Margaret L. Pfeiffer

The patient presenting with acute dysentery – A systematic review

OBJECTIVES The etiologies, clinical presentations and diagnosis of acute pathogen-specific dysentery in children and adults in industrialized and developing regions is described to help develop recommendations for therapy. METHODS We conducted a systematic review of literature published between January 2000 and June 2011 to determine the frequency of occurrence of pathogen-specific dysentery. RESULTS Shigella, Salmonella, and Campylobacter remain the most frequent bacterial causes of dysentery worldwide. Shiga toxin-producing Escherichia coli (STEC) is potentially important in industrialized countries. Entamoeba histolytica must be considered in the developing world, particularly in rural or periurban areas. Clinicians should use epidemiological clues and knowledge of endemicity to suspect Vibrio spp., Aeromonas spp., Plesiomonas spp., Yersinia enterocolitica, Clostridium difficile, Cytomegalovirus or Schistosoma mansoni in cases presenting with dysentery. A single fecal sample studied for etiologic agents is the customary way to make an etiologic diagnosis. CONCLUSIONS While a majority of dysenteric cases will not have an identifiable agent causing the illness, when an etiologic organism is identified, other than STEC, each has a specific recommended form of therapy, which is provided in this review.

Sentinel Lymph Node Biopsy for Eyelid and Conjunctival Tumors: What Have We Learned in the Past Decade?

Purpose: To describe current indications, methods, and outcomes of sentinel lymph node (SLN) biopsy for eyelid and conjunctival tumors. Methods: Review of experience to date and relevant articles published in PubMed in English. Results: The use of SLN biopsy for conjunctival and eyelid tumors has evolved greatly in the past decade, and positive SLNs have been reported for conjunctival and eyelid melanoma, eyelid Merkel cell carcinoma, eyelid sebaceous carcinoma, and eyelid squamous cell carcinoma. Current indications for SLN biopsy of eyelid and conjunctival malignancies are the presence of conjunctival melanomas ≥2 mm in histologic thickness and/or histologic ulceration; cutaneous eyelid melanomas ≥1 mm thick, those with >1 mitotic figures per high-power field, and/or those with histologic ulceration; sebaceous carcinomas ≥10 mm in width; and Merkel cell carcinomas of any size. The frequency of false-negative biopsy results seems to be decreasing as more experience is gained with the technical nuances of the procedure and with the complex lymphatic drainage of the head and neck region. Given the emerging data published on feasibility and reported cases of microscopically positive SLNs identified in patients with otherwise normal examination of the regional lymph nodes and normal imaging studies, it seems appropriate to continue to further evaluate SLN biopsy for selected ocular tumors in future prospective studies. Conclusions: SLN biopsy is feasible for eyelid and conjunctival tumors, and continued use of the procedure is recommended. Future multi-institutional trials are needed to expand on currently available data, fine-tune patient selection criteria, and elucidate the relationships between SLN status and patient survival and tumor recurrence.

Targeted therapy for orbital and periocular basal cell carcinoma and squamous cell carcinoma.

Purpose: To review the literature on targeted therapy for orbital and periocular basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) and provide examples of patients recently treated with such therapy. Methods: The authors reviewed the literature on clinical results of targeted therapy and the molecular basis for targeted therapy in orbital and periocular BCC and cutaneous SCC. The authors also present representative cases from their practice. Results: Mutation in the patched 1 gene (PTCH1) has been implicated in BCC, and overexpression of epidermal growth factor receptor (EGFR) has been shown in SCC. Vismodegib, an inhibitor of smoothened, which is activated upon binding of hedgehog to Ptc, has been shown to significantly decrease BCC tumor size or even produce complete resolution, especially in cases of basal cell nevus syndrome. Similarly, EGFR inhibitors have been shown to significantly decrease SCC tumor size in cases of locally advanced and metastatic disease. The authors describe successful outcomes after vismodegib treatment in a patient with basal cell nevus syndrome with numerous bulky lesions of the eyelid and periocular region and erlotinib (EGFR inhibitor) treatment in a patient with SCC who was deemed not to be a good surgical candidate because of advanced SCC of the orbit with metastasis to the regional lymph nodes, advanced age, and multiple medical comorbidities. Conclusions: Targeted therapy using hedgehog pathway and EGFR inhibitors shows significant promise in treatment of orbital and periocular BCC and cutaneous SCC, respectively. Such targeted therapy may be appropriate for patients who are not good candidates for surgery.

Value of positron emission tomography/computed tomography in diagnosis and staging of primary ocular and orbital tumors

Accurate and reliable staging methods are crucial for optimal care of patients with ocular and orbital malignancies. Positron emission tomography/computed tomography (PET/CT) has recently emerged as a staging tool in the field of ophthalmic oncology. For detecting primary ocular or orbital lesions, PET/CT does not seem to provide an advantage over clinical ophthalmologic examination or conventional imaging studies such as CT or magnetic resonance imaging of the orbit. However, PET/CT may detect distant metastatic lesions that conventional imaging studies miss. For orbital and ocular adnexal lymphoma, use of PET/CT has been proven to be feasible and is now accepted both as a standard part of the initial staging work-up and for the assessment of response to therapy. For other ophthalmic tumors, PET/CT seems most appropriate for advanced metastatic tumors of the orbit, eyelid, and eye, for which the detection of distant metastasis with 1 comprehensive study may be preferable to performing multiple CT scans with contrast.

