An unusual case of Merkel cell carcinoma.

PURPOSE: Merkel cell carcinoma (MCC) is a rare aggressive neuroendocrine tumor of the skin mainly found in elderly white patients. Due to its poor prognosis with distant metastases in up to 33% and local recurrence in 25-33% and a 5 year disease-specific survival of 64% (1-2) its early diagnosis and appropriate treatment is mandatory. METHODS: The study is an exceptional clinical case of a patient with a large inoperable MCC unable to be treated according to treatment guidelines due to her old age. We review the literature addressing treatment options. RESULTS: The patient was treated with palliative definitive radiotherapy to her large MCC of the left lower leg. She showed a rapid clinical response to four palliative radiation doses of 7 Gy each, necrosis of tumor mass and persistent clearing at a follow-up of 32 weeks. Our patient was very unusual in terms of her extensive MCC and her rapid and complete response to palliative radiotherapy lasting for 6 months at present. CONCLUSIONS: As MCC is an aggressive tumor, best survival is achieved with early diagnosis in a localized stage and prompt adequate surgery and further stage-adjusted treatment. Thus, the differential diagnosis of MCC should not be dismissed in a reddish nodule on the leg, and every excision should be submitted to pathology. In accordance with the literature we demonstrate here that definitive radiotherapy is an effective treatment option for inoperable MCC, which in this individual patient produced necrosis of the extensive tumor mass after only four palliative doses.

Acrokeratosis paraneoplastica of Bazex as an indicator for underlying squamous cell carcinoma of the lung.

PURPOSE: Obligatory cutaneous paraneoplastic disorders comprising acanthosis nigricans maligna, erythema gyratum repens, paraneoplastic pemphigus, hypertrichosis lanuginosa acquisita, erythema necrolyticum migrans and acrokeratosis paraneoplastica are rare. However, as markers of an underlying internal malignancy they are of utmost importance for the patient. Acrokeratosis paraneoplastica (first described by Gougerot and Rupp in 1922) was named after Bazex who had then reported several cases in a French dermatological journal since 1965 (Bazex et al. in Bull Soc Fr Dermatol Syphiligr 72:182, 1965; Bazex and Griffiths in Br J Dermatol 102:301-306, 1980). METHOD: The study is a clinical case of a patient with acrokeratosis paraneoplastica. RESULTS: the patient was later diagnosed with a cervical lymph node metastasis and thereafter with a primary squamous cell carcinoma of the left upper lobe and upon treatment responded with the clearing of the skin changes. CONCLUSION: Identification of a paraneoplastic syndrome may enhance the earlier diagnosis of the associated tumor and may thus enable curative treatment.

Three-dimensional power Doppler ultrasound assessment of the cervix for the prediction of successful induction of labor with prostaglandin in prolonged pregnancy.

OBJECTIVE: The purpose of this study was to determine whether 3-dimensional (3D) power Doppler ultrasound examination of the cervix can predict the success of labor induction with prostaglandin in prolonged pregnancy. METHODS: A prospective study was conducted with 36 women undergoing labor induction with prostaglandin at 41 gestational weeks 5 days and later. All 36 women underwent a transvaginal 2-dimensional gray scale ultrasound examination and a 3D power Doppler ultrasound examination of the cervix immediately before a planned post-term checkup. The analyzed variables were length, anterior-posterior diameter, and width of the cervix and any cervical funneling, cervical volume (in cubic centimeters), vascularization index, flow index, vascularization flow index, parity, and Bishop score. Results were compared among women with start of labor at 12 hours or less and more than 12 hours after application of the first prostaglandin suppository and among women who had delivery at 24 hours or less and more than 24 hours after the start of induction. RESULTS: Sonographically measured cervical length was shorter (mean, 1.8 versus 2.4 cm; P = .04), the Bishop score was higher (median, 5 versus 3; P = .02), and more women were parous (70% versus 37%; P = .05) among women who were in labor within 12 hours than in those who were not. The Bishop score was higher (median, 4 versus 2; P = .03) and more women were parous (69% versus 23%; P = .01) among women who had delivery at 24 hours or less than among those who did not. Cervical volume and the results of the 3D power Doppler ultrasound examination did not differ among women with different outcomes of labor induction. CONCLUSIONS: In women undergoing induction of labor with prostaglandin at 41 gestational weeks 5 days or later, sonographic cervical length, Bishop score, and parity are related to the success of labor induction, whereas cervical volume and the results of the 3D power Doppler examination are not.

[Differential Diagnosis Macro CK Type 1 in Thoracic Pain Syndrome and Increased CK-MB]. / Differentialdiagnose Makro-CK Typ 1 bei thorakalen Schmerzen und erhöhter CK-MB.

BACKGROUND: Macro CK (creatine kinase) as a reason for high CK values has been known since 1979. Even in the era of troponin determination for the diagnosis of myocardial infarction, an elevated CK value can still cause confusion, especially as CK-MB rises earlier than troponin. The case report should remind us of this often forgotten differential diagnosis of elevated CK. CASE REPORT: A 73-year-old patient was treated with leuprorelin hormone therapy for prostate cancer (stage pT1c G2). In addition, he received percutaneous radiation therapy of the prostate and high-dose-rate brachytherapy twice with 10 Gy each. Close to 1 year later, he complained for the first time of dyspnea on exertion and thoracic tightness. Serum CK was 232 U/l, and CK-MB 62 U/l, which was confirmed by several controls. Troponin T test was negative, and GOT, GPT, LDH, and PSA were all within the normal range. Acute myocardial infarction was ruled out on clinical grounds and by six sequential ECGs. Subsequently, the patient remained without further cardiac complaints and in good condition. Isoenzyme electrophoresis finally solved the problem and revealed CK-BB-IgG complex type 1 (macro CK-1). CONCLUSION: High CK-MB values in cardially healthy patients should remind us of the possibility of macro CK which is seen in approximately 0.5% of cases and should be included in the differential diagnosis.