An unusual case of recurrent haemoptysis after ablation for atrial fibrillation requiring pneumonectomy: a case report.

Background: Pulmonary vein (PV) stenosis is a rare complication after catheter ablation for atrial fibrillation (AF). While there have been reported anecdotal cases of complete PV stenosis requiring pulmonary lobectomy, only one case of pneumonectomy has been documented so far. Case summary: A 42-year-old man was referred to our Thoracic Surgery Unit for recurrent haemoptysis and exertional dyspnoea over the past 4 years and a recent finding of left PV occlusion. He suffered of relapsing AF that had almost five recurrences and that underwent a total of two percutaneous catheter ablations within a 7-year period. He also experienced a hospitalization for multifocal lobar pneumonia. Two attempts of percutaneous transluminal angioplasty (PTA) were unsuccessful. Due to the severity and the duration of PV occlusion, the previous PTA failure, the patient's age, and his symptoms, a left pneumonectomy was performed. During the postoperative period, the patient experienced only mild anaemia effectively managed with blood transfusions. Five months after surgery, he has no recurrence of symptoms. Discussion: When the PV stenosis is complete, PTA may face high failure and recurrence rates. In this setting, anatomical pulmonary resections may represent a valid option to allow symptom relief and resolution.

Laparoscopic Trans-Abdominal Right Adrenalectomy for a Large Primitive Adrenal Oncocytic Carcinoma: A Case Report and Review of Literature.

BACKGROUND Adrenocortical oncocytic neoplasms (AONs) are extremely rare tumors. AONs are classified as: oncocytoma (AO), oncocytic neoplasm of uncertain malignant potential (AONUMP), and oncocytic carcinoma (AOC). Among the 162 reported cases of AONs in the literature, 30 cases were classified as malignant. Adrenalectomy is the treatment of choice for AON. CASE REPORT We report the case of a 48-year-old man with a primitive 12-cm mass affecting the right adrenal gland, detected by ultrasonography during follow-up for alcoholic liver cirrhosis. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed a mass of the right adrenal gland compressing the inferior vena cava (IVC) and dislocating the right lobe of the liver, with no invasion of kidney, liver, or IVC. Preoperative blood tests showed mild transaminase increase. Laparoscopic right adrenalectomy with lateral transperitoneal approach was performed. The postoperative course was uneventful. The lesion was diagnosed as a primitive adrenal oncocytic carcinoma (AOC). No recurrence was evidenced during 24-month follow-up. CONCLUSIONS Although AONs are very rare, they must be considered in the differential diagnosis of adrenal masses due to their prognostic difference compared to non-oncocytic tumors. AOCs are a rare presentation of AONs. Only 30 cases are described in the literature. Laparotomic adrenalectomy is the treatment of choice for AOC. We report the first case of laparoscopic lateral trans-abdominal adrenalectomy for a voluminous AOC (120×95×110 mm) and we review the literature regarding AOCs. Laparoscopy in experienced hands is safe and effective for the treatment of AONs. Despite the rarity of AOC, a case series should be performed to confirm the results of our case report.

Evaluation of a digital diabetes prevention program adapted for the Medicaid population: Study design and methods for a non-randomized, controlled trial.

Previous studies have shown that lifestyle modification can successfully prevent or delay development of type 2 diabetes. This trial aimed to test if an underserved, low-income population would engage in a digital diabetes prevention program and successfully achieve lifestyle changes to reduce their risk of type 2 diabetes. Participants were recruited from three health care facilities serving low-income populations. The inclusion criteria were: a recent blood test indicating prediabetes, body mass index (BMI) > 24 kg/m2, age 18-75 years, not pregnant, not insured, Medicaid insured or Medicaid-eligible, internet or smartphone access, and comfort reading and writing in English or Spanish. A total of 230 participants were enrolled and started the intervention. Participants' average age was 48 years, average BMI = 34.8, average initial HbA1c = 5.8, 81% were female, and 45% were Spanish speaking. Eighty percent had Medicaid insurance, 18% were uninsured, and 2% were insured by a medical safety net plan. Participants completed a health assessment including measured anthropometrics, HbA1c test, and self-report questionnaires at baseline, 6 and 12 months. The 52-week digital diabetes prevention program included weekly educational curriculum, human health coaching, connected tracking tools, and peer support from a virtual group. Qualitative data on implementation was collected with semi-structured interviews with key informants to understand the barriers, keys to success, and best practices in the adoption of the program within the clinical setting. This paper describes the study design and methodology of a digital diabetes prevention program and early lessons learned related to recruitment, enrollment, and data collection.

