Propafenone hepatotoxicity: report of a new case and review of the literature

Propafenone is a class Ic antiarrhythmic drug. It is a beta-adrenergic blocker that causes bradycardia and bronchospasm. It is metabolized primarily in the liver. Its bioavailability and plasma concentration differ among patients under long-term therapy. They are genetically determined by the hepatic cytochrome P-450 2D6. Hepatic toxicity is highly uncommon. To date, only eight patients were reported in the reviewed world literature. In this article, one new case will be reported emphasizing the importance of medication history taking in patients presenting with new-onset liver enzymes abnormalities

Successful closure of pharyngo-cutaneous and phayryngo-tracheal fistulas using removable hypopharyngeal stent after laryngectomy for laryngeal carcinoma

Placement of removable stents to close pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy has not been reported before. This case presents the feasibility of removable esophageal stent in closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Consecutive patients who underwent placement of removable esophageal stent for closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Three patients underwent successful stent placement in the hypopharynx. The stents were well tolerated. Patient one had the stent for 14 months, leading to complete healing of the fistula. Removal was successful. The second patient was palliated but died 8 weeks after stent placement. The third patient has successful palliation of his tracheo-esophageal fistula and the stent is being exchanged every 3-4 months to palliate his fistula. Closure of pharyngo-cutaneous and tracheo-esophageal fistulas is feasible with esophageal removable stents. These stents provide alternative options when dealing with these challenging problems

Combined use of EUS-guided FNA and immunocytochemical stains disclosed metastatic and unusual diseases in the evaluation of mediastinal lymphadenopathy of unknow etiology

Mediastinal lymphadenopathy [ML] is a cause for concern, especially in patients with previous malignancy. We report our experience with the use of endoscopic ultrasound-guided fine needle aspiration [EUS-FNA] with immunocytochemical stains in patients being evaluated for ML. Retrospective analysis of patients with ML of unknown origin who underwent EUS-FNA. On-site evaluation was performed by experienced cytologist, and special immunocytochemical stains were requested as indicated. A total of 116 patients were included, and a total of 136 mediastinal LN were sampled. Prior malignancy was present in 45%. The most common site of examined lymph node [LN] were subcarinal [76%, 103 LN]. The median long and short axis diameters were 28 mm and 13 mm, respectively. FNA was read on-site as malignant, 21 [16%]; benign, 100 [76.9%]; suspicious, six [4%]; atypical, 3 [2%]; and inadequate sample, six [4%]. Sixty-four LN were deferred for additional studies; 22 for immunocytochemical and 26 for Gimesa [GMS] stain and 21 for flow cytometry. Final FNA read was malignant in 28 [21%], benign in 103 [76%], suspicious in three [2%], and atypical in two [1%]. Metastatic malignancies disclosed included Hodgkin's and Non-Hodgkin's lymphoma, melanoma, hepatoma, breast, lung, colon, renal, endometrial, Fallopian tube, and unknown carcinoma. The sensitivity, specificity, and accuracy of the final FNA read to predict malignancy were 100%. EUS-guided FNA with additional ancillary studies is useful in disclosing metastatic ML from a variety of neoplasms. Due to its safety and accuracy profile, it should be considered the test of choice in evaluating abnormal ML in appropriately selected patients

Unusual, metastatic, or neuroendocrine tumor of the pancreas: a diagnosis with endoscopic ultrasound-guided fine-needle aspiration and immunohistochemistry

