Clinical and Histological Response to Talimogene Laherparepvec Therapy in Advanced Melanoma: Impact on Overall Survival.

BACKGROUND: Talimogene laherparepvec (T-VEC) is an FDA-approved oncolytic herpesvirus therapy used for unresectable stage IIIB through IV metastatic melanoma. However, the correlation between clinical complete response (cCR) and pathologic complete response (pCR) in patients treated with T-VEC is understudied. STUDY DESIGN: We conducted a retrospective study from a prospectively maintained IRB-approved melanoma single-center database in patients treated with T-VEC from October 2015 to April 2022. Patients were categorized into 3 groups: cCR with pCR, cCR without pCR, and less than cCR. The primary endpoint was overall survival. We used descriptive statistics, chi-square tests, and Wilcoxon rank-sum tests to compare key covariates among exposure groups. We used survival analysis to compare survival curves and reported hazard ratio of death (95% CI) across exposure groups. RESULTS: We included 116 patients with a median overall survival (interquartile range) of 22.7 (14.8-39.3) months. The majority were men (69%) and White (97.4%), with a median age of 74.5 years. More than half of patients (n = 60, 51.6%) achieved cCR. Distribution among the groups was as follows: cCR with pCR (35.3%), cCR without pCR (16.3%), and less than cCR (48.4%). Median overall survival time (interquartile range) was 26.5 (18.6-36.0) months for cCR with pCR, 22.7 (14.4-35.5) months for cCR without pCR, and 17.8 (9.2-47.0) months for less than cCR (log-rank p value = 0.0033). CONCLUSIONS: Patients achieving cCR with pCR after T-VEC therapy have the most favorable overall survival outcomes, whereas those achieving cCR without pCR have inferior survival and those achieving less than cCR have the poorest overall survival outcomes. These findings emphasize the importance of histological confirmation and provide insights for optimizing T-VEC therapy in patients with advanced melanoma.

Incidental finding of double appendix during laparotomy for intussusception: A case report.

INTRODUCTION: A double caecal appendix is an uncommon anatomical variation with significant surgical implications. A few cases of the double caecal appendix have been reported worldwide, mostly in adults. The diagnosis is, usually incidental, typically made intraoperatively. CASE REPORT: We present the case of a 6-month-old boy with an incidental diagnosis of the double appendix during laparotomy for intussusception. DISCUSSION: The double appendix can be classified using the Cave-Wallbridge classification, which identifies three types of the duplicated appendix: A, B, and C. The complication of appendiceal duplications includes acute appendicitis, colonic perforation, obstruction, bleeding, pain, failure to thrive, abdominal mass. In the case of abdominal pain with diagnostic uncertainty, with appropriate patient selection (without hemodynamic instability), diagnostic laparoscopy may be offered as an initial intraoperative evaluation, and if the procedure cannot be safely completed laparoscopically, it can be converted to a laparotomy. CONCLUSION: Although uncommon, knowledge of appendiceal duplication is of great significance in the surgical patient, as a missed diagnosis or delay in diagnosis in symptomatic patients may result in increased morbidity and possibly mortality secondary to sepsis, with its medico-legal ramifications in today's practice of medicine.

Gut Microbiome Modulation Via Fecal Microbiota Transplant to Augment Immunotherapy in Patients with Melanoma or Other Cancers.

PURPOSE OF REVIEW: We review emerging evidence regarding the impact of gut microbes on antitumor immunity, and ongoing efforts to translate this in clinical trials. RECENT FINDINGS: Pre-clinical models and human cohort studies support a role for gut microbes in modulating overall immunity and immunotherapy response, and numerous trials are now underway exploring strategies to modulate gut microbes to enhance responses to cancer therapy. This includes the use of fecal microbiota transplant (FMT), which is being used to treat patients with Clostridium difficile infection among other non-cancer indications. The use of FMT is now being extended to modulate gut microbes in patients being treated with cancer immunotherapy, with the goal of enhancing responses and/or to ameliorate toxicity. However, significant complexities exist with such an approach and will be discussed herein. Data from ongoing studies of FMT in cancer will provide critical insights for optimization of this approach.

Rethinking the Use of Routine Platelet Transfusions for Head Injured Patients on Antiplatelet Therapy.

Traumatic brain injury is responsible for over one million hospital visits, and thousands of deaths annually. The aging population is associated with an increased use of anticoagulation and antiplatelet agents which complicates traumatic brain injury. The use of antiplatelet agents significantly increases baseline risk of intracranial hemorrhage. However, routine platelet transfusion in an attempt to reverse the effects of antiplatelet agents may be detrimental. Here, we report a case of an elderly woman with mild traumatic brain injury, who suffered a tragic demise after platelet transfusion.

Celiac Artery Compression Syndrome in a Middle-age Woman Treated Laparoscopically.

Celiac artery compression syndrome is an anatomic compression of the celiac axis by the median arcuate ligament. Patients often present with postprandial pain, as well as symptoms of gastroparesis. It is usually a diagnosis of exclusion. The treatment is aimed at relieving the compression of the celiac artery, and neurolysis. We present a case of a 55-year-old woman with celiac artery compression syndrome treated by laparoscopic decompression of the median arcuate ligament.

Ectopic Endometriosis Seeded to the Rectus Muscle.

Endometriosis is a pathological condition whereby endometrial glands and stroma are located outside the physiologically expected location, the uterus. A lesion is usually located in the pelvis but can also occur in the diaphragm, bowel, pleural cavity, or surgical scar. It is a benign estrogen-dependent condition. Here, we present the case of a 40-year-old woman with ectopic endometriosis.

Endometriosis of the Vermiform Appendix Presenting as Acute Appendicitis.

