Metastatic melanoma of unknown primary in the temporalis muscle

Melanomas are aggressive cancers that present as cutaneous, mucosal and ocular lesions with the ability to metastasise widely. There are, however, occasions where lesions are found in distant sites such as lymph nodes, viscera and subcutaneous tissues without clinically apparent skin involvement. This is known as metastatic melanoma of unknown primary (MUP). Its presentation in skeletal muscle is rare, and the available literature is sparse. This article presents an 85-year-old woman with a MUP presenting in the right temporalis muscle, which was diagnosed with the aid of the ultrasound-guided core biopsy. The melanoma deposit was successfully excised, and no recurrence was identified. The patient is now under close follow-up.

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Severe crush injury to the lower extremity after a snowmobile accident in rural Greenland

Description

In Arctic Greenland, the traditional transportation method of dogsledding is increasingly being replaced by snowmobiles. Snowmobile-related injuries and fatalities are increasing, causing 281 hospitalisations yearly in Wisconsin alone.1 Injuries often include musculoskeletal damage.2 Greenland is a vast country spanning 2,600 km from North to South, with extreme weather conditions making provision of healthcare a logistical challenge.

We present the case of a 24-year-old man involved in a high-speed snowmobile collision in rural Northern Greenland. Snowmobiling at night, his vehicle was impacted by another snowmobile, crushing his left lower extremity (figure 1). He was evacuated by helicopter more than 800 km south to Greenland's referral hospital in the capital city Nuuk for surgical care. The fracture was fixated externally with the Hoffman frame. The ruptured muscle and skin was sutured, leaving a 4 cm skin defect treated with negative pressure wound therapy. Due to subsequent...

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Shotgun wound to the leg: strategies in managing acute arterial injury and bullet emboli to the heart and lungs

Description

A 26-year-old man presented to the emergency department with an accidental self-inflicted shotgun wound to the posterior right thigh with a pulsatile bleed. On arrival, the heart rate was 154 bpm with no measurable blood pressure. After resuscitation with 2 L crystalloid and 1 unit packed red blood cells, the heart rate decreased to 102 bpm; the systolic blood pressure was 80 mmHg. Pedal pulses were palpable on the left; no Doppler signals were appreciated on the right.

Given the large posterior thigh wound with buckshot visible at the entry site, a long-segment arterial injury was suspected. Vascular surgery was consulted and the left groin was accessed. An arteriogram revealed active extravasation from the right superficial femoral artery, with multiple contrast extravasation sites requiring two expandable covered stents. Completion angiography demonstrated cessation of extravasation with excellent distal flow. On the second postoperative day, the patient's haemoglobin decreased from 10 to 7 g/dL....

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Secondary aortoduodenal fistula and the unrecognised herald bleed

A 65-year-old man with history of aortobifemoral surgery 4 years ago was admitted to hospital after sudden abdominal pain. Initially misdiagnosed as renal colic, he was treated with analgesics, and while on observation he started with haematemesis, rapidly responding to volume infusion. Upper gastrointestinal endoscopy showed fresh blood in the stomach with no visible active bleeding. CT scan showed an important contrast extravasation from the aorta to the third duodenal portion, restarting haemodynamic instability and a cardiac arrest. Cardiopulmonary resuscitation (CPR) manoeuvres followed by intense fluid resuscitation and urgent laparotomy with a fast transabdominal supracoeliac aortic clamping was performed. After multiple blood and plasma unit transfusion and intravenous norepinephrine, two more cardiac arrests were recovered. Unfortunately, after aggressive management, the patient rapidly deteriorated and deceased on the table. Aortoduodenal fistula is a rare entity causing life-threatening bleeding. Its diagnosis requires high clinical suspicion and surgery offers the only hope for survival.

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Immunotherapy for hepatocellular carcinoma patients: is it ready for prime time?

Abstract

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second most common cause of cancer death worldwide. Current treatment options for patients with intermediate and advanced HCC are limited, and there is an unmet need for novel therapeutic approaches. HCC is an attractive target for immunomodulation therapy, since it arises in an inflammatory milieu due to hepatitis B and C infections and cirrhosis. However, a major barrier to the development and success of immunotherapy in patients with HCC is the liver's inherent immunosuppressive function. Recent advances in the field of cancer immunology allowed further characterization of immune cell subsets and function, and created new opportunities for therapeutic modulation of the immune system. In this review, we present the different immune cell subsets involved in potential immune modulation of HCC, discuss their function and clinical relevance, review the variety of immune therapeutic agents currently under investigation in clinical trials, and outline future research directions.

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Absolute lymphocyte counts at end of induction correlate with distinct immune cell compartments in pediatric B cell precursor acute lymphoblastic leukemia

Abstract

Several retrospective studies in children with B cell precursor (BCP) acute lymphoblastic leukemia (ALL) provided clinical evidence that higher absolute lymphocyte counts (ALC) early into treatment significantly correlated with improved relapse-free and overall survival. It still remains unknown, however, whether the predictive role of higher ALCs reflects general bone marrow recovery or a more specific attribute of immune function. To investigate this question, we implemented a prospective observational cohort study in 20 children with BCP ALL on day 29 (D29) of induction chemotherapy and immunophenotyped their lymphoid (T, B and natural killer cells) and myeloid (neutrophils, monocytes, dendritic cells) compartments. In a first evaluation of a cohort treated with Children's Oncology Group-based induction chemotherapy, the immune cell compartments were differentially depleted at D29. Neither gender, risk status, minimal residual disease, nor bone marrow recovery markers correlated with D29 ALC. In contrast, both CD3⁺ T cell and dendritic cell compartments, which did not correlate with age, significantly correlated with D29 ALC (p < 0.0001). In addition, subset complexity of cellular immune compartments was preserved at D29. This study reveals that D29 ALC significantly correlates with distinct immune cell compartments but not with bone marrow recovery markers, suggesting that higher D29 ALCs may contribute to leukemia control by inducing specific host immune activity.

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Image Gallery: A case of chronic eosinophilic leukaemia

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