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Possible Vitamin D/ Parathyroid Hormone Abnormality_1

51-year-old female with vitamin D deficiency and incompatibility between the PTH and vitamin D levels. She reports that as a child she had numerous cavities in her jaw, and her daughter also had multiple tooth fillings. She wonders whether the reason could be genetic abnormality.

 

Vitamin D Abnormality / Parathyroid Hormone Abnormality

51-year-old female with vitamin D deficiency among other medical problems: high blood pressure, episodes of transient syncope, and sleep apnea. In the expert's opinion frequent changes and discontinuations of drugs as well as big intervals between one dose to another, can be responsible for hypertensive crisis. Therefore the expert recommends to stop too frequent investigations , and instead focus on appropriate treatment, that should be combination of Angiotensin Receptor Blocker and diuretics.

End Stage Renal Disease

54-year-old obese male with end stage renal disease due to membranous nephropathy, has received 2 renal transplants in the past and is highly sensitized. He underwent coronary angiography for vessel CAD, and PTCAs and stanting were performed. His current treatment consists of multiple medications including mycophylate according to the instructions of his transplant nephrologist. His cardiologists sees no contraindication to transplantation.

Severe Osteoporosis and Multiple Vertebral Fractures

82-year-old female with severe osteoporosis manifests with vertebral fractures. During treatment with Risedronate, she suffered another fracture. In the expert's opinion, taking into account the patient's age, the presence of fractures and low BMD, the patient is at a very high risk to develop a recurrent fracture so treatment must be given. The expert recommends to rule out secondary causes for osteoporosis such as vitamin D deficiency, to keep a healthy as possible way of life, and change the treatment with Risedronate to Forteo (Teriparatide).

Metastatic non small cell lung Cancer

67 year old male, previously a heavy smoker, suffering for 2 months from weakness, diminished appetite and weight loss. Tests showed a mass in right arm, possibly attached to muscle, and tenderness in right ribs. Chest CT showed a mass in LLL, lung foci, suspected secondary spread and masses in upper abdomen. CT guided biopsy from right lung mass was consistent with non small cell carcinoma with extensive necrosis. SPECT bone scan showed many focal findings in the vertebrae L,D2,7, most of the ribs bilaterally and in the limbs- suspected for secondary pathology.

Multirelapse Squamed Carcinoma of the Skin

75-year-old male with a cutaneous squamous cell carcinoma resected from the right eyebrow in 2003. In 2006, the patient underwent resection of an ipsilateral squamous cell carcinoma in the parotid bed that was presumably a nodal metastasis. He then experienced local relapse treated with resection and adjuvant radiotherapy. There was recurrent disease involving the right cheek excised in 2008. In 2009, another recurrence led to resection with orbital exenteration. Pathology showed squamous cell carcinoma, with perineural invasion, and extension into the orbital muscles.

Recurrent miscarriage

42-year-old patient with hypothyroidism (Hashimoto's) with a history of primary recurrent abortions, probably due to a uterine septum. She underwent 2 IVF cycle, the 2nd – with poor response. The expert suggests some diagnostic and therapeutic strategies.

Child suffering from NF-1 and optic nerve glioma

5-year-old boy with diagnosis of neurofibromatosis type 1 underwent ophthalmological evaluation that showed picture of slight reduction in visual acuity of the right eye and severe hypovision of the left eye with slight reduction of the bilateral visual field. MRI showed presence of a big expansive lesion and of right temporopolar arachnoid cyst. The treating doctors recommended an urgent surgery in order to reduce the cerebral hypertension.

2nd infertility and repeated implantation failure_1
41-year-old female with 2nd infertility and repeated implantation failure was treated with 4 long protocols with no success. The expert suggests to perform diagnostic hysteroscopy, hysterosalpingogram, and thrombophylia workup, to switch from the long protocols to a short one, and try to do double transfer or blastocyst transfer and consider assisted hatching as well.
Glioblastoma of the right temporal occipital region

A 61 year old male who presented with an epileptic episode was evaluated. A temporo-parietal-occipito mass was detected on MRI and PET CT. A follow-up MRI one year later showed progression of the lesion. One month later he had a craniotomy and what seems to be a partial removel of the mass. The pathology revealed glioblastoma. He was scheduled for radiotherapy two months later. The post operative MRI showed post operative changes including blood at the surgical cavity. However, there is a significant residual tumor present which is enhancing following administration of contrast.

Chronic Glomerulonephritis with immune complexes

42-year-old female with chronic renal insufficiency secondary to immune complex mediated glomerulonephropathy, hypertension, Type 2 diabetes mellitus, and hyperlipidemia. The recommended solution for her is kidney transplant.

Metastatic, Non Small Cell Lung Cancer – further opinion

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.

Metastatic, Non Small Cell Lung Cancer

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.

Nephroblastoma (Wilms’ Tumor)

5-year-old girl with a suspected diagnosis of stage 1 Wilms' tumor.
The child's current presentation was an incidental finding of left abdominal swelling. The reports of the abdominal US, total body CT together with normal values of catecholamine metabolites seem to support the diagnosis of Wilms' tumor.
 

