Scrotal Wall Metastasis from Adenocarcinoma of Unknown Origin, with Concurrent Extramammary Paget's Disease - a Case Report

INTRODUCTION

Scrotal cancer is a very rare disease, with the most common subtype being squamous cell carcinoma. Metastatic carcinoma to the scrotal wall is very rare. A histological finding of adenocarcinoma in a scrotal malignancy invariably suggests a metastasis from another primary cancer. We describe an enigmatic case of metastatic adenocarcinoma to the scrotum managed as metastatic adenocarcinoma of unknown origin. Attempts to identify a primary cancer were complicated by ambiguous diagnostic results. This is the first case in literature of metastatic cancer to the scrotum from an adenocarcinoma of unknown origin, and this was complicated by concurrent extramammary Paget's disease.

CASE PRESENTATION

A 70-year-old male presented with painless progressive scrotal skin swelling, which was shown on histology to be adenocarcinoma. Immunohistochemistry showed prostatic lineage markers. However, the argument for a prostatic primary was weakened by negative prostate transrectal ultrasound biopsy findings and negative radiological findings. The scrotal metastatic adenocarcinoma was managed as metastatic adenocarcinoma of unknown origin. A differential of occult poorly differentiated prostatic primary was considered in view of the clinical phenotype of an elderly male patient with extensive sclerotic bony metastases, immunohistochemistry results and relatively low PSA level in relation to systemic burden of disease. The patient was managed with palliative systemic chemotherapy (carboplatin/paclitaxel) with initial disease response, but eventually developed progressive disease.

DISCUSSION AND CONCLUSION

Finding of adenocarcinoma in scrotal skin malignancy indicates a metastasis and should prompt further work-up to identify a primary cancer, particularly of other genitourinary or lower gastrointestinal origin, so that treatment can be targeted at the underlying primary malignancy. However, attempts to identify a primary cancer might be complicated by ambiguous diagnostic results.

Randomized Controlled Trial Comparing Drug-coated Balloon Angioplasty versus Conventional Balloon Angioplasty for Treating Below-the-Knee Arteries in Critical Limb Ischemia: The SINGA-PACLI Trial

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.

Oral vs Intravenous Antibiotics for Patients With Klebsiella pneumoniae Liver Abscess: A Randomized, Controlled Noninferiority Study

BACKGROUND

Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA.

METHODS

This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein <20 mg/L, and reduction in abscess size. A noninferiority margin of 12% was used.

RESULTS

Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, -4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group.

CONCLUSIONS

Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA.

CLINICAL TRIALS REGISTRATION

NCT01723150.

A practical and adaptive approach to lung cancer screening: a review of international evidence and position on CT lung cancer screening in the Singaporean population by the College of Radiologists Singapore

Lung cancer is the leading cause of cancer-related death around the world, being the top cause of cancer-related deaths among men and the second most common cause of cancer-related deaths among women in Singapore. Currently, no screening programme for lung cancer exists in Singapore. Since there is mounting evidence indicating a different epidemiology of lung cancer in Asian countries, including Singapore, compared to the rest of the world, a unique and adaptive approach must be taken for a screening programme to be successful at reducing mortality while maintaining cost-effectiveness and a favourable risk-benefit ratio. This review article promotes the use of low-dose computed tomography of the chest and explores the radiological challenges and future directions.

Preparing IR for COVID-19: The Singapore Experience

This paper describes country-wide special measures undertaken for interventional radiology staff during the current coronavirus disease 2019 (COVID-19) pandemic. Although each interventional radiology service around the world faces unique challenges, the principles outlined in this article will be useful when designing or strengthening individual practices and integrating them within wider hospital and national measures. Moving beyond the current outbreak, these measures will be useful for any future infectious diseases which are likely to arise.

Radiology Preparedness in the Ongoing Battle against COVID-19: Experiences from Large to Small Public Hospitals in Singapore

The coronavirus disease 2019 (COVID-19) pandemic presents an unprecedented challenge to the health care systems of the world. In Singapore, early experiences of the radiology community on managing this pandemic was shaped by lessons learned from the severe acute respiratory syndrome outbreak in 2003. This article surveys the operational responses of radiology departments from six public hospitals in Singapore. © RSNA, 2020.

Amplatzer vascular plug in occlusion of a pulmonary arteriovenous malformation

Pulmonary arteriovenous malformation is a rare condition with abnormal communication of the pulmonary artery with the pulmonary vein. It is associated with significant morbidity and mortality when patients develop complications. Patients with symptomatic pulmonary arteriovenous malformation should be considered for intervention. We describe the case of a 54-year-old woman with a large right pulmonary arteriovenous malformation who presented with right chest pain due to hemothorax. She underwent successful embolotherapy with an Amplatzer plug.

