Large Necrotic Mass Research Articles

SUN-612 Pleural Effusions Revealing Anaplastic Dedifferentiation of Papillary Thyroid Carcinoma

Anaplastic dedifferentiation of papillary thyroid carcinoma to lung, pleura and lymph nodes is rare, rapidly progressive and fatal. We report a case of a firefighter who survived the World Trade Center collapse presenting with a large thyroid mass, worsening pleural effusions and pulmonary nodules. A 49-year-old male with history of diabetes and hypertension presented to the Emergency Department with several days of shortness of breath. Vitals were significant for hypoxia, tachypnea and tachycardia. CT Angiography revealed a large (5 x 7 cm) necrotic mass with direct extension to the mediastinum with multiple metastatic lymph nodes in the hila and lungs with bilateral pleural effusions. Dyspnea was relieved in the Emergency Department with placement of a pigtail catheter and pleural fluid was sent for cytology. Further history from family revealed the patient had worked as a firefighter at the World Trade Center for four months. After September 11th, he followed in the WTC survivor clinic in Manhattan with chest x-rays twice a year, the last of which had no abnormalities. Family also reported months of worsening dyspnea with a “high-pitched voice”, weakness and a 20-pound weight loss. Social history was significant for active tobacco use of a pack-per-day for ten years. In the Emergency Department, the patient was placed on supplemental oxygen and otolaryngology performed nasopharyngolaryngoscopy that showed right vocal cord immobility and mild tracheal compression. High-dose dexamethasone taper was initiated. In the hospital, the patient’s respiratory status worsened and he became increasingly septic. Antibiotics were begun for presumed pneumonia. Due to worsening hypercapnea and tracheal compression, the decision was made with family to intubate and vasopressors were begun for hypotension. Interventional radiology performed a biopsy of the thyroid mass revealing papillary carcinoma, but lung nodule biopsy was unrevealing. Subsequent pleural fluid analysis showed poorly differentiated malignant cells with a high degree of nuclear pleomorphism and bizarre shapes suggestive of anaplastic features. Immunohistochemistry was positive for Paired Box Gene 8 (PAX8) and Cytokeratin 7 (CK7). As PAX8 is specific for thyroid cancer, the pleural effusions were thought to be metastatic adenocarcinoma from anaplastic dedifferentiation of papillary thyroid cancer. Given clinical status, the patient was not a candidate for chemotherapy. A goals-of-care decision was made to focus on comfort and the patient passed comfortably with family at bedside. Anaplastic thyroid tumors account for less than two-percent of all thyroid cancers. However, they are rapidly progressive and fatal with tumor burden often doubling in under a week’s time. Identifying these tumors earlier remains a goal in reducing the rate of anaplastic tumors in patients with carcinogenic exposure, such as our patient.

Chronic Inflammatory Demyelination Polyneuropathy (CIDP) Associated with Colorectal Cancer

Introduction: Chronic inflammatory demyelinating polyneuropathy (CIDP) occurs in about 1-2 persons per 100,000 adults. It is a progressive relapsing distal neuropathy developing due to several humoral and cell-mediated mechanisms causing injury of the myelin sheet. We describe a rare case of a patient with CIDP. Case Description: A 32-year-old female with the history of CIDP and iron deficiency anemia presented with lightheadedness, malaise and black stools associated with episodic epigastric pain, SOB, nausea, and constipation. Vitals were stable and physical examination revealed conjunctival pallor with mild generalized abdominal discomfort. Laboratory workup revealed severe microcytic anemia. The endoscopic evaluation showed two large necrotic masses in the duodenum and ascending colon consistent with malignancy. Computed tomography of the abdomen showed an ascending colon mass directly invading into the duodenum and was confirmed to be an infiltrating colorectal adenocarcinoma. Discussion: CIDP is associated with human immunodeficiency virus infection and inflammatory bowel disease and malignancies including lymphoma, melanoma, renal, breast and lung cancers. However, its association with colorectal cancer is not well described. So far two cases of colorectal adenocarcinoma with distal acquired demyelinating sensory neuropathy and one case with motor neuropathy-CIDP phenotype have been reported. In two patients CIDP preceded the diagnosis of malignancy who presented with constipation and abdominal pain. Two patients showed resolution of CIDP after surgical treatment of cancer. All patients were found to have anti-myelin glycoprotein antibodies. Conclusion: CIDP can be a presentation of an underlying GI malignancy similar to our patient. Therefore, in patients with a new diagnosis of CIDP, consideration can be made to evaluate for colon cancer.

