Renal Clear Cell Carcinoma (RCC) comprises over 80% of renal malignancies in adults. Thyroid gland metastasis is rare in RCC. Few studies have described cases of RCC mistaken for benign arteriovenous malformation (AVM). To the best of our knowledge, an AVM arising from underlying RCC metastasis to the brain has not yet been reported. The current study presents a case of RCC metastasis to the thyroid gland, with an AVM identified to be a result of metastatic involvement in the brain. A 45-year-old African-American female presented with left-sided weakness, slurred speech, facial droop and seizure. The patient's medical history was notable for a diagnosis of RCC, 2010 American Joint Committee on Cancer Tumor-Node-Metastasis Stage 1B (T1B, N0, M0) grade III status post-right partial nephrectomy. Computed tomography (CT) imaging revealed a soft-tissue mass, suspected to be metastasis, in the left lobe of the thyroid, in addition to a 1.9 cm right intracranial mass in the parietal lobe. Positron emission tomography/computed tomography revealed a hypermetabolic area in the thyroid. Fine needle aspiration of the thyroid, and subsequent histopathological analysis, suggested a diagnosis of RCC metastasis. Subsequent immunohistochemical analysis of the thyroid tumor confirmed RCC metastasis. The patient also underwent a right partial craniotomy with resection of the intra-axial mass. Initial pathology was suggestive of an AVM. After several months, the patient was readmitted with headache, nausea and vomiting. Repeat imaging revealed recurrence of a 3.9 cm mass that was negative for AVM on biopsy; however, the immunostaining markers were positive for RCC. Recent literature suggests a link between AVMs and RCC as each exhibit highly vascular characteristics. RCC is a particularly vascular tumor that has been demonstrated to lead to the abnormal expression of various angiogenesis-promoting growth factors, including vascular endothelial growth factor. These angiogenic factors are vital to the pathophysiological pathway involved in the tumorigenesis and progression of RCC, and may explain the development of AVMs within these neoplasms, as demonstrated in the case presented in the current study.
Background:Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting.Materials and Methods:Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access.Results:With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up.Conclusions:Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.
Background: The 12-lead electrocardiogram (ECG) remains a cost-effective diagnostic tool in risk stratification for cardiovascular disease. Little is known of the prognostic value of QRS duration but recent reports suggest that a prolonged QRS duration may be associated with adverse outcomes. We investigated the relationship between QRS duration and long term mortality in Veterans with atherothrombotic risk factors. Methods: We retrospectively collected data from a Veterans Affairs (VA) medical center for consecutive patients (October 2001 to January 2005) to determine the long term mortality rates associated with different intervals of QRS duration in patients who presented for coronary angiography. Results: Of the 1193 charts reviewed, 1186 had a QRS duration reading recorded. For these 1186 patients the mean follow-up period was 103±52 months. Mean age was 63.2±10.8 years with 98% male. Mean body mass index was 30.0±5.9. The prevalence of comorbidities was: hypertension (88%), hyperlipidemia (79%), obstructive coronary artery disease (73%), left ventricular hypertrophy (50.4%), diabetes mellitus (45%), peripheral vascular disease (17%), and cerebrovascular accident (8%). Mean left ventricular ejection fraction (LVEF) was 47±13%, and mean PR interval was 172.5±30.5 milliseconds (ms). Most patients were on beta-blocker (82%). Among patients with bundle branch blocks (BBB), left BBB was present in 4.6% and right BBB was present in 6.9%. Mean QRS duration was 102.2±23.6 ms. As the QRS duration increased by intervals of 10-milliseconds, the mortality rate (%) increased [QRS ≤100 (40.7%), 101 to 110 (51.3%), 111 to 120 (66.3%), >120 (71.2%), p<0.001]. Among patients with QRS duration >120, mortality was higher in those >150 vs. 121 to 150 (79.7% vs 65.7, p=0.045). While QRS duration was a significant univariate predictor of morality, QRS duration is not significant when adjusted for 10 covariates listed above (odds ratio = 1.00 [95% Cl = 0.98 to 1.01], p = 0.72). Conclusion: Long term mortality was higher as QRS duration increased. QRS duration had utility in predicting mortality within this cohort of US Veterans with atherothrombotic risk factors.
Background: First-degree atrioventricular (AV) block [PR interval exceeding 200 milliseconds (ms)] on a 12-lead electrocardiogram is a common finding. Previous studies suggested that first-degree AVB has a benign prognosis, but more recent reports suggest that first-degree AVB may be associated with adverse outcomes. We investigated the relationship between PR interval and long term morality in U.S. Veterans with atherothrombotic risk factors. Methods: We retrospectively collected and analyzed data from a Veterans Affairs (VA) medical center for consecutive patients (October 2001 to January 2005) who presented for coronary angiography. Results: Of 1193 charts, 1082 had a PR interval reading recorded (mean = 172.5±30.5 ms; median = 168 ms [range 59-334]). Mean follow-up period was 103±52 months. Mean age was 63.2±10.8 years with 98% male. Mean body mass index was 30.0±5.9. The prevalence of selected comorbidities was: hypertension (88%), hyperlipidemia (79%), obstructive coronary artery disease (73%), diabetes mellitus (45%), smoker (39%), history of peripheral vascular disease (17%), and history of cerebrovascular accident (8%). Mean left ventricular ejection fraction was 47%±13%. Eighty-two percent were on beta-blockers (BB), and 25% were on calcium channel blockers (CCB) while intraventricular conduction delay was seen in 6%. In a comparison of patients with PR interval ≤200 ms (n=936) vs. >200 ms (n=146), long term mortality was higher with PR interval >200 ms (58.2% vs. 44.4%, p=0.002). Mortality rate was also higher with patients on BB or CCB vs. not on either (49.8% vs 39.7%, p=0.024). While PR interval was a significant univariate predictor of mortality, it was not significant when adjusted for the covariates listed above [not including BB and CCB] (odds ratio = 1.08 [95% Cl = 0.70 to 1.66], p = 0.73). Conclusion: In this study of US Veterans with atherothrombotic risk factors, the long term mortality rate was higher with first-degree AV block. PR interval has prognostic value within this specific cohort.
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