27402652
Primary peritoneal carcinoma: a diagnostic dilemma
We read with deep interest the report by Bhuyan et al. [1] detailing diagnosis and management aspects of extra ovarian primary peritoneal carcinoma (EOPPC). Indeed the clinician is intrigued by the presentation of EOPPC and equally challenging is the management because of limited guidance available in literature with these tumours. We recently diagnosed EOPPC in a 62-year-old lady and would like to share the atypical presentation of the carcinoma. This patient had received six cycles of chemotherapy (paclitexal and cisplatin) for papillary adenocarcinoma. At prior exploratory laparotomy, there was an inoperable mass adherent to transverse colon serosa with liver metastasis. As no primary site of tumour was discernable, biopsies from peritoneum and peritoneal washings were taken revealing papillary adenocarcinoma. Post chemotherapy, computed tomography scan showed resolution of ascitis, normal-sized bilateral adnexa and uterus; however, omental thickening and liver metastasis still persisted. Serum CA125 level decreased from 200 to 17.5 IU/ml. At subsequent debulking laparotomy, there was no free Xuid in abdomen but a large desmoplastic transverse colon [2] was seen. The uterus with bilateral adnexa was normal in size and shape; however, multiple hard peritoneal deposits ranging 1–10 cm in size were present in the mesentery, inWltrating up to the wall of transverse colon. Panhysterectomy and resection of transverse colon mass was done. The second laparotomy again could not reveal the primary site of tumour. Repeated histopathology of colonic segment showed serous papillary adenocarcinoma with numerous psammoma bodies inWltrating serosa and reaching up to muscularis propria. Both ovaries showed superWcial cortical involvement by the same tumour (Figs. 1, 2). Serosal aspect of both fallopian tubes, mesentery and parametrium were also studded with the same tumour. Since the gynaecologic oncology group criteria were fulWlled in our case, a diagnosis of EOPPC was rendered [3]. In our case, positive immunostaining for pan-cytokeratin (CK) and estrogen receptor, and negative staining for calretinin further supported the
15280827
An Unusual Etiology of Spontaneous Pyometra Perforation; A Case Report
Introduction By presenting this case we aimed to describe an uncommon complication of generalized peritonitis following spontaneous pyometra perforation in untreated cervical carcinoma. Case Presentation This report describes a 60-year-old postmenopausal woman presenting with clinical features mimicking intestinal perforation who was later diagnosed as cervical carcinoma with pyometra perforation at exploratory laparotomy. The patient had good post-operative recovery following drainage and peritoneal lavage. Conclusion Spontaneous pyometra perforation in a case of untreated carcinoma of cervix is a rare condition, yet it should be suspected and kept in the differential diagnosis of acute abdomen in elderly women.
19302108
Gone astray: Imaging suggested an ovarian tumor, but physicians identified something quite different.
26142710
Pregnancy concomitant with metastatic adult granulosa cell tumor
IntroductionMetastatic adult granulosa cell tumor of the ovary is rarely encountered with pregnancy.Case report and resultsPrimigravida (26 years) presented at 20 weeks of gestation with acute abdomen and clinical evidence of supraclavicular lymphadenopathy and ascites. She was diagnosed of adult granulosa cell tumor (AGCT) of the right ovary following right salpingoophrectomy done 1 month prior to conception. Fine needle aspiration cytology of supraclavicular lymph node, revealed it to be a metastatic AGCT. Chemotherapy was given antepartum and she delivered a healthy preterm baby at 30 weeks. Subsequently, she had optimal debulking surgery following 6 cycles of cisplatin-based chemotherapy. Baby at 10 months of age was with normal milestones.ConclusionsThe case is an unusual presentation of metastatic adult granulosa cell tumor at child bearing age. Although rapidly progressing, successful prolongation of pregnancy till 30 weeks of gestation was possible with the judicious use of chemotherapy. Fetal and maternal outcomes were favorable.