Diffuse Large B-cell Lymphoma Presenting as Upper Gastrointestinal Bleeding

Gastric lymphoma is a rare cause of GI bleeding. We hereby report a case of diffuse large B-cell lymphoma that extensively invaded the stomach, spleen and pancreatic tail and demonstrates the aggressive nature of the disease and our diagnostic and therapeutic approach. A 74-year-old woman with a history of peptic ulcer disease presented with dark output from her nasogastric tube and melena. CT without contrast two months ago showed a large necrotic mass invading the spleen, for which she underwent a non-diagnostic CT-guided para-aortic lymph node biopsy as well as laparoscopic biopsy of greater curvature lymph node and retroperitoneal mass that was suspicious for lymphoma. On presentation, she was febrile, hypotensive and tachycardic. She was intubated and sedated. Labs revealed a Hgb of 7.9 g/dL, WBC 33.8 K/mm, AST 125 IU/L, ALP 186 U/L, alb 1.6 g/dL, T bili 2.4 mg/dL. CT scan on admission showed heterogeneous neoplasm involving the pancreatic tail, gastric body, spleen and metastatic upper abdominal lymphadenopathy (Figure 1). PET demonstrated an intensely FDG-avid confluent mass involving the pancreatic tail, spleen and greater curvature of the stomach with FDG-avid abdominal adenopathy (Figure 2). EGD showed a nonbleeding, large infiltrative non-circumferential mass on the lesser curvature of the stomach (Figure 3). A review of the prior laparoscopic biopsies showed large atypical cells of B-cell origin based on PAX5, CD19 and CD79a expression, diagnosis of a diffuse large B-cell lymphoma was made. Results of EGD with biopsy and laparoscopic biopsy were consistent. Given recurrent active bleeding requiring vasopressors and transfusions, IR was consulted and hemostasis achieved with embolization of left gastric and splenic artery. However, she died soon after discharge due to the diffuse nature of the disease. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma. Since DLBCL can advance quickly, it usually requires immediate chemotherapeutic treatment once the diagnosis is established. Surgery is considered as second-line treatment for severe perforation, bleeding, or a need for palliative treatment. An EGD can help confirm the diagnosis and rule out other sources of bleeding. In this setting, EGD biopsy could have obviated the need for a laparoscopic biopsy. Given the extent of tumor involvement in our case, endoscopic hemostasis is rarely successful and IR is necessary for hemostasis.Figure: A large mass inseparable from the pancreatic tail and gastric antrum inferiorly was seen on CT abdomen/pelvis. This appears to invade the spleen at the splenic hilum and the largest component of the mass measures up to 11 x 7.2 x 12 cm.Figure: Intensely FDG-avid confluent mass with central necrosis is noted involving the pancreatic tail, spleen and greater curvature of the stomach, correlating to hypoenhancing mass noted on CT measuring approximately 11.5 x 7.2 cm.Figure: EGD showed a large, infiltrative mass with oozing and stigmata of recent bleed.

Unexpected cases of uterine necrosis secondary to clostridial sepsis: an evolving concern?

