Large Malignant Pheochromocytoma Causing Cardiac Failure and Metastasis: A Case Report With Review of Literature.

Extra-adrenal functional neuroendocrine neoplasms are termed paragangliomas. We describe a case of a large abdominal neuroendocrine tumor that was proved to be a paraganglioma on biopsy. Unfortunately, the patient presented with high output heart failure, an extremely rare complication of paraganglioma. Prior to surgical biopsy, the patient underwent a complete invasive and non-invasive cardiac workup, in addition to biochemical testing. On a PET CT, the retroperitoneal neuroendocrine tumor was shown to have been metastasized to the spine. Chemotherapy targeted at somatostatin analogs was initiated. The unique presentation and rare complications are presented with relevant review of literature to highlight the spectrum of disease geared towards diagnostic and interventional radiologists. It is crucial to understand the broad spectrum of disease and include this entity in the differential diagnosis of a retroperitoneal mass. Equally significant is to consider potential complications such as metastases and cardiac failure to guide appropriate workup and management.

Establishing magnetic resonance imaging as an accurate and reliable tool to diagnose and monitor esophageal cancer in a rat model.

OBJECTIVE: To assess the reliability of magnetic resonance imaging (MRI) for detection of esophageal cancer in the Levrat model of end-to-side esophagojejunostomy. BACKGROUND: The Levrat model has proven utility in terms of its ability to replicate Barrett's carcinogenesis by inducing gastroduodenoesophageal reflux (GDER). Due to lack of data on the utility of non-invasive methods for detection of esophageal cancer, treatment efficacy studies have been limited, as adenocarcinoma histology has only been validated post-mortem. It would therefore be of great value if the validity and reliability of MRI could be established in this setting. METHODS: Chronic GDER reflux was induced in 19 male Sprague-Dawley rats using the modified Levrat model. At 40 weeks post-surgery, all animals underwent endoscopy, MRI scanning, and post-mortem histological analysis of the esophagus and anastomosis. With post-mortem histology serving as the gold standard, assessment of presence of esophageal cancer was made by five esophageal specialists and five radiologists on endoscopy and MRI, respectively. RESULTS: The accuracy of MRI and endoscopic analysis to correctly identify cancer vs. no cancer was 85.3% and 50.5%, respectively. ROC curves demonstrated that MRI rating had an AUC of 0.966 (p<0.001) and endoscopy rating had an AUC of 0.534 (p = 0.804). The sensitivity and specificity of MRI for identifying cancer vs. no-cancer was 89.1% and 80% respectively, as compared to 45.5% and 57.5% for endoscopy. False positive rates of MRI and endoscopy were 20% and 42.5%, respectively. CONCLUSIONS: MRI is a more reliable diagnostic method than endoscopy in the Levrat model. The non-invasiveness of the tool and its potential to volumetrically quantify the size and number of tumors likely makes it even more useful in evaluating novel agents and their efficacy in treatment studies of esophageal cancer.

Simultaneous augmentation/mastopexy: a retrospective 5-year review of 332 consecutive cases.

BACKGROUND: Of all mastopexies performed in the authors' facility, approximately 77 percent of patients have an implant placed simultaneously. The unique challenges and safety concerns associated with the simultaneous augmentation/mastopexy procedure merit a deeper evaluation of its use and associated risks. METHODS: A retrospective analysis of 430 mastopexy operations, including 332 simultaneous augmentation mastopexies, was performed. Patient demographics, patient selection, and operative approach were evaluated and correlated with surgical outcomes. Complications and reoperation rates were measured and compared with published reports in the literature. RESULTS: For simultaneous augmentation/mastopexy procedures, the overall complication rate was 22.9 percent (primary cases, 20.4 percent; secondary cases, 28.9 percent). Tissue- and implant-related complication rates were 15.1 and 7.8 percent, respectively. The overall reoperation rate was 23.2 percent (primary cases, 20.0 percent; secondary cases, 30.9 percent). Tissue- and implant-related reoperation rates were 13.3 and 9.9 percent, respectively. The most common complications were capsular contracture (13 of 332), poor scarring (11 of 332), and recurrent ptosis (11 of 332). They were also the most common indications for reoperation (11 of 332 for each one). The mastopexy-only reoperation rate of 10.2 percent was comparable to the tissue-related reoperation rate of 13.3 percent. CONCLUSIONS: Although the measured reoperation rate (23.2 percent) may be higher than that of either procedure performed independently, the revision rate of combining the procedures was not more than additive. With appropriate patient selection and a carefully planned operative approach, the authors believe a one-stage procedure can be safely performed with acceptable complication and reoperation rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Identification of penile inputs to the rat gracile nucleus.

Neurons in the medullary reticular formation (MRF) of the rat receive a vast array of urogenital inputs. Using select acute and chronic spinal cord lesions to identify the location of the ascending neural circuitries providing either direct or indirect inputs to MRF from the penis, our previous studies demonstrated that the dorsal columns and dorsal half of the lateral funiculus convey low- and high-threshold inputs, respectively. In the present study, the gracile nucleus was targeted as one of the likely sources of low-threshold information from the penis to MRF. Both electrophysiological recordings and neuroanatomical tracing [injection of cholera toxin B subunit (CTB) into a dorsal nerve of the penis] were used. After discrimination of a single neuron responding to penile stimulation, testing for somatovisceral convergence was done (mechanical stimulation of the distal colon and the skin over the entire hindquarters). In 12 rats, a limited number of neurons (43 in total) responded to penile stimulation. Many of these neurons also responded to scrotal stimulation (53.5%, dorsal and/or ventral scrotum) and/or prepuce stimulation (46.5%). Histological reconstruction of the electrode tracks showed that the majority of neurons responding to penile stimulation were located ventrally within the medial one-third of the gracile nucleus surrounding obex. This location corresponded to sparse innervation by CTB-immunoreactive primary afferent terminals. These results indicate that neurons in the gracile nucleus are likely part of the pathway that provides low-threshold penile inputs to MRF, a region known to play an important role in mating processes.