43350372
Morbidly Adherent Placenta: A Critical Review
ObjectiveTo evaluate the demographic profile, high risk factors, fetomaternal outcome and management options in morbidly adherent placenta (MAP).Study DesignRetrospective analysis.MethodologyReview of 20 case records of women with MAP during year 2001–2006.ResultsThe mean age and parity of the women was 27.7 ± 4.2 years and 2.5 respectively. 70 % women had previous uterine scar, and similar number had placenta previa. 60 % women presented with antepartum hemorrhage and 20 % with retained placenta. 85 % women underwent hysterectomy with 5 % requiring internal iliac artery ligation, another 5 % partial cystectomy and 15 % bladder repair. Blood loss was between one and nine litres requiring an average of six units whole blood and 4 units FFP. There were six (30 %) maternal deaths. 55 % of the newborns were preterm and the perinatal mortality was 33.3 %.ConclusionCesarean section and placenta previa are significant risk factors. MAP is associated with high fetomaternal morbidity and mortality.
17705748
Placental Mesenchymal Dysplasia: A Case Report
Introduction. A rare case of histologically proven placental mesenchymal dysplasia (PMD) with fetal omphalocele in a 22-year-old patient is reported. Material and Methods. Antenatal ultrasound of this patient showed hydropic placenta with a live fetus of 17 weeks period of gestation associated with omphalocele. Cordocentesis detected the diploid karyotype of the fetus. Patient, when prognosticated, choose to terminate the pregnancy in view of high incidence of fetal and placental anomalies. Subsequent histopathological examination of placenta established the diagnosis to be placental mesenchymal dysplasia. Conclusion. On clinical and ultrasonic grounds, suspicion of P.M.D. arises when hydropic placenta with a live fetus presents in second trimester of pregnancy. Cordocentesis can detect the diploid karyotype of the fetus in such cases. As this condition is prognostically better than triploid partial mole, continuation of pregnancy can sometimes be considered after through antenatal screening and patient counseling. However, a definite diagnosis of P.M.D. is made only on placental histology by absence of trophoblast hyperplasia and trophoblastic inclusions.
8134220
Prognostic factors in ovarian cancer: how close are we to a complete picture?
Prognostic factors in ovarian cancer: how close are we to a complete picture? Ovarian cancer is the fourth most common cause of cancer-related death in women, but is the most lethal of the gynaeco-logical malignancies with 30–40% overall survival at 5 years [1]. This is in part because the majority of patients with ova-rian cancer present with advanced disease, and treatment options at presentation are confined to a combination of debulking surgery and platinum based chemotherapy, which are only partially effective [2]. Consequently, almost all patients with advanced disease ultimately relapse and die of their disease. Advances in the management of these patients are therefore urgently required. Prognostic factors are defined as phenotypes which correlate with overall survival. In general prognostic factors reflect the intrinsic biology of a tumour (e.g. histological subtype, grade), disease extent (e.g. stage) and/or the capacity of a patient to cope with the morbidity associated with the tumour and treatment (e.g. performance status). As well as these pretreatment factors, others which may impact on outcome include the treatment received by a patient (e.g. optimal surgical cytore-duction, platinum-based chemotherapy), and the effect of treatment on the tumour (e.g. complete response) or the patient (e.g. myelosuppression). As clinical tools, prognostic factors can potentially help in individualising treatment for patients. In properly staged early disease (stage Ia/b), patients have a better prognosis and the benefits of adjuvant chemotherapy may be confined to those with adverse features (e.g. histological subtype or grade) [3]. In this context a prognostic factor with a good positive or negative predictive value for individual patients, would be useful in deciding which patients should receive chemotherapy and those for whom the toxicity was not justified. In contrast, in advanced disease, the majority of patients benefit from paclitaxel –carboplatin chemotherapy and debulking surgery. As there are no established alternatives for patients with either good or poor prognosis, pretreatment prognostic stratification has little influence on clinical management [2]. Instead, pre-treatment markers predictive of response or resistance to individual cytotoxic drugs would be more useful in this context for treatment selection. As research tools, prognostic factors can help identify subgroups of patients with especially poor prognosis and alert us to the need to develop alternative treatment strategies for these patients, while in clinical trials prognostic factors are used to balance patients between treatment arms to minimise the risk of confounding. Prognostic factor studies can also provide useful insights into …
1052854
Photodynamic effects of chloroaluminum phthalocyanine tetrasulfonate are mediated by singlet oxygen: in vivo and in vitro studies utilizing hepatic microsomes as a model membrane source.
