Role of Chemotherapy and Mechanisms of Resistance to Chemotherapy in Metastatic Castration-Resistant Prostate Cancer.

Chemotherapy using the taxanes, docetaxel and cabazitaxel, remains an important therapeutic option in metastatic castration-resistant prostate cancer (CRPC). However, despite the survival benefits afforded by these agents, the survival increments are modest and resistance occurs universally. Efforts to overcome resistance to docetaxel by combining with biologic agents have heretofore been unsuccessful. Indeed, resistance to these taxanes is also associated with cross-resistance to the antiandrogen drugs, abiraterone and enzalutamide. Here, we discuss the various mechanisms of resistance to chemotherapy in metastatic CRPC and the potential role of emerging regimens and agents in varying clinical phases of development.

A large thigh mass: a blood clot or a rare skeletal muscle metastasis from renal cell carcinoma.

BACKGROUND: Renal cell carcinoma (RCC) is a tumor known for its unusual presentations and high rate of metastasis. Metastasis to lung, liver, bone and brain are common, but to skeletal muscle(SM) is very rare. Because only 11% of the RCC metastases to SM present after 10 years of initial presentation, there is no general consensus for its annual surveillance. METHODS: We report a case of a 58 year old male with a history of RCC, initially diagnosed 11 years ago, who presented with a large SM mass. A large mass measuring more than 25 cm was located in left posterior thigh and was present for more than a year. It initially was diagnosed as a large blood clot and was treated with warfarin for more than 6 months. Clinical work up including FDG-PET/CT and MRI raised the possibility of a tumor, but a negative biopsy made the diagnosis uncertain. Because of high suspicion for a tumor, patient underwent a complete resection of the mass. RESULTS: The resected mass measuring 28 × 18 × 7 cm was detailed as the largest skeletal muscle metastasis from RCC ever reported. CONCLUSION: This case emphasizes the importance of maintaining a high suspicion for metastasis even in less common metastatic sites mainly in patients with a history of RCC. It also highlights the importance of annual surveillance for metastasis in patients with RCC even after 10 years of initial presentation using FDG-PET/CT.

Recurrent diabetic ketoacidosis in two community teaching hospitals.

OBJECTIVE: To identify the factors that influence recurrent (one or more previous episodes) diabetic ketoacidosis (DKA), which we refer to as recurrent DKA, in two private community teaching hospitals. METHODS: Retrospective chart review of the demographics, diabetes treatment regimens, diabetes education, medical comorbidities, medical insurance status, and mental illness/psychosocial factors of 80 patients with recurrent DKA who were admitted to the resident teaching services at two Birmingham, Alabama community teaching hospitals, Trinity Medical Center (TMC) and Princeton Baptist Medical Center (PBMC), between May 2006 and May 2012. RESULTS: The average number of admissions for recurrent DKA was 2.5 per patient. Eighty-four percent of the episodes of recurrent DKA were due to omission of insulin; 44% of patients reported omission of insulin because of illness and 40% stopped insulin for unknown reasons. Medical illnesses, including infection, accounted for only 31% of recurrent DKA admissions. CONCLUSION: Omission of insulin is the major cause of recurrent DKA. Psychosocial and socioeconomic factors contribute to poor adherence to therapy. Identifying these factors and instituting appropriate interventions may reduce the incidence of recurrent DKA.

Pretibial myxedema without ophthalmopathy: an initial presentation of Graves' disease.

OBJECTIVE: To report a rare case of Graves' disease without ophthalmopathy presenting with pretibial myxedema (PM) as an initial presentation. METHODS: We present the clinical history, physical findings, laboratory studies and biopsy data of a 62-year-old man with a history of uncontrolled type 2 diabetes (DM2) presenting with arm and leg skin lesions in the absence of other physical findings. Histopathology confirmed PM. Graves' disease and its association with PM without Graves' ophthalmopathy and the pertinent literature are reviewed. RESULTS: A 60-year-old man with a history of uncontrolled DM2 presented for glycemic management. He described symptoms of anxiety, insomnia and fatigue for the last 5 to 6 months. He described diffuse chest pain, occasionally associated with palpitations, and a 50-pound weight loss. He also complained of severe itching and burning of his arms and legs for the past several months. Subsequent thyroid studies revealed hyperthyroidism suggestive of Graves' disease. In the interim, he was hospitalized for atrial flutter and was cardioverted. After being started on methimazole, his symptoms abated. His skin lesions were biopsied, and the leg biopsy was consistent with PM. He however had no lid lag or proptosis characteristic of Graves' disease. He subsequently underwent radioiodine ablation. His hyperglycemia was better control led after treatment of his hyperthyroidism. CONCLUSIONS: PM is an autoimmune manifestation of Graves' disease. Almost all cases of thyroid dermopathy are associated with relatively severe ophthalmopathy. Usually ophthalmopathy appears first and dermopathy much later. However, this case represents a rare initial presentation of Graves' disease with PM without ophthalmologic symptoms or findings. Hyperthyroidism is typically associated with worsening glycemic control and increased insulin requirements. In patients with diabetes having hyperthyroidism, deterioration in glycemic control should be anticipated and treatment should be adjusted accordingly. Restoration of euthyroidism will lower the blood glucose level.

Incremental role of three-dimensional over two-dimensional ultrasound in the assessment of traumatic peripheral arteriovenous fistula.

We present a patient with an accidental self-inflicted stab wound to his right thigh in whom three-dimensional (3D) ultrasound was able to find two communications between the right femoral artery and the femoral vein, in contrast to two-dimensional (2D) peripheral ultrasound which could find only one communication between them, thereby showing an incremental value of 3D over 2D ultrasound.