Background: Clostridial sepsis is rare, clinically difficult to manage and frequently fatal. When associated with gynaecological cases it can cause necrosis of the myometrium and is more commonly associated with women who are post-partum and those who have undergone a termination of pregnancy. Limited cases have been described in patients who had a gynaecological malignancy. In total seven cases of myometrial necrosis have been documented, which are attributable to Clostridium Perfringens, in non pregnant women. This article reports two further cases; one due to C. Perfringens and another due to Clostridium Sordelli. Cases of myometrial necrosis due to C. Sordelli are extremely rare and from a literature review no previous cases have been reported in women with a gynaecological malignancy. Cases: A 77 year old woman presented with pyrexia and brown vaginal discharge. On examination a large pelvic mass was noted. Investigations including bloods, blood cultures and radiological scans were performed. The CT scan showed a distended endometrial cavity filled with fluid and gas. Biopsy of the cervix and endometrium found a poorly differentiated squamous cell carcinoma, likely cervical in origin. Blood cultures confirmed C. Perfringens therefore leading to a diagnosis of clostridial sepsis with probable myometrial necrosis. The second case of clostridial sepsis was found in a 79 year old woman who presented with vaginal bleeding, abdominal pain and general malaise. Multiple investigations were undertaken including a CT scan, which showed a large pelvic necrotic mass. The blood cultures confirmed the presence of C. Sordelli. Antibiotic treatment was administered however surgical treatment was considered to be inappropriate due to the extent of disease. Results: Both patients deteriorated becoming haemodynamically unstable with multi-organ failure. Treatment was withdrawn following discussions with the families and respecting the patient's prior wishes facilitating a peaceful death with suitable end of life care. Conclusion: This report continues to demonstrate fatal outcomes associated with Clostridial sepsis, particularly in patients with an underlying gynaecological malignancy. These two cases occurred within a few months of each other and show many similarities. This highlights that Clostridial sepsis leading to myometrial necrosis should be more readily considered in patients presenting with a probable gynaecological malignancy and pyrexia. Unfortunately both of these cases ended with the patients’ death however cases in the literature have reported patient recovery following early surgical intervention and antibiotic treatment. These illustrate that prompt diagnosis can allow for appropriate management and counselling for the patients and relatives.

Basaloid squamous cell carcinoma of the maxilla: Report of a case and literature review

PurposeBasaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma characterized by a highly aggressive clinical course. Though typically found in the larynx, oropharynx, and hypopharynx, we report a rare case of BSCC originating in the maxillary sinus in an otherwise healthy 32-year-old male. Materials and methodsSingle case report of a patient with BSCC of the maxillary sinus and retrospective chart review of all cases of BSCC of the maxilla at a single academic institution between January 1, 1986 and December 31, 2013. The MEDLINE database was additionally queried for all case series or reports of BSCC arising in the maxilla, and pertinent clinical data were extracted. ResultsThe clinical presentation, disease course, and management of a patient with BSCC of the maxilla are presented. In this recent case, the patient presented with persistent alveolar pain and a nonhealing tooth infection. Radiographic studies demonstrated a large necrotic mass in the left maxillary sinus that was biopsy-proven as BSCC. The patient underwent surgical resection followed by postoperative radiation without complications. ConclusionsBSCC of the maxilla is a rare oncologic entity that may progress to late disease stage without obvious clinical signs or symptoms. Optimal treatment involves complete surgical resection followed by postoperative.

Presumed Reactive Polyarthritis and Granulomatous Vasculitis in a Mississippi Sandhill Crane (Grus canadensis pulla)

A 1.5-year-old female Mississippi sandhill crane (Grus canadensis pulla) was presented and managed for a polyarthritis of the intertarsal and tarsophalangeal articulations. Results of aerobic bacterial cultures, Mycoplasma species culture, and polymerase chain reaction testing of articular fluid did not identify any causative organisms. Results of radiographs and cytologic examination of articular fluid were consistent with an inflammatory, nonerosive polyarthritis. The arthritis did not improve with systemic anti-inflammatory and antibiotic treatment and with joint lavage. A large necrotic granulomatous mass was detected on the right shoulder area from which Staphylococcus aureus and Enterococcus species were isolated as opportunistic pathogens. Two days after surgical resection of the mass, the distal polyarthritis resolved. Histopathologic examination of the mass was consistent with granulomatous vasculitis with abscess formation of unknown origin. In this crane, the unresponsiveness to standard therapy, the presence of an infected and inflammatory mass, and the resolution of the polyarthritis after the resection of the mass strongly supported a diagnosis of reactive immune-mediated nonerosive polyarthritis. Analysis of this case suggests that immune-mediated idiopathic arthritis should be a differential diagnosis of distal polyarthritis in cranes and that an inciting source remote from the joints should be investigated in case of lack of response to standard therapy.