Chloroaluminum phthalocyanine tetrasulfonate (AlPcTS) is a promising photosensitizer for the photodynamic therapy (PDT) of cancer. In this study, we investigated the in vivo and in vitro photodestruction of hepatic microsomal membranes by AlPcTS and studied the role of reactive oxygen species in this process. Irradiation of hepatic microsomes prepared from AlPcTS-pretreated SENCAR mice to approximately 675 nm light resulted in rapid destruction of cytochrome P450 and associated monooxygenase activities, and enhancement of lipid peroxidation in a light-dose-dependent manner. The specificity of AlPcTS and light dependency on photodestruction of microsomal membranes was confirmed by Western blot analysis. Similar results were obtained when AlPcTS was added in vitro to a suspension of hepatic microsomes prepared from control animals followed by irradiation to approximately 675 nm light. Among the quenchers of singlet oxygen, superoxide anion, hydrogen peroxide, and hydroxyl radical, only the quenchers of singlet oxygen such as sodium azide, histidine, and 2,5-dimethyl furan afforded substantial protection in a dose-dependent manner against AlPcTS-mediated photodestruction of cytochrome P450 and associated monooxygenase activities, and photoenhancement of lipid peroxidation under both in vivo and in vitro conditions. These results suggest that lipid-rich microsomal membranes may be the potential targets of cell injury by AlPcTS-based PDT and that this process is mediated by singlet oxygen.
30308813
Strategies and feasibility of hypertension control in a prevalent hemodialysis cohort.
BACKGROUND
There are few data to demonstrate the feasibility of long-term blood pressure (BP) control using short dialysis sessions as practiced in the US. Control of hypertension in hemodialysis patients may reduce the risk of cardiovascular events.


METHODS
Forty-two dialysis patients had BPs and weights recorded before and after dialysis for two consecutive weeks and were followed by one physician over three years. Patients were treated by ultrafiltration and conventional antihypertensive drugs and BPs were repeated at three years in the 32 survivors.


RESULTS
93% of the patients (39/42) were African-American. At inception, 85% of the patients were hypertensive with BPs of 154 +/- 23/83 +/- 14 mmHg and 137 +/- 22/74 +/- 14 mmHg pre- and post-dialysis, respectively. The response to ultrafiltration was dependent upon gender, with women having a greater BP reduction compared to men. At three-year follow-up, the BP had dropped significantly in the survivors a mean of 9.4/6.7 mmHg. Pre- and post-dialysis weights, post dialysis BP and interdialytic weight-gain were unchanged. The BP reduction was achieved by an increase in the number of antihypertensive medications from 0.91 +/- 0.86 medications to 1.41 +/- 1.16. Improved BP control did not worsen the efficiency of dialysis (Kt/V). The use of beta-blockers doubled during the period of follow-up. Compared to the USRDS average cardiovascular death rate, the risk of cardiovascular deaths was improved 80% over three years.


CONCLUSION
Long-term BP reduction can be achieved through the use of antihypertensive agents and volume control in a predominantly African-American hemodialysis population. This may impact cardiovascular mortality.
16937355
Intradialytic hypertension is a marker of volume excess.