Clinical value of magnetic resonance imaging and other baseline testing for conjunctival mucosa-associated lymphoid tissue lymphoma

Abstract The objective of this study was to assess the value of magnetic resonance imaging (MRI) of the orbit for conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma. The yield of other staging tests at baseline were also evaluated. Twenty-one consecutive patients treated for conjunctival MALT lymphoma were retrospectively studied. Lymphoma was staged according to both the Ann Arbor system and the seventh edition of the AJCC [American Joint Committee on Cancer] cancer staging manual. Findings on MRI of the orbit, whole-body positron emission tomography/computed tomography (PET/CT), CT of the chest/abdomen/pelvis, bone marrow (BM) biopsy and gastrointestinal (GI) endoscopy were recorded. Seventeen patients had orbital MRI. Fourteen of 17 patients (82%) with obvious conjunctival MALT lymphoma on clinical examination had a negative MRI scan. Only three patients had subtle conjunctival enhancement on orbital MRI. Ann Arbor stage at presentation was as follows: stage IE (15 patients), stage IIE (two patients) and stage IV (four patients). Eighteen of 21 patients had total-body PET/CT; four patients (22%) had hypermetabolic activity evident on PET scan. All 21 patients had bilateral BM biopsies. Fifteen of 21 patients (71%) had GI endoscopy. None of the patients had a positive BM biopsy or findings on GI endoscopy. Our data suggest that orbital MRI has a very low yield for identification of conjunctival MALT lymphoma. Clinical examination is critical in diagnosing and assessing treatment response in conjunctival MALT lymphoma. The yield for GI endoscopy and BM biopsy may also be low in staging of conjunctival MALT lymphoma.

Correlation of American Joint Committee on Cancer T category for eyelid carcinoma with outcomes in patients with periocular Merkel cell carcinoma.

Purpose: Merkel cell carcinoma is a rare but potentially deadly cancer of the eyelid. To date, no studies have reported on clinical parameters at initial presentation of the eyelid tumor that may correlate with disease-free survival (DFS). The purpose of this study was to determine whether the American Joint Committee on Cancer (AJCC) T category for eyelid carcinoma correlates with metastasis and DFS in patients with Merkel cell carcinoma of the periocular region. Methods: This is a retrospective cohort study from a tertiary referral cancer center. All consecutive patients treated for eyelid or periocular Merkel cell carcinoma between November 1, 1998, and November 1, 2012, were reviewed. The main outcome measures included AJCC T category for eyelid carcinoma and Merkel cell carcinoma at presentation, nodal metastasis at presentation, metastasis during follow up, and DFS. Results: The study included 18 patients, 7 men and 11 women, with median age of 68.5 years. The AJCC T categories for both eyelid carcinoma and Merkel cell carcinoma were significantly correlated with DFS. Using the T categories for eyelid carcinoma, when TX and T2a were grouped into a single category and T2b and T3a into another category, the estimated DFS rate at 3 years was 100% for patients with TX or T2a lesions and 57% for patients with T2b or T3a lesions (p = 0.0298). Four patients (22%) had lymph node metastasis at presentation. Presence of lymph node metastasis at presentation was the strongest single predictor of shorter DFS and an increased risk of metastasis during follow up (p = 0.0222). Conclusions: The AJCC eyelid carcinoma T at presentation correlates with DFS in patients with Merkel cell carcinoma of the periocular region. The DFS rate at 3 years was significantly worse for patients with T2b or more extensive tumors by eyelid carcinoma T category. Presence of lymph node metastasis at presentation was predictive of shorter DFS and an increased risk of metastasis during follow up.

Regional Nodal Recurrence of Sebaceous Carcinoma of the Caruncle 11 Years After Primary Tumor Resection

action against CPXV, facilitating viral persistence and the graft failure. It is unclear whether the underlying diabetic condition had any effect on disease progression. No specific antiviral therapy exists for CPXV infection, but the application of cidofovir probably inhibited viral replication. Nevertheless, therapeutic options are limited, underscoring the potential risk of CPXV infection to humans.

Late‐onset Leber hereditary optic neuropathy

While Leber hereditary optic neuropathy typically causes bilateral visual loss in the second through fourth decades, we highlight visual loss from Leber hereditary optic neuropathy in older patients to characterize the clinical features of this cohort.

Sentinel lymph node biopsy for ocular adnexal melanoma

We sought to update our prior report of findings on sentinel lymph node biopsy (SLNB) and predictors of a positive SLN in patients with conjunctival or eyelid melanoma.

Epithelial, non-melanocytic and melanocytic proliferations of the ocular surface.

Ocular surface tumors are commonly encountered by ophthalmologists and ophthalmic pathologists. These tumors have varied clinical manifestations. In this article, we discuss the most commonly encountered non-melanocytic and melanocytic ocular surface tumors, with emphasis on their common clinical features, morphologic patterns, and prognostic factors.