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Dedifferentiated liposarcoma is typically a nonlipogenic high-grade sarcoma that arises from well-differentiated liposarcoma. It most commonly presents as a large mass in the retroperitoneum. Significant involvement of the gastrointestinal tract by dedifferentiated liposarcoma is uncommon. We present a unique case of dedifferentiated liposarcoma radiographically mimicking a primary colon mass with resulting intussusception; stranding of the adjacent adipose tissue was presumed to be a secondary reactive change. On histopathologic analysis of the hemicolectomy specimen, a high-grade sarcoma was seen growing through the colonic wall, and the majority of the surrounding pericolonic adipose tissue was actually composed of well-differentiated liposarcoma with characteristic fibrous bands rather than benign fat with reactive fibrosis. This case raises awareness that well-differentiated liposarcoma and dedifferentiated liposarcoma can rarely present as a primary intestinal mass mimicking colon cancer or other more common entities. When radiographic examination shows a perigastrointestinal or retroperitoneal fatty mass and/or stranding of the fat adjacent to a solid gastrointestinal mass, this unusual scenario should be considered in the radiologic differential diagnosis. Pathologists should keep dedifferentiated liposarcoma in the initial histologic differential diagnosis for any high-grade spindle cell tumor of the retroperitoneum or intra-abdominal visceral organs.

Background Opioid abuse is widespread in the United States and the risk for chronic use is increased in surgical patients, including patients with thyroid and parathyroid. Methods Records for 171 patients prior to and 67 patients following implementation of an enhanced recovery after surgery (ERAS) protocol for ambulatory thyroid/parathyroid surgeries were reviewed. The ERAS included superficial cervical plexus block, multimodal premedication, and postoperative reliance on acetaminophen and ibuprofen with judicious prescribing of opioids. Results Post‐ERAS patients were prescribed a mean 72 morphine milligram equivalents (MME); pre‐ERAS patients were prescribed a mean 163 MME (p < 0.001). 97.1% of pre‐ERAS patients were prescribed opioids with 91.1% filled; 68.7% of post‐ERAS study patients were prescribed opioids with 84.8% filled. Conclusion Implementation of ERAS and focus on prescribing practices decreased the MME prescribed and used for ambulatory thyroid and parathyroid surgery. Future steps include increased patient education and tracking pain scores and medication utilization out of hospital.

Objective Variants of primary hyperparathyroidism (pHPT), described as normocalcemic (NC) and normohormonal (NH), can confuse the diagnosis of classic pHPT. Data Sources A MEDLINE search was performed for variants of pHPT using the PubMed database (last queried October 2019). Review Methods The search was restricted to articles published after 1960 that were specific to humans. Studies were included in our analysis if laboratory values and incidence of end-organ involvement were reported for NCpHPT and NHpHPT variants. The search returned 189 articles; 27 additional studies were identified and included for a total of 216. Non-English-language studies were excluded. Abstracts were screened, full-text articles were then assessed, and 82 articles were excluded. Data were pooled using a random-effects model in studies that compared NC or NH pHPT to classic pHPT. Comparative laboratory values are presented. Conclusion This analysis compares NCpHPT and NHpHPT to classic pHPT. Nephrolithiasis was 21.7% (NCpHPT), 15.9% (classic pHPT), and 25.4% (NHpHPT). Decreased bone mineral density was 49.7% (NCpHPT), 39.7% (classic pHPT), and 40.3% (NHpHPT). Fractures in the NCpHPT group were not significantly different from the classic pHPT. Hypertension in the NCpHPT group was significantly less than classic pHPT (odds ratio, 0.59; 95% CI, 0.40-0.88). Implications for Clinical Practice This information may serve to inform clinicians of the laboratory subtleties of these variants that are being seen with greater frequency in contemporary practice.

Intraoperative testing habits and opinions regarding testing during cochlear implantation vary widely among otologic surgeons. The majority of surgeons use testing but many think there is minimal benefit and that surgical decision-making is rarely impacted. The importance of testing may change as electrodes continue to evolve.

Since 2005, we have used the Ethylene vinyl alcohol copolymers (Onyx 18 and Onyx 34) in the treatment of 29 patients with high flow arteriovenous vascular malformations. There were 20 females and 9 males with ages ranging from 1-67 years (mean 28 years). Nineteen of the malformations involved the extremities and 10 involved the chest, abdominal wall or pelvis. All patients were evaluated with MRI/MRA pre-treatment and ultrasound if necessary to document lesion visibility. Onyx 18 was delivered by subselective transarterial and /or venous microcatheter techniques with or without ultrasound and fluoroscopic guided direct injection under tourniquet control. Tissues from patients whose embolized lesions were subsequently explanted were examined histologically, employing standard Hematoxylin and Eosin staining. Results: Ethylene vinyl alcohol copolymer (Onyx) was found to be durable and effective. Its visibility allowed observation of filling of the malformation interstices. There was minimal post procedure discomfort with Onyx. Of the thirty-nine patients, two developed an area of skin ulceration, and one had worsening of a pre-existing radiation burn. There was one minor complication with migration of a small Onyx fragment to the lung, without sequelae. In patients who received multiple treatments, multiple imaging obliquities were sometimes needed to allow visualization of untreated portions of the lesion. On H & E stains, the filling of the intraluminal spaces of the malformation with associated foreign body type giant cell reaction was observed. Conclusions: Ethylene vinyl alcohol copolymer is a safe, durable agent for treatment of high flow arteriovenous malformations.

Autologous hematopoietic stem cell transplant (AHSCT) is the standard of care in the treatment of multiple myeloma worldwide. Infections are one of the most common complications of the chemotherapy regimen and AHSCT. Thrombotic microangiopathies are one of the rare but potentially life-threatening complications of infections associated with AHSCT. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (HUS) are two most common type of thrombotic microangiopathies. The HUS is classically related to diarrheal illness such as with <em>E.coli</em> strain O157: H7 that produce Shiga-like toxins. But it has never been described with <em>Enterococcus</em> <em>raffinosus</em> urinary tract infections (UTI). Here we are describing a case of atypical HUS associated with <em>Enterococcus</em> <em>raffinosus</em> UTI in a patient with multiple myeloma after AHSCT. The management of atypical HUS especially after AHSCT is challenging. Eculizumab, a humanized monoclonal antibody against complement protein C5, and thrombomodulin have emerging role in the management of some cases, but more studies are needed to define evidence-based management of this condition.

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