ABSTRACT
Background/Objective: Pheochromocytoma can recur years after curative surgical resection. Rarely, it may reoccur as metastasis. Here, we present a case of metastatic pheochromocytoma to the bones in a patient with neurofibromatosis type 1 (NF1), 8 years after initial resection of primary bilateral adrenal pheochromocytomas without metastases. Case Report: A 44-year-old woman presented with diffuse body pain and palpitations. Her past medical history included NF1 and hypertension. Eight years prior to her current presentation, she had undergone a bilateral adrenalectomy for the management of bilateral adrenal pheochromocytomas. Her plasma metanephrines normalized after surgery and remained normal at her 1-year postoperative visit. She was subsequently lost to follow-up until her current presentation. Our evaluation revealed significantly elevated urine and plasma metanephrines as well as innumerable DOTATATE avid lesions along the axial and perpendicular spine compatible with a metastatic neuroendocrine tumor. She was started on doxazosin and metoprolol and discharged home with a plan to be seen by Oncology to discuss systemic therapy. Discussion: Predicting malignant disease in patients with primary tumors without metastases is challenging. There is no single factor that can reliably predict tumor behavior. It is unknown if individuals with NF1, who have a genetic predisposition for developing pheochromocytomas, are at an increased risk of malignant disease. Conclusion: Due to a lack of accurate predictors, annual biochemical testing is recommended after primary tumor resection and in patients with a genetic predisposition. Strict lifelong follow-up should be strongly considered due to a possible higher risk of malignant disease.
ABSTRACT
INTRODUCTION: Diabetic nephropathy remains a significant economic and social burden on both the individual patient and health-care systems as the prevalence of diabetes increases in the general population. The complex pathophysiology of diabetic kidney disease poses a challenge in the development of effective medical treatments for the disease. However, the multiple facets of diabetic nephropathy also offer a variety of potential strategies to manage this condition. AREAS COVERED: We retrieved PubMed, Cochrane Library, Scopus, Google Scholar, and ClinicalTrials.gov records to identify studies and articles focused on new pharmacologic advances to treat diabetic nephropathy. EXPERT OPINION: RAAS blockers have remained the mainstay of therapy for DM nephropathy for many years, with only recent advancements with SGLT2 inhibitors and nonsteroidal MRAs. Better understanding of the long-term renal effects of ambient hyperglycemia, ranging from hemodynamic changes to increased production of oxidative and pro-inflammatory substances, has evolved our approach to the treatment of diabetic nephropathy. With continuing research for new therapeutics as well as combination therapy, the medical community may be able to better ease the burden of diabetic kidney disease.
Subject(s)
Diabetes Mellitus , Diabetic Nephropathies , Humans , Diabetic Nephropathies/drug therapyABSTRACT
Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.
ABSTRACT
The occurrence of 2 synchronous primary cancers of different origin in the head and neck region is rare. The incidence of thyroid carcinoma found during surgical resection of primary oral squamous cell carcinoma (SCCa) is about 0.3% to 1.9% of patients. Because of the rarity of cases, there is no consensus on management. To clarify significance and management of such lesions, we report 13 cases in which incidental thyroid carcinoma was discovered during surgical resection for primary oral SCCa. A total of 1295 cases of head and neck SCCa from a 4-year period were reviewed, of which we found 13 cases of concurrent thyroid malignancy, providing an incidence rate of approximately 1%. Of these patients, 61.5% received a total or hemithyroidectomy and, of those, 62.5% received radioactive iodine for their thyroid carcinoma; 38.4% did not receive treatment for their thyroid malignancy. The mortality rate for this case series was 23%, of which all deaths were attributed to complications from SCCa. There were no cases where mortality was related to the thyroid carcinoma. Overall, this is consistent with the consensus that incidental thyroid carcinoma found during oral SCCa resection is insignificant compared with the aggressiveness of the primary malignancy.