Practical Suggestions for Prevention of Complications Arising from Oxidized Cellulose Retention: A Case Report and Review of the Literature.

BACKGROUND Bleeding is a major intraoperative complication during surgical procedures. When conventional methods such as ligature and diathermocoagulation are ineffective for bleeding management, hemostatic agents should be used. Oxidized cellulose is one of the major hemostatic agents used worldwide. Oxidized cellulose is often left in situ after hemostasis because of its high level of reabsorption that lasts up to 8 weeks. However, 38 cases of retaining-associated complications are reported in the literature. CASE REPORT A 51-year-old male patient presented in our emergency department with acute abdominal pain, nausea, and vomiting. The patient had been admitted in our department for laparoscopic cholecystectomy for acute cholecystitis 25 months previously. Abdominal ultrasound and CT scan showed the presence of a cystic circular mass, with homogeneous fluid content, close to the surgical clips of the previous surgery, resembling a "neogallbladder". Laparoscopic abdominal exploration and drainage were performed. Histological examination reported protein-based amorphous material with rare lymphocytes and macrophages. Culturing was negative for bacterial growth. The patient was discharged uneventfully on the 4 th postoperative day. The primary surgical report was evaluated with evidence of application of Gelita-Cel ® Standard for hemostatic purposes. Results of 12-month follow-up were normal. CONCLUSIONS Herein, we report the first case of a complication associated with the use of Gelita-Cel ® Standard. We reviewed the literature to better define the purpose and limits of oxidized cellulose use as a hemostatic agent. Despite the fundamental role of oxidized cellulose as a hemostatic agent, we provide some practical suggestions to prevent the reported severe complications and surgical overtreatments.

What is this very big skin lesion?

This clinical image shows the importance of the early diagnosis and treatment of any suspicious skin lesion.

Adrenal Ganglioneuroblastoma in Adults: A Case Report and Review of the Literature.

Incidentally discovered adrenal masses are very common given the increased number of imaging studies performed in recent years. We here report a clinical case of a 20-year-old woman who presented with left flank pain. Ultrasound examination revealed a contralateral adrenal mass, which was confirmed at computed tomography (CT) scan. Hormonal hypersecretion was excluded. Given the size (11 × 10 × 7 cm) and the uncertain nature of the mass, it was surgically removed and sent for pathological analyses. Conclusive diagnosis was ganglioneuroblastoma. Ganglioneuroblastoma is an uncommon malignant tumor, extremely rare in adults, particularly in females. This neoplasm is frequently localized in adrenal gland.

Assessing the Use of Mobile Health Technology by Patients: An Observational Study in Primary Care Clinics.

BACKGROUND: There is significant potential for mobile health technology to improve health outcomes for patients with chronic diseases. However, there is a need for further development of mobile health technology that would help to improve the health of lower-income communities. OBJECTIVE: The study objective was to assess mobile phone and app usage among a culturally diverse patient population, and to determine whether patients would be interested in using mobile health technology to help manage their chronic diseases. METHODS: An observational study was conducted with patients of the Internal Medicine resident primary care clinics of Los Angeles County and University of Southern California (LAC+USC) Medical Center. Self-reported information regarding demographics, current mobile phone usage, current mobile health app and social media usage, barriers to using mobile phones or mobile health apps, and interest in using a mobile health app was collected. RESULTS: Ninety-one percent of patients owned a mobile phone, with 76% (169/223) of these reporting having a mobile phone with Internet capability. Fifty-seven percent of subjects used mobile apps on their mobile phones, and 32% (41/130) of these used mobile apps related to their health. Eighty-six percent (207/241) of respondents voiced interest in using a mobile app to improve their health, and 40% (88/221) stated they would use such an app daily. Patients stated they would find the mobile health app most useful for nutrition, exercise, and obtaining general information on medical conditions. CONCLUSIONS: Despite the fact that the majority of our primary care patients were of lower socioeconomic status, they utilized mobile phones with Internet and mobile app capabilities to a great extent. There was substantial interest among our patients in using mobile health technology to both manage chronic disease and improve overall health. Given that cultural, educational, and socioeconomic disparities strongly correlate with higher rates of chronic diseases such as obesity, diabetes and hypertension, access to culturally relevant mobile health tools may empower patients in these populations to improve health outcomes.