Inhibition of the acquisition of conditioned place aversion by dopaminergic lesions of the central nucleus of the amygdala in morphine-treated rats

The negative affective state of opiate abstinence plays an important role in craving and relapse to compulsive drug use. The dopamine system participates in the reward effects of opiate use and the aversive effect of opiate abstinence. The amygdala is an essential neural substrate for associative learning of emotion. To establish a model of conditioned place aversion (CPA) in morphine-treated rats, we used different visual and tactual cues as conditioned stimuli (CS) within a conditioning apparatus. An injection of naloxone served as the unconditioned stimulus (US). The 6-hydroxydopamine (6-OHDA) lesion technique was used to investigate the effects of the dopaminergic system of the central nucleus of the amygdala (CeA) on naloxone-induced CPA. Rats were rendered physically dependent via administration of increasing doses of morphine delivered via intraperitoneal injection. Doses increased by 20 % each day for 14 days, starting from an initial dose of 6 mg/kg. All rats also received a low dose of naloxone (0.1 mg/kg) by injection 4 hours after morphine treatment on days 11 and 13 to induce CPA in a biased two-compartment conditioned place apparatus. Morphine-dependent rats with sham lesions were found to develop significant CPA after naloxone treatment. Bilateral 6-OHDA lesions of the CeA impaired the acquisition of CPA but had no effect on locomotor activity. These results suggest that the dopaminergic system of the CeA plays an important role in the negative affective state of opiate abstinence.

Ultrasonographical diagnosis of acute gynaecological pain

Acute pelvic pain is a common presentation in women. There are a myriad of causes, both gynaecological and non-gynaecological in origin. Ultrasonography is well-established as the primary initial investigation of choice. Familiarity with the imaging features of the commonly-associated conditions aids in the rapid diagnosis, and immediate management of the patient. This article provides a pictorial review of the common gynaecological causes of pelvic pain.

Novelty-seeking behavior and stress-induced locomotion in rats of juvenile period differentially related to morphine place conditioning in their adulthood

The relationship between motor responses in a novel environment and susceptibility to place conditioning effect of psychostimulants has been reported in adult rats. However, it is in question whether this correlation could be generalized to motor activity in rats of juvenile period and place conditioning effect in their adulthood for narcotic morphine. In the present study, we tested locomotor activity in an arena open-field and the subsequent novelty-seeking behavior after adaptation process in juvenile rats (P42) and morphine (2 mg/kg) place conditioning effect 56 days later in the same rats' adulthood (P98). Our results showed that rats with high response to novelty (HRN) spent more prolonged duration in the drug-paired compartment in the place conditioning test compared with their low response counterparts (LRN), with the latter group no salient change on this measure. Moreover, rats with high response to the open-field test (HRS) expressed equally elevated duration in drug-paired side relative to their low response counterparts (LRS). The present research demonstrated that novelty-seeking behavior and locomotor activity in the open-field in rats of juvenile period differentially related to morphine place conditioning in their adulthood, with slow acquisition of morphine place conditioning effect in LRN animals.

Surgical results of intercondylar fractures of the adult femur

INTRODUCTION

Although surgical treatment of intercondylar fractures of the adult femur gives satisfactory results in the majority of cases, there are complications reported with operative management. We aim to analyse the surgical results of these cases performed in our institution and compare them to other reported series.

MATERIALS AND METHODS

A total of 16 patients with intercondylar fractures of the femur were operatively treated from 1989 to 1997. The ages of these patients ranged from 24 to 77 years, with a mean age of 42 years. Average length of follow-up was 28 months. The fractures were classified according to AO classification. Twenty-five per cent of the fractures were significantly comminuted. They were internally fixed with various implants such as cancellous screw fixation, dynamic condylar screw plate, condylar blade plate and condylar buttress plate.

RESULTS

Average time to full weight bearing was 12 weeks. Results of treatment were assessed according to the criteria described by Shelbourne. Eighty-three per cent of minimally comminuted fractures had a good result, but only 50% of significantly comminuted fractures did well.

CONCLUSIONS

We recommend the use of anterior midline approach and condylar buttress plate for very comminuted fractures. Infection, if detected early and treated aggressively could avoid a poor outcome. Elderly patients should benefit from internal fixation and earlier mobilisation.

Prostaglandins versus oxytocin for prelabour rupture of membranes at or near term

BACKGROUND

The conventional method of induction of labour is with intravenous oxytocin. More recently, induction with prostaglandins, followed by an infusion of oxytocin if necessary, has been used.

OBJECTIVES

The objective of this review was to assess the effects of induction of labour with prostaglandins compared with oxytocin, at or near term.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials of early stimulation of uterine contractions with prostaglandins (with or without oxytocin) versus with oxytocin alone (not combined with prostaglandins) in women with spontaneous rupture of membranes before labour (34 weeks or more gestation).

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Seventeen trials were included. Most of the trials were of moderate to good quality. Based on six trials, prostaglandins compared with oxytocin were associated with increased chorioamnionitis (odds ratio of 1.49, 95% confidence interval 1.07 to 2.09) and maternal nausea/vomiting. Based on eight trials, prostaglandins were associated with a decrease in epidural analgesia, odds ratio of 0.85, 95% confidence interval 0.73 to 0.98 and internal fetal heart rate monitoring (based on one trial). Caesarean section, endometritis and perinatal mortality were not significantly different between the groups.

