Sclerotic Bone Metastasis in Pulmonary Adenocarcinoma

Pulmonary adenocarcinoma is one of the major types of lung cancers in which metastasis is very common and it accounts approximately to one-third of all primary pulmonary cancers. Although a minority of patients with lung cancer are asymptomatic, which gets usually detected in routine chest radiography, most of the patients present with some symptoms. Lung cancer metastasis may occur virtually in every organ system. Patients with non-small-cell lung cancer commonly have extrathoracic metastases to the adrenal glands, liver, brain, bones, and lymph nodes at presentation. Approximately one-third of patients with lung cancer will present with symptoms related to extrathoracic spread. Metastasis to the bone is not uncommon in lung cancer; however, osteoblastic bone metastasis is very rare. Here we present a 30-year-old female diagnosed to have pulmonary adenocarcinoma with multiple sclerotic bony lesions in the vertebra.

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Progression-Free Survival at 24 Months (PFS24) and Subsequent Outcome For Patients With Diffuse Large B-Cell Lymphoma (DLBCL) Enrolled On Randomized Clinical Trials

Abstract

Background

Patients with diffuse large B-cell lymphoma treated with first-line anthracycline based immunochemotherapy and remaining in remission at two years have excellent outcomes. This study assessed overall survival (OS) stratified by progression-free survival at 24 months (PFS24) using individual patient data from patients with DLBCL enrolled in multi-center, international randomized clinical trials as part of the SEAL collaboration.

Patients and Methods

PFS24 was defined as being alive and progression-free 24 months after study entry. OS from PFS24 was defined as time from identified PFS24 status until death due to any cause. OS was compared to each patient's age-, sex-, and country-matched general population using expected survival and standardized mortality ratios (SMRs).

Results

5853 patients enrolled in trials in the SEAL database received rituximab as part of induction therapy and were included in this analysis. The median age was 62 years (range 18-92), and 56% were greater than 60 years of age. At a median follow-up of 4.4 years, 1337 patients (23%) had disease progression, 1489 (25%) had died, and 5101 had sufficient follow-up to evaluate PFS24. 1423 evaluable patients failed to achieve PFS24 with a median OS of 7.2 months (95% CI 6.8-8.1) after progression; 5-year OS after progression was 19% and SMR was 32.1 (95% CI: 30.0-34.4). 3678 patients achieved PFS24; SMR after achieving PFS24 was 1.22 (95% CI: 1.09-1.37). The observed OS versus expected OS at 3, 5, and 7 years after achieving PFS24 was 93.1% vs. 94.4%, 87.6% vs. 89.5%, and 80.0% vs. 83.7%, respectively.

Conclusion

Patients treated with rituximab containing anthracycline-based immunochemotherapy on clinical trials who are alive without progression at 24 months from the onset of initial therapy have excellent outcomes with survival that is marginally lower but clinically indistinguishable from the age-, sex-, and country-matched background population for seven years after achieving PFS24.

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Improving Clinical Proficiency Using a 3-Dimensionally Printed and Patient-Specific Thoracic Spine Model as a Haptic Task Trainer

Background and Objectives Advanced haptic simulators for neuraxial training are expensive, have a finite life, and are not patient specific. We sought to demonstrate the feasibility of developing a custom-made, low-cost, 3-dimensionally printed thoracic spine simulator model from patient computed tomographic scan data. This study assessed the model's practicality, efficiency as a teaching tool, and the transfer of skill set into patient care. Methods A high-fidelity, patient-specific thoracic spine model was used for the study. Thirteen residents underwent a 1-hour 30-minute training session prior to performing thoracic epidural analgesia (TEA) on patients. We observed another group of 14 residents who were exposed to the traditional method of training during their regional anesthesia rotation for thoracic epidural placement. The TEA was placed for patients under the supervision of attending anesthesiologists, who were blinded to the composition of the study and control groups. As a primary outcome, data were collected on successful TEAs, which was defined as a TEA that provided full relief of sensation across the entire surgical area as assessed by both a pinprick and temperature test. Secondary outcomes included whether any assistance from the attending physician was required and failed epidurals. Results A total of 27 residents completed the study (14 in the traditional training, 13 in the study group). We found that the residents who underwent training with the simulator had a significantly higher success rate (11 vs 4 successful epidural attempts, P = 0.002) as compared with the traditional training group. The control group also required significantly more assistance from the supervising anesthesiologist compared with the study group (5 vs 1 attempt requiring guidance). The number needed to treat (NNT) for the traditional training group was 1.58 patients over the study period with a 95% confidence interval of 1.55 to 1.61. Conclusions By using patient-specific, 3-dimensionally printed, thoracic spine models, we demonstrated a significant improvement in clinical proficiency as compared with traditional teaching models. Accepted for publication January 31, 2018. Address correspondence to: Robina Matyal, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (e-mail: rmatyal1@bidmc.harvard.edu). Research support was provided by the Foundation for Anesthesia Education and Research Grant. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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The 8th edition American Joint Committee on gastric cancer pathological staging classification performs well in a population with high proportion of locally advanced disease

