Metastatic Complications Research Articles

Minimally invasive surgery in the treatment of thoracolumbar metastatic tumors

Minimally invasive spine surgery (MISS) attempts to minimize the collateral damage inflicted upon the paraspinous musculature and joints during the traditional open approaches. Preservation of muscle attachments, innervation and joint structure may provide improved post-operative axial stability, thereby allowing implementation of shorter instrumentation constructs, decreasing post-operative pain, providing earlier mobilization and shorter hospitalization duration, and making spinal surgery available to a broader patient population. In patients with metastatic cancer, wound complications or early hardware failure may delay radiation and systemic therapy and have devastating consequences in their overall treatment of cancer. The rate of wound healing may be improved by minimizing the extent of dissection and the size of the incision. We review the published experience with the implementation of MISS in patients with thoracolumbar spine metastases and provide an illustrative case.

Severe intestinal ischemia as a presenting feature of metastatic ileal carcinoid tumor: role of MDCT with coronal reformation in the early diagnosis

Intestinal ischemia is a rare but potentially fatal complication of mesenteric metastasis of intestinal carcinoid tumor and its mechanism isn't entirely clear. We present a case of intestinal ischemia secondary to metastatic ileal carcinoid tumor diagnosed by CT that showed a small mesenteric mass with an extensive desmoplastic reaction causing an intense involvement of the small bowel. Improvements in CT technology with the use of MDCT scanners and advanced reformatting capabilities play an important role in the early diagnosis and accurate recognition of this entity and its need for immediate treatment.

Community-onset bacteremia may be an ominous sign

Several community-acquired infections, such as pneumonia, urinary tract infection, and diarrhea, may be associated with bacteremia in a minority of patients. Bacteremia is considered to be a normal variation of the clinical presentation of such infections and, as such, it generally does not change the physician’s approach to therapeutic managment of the infection. However, experienced physicians are clearly aware of the possibility that bacteremia may lead to secondary metastatic complications, such as bacterial arthritis, spondylodiscitis, or endocarditis. Certain pathogens, such as pneumococci, are more frequently associated with such complications than others, such as, for example, Escherichia coli. Good clinical management of these infections requires that the patient be examined at frequent intervals to control the development of such complications and to ensure that the duration of antibiotic therapy is carefully tailored to the clinical course of the specific infection. Although all experienced infectious disease physicians have been confronted earlier or later in their medical career with infections that have taken a lethal course, a significant risk of a lethal outcome is usually not associated with community-acquired bacteremia within our current conceptual framework of these types of infections. The study by Laupland et al. [1] in this issue of Infection provides the reader with a very interesting insight into shortand longterm mortality associated with community-onset bacteremia. The study is based on data on the Calgary Zone complied in the electronic surveillance system database of the Alberta Health Services System. Analysis of this database by the authors revealed that 12% of 2,448 patients died within 28 days following the diagnosis of communityacquired bacteremia and that one quarter of the patients had died by 1 year post-diagnosis. While these rates reflect all-cause case fatality, they seem to be higher than those most clinicians would expect to experience in their daily practice. Not unexpectedly, older age and significant co-morbidities were independently associated with late mortality. In contrast, bacteremia caused by Streptococcus pneumoniae was not associated with late mortality. While this study does not answer the question of whether early appropriate antibiotic therapy reduces both shortand longterm mortality, the data are nevertheless interesting, showing that patients with bacteremia may have an increased risk of dying within 1 year, especially if underlying diseases, older age, prolonged hospitalization, and polymicrobial infection are present as risk factors. These data will most likely not change our diagnostic and therapeutic approach to managing patients with suspected bacteremia, but they will help us to have a more sober outlook regarding the prognosis of patients with community-acquired bacteremia, especially when risk factors are present.

Lemierre's Syndrome in a Patient with Severe Lupus Nephritis

Lemierre's syndrome is a rare septic thrombophlebitis of the internal jugular vein with frequent metastatic complications following an acute oropharyngeal infection. Immunocompromised patients are at higher risk of developing this syndrome owing to the decreased host response and increased risk of oropharyngeal sepsis. We herein report a 24-year-old woman with severe lupus nephritis on immunosuppressive therapy, who developed Lemierre's syndrome following a pharyngeal infection despite an adequate and timely antibiotic therapy. We hereby draw an attention to the importance of accurate and timely diagnosis and appropriate management of Lemierre's syndrome in immunocompromised patients so as to achieve a successful prognosis for this deadly infection.

