Symptomatic Cerebral Metastases In Malignant Pleural Mesothelioma: A Rare Case Report

Casestudy: Malignant mesothelioma is an aggressive tumor with dismal prognosis. Incidence in the United States is approximately 3300 cases/year, and the most common site is the pleura. Although mesothelioma is usually a locally invasive tumor, distant metastases to liver, adrenal glands, kidney and contralateral lung have been described. Brain metastases are observed in less than 3% of metastatic cases and most have been detected incidentally at autopsy. Symptomatic brain metastases are unusual. We describe a case of a 77 year old gentleman with history of occupational asbestos exposure who presented with shortness of breath and dry cough. The radiological investigations revealed left pleural thickening with pleural effusion, which on biopsy proved to be biphasic malignant mesothelioma. Despite multi-modality therapy, the patient showed local disease progression. Following 37 months of initial diagnosis, he developed progressive left-sided weakness. Brain MRI revealed a 1.7 cm enhancing mass involving right posterior frontal lobe, with extensive edema in the surrounding tissue. On biopsy, mass was composed of nests and sheets of round-to-spindled cells with scant eosinophilic cytoplasm, separated by fibrous septa. Brisk mitotic activity and necrosis were present. There was a sharp border with adjacent brain parenchyma. The tumor was positive for WT-1, calretinin, and cytokeratins and negative for Ber-Ep4 and glial fibrillary acid protein by immunohistochemistry. The histological appearance of the tumor was similar to that of the pleural biopsy. Thus a diagnosis of metastatic malignant mesothelioma was made. This solitary metastasis was treated with resection and post-operative stereotactic radiation. The 3-month follow-up brain MRI revealed nodular enhancement within the cavity with multiple supra- and infra-tentorial enhancing lesions, and leptomeningeal enhancement, most consistent with progressing metastatic disease. With the advancements in treatment options that has improved survival in malignant mesothelioma patients, the pathologist and neurosurgeon should be aware of the diagnostic possibility intra-operatively which may alter the management.

Dose comparison trial of sustained-release fampridine in multiple sclerosis

OBJECTIVE

To examine the efficacy and safety of three different doses of sustained-release fampridine in people with multiple sclerosis (MS).

METHOD

This multicenter, randomized, double-blind, placebo-controlled, parallel-group study recruited 206 participants at 24 centers in the United States and Canada. After a single-blind, 2-week placebo run-in, participants were randomly assigned to receive fampridine (10, 15, or 20 mg twice daily) or placebo for 15 weeks. The primary efficacy variable was percent change in walking speed based on the timed 25-foot walk.

RESULTS

Trends for increased walking speed were consistent across dose groups vs placebo, but not significant, on the prospective analysis. An increase from baseline in lower extremity strength during the 12-week stable-dose period was seen in the groups receiving 10- and 15-mg doses, compared with placebo (p = 0.018 and 0.003). There were no significant changes in other secondary assessments. Post hoc analysis revealed subsets of participants in each dose group with walking speeds during the treatment period that were consistently faster than during the nontreatment period. There were significantly more "consistent responders" in the drug-treated groups than in the placebo group (36.7% compared with 8.5%). Consistent responders showed significantly greater improvement in self-assessed ambulation on the 12-Item MS Walking Scale than did nonresponders. Fampridine was generally well tolerated. Severe and serious adverse events were more frequent at the highest dose.

CONCLUSIONS

This phase 2 study suggests that a subgroup of patients, when treated with fampridine, experiences a clinically relevant improvement in walking ability, which is sustained for at least 14 weeks.

The hospitalist: new boon for internal medicine or retreat from primary care?

The growing reliance on hospitalists in the United States has implications for several areas of internal medicine, including patient care, administration, clinical practice, and medical education. This paper discusses some of the potential advantages and disadvantages of the use of hospitalists in each of these areas. The new hospitalist practice mode highlights long-standing tensions about the role and direction of internal medicine, tensions that affect generalist and specialty care in both outpatient and hospital settings. The career trajectory of hospitalists will depend on whether burnout is a problem and on whether hospitalists will be able to compete effectively with sub-specialists, such as cardiologists and physicians specializing in AIDS. Clearly, hospitalism meets a clinical need and expands opportunities for internists, but it is important that it not overreach, forfeiting primary care turf and distorting medical education. This new field warrants close monitoring because of its potential effects and because-unlike related fields, such as emergency medicine and intensive care--its birth was strongly influenced by system-wide financial considerations.

Suspected obstructive jaundice: a decision analysis of diagnostic strategies

Clinical decision analysis and a computer model were used to evaluate ten diagnostic strategies for the diagnosis of extrahepatic obstructive jaundice. The sensitivity, specificity, complications, and costs of currently used individual tests were used to determine the overall sensitivity, specificity, complications, and costs of each strategy at different disease prevalences. In patients with a low probability of extrahepatic obstructive jaundice (less than or equal to 20%), the optimal strategy begins with ultrasonography, followed by a cholangiogram when dilated ducts are present. When dilated ducts are not present, patients may be observed clinically and endoscopic retrograde cholangiopancreatography is done if the jaundice does not resolve. In patients with a higher probability of extrahepatic obstructive jaundice, a cholangiogram is needed for an accurate diagnosis. In patients with a low probability of extrahepatic obstructive jaundice, the optimal strategy has an overall sensitivity of 92% and a specificity of 99%. About 40% of patients need a cholangiogram at an average cost of $1000 per patient. In patients with a higher probability of extrahepatic obstructive jaundice, the optimal strategy has an overall sensitivity of 97%, specificity of 98%, and cost of $1000 to $1200 per patient.

Infectious mononucleosis in patients aged 40 to 72 years: report of 27 cases, including 3 without heterophil-antibody responses

Epstein-Barr-virus (EBV)-induced infectious mononucleosis usually occurs in young adults between the ages of 15 and 30. When it occurs in older individuals, it frequently presents diagnostic problems. This report describes data from 27 such patients aged 40 to 72, all of whom had definitive evidence of a current EBV primary infection. Protracted fever, jaundice, pleural effusion, anemia, or the Guillain-Barré syndrome were dominant clinical findings among these patients. Fourteen patients were hospitalized and numerous diagnostic procedures were performed, including bone-marrow aspirations (8 patients), abdominal CAT scan procedures (4 patients), and liver (2 patients) or lymph-node biopsies (1 patient). Overall, the laboratory data in these patients were similar to those seen in young adults, with the exception of more marked hepatic dysfunction and more prominent antibody responses to the restricted (R) component of the early antigen complex. Particularly difficult were the diagnostic problems encountered in three patients in this study (3/27) who failed to develop heterophil antibodies.