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Tongue: the unusual site in malignant pleural mesothelioma.
No full textMalignant mesotheliomas (MMs) are malignancies of the mesothelium, with primary deposits originating in the pleura, peritoneum, pericardium and the tunica vaginalis (ie, testicular). Metastatic spread is commonly reported to affect the liver, adrenal glands, kidney and contralateral lung (in cases of malignant pleural mesothelioma). Metastases to distant sites are uncommon. Spread to the oral cavity in particular is very rare. A total of 23 cases of metastatic spread to the oral cavity have been reported in the literature to date; of those, 9 cases have been to the tongue. Given the rarity of the site of metastasis, the management remains challenging. This case highlights a rare site of metastasis in MM, discusses treatment options available and briefly talks about technical limitations in treating a mobile structure such as the tongue. Good palliative and supportive care is crucial in managing cases where no curative treatment is possible
Management of Primary Retroperitoneal Sarcoma (RPS) in the Adult: An Updated Consensus Approach from the Transatlantic Australasian RPS Working Group.
No full textBACKGROUND
Retroperitoneal soft tissue sarcomas comprise a heterogeneous group of rare tumors of mesenchymal origin that include several well-defined histologic subtypes. In 2015, the Transatlantic Australasian RPS Working Group (TARPSWG) published consensus recommendations for the best management of primary retroperitoneal sarcoma (RPS). Since then, through international collaboration, new evidence and knowledge have been generated, creating the need for an updated consensus document.
METHODS
The primary aim of this study was to critically evaluate the current evidence and develop an up-to-date consensus document on the approach to these difficult tumors. The resulting document applies to primary RPS that is non-visceral in origin, with exclusion criteria as previously described. The relevant literature was evaluated and an international group of experts consulted to formulate consensus statements regarding the best management of primary RPS. A level of evidence and grade of recommendation were attributed to each new/updated recommendation.
RESULTS
Management of primary RPS was considered from diagnosis to follow-up. This rare and complex malignancy is best managed by an experienced multidisciplinary team in a specialized referral center. The best chance of cure is at the time of primary presentation, and an individualized management plan should be made based on the 29 consensus statements included in this article, which were agreed upon by all of the authors. Whenever possible, patients should be enrolled in prospective trials and studies.
CONCLUSIONS
Ongoing international collaboration is critical to expand upon current knowledge and further improve outcomes of patients with RPS. In addition, prospective data collection and participation in multi-institution trials are strongly encouraged
Neoadjuvant chemoradiotherapy or chemotherapy: what is the future of oesophageal cancer management?
No full textDifferential diagnosis and management of hyperpigmentation.
No full textThere is an increasing recognition of ethnic dermatology to reflect the rising skin of colour (SOC) population. Hyperpigmentary disorder is one of the commonest skin concerns in SOC but there have been limited training available in this field of dermatology. Variations in skin colour is genetically determined by the amount of melanin content, eumelanin:pheomelanin ratio and size of melanosomes but also influenced by extrinsic factors such as ultraviolet (UV) and hormones. Hyperpigmentation is a broad terminology describing increased pigmentation and making a correct diagnosis is an important first step in the successful management of hyperpigmentary disorder. A systematic approach based on its pathogenesis (e.g., reactive vs. non-reactive, increased melanin vs. increased number of cells or epidermal vs. dermal pigmentation) aided by a detailed history and clinical examination would be best way to diagnose a hyperpigmentary disorder. Based on its pathogenesis, management can be planned. For epidermal hyperpigmentation caused by increased melanin, topical skin lightening agents targeting inhibition of tyrosinase or melanosome transfer as well as increasing keratinocyte turnover can be used. Hydroquinone-containing cream is the gold standard treatment for epidermal hyperpigmentation. Alternative treatments include laser toning or chemical peels. However, increased dermal pigmentation is more challenging to target with topical treatments. If hyperpigmentation is due to the increased number of melanocytes or keratinocytes, high-fluence treatment with laser would be most appropriate
Predicting sex from retinal fundus photographs using automated deep learning.
No full textDeep learning may transform health care, but model development has largely been dependent on availability of advanced technical expertise. Herein we present the development of a deep learning model by clinicians without coding, which predicts reported sex from retinal fundus photographs. A model was trained on 84,743 retinal fundus photos from the UK Biobank dataset. External validation was performed on 252 fundus photos from a tertiary ophthalmic referral center. For internal validation, the area under the receiver operating characteristic curve (AUROC) of the code free deep learning (CFDL) model was 0.93. Sensitivity, specificity, positive predictive value (PPV) and accuracy (ACC) were 88.8%, 83.6%, 87.3% and 86.5%, and for external validation were 83.9%, 72.2%, 78.2% and 78.6% respectively. Clinicians are currently unaware of distinct retinal feature variations between males and females, highlighting the importance of model explainability for this task. The model performed significantly worse when foveal pathology was present in the external validation dataset, ACC: 69.4%, compared to 85.4% in healthy eyes, suggesting the fovea is a salient region for model performance OR (95% CI): 0.36 (0.19, 0.70) p = 0.0022. Automated machine learning (AutoML) may enable clinician-driven automated discovery of novel insights and disease biomarkers
Differential diagnosis of adipocytic differentiation in androgen-secreting mature ovarian teratoma with Leydig cell hyperplasia.