REVIEWER'S CONCLUSIONS

Women with prelabour rupture of membranes at or near term having their labour induced with prostaglandins appear to have a lower risk of epidural analgesia and fetal heart rate monitoring. However there appears to be an increased risk of chorioamnionitis and nausea/vomiting with prostaglandins compared to oxytocin.

Prostaglandins versus oxytocin for prelabour rupture of membranes at term

BACKGROUND

The conventional method of induction of labour is with intravenous oxytocin. More recently, induction with prostaglandins, followed by an infusion of oxytocin if necessary, has been used.

OBJECTIVES

The objective of this review was to assess the effects of induction of labour with prostaglandins versus oxytocin for prelabour rupture of membranes at term.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials of early stimulation of uterine contractions with prostaglandins (with or without oxytocin) versus with oxytocin alone (not combined with prostaglandins) in women with spontaneous rupture of membranes at term (37 weeks or more gestation).

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Eight trials were included. Based on three trials, prostaglandins compared to oxytocin were associated with increased chorioamnionitis (odds ratio of 1.51, 95% confidence interval 1.07 to 2.12) and neonatal infections (odds ratio 1.63, 95% confidence interval 1.00 to 2.66). Based on four trials, prostaglandins were associated with a decrease in epidural analgesia (odds ratio of 0.86, 95% confidence interval 0.73 to 1.00) and internal fetal heart rate monitoring (based on one trial). Caesarean section, endometritis and perinatal mortality were not significantly different between the groups.

REVIEWER'S CONCLUSIONS

Women with prelabour rupture of membranes at term having their labour induced with prostaglandins appear to have a lower risk of epidural analgesia and fetal heart rate monitoring. However there appears to be an increased risk of chorioamnionitis and neonatal infections after prostaglandin induction compared to oxytocin.

Prostaglandins for prelabour rupture of membranes at or near term

BACKGROUND

Induction of labour after prelabour rupture of membranes may reduce the risk of neonatal infection. However an expectant approach may be less likely to result in caesarean section.

OBJECTIVES

The objective of this review was to assess the effects of induction of labour with prostaglandins versus expectant management for prelabour rupture of membranes at or near term.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing early use of prostaglandins (with or without oxytocin) with no early use of prostaglandins in women with spontaneous rupture of membranes before labour, and 34 weeks or more of gestation.

DATA COLLECTION AND ANALYSIS

Trials were assessed for quality and data were abstracted.

MAIN RESULTS

Fifteen trials were included. Most were of moderate to good quality. Different forms of prostaglandin preparations were used in these trials and it may be inappropriate to combine their results. Induction of labour by prostaglandins was associated with a decreased risk of chorioamnionitis (odds ratio 0.77, 95% confidence interval 0.61 to 0.97) based on eight trials and admission to neonatal intensive care (odds ratio 0.79, 95% confidence interval 0. 66 to 0.94) based on seven trials. No difference was detected for rate of caesarean section, although induction by prostaglandins was associated with a more frequent maternal diarrhoea and use of anaesthesia and/or analgesia. Based on one trial, women were more likely to view their care positively if labour was induced with prostaglandins,.

REVIEWER'S CONCLUSIONS

Induction of labour with prostaglandins appears to decrease the risk of maternal infection (chorioamnionitis) and admission to neonatal intensive care. Induction of labour with prostaglandins does not appear to increase the rate of caesarean section, although it is associated with more frequent maternal diarrhoea and pain relief.

Oxytocin for prelabour rupture of membranes at or near term

BACKGROUND

Induction of labour after prelabour rupture of membranes may reduce the risk of neonatal infection.

OBJECTIVES

The objective of this review was to assess the effects of induction of labour with oxytocin versus expectant management for prelabour rupture of membranes at or near term (34 weeks or more).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials of early use of oxytocin versus no early use of oxytocin for spontaneous rupture of membranes, before labour (34 weeks gestation or more).

DATA COLLECTION AND ANALYSIS

Trials were assessed for quality and data were abstracted.

MAIN RESULTS

Eighteen studies were included. The trials were of variable quality with potential for significant bias. Compared to expectant management, induction of labour by oxytocin was associated with a decreased risk of maternal infection (odds ratio for chorioamnionitis of 0.63, 95% confidence interval 0.51 to 0.78, endometritis 0.72, 95% confidence interval 0.52 to 0.99). There was also a decreased risk of neonatal infection (odds ratio 0.64, 95% confidence interval 0.44 to 0.93). The size of this effect may have been biased in favour of oxytocin. Based on one trial, women were more likely to view their care positively if labour was induced with oxytocin. Caesarean section rates were not statistically different between groups, although the trend was towards fewer interventions with expectant management. Oxytocin was associated with more frequent use of pain relief and internal fetal heart rate monitoring. Perinatal mortality rates were low and not significantly different between groups, although the trend was towards fewer deaths with induction of labour by oxytocin.

REVIEWER'S CONCLUSIONS

Induction of labour by oxytocin may decrease the risk of maternal and neonatal infection compared to expectant management. Induction of labour with oxytocin does not appear to increase the rate of caesarean section, although it may increase use of pain relief and internal fetal heart rate monitoring.