Glioblastoma multiforme is the most common malignant primary brain tumor in adults. Histone H3 mutations have been identified in pediatric and adult gliomas, with H3K27M mutations typically associated with a posterior fossa midline tumor location and poor prognosis. Leptomeningeal disease is a known complication of histone-mutant glioma, but uncommon at the time of initial diagnosis. We describe a case of glioblastoma with H3K27M mutation that initially presented with progressive vision loss due to diffuse leptomeningeal disease in the absence of a mass lesion other than a small cerebellar area of enhancement and with cerebrospinal fluid cytology negative for malignant cells on two occasions, highlighting the importance of including primary CNS malignancies in the differential of diffuse radiographic leptomeningeal enhancement.
IntroductionLeiomyosarcomas (LMS) involving the inferior vena cava (IVC) is a clinically rare entity, accounting for approximately 0.5% of all adult sarcomas.Case presentationA 67-year-old male presented to the emergency department with mild back and lower abdominal pain. During the workup, a computed tomography scan without contrast showed an area of decreased attenuation within the liver adjacent to the intrahepatic IVC. Magnetic resonance imaging confirmed the involvement of the retro-hepatic IVC; biopsy confirmed the diagnosis of LMS. Given the location of the involvement of the retro-hepatic IVC, liver explantation was deemed necessary for adequate tumor resection. The superior extension of the tumor toward the heart necessitated Cardio-Pulmonary (CPB). The patient successfully underwent a complex surgical procedure involving liver explantation with ex vivo back-table resection of the retro-hepatic LMS, replacement of the retro-hepatic vena cava with a ringed Gore-Tex graft, liver re-implantation, and hepatic vein-atrial reconstruction under cardiopulmonary bypass. There were no intraoperative or post-op complications.DiscussionThe role of vascular reconstruction of the IVC varies depending on the level and extent of the tumor, with options ranging from primary repair, ligation, or reconstruction dictated. Surgical resection with negative margins remains the treatment of choice due to the lack of efficacy of adjuvant therapies. Importantly, liver explantation offers a chance for complete surgical resection and reconstruction. Similarly, the complex nature of the tumor necessitated a pioneering approach involving direct hepato-atrial venous anastomosis.ConclusionTo the best of our knowledge, this is the first reported case in which the hepatic veins were anastomosed directly to the right atrium while also replacing the native vena cava with a separate graft.
Background/Objectives
Obesity is a global health challenge that affects > 1/3 adults worldwide. Obesity and frailty pose considerable health risks due to their potential to interact and amplify one another’s negative effects. Therefore, we sought to compare the discriminatory thresholds and independent relationship of the risk analysis index (RAI), 5-factor modified frailty index (m-FI-5) and greater patient age for the primary endpoint of 30-day postoperative mortality.
Subjects/Methods
We included spine surgery patients ≥ 18 years old, from the American College of Surgeons National Quality Improvement program database from 2012-2020, that were classified as obese. We performed receiver operating characteristic curve analysis to compare the discrimination threshold of RAI, mFI-5, and patient age for 30-day postoperative mortality. Risk-adjusted analyses were performed.
Results
Overall, there were 149 163 patients evaluated, and in the ROC analysis for 30-day postoperative mortality, RAI showed superior discrimination C-statistic 0.793 (95% CI: 0.773-0.813), compared to mFI-5 C-statistic 0.671 (95% CI 0.650-0.691), and patient age C-statistic 0.686 (95% CI 0.666-0.707). By subgroups for obesity class I-III, consistent results were observed (C-statistics range: RAI 0.767-0.808; mFI-5 0.642-0.693; patient age 0.665-0.706). In the risk-adjusted analyses, frailty had a dose-dependent relationship with 30-day postoperative mortality, and the RAI had a larger effect size (p<0.001). Additionally, obesity and frailty had a synergistic dose-dependent relationship across obesity class I-III (p<0.001).
Conclusion
In this study of 149 163 patients classified as obese and undergoing spine procedures in an international prospective surgical database, the RAI demonstrated superior discrimination compared to the mFI-5 and patient age in predicting 30-day postoperative mortality risk. The deleterious effects of frailty and obesity were synergistic as their combined effect predicted worse outcomes.
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