Role of frozen section examination in the management of testicular nodules: a useful procedure to identify benign lesions.

PURPOSE: To assess the validity of frozen section examination (FSE) on testis nodules. MATERIALS AND METHODS: A series of 86 preselected patients with testicular nodules were recruited in this study. Nodules smaller than 2 cm had been surgically removed and biopsies of the margins performed. Larger nodules were just biopsied. Orchiectomy was the treatment of choice for malignant lesions and stromal tumors. Conservative surgery was performed on 2 previously monorchid patients with Leydig cell tumor because of the presence of just one testis. Conservative surgery was the treatment of choice for benign lesions in 32 cases. RESULTS: At FSE we observed that nodules were malignant germinal tumors in 47% of the cases, stromal tumors in 7% of the cases, benign lesions in 45% of the cases and doubtful for lymphoproliferative lesion in 1 case. The diagnosis made by FSE were confirmed in the definitive ones in all of them, we reported just 2 cases of Leydig cell tumor and benign fibrosis lesion. In these 2 cases, definitive histology of the collected specimens revealed areas of Leydig cell hyperplasia and seminomatous foci, respectively. CONCLUSION: Our data suggest that FSE is a valid tool to discriminate between benign and malignant neoplastic lesions, particularly when an adequate sample is available.

In search of an unstimulated thyroglobulin baseline value in low-risk papillary thyroid carcinoma patients not receiving radioactive iodine ablation.

BACKGROUND: The clinical use of serum thyroglobulin (Tg) as a tumor marker in papillary thyroid cancer (PTC) patients following total thyroidectomy continues to evolve, due in part to the introduction of more sensitive (second generation) Tg immunometric assays (Tg(2G)IMA, functional sensitivity ≤ 0.10 ng/mL), and the implementation of new recommendations against radioactive iodine ablation (RAIA) for patients at the lowest risk of recurrence. As a result, there is a need to establish the optimal timing and interpretation of serum Tg values while on levothyroxine-induced suppression of thyrotropin (TSH) in thyroidectomized PTC patients with a thyroid remnant. This study examines the pattern of decline and eventual baseline value of unstimulated Tg (uTg) concentrations following total thyroidectomy in patients with low-risk PTC who did not receive RAIA. METHODS: The medical records of consecutive patients with thyroid cancer seen at the Los Angeles County + USC Medical Center were retrospectively reviewed. Serial uTg and TSH values from Tg-antibody negative low-risk PTC patients treated with total thyroidectomy and no RAIA were analyzed. Patients were stratified by degree of TSH suppression to assess the effect on uTg. Serial postoperative uTg values were evaluated for the temporal pattern of decline and ultimate baseline. Patients with medullary thyroid cancer (MTC) were studied as a surgical reference group. RESULTS: Records from 577 consecutive thyroid cancer patients were reviewed, of which 36 met all criteria for inclusion. By 6 months, uTg fell to <0.5 ng/mL in 61% of patients and all patients demonstrated uTg < 0.5 ng/mL 2 years after surgery. During a median follow up of 5.7 years, uTg values remained below this level. The median uTg values in patients with papillary microcarcinoma, PTC, and MTC were similar at 0.11, 0.12, and 0.09 ng/mL, respectively. Further decline in uTg was not observed once the TSH was <0.5 mIU/L. CONCLUSIONS: The uTg values during TSH suppression in Tg antibody-negative, low-risk PTC patients who did not receive RAIA were below 0.5 ng/mL by 6 months postoperatively in most cases and remained stable over the duration of patient follow-up.

Inverted papilloma of the bladder: a review and an analysis of the recent literature of 365 patients.

