Introduction: Small cell prostate cancer (SCPC) is a rare histologic subtype of prostate cancer, for which the optimal staging strategy remains unclear. Method: The Surveillance, Epidemiology, and End Results database was used to analyze the incidence and outcomes of SCPC between the years 2004 through 2016. Limited-stage SCPC (LS-SCPC) was defined as SCPC without any metastasis regardless of local invasion. Extensive stage SCPC (ES-SCPC) was defined as any metastasis to lymph nodes and/or to distant organs. Result: A total of 403 SCPC patients were included in the study cohort, accounting for 0.056% of all prostate cancer cases (n=719,655). Of the 358 patients with known metastasis status, 275 (76.8%) patients had ES-SCPC, whereas 83 (23.2%) patients had LS-SCPC. LS-SCPC was associated with better overall survival (17 vs. 9 mo, P<0.001) and disease-specific survival (25 vs. 10 mo, P<0.001) compared with ES-SCPC. All LS-SCPC patients had a similar overall survival regardless of T stage. Similarly, all ES-SCPC patients had similar outcomes regardless of metastasis sites. High prostate-specific antigen (PSA) is paradoxically associated with superior outcome in both localized stage patients (PSA≥4 vs. PSA<4, 19 vs. 10 mo, P=0.002) and extensive stage patients (PSA≥20 vs. PSA<20, 13 vs. 9 mo, P=0.02). Multivariate analysis of treatment showed that chemotherapy was associated with improved survival in ES-SCPC with hazard ratio of 0.52. Conclusion: Similar to small cell lung cancer, SCPC can be staged into LS-SCPC or ES-SCPC. The binary staging system correlates well with prognosis.
Pembrolizumab is an immune checkpoint inhibitor being increasingly used as immunotherapy for a multitude of cancers. With the increasing use of these agents, various immune-related adverse events are being recognized. Lichenoid reaction, pruritus, and eczema are well-established cutaneous side effects of pembrolizumab, but bullous pemphigoid (BP) is a rare side effect of the drug. It is difficult to establish this diagnosis because it needs a detailed history of the timeline of the evolution of symptoms and careful ruling out of other etiologies, especially other drugs. Here, we present the case of a 66-year-old male who developed BP after receiving pembrolizumab therapy for non-small-cell lung cancer. Discontinuation of pembrolizumab and the use of topical and systemic steroids led to the complete resolution of symptoms. Physicians should be aware of this potential complication and keep it on their differential diagnosis when treating patients on immune checkpoint inhibitors.
Pituitary apoplexy (PA) is an expansion of a pituitary adenoma due to infarction or hemorrhage of the gland. The term apoplexy usually describes larger bleeds leading to a sudden onset of symptoms. Although it is a rare condition, it can be a life-threatening emergency. PA usually presents with severe headache, nausea, vomiting, visual acuity, and field defects, frequently involving the cranial nerves directly adjacent to the pituitary gland, including third (oculomotor) cranial nerve, fourth (trochlear) cranial nerve, ophthalmic and maxillary branches of the fifth (trigeminal) cranial nerve, and, less commonly, the sixth (abducens) cranial nerve.Here, we present the case of a 36-year-old male who presented with a one-week history of worsening headache associated with double vision. On physical examination, the patient was noted to have left abducens nerve palsy. MRI brain showed anterior right T1 hyperintensity in the pituitary representing blood products. The patient was treated with analgesics and hormonal therapy with improvement in symptoms and eventual resolution of PA without the need for surgical intervention. PA is an unusual cause of acute isolated abducens nerve palsy which should be identified promptly as it is a life-threatening emergency that can be treated immediately with hormonal replacement followed by a decision to manage conservatively or surgically. The long-term follow-up includes endocrine assessment, visual assessment, and imaging surveillance.
