Granuloma Faciale Successfully Treated With Long-Pulsed Tunable Dye Laser

BACKGROUND: Granuloma faciale has been treated in the past with different modalities but the majority have had the risk of scarring. OBJECTIVE: Based on the principle of selective photothermolysis, we considered using the newer long-pulsed tunable dye laser for the treatment of granuloma faciale to target the vessels and minimize scarring. METHODS: Confirmation of the diagnosis by a punch biopsy of the lesion was followed by three treatments on separate occasions 6 weeks apart with the long-pulsed tunable dye laser. RESULTS: There was significant flattening of the lesions after two treatments, with complete clearing after the third. No scarring was detectable and there was no recurrence in the 9-month follow-up. CONCLUSION: We conclude that granuloma faciale may be successfully treated with the long-pulsed tunable dye laser with minimal risk of scarring, especially in cosmetically sensitive areas.     

Syringocystadenocarcinoma Papilliferum: Successfully Treated With Mohs Micrographic Surgery

BACKGROUND: Syringocystadenocarcinoma papilliferum, a rare sweat gland carcinoma, is the malignant counterpart of syringocystadenoma papilliferum. OBJECTIVE: To demonstrate a rare case of syringocystadenocarcinoma papilliferum successfully treated with Mohs micrographic surgery. METHODS: A 60-year-old male presented with two verrucous plaques on his right auricle since childhood. These two plaques became ulcerated, more painful, and pruritic in 1 year. Histopathologic examination revealed syringocystadenocarcinoma papilliferum. RESULTS: Mohs micrographic surgery with reconstruction of right auricle was performed subsequently. There are no signs of recurrence or metastasis 6 years after operation. CONCLUSION: Syringocystadenocarcinoma papilliferum can be successfully treated with Mohs micrographic surgery.     

Ureteral Complications in Renal Transplant Recipients Successfully Treated With Interventional Radiology

Introduction

Ureteral complications in renal transplantation occur in approximately 8% of renal transplant recipients, occasionally leading to graft loss. This retrospective study presents a single-center experience in managing ureteral complications with interventional radiology as well as the long-term graft function and recipient survival.

Patients and Methods

We analyzed 21 renal transplant recipients with ureteral problems.

Results

Nine patients experienced urinary leak, six patients had ureteric obstruction, and six patients had obstruction preceded by leak. Median recipient age was 48 (range, 20-63) years; 71% (15/21) of the patients were male and 66.6% (14/21) of transplants were derived from cadaveric donors. Ureteral complications were diagnosed at a mean of 18 days (range, 12-47) after renal transplantation. Initially a percutaneous nephrostomy was performed, followed by antegrade placement of a nephroureteral stent. In cases with ureteral obstruction, ureteral balloon dilation was performed prior to placement of the stent. Median time to the procedure was 53 days, and median follow-up for the purposes of this study was 57 months. Renal graft function improved following treatment of the ureteral complication. Mean serum creatinine values prior to and after the intervention were 4.8 ± 2.12 and 1.79 ± 0.58 mg/dL, respectively (P<.0001). Functional renal grafts were observed at the first, third, and fifth posttransplantation year among 100%, 95.2% and 80.9% of patients, respectively. It should be further noted that no graft was lost due to a ureteral complication.

Conclusions

Interventional radiology was successful in treating immediate and long-term ureteral problems among renal transplant recipients with preservation of good renal function and patient survival.     

Undifferentiated Embryonal Sarcoma of the Liver Successfully Treated With Chemotherapy and Liver Resection

Undifferentiated embryonal sarcoma is the third most common malignant tumor of the liver in children, accounting for 13% of hepatic malignancies in this age group. It has been considered an aggressive neoplasm with very poor prognosis until the late 1980s, when long-term survivors were reported after multiagent chemotherapy followed by resection. We, herein, report two pediatric cases of undifferentiated embryonal sarcoma treated successfully with surgical resection after neoadjuvant chemotherapy based on therapy used in childhood soft tissue sarcomas and in childhood hepatic malignancies. The first patient also had a concurrent cerebellar tumor (pilocytic astrocytoma), for which he first underwent craniotomy and resection, delaying the liver tumor resection by 10 weeks. They are alive and tumor free at 48 months (case no. 1) and 18 months (case no. 2) following neoadjuvant chemotherapy and liver resection. This paper was presented as a poster at the American Hepato–Pancreato–Biliary Association Annual Meeting, March 10, 2006, Miami Beach, Florida, USA     

A Case of Central Metanephric Adenoma Successfully Treated With Laparoscopic Nephron-sparing Surgery

Metanephric adenoma is an extremely rare renal tumor and, even more infrequently, is centrally located. Herein we summarize a series of images concerning a central metanephric adenoma in a female adult successfully treated with laparoscopic nephron-sparing surgery. The patient presented with no symptoms but was found to have a lesion in the middle portion of the left renal parenchyma for 1 month prior. She underwent retroperitoneal laparoscopic nephron-sparing surgery with total resection of the renal mass. To our knowledge, we present here the most detailed, challenging, and complicated laparoscopic nephron-sparing surgery yet to be reported with a diagnosis of metanephric adenoma in the central location.     