Importance of Examining Distal Duodenum on Standard Upper Endoscopy

Objective: Encourage endoscopists to examine beyond the second portion of the duodenum with upper endoscopy. Case Presentation: A 47-year-old, African-American female, presented to the emergency room with shortness of breath and fatigue. She had received oral iron supplementation for 6 months for iron deficiency anemia, attributed to menorrhagia. There was no history of nausea, vomiting, abdominal pain, difficulty swallowing, hematemesis, melena, or rectal bleeding. She reported a 15-pound weight loss over the last 3 months and vague back discomfort. She admitted to occasional NSAID use for joint pains. Past medical history revealed fibroadenoma of the breast. There was no significant family history of gastrointestinal disease or malignancy. Vital signs were stable. Examination was notable for pale skin and brown, hemoccult positive stool. The remainder of the examination was negative. Labs showed hemoglobin 6 g/dL, hematocrit 19.5%, MCV 79 and low iron, ferritin, and transferrin saturation. Platelet count, INR, LFTs and CHEM-7 were normal. On upper endoscopy, the esophagus, stomach, duodenal bulb and second portion of the duodenum were normal. Upon entering the third portion duodenum a large circumferential necrotic mass with ulceration and oozing on contact was identified. Biopsy returned moderately differentiated adenocarcinoma. CT scan was negative for pancreatic, lymphatic or liver involvement. She underwent a Whipple procedure with an uneventful post-operative course. Conclusion: Examining the third portion of the duodenum is recommended since lesions may be present beyond the proximal duodenum. Though small bowel cancer currently represents less than 5% of GI cancers, demographic studies suggest its incidence may be on the rise1. Furthermore, about 45% of duodenal adenocarcinomas occur in the third and fourth portions2. Depth of insertion for upper endoscopy is not clearly standardized, but the exam is often limited to the second portion of the duodenum. In our hospital, we have recently encountered cases of tumors in the third and fourth portions of the duodenum which would have been missed without careful examination of this region. Therefore, we encourage endoscopists to examine beyond the second portion of the duodenum. In this case, patient was spared additional endoscopic procedures and delay in diagnosis.

Pulmonary lymphomatoid granulomatosis mimicking lung cancer

Lymphomatoid granulomatosis (LYG) of the lung is an extremely rare, Epstein-Barr virus-related lymphoproliferative disease. We report a case of pulmonary LYG that presented as a large necrotic mass.

A Rare Etiology of Brain Metastasis: Squamous Cell Carcinoma of the Esophagus

Purpose: Metastatic spread to the central nervous system, though a relatively common occurrence with systemic cancer is a rare occurrence with esophageal carcinoma with an estimated incidence of 1.5%. Most recent cohort studies show increased incidence of brain metastasis which was attributed to recent advances in neuroimaging and increased survival after aggressive treatment leading to frequent early detection of brain metastasis. A comprehensive literature review shows contradicting evidence about long term versus palliative treatment for brain metastasis, along with the need for identifying risk factors and the utility of frequent brain imaging as a part of protocol in follow up of patients with esophageal carcinoma, which warrants for large scale prospective studies. A 52 year old female status post surgical resection, chemotherapy and radiation for poorly differentiated squamous cell esophageal carcinoma presented with complaints of dull constant frontal headache for two month duration. She complained of new onset swelling on the lateral aspect of right eye for seven days with dizziness, unstable gait and episodes of lethargy. Past medical history included HIV on HAART medication with last CD4 count of 849 and hypertension. On examination a 4 cm hard non tender swelling on lateral aspect of right eye with no skin changes. Toxoplasma IgM and IgG, VDRL and hepatitis profile were negative with normal complete blood picture, chemistry and liver function. CT head showed edema in the right frontal lobe secondary to a 4*3 cm large necrotic mass with midline shift of 6-mm. Bone defects were noted right frontal and parietal along with compression of the anterior horn of the right lateral ventricle. MRI with contrast showed irregular rim enhancement of the frontal lesion along with two ring enhancing lesions involving the right frontal and temporal bone with destruction. Further work up showed a solitary hepatic mass on the right lobe with no lesions in chest. Excisional biopsy showed islands of poorly differentiated squamous cell carcinoma lying against neurofibrillary background of the brain tissue. She received post excision radiation therapy but expired in four months. Most commonly secondary to adenocarcinoma of esophagus, a relatively short interval was noted for metastasis to the brain from diagnosis which is associated with poor prognosis with median survival of 3.6 to 3.9 months. In general, surgical excision is done in cases with a solitary lesion or life threatening complication but palliative whole brain radiotherapy for multiple or inoperable lesions. Surgical excision of solitary/single lesion combined with adjuvant whole brain radiotherapy yields a better survival than radiotherapy alone.