Appearance of Klebsiella Pneumoniae Liver Abscess Syndrome in Argentina: Case Report and Review of Molecular Mechanisms of Pathogenesis

Klebsiella pneumoniae liver abscess syndrome (KLAS) is an emerging invasive infection caused by highly virulent community-acquired strains of K. pneumoniae displaying hypermucoviscosity. The salient features of this syndrome include the presence of bacteremia, primary monomicrobial liver abscess, and metastatic complications. A previously healthy Argentinean man presented with fever and found to have liver abscess caused by K. pneumoniae with metastatic seeding of gastric wall. Cultures from blood and liver abscess grew hypermucoviscous K1 K. pneumoniae with sequence type (ST) 23 by multilocus sequence typing (MLST), positive for rmpA (regulator of mucoid phenotype A), wzyKpK1 (capsular polymerase) and aerobactin genes. The hypermucoviscous phenotype of this K. pneumoniae isolate was readily identified by the "string test" (colonies formed a long string when touched with a loop). The patient responded favourably to percutaneous drainage of the abscess and antibiotics. This is the first documented report of KLAS described in Argentina, and may signal the emergence of this syndrome in South America.

Meningeal carcinomatosis diagnosed during stroke evaluation in the emergency department

A 70-year-old female presented to the emergency department with a 3-day history of intermittent dysphasia and right facial droop. Computed tomography (CT) and magnetic resonance imaging (MRI) were obtained, and the patient was found to have meningeal carcinomatosis, also known as leptomeningeal metastases. Meningeal carcinomatosis is a rare metastatic complication of some solid tumors and hematopoietic neoplasms, and has a median survival rate of 2.4 months. The role of the emergency physician is to appropriately diagnose this condition, treat emergent side effects, provide symptomatic relief, and ensure multi-disciplinary management.

Hepatic resection for metastatic breast cancer: A systematic review

BackgroundSystemic chemotherapy is the mainstay of treatment for metastatic breast cancer with the role of surgery being strictly limited for palliation of metastatic complications or locoregional relapse. An increasing number of studies examining the role of therapeutic hepatic metastasectomy show encouraging survival results. A systematic review was undertaken to define its safety, efficacy and to identify prognostic factors associated with survival. MethodsElectronic search of the MEDLINE and PubMed databases (January 2000–January 2011) to identify studies reporting outcomes of hepatectomy for breast cancer liver metastases (BCLM) with hepatectomy was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Safety and clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies. ResultsNineteen studies were examined. This comprised of 553 patients. Hepatectomy for BCLM was performed at a rate of 1.8 (range, 0.7–7.7) cases per year in reported series. The median time to liver metastases occurred at a median of 40 (range, 23–77) months. The median mortality and complication rate were 0% (range, 0–6%) and 21% (range, 0–44%), respectively. The median overall survival was 40 (range, 15–74) months and median 5-year survival rate was 40% (range, 21–80%). Potential prognostic factors associated with a poorer overall survival include a positive liver surgical margin and hormone refractory disease. ConclusionHepatectomy is rarely performed for BCLM but the studies described in this review indicate consistent results with superior 5-year survival for selected patients with isolated liver metastases and in those with well controlled minimal extrahepatic disease. To evaluate its efficacy and control for selection bias, a randomised trial of standard chemotherapy with or without hepatectomy for BCLM is warranted.

Radical excision with five-centimeter margins for treatment of feline injection-site sarcomas: 91 cases (1998–2002)

To evaluate outcomes of radical excision of feline injection-site sarcomas (ISS) via assessment of local recurrence and metastasis rates, survival times, and complications associated with surgery. Retrospective case series. 91 cats with ISS. Medical records of cats that had radical excision of ISS without adjunctive treatment were reviewed. Information extracted included sex, type of surgical procedure, histologic tumor grade, tumor diameter, time from tumor detection to definitive surgery, complications associated with surgery, whether tumors recurred locally or metastasized, and survival times. Diagnosis of ISS was histologically confirmed, and additional follow-up was performed. Overall median survival time was 901 days. Thirteen of 91 (14%) cats had local tumor recurrence; 18 (20%) cats had evidence of metastasis after surgery. Median survival time of cats with and without recurrence was 499 and 1,461 days, respectively. Median survival time of cats with and without metastasis was 388 and 1,528 days, respectively. Tumor recurrence and metastasis were significantly associated with survival time, whereas other examined variables were not. Major complications occurred in 10 cats, including 7 with incisional dehiscence. Radical excision of ISS resulted in a metastasis rate similar to rates reported previously; the local recurrence rate appeared to be substantially less than rates reported after less aggressive surgeries, with or without adjuvant treatment. Major complication rates were similar to rates reported previously after aggressive surgical resection of ISS. Radical excision may be a valuable means of attaining an improved outcome in the treatment of feline ISS.

