Intramural gastric pseudocyst: A case report and a comprehensive literature review.

RATIONALE: Intramural pseudocyst, although first reported several decades ago, is a rare entity. Scientific knowledge regarding its clinical management is sparse. PATIENT CONCERNS: We present three cases to show the diverse clinical patterns of patients diagnosed with an intramural gastric pseudocyst. DIAGNOSIS: A final diagnosis should rest on proper evaluation by cross sectional imaging, including computer tomography and magnetic resonance imaging. Endoscopic ultrasound adds to the work-up. INTERVENTIONS: Previously, identified "lesions of the gastric wall" were not well recognized as an intramural pseudocyst, and treatments including resectional surgery were employed. Contemporary proper diagnostics should provide support to a less aggressive treatment approach. OUTCOMES: While an indolent natural history without any clinical symptoms or discomfort could be expected in most cases, individual clinical evaluation should be applied. LESSONS: A heterogeneous information pattern from the limited number of cases in the literature makes it difficult to draw any firm conclusions. Attention to this rare condition should be increased to help clinicians arrive at a correct diagnosis and possibly prevent some patients from being over treated or from the use of unnecessary surgery.

Primary Leiomyosarcoma of the Pancreas-a Case Report and a Comprehensive Review.

PURPOSE: Primary mesenchymal tumors of the pancreas are rare, with leiomyosarcomas the most encountered entities among the pancreatic sarcomas. With few exceptions, single case reports published over the last six decades constitute the entire scientific literature on this topic. Thus, evidence regarding clinical decision-making is scant. METHODS: Based on a case report and an extensive literature search in PubMed, we discuss the clinical aspects and current management of this rare malignancy. RESULTS: We identified only two papers with more than a single case presentation; these institutional patient series were limited to five and nine patients. Additionally, a few papers sought to summarize the individual case reports published in the English and/or Chinese language. The clinical presentation is rather non-specific. Moreover, modern imaging modalities are insufficiently accurate to diagnose leiomyosarcoma of the pancreas. Treatment goals include a complete resection with free margins. Proper morphologic examination using immunohistochemistry and the application of a grading system are clinically important for prognostication. The efficacy of adjuvant treatments has not been established. CONCLUSION: Primary pancreatic leiomyosarcoma is extremely rare, and the scientific literature is primarily based on single case reports. Conclusions on management and prognosis should be drawn with caution. A multidisciplinary team consultation is warranted to discuss a thorough individual treatment plan based on the available scientific literature, despite its low evidence level.

Primary adenoid cystic carcinoma of the breast: Case report and review of the literature.

UNLABELLED: Adenoid cystic carcinoma of the breast is a very rare neoplasm. We report a case of adenoid cystic carcinoma of the right breast presented with painless lump in the upper outer quadrant managed with lumpectomy, axillary lymph node staging and adjuvant local external radiotherapy to the whole breast with simultaneous integrated boost to the site of primary disease using respiratory gated intensity modulated radiotherapy. The available literature is reviewed. KEYWORDS: Adenoid cystic cancer breast, mastectomy, adjuvant radiotherapy.

Respiratory gated simultaneous integrated boost-intensity modulated radiotherapy (SIB-IMRT) after breast conservative surgery for carcinoma of the breast: The Salmaniya Medical complex experience.

PURPOSE: To present our clinical experience using SIB-IMRT Technique for Intact Breast cancer. MATERIALS AND METHODS: A retrospective review of 45 cases of Stage I-IV breast cancer patients treated with SIB-IMRT with respiratory gating after Conservative treatments from 25th November 2008 to 16th February 2010. The most common fractionation was 1.8 Gy to Ipsilateral Breast tissue and 2.2 Gy to the lumpectomy cavity giving whole breast dose as 50.4 Gy and Lumpectomy cavity dose as 61.6 Gy over 28 fractions concomitantly. Respiratory gating was done and CT-images were taken in inspiratory breath hold position. RESULTS: A total of 45 patients with breast cancer - stage I (17.7%), II (71%), III (8.9%), IV (2.2%) were treated with SIB- IMRT with respiratory gated radiotherapy. Out of 45 patients, 24 are of left sided breast cancer and 21 are of right sided breast cancer patients. The median, Dose maximum (D-max) in SIB-IMRT is 106.2% of prescribed lumpectomy site dose. The median isodose line prescribed to PTV-2 is 100%. The Conformity index (CI) is 0.9688 (median value) and Homogeneity index (HI) 1.06 (median). The median ipsilateral lung, mean dose is 21.66 Gy and V-20 is 37.4%. For left sided cases the median value of mean heart dose, V-30 and V-40 are 22.98 Gy, 23.45% and 9.45 % respectively. Acute skin toxicity was of Grade-I in 2.2 %, Grade-II in 64.4 %, Grade-III in 31.1 %, and Grade-IV in 2.2 %. The global Breast cosmoses were seen excellent in majority (93%) of case at median follow up of 8 months duration. CONCLUSIONS: Breast SIB-IMRT Technique is feasible and comparable with other treatment techniques with reduced treatment duration by six fractions. At median follow up of 8 months the skin toxicity and cosmoses are excellent in high percentage of cases.

Acute respiratory distress syndrome in poor prognostic germ cell tumor with multiple lung metastases: a case report.