Epithelioid sarcoma of the spine: a case report and review

Epithelioid sarcoma is a rare malignant soft tissue neoplasm commonly involving extremities of young adults and rarely occurring in the trunk area. It re-sembles a chronic inflammatory process and mimics benign reactive granuloma or other benign diseases. Despite its indolence and slow growth, the prognosis is poor with high recurrence and early lymph node spreading and hematogeneous distant metastasis. Involvement of the spine is extremely rare and diffi-cult to diagnose correctly in clinical presentation and pathology. We describe our experience a case of epi-thelioid sarcoma involving lumbar spine. A pre-ope- rative spine MRI showed a large solid and necrotic paraspinal mass which extended into the spinal canal with cord compression, and bone destruction. Final correct diagnosis was confirmed by immunohisto-chemical studies. When young adults present with a spinal lesion that has unusual large necrotic soft tissue mass, immunohistochemical studies are recommended for promptly determining the possibility of spinal epithelioid sarcoma.

Primary malignant melanoma presenting as FDG avid large necrotic splenic mass with metastatic retroperitoneal adenopathy: FDG-PET and histopathological correlation

Primary malignant melanoma presenting as FDG avid large necrotic splenic mass with metastatic retroperitoneal adenopathy: FDG-PET and histopathological correlation

Synovial sarcoma of the lung presenting late with compression of mediastinal structures and its successful resection: A case report

Synovial sarcoma accounts for 5-14% of all soft tissue tumours. We present a case of 35 year-old male who presented with five months history of progressively increasing shortness of breath and cough. On evaluation, there was no air entry on the left side. CAT scan chest showed a large necrotic mass involving the entire left hemi-thorax. The tru-cut biopsy of this mass was done and it showed synovial sarcoma. The entire tumour along with the lung and the pericardium was removed completely. The patient had an uneventful recovery and was discharged home in 10 days with follow-up for adjuvant chemotherapy. Due to the rarity of this disease, no guidelines for the treatment are available. Main existing treatment includes surgery followed by either radiation, chemotherapy or both. Synovial sarcoma should be considered in the differentials of an adolescent or adult male patient presenting with a mass in the thorax.

Anaplastic thyroid carcinoma: computed tomographic differentiation from other thyroid masses

