Citations

Percutaneous image-guided ablation is an increasingly common treatment for a multitude of solid organ malignancies. While historically these techniques have been restricted to the management of small, unresectable tumors, there is an expanding appreciation for the systemic effects these locoregional interventions can cause. In this review, we summarize the mechanisms of action for the most common thermal ablation modalities and highlight the key advances in knowledge regarding the interactions between thermal ablation and the immune system.

Abstract: Cellular blue nevomelanocytic lesions (CBNLs) frequently pose diagnostic problems to pathologists, and their biological potential may be difficult to establish. In this study, the authors have analyzed the clinical, histological, and outcome data of 37 cellular blue nevomelanocytic lesions and the molecular characteristics of 4 lesions. The cohort of cases comprised 8 cellular blue nevi (CBNs), 17 atypical cellular blue nevi (ACBNs), and 12 blue-nevus–like melanomas (BNLMs) with a mean follow-up of 5 years. The average age at diagnosis was 25.9 years for patients with ACBN, versus 30.4 years for CBN, and 44.6 years for BNLM. Both CBN and ACBN occurred most frequently on the trunk or extremities, whereas BNLM primarily involved the scalp. Histologically, CBN and ACBN were characterized by a mean diameter of <1 cm, absence of necrosis, low mitotic rate (mean: 1–2 mitotic figures/mm2), little or no infiltrative properties, and usually low-grade cytologic atypia. In contrast, BNLM had a mean diameter of 1.6 cm, necrosis, tissue infiltration, greater mitotic activity (mean: 6 mitotic figures/mm2), and high-grade cytologic atypia. ACBNs often were larger, more densely cellular, exhibited higher mitotic counts, and were cytologically more atypical than CBN. Seven CBN cases with follow-up had a benign clinical course (average follow-up of 4.7 years). Among 6 patients with ACBN who underwent sentinel lymph node (SLN) biopsy, 3 were positive, and a single additional case had 1 positive non-SLN (this patient did not have a SLN biopsy performed). All 14 cases of ACBN with follow-up were alive and without recurrence with mean follow-up of 5 years. Of the 9 melanoma cases with follow-up, 3 patients with SLN and non-SLN involvement died from their disease (average follow-up of 4.8 years). Array comparative genomic hybridization was performed on 2 ACBNs and 1 BNLM: One of the 2 ACBNs showed chromosomal aberrations and 1 BNLM showed multiple chromosomal gains and losses. Multiplex polymerase chain reaction was performed on 1 ACBN, and no mutations were found. From these results, the authors conclude that ACBN occupy an intermediate position within the spectrum of CBN and BNLM, yet many lesions cannot be reliably distinguished from either CBN or BNLM because of overlapping histologic features. However, in general, ACBNs seem to aggregate more closely with CBN in terms of clinical, histological, molecular profile (limited data), and biological behavior.

Objective To describe findings and outcomes of 331 bilateral inferior petrosal sinus sampling (BIPSS) procedures performed in 327 patients evaluated for Cushing disease (CD). Materials and methods The radiology department's electronic database was searched to identify all BIPSS procedures (1990–2013). Electronic medical records were used to identify demographics, laboratory, procedural, surgical and pathologic findings. Results A total of 331 BIPSS procedures were performed in 327 patients (254 F, 73 M), mean age 41 (range 7–81) years. The overall technical success rate was 88% for bilateral cannulation, though nearly two-thirds of the technical failures had unilateral sampling that diagnosed CD. Of the 331 BIPSS procedures, 40 were performed without, and 291 with stimulation by Acthrel or desmopressin. Sensitivity was 89–94% for unstimulated BIPSS, 96% for stimulated BIPSS, and 77% for MRI. BIPSS lateralization was accurate in about half of patients, compared with 75% accuracy for MRI. Mean inferior petrosal sinus (IPS):peripheral adrenocorticotropic hormone ratio was 17.3 (SE 1.8) at baseline, and 99.2 (SE 14.8) at 3 min, with decreasing values over time. All patients with follow-up after surgical resection for centralizing BIPSS were reported to be cured, with cortisol levels significantly decreased from 19 to 4 μg/dL (p<0.0001). Complications from BIPSS were rare, including groin hematoma (2.5%), but no thromboembolic complications were seen. Conclusions BIPSS remains the ‘gold standard’ for diagnosing CD. Stimulation with Acthrel or desmopressin is key to increasing specificity. When only one IPS can be successfully cannulated, results may still be diagnostic. BIPSS findings cannot be used to accurately lateralize lesions within the pituitary.