Endometriosis is characterized by the growth of endometrial tissue outside the uterine cavity. Endometriosis of the appendix is rare and its preoperative diagnosis is difficult. We report the case of a postmenopausal woman who presented with right lower quadrant abdominal pain concerning for acute appendicitis. Histopathological examination of her appendix revealed endometriosis and her abdominal pain resolved after appendectomy.

Successful Retrieval of a Retained Rectal Foreign Body in the Emergency Department.

Rectal foreign bodies are a common presenting complaint in the emergency department. Anal eroticism is the major reason for the majority of cases of rectal foreign bodies. A high index of suspicion is required to accurately diagnose a rectal foreign body as patients are often embarrassed about their condition and may not present in a timely fashion to be evaluated or volunteer their history. Extraction techniques include transanal, endoscopic, and laparotomy with repair of complications. Here, we present the case of successful transanal manual removal of a retained dumbbell in the rectum of a middle-aged man.

Retained Gallstone Presenting as Large Intra-abdominal Mass Four Years after Laparoscopic Cholecystectomy.

Gallstone spillage is a common intraoperative event during laparoscopic cholecystectomy (LC). Patients present months to years with nonspecific symptoms after the original procedure. The complications of retained peritoneal gallstones are infrequent. Having a high index of suspicion is the key to early diagnosis. Every effort should be made to remove spilled gallstones at the index operation to prevent future complications, however, conversion from laparoscopy to laparotomy for retrieval of spilt gallstone is not recommended. Here we present a case of retained gallstone presenting as a large intra-abdominal mass four years after laparoscopic cholecystectomy in a middle age bariatric patient.

Fulminant Hepatic Failure and Fatal Cerebral Edema Following Clostridium perfringens Bacteremia: Case Report and Review of Literature.

Clostridium perfringens (CP) bacteremia is a rare but rapidly fatal infection. Only 36 cases of CP bacteremia with gas containing liver abscesses on image studies have been reported in the literature since 1990. In this report, we describe a 65-year-old diabetic male with CP bacteremia which progressed into fulminant hepatic failure with subsequent fatal cerebral edema.

Severe Acute Respiratory Distress Syndrome after Laparoscopic Appendectomy in a Young Adult.

Severe acute respiratory distress syndrome after laparoscopic appendectomy for acute appendicitis in a young adult is an uncommon complication. We describe the case of a 25-year-old male who developed severe acute respiratory distress syndrome after an uneventful laparoscopic appendectomy for a perforated appendix, requiring mechanical ventilation in the intensive care unit.

Acute Brachial Artery Occlusion in an Elderly Patient With Acute Myocardial Ischemia.

We present a case of left upper extremity paresis secondary to acute brachial artery occlusion in an elderly female with active non-ST segment elevation myocardial ischemia (NSTEMI) in the setting of paroxysmal atrial fibrillation. The patient was initially suspected to have a cerebrovascular attack (CVA); however, computed tomography (CT) head was negative for acute stroke. The diagnosis was confirmed by computed tomographic angiography (CTA) of the upper extremity, confirming the diagnosis of acute left brachial artery occlusion. In evaluating a patient with concern for acute stroke with atypical presentation, it is essential to obtain a complete history and perform a rapid and thorough examination. Acute limb ischemia (ALI) should be considered in the differential diagnosis of CVA with atypical presentation.

A Giant Adrenal Mass in a Super Obese Patient.

Giant pheochromocytomas (Pheo) are rare entities requiring clinical suspicion coupled with strategic diagnostic evaluation to confirm the diagnosis. The majority of cases are discovered incidentally. The diagnosis consists of biochemical evaluation and imaging study to localize the mass. Pathological examination confirms the diagnosis. The female patient in this case report presented with chest pain, palpitation of three weeks duration and was found on evaluation to have an abdominal mass concerning for pheochromocytoma. She was treated with surgical resection. The pheo measured 20.5 x 18 x 10 cm and weighed 2,582 grams. Pathological examination confirmed the diagnosis of pheochromocytoma.

Large Unilateral Adrenal Mass with Surrounding Brown Fat: A Case Report.

Pheochromocytomas are rare tumors derived from chromaffin cells located in the adrenal and extra adrenal tissues. Pheochromocytomas are diagnosed biochemically and localized using different imaging modalities. The definitive management is surgical resection. Brown adipose tissues are normally present during fetal development, with regression over time. Brown adipose tissues are thermogenic and usually located in the neck, mediastinum, and retroperitoneum. Here, we report a case of a unilateral pheochromocytoma surrounded by brown fat. The abnormal stimulation of brown fat noted on positive emission tomography scan (PET) resolved after the pheochromocytoma was resected.

Natural History Of an Untreated Type 1 Endoleak: A Case Report.

We present a case of giant abdominal aortic aneurysm greater than 17 cm complicated by an endoleak, demonstrating the natural history of an untreated Type 1 endoleak.

Anal Melanoma in an Elderly Woman Masquerading as Hemorrhoid.

Anal melanoma is a rare and aggressive neoplasm of the anal canal seen in the elderly population in the six or seventh decade of their lives. Presentation is usually nonspecific and diagnosis is often delayed or missed initially. The management is surgical and prognosis is poor. Here we present a case of anal melanoma in an elderly patient masquerading as hemorrhoid.

Retroperitoneal Mass Masquerading as Failure to Thrive in a 91-year-old Woman.

Failure to thrive (FTT) is a state of overall decline. Patients often present with weight loss, poor appetite, malnutrition, and decreased physical functioning. The etiology is multifactorial including chronic diseases, functional impairments, and acute illnesses. Evaluation for reversible causes is paramount, and treatment is aimed at maintaining or improving functional status. We present a case of a 91-year-old woman with a retroperitoneal mass that was found on workup for failure to thrive.