Anaplastic thyroid carcinoma is rare but is one of the most aggressive malignancies. Therefore, accurate diagnosis is important in order to provide appropriate therapy. To establish useful computed tomographic (CT) criteria for differentiating anaplastic carcinoma from other thyroid masses. The CT scans of nine patients with anaplastic carcinomas were retrospectively reviewed and compared with those of 32 patients with papillary carcinomas (n = 12) or benign lesions (n = 20) exceeding a maximum diameter of 2.0 cm. Image analysis was performed according to the following CT parameters: size, margin (well defined or ill defined), composition (cystic, mixed, or solid), mean attenuation value, ratio of attenuation of the mass to that of the adjacent muscle (M/m attenuation ratio), necrosis (present or absent), and calcification (stippled, nodular, or absent) of the thyroid mass; and tumor-spreading patterns including the presence of surrounding normal thyroid tissue in the involved lobe, involvement of the contralateral thyroid lobe, extension into the adjacent structures, and cervical lymphadenopathy. Anaplastic carcinomas appeared as large (average 4.6 cm), solid (100%), and ill-defined (88.9%) masses accompanied by necrosis (100%), nodular calcification (44.4%), direct invasion into the adjacent organs (55.6%), and cervical lymph node involvement (77.8%). Tumor necrosis was the most valuable parameter in differentiating anaplastic carcinomas from other thyroid masses. Patient age (>70 years) and low attenuation value on postcontrast scan (attenuation value <100 HU, or M/m attenuation ratio <1.3) are also helpful predictors for anaplastic carcinoma. If a patient is older than 70 years of age and has a large necrotic thyroid mass of low attenuation, anaplastic carcinoma should be included in the differential diagnosis.

Impact of Surgery on Advanced Gastrointestinal Stromal Tumors (GIST) in the Imatinib Era

The role for surgery in patients with "unresectable" gastrointestinal stromal tumors (GIST) treated with imatinib is still not defined. The objective of this retrospective study was to evaluate the feasibility and benefit of this secondary surgery. Progression-free survival (PFS) in a group of patients who underwent secondary surgery was compared to that of patients treated exclusively with imatinib. Of 180 patients with unresectable GIST treated with Imatinib, 22 (12%) underwent secondary surgery, following which one patient achieved a complete radiological response, 19 achieved a partial response (PR), in one patient the disease was stable, and in one patient there was reactivation of local occlusive disease after an initial PR. No patient with overall progression was to undergo surgery. At the beginning of imatinib therapy, five patients with metastases underwent emergency surgery [hemorrhage (n = 3) due to rupture of large necrotic masses], which ultimately resulted in three of the five patients dying postoperatively. A macroscopically complete resection was achieved in all primary tumors (5/5) and in ten of the 17 metastases. Pathological analysis revealed two complete response (CR) and 17 PR, and no treatment effect was evidenced in three patients. Two-year overall survival after surgery was 62%. The median PFS calculated from the initiation of imatinib therapy was 18.7 months for all operated patients and 23.4 months after planned surgery. Primary tumors that become amenable to surgery with prior imatinib therapy, evolving necrosis and localized progression (to avoid life-threatening complications) could benefit from this secondary surgery. For the majority of other residual lesions, the potential benefit of secondary surgery should be evaluated in randomized studies in the future since PFS is similar to that reported among non-operated patients.

Aspergillose nécrosante semi invasive chez un enfant de 14 ans atteint de mucoviscidose

Aspergillosis colonisation in cystic fibrosis (CF), usually due to Aspergillus fumigatus (AF), classically presents as allergic bronchopulmonary aspergillosis. However, aspergillus infection can produce a range of manifestations: from minor colonization to an invasive infection.A 14-year-old CF patient, chronically colonized with Staphylococcus aureus and Pseudomonas aeruginosa, presented with acute right-sided chest pain, a moderate fever and no modification of the sputum. The chest X-ray showed a 5 cm round opacity. Laboratory parameters were WBC 24,500 G/l, CRP 27 mg/l, Total IgE 1527 UI/l, Specific Aspergillus fumigatus IgE 31 UI/l. Bronchoscopy revealed external compression of the middle lobe bronchus with mucopurulent secretions coming from apical segment of the lower lobe. Bronchoalveolar lavage revealed the presence of pseudomonas aeruginosa 103 CFA/ml, staph aureus 107 CFA/ml and one colony of AF. Chest CT scan showed a large necrotic mass with an air-fluid level located in the apical segment of the right lower lobe. Initial therapy with itraconazole and corticosteroid was replaced by voriconazole, caspofungin, metronidazole and linezolide. Treatment was well tolerated and after 8 weeks the chest X-ray appearances had returned to normal.The possible diagnoses and therapeutic options are discussed. Conventional antifungal treatment with amphotericin B is limited by nephrotoxicity. These newer antifungal agents appear to be effective and well-tolerated.