A 62-year-old woman with idiopathic cardiomyopathy and class IIIB/stage C heart failure sustained right pulmonary artery injury from a Swan-Ganz catheter during a pretransplant work up. Postprocedure, it was noted that the patient's segmental pulmonary artery catheter was wedged for an unclear period of time. The patient developed a small volume of blood-tinged sputum and a chest CT revealed a 1.3 cm pseudoaneurysm in the right middle lobe medial segment pulmonary artery and a small area of haemorrhage. The patient underwent pulmonary artery preserving coil embolisation of the pseudoaneurysm to prevent further right heart strain, given an ejection fraction of 20%, which resolved haemoptysis. Imaging studies showed preserved distal outflow and no evidence of residual pseudoaneurysm filling.

Objectives To determine the proportion of nursing home ( NH ) residents ( NHR ) with overactive bladder ( OAB ) or urinary incontinence ( UI ) with potential pharmacodynamic contraindications to antimuscarinic treatment because of concomitant anticholinergic medications or acetylcholinesterase inhibitors ( AC h EI s) and nonpharmacological limitations to antimuscarinic treatment. Design Cross‐sectional retrospective analysis. Setting U.S. skilled nursing facilities. Participants Nursing home residents with a diagnosis of OAB or UI . Measurements Linked and deidentified pharmacy claims and Minimum Data Set ( MDS ) 3.0 records (October 1, 2010 to September 30, 2012). Results Of NHR s, 71.3% received at least one anticholinergic medication. Medications that can cause or worsen UI were used commonly. AC h EI s and antimuscarinic treatment were prescribed concurrently in 24% of NHR s with OAB or UI . NHR s with OAB or UI were more likely to have concurrent moderate to severe cognitive impairment ( MSCI ) (70.1%) than those without (29.9%) ( P < .001). NHR s with or without OAB or UI and with MSCI were more likely to be treated with an anticholinergic medication than those without MSCI ( P = .001). When NHR s with MSCI , severe mobility impairment ( SMI ), and anticholinergic medication and AC h EI use were excluded, only a small proportion of NHR s were potential candidates for antimuscarinic treatment (6.6% with OAB or UI , 6.2% with UI ). Conclusions This study advances understanding of the challenges in prescribing antimuscarinic treatment safely and appropriately in elderly NHR s with a high prevalence of drug interactions, underlying MSCI , and SMI .

A 37-year-old African-American woman with end-stage renal disease presumed to be secondary to diabetes mellitus type 2, on daily peritoneal dialysis, was admitted for a painful left lower extremity lesion. Examination revealed a large, dusky, tender region over the left lateral thigh. She was on warfarin for mechanical heart valves. Despite discontinuation of warfarin and placement on heparin, the lesion progressed to extend to the medial left thigh and medial and lateral right thigh. CT scan demonstrated arteriolar medial calcification and vascular calcification of the small subcutaneous vessels, without evidence of abscess or haematoma. The patient declined punch biopsy. Given the known risk factors of high calcium-phosphate and radiological findings, a diagnosis of calcific uraemic arteriolopathy was made. Phosphate-binder therapy was optimised. She was transitioned to daily haemodialysis, and sodium thiosulfate was initiated. Skin lesions demonstrated improvement at her 5 weeks posthospitalisation follow-up.