT), plasma endotoxin, and ileal villi injury in a rat model of hemorrhagic shock. METHODS: Sprague-Dawley rats were fed daily with three different diet supplements: phosphate buffered saline, Bifidobacteria (10(9) colon-forming units/day), or microencapsulated Bifidobacteria (10(9) colony-forming units/day). After 7 d of treatment, rats were anesthetized for hemorrhagic or sham shock. Then a laparotomy was performed to determine microbiological analysis of cecal content, BT to mesenteric lymph nodes, plasma endotoxin, and terminal ileal villous damage. RESULTS: In the hemorrhagic-shock model, rats pretreated with Bifidobacteria showed decreases in total aerobes in cecum, magnitude of total aerobes to BT, levels of plasma endotoxin, and percentage of ileal villous damage when compared with rats treated with phosphate buffered saline. Encapsulated Bifidobacteria induced greater decreases than intact Bifidobacteria in this model, except for no difference in percentage of ileal villous damage between the two groups. In addition, the incidence of BT was decreased in hemorrhagic rats pretreated with Bifidobacteria compared with control. However, the magnitude of total anaerobes and Bifidobacteria BT were similar among hemorrhagic-shocked rats receiving three different supplements. CONCLUSION: Bifidobacteria can be useful in preventing BT in hemorrhagic-shocked rats, and encapsulated Bifidobacteria can augment this effect further. Peroral administration of Bifidobacteria may be a favorable strategy to prevent sepsis and multiple organ dysfunction syndrome in hemorrhagic shock.