Patients With Unusual Bladder Malignancies and a Rare Cause of Splenomegaly

An 82-year-old white woman with a congenital coccygeal deformity and neurogenic bladder, who had been on intermittent catheterization for the previous 20 years presented with gross hematuria. The warfarin that she was taking for atrial fibrillation was stopped. Intravenous urography showed a filling defect in the bladder. Cystoscopy was performed and revealed a large necrotic mass inside the bladder neck on the left side extending within the bladder for several centimeters. Tissue biopsy revealed transitional cell carcinoma of the bladder. A review of her computed tomography (CT) scan revealed asymmetric urinary bladder wall thickening with a large partially calcified soft tissue mass along the inferolateral left side of the floor, with displacement of the urethra. Numerous bladder diverticula were noted. Radical cystectomy was performed and revealed a high-grade invasive undifferentiated small-cell carcinoma of the bladder (Fig 1) with positive synaptophysin staining (Fig 2), which invaded through muscularis propria and into perivesical soft tissue with a positive margin. The tumor rapidly recurred in the pelvis on a CT scan performed during the first cycle of chemotherapy (Fig 3, arrow). The patient received two cycles of chemotherapy with carboplatin and etoposide, followed by two more cycles with concurrent radiotherapy for 5 weeks. Small-cell carcinoma of the bladder is a rare tumor, and a few cases have been reported in the English medical literature. In more than half of these cases, the tumor has been a mixture of small-cell carcinoma with transitional cell carcinoma, adenocarcinoma, or both. Histologically, the tumor is similar to small-cell carcinoma of the lung, with comparable immunoreactivity and the presence of neurosecretory granules on electron microscopy. Hematuria is the most frequent presenting symptom. Small-cell carcinoma of bladder usually has an aggressive clinical course characterized by early systemic dissemination and death from metastatic disease. Long-term disease-free intervals are rare, and most patients experience systemic disease recurrence within 2 years. Because of the rarity of

LUPRON-INDUCED PARASITIC FIBROID EROSION INTO THE RECTOSIGMOID COLON

A 34 y.o. woman with two months of anemia and rectal symptoms was referred to our service by gynecology. She underwent termination of pregnancy four months previously at 12 weeks gestation due to large subserosal fibroid tumors; Lupron® was started at this time and a myomectomy planned. She noted rectal discomfort with intermittent bleeding. She had no abnormal vaginal bleeding, but did have occasional abdominal pain from the fibroids. Past medical and surgical history were otherwise unremarkable. Medications included iron and ibuprofen in addition to Lupron®. She did not use tobacco, alcohol or illicit drugs; family history was non-contributory. On physical examination, she was thin with normal vital signs; a large fibroid uterus was palpated; rectal exam was normal with Hemoccult® positive brown stool. Her hemoglobin was 7.6 g/dL with an MCV of 78. Colonoscopy revealed friable rectal mucosa and two flat polypoid lobulated rectal lesions with exudative ulceration. Histology showed non-specific inflammation and granulation tissue. Two weeks post-procedure, the patient presented with abdominal pain and a large necrotic rectal mass protruding from the anus upon attempt to defecate. A CT showed a large irregular mass in the pelvis compatible with a uterine fibroid eroding into the anterior rectosigmoid wall. Under anesthesia, the mass was mobilized and delivered per rectum. Histology showed an infarcted smooth muscle neoplastic process (15 × 6.7 × 2.5 × cm) consistent with a fibroid. A flexible sigmoidoscopy four weeks later revealed a four cm tract in the anterior rectal wall. She had a myomectomy two months later and is no longer anemic. A subsequent CT scan showed no evidence of the prior colonic defect. A “parasitic” fibroid is one that attaches to another organ, such as the rectosigmoid colon in our patient. Her case was further complicated by fibroid erosion through the bowel wall. Lupron®, a GnRH analogue, may have contributed to this process: by suppressing estrogenic stimulation, it shrinks fibroids via hyaline degeneration and necrosis which may obliterate the fibroid-myometrium interface. This case highlights the need for clinical vigilance when caring for women with large fibroid tumors who present with rectal symptoms and are taking a GnRH analogue.