OBJECTIVES: Until the 1970s, inverted urothelial papilloma (IUP) of the bladder was generally regarded as a benign neoplasm. However, in the 1980s, several reported cases suggested the malignant potential of these papillomas, including cases with features indicative of malignancy, recurrent cases, and cases of IUP synchronous or metachronous with transitional cell carcinoma. The aim of this systematic review and analysis of the literature since 1990 to date is to contribute to unresolved issues regarding the biological behavior and prognosis of these neoplasms to establish some key points in the clinical and surgical management of IUP. MATERIALS AND METHODS: Database searches yielded 109 references. Exclusion of irrelevant references left 10 references describing studies that fulfilled the predefined inclusion criteria. RESULTS: One problem regarding these neoplasms is the difficulty of obtaining a correct histopathologic diagnosis. The main differential diagnosis is endophytic urothelial neoplasia, including papillary urothelial neoplasia of low malignant potential or urothelial carcinoma of low or high grade, while other considerably rare differential diagnoses include nephrogenic adenoma, paraganglioma, carcinoid tumor, cystitis cystica, cystitis glandularis, and Brunn's cell nests. The size of the lesions ranged from 1 to 50 mm (mean 12.8 mm). Most cases occurred in the fifth and sixth decade of life. The mean age of affected patients was 59.3 years (range 20-88 years). Analysis of the literature revealed a strong male predominance with a male/female ratio of 5.8:1. The most commonly reported sites of IUP were the bladder neck region and trigone. Of 285 cases included in 8 studies, 12 cases (4.2%) were multiple. Out of the total of 348 patients, 6 patients (1.72%) had a previous history of transitional cell carcinoma of the urinary bladder, 5 patients (1.43%) had synchronous transitional cell carcinoma of the urinary bladder, and 4 patients (1.15%) had subsequent transitional cell carcinoma of the urinary tract. The time before recurrence was <45 months (range 5-45 months, mean 27.7 months) after surgery. CONCLUSIONS: Inverted papilloma could be considered a risk factor for transitional cell carcinoma, and it is clinically prudent to exclude transitional cell cancer when it is diagnosed. Follow-up is needed if the histologic diagnosis is definitive or doubtful. We recommend 4-monthly flexible cystoscopy for the first year and then every 6 months for the subsequent 3 years. Routine surveillance of the upper urinary tract in cases of inverted papilloma of the lower part of the urinary tract is not deemed necessary.

Critical evaluation of the American Joint Committee on Cancer TNM nodal staging system in patients with lymph node-positive disease after radical cystectomy.

BACKGROUND: The current 7th edition of the American Joint Committee on Cancer TNM staging system for bladder cancer stages lymph node (LN)-positive disease based on LN location rather than LN size. In addition, common iliac LNs are now considered regional LNs. Whether these changes improve prognostication for node-positive patients, however, remains unclear. OBJECTIVE: To investigate whether the 7th edition of the TNM nodal staging system provides superior prognostication compared with the 6th edition. DESIGN, SETTING, AND PARTICIPANTS: Patients between 2002 and 2008 with LN metastases after radical cystectomy combined with extended or superextended LN dissection were included. Patients were staged using both TNM staging systems. Median follow-up was 54 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Kaplan-Meier curves were used to estimate overall survival (OS) and recurrence-free survival (RFS). Log-rank tests and Cox proportional hazard regression models were used to test associations of pathologic variables with OS and RFS. RESULTS AND LIMITATIONS: Included were 146 patients with LN metastases of whom 131 patients underwent superextended LN dissection and 15 patients underwent extended LN dissection. Although in the 7th TNM edition many patients moved from the N2 category to the N3 category, RFS did not significantly differ within the nodal subgroups in either editions. LN metastases at or above the aortic bifurcation were not associated with decreased RFS (p=0.67). On multivariable analysis, the presence of extravesical disease (hazard ratio [HR]: 2.84; p=0.002), absence of adjuvant chemotherapy (HR: 0.32; p<0.0001), and more than six positive LNs (HR: 2.72; p=0.007) were associated with decreased RFS. This was a retrospective study with inherent limitations. CONCLUSIONS: LNs at or above the aortic bifurcation should be considered regional LNs. Neither the 6th nor the 7th TNM staging system performed well as a prognostic tool. A better staging system for LN-positive bladder cancer needs to be developed.

A proposed new technique in prostate cancer tissue bio-banking: our experience with a new protocol.