Squamous Cell Carcinoma of the Big Toe Successfully Treated by Intra-Arterial Infusion With Methotrexate

BACKGROUND: For preservation of integrity of appearance and function in a 57-year-old male with a squamous cell carcinoma of his left big toe who had refused amputation, intra-arterial infusion with methotrexate was used. OBJECTIVE: To evaluate the effectiveness of arterial infusion with methotrexate in this uncommon big toe cancer. METHODS: Left external iliac arterial catheterization and infusion with methotrexate (50 mg) were used every 24 hours plus simultaneous intramuscular injection of 6 mg of leucovorin every 6 hours for 8 days. RESULTS: At 7 years and 3 months after therapy, the patient was in sustained complete remission with a functionally normal left foot. CONCLUSION: This case study suggests that intra-arterial infusion chemotherapy is a simple and effective method for big toe squamous cell carcinoma with the unique advantage of preservation of organ and function. It can be considered as an effective alternative treatment.     

Laparoscopic Roux-en-Y Gastric Bypass Complicated by a Mesocolic Jejunal Stricture Successfully Treated with Endoscopic TTS Balloon Dilation

Even though Roux-en-Y gastric bypass is the most commonly performed bariatric surgery in the United States, it is not without post surgical complications. The development of a mesocolic jejunal stricture after a laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a rare complication. We present a patient who manifested, at 5 weeks post-LRYGBP, symptoms of nausea, vomiting, and an inability to tolerate an oral diet. The patient was found to have a stricture at the efferent Roux limb consistent with a mesocolic stricture which was successfully resolved with through the scope (TTS) balloon dilatation. There was no apparent cause of the patient’s stenosis with no evidence of an anastomotic breakdown or major inflammatory process. The patient presented for follow-up after her dilatation was noted to have complete resolution of her symptoms and continued to lose weight. This is the first known case of a mesocolic jejunal stricture successfully treated with TTS balloon dilation.     

Recurrent Membranous Nephropathy After Kidney Transplantation Associated With Phospholipase A2 Receptor and Successfully Treated With Rituximab: A Case Report

Primary membranous nephropathy (MN) is an organ-specific autoimmune disease mainly caused by autoantibodies acting against the podocyte antigen M-type phospholipase A2 receptor 1 (PLA2R). Herein we present the clinical and histologic findings, including PLA2R staining, of early recurrent MN after kidney transplantation that was successfully treated with rituximab.A 60-year-old Japanese man had end-stage renal failure due to steroid-resistant primary MN and underwent ABO-incompatible living donor kidney transplantation. At 1 month after transplantation, a protocol biopsy revealed positive granular staining of IgG, C4d, and PLA2R on glomerular capillaries (GCs) without any abnormalities on light microscopy (LM). Although the patient had low-level proteinuria, recurrent MN was suspected based on the positive PLA2R staining; he was treated with an angiotensin receptor blocker and a single dose of 200 mg rituximab. However, proteinuria gradually increased to 877 mg/d. At 21 months after transplantation, a graft biopsy revealed spikes along the outer aspects of GC on LM, with stronger staining for PLA2R than that at 1 month after transplantation. A single dose of 500 mg rituximab was added, which effectively reduced proteinuria, and clinical remission continued until 3 years after transplantation. The latest graft biopsy showed reduced staining of PLA2R. The disease activity and therapeutic effect were well-reflected in the intensity of PLA2R staining.An approach intending an early diagnosis by protocol biopsy using PLA2R immunostaining is made and early treatment with rituximab will help reduce the risk of kidney graft loss due to recurrent primary MN.     

Antibody Mediated Rejection Associated With Complement Factor H–Related Protein 3/1 Deficiency Successfully Treated With Eculizumab

Antibody mediated rejection (AMR) activates the classical complement pathway and can be detrimental to graft survival. AMR can be accompanied by thrombotic microangiopathy (TMA). Eculizumab, a monoclonal C5 antibody prevents induction of the terminal complement cascade (TCC) and has recently emerged as a therapeutic option for AMR. We present a highly sensitized 13‐year‐old female with end‐stage kidney disease secondary to spina bifida‐associated reflux nephropathy, who developed severe steroid‐, ATG‐ and plasmapheresis‐resistant AMR with TMA 1 week post second kidney transplant despite previous desensitization therapy with immunoglobulin infusions. Eculizumab rescue therapy resulted in a dramatic improvement in biochemical (C3; creatinine) and hematological (platelets) parameters within 6 days. The patient was proven to be deficient in complement Factor H‐related protein 3/1 (CFHR3/1), a plasma protein that regulates the complement cascade at the level of C5 conversion and has been involved in the pathogenesis of atypical hemolytic uremic syndrome caused by CFH autoantibodies (DEAP‐HUS). CFHR1 deficiency may have worsened the severe clinical progression of AMR and possibly contributed to the development of donor‐specific antibodies. Thus, screening for CFHR3/1 deficiency should be considered in patients with severe AMR associated with TMA.