Choc initial du brûlé. Physiopathologie : principes thérapeutiques

Widespread destruction of the skin induces a large necrotic mass and a break of the skin barrier. It also leads to an intense inflammatory reaction. This activates keratinocytes, endothelial cells and neutrophils. Certain mediators (e.g. endothelin, histamine, bradykinin, serotonin, catecholamines, vasopressin, prostaglandins, cytokines and nitrogen monoxide) are thus released in large quantities and act both at the site of the burns and at a distance. The abnormally high level of albumin in the capillary wall and the increased capacity of absorption of the interstitial areas around the burns are the main abnormalities observed. This results in a hypovolemia associated with a hemoconcentration, hyponatremia, hypoalbuminemia, systemic vasoconstriction and myocardial malfunction, which is difficult to evidence. During the initial phase, the major risk is the appearance of hypovolemic shock, which is rapidly irreversible if early treatment is not administered. Vascular filling with iso- or hyper-osmolar sodium crystalloids, associated with buffer solutions, is the first line. There is still debate regarding the best moment at which to give albumin. A hyperkinetic shock may occur after several hours and despite the filling. The symptoms are tachycardia, increased heart rate and a dramatic decrease in systemic vascular resistance. This may lead to metabolic acidosis and multi-organ failure. Study of the hemodynamic profile of the patient allows the rational use of pressor amines and haemodialysis.

Neurilemmomas of the paranasal sinuses

Within the head and neck region, neurilemmomas are rarely found in the nasal cavity or paranasal sinuses. A 70-year-old man presented with complaints of left-sided epiphora, rhinorrhea, epistaxis, and transient diplopia. Nasal endoscopy showed a large necrotic mass filling the left middle meatus. A computed tomography scan showed a large left ethmoid mass, with erosion of the medial wall of the orbit and the anterior cranial base. Multiple biopsies were nondiagnostic. Complete excision of the tumor was performed with endoscopic techniques. Small dural defects were repaired with a middle turbinate mucosal flap. Postoperatively, the patient was treated with nasal packing and a lumbar spinal drain. Final pathology showed a benign neurilemmoma. There has been no evidence of recurrence or cerebrospinal fluid leakage in follow-up. A review of the literature shows a similar presentation of patients with neurilemmomas of the paranasal sinuses. Bony destruction and intracranial extension is viewed. Lack of encapsulation and locally destructive growth in an otherwise histologically typical neurilemmoma should not suggest malignant potential. Many benign tumors of the paranasal sinuses with bone destruction may be removed by using endoscopic techniques. (Am J Otolaryngol 2001;22:215-218. Copyright © 2001 by W.B. Saunders Company)

Primary malignant localized fibrous tumours of the pleura: Clinical, radiological and pathological features

Localized fibrous tumours of the pleura are rare primary pleural tumours that may exhibit malignant behaviour in approximately 20% of cases. The clinical, radiological and pathological features of five patients with malignant localized fibrous tumours of the pleura are presented. Clinical symptoms included chest pain, breathlessness and cough. Hypertrophic pulmonary osteoarthropathy (HPOA) occurred in one patient. Chest radiographs and thoracic computed tomography (CT) demonstrated large necrotic masses, with focal calcification and compressive atelectasis of the underlying lung. Histological features were variable and resulted in designation of these tumours as localized fibrous tumours of the pleura of low or high grade malignancy. The grading of malignancy did not correlate with final outcome, adequacy of surgical excision being the most important factor. These tumours have been referred to as benign pleural fibromas or localized mesotheliomas, but these names are inaccurate and the term localized fibrous tumour of the pleura is to be preferred. This term should also include tumours such as malignant fibrous histiocytoma of the pleura.