The aim of our study, beyond validating a method of collecting and storing biological samples from patients with prostate cancer, was to validate an innovative biopsy method for the creation of a biobank of prostatic frozen tissues. Patients referred to our hospital between November 2008 and March 2010 to undergo radical prostatectomy were invited to participate in the study. Each patient's data were stored in two databases (personal information and clinical database) while samples of urine, blood and its derivatives, fresh material and formalin-processed tissue were stored in a correlated biobank. The proposed method for collecting fresh material was to take samples of the neoplastic tissue by carrying out targeted biopsies in the area indicated by the biopsy mapping as the site of the malignancy, under manual palpation to identify the neoplastic nodule. The site of sampling was marked by an injection of India ink. 55 patients agreed to participate in the study. In 43 cases biopsies were correct, with a mean of 48% of core involved by tumour (range, 10-90%). Overall the tumour detection rate was 78.2%. The protocol for collecting biological material and the new method for collecting fresh tissue reduce internal steps and staff involved, thereby reducing all those variables that cause heterogeneity of material and changes in its quality. This process provides high quality, low cost material for research on prostate cancer. The features of the collection protocol mean that the protocol can also be used in non-academic centres with only limited research funds.

Development of a chimeric recombinant disintegrin as a cost-effective anti-cancer agent with promising translational potential.

Vicrostatin (VCN) is a chimeric recombinant disintegrin generated in Origami B (DE3) Escherichia coli as a genetic fusion between the C-terminal tail of a viperid disintegrin echistatin and crotalid disintegrin contortrostatin (CN). The therapeutic modulation of multiple integrin pathways via soluble disintegrins was previously shown by us and others to elicit potent anti-angiogenic and anti-metastatic effects in several animal cancer models. Despite these favorable attributes, these polypeptides are notoriously difficult to produce recombinantly in significant quantity due to their structure which requires the correct pairing of multiple disulfide bonds for biological activity. In this report, we show that VCN can be reliably produced in large amounts (yields in excess of 200 mg of active purified disintegrin per liter of bacterial culture) in Origami B (DE3), an E. coli expression strain engineered to support the folding of disulfide-rich heterologous proteins directly in its oxidative cytoplasmic compartment. VCN retains the integrin binding specificity of both parental molecules it was derived from, but with a different binding affinity profile. While competing for the same integrin receptors that are preferentially upregulated in the tumor microenvironment, VCN exerts a potent inhibitory effect on endothelial cell (EC) migration and tube formation in a dose-dependent manner, by forcing these cells to undergo significant actin cytoskeleton reorganization when exposed to this agent in vitro. Moreover, VCN has a direct effect on breast cancer cells inhibiting their in vitro motility. In an effort to address our main goal of developing a clinically relevant delivery method for recombinant disintegrins, VCN was efficiently packaged in liposomes (LVCN) and evaluated in vivo in an animal breast cancer model. Our data demonstrate that LVCN is well tolerated, its intravenous administration inducing a significant delay in tumor growth and an increase in animal survival, results that can be partially explained by potent tumor apoptotic effects.

[Intestinal neuroendocrine tumor. Case report and review of the literature]. / Carcinoma endocrino (carcinoide) ileale. Caso clinico e revisione della letteratura.

Gastroenteropancreatic (GEP) neuroendocrine tumors are rare neoplasm and have proved to be slow growing malignancies which involve many organs and most frequently the gastrointestinal tract. They have a peculiary biological behaviour: most of them have endocrine function (carcinoid syndrome); many are clinically silent until late presentation. Symptoms are non specific; the most common are abdominal pain, nausea and vomiting, weight loss and gastrointestinal (GI) blood loss. Incidental carcinoid, discovered at the time of another procedure, occurred in 40% of patients, and in multiple site throughout the GI tract. Here we report a case of a 73-year-old male with an adenomatous colonic polyp, not suitable of endoscopic treatment, and a synchronous carcinoid of small intestine discovered during surgical procedure. Therefore we performed a review of literature with particular attention to diagnosis and strategy of the treatment.

Laparoscopic diagnosis of pleural mesothelioma presenting with pseudoachalasia.