BACKGROUND
Intradialytic blood pressure (BP) profiles have been associated with all-cause mortality, but its pathophysiology remains unknown. We tested the hypothesis that intradialytic changes in BP reflect excess volume.


METHODS
The dry weight reduction in hypertensive haemodialysis patients (DRIP) trial probed dry weight in 100 prevalent haemodialysis patients; 50 patients who did not have their dry weight probed served as time controls. In this post hoc analysis, intradialytic BP was recorded at each of the 30 dialysis treatments during the trial. The slope of intradialytic BP over dialysis was calculated by the log of BP regressed over time. Using a linear mixed model, we compared these slopes between control and ultrafiltration groups at baseline and over time, tested the effect of dry weight reduction on these slopes and finally tested the ability of change in intradialytic slopes to predict change in interdialytic systolic BP.


RESULTS
At baseline, intradialytic systolic and diastolic BP dropped at a rate of ~3%/h (P < 0.0001). Over the course of the trial, compared to the control group, the slopes steepened in the ultrafiltration group for systolic but not diastolic BP. Those who lost the most post-dialysis weight from baseline to 4 weeks and baseline to 8 weeks also experienced the greatest steepening of slopes. Each percent per hour steepening of the intradialytic systolic BP slope was associated with 0.71 mmHg [95% confidence interval (CI) 0.01-1.42, P = 0. 048] reduction in interdialytic ambulatory systolic pressure.


CONCLUSIONS
Intradialytic BP changes appear to be associated with change in dry weight among haemodialysis patients. Among long-term haemodialysis patients, intradialytic hypertension may, thus, be a sign of volume overload.
205502379
Mediastinal mass in an asthmatic patient.
A 52-year-old man with a 2-year history of asthma was referred to theChestClinic becauseofworseningdyspnoea of 1-year duration. He was non-compliant with inhalers and was taking oral prednisolone as needed for control of asthma. There were no other complaints. Physical examinationshowedanobeseman(bodymass index37.8 kg/m) with cushingoid habitus. Examination of the respiratory system showed diffuse bilateral wheeze. Cardiovascular, neurological and abdominal examinations were normal. Spirometry showed moderate airway obstruction with significant bronchodilator reversibility. A chest radiograph showed a superior mediastinal widening. The possibility of upper airway obstruction secondary to the mediastinal mass was considered. Subsequently, high-resolution computed tomography (CT, Fig. 1) showed a low-attenuation unencapsulated mass in the anterior mediastinum (bold arrow), para-aortic (arrow head) and the paratracheal region (small arrow). Also seen was increased extrapleural fat (cleaved arrow head) consistent with a diagnosis of mediastinal lipomatosis. Serum cortisol at 8.00 hours was 55 nmol/L, suggesting suppression of endogenous cortisol secretion. The patient was initiated on inhaled steroids. Prednisolone 20 mg/daywas continued and slowly tapered by 2.5 mg/month. The patient was advised therapeutic lifestyle changes in the form of strict diet control and exercise. He lost 8 kg of weight over the next 6 months and is doing well on follow up. A short Synacthen test with 250 lg Synacthen was carried out at 6 months, which showed an incremental cortisol response of 330 nmol/L at 1 h. Mediastinal lipomatosis is a benign condition that can occur either secondary to obesity and exogenous Cushing’s syndrome, or as a part of symmetrical lipomatosis and is a rare cause of mediastinal mass. Its usual appearance at CT is smooth widening of the upper anterior mediastinum without tracheal deformity. Associated increase in extrapleural fat is a helpful diagnostic feature. At CT the uniform density of fat (270 to 2130 Hounsfield units) is obvious. The importanceof identifying this condition is the fact that except for the radiological opacity, it is an ‘innocent bystander’ and is generally of no pathophysiological consequence to the patient. A condition that resembles mediastinal lipomatosis, but needs to be differentiated, is multiple symmetrical lipomatosis; however, in this condition, multiple masses of benign fat compress the mediastinal structures especially trachea.