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Background Dressing materials are known to influence post-operative surgical wound healing and scar formation (SF). A particular dressing that could promote wound hydration is essential to ensure quick epithelialization and reduce SF. This study examined the effectiveness of a novel Continuous Diffusion of Oxygen (CDO) dressing to reduce scar length post cervicotomy. Methods A randomized controlled trial was performed in patients undergoing cervicotomy, either for thyroid or parathyroid disease. Patients were randomized to either control (CG) or intervention (IG) groups. The IG received a portable CDO system (TransCu O2, EO2 Concepts Inc., TX, USA), whereas the CG received a standard dressing for a 4-week period. The primary outcome was >10% of scar length reduction and %change in scar length. Results 21 patients were recruited (Age: 53 ± 16 years; 90% female; CG = 9, IG = 12). 5 patients were lost to follow-up. At 4 weeks, 88.8% of the IG significantly achieved >10% of scar reduction (versus CG = 28.5%, d = 0.48, P = 0.049), showing a 40.4% smaller scar (15.7% versus 11.2%, d = 0.13, P = 0.72) compared to the CG. However, the difference was not significant. A sub-sample of patients undergoing thyroidectomy showed a significant scar reduction using CDO (IG = 11.6% versus CG = 5.1%, d = 2.96, P = 0.009). Conclusions This is the first study to assess scar reduction using CDO adjunct therapy after cervicotomy. Advanced CDO dressings may assist wound healing showing improved outcomes for scar visualization in patients undergoing thyroidectomy. A larger sample is required to validate this observation.

Background and Aims Currently used endoscopic items for the assessment of pouchitis and cuffitis have deficiencies in reliability and validation. We assessed the reliability and accuracy of new endoscopic items for pouchitis and of the Ulcerative Colitis Endoscopic Index of Severity [UCEIS] for cuffitis. Methods Three new endoscopic items were assessed and included in the Monash pouchitis endoscopic subscore: bleeding [absent/contact/spontaneous]; erosions [absent/ Results All three Monash endoscopic items had substantial intra-rater reliability with intraclass correlation coefficients [ICCs] >0.61 [95% CI >0.61], compared with only ulcers from the currently used PDAI endoscopic subscore, but inter-rater reliability was only substantial for ulceration and no better than those of the currently used endoscopic items. The Monash endoscopic subscore had a strong positive correlation with the reference standard global endoscopic lesion severity r = 0.80 [95% CI 0.80-0.80] and the reference standard PDAI endoscopic subscore r = 0.70 [95% CI 0.67–0.73], which was higher than the correlation observed for the currently used PDAI endoscopic subscore. The UCEIS had substantial intra-rater reliability, but only fair inter-rater reliability and poor diagnostic performance for cuffitis. Conclusions The Monash endoscopic items, and endoscopic subscore they generate, have enhanced overall performance compared with the currently used PDAI items and subscore. Further validation and responsiveness to change in disease state are indicated.

Objective This study examined office workstation types' impact on the relationship between fatigue and three health metrics: physical activity, stress, and sleep quality. Methods Data from 225 office workers were collected for perceived fatigue, perceived sleep quality (Pittsburgh Sleep Quality Index [PSQI]), physiological stress response (standard deviation of heart rate variability [HRV]), and physical activity (total activity in minutes) during three consecutive workdays. Stress and physical activity were measured using chest-worn sensors. Workers were then categorized as tired or not-tired based on the median of the fatigue rating. Results Among tired workers, open-bench seating workers had increased physical activity, improved sleep quality, and reduced stress compared with workers in private offices and cubicles. Conclusions Office workstation types influence physical activity and levels of stress during work hours, which in turn affect sleep quality.

Background and Aims In symptomatic patients with ileoanal pouches, pouchoscopy is needed for accurate diagnosis but is invasive. We aimed to assess the utility of non-invasive gastrointestinal ultrasound and faecal calprotectin in ileoanal pouch patients. Methods Patients with an ileoanal pouch were consecutively enrolled in this cross-sectional study from clinics in Victoria, Australia. The pouchitis disease activity index was used as a reference standard. Video-recorded pouchoscopies were reviewed by three gastroenterologists. Pouch, pre-pouch, and cuff biopsies were reviewed by a single pathologist. Ultrasound was performed by a single gastroenterologist transabdominally and transperineally. Faecal calprotectin was measured from morning stool samples. All examiners were blinded to patients’ clinical history. Results A total of 44 participants had a pouchoscopy, of whom 43 had a faecal calprotectin test and 42 had an ultrasound; 17 had pouchitis, 15 had pre-pouch ileitis, and 16 had cuffitis. Pouch wall thickness of Conclusions Faecal calprotectin and ultrasound are accurate and complementary tests to diagnose and localise inflammation of the ileoanal pouch. Prospective studies are needed to validate proposed sonographic indices and calprotectin levels.