Pseudoachalasia due to pleural mesothelioma is an extremely rare condition. A 70-year-old woman presented with progressive dysphagia for solid and liquids and a mild weight loss. A barium swallow study revealed an esophageal dilatation and a smoothly narrowed esophagogastric junction. An esophageal manometry showed absence of peristalsis. Endoscopy demonstrated an extrinsic stenosis of the distal esophagus with negative biopsies. A marked thickening of the distal esophagus and a right-sided pleural effusion were evident at computed tomography (CT) scan, but cytological examination of the thoracic fluid was negative. Endoscopic ultrasound showed the disappearance of the distal esophageal wall stratification and thickening of the esophageal wall. The patient underwent an explorative laparoscopy. Biopsies of the esophageal muscle were consistent with the diagnosis of epithelioid type pleural mesothelioma. An esophageal stent was placed for palliation of dysphagia. The patient died four months after the diagnosis. This is the first reported case of pleural mesothelioma diagnosed through laparoscopy.

Laparoscopic resection for incidentally detected Meckel diverticulum.

The management of Meckel diverticulum found unexpectedly during an abdominal operation remains controversial. Most published reports have included only patients undergoing diverticulectomy or bowel resection through laparotomy. We report a case of a carcinoid tumor in a Meckel's diverticulum which was incidentally detected and removed during laparoscopic inguinal hernia repair. Although there is no compelling evidence in the literature to recommend prophylactic diverticulectomy, laparoscopic stapled resection represents a viable and safe approach in healthy individuals undergoing elective surgery for other purposes.

The role of epithelial-mesenchymal transition in cancer pathology.

Invasion, the hallmark of malignancy, consists in the translocation of tumour cells from the initial neoplastic focus into neighbouring host tissues, and also allows tumour cells to penetrate vessel endothelium and enter the circulation to form distant metastasis. A histological pattern found at the periphery of carcinomas is the presence of individual malignant cells detached from the tumour mass and staying independently within the interstitial matrix of the stroma. While they are readily identified by the pathologist as invading malignant cells, their relationship with the compact-appearing portions of the tumour as well as the mechanism underlying the development of this pattern are not immediately evident at histological level. There is growing evidence suggesting that this change in tumour tissue architecture takes place through a peculiar phenotype modulation known as epithelial-mesenchymal transition (EMT). The essential features of EMT are the disruption of intercellular contacts and the enhancement of cell motility, thereby leading to the release of cells from the parent epithelial tissue. The resulting mesenchymal-like phenotype is suitable for migration and, thus, for tumour invasion and dissemination, allowing metastatic progression to proceed. Although the molecular bases of EMT have not been completely elucidated, several interconnected transduction pathways and a number of signalling molecules potentially involved have been identified. These include growth factors, receptor tyrosine kinases, Ras and other small GTPases, Src, beta-catenin and integrins. Most of these pathways converge on the down-regulation of the epithelial molecule E-cadherin, an event critical in tumour invasion and a 'master' programmer of EMT. E-cadherin gene is somatically inactivated in many diffuse-type cancers such as lobular carcinoma of the breast and diffuse gastric carcinoma, in which neoplastic cells through the entire tumour mass have lost many of their epithelial characteristics and exhibit a highly invasive, EMT-derived histological pattern. E-cadherin down-modulation is also seen in solid, non-diffuse-type cancers at the tumour-stroma boundary where singly invading, EMT-derived tumour cells are seen in histological sections. In this latter scenario, E-cadherin loss and EMT could be transient, reversible processes possibly regulated by the tumour microenvironment and, as a matter of fact, neoplastic cells that have undergone EMT during invasion seem to regain E-cadherin expression and their epithelial, cohesive characteristics at the secondary foci. Since the molecules involved in EMT represent potential targets for pharmacological agents, these findings open new avenues for the control of metastatic spread in the treatment of malignancies.

Carcinoma of the neck showing thymic-like elements (CASTLE): report of a case and review of the literature.

Carcinoma showing thymic-like elements (CASTLE) is a rare tumor affecting thyroid and neck soft tissues, which has to be distinguished from squamous cell and anaplastic thyroid carcinoma, because it has a better prognosis. We report a new case of CASTLE which occurred in a patient submitted to total thyroidectomy with central neck dissection. The tumor stained positively for CD5, which seems to be the most useful marker in the differential diagnosis. By the analysis of the 18 cases reported in literature, total thyroidectomy with selective modified neck dissection should be the treatment of choice and radiotherapy should be considered for patients with positive nodal status.