Management of liver trauma in adults.

The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.

Confirmation of a potential biomarker for early-stage pancreatic cancer.

INTRODUCTION: Pancreatic cancer has a dismal prognosis because it is often diagnosed at an advanced stage. Therefore, serological biomarkers are eagerly sought for early detection. The digestive enzyme pro-carboxypeptidase A (PCPA) may be able to fill this role. The purpose of this study was to validate and extend previous research done at New York University (NYU), demonstrating that measurement of serum PCPA is a sensitive biomarker for early stage pancreatic cancer. MATERIALS AND METHODS: Samples were collected from 10 early and 16 late stage patients at Jersey Shore University Medical Center (JSUMC) and Robert Wood Johnson Hospital (RWJ) with adenocarcinoma of the head of the pancreas. RESULTS: The percentages of early and late stage cancer patients with PCPA values above the upper limit (2.35 u/L) were 90.0% and 56.0%, respectively. Mean PCPA values for early and late stage cancer were determined to be 22.95 u/L and 3.55 u/L, respectively. In one case, the prospective patient was detected by our assay one month before diagnosis. Additionally, data from an ampullary cancer patient supports the proposed mechanism behind this test. CONCLUSIONS: Combining the JSUMC and NYU results show 94% sensitivity, demonstrating that determining serum PCPA has the requisite sensitivity to detect early stage pancreatic cancer.

Single nucleotide polymorphisms act as modifiers and correlate with the development of medullary and simultaneous medullary/papillary thyroid carcinomas in 2 large, non-related families with the RET V804M proto-oncogene mutation.

BACKGROUND: Single nucleotide polymorphisms (SNPs) may function as modifiers of the RET proto-oncogene, resulting in the expression of medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC). We present 2 non-related Italian-American families (Family 1, n = 107; Family 2, n = 31) with the RET V804M mutation. We have correlated the presence of specific SNPs and the rare RET V804M mutation to MTC, C-cell hyperplasia (CCH), and PTC. METHODS: Sequencing was performed on exons 10, 11, and 13-16 of the RET proto-oncogene. The presence of MTC, CCH, and PTC were correlated to specific SNPs. RESULTS: In both families, 3 SNPs in exon 11 (G691S), exon 13 (L769L), and exon 15 (S904S) were detected in 100% of patients with overt MTC. The SNP L769L was present in all patients including patients with PTC, MTC, and CCH. CONCLUSION: SNP analysis revealed a similar pattern between the 2 families. SNPs in exon 11 (G691S) and exon 15 (S904S) appear to influence the development of MTC. A SNP in exon 13 (L769L) may serve as a modifier in the development of simultaneous MTC and PTC, as well as presentation of MTC, in patients with the RET V804M mutation.

One hundred and seven family members with the rearranged during transfection V804M proto-oncogene mutation presenting with simultaneous medullary and papillary thyroid carcinomas, rare primary hyperparathyroidism, and no pheochromocytomas: is this a new syndrome--MEN 2C?

BACKGROUND: The rearranged during transfection (RET) V804M proto-oncogene mutation is rare and associated with medullary thyroid carcinoma (MTC). We present 40 members from a total cohort of 107 family members with this mutation. METHODS: Family members were tested for RET mutations, calcitonin levels, and screened for pheochromocytoma and primary hyperparathyroidism (PHPT). Thyroidectomies were performed on 15 members. Surgery and pathology reports were obtained and reviewed. A pedigree was constructed. RESULTS: A high penetrance was found for MTC and simultaneous papillary thyroid carcinoma (PTC; 40%). The incidence of PHPT was low (13%). There were no findings of pheochromocytoma. The course in the first family generation was indolent, with late onset of MTC. The second generation experienced earlier disease development; onset occurred earliest in the third generation. The second generation experienced a higher incidence of PTC than the first. CONCLUSION: This is the largest family with this mutation reported to date. However, it does not fit the classic familial MTC or MEN 2A cancer syndrome. Considering that PTC is not an incidental finding, but the result of an inherited RET V804 M mutation, we propose to identify this phenotypic expression as a unique syndrome consistent with manifestations of MTC, PHPT, and PTC.

Pancreatic injury.

Injury to the pancreas, because of its retroperitoneal location, is a rare occurrence, most commonly seen with penetrating injuries (gun shot or stab wounds). Blunt trauma to the pancreas accounts for only 25% of the cases. Pancreatic injuries are associated with high morbidity and mortality due to accompanying vascular and duodenal injuries. Pancreatic injuries are not always easy to diagnose resulting in life threatening complications. Physical examination as well as serum amylase is not diagnostic following blunt trauma. Computed tomography (CT) scan can delineate the injury or transaction of the pancreas. Endoscopic retrograde pancreaticography (ERCP) is the main diagnostic modality for evaluation of the main pancreatic duct. Unrecognized ductal injury leads to pancreatic pseudocyst, fistula, abscess, and other complications. Management depends upon the severity of the pancreatic injury as well as associated injuries. Damage control surgery in hemodynamic unstable patients reduces morbidity and mortality.

A thyroglossal duct cyst presenting as a thyroid nodule in the lateral neck.

The patient is a 55-year-old female with a history of multinodular goiter. She was followed for several years for a dominant left-sided superior pole thyroid nodule. Several prior fine needle aspiration biopsies had been performed. All were consistent with the diagnosis of degenerative colloid nodule. Eventually she developed symptoms of intermittent choking and shortness of breath and presented for surgical evaluation. On physical examination, including ultrasound, a left-sided superior thyroid nodule was noted. At operation, the nodule was found to be completely separate from the thyroid. Dissection revealed a thyroglossal duct cyst (TDC) located lateral to the superior pole of the thyroid gland, attached to the mid portion of the hyoid bone by a pedicle. The standard Sistrunk procedure was performed. Here we describe an unusual late presentation of a TDC located lateral to a multinodular goiter and producing compressive symptoms.