BackgroundGreat progress has recently been made in the treatment of metastatic renal cell carcinoma, including the introduction of nivolumab, an immune checkpoint inhibitor. Despite promising results, this treatment brings a completely new spectrum of adverse events, distinct from those experienced with small-molecule kinase inhibitors. Neurologic immune-related adverse events may be serious and potentially life-threatening complications requiring immediate immunosuppressive therapy. Only a few cases of immune-related encephalitis induced by checkpoint inhibitors have been described and the data regarding the management of this serious adverse event are limited.Case presentationWe report the case of a 63-year-old white man with metastatic renal cancer who developed severe chorea-like dyskinesia during nivolumab therapy. The findings on brain magnetic resonance imaging and flow cytometry of cerebrospinal fluid, and the positivity of anti-paraneoplastic antigen Ma2 immunoglobuline G class autoantibodies were consistent with a diagnosis of immune-related encephalitis. High-dose intravenous corticosteroid therapy was started immediately, with no signs of improvement, even when infliximab was added. Our patient refused further hospitalization and was discharged. Three weeks later, he presented with signs of severe urosepsis. Despite intensive treatment, he died 4 days after admission.ConclusionsThe management of less frequent immune-related adverse events has not been fully established and more information is required to provide uniform recommendations. Immune-related encephalitis is a severe and potentially fatal complication requiring immediate hospital admission and extensive immunosuppressive therapy. The examination of cerebrospinal fluid for paraneoplastic antibodies, such as anti-N-methyl-D-aspartate receptor and anti-Ma2 antibodies, in order to distinguish autoimmune etiology from other possible causes is essential and highly recommended.Electronic supplementary materialThe online version of this article (10.1186/s13256-018-1786-9) contains supplementary material, which is available to authorized users.

Non-traumatic atlanto-axial subluxation (AAS) is an uncommon complication of upper neck inflammatory processes and head and neck surgery. It is also known under the eponym of Grisel's syndrome (GS). We present a case report of a 6-year-old boy with GS that resulted from a retropharyngeal abscess. A diagnosis was not made until 2 months after the occurrence of infection. Re-evaluation of repeated CT scans of the neck showed the sequential development of AAS. These findings implied that the pathogenesis of GS is a distention of the ligaments between the atlas and axis rather than loosening of the ligaments caused by the spread of an inflammatory edema from the soft tissues of the neck as has been proposed by others.

Primary endovascular therapy for acute embolic SMA occlusion with on-demand laparotomy is a recommended algorithm used in our centre to treat SMA occlusion. This combined approach for the treatment of AMI is associated with in-hospital mortality rate of 27.0 %.

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Situs viscerum inversus totalis is a rare disorder presenting with complete transposition of thoracic and abdominal viscera. It is associated with certain organ anomalies, but it is not a predisposing factor to cholecystolithiasis. To date, fewer than 100 cholecystectomies in patients with situs inversus have been published worldwide. We report a case of a 75-year-old woman referred to our hospital with abdominal pain in the left hypochondrium. Situs inversus totalis and acute calculous cholecystitis were diagnosed and successfully conservatively treated with antibiotics. The patient underwent elective laparoscopic cholecystectomy 3 months later. The procedure and postoperative course were uneventful and the patient recovered well. The clinical presentation of these patients with cholecystolithiasis may be confusing and vague and the correct diagnosis delayed. Laparoscopic cholecystectomy is the gold standard in the treatment even though the operation requires some modifications in operating theatre arrangement and position of the surgical team. Most surgeons are right-handed, and to operate laparoscopically in the “mirror image” anatomical situation using mainly the left hand for dissection may be stressful, uncomfortable and more time-consuming. Some recommendations to overcome this issue have been published. In conclusion, the above-mentioned anomaly may cause some risk and delay of the exact diagnosis, but it is not dangerous in itself. Laparoscopic cholecystectomy is a safe procedure, even in the case of acute cholecystitis, if performed by an experienced laparoscopic surgeon. The most dangerous is always an incautious and too self-confident surgeon.