A 59-year-old woman with a history of systemic lupus erythematosus and arthritis (chronic naproxen use) presented for evaluation of iron deficiency anemia (IDA). Her laboratory test results were consistent with IDA. Upper endoscopy and colonoscopy were nonrevealing. Evaluation with capsule endoscopy revealed a concentric ulceration in the jejunum. Other common causes of IDA including celiac disease, gastrinoma, inflammatory bowel disease, and malignancy were ruled out (Figure 1). This diaphragm-like structure is a rare, but pathognomonic, feature of nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy (Figure 1). 1 Patients with NSAID-induced enteropathy present with IDA or symptoms of small bowel obstruction due to diaphragm lesions of the jejunum. 2 Iron supplementation resulted in partial improvement of her IDA. This case report highlights the use of new diagnostic modalities, such as video capsule endoscopy, for diagnosis of small bowel injuries caused by NSAIDs. Video capsule endoscopy may assist in identifying these lesions and may be followed by double-balloon enteroscopy if pathologic diagnosis is required.
Introduction: Thrombocytopenia is a common occurrence in critically ill patients and results in an array of diagnostic workup. Heparin induced thrombocytopenia (HIT) is one of the most frequently ordered tests in this scenario, although it is a less common cause (0.02-0.5%) The over testing and treatment of HIT in Intensive Care Unit (ICU) can lead to a change in medications, and result in side effects, increased ICU length of stay and increased costs. Current guidelines recommend 4-Ts criteria to evaluate the clinical HIT probability in general population, but it may also be used in Intensive Care Unit (ICU) patients. Here, we want to analyze the the usage of 4Ts score in a community hospital and to understand its correlation with HIT testing to see if HIT testing could have been avoided. Methods: We performed a retrospective chart review of adult patients who underwent testing for Heparin Induced Thrombocytopenia anti-platelet factor 4 antibody (anti- PF4 Ab) in ICU at our institution from 03/01/2012 to 02/01/2018. The primary outcomes were set to identify (1) the extent of inappropriate of HIT testing and its consequences in patients with low 4Ts scores, and (2) if 4Ts score as a potential predictor of length of stay and mortality in ICU. As a secondary outcome, we assessed if Body Mass Index (BMI) and Recent Surgery are related to false positive anti-PF4 Ab test. Kruskal-Wallis test and Fisher Exact test were used. Results: A total of 66 patients were identified. The mean age was 64 yr and the male-female ratio was similar. 40 patients had recent surgery in the past 3 months. The cause of thrombocytopenia other than HIT was possible or definite in 62 patients with sepsis being the most common cause (56.45%). 30 patients had low probability 4-Ts scores, 28 had intermediate and 7 had high probability. HIT was confirmed (Serotonin Release Assay-SRA positive) in 0%, 7.14% and 12.5% of patients with low, intermediate and high probability 4Ts scores, respectively. In the patients with low probability 4Ts and anti-PF4 Ab testing, heparin was held in 24 (80%) and the anti-coagulation was switched (to either fondaparinux or argatroban) in 10 (33.33%). In those patients with anticoagulation switch, 3 had minor bleeding. There was no difference in the ICU length of stay (p=0.1712) and mortality (p=0.149) between patients with low, intermediate and high probability 4Ts scores. Patients with BMI ≥40 kg/m2 had twice the percentage of false positive anti-PF4 Ab testing compared with the rest, but the results were not significant (p=0.285). Recent surgery was not related to the false positive anti-PF4 Ab testing (p=1). Conclusion: As no patient with low-probability 4Ts score had confirmed HIT, low 4Ts may be a good estimator of the unlikeliness of HIT even in critically ill patients. We found discrepancy in the recommendations and usage of Anti-PF4 Ab testing in our institution. This has resulted in switching of heparin to other, more expensive anti-coagulations. This may very well be the situation in many other similar institutions. This could partly be due to lack of awareness of HIT testing guidelines in the critical care setting. We recommend the use of 4Ts scoring and more sensible testing and treatment of HIT in ICU patients. Although we could not demonstrate the statistical association between morbid obesity and false positive anti-PF4 Ab, our study might have been underpowered by low subgroup population of such patients. We propose further studies about HIT testing and treatment to include morbidly obese patients as a separate sub-group. Disclosures No relevant conflicts of interest to declare.
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