Tumor-to-tumor spread: a case report and literature review of renal cell carcinoma metastasis into thyroid cancer.

Tumor-to-tumor metastasis is a rare, yet important entity. Patients with a history of renal cell carcinoma (RCC) may have tumor deposits to the thyroid gland preceding or following their initial cancer diagnosis for many years. The diagnosis can be challenging, and clinicians must remain suspicious of a newly found thyroid nodule in a patient with a history of RCC. In this review, we report a case of a patient with RCC who was incidentally found to have a thyroid nodule on surveillance imaging found to be consistent with tumor-to-tumor metastasis from RCC into papillary thyroid carcinoma. It is imperative to consider this diagnosis as the thyroid is the most common site of spread, and treatment with partial or total thyroidectomy has led to improved survival.

Early Uncomplicated Appendicitis-Who Can We Treat Nonoperatively?

This study evaluated nonoperative treatment for mild appendicitis and reviewed selection criteria to be used in introducing this option into clinical practice. A retrospective review of 73 consecutive cases of appendicitis treated by a single surgeon from 2011 to 2013 was completed. Patients who were diagnosed with mild appendicitis meeting the criteria of an APPENDICITIS scoring algorithm proposed in this manuscript were considered for nonoperative management. An additional 17 patients with mild appendicitis were offered and successfully treated nonoperatively between 2014 and 2016 and reviewed. Of these original 73 patients, 37 had moderate to severe appendicitis and directly underwent appendectomy. The remaining patients were diagnosed with mild appendicitis and considered eligible for nonoperative management. Of these, 14 patients were offered nonoperative therapy. Thirteen responded successfully; one patient responded partially, but later opted for surgery. In 2014, this scoring system and preliminary results were shared with the other surgeons in our department. Nonoperative management was then selectively adopted by a few of the surgeons from 2014 to 2016 with another 17 patients (APPENDICITIS score of 0 or 1) being offered and successfully managed nonoperatively. Patients with mild or early appendicitis can be successfully managed nonoperatively. A proposed APPENDICITIS scoring system may provide a helpful mnemonic for successfully selecting patients for this option.

What have we learned over the past 20 years about appendicitis in the elderly?

BACKGROUND: This study evaluates appendicitis in the elderly, comparing our findings to those previously published a decade earlier. METHODS: Comparison of appendicitis in the elderly (aged 60 years and older) from 1978 to 1988 with the following 10 years, 1988 to 1998. RESULTS: Overall (1978-1998) 26% of patients presented typically, one third delayed seeking care, with only half diagnosed correctly on admission. Computed tomography (CT) use increased (44% versus rarely in the previous decade). Perforation rates declined (72% first group versus 51% second group) with a concomitant drop in complications from 32% to 21% respectively. Overall, three fourths of complications occurred in patients with perforated appendicitis. Mortality rates remained constant. CONCLUSIONS: Appendicitis in the elderly is a difficult problem with delays in medical care, non-typical presentation resulting in incorrect diagnosis, relatively high rates of perforation often with associated postoperative complications and mortality. A higher index of suspicion with liberal early utilization of CT in uncertain cases may result in more appropriate management.

Does preoperative rofecoxib (Vioxx) decrease postoperative pain with laparoscopic cholecystectomy?

BACKGROUND: A prospective, randomized, double-blinded clinical trial was designed to study the effects of preemptive rofecoxib (Vioxx) analgesia in patients undergoing elective laparoscopic cholecystectomy. METHODS: One hundred-twenty patients were enrolled in the study over a 21-month period, and 116 completed the study. One half of the patients received 50 mg rofecoxib preoperatively and the other half, placebo. Both groups were demographically similar. Medical information, patient and nursing assessments, and surgical data were evaluated. RESULTS: A significant reduction in requirements for postoperative narcotic analgesic dosing was noted in the rofecoxib group. In addition, patients receiving rofecoxib reported significantly less nausea and improvement in their activity level when compared with the control group. No complications were encountered with the preoperative use of rofecoxib. CONCLUSIONS: We conclude that in patients undergoing laparoscopic cholecystectomy, preoperative administration of rofecoxib in selected patients may facilitate postoperative recovery and decrease postoperative narcotic requirements.

Metastatic renal cell carcinoma to the thyroid gland.

OBJECTIVE: To examine the presentation, diagnosis, and appropriate management of renal clear cell carcinoma metastasis to the thyroid gland. METHODS: We describe a clinical case of solitary thyroid metastasis from renal clear cell carcinoma and present a comprehensive review of the related English-language literature. Common patterns of presentation and generalized overall management recommendations are evaluated and summarized. RESULTS: Eight years after nephrectomy for renal carcinoma at age 61 years, a man presented with a thyroid mass. Cytology and histopathologic surgical findings were consistent with a solitary metastasis most compatible with metastatic clear cell carcinoma from his previous renal carcinoma. After left thyroid lobectomy and isthmusectomy, the patient remains disease-free 5 years later. Although uncommon, nearly 150 cases of clinically recognized metastatic renal cell carcinoma to the thyroid have been reported in the English-language literature. Metastatic disease from the kidney to the thyroid gland can occur more than 20 years after nephrectomy with the average time interval being 7.5 years. Obtaining a full clinical history in any patient who presents with a thyroid nodule is essential to allow consideration of possible metastatic disease from previous primary tumor. Metastatic disease to the thyroid gland can be correctly diagnosed preoperatively. If metastatic renal cancer is limited to the thyroid gland only, prompt, appropriate surgical intervention can be curative. CONCLUSION: Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of renal cell carcinoma.

Ileal pouch perforation in pregnancy: report of a case and review of the literature.

Acute abdominal pain, especially in the presence of free intra-abdominal air, in a pregnant patient who has previously undergone ileal pouch-anal anastomosis may be a result of acute perforation of the pouch. The case of a 30-year-old multigravida with an uncomplicated pregnancy at 27 weeks gestation who was admitted to the perinatal ward for preterm labor is described. The patient's past medical history was significant for an ileal pouch-anal anastomosis for ulcerative colitis. Forty-eight hours after admission, she acutely developed generalized abdominal pain with associated dyspnea. A spiral CT of the chest to rule out pulmonary embolus revealed free intra-abdominal air. An emergency cesarean section was performed, which resulted in a viable female infant. The etiology for the free air was a perforation of the ileal pouch secondary to adhesions to the posterior part of the uterus. Perforation of the pouch has been reported secondary to a variety of factors. However, no cases of ileal pouch perforation in pregnancy have been reported. Adhesions that involve the pouch and an enlarged contracting uterus may result in perforation of the pouch. Awareness and knowledge of this potential complication may lead to earlier recognition and optimal management.