Metastatic Anorectal Melanoma Presenting as Seizures: An Infrequent Culprit.

Anorectal malignant melanoma is a rare culprit of malignancies in the anorectal region. With a presentation that mimics the vastly more common colorectal tumours, clinical misdiagnosis and diagnostic delays often occur, contributing to a dismal prognosis. The authors report a case of metastatic anorectal malignant melanoma presenting as seizures. Though our standard diagnostic pathway for suspected anorectal malignancies was followed, and despite the patient having computerized tomography (CT) of the head earlier, this presentation nonetheless led to a prolongation of time needed to reach histological diagnosis and delay in commencing definitive treatment. It also highlights the paucity of research into the pathophysiology and management of this infrequent but aggressive disease, and the need for raising awareness about this condition to the medical community so that it is considered as a plausible differential diagnosis from the outset and diagnostic pathways adjusted accordingly.

Local Protocol for Management of Low-Grade Appendiceal Mucinous Neoplasm (LAMN).

The management and surveillance of low-grade appendiceal mucinous neoplasm (LAMN) is a confusing topic in the colorectal MDM. This study was aiming to provide a local protocol for our trust for such cases. From prospectively maintained database, patients who underwent appendicectomy between 2011 and 2017 were identified. Those with histological confirmation of LAMN were included. Retrospective analysis of operative notes, investigations and follow-up, return to theatres or development of pseudomyxoma peritonei (PMP) was performed. Four thousand six hundred twenty-eight patients had appendicectomy; 36 were diagnosed with LAMN. Age range was 30-88 (20 females). Fifteen had their operation as emergency and 13 elective, either for abnormal-looking appendix on CT scan or as part of elective right hemicolectomy. In 8 patients, LAMNs were diagnosed incidentally during other surgery either intraoperatively or on histology. Two patients had mucus in the peritoneal cavity (not sampled). The remaining 34 had either contained mucocele or inflamed appendix. Regarding follow-up, 28 patients had CT scans only, and 2 had ultrasound scan (USS). Two had both CT and USS. Three had CT and MRI scans. One patient did not have radiological investigations. Eighteen patients had colonoscopies (50%). Three patients had no follow-up, while 33 had 5-year follow-up. Ten patients are still currently under follow-up. None of the 36 patients required further surgeries related to LAMN, and none has developed PMP to date of the study. We have developed a local protocol based on our findings and literature review for management and surveillance of LAMN in line with national centres.

Microsatellite instability in hepatocellular carcinoma in non-cirrhotic liver in patients older than 60 years.

AIM: Hepatocellular carcinoma (HCC) in otherwise normal liver is rare, its pathogenesis remains obscure and the literature on the subject is scarce. We investigated microsatellite instability (MSI) in eight elderly patients (median age 70.7, range 63-76 years) without a clinical history of liver disease and who underwent liver resection for HCC in otherwise normal background liver between 2001 and 2005 at King's College Hospital, London. METHODS: Immunohistochemistry for mutL homolog 1 (MLH1), mutS homolog 2 (MSH2), mutS homolog 6 (MSH6) and post-meiotic segregation increased 2 (PMS2) was carried out on formalin-fixed and paraffin-embedded sections of tumor and background liver. MSI analysis was performed using a panel of monomorphic microsatellites markers: BAT-25, BAT-26, NR21, NR24 and NR27 and pentaplex PCR. RESULTS: All HCC were solitary large tumors. Two also had satellite nodules. The background liver was usually unremarkable. There was nuclear expression of MLH1, MSH2, MSH6 and PMS2 in all tumors excluding a DNA mismatch repair defect. The same pattern of staining was noted in the hepatocytes of the background liver of all cases. No differences between microsatellite lengths in the background liver and in the tumor, as assessed in PCR products, were found for any of the five microsatellite markers in any patients. These findings provided no evidence for MSI. CONCLUSION: Our study showed that MSI is not implicated in the pathogenesis of a subset of HCC affecting elderly patients without chronic liver disease. Further studies are needed to clarify the pathogenesis of HCC in this particular setting.

Lepromatous lymphadenitis masquerading as lymphoma.

A 70-year-old male presented with multiple lymphadenopathy and a strong clinical suspicion of non-Hodgkin's lymphoma. Cervical and axillary nodes were excised and were sent for histopathological evaluation, which revealed aggregates of lepra cells loaded with lepra bacilli. Clinicians practising in leprosy endemic areas should keep lepromatous lymphadenitis in mind while investigating patients with lymphadenopathy.

Infusion of routinely stored blood may limit reperfusion injury to acutely ischemic myocardial cells.

Emergency thrombolysis and restoration of blood supply to acutely ischemic myocardium kills many reversibly injured muscle cells by free radicals generation and calcium influx. Such reversibly injured cells form the major bulk during the initial 10-20 min of ischaemia and in an era where emergency recanalization of arteries is possible, reperfusion injury becomes significant. Therefore, researchers have been trying to find out ways to limit the reperfusion injury by using antioxidants, complement inhibitors or by reperfusion of leucodepleted autologous blood. Red cell concentrates routinely available in blood banks are already depleted of plasma and hence calcium (chelated to the anticoagulant), leukocytes and most viable plasma proteins including complement. They have reduced oxygen content by virtue of storage; hence there might be less free radical generation. So infusion of such a blood through an intracoronary catheter might limit reperfusion injury. Addition of antioxidants or controlling the oxygen content while infusing this blood might give additional benefits. This hypothesis might be tested in animals by inducing controlled ischaemia with reperfusion of homologous cross-matched and group tested blood followed by cardiac radioactive scans. If the experimental results permit, clinical trials might be carried out eventually.

Left shoulder region metastasis from hepatocellular carcinoma as an initial presentation--a case report.

Hepatocellular carcinoma metastasis as a soft tissue mass is rare; we came across a 65 years old female who presented with a left shoulder region mass. There was no previous history of any liver disease and liver function tests were normal. Histologically, it turned out to be a metastasis from hepatocellular carcinoma.