Glioblastoma

55-year-old female was diagnosed with glioblastoma after suffering increasing headaches, and was treated with radiation with concurrent Temodal. MRI exam that was performed after 2 additional cycles of CCNU showed tumor progression. The expert recommends different further treatment options.

NF-1 and optic nerve glioma – additional opinion

5-year-old boy with diagnosis of neurofibromatosis type 1 underwent ophthalmological evaluation that showed reduction in visual acuity and reduction of the bilateral visual field. MRI showed presence of a big expansive lesion and of temporopolar arachnoid cyst. The treating doctors recommended an urgent surgery in order to reduce the cerebral hypertension. In the expert's opinion, after having seen the images, the arachnoid cyst has not changed that much, and probably has little impact or effect, and therefore meanwhile no surgery is warranted.

Cystic Neoplasms of the Pancreas

The expert shares broad information regarding Cystic neoplasms of the pancreas: categories, symptoms, diagnosis, treatment, risks and outcomes, and qualifications for performing surgery on the pancreas.

 

Pulmonary heteroplasia

66-year-old female was diagnosed with lung tumour within the right hemithorax with concomitant pulmonary nodules and a measurable enlargement of lymph nodes. FBS was positive for well differentiated neuroendocrine carcinoma and a needle biopsy revealed adenocarcinoma with associated neuroendocrine differentiation. The patient was then treated with altogether four courses of induction chemotherapy.

Respiratory Insufficiency with Tracheotomy_1

72-yaer-old female was hospitalized due to bronchopneumonia complicated by septic shock. Her complicated diagnosis was: acute respiratory insufficiency with recent results of right mediobasal bronchopneumonic foci with respiratory distress, Hypertensive hypertrophic heart disease, Renal insufficiency, Anemia, Drained left PNX, Tracheomalacia, and Gastritis, and various medical procedures were performed, including Tracheostomy.

Erectile Dysfunction in Diabetes

50-year-old male complaining of gradual appearance of erectile dysfunction up to absolute impossibility of even just a single erectile event. His medical history is significant for Type II Diabetes Mellitus and prostatitis. He started taking Cialis, Levitra, and then Viagra without obtaining any benefit. He underwent EMG of the inferior limbs and hematochemical examinations, that revieled signs of diabetic polyneuropathy, and possible superimposed lumbosacral radiculopathy. The possibility to give intracavernous penile injections has been proposed.

Ischemic Heart Disease

A very physically active 49-year-old male with a history of labile hypertension and hypercholesterolemia with an LDL cholesterol of 126 mg%. He underwent an exercise stress test which revealed reversible inferoseptal ischemia at a peak heart rate of 171 bpm and peak blood pressure of 195/85. In the expert's opinion, the results suggest that the patient has silent myocardial ischemia and may be at risk for sudden cardiac death, especially in light of the marked exertional level of activity.

Demyelinizing Disease

47-year-old female with a diagnosis of Multiple Sclerosis ,who suffers from progressive tetraparesis, more pronounced in the lower extremities. Her treatment included mitoxantrone and Interferon-beta treatment, both were discontinued because of side effects. Her movement difficulties, due to the left lower limb rigidity, are increasing progressively.

Anemia due to blood loss in obscure intestinal bleeding

43 years old patient without any notable pathologies in anamnesis. After two episodes of severe hematochezia the patient underwent EGD, Colonoscopy, digestive system X-rays with contrast medium and capsule endoscopy camera (digestive system micro camera) without any pathological evidences

spreading pancreatic cancer

33-year-old female was diagnosed with multiple endocrine neoplasia of the pancreas. She underwent removal of the pancreatic lesion and lymph node dissection, another surgery to remove the distal pancreas and spleen, and parathyroidectomy, but the Octreoscan revealed recurrence.  

Autoimmune hepatitis/cholangitis in patient with Crohn’s disease.

18 years old male. 4 months ago the patient was hospitalized due to epigastric abdominal pain, lack of appetite and weight loss. He was diagnosed with Crohn’s disease.
Hepatic biopsy, that was performed during this hospitslization, showed evidence of an overlap syndrome picture (cholangitis/hepatitis). He was initially treated with Cortisone and Azathioprine.

Hypertensive Patient with mostly uncontrolled Blood Pressure

A known hypertensive female patient whose blood pressure is mostly uncontrolled. The expert recommends to focus on appropriate treatment which should include fixed combination of Angiotensin Receptor Blocker and diuretics together with 24 hour blood pressure monitoring. The expert emphasize that frequent changes, discontinuations of drugs or big intervals between one dose to another can be responsible for hypertensive crisis.