To determine the yield of endoscopic ultrasound-guided fine-needle aspiration [EUS-FNA] in combination with immunostains in diagnosing unusual solid pancreatic masses [USPM] in comparison with pancreatic adenocarcinoma [ACP]. All EUS-FNA of solid pancreatic masses performed with a 22-gauge needle were included. Data on clinical presentations, mass characteristics, presence of pancreatitis, yield of tissue, and final diagnosis were compared between the two groups. On site cytopathology was provided and additional passes were requested to perform immunostains. Two hundred and twenty-nine cases with either adenocarcinoma or USPM were included. The median age of the cohort was 65 years. ACP [210/229, 92%] accounted for the majority of the cases. The USPM included neuroendocrine [NET] masses [n=13], metastatic renal carcinoma [n=3], metastatic melanoma [n=l], lymphoma [n=l], and malignant fibrous histiocytoma [n=l]. Subjects with ACP were significantly more likely to present with loss of weight [P=0.02] or obstructive jaundice [P<0.001]. Subjects with ACP were more likely to have suspicious/atypical FNA biopsy results as compared with USPM [10% vs 0%]. The sensitivity of EUS-FNA with immunostains was 93% in ACP as compared with 100% in USPM. Diagnostic accuracy was higher in USPM as compared with ACP [100% vs 93%]. EUS-FNA using a 22-gauge needle with immunostains has excellent diagnostic yield in patients with USPMs, which is comparable if not superior to the yield in pancreatic adenocarcinoma

Predictors of malignancy in EUS-guided FNA for mediastinal lymphadenopathy in patients without history of lung cancer

Mediastinal lymphadenopathy [ML] poses a great diagnostic challenge. To investigate the predictors of malignancy in endoscopic ultrasound [EUS]-guided fine-needle aspiration [FNA] of ML in patients without known lung cancer. Retrospective study. Tertiary referral center. One hundred eight patients without known lung cancer who underwent EUS guided-FNA for ML between 2000 and 2007. All subjects underwent EUS-guided FNA. Data was collected on patients' demographics, and lymph node [LN] characteristics. Diagnosis of LN malignancy was based on FNA findings and clinical follow-up. One hundred eight patients were analyzed; 58 [54%] were men and 87 [79%] were Caucasian. Mean age was 55 years. Prior malignancy was present in 48 [43%] patients. A total of 126 FNA samples from 126 distinct LNs were performed. Twenty-five [20%] LNs were positive for malignancy. Mean short and long-axis for LNs were 13 and 29 mms respectively. Round shape and sharp borders were found in 29 [15%] and 25 [22%] LNs, correspondingly. Independent predictors of a malignant FNA were: Prior cancer [OR 13.10; 95% CI 2.7-63.32; P = 0.001], short axis [OR 1.10; 95% CI 1.00-1.22; P = 0.041] and sharp LN borders [OR 5.47; 95% CI 1.01-29.51; P = 0.048]. Age, race, gender, long axis, round shape were not associated with cancer in our cohort. Limitations: Retrospective design and lack of surgical gold standard. Increased risk of malignancy was associated with prior history of cancer, larger LN short axis and presence of LN sharp borders. These predictors may help guide endoscopists perform FNA in malignant LNs, increasing the overall efficiency of EUS-FNA for ML

Transduodenal EUS-guided FNA of the right adrenal gland to diagnose lung cancer where percutaneous approach was not possible

Although endoscopic ultrasound-guided fine needle aspiration [EUS-guided FNA] of the left adrenal gland is safe and accurate compared to the percutaneous approach, there are no reports to our knowledge about EUS-guided FNA of the right adrenal gland performed in Lebanon and the Middle East. We report the case of a 64-year-old male who presented with a swollen right calf and right flank pain and was diagnosed with deep vein thrombosis with a right calf deep venous thrombosis. A computerized tomography of the chest and abdomen revealed a round solid mass of the right adrenal gland, a right upper lobe mass and centrilobular emphysema of both lungs. Percutaneous biopsy of the right adrenal gland was declined as the patient was quoted a high risk of bleeding. EUS-guided FNA of the right adrenal was performed via the transduodenal approach confirming the final diagnosis of metastatic lung cancer. This case shows that the right adrenal gland can be sampled with EUS-FNA via the duodenal approach to diagnosed metastatic lung cancer, especially when the percutaneous approach is not feasible