f*********1
发帖数: 189 | 1 An old patient with PMH of laryngeal cancer, now presents with left upper
quadrant pain. What differential diagnosis is on your list?
A lot of Pictures are going to come back later. |
f*********1
发帖数: 189 | 2 first picture is the original laryngeal cancer
2nd picture is the patient's CT CAP s/p largngeal ca treatment.
Do you find something wrong with this patient? |
S******9
发帖数: 2837 | |
f*********1
发帖数: 189 | 4 what do you think is that?
【在 S******9 的大作中提到】
: 脾脏有一个低密度影
|
f*********1
发帖数: 189 | 5 This is the patient's CT CAP when he presents to the emergency dept. |
a********n
发帖数: 182 | |
I****a
发帖数: 407 | 7 It is rare to have splenic metastasis. I suspect this is some sort of
infection with abscess formation or bleeding. |
f*********1
发帖数: 189 | 8 Icetea, you are right, and I was shocked when I saw it:)
Here is what I found after googling:)
"A
lthough the spleen is the most vascular organ in the
body, it is an infrequent site of tumor metastases.
1
Explanations proposed for the relative paucity of splenic
metastases have included (1) the sharp angle made by the
splenic artery, which makes it difficult for tumor emboli
to enter the spleen; (2) the rhythmic contractile nature of
the spleen, which squeezes out the tumor embolus and
prevents its lodging in the spleen; (3) the absence of afferent lymphatics
to bring metastatic tumor to the spleen;
and (4) antitumor activity due to a high concentration of
lymphoid tissue in the spleen.
2
Apart from these factors,
the frequency of splenic metastases may have been underestimated; splenic
metastases are often asymptomatic,
as the spleen is an internal organ and has a large functional reserve.
splenic metastases are uncommon. They
were often asymptomatic and were detected as part of
multiorgan metastases. Symptomatic cases, albeit rare, do
occur and may give rise to splenic rupture." |
f*********1
发帖数: 189 | 9 Questions:
Can aspirin itself cause bleeding?
Can heparin itself cause bleeding?
Will heparin and aspirin together promote more bleeding?
What is the most easily bleeding site/organ for a patient on aspirin?
What is the most easily bleeding site/organ for a patient on heparin?
Some who can help with the answers? thank you. |
f*********1
发帖数: 189 | 10 Icetea and A++, what are the roles of steroids in
GBM?
Brain Metatstasis?
CNS lymphoma?
Brain edema?
Inflammation?
Could you please help with the questions?
I am going to post some brain images later, which I myself was confused:) |
|
|
I****a
发帖数: 407 | 11 Corticosteroid has no direct anti tumor activity towards GBM however it is
very helpful reducing edema and inflammation, this is also true for
metastatic brain lesions. Regarding edema caused by bleeding/abscess, I
guess it is not very clear, it depends on each patient's clinical situation.
For CNS lymphoma, corticosteroid does have substantial anti tumor activity.
You would want to talk to hem/onc before you give steroid for somebody whom
you suspect CNS lymphoma because it will substantially lower the positive
biopsy yield.
【在 f*********1 的大作中提到】
: Icetea and A++, what are the roles of steroids in
: GBM?
: Brain Metatstasis?
: CNS lymphoma?
: Brain edema?
: Inflammation?
: Could you please help with the questions?
: I am going to post some brain images later, which I myself was confused:)
|
I****a
发帖数: 407 | 12 The only splenic metastasis I saw was from Pheochromocytoma.
Like spleen, muscle is also a rare organ to get metastasis for reasons I do
not understand, albeit it could form primary sarcoma.
【在 f*********1 的大作中提到】
: Icetea, you are right, and I was shocked when I saw it:)
: Here is what I found after googling:)
: "A
: lthough the spleen is the most vascular organ in the
: body, it is an infrequent site of tumor metastases.
: 1
: Explanations proposed for the relative paucity of splenic
: metastases have included (1) the sharp angle made by the
: splenic artery, which makes it difficult for tumor emboli
: to enter the spleen; (2) the rhythmic contractile nature of
|
A*******s
发帖数: 9638 | 13 I think it is a spleen infarction. Cancer state is the cause of thrombosis.
【在 f*********1 的大作中提到】
: what do you think is that?
|
f*********1
发帖数: 189 | 14 Interesting. What is the evidence of spleen infarction? What support you
think it is spleen infarction? How do you manage spleen infarction?
【在 A*******s 的大作中提到】
: I think it is a spleen infarction. Cancer state is the cause of thrombosis.
|
f*********1
发帖数: 189 | 15 A++. 请过来讲讲：
Can aspirin itself cause bleeding?
Can heparin itself cause bleeding?