A Very Unusual Presentation of Metastatic Colon Cancer

This case highlights two very rare complications of metastatic colorectal carcinoma. It describes a 59 year old female with both cutaneous and endometrial metastases from colorectal carcinoma. While both of these presentations are very unusual, they highlight the need to be vigilant about the detection of metastatic complications during follow up.

Arteriovenous Graft Infection

There are a limited number of publications on the features of arteriovenous graft infection in hemodialysis patients. The authors compared the clinical presentation, complications, and outcomes of infections of thigh and upper extremity grafts. The authors queried a prospective access database at a large university medical center and identified 132 patients with graft infections (40 in the thigh and 92 in the upper extremity) requiring surgical excision. The authors collected information regarding the microbiology, complications, and clinical outcomes. The two graft groups were similar in age, gender, race, and frequency of diabetes. The median age of infected grafts was 162 days for thigh grafts versus 168 days for upper extremity grafts (P = 0.35). Thigh graft infections were more likely than upper extremity graft infections to be caused by a Gram-negative rod (31% versus 4%; P = 0.003), and more likely to result in a metastatic infection (15% versus 3%; P = 0.02). The duration of hospitalization associated with graft infection was similar (10.8 ± 5.4 versus 8.7 ± 6.3 days; P = 0.09). Finally, median catheter dependence was longer after thigh graft than upper arm graft infections (319 versus 237 days; P = 0.04). As compared with upper extremity graft infections, thigh graft infections requiring excision are more likely to be caused by Gram-negative bacteria and to result in serious metastatic complications. These differences may require different empiric antibiotics and a higher index of suspicion for infection in hemodialysis patients with thigh grafts.

Emerging infectious endocarditis due to Scedosporium prolificans: a model of therapeutic complexity

Scedosporium prolificans is an emerging agent for severe infections. Although among the dematiaceous fungi Scedosporium is the most frequently isolated in blood cultures, Scedosporium endocarditis is rarely reported. We show herein a patient with acute leukaemia who developed S. prolificans endocarditis. Twelve cases were found in an extensive review of the English literature. In six cases (46%), there was predisposing heart conditions such as a prosthetic valve or an intracavitary device. Only 4 patients (31%) were immunocompromised hosts with haematologic neoplasia, solid-organ transplantation or acquired immunodeficiency syndrome (AIDS). Exposure to Scedosporium was observed in immunocompetent patients who developed infection while in the community. Scedosporium endocarditis occurred on both sides of the heart. Systemic and pulmonary emboli and other metastatic complications were seen in all of these patients. The overall mortality was 77% and, specifically, all of the immunocompromised hosts and 6 out of 7 patients with mitral or aortic valve endocarditis died. Patients with right-sided endocarditis associated with a removable intracardiac device exhibited a better prognosis. Scedosporium endocarditis, although still rare, is an emerging infection with an ominous prognosis. At the present time, valve replacement or the removal of cardiac devices plus combined antifungal treatment may offer the best possibility of cure.

Community‐acquired Klebsiella pneumoniae liver abscesses — an “emerging disease” in Australia

Liver abscess due to Klebsiella pneumoniae infection has been widely reported in Asia, but rarely reported in Australia until now. We describe four previously well Asian-born patients who presented across Australia with community-acquired K. pneumoniae liver abscesses. With prompt recognition, appropriate antibiotics and early drainage, outcome is significantly improved, although vigilance for metastatic complications is essential.

Do Neutrophils Play a Role in Establishing Liver Abscesses and Distant Metastases Caused by Klebsiella pneumoniae?

Serotype K1 Klebsiella pneumoniae is a major cause of liver abscesses and endophthalmitis. This study was designed to identify the role of neutrophils in the development of distant metastatic complications that were caused by serotype K1 K. pneumoniae. An in vitro cellular model was used to assess serum resistance and neutrophil-mediated killing. BALB/c mice were injected with neutrophils containing phagocytosed K. pneumoniae. Serotype K1 K. pneumoniae was significantly more resistant to serum killing, neutrophil-mediated phagocytosis and intra-cellular killing than non-K1 isolates (p<0.01). Electron microscopic examination had similar findings as in the bioassay findings. Intraperitoneal injection of neutrophils containing phagocytosed serotype K1 K. pneumoniae led to abscess formation in multiple sites including the subcutaneous tissue, lung, and liver, whereas no abscess formation was observed in mice injected with non-K1 isolates. The resistance of serotype K1 K. pneumoniae to complement- and neutrophil-mediated intracellular killing results in the dissemination of K. pneumoniae via the bloodstream. Escape from neutrophil intracellular killing may contribute to the dissemination and establishment of distant metastases. Thus, neutrophils play a role as a vehicle for helping K. pneumoniae and contributing to the establishment of liver abscess and distant metastatic complications.