Publication date: Available online 11 June 2018
Source:European Journal of Surgical Oncology
Author(s): Shu-Fang Huang, Ti-Hsuan Chien, Wen-Liang Fang, Frank Wang, Chun-Yi Tsai, Jun-Te Hsu, Chun-Nan Yeh, Tse-Ching Chen, Ren-Chin Wu, Cheng-Tang Chiu, Ta-Sen Yeh
BackgroundThe 8th edition of AJCC gastric cancer pathological staging system (AJCC8) derived from the IGCA database needs an external validated in cohorts with higher proportion of advanced disease.Patients and methodsA total of 5,386 gastric cancer patients treated at Chang Gung Memorial Hospital (CGMH) and Veteran General Hospital in Taipei (TVGH) were enrolled. Clinicopathological data of the IGCA series and the CGMH/TVGH cohort were compared. Cumulative survival curves of the CGMH/TVGH cohort as stratified by the AJCC7 and the AJCC8 were compared. Lymph node ratio (LNR) was analyzed in patients with N3b disease.ResultsPatients in the CGMH/TVGH cohort were older and had more advanced tumor stage (stage III, 49% versus 26%, p<0.001) than those in the IGCA cohort. The median survival of stages IIIA, IIIB, and IIIC as defined by the AJCC 8 were 49, 27 and 15 months, respectively, with narrower 95% confidence intervals, in comparison with 62, 30 and 18 months, respectively, as defined by the AJCC7. The AJCC8 exhibited better homogeneity within stages and discriminatory ability between stages, compared to the AJCC7. Six hundred and four patients with N3b disease were stratified by LNR into three subgroups, and their median survival were 31, 17, and 11 months, respectively (p<0.001). LNR further appeared as a powerful outcome predictor of N3b disease (HR, 3.1).ConclusionThe AJCC8 performs well in patients with high proportion of advanced gastric cancer. We recommend that LNR is a supplementary prognostic indicator for N3b disease.



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Fellatio-associated erythema of the soft palate: an incidental finding during a routine dental evaluation

Oral lesions can have widely variable aetiology, hence, the importance of a comprehensive history and oral examination. We describe the case of a 47-year-old man who presented with an incidental erythematous lesion of the soft palate. The diagnosis was established during a routine dental examination. We found the lesion to be associated with the practice of fellatio. Oral sex is a very common sexual practice, and as clinicians we should consider it as a potential cause of palatal lesions in our differential diagnosis. This should also raise our suspicion for sexually transmitted diseases in high-risk patients.

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Recurrent meningitis caused by idiopathic cerebrospinal fluid rhinorrhoea from the sphenoid sinus

Description

A 41-year-old woman with 7 days of fever and headache had loss of consciousness 1 day prior to presentation. Despite the absence of trauma or other significant medical history, she had two episodes of meningitis in the previous 6 months. Physical examination showed no nuchal rigidity or abnormal findings on nasal endoscopy. Lumbar puncture showed a cerebrospinal fluid cell count of 750/μl. CT showed a bony defect of the posterior wall of the sphenoid sinus, which was filled with a soft tissue density. MRI showed fluid intensity in the same area (figure 1A, B). The diagnosis was recurrent meningitis due to possible idiopathic cerebrospinal fluid rhinorrhoea. Although a cisternogram is normally recommended, emergency drainage of the sphenoid sinus with antibiotic treatment was prioritised because of her deteriorating condition. With various possible diagnoses, an experienced surgeon operated on the patient. 

Figure 1

A bony defect of...

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Management of placenta percreta in a Jehovahs Witness patient

Placenta percreta is increasing in incidence and is associated with the risk of life-threatening haemorrhage. Patients who do not accept blood products present a unique challenge to obstetrician-gynaecologists. In this case report, we present the case of a 42-year-old pregnant Jehovah's Witness with a complete placenta previa and confirmed percreta at 26 weeks' gestation. Due to her religious beliefs against the use of blood products, she was managed with a stepwise surgical approach which involved caesarean delivery with internal iliac (hypogastric) artery ligation, weekly methotrexate and delayed hysterectomy 6 weeks later. Non-traditional, alternative approaches to the management of abnormal placentation in patients declining blood products warrant exploration.

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