Will heparin and aspirin together promote more bleeding?
What is the most easily bleeding site/organ for a patient on aspirin?
What is the most easily bleeding site/organ for a patient on heparin?
Aspirin and heparin have frequently showed up in USMLEs and been frequently
used clinically, but I am still 雾里看花，一知半解：）
在哪里看到一个不是医生的病人家属写的可怕的故事，印象是美国的几种抗凝药里，有
一种中国人如果用了，副作用比较大？ |
f*********1
发帖数: 189 | 16 Thank you!
1. "For CNS lymphoma, corticosteroid does have substantial anti tumor
activity." Some references or articles on this?
2. For GBM post-surgery and radiation (especially stereotatic radiotherapy),
how do you differentiate disease progression (viable residual tumor) Versus
treatment effects (necrosis)?
situation.
.
whom
【在 I****a 的大作中提到】
: Corticosteroid has no direct anti tumor activity towards GBM however it is
: very helpful reducing edema and inflammation, this is also true for
: metastatic brain lesions. Regarding edema caused by bleeding/abscess, I
: guess it is not very clear, it depends on each patient's clinical situation.
: For CNS lymphoma, corticosteroid does have substantial anti tumor activity.
: You would want to talk to hem/onc before you give steroid for somebody whom
: you suspect CNS lymphoma because it will substantially lower the positive
: biopsy yield.
:
:
|
f*********1
发帖数: 189 | 17 Icetea, here is my questions 3:
What is the meachanisms that
"For CNS lymphoma, corticosteroid does have substantial anti tumor
activity."?
Question 4:
If steroids have substantial anti tumor activity for CNS lymphoma, do
steroid have effects on other lymphoma, too? |
A*******s
发帖数: 9638 | 18 I know nothing about spleen but infarction, lol
Wait Ruby back. She is an expert on CT.
There is no treatment for infarction.
【在 f*********1 的大作中提到】
: Interesting. What is the evidence of spleen infarction? What support you
: think it is spleen infarction? How do you manage spleen infarction?
|
A*******s
发帖数: 9638 | 19 Are these your attending's questions?
The answers are yes. Rare but yes.
ASA frequently causes skin bruises and sometimes GI ulcers/bleeding.
Heparin causes more internal bleeding.
【在 f*********1 的大作中提到】
: Questions:
: Can aspirin itself cause bleeding?
: Can heparin itself cause bleeding?
: Will heparin and aspirin together promote more bleeding?
: What is the most easily bleeding site/organ for a patient on aspirin?
: What is the most easily bleeding site/organ for a patient on heparin?
: Some who can help with the answers? thank you.
|
I****a
发帖数: 407 | 20 The mechanism is not well understood but there are evidence of enhancement
of apoptosis of lymphoma cells. It has broad activity towards almost all
lymphomas. It is hard to tell between inflammation due to radiation versus
tumor necrosis in GBM, the CT/MRI appearance might get worse with concurrent
chmemoradiation, which does not mean treatment is futile.
【在 f*********1 的大作中提到】
: Icetea, here is my questions 3:
: What is the meachanisms that
: "For CNS lymphoma, corticosteroid does have substantial anti tumor
: activity."?
: Question 4:
: If steroids have substantial anti tumor activity for CNS lymphoma, do
: steroid have effects on other lymphoma, too?
|
|
|
f*********1
发帖数: 189 | 21 Question 5: I saw the hematologists use R-CHOP and RICE, and sometimes
they use hyper-
CVAP (forget the exact name, I may be wrong, lol), and they use salvage
therapy sometimes. Some patients got stem cell transplants.
Icetea, could you please talk about the lymphoma treatment? In what
situation do you choose which protocol?
Question 6: Steroids have anti-lymphoma activity, then steroid can be
included in lymphoma chemotherapy? If not, why?:)
enhancement
all
versus
concurrent
【在 I****a 的大作中提到】
: The mechanism is not well understood but there are evidence of enhancement
: of apoptosis of lymphoma cells. It has broad activity towards almost all
: lymphomas. It is hard to tell between inflammation due to radiation versus
: tumor necrosis in GBM, the CT/MRI appearance might get worse with concurrent
: chmemoradiation, which does not mean treatment is futile.
|
f*********1
发帖数: 189 | 22 Lol:) Co-wait/
【在 A*******s 的大作中提到】
: I know nothing about spleen but infarction, lol
: Wait Ruby back. She is an expert on CT.
: There is no treatment for infarction.
|
I****a
发帖数: 407 | 23 Almost all standard chemotherapy contains steroid, R-CHOP has P ( prednisone
) and HyperCVAD has D (Dexamesasone)
Lymphoma has many kinds with different underlying molecular signature and
aggressiveness therefore they are approached differently. R-CHOP is standard
treatment for non-super aggressive lymphomas and HyperCVAD is used in super
aggressive lymphoma such as Burkitt lymphoma.