Community‐acquired Klebsiella pneumoniae liver abscesses — an “emerging disease” in Australia

Liver abscess due to Klebsiella pneumoniae infection has been widely reported in Asia, but rarely reported in Australia until now. We describe four previously well Asian-born patients who presented across Australia with community-acquired K. pneumoniae liver abscesses. With prompt recognition, appropriate antibiotics and early drainage, outcome is significantly improved, although vigilance for metastatic complications is essential.

Bacteraemia and subsequent vertebral osteomyelitis: a retrospective review of 125 patients

Vertebral osteomyelitis (VO) is associated with considerable morbidity and its incidence seems to be increasing. Haematogenous spread is an important aetiological factor. The objective was to describe a series of patients with VO and to search for a relationship between preceding bacteraemia and subsequent VO with the same pathogen. A retrospective study of all treated cases of VO in a tertiary hospital over a 10-year period. There were 129 cases of VO (involving 125 patients) that received antimicrobial treatment. Eighty-three (66%) were male and the mean age was 59.5 years (range 1 month to 87 years). The vertebral level involved was lumbar in 66 (53%) cases and thoracic in 35 (28%) cases. Seventy-four cases (59%) had a microbiologically confirmed aetiology. The diagnostic yield from procedures was 46 and 36% from blood culture and bone biopsy, respectively. Staphylococcus aureus was the most common pathogen [38 of 74 (51%) cases]. Nine of 38 (24%) cases of Staphylococcus aureus VO had a preceding bacteraemia with the same pathogen in the previous year. Staphylococcus aureus is an important pathogen causing bacteraemia with the ability to cause metastatic complications including VO. The high proportion of cases developing VO following a documented bacteraemia, sometimes many months previously, reinforce the importance of adequate aggressive treatment for bacteraemia. VO must be considered in all patients presenting with back pain up to a year after bacteraemia. Previous bacteraemias with relevant pathogens can help guide antibiotic treatment at presentation of VO and if biopsy cannot be obtained.

Demographic and Clinical Trends of Klebsiella Liver Abscesses (KLA): A Single Center Experience

Purpose: Primary liver abscess caused by Klebsiella pneumoniae(KLA) is increasingly becoming common in the United States. We examined the demographic and clinical trend of three patients diagnosed with KLA at our institution. The demographic data and clinical characteristics of our patients are presented in Table 1. Discussion: PLA (pyogenic liver abscess) is a potentially life-threatening disease and the diagnosis is challenging. The pathogen for PLA is changing and K. pneumoniae has replaced E. coli as a leading pathogen for PLA. Our series indicates and validates important differences between the two agents. KLA is more likely to present with non specific symptoms and has a stronger association with diabetes due to impaired neutrophil phagocytosis of K1 and K2 capsular serotypes. These abscesses are larger in diameter often with no recognizable source of infection. Importantly they may be associated with metastatic complications which may warrant modification of therapy. Since Klebsiella is intrinsically resistant to ampicillin, use of the standard ampicillin based regimen may be associated with increased mortality. Catheter drainage has been associated with improved outcomes and therefore should be considered early. We conclude that these characteristics, though not specific, if recognized early can lead to prompt diagnosis, appropriate management and better prognosis in this group of patients.

Hepatocellular Carcinoma with Metastatic Extension into Right Atrium and Pulmonary Embolism

Purpose: Hepatocellular carcinoma (HCC) is the third leading cause of cancer mortality worldwide. The incidence of HCC tripled between 1975 and 2005 in the United States to 4.9 per 100,000. Reports of HCC and extension into the right atrium are rare. We report a patient with HCC who presented with findings of both pulmonary embolism (PE) and extension of HCC into the right atrium. Methods: A 73 y/o African American male with a past medical history pertinent for hepatitis B and hepatitis C cirrhosis, presented with dyspnea and chest pain upon exertion for 2 weeks. Workup for acute coronary system was negative by cardiac enzyme markers and electrocardiogram. The patient underwent a CT angiogram that revealed filing defects suggestive of bilateral PE. He was started on heparin infusion for anticoagulation therapy that was later discontinued secondary to spontaneous gingival bleeding. Results: A transthoracic 2-D echocardiogram visualized an abnormal large organized mass density with numerous fibrinous strands in the right atrium. Triple phase CT scan of the liver showed multifocal masses with large filling defect in left hepatic vein, propagating into IVC and right atrium, consistent with HCC. His Alphafetoprotein level was greater than 3000, which was previously normal three years ago. Discussion was done with the patient in regards to diagnosis and surgical considerations. The patient was transferred to a skilled nursing facility with hospice after he declined further interventions. Conclusion: Clinical manifestations of HCC vary. Patients may present with dyspnea, chest pain, or heart failure. Our patient had evidence of PE likely secondary to metastatic complications of HCC. There have been several previous case reports with patients having PE secondary to HCC. In a patient with HCC who present with respiratory symptoms, one must consider metastasis and tumor emboli in the differential.Figure: Top: Transthoracic echocardiogram showing a right atrium mass. Bottom: Triphasic CT scan of abdomen showing hypodense mass in right atrium. B. Hypodense mass in the inferior vena cava seen on coronal reconstruction.