Infiltrating Duct Carcinoma of Breast – additional opinion

51-year-old female was diagnosed with stage I, Grade I infiltrating duct carcinoma of the breast. Estrogen receptors were highly positive and Progesterone receptors negative. Based on these findings the expert advises that she receive adjuvant radiotherapy and hormonotherapy. The adjuvant hormonotherapy consist of initial treatment by Tamoxifen for 2 years, thereafter switched to an Aromatase Inhibitor. The expert also informs the patient about potential side effects of Tamoxifen treatment, which are not frequent and generally mild.

Rectal Carcinoma, Gastric Carcinoma, Metastases.

52-year-old male was diagnosed in 2004 with a carcinoma of the lower rectum and underwent surgical anterior resection of the rectal tumor which was a well differentiated adenocarcinoma. In 2008 he underwent emergency operation for a perforated pyloric ulcer and then a radical resection of a gastric tumor which infiltrated the entire thickness of the gastric wall. It was a G3 diffuse type adenocarcinoma with signet ring cells, at pT3N2 stage.

Massive Portal and Mesenteric Vein Thrombosis

47-year-old male presented with un-provoked portal and mesenteric vein thrombosis that caused persistent radiating pains of upper abdominal quadrants. The examinations found heterozygous factor II mutation, and family survey for the factor II mutation was recommended. The patient started anticoagulant therapy. In the expert's opinion, the main risk factors for portal vein thrombosis are: Prothrombotic disorder, abdominal inflammation, cirrhosis, cancer, abdominal intervention and abdominal infection.

Endometrial Cancer

52-year-old female with a diagnosis of stage IIIC Grade 3 endometrial cancer. Following the adequate surgery she was started on a chemotherapy protocol, including Taxol, Epirubicin and Cisplatinum. However the first course caused severe toxicity and was switched to Taxol and carboplatinum. One treatment option is by intense combination chemotherapy, and therefore the expert supports the protocol used by this case. Another option is endocrine manipulation by hormone therapy.

Multiple miscarriages

31-year-old woman suffering from secondary recurrent abortions. During a 2 year period, she underwent 4 miscarriages with a thorough investigation, including genetic, anatomic, immune and thrombophilic testing. Nothing of significance has emerged to justify 4 miscarriages.

IgG Multiple Myeloma

57-year-old male who was found to have back pain and hyperglobulinemia approximately. Marrow biopsy was consistent with IgG myeloma. He was treated with steroids and local radiotherapy with improvement in symptoms and a modest reduction in the M-component. He received melphalan-based autologous stem cell transplantation, which was complicated by reversible respiratory failure. Unfortunately, he relapsed and was treated with bortezomib and steroids for 6 cycles followed by thalidomide. The disease has responded to therapy.

Cystic Pleuro-Pulmonary Blastoma – additional opinion

2-year-old girl was diagnosed with pleuropulmonary blastoma (PPB). She presented with cough and fever which was treated as pneumonia. When her symptoms did not improve, a chest X-ray showed a right lower lobe infiltrate with pleural effusion and a cystic lesion superiorly. She was further treated with antibiotics and improved clinically, but follow-up with chest CT showed a persistent cystic area in the right lower lobe and pneumothorax. She thus underwent pleural drainage and thoracoscopic biopsy, revealing a diagnosis of "cystic pleuropulmonary blastoma".

Cystic Pleuro-Pulmonary Blastoma

2-year-old female had been diagnosed with Pleuropulmonary Blastoma. The disease extent included the lung and pleura with no signs of metastatic spread. It was decided to start with 3 cycles of chemotherapy and afterwards to carry out a CT scan reassessment and surgical operation. The expert agrees that patients treated with combination of chemotherapy and complete surgical resection do better. Achieving total resection of the tumor results in a significantly better prognosis, whereas extrapulmonary involvement at diagnosis results in worse prognosis.

Pulmonary heteroplasia_2

66-year-old female was diagnosed, following persistent cough, with non-operable tumor of her lung with satellite nodules, and chemotherapy was initiated (first Cisplatin and Gemcitabine, and then switched to Tarceva). Response evaluation following the fourth cycle of chemotherapy showed either stability or an initiation of tumor response, but bone scintigraphy that was performed 6 months later revealed an area of increased uptake in the left hemithorax which could be suggestive of a secondary bone lesion.

Relapse of Chondrosarcoma of Cervical Spine

59-year-old male, suffering from locally recurrent second degree chondrosarcoma of the cervical spine. Following diagnosis his treatment was composed of 3 locoregional interventions: surgery, hemivertebrectomy, and adjuvant fractionated proton beam radiation therapy.

Small Cell Neuroendocrine Tumor of the Cervix – additional opinion

36-year-old otherwise healthy female presented with an atypical pap smear. Biopsy of cervix revealed poorly Differentiated Neuroendocrine Carcinoma. Immunohistochemical staining showed the cells positive for NSE, SYN, CHR, and 90% positive for Ki67 (proliferative index). The findings of the PET-FDG test showed pathological absorption of FDG as a primary tumor of the cervix, towards the left side of the body. Moreover, evidence is seen of nodal metastatic spread in the retroperitoneum and pelvis, mainly on the left.