RICE is more used in second line.
【在 f*********1 的大作中提到】
: Question 5: I saw the hematologists use R-CHOP and RICE, and sometimes
: they use hyper-
: CVAP (forget the exact name, I may be wrong, lol), and they use salvage
: therapy sometimes. Some patients got stem cell transplants.
: Icetea, could you please talk about the lymphoma treatment? In what
: situation do you choose which protocol?
: Question 6: Steroids have anti-lymphoma activity, then steroid can be
: included in lymphoma chemotherapy? If not, why?:)
:
: enhancement
|
I****a
发帖数: 407 | 24 1. On the contrary, BRAF inhibitor is used for mutated BARFV600E
2. EGFR monocloncal antibody is only useful in KRAS wild type patient
because mutated KRAS does not need upstream EGFR signaling to activate
downstream targets.
3. EGFR tyrosine kinase inhibitor is good for EGFR mutated patient
4. ALK TKI is good for ALK-EML4 translocation patient.
【在 f*********1 的大作中提到】
: Icetea, here is my questions 3:
: What is the meachanisms that
: "For CNS lymphoma, corticosteroid does have substantial anti tumor
: activity."?
: Question 4:
: If steroids have substantial anti tumor activity for CNS lymphoma, do
: steroid have effects on other lymphoma, too?
|
f*********1
发帖数: 189 | 25 赞 Icetea! 谢谢！
1. What is the indication for salvage therapy in lymphoma?
2. Do you frequently see CLL transform to LDBCL? How do you know or make
the diagnosis of CLL transform to LDBCL? |
I****a
发帖数: 407 | 26 1. if lymphoma does not go away with first line therapy or it comes back
after it goes into complete remission.
2. The phenomena is named Richter's transformation, it happens probably
around 5% times
【在 f*********1 的大作中提到】
: 赞 Icetea! 谢谢！
: 1. What is the indication for salvage therapy in lymphoma?
: 2. Do you frequently see CLL transform to LDBCL? How do you know or make
: the diagnosis of CLL transform to LDBCL?
|
A*******s
发帖数: 9638 | 27 你得给icetea包子了， 最近你挣了不少了吧？ lol
【在 f*********1 的大作中提到】
: 赞 Icetea! 谢谢！
: 1. What is the indication for salvage therapy in lymphoma?
: 2. Do you frequently see CLL transform to LDBCL? How do you know or make
: the diagnosis of CLL transform to LDBCL?
|
f*********1
发帖数: 189 | 28 赞！谢谢！请吃包子：）
【在 I****a 的大作中提到】
: 1. if lymphoma does not go away with first line therapy or it comes back
: after it goes into complete remission.
: 2. The phenomena is named Richter's transformation, it happens probably
: around 5% times
|
f*********1
发帖数: 189 | 29 The patient was then found to have a spiculated lung nodule on CT and a
brain meta on brain MRI.
【在 A*******s 的大作中提到】
: 你得给icetea包子了， 最近你挣了不少了吧？ lol
|
A*******s
发帖数: 9638 | 30 I see. But the spleen abnormality could still be an infarct. :)
【在 f*********1 的大作中提到】
: The patient was then found to have a spiculated lung nodule on CT and a
: brain meta on brain MRI.
|
|
|
R*******t
发帖数: 367 | 31 There is heterogenous sub capsular scalloping around the spleen, most
suggestive of sub capsular bleeds, presumably at bleeds with re-bleeds. If
the patient does not have trauma, then coagulopathy with meds or neoplasms
should be considered. I don't see the typical wedge-shaped hypo attenuation
seen with arterial infarct, But venous infarct can't be excluded. Although
post-infarct hemorrhage is not very commonly seen.
There is obvious intervals growth of a central hypo attenuating mass, what
is the interval between the two studies? Months or weeks? It is not likely
mets, but primary neoplasms such as lymphoma or atypical infection,
lymphoproliferative disorder can be considered.
Regardless, this spleen needs to come out. Then we will know from pathology. |
R*******t
发帖数: 367 | 32 There is case report of laryngeal adenocystic carcinoma metastasized to the
spleen. I guess it is rare but not impossible, and mets in this case can't
be excluded either. |
f*********1
发帖数: 189 | 33 Ruby, thank you!
the
【在 R*******t 的大作中提到】
: There is case report of laryngeal adenocystic carcinoma metastasized to the
: spleen. I guess it is rare but not impossible, and mets in this case can't
: be excluded either.
|