Pneumocephalus as a complication of esophageal carcinoma

A 73-year-old man presented with a loss of consciousness. He was comatose at the time of admission with a GCS of 5 and no localized neurological signs. Medical records indicated that the patient had undergone surgical treatment for esophageal carcinoma 2 years previously. Metastases developed in the reconstructed stomach tube and middle esophagus 6 months after surgery, and the patient had therefore received radiotherapy. Computed tomography (CT) of the head revealed gaseous distention in the subarachnoid space around the cortex. Some air was visible around the brain stem (Fig.​(Fig.1).1). No head injuries and no skull-base fracture were observed. The radiological diagnosis was a pneumocephalus. He died 2 days after admission. Fig. 1 Axial CT of the brain showing profound gaseous attenuation in the subarachnoid space, cortical sulci and ambient cistern Pneumocephalus is a rare disease that has most often been described as a result of skull base fracture or intracranial and spinal operations. A subarachnoid-pleural fistula and intracranial air may occur after lung resection [1]. Willheim reported pneumocephalus as a complication of metastases in sacral carcinoma [2]. This is a very rare eroding tumor that may cause pneumocephalus without either trauma or surgery. We think that the destruction of the esophagus and tissue of the esophageal carcinoma, which was hastened by eroding bone, caused a communication between the subarachnoid space and esophagus. The diagnosis was of pneumocephalus as a complication of esophageal carcinoma.

Leptomeningeal Metastasis

Leptomeningeal metastasis occurs in ~5% of all patients with cancer and is the third most common metastatic complication of the central nervous system. Staging of leptomeningeal metastasis includes contrast-enhanced brain and spine magnetic resonance imaging and radionuclide cerebrospinal fluid (CSF) flow study. Treatment, when clinically indicated, often requires administration of involved-field radiotherapy to bulky or symptomatic disease sites as well as intra-CSF and systemic chemotherapy. The use of high-dose systemic therapy may benefit selected patients with breast- or lymphoma-related leptomeningeal metastasis and obviate the need for intra-CSF chemotherapy. Intra-CSF drug therapy primarily utilizes one of three chemotherapeutic agents (e.g., methotrexate, cytosine arabinoside, and thiotepa) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Beginning to be utilized are novel intra-CSF agents, such as the targeted monoclonal antibodies rituximab (anti-CD20 for B-cell lymphoma-related leptomeningeal metastasis) and trastuzumab (anti-Her2/neu for breast cancer-related leptomeningeal metastasis). Although treatment of leptomeningeal metastasis is palliative with median patient survival of 2 to 3 months, treatment may afford stabilization and protection from further neurologic deterioration in patients with leptomeningeal metastasis.

Clinical, microbiologic, and genetic determinants of persistent methicillin-resistant Staphylococcus aureus bacteremia

Methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) often persists despite full susceptibility to vancomycin; therefore, associated factors were assessed. A retrospective cohort analysis of 222 patients with MRSAB treated with vancomycin was conducted; patients with persistent MRSAB (pMRSAB) were compared to those with nonpersistent bacteremia (NPB). Incidence of pMRSAB was 9%. More patients with vancomycin MIC = 2 mg/L had pMRSAB (16%) compared to patients with vancomycin MIC <2 mg/L (5%), P = 0.012. SCC mec type and Panton–Valentine leukocidin production were similar between patients with pMRSAB and NPB. There was no difference in vancomycin troughs, time to first dose, or area under the concentration–time curve/MIC between groups. More metastatic complications were observed in pMRSAB 63% versus NPB 32% ( P = 0.005). Multivariate analysis found endocarditis (odds ratio [OR], 2.3; P = 0.021), complicated MRSAB (OR, 2.6; P = 0.009), vancomycin MIC = 2 (OR, 2.6; P = 0.009), and septic shock (OR 2.2 P = 0.031), which were independent predictors of pMRSAB.