No full textMature cystic teratomas (dermoid cysts) of the ovary are very rarely associated with androgen production. The source of androgens in these cysts may be tumours such as Sertoli-Leydig cell tumour or Leydig cell hyperplasia. In this study, we present a case of virilisation in a postmenopausal female patient, where Leydig cell hyperplasia in a mature cystic teratoma was found to be responsible for the production of testosterone. In addition, extensive areas of lipomatous differentiation were identified. These areas showed significant alterations in adipocytic morphology, and differential diagnoses such as spindle cell lipoma (SCL) and atypical lipomatous tumour (ALT) were excluded after additional workup. Adipose tissue is traditionally described as an energy reservoir, but recently it has become clear that adipose tissue is a complex endocrine organ with additional metabolic roles in whole body homeostasis. Exuberant proliferation of lipomatous tissue in this teratoma raises the possibility of a synergistic role of Leydig cells and adipocytes in the development of hyperandrogenism
Hepatocyte necrosis on liver allograft biopsy: Normothermic machine perfusion is the ideal platform for using these grafts in high risk recipients.
No full textHepatocyte necrosis is an undesired finding on liver allograft biopsy and donor transaminases are considered surrogate markers for donor liver allograft quality. Mild to moderate elevation of donor transaminases are not a contraindication to transplantation, however severe elevation often denotes ischaemic hepatocyte necrosis and these grafts are seldom considered for transplantation
Sorafenib is associated with a reduced rate of tumour growth and liver function deterioration in HCV-induced hepatocellular carcinoma.
No full textPURPOSE
Sorafenib has been the standard of care for patients with advanced hepatocellular carcinoma and although immunotherapeutic approaches are now challenging this position, it retains an advantage in HCV seropositive patients. We aimed to quantify the rate of tumour progression in patients receiving sorafenib and relate this figure to survival, both overall, and according to viral status.
PATIENTS AND METHODS
Using serial data from an international clinical trial we applied a joint model to combine survival and progression over time so as to estimate the rate of tumour growth as assessed by tumour burden and serum AFP, and the impact of treatment on liver function.
RESULTS
High tumour burden at baseline was associated with an increased risk of death. In patients still alive at the end of the study, the progression in relation to tumour burden was very low compared to those who died within the study. Overall, the change in mean tumour burden was 0.12 mm per day or an absolute growth rate of 3.6mm/month. Median doubling time (DT) was 665 days. For those who progressed above 0.12mm per day or 12% rate, median survival was 234 days compared to 384 days if the rate was below 12%. Tumour growth rate and serum AFP rise were significantly lower in those who were HCV seropositive as was the rate of decline in liver function. These results were replicated in two independent patient groups.
CONCLUSION
Our analysis suggests that sorafenib treatment is associated with improved survival in patients with advanced hepatocellular carcinoma mainly by decreasing the rate of tumour growth and liver function deterioration among patients with HCV infection.
LAY SUMMARY
Among patients receiving sorafenib for advanced hepatocellular carcinoma the rate of tumour growth (as assessed by changes in tumour size and the biomarker AFP) and the deterioration of liver function is less in those who have the Hepatitis C virus, than those who do not.
CLINICAL TRIALS DATA
The clinical trials data belongs to Bristol Myers Squibb and AbbVie Inc. The clinical data belongs to Cambridge University Hospitals NHS Foundation Trust
Suicide in anaesthetists: a systematic review.
No full textEvidence suggests that healthcare professionals are at an increased risk of dying by suicide, with anaesthetists at particularly high risk. However, much of the data on which this is based are historical. With a focus on the epidemiology and methods used, we conducted a systematic review of evidence regarding suicide and suicidal behaviour among anaesthetists to provide a more contemporary summary. The systematic review process was adapted from a previous similar study in veterinary surgeons and was consistent with recommended guidance. We identified 54 articles published in or after 1990 that had anaesthetist-specific data and met the inclusion criteria. Seven of these reported epidemiological data, of which four were published after 2000. Although none of the more recent studies reported standardised mortality rates specific to suicide in anaesthetists, the proportion of anaesthetists dying by suicide was increased with respect to comparator groups, which is consistent with previous findings. Eleven studies that included information on suicidal behaviour reported suicidal ideation in 3.2-25% of individuals (six studies) and suicide attempts in 0.5-2% (four studies). Studies reporting methods of suicide highlighted the use of anaesthetic drugs, particularly propofol, supporting the suggestion that the increased risk of suicide in anaesthetists may be related to the availability of the means. We discuss our findings in relation to other recently published data and guidance concerning mental health problems in anaesthetists