Objectives:To retrospectively compare late toxicity of conventional-dose three-dimensional conformal radiation therapy (3D-CRT) and high-dose intensity-modulated radiation therapy (IMRT) for prostate cancer. Methods: A total of 340 patients with T1-3 prostate cancer were treated with 3D-CRT (n = 228) and IMRT (n = 112). The median follow-up time was 5.9 years and 3.0 years, respectively. The prescription dose was 70 Gy for 3D-CRT and 78 Gy for IMRT. Late gastrointestinal (GI) and genitourinary (GU) toxicities were graded according to the Fox Chase modification of the Radiation Therapy Oncology Group and Late Effects Normal Tissue Task Force criteria. Results: There was no difference between 3D-CRT and IMRT in the incidence of GI and GU toxicity at 3 years. On multivariate analysis, transurethral resection of prostate/open transvesical prostatectomy (TURP/TVPE) for benign prostatic hyperplasia, carried out before radiotherapy, significantly increased the risk of Grade Ն2 GU toxicity (risk ratio 1.88). Among patients who experienced TURP/TVPE, the 5-year actuarial likelihood of Grade 2-3 urinary incontinence was 23%, compared with 9% for those without prostate surgery (P = 0.01). Conclusions: Tolerance of 3D-CRT and IMRT was similar, despite the use of high radiation dose with IMRT. Previous TURP/TVPE increased the risk of GU toxicity.

IntroductionThe standard radical treatment of renal cell carcinoma is surgical resection, but it is not suitable for patients with serious medical comorbidities and solitary kidney tumors. Minimally invasive ablation techniques could be an appropriate therapeutic alternative.AimTo retrospectively evaluate the technical success, mid-term and long-term efficacy and safety of radiofrequency and microwave ablation in patients with small renal tumors.Material and methodsOver the course of 10 years, 91 ablation procedures in 64 patients for 68 tumors, of size 12–60 mm, were performed using only conscious sedation. These ablations were done under the guidance of computed tomography. We treated 41 males and 23 females with solitary kidney tumors (14 cases) and tumors in non-surgical candidates (54 cases).ResultsIn 50 (73.5%) tumors single treatment was successful; in 13 (19.1%) cases a second procedure was used successfully, and in the 5 largest tumors (sizes 45–60 mm, 7.4%) a third treatment was necessary. Within the follow-up 10 (15.6%) patients died, but none due to metastatic renal cell carcinoma. Only 1 serious complication was observed – retroperitoneal and psoatic hematoma. Early recurrence occurred in 18 (26.5%) tumors. Late recurrence was detected in 5 (7.4%) cases. In all cases complete local control of the renal tumors was reached.ConclusionsPercutaneous ablation is a very effective treatment for patients with small renal tumors of the T1a group with a minimal complication rate.

A b s t r a c tIntroduction: The preferred treatment for acute cholecystitis is cholecystectomy, but for patients with precluded general anesthesia due to critical illness or multiple medical comorbidities it is not suitable. Cholecystostomy could be a minimally invasive therapeutic alternative. Aim: To retrospectively evaluate the indications, technical features, efficacy, complications, patients' development and relationships among monitored parameters of percutaneous computed tomography (CT)-guided cholecystostomies in cases of acute cholecystitis and find the role of this procedure in appropriate treatment selection. Material and methods: Over the course of 10 years, 75 percutaneous cholecystostomy procedures in 69 patients were performed in cases with diagnosed acute cholecystitis, precluded general anesthesia and contraindicated cholecystectomy by an experienced surgeon and anesthesiologist. These interventions were done using only local anesthesia. The patients were men in 39 cases and women in 33 cases, aged 33 to 91 years. Results: Technical success was achieved in all cases. The indications were sepsis in 34 (45.3%) cases, bridging acute gallbladder inflammatory status in 15 (20%) interventions, serious medical comorbidities in 8 (10.7%) cases, disseminated malignancy and cardiac failure in 6 cases each (both 8%) and neurological affections in 5 (6.5%) cases. Cholecystostomy was frequently the final solution in acalculous cholecystitis (79.3%). The 30-day mortality rate was determined at 10.7% and the overall complication rate was 21.3%, but all of these complications were managed conservatively or using minimally invasive treatment. Conclusions: Percutaneous CT-guided cholecystostomy is reserved for patients with a serious medical status for various reasons that preclude surgical treatment and general anesthesia. Simultaneously, technical success and efficacy are high and the complication rate is acceptable.