Ultrasonography (gray scale) of the scrotal contents was used to identify 3 patients with testicular rupture after groin trauma, which was confirmed at operation. Ultrasound examination was helpful in identifying rapidly those patients who needed surgical repair.
Objective: Left ventricular reconstruction (LVR) is performed to improve the morphologic structure and function of the heart in patients with heart failure. This procedure has been performed at the Cleveland Clinic Foundation since 1997. We assessed mortality, functional status, and predictors of outcome in these patients. Methods: Data were extracted from multiple prospectively acquired datasets on demographic, clinical, and operative details of 220 consecutive patients who underwent LVR between July 1997 and July 2003, where the indication for surgery was heart failure (of whom 66% had New York Heart Association (NYHA) functional class III or IV symptoms). Mortality, functional status, and postoperative complications were ascertained by reference to the clinical record, social security death index, and by phone contact. Mean preoperative left ventricular ejection fraction (LVEF) was 21.5 ± 7.3% and mean left ventricular end-diastolic diameter was 6.4 ± 1.0 cm. The mean age was 61.4 ± 9.0 years and 80% were male. The majority (86%) of patients underwent concomitant coronary artery bypass grafting and 49% underwent mitral valve surgery. Results: Thirty-day mortality was 1% and survival at 1, 3, and 5 years was 92%, 90%, and 80%, respectively. Of the survivors for whom data on NYHA functional class were available, 85% were in NYHA functional class I or II. Mortality was predicted by reduced preoperative ejection fraction ≪20% (unadjusted hazard ratio 1.53, p = 0.02), body mass index ≤ 24 kg/m2 (unadjusted hazard ratio 1.69, p = 0.01), QRS duration ≥ 130 ms (unadjusted hazard ratio 1.66, p = 0.01) and the requirement for renal replacement therapy postoperatively (unadjusted hazard ratio 3.85, p ≪ 0.01). Mean LVEF improved to 24.7 ± 8.86% (p ≪ 0.01) and left ventricular volumes were also significantly reduced. Conclusions: In selected patients with heart failure, LVR, in conjunction with revascularization and valve surgery, is associated with excellent survival, improved symptoms, and improved LVEF and left ventricular dimensions.
Bacillus Calmette-Guerín (BCG), Corynebacterium parvum, and various mycobacterium fragments were injected intramurally into mouse bladders and the resulting systemic humoral stimulation and local histologic reactions were evaluated. C. parvum and methanol extracted residue of BCG elicited significant immunostimulation without producing irreversible bladder damage. The severe histologic disruption caused by BCG could be reduced by the antituberculus drug isoniazed without abrogating the humoral stimulation. Intramural bladder injection of BCG produced greater humoral stimulation than subcutaneous administration.
Introduction: Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous malignancy that typically affects elderly Caucasians and immunocompromised patients. It arises from primary neural cells and has a predilection for regional lymphatic metastasis as well as distant spread to the skin, lung, liver, brain and bones. Metastasis to the bowel is rare; there have only been 6 previous reports of spread to the stomach, small bowel or colon and 1 describing spread to the small bowel mesentery. This case reports a patient with MCC who was found to have metastasis to the duodenum presenting with melena and anemia. Case Presentation: A 79 year old male with a history of MCC, atrial fibrillation and an aortic valve replacement presented with four days of melena. He was diagnosed with MCC of the right upper extremity two years prior, treated with surgery and radiation. He had local recurrence, currently being treated with chemotherapy and radiation. A recent PET scan showed increased marrow uptake along with pancytopenia, suggesting bone marrow infiltration. Otherwise he was without known metastatic disease. The patient underwent an EGD which revealed a large, fungating, ulcerative mass in the first and second portions of the duodenum. Histopathology revealed sheets of small hyperchromatic cells with nuclear molding and scant cytoplasm filling the lamina propria. Immunologic staining was positive for AE1/AE3 cytokeratin, perinuclear dot-like expression of CK 20, CD 56 and chromogranin. These findings were consistent with a diagnosis of metastatic MCC. Discussion: MCC remains a rare cutaneous malignancy, however its incidence has tripled over the last two decades. Up to fifty percent of patients will eventually develop metastasic disease, most commonly to regional lymph nodes, other skin sites, lung, liver, brain and bone. Spread to the bowel is very unusual, with only six previous cases reported between 1985 and 2010 describing lesions in the upper and lower gastrointestinal tract. An additional case in 2011 described a lesion in the mesentery which infiltrated the small bowel causing vague abdominal pain. This case highlights the utility in knowing the type of cutaneous malignancy in a patient's history when evaluating abdominal symptoms, to determine if metastatic disease is a concern.
Purpose: The pattern of metastasis from esophageal adenocarcinoma usually is a result of direct invasion into paraesophageal tissues. When hematogeneous spread occurs, it tends to affect the lungs, liver and bone. This case describes a patient with a primary adenocarcinoma of the gastroesophageal junction (GEJ) with metastasis to the rectum, which has not been previously reported. For unclear reasons the rectum is a rare site of metastasis and has been primarily described with lobular breast carcinomas. A 42 year old Caucasian male complained of heartburn, hiccups, dysphagia, postprandial vomiting, and a 20 lb. weight loss. EGD showed a 5 cm circumferential, ulcerating mass at the GEJ, found to be invasive adenocarcinoma. CT scan was without metastasis and EUS and PET scan revealed a T3N0M1A tumor. The patient underwent neoadjuvant chemoradiation, followed by esophagectomy with negative margins and lymph nodes. Follow-up imaging, however, showed metastases to his ribs, calvarium, parotid gland and pelvic musculature. A rib biopsy confirmed metastatic adenocarcinoma. Sixteen months after diagnosis he complained of rectal burning. A lower EUS showed a transmural anal nodule with normal overlying mucosa, found to be metastatic adenocarcinoma. While immunohistochemical staining was not able to be performed, the native rectal glands lacked in situ components to suggest a primary neoplasm and the tumor cells originated extraluminally and were invading into the rectal lumen. Local spread of esophageal adenocarcinomas by direct invasion is common due to the lack of a serosal layer. Hematogenous spread to distant sites most commonly affects the lungs, liver, peritoneum and bone. Unusual sites of metastasis previously reported include the scalp, testicle, prostate, retina, distant skeletal muscle and skin overlying the breast. To our knowledge, there have not been any previously reported cases of rectal metastasis from esophageal or GEJ adenocarcinomas. For unclear reasons, the rectum is an uncommon site of distant metastasis. The rectal venous plexus is contained in loose connective tissue, resulting in poor protection from surrounding structures. They are subsequently less resistant to elevated blood pressures and vulnerable to constriction with muscle contraction. Structures with a propensity for metastasis have a constant, rich blood flow. It has been proposed that skeletal muscle may be a rare site of distant metastasis due to a susceptibility to variable blood flow and tissue pressures, which adversely affects tumor implantation. The inability of the rectal venous plexus to resist high pressures may suggest that a similar process prevents the rectum from being a site of metastasis.
