Benefit of a second opinion for lung cancer: no metastasis to the kidney but a synchronous primary renal neoplasm.

BACKGROUND: The finding of a renal mass on imaging is suggestive of metastatic non-small cell lung cancer in the presence of a lung tumor but can also have another origin. CASE REPORT: We describe the case of a patient diagnosed with stage IV lung cancer based on a renal metastasis. A second opinion including review of histopathological data and additional imaging followed by lung surgery and cryoablation of the kidney lesion revealed two tumors of different origins, non-small cell lung cancer and a renal cell carcinoma. DISCUSSION: The presence of a renal mass diagnosed on a CT scan in a patient with lung cancer is not always synonymous with metastatic disease. Confirmation of diagnosis by tissue sampling is mandatory, especially if a synchronous primary tumor is possible.

Benefit of a second opinion: From metastatic disease to resectable lung cancer with sarcoid-like reaction.

BACKGROUND: Mediastinal lymphadenopathy in combination with lung cancer is suggestive for lymph node metastases but can also have other origins. CASE REPORT: We describe a patient diagnosed with stage IV lung cancer presenting with parenchymal lesions and enlarged mediastinal lymph nodes. A second opinion including FDG-PET scan review and a mediastinoscopy followed by surgery revealed tumor specimens originating from a single primary tumor with a sarcoid-like reaction in the mediastinal lymph nodes, changing the diagnosis from metastasized to resectable lung cancer. DISCUSSION: PET positive lesions are not always synonymous with metastatic disease in the presence of a malignant tumor. Conscientious review of FDG-PET scans and tissue sampling are therefore mandatory to determine definitive staging and subsequent interventions.

Early angiopoietin-2 levels after onset predict the advent of severe pancreatitis, multiple organ failure, and infectious complications in patients with acute pancreatitis.

BACKGROUND: Acute pancreatitis is a severe condition that requires early identification of patients at risk of developing potentially lethal complications. Current clinical scoring systems and biochemical parameters are insufficient. In this study, we aimed to assess whether early plasma Angiopoietin-2 (Ang-2) is associated with adverse outcomes in patients with predicted severe acute pancreatitis (SAP). STUDY DESIGN: This analysis is a substudy of the PROPATRIA trial (probiotics vs placebo in patients with predicted SAP). The Ang-2 levels were measured prospectively in plasma in the first 5 days after admission in 115 patients. RESULTS: Early Ang-2 levels were higher in patients who developed SAP: 6.4 vs 3.1 µg/L (p < 0.001) and also were higher in patients who developed multiorgan failure in the first week (p = 0.001) and after the first week (p = 0.049). Furthermore, high Ang-2 levels were associated with infectious complications in the first week (p < 0.001) and after the first week (p < 0.001). Finally, plasma Ang-2 was significantly higher in patients who died (p < 0.001) and in patients who developed bowel ischemia (p < 0.001). As a predictor of adverse outcomes, plasma Ang-2 was superior to a number of current scores, such as the APACHE II score, the Imrie score, C-reactive protein, lipopolysaccharide binding protein, and procalcitonin. CONCLUSIONS: In the setting of this randomized controlled trial, early plasma Ang-2 was found to be an accurate predictor of SAP, multiorgan failure, and infectious complications. As a biomarker, it did outperform all of the investigated conventional predictors that are currently used in clinical practice.

Small bowel preservation for intestinal transplantation: a review.

Intestinal transplantation has become the therapy of choice for patients with intestinal failure and life-threatening complications from total parenteral nutrition. Results, however, remain inferior as compared with other transplant types with the quality of the organ graft as the most important factor of outcome after transplantation. The intestine is extremely sensitive to ischemia. Unfortunately, a relatively long ischemic preservation period is inevitable. The current standard in organ preservation [cold storage (CS) with University of Wisconsin solution] was developed for kidney/liver preservation and is suboptimal for the intestinal graft despite good results for other organs. This review aimed at appraising the results from the use of previously applied and recently developed preservation solutions and techniques to identify key areas for improvement. As the studies available do not reveal the most effective method for intestinal preservation, an optimal strategy will result from a synergistic effect of different vital elements identified from a review of published material from the literature. A key factor is the composition of the solution using a low-viscosity solution to facilitate washout of blood, including amino acids to improve viability, impermeants and colloids to prevent edema, and buffer for pH-homeostasis. Optimizing conditions include a vascular flush before CS and luminal preservation. The most effective composition of the luminal solution and a practical, clinically applicable optimal technique are yet to reach finality. Short-duration oxygenated arterial and/or luminal perfusion have to be considered. Thus, a tailor-made approach to luminal preservation solution and technique need further investigation in transplant models and the human setting to develop the ultimate technique meeting the physiologic demands of the intestinal graft during preservation.

Brain death induces inflammation in the donor intestine.

BACKGROUND: Brain death donors are frequently used for transplantation. Previous studies showed that brain death (BD) negatively affects the immunological and inflammatory status of both liver and kidney. Because the intestine is increasingly used as a donor organ and no information on effects of BD on small intestine is available we performed this study. METHODS: We studied the inflammatory and apoptotic changes in donor intestine after BD induction. Brain death was induced in rats by inflation of a balloon catheter. Three groups (n=6) were compared: 1-hr BD, 4-hr BD, and sham-operated controls. RESULTS: An increased polymorphonuclear cell influx in ileum, as a measure of inflammation, was observed in 1- and 4-hr BD group compared with controls. Jejunum showed a significant increase at the 4-hr BD group compared with the control group. Intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, and interleukin-6 were upregulated after 1- and 4-hr BD. Caspase-3 positive cells were found in jejunum and ileum after 4-hr BD on the top of the villi. Serum interleukin-6 was severely elevated in the 1- and 4-hr brain dead rats. CONCLUSION: These data show the early occurrence of intestinal inflammation and apoptosis after BD induction. These events may ultimately have a negative influence on the outcome of intestinal transplantation.