We report a case which is unique as this patient was diagnosed pathologically as adenocarcinoma of the endometrium but clinically progressed as germ cell tumor. This was evident by progressive and rapid raised tumor markers (BHCG & LDH) with the development of multiple bilateral lung metastases. She was treated by administrating low doses of systemic combination chemotherapy as per the literature. Unfortunately, she developed acute respiratory distress syndrome as the complication of treatment and died due to it.

Pharmacokinetic evaluation of two ibuprofen-codeine combinations.

The pharmacokinetics of ibuprofen and codeine were compared when given alone or in combination. Six treatments (ibuprofen 400 mg, codeine 60 mg, ibuprofen 400 mg and codeine 30 mg in two separate tablets, ibuprofen 400 mg and codeine 30 mg in one combination tablet, ibuprofen 400 mg and codeine 60 mg in two separate tablets, and ibuprofen 400 mg and codeine 60 mg in one combination tablet) were evaluated. Twenty-four healthy subjects were enrolled in the randomized block design study. Ibuprofen and codeine plasma concentrations were measured by reversed-phase liquid chromatography with UV and fluorescence detection. Pharmacokinetic parameters were estimated by non-compartmental data analysis techniques. Ibuprofen and codeine pharmacokinetic parameters obtained in this study were in agreement with previously published values. In addition, no pharmacokinetic interaction could be detected between codeine and ibuprofen when given alone or in combination. Furthermore, the similar half-life of both drugs (2-2.5 h) is advantageous for a fixed drug combination. The results suggest that ibuprofen and codeine can be given safely in a single oral dosage form.

Increased erythrocyte and protein binding of codeine in patients with sickle cell disease.

Erythrocyte binding and plasma protein binding of codeine in sickle cell patients and healthy controls were determined. A reversed-phase HPLC procedure was used for codeine analysis. Codeine was extracted from alkalinized plasma, separated on a CN column, and assayed by fluorescence detection. The erythrocyte-buffer partition coefficient was significantly higher in sickle cell patients (1.72 +/- 0.21) than in healthy controls (1.25 +/- 0.14). No time dependence of partitioning was observed. The fraction of codeine bound to plasma proteins, determined by ultrafiltration, was significantly higher in sickle cell patients (66.0% +/- 8.6%) than in healthy controls (30.5% +/- 2.7%). No concentration dependence of erythrocyte or protein binding was observed. Further studies were performed to elucidate the binding mechanisms. From a ghost cell binding study it was concluded that the major binding sites for codeine are in the cell membrane. A decrease in codeine binding was observed in the presence of bilirubin. Codeine binding to alpha 1-acid glycoprotein was found to be minimal. The levels of alpha 1-acid glycoprotein and other glycoproteins in sickle cell patients and healthy controls were measured by glycoprotein electrophoresis. The results showed no significant difference between the two groups. Plasma protein electrophoresis was performed for the two groups. The results showed a significant difference in gamma-globulin levels between sickle cell patients and healthy controls. Codeine is known to bind to gamma-globulin, a fact that may explain in part the observed increase in the plasma protein binding of codeine in sickle cell patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Codeine disposition in sickle cell patients compared with healthy volunteers.

The pharmacokinetics of codeine were determined after oral administration of codeine sulfate (60 mg) with sickle cell patients (SCPs) and healthy controls (HCs). Plasma concentrations of codeine were measured by reversed-phase high-pressure liquid chromatography with fluorescence detection. Pharmacokinetic parameters were calculated using both compartmental and noncompartmental analysis. No significant differences were observed in time to reach maximum peak plasma concentration (tmax) (1.0 +/- 0.4 versus 1.4 +/- 1.0 hours), maximum peak plasma concentration (Cmax) (172 +/- 25 versus 225 +/- 97 ng/mL), area under the curve (AUC infinity) (590 +/- 96 versus 779 +/- 234 ng*h/mL), and Cl/F (104 +/- 17 versus 89 +/- 27 L/h) between SCPs and HCs. Conversely, significant differences were observed in mean residence time (MRT) (3.7 +/- 0.3 versus 4.7 +/- 0.3 hours) and half-life (t1/2) (1.7 +/- 0.2 versus 2.8 +/- 0.3 hours). In a separate study, significant differences were observed in the in vitro plasma protein binding of codeine in SCPs (66.0 +/- 8.6%) and HCs (30.5 +/- 2.7%) as well as in vivo binding (68.4 +/- 11.1% for SCPs versus 29.2 +/- 3.4% for HCs). Codeine is a relatively high-extraction drug that is primarily eliminated by metabolism in the liver. Generally, the clearance of such drugs is approximately equal to hepatic blood flow and is not affected by changes in protein binding. Therefore, the change in t1/2 observed in SCPs can be attributed to changes in volume of distribution rather than clearance.

Endoscopic diagnosis of ascites in Assiut province, upper Egypt.

Fifty-nine case of ascites not due to cardiac or renal disease were subjected to clinical, endoscopic and laboratory investigations, including bacteriology and histopathology. Provisional diagnosis divided the cases into 38 patients with ascites as the main finding, and 21 patients with liver cirrhosis and ascites. After investigation, the final diagnosis was totally different from the provisional in 15 cases. Predominance of tuberculosis of the peritoneum per se or in addition to liver cirrhosis was striking, and its documentation was possible only through laparoscopy and biopsy. Oesophagoscopy, a simple procedure, revealing varices in undiagnosed ascites, points to liver cirrhosis. Laparoscopy confirms the diagnosis and reveals other additional factors for ascites as malignancy or tuberculosis.