BACKGROUND/OBJECTIVES Increased rates of histopathological misdiagnosis of melanoma have been associated with incisional punch more so than shave biopsy when compared with complete excisional biopsy. It is unknown how the increasing utilisation of shave biopsy may impact melanoma diagnosis. The extent to which the provision of clinical information to the pathologist may improve diagnostic accuracy remains unclear. This study assessed the impact of both initial biopsy technique and provision of adequate clinical information to pathologists on the accuracy of histopathological diagnosis of melanoma and disease progression. METHODS We conducted a retrospective cohort with nested case-control study of all histopathological false-negative and false-positive melanoma diagnoses from January 2014 to May 2019 from the Victorian Melanoma Service electronic database. Cases were assessed for the initial biopsy type, provision of clinical information on pathology request forms and disease progression associated with false-negative diagnosis. RESULTS Partial shave biopsy had higher odds of false-negative (OR 5.19, 95% CI 2.89-9.32; P

This study examined office workstation types' impact on the relationship between fatigue and three health metrics: physical activity, stress, and sleep quality.Data from 225 office workers were collected for perceived fatigue, perceived sleep quality (Pittsburgh Sleep Quality Index [PSQI]), physiological stress response (standard deviation of heart rate variability [HRV]), and physical activity (total activity in minutes) during three consecutive workdays. Stress and physical activity were measured using chest-worn sensors. Workers were then categorized as tired or not-tired based on the median of the fatigue rating.Among tired workers, open-bench seating workers had increased physical activity, improved sleep quality, and reduced stress compared with workers in private offices and cubicles.Office workstation types influence physical activity and levels of stress during work hours, which in turn affect sleep quality.

ObjectiveManagement of covert submucosal invasive cancer (SMIC) discovered after piecemeal endoscopic mucosal resection (pEMR) of large (>20 mm) non-pedunculated colorectal polyps is challenging. The residual cancer risk is largely unknown. We sought to evaluate this in a large tertiary referral cohort.DesignCases of covert SMIC following pEMR were identified and followed. Oncological outcomes after surgery were divided based on residual intramural cancer, lymph node metastases (LNM) or both. Risk factors for residual intramural cancer and LNM were analysed based on the original pEMR histological variables. Risk parameters were analysed with respect to low and high-risk variables for residual intramural cancer and LNM.ResultsAmong 3372 cases of large non-pedunculated colorectal polyps, 143 cases of covert SMIC (4.2%) were identified. 109 underwent surgical resection. Histological analysis of pEMR histology was available in 98 of 109 (90%) cases. 62 cases (63%) had no residual malignancy. 36 cases had residual malignancy (residual intramural cancer n=24; LNM n=5; both n=7). All cases of residual intramural cancer could be identified by a R1 histological deep margin. Cases with poor differentiation (PD) and/or lymphovascular invasion (LVI) had a high risk of LNM (12/33), with a very low risk without these criteria (ConclusionThe majority of cases of large non-pedunculated colorectal polyps with covert SMIC following pEMR will have no residual malignancy. The risk of residual malignancy can be ascertained from three key variables: PD, LVI and R1 deep margin.

Background: Lentigo maligna (LM) characteristically has an ill-defined margin and may require multiple excisions to achieve complete excision with 5mm margins. In vivo reflectance confocal microscopy (RCM) is a non-invasive tool recognised as useful in the management of LM. The authors aimed to determine whether the use of RCM prior to surgical excision reliably increased the rate of complete excision when compared with standard surgical excision. Methods: This prospective pilot study included patients with biopsy-proven LM of head and neck region who sought consultation for surgical management from May 2017 to May 2019 at the Victorian Melanoma Service, Melbourne. Patients were randomised to two groups based on the availability of RCM — Group 1, RCM-guided surgical excision, and Group 2, standard surgical excision. Outcomes were measured based on clinical markings and histopathological margins achieved and reported as RCM or surgical margin excess or deficit. Ethics approval for the study was obtained from the Research Governance Unit of The Alfred Hospital, Melbourne. Results: Results demonstrated that RCM marking of lesion margins was in excess in 69 percent of cases, in deficit in 22 per cent and accurate in nine per cent after histopathological analysis of the specimens. In comparison, lesions that were surgically marked were removed with margins in excess in 43 per cent of cases, in deficit in 11 per cent and accurate in 46 per cent. Conclusion: This pilot study demonstrates that RCM did not increase the accuracy of LM surgical excision in comparison with standard surgically marked excisions.

Mucormycosis carries a high mortality rate with few therapeutic options available. We describe a man with pulmonary/splenic mucormycosis complicating hypoplastic myelodysplastic syndrome on a background of chronic kidney disease, who achieved a complete response with salvage isavuconazole therapy following intolerance of consecutive courses of liposomal amphotericin and posaconazole therapy.

Gut ischemia is common in critically ill patients, promoting thrombosis and inflammation in distant organs. The mechanisms linking hemodynamic changes in the gut to remote organ thrombosis remain ill-defined. We demonstrate that gut ischemia in the mouse induces a distinct pulmonary thrombotic disorder triggered by neutrophil macroaggregates. These neutrophil aggregates lead to widespread occlusion of pulmonary arteries, veins, and the microvasculature. A similar pulmonary neutrophil-rich thrombotic response occurred in humans with the acute respiratory distress syndrome. Intravital microscopy during gut ischemia-reperfusion injury revealed that rolling neutrophils extract large membrane fragments from remnant dying platelets in multiple organs. These platelet fragments bridge adjacent neutrophils to facilitate macroaggregation. Platelet-specific deletion of cyclophilin D, a mitochondrial regulator of cell necrosis, prevented neutrophil macroaggregation and pulmonary thrombosis. Our studies demonstrate the existence of a distinct pulmonary thrombotic disorder triggered by dying platelets and neutrophil macroaggregates. Therapeutic targeting of platelet death pathways may reduce pulmonary thrombosis in critically ill patients.

BACKGROUND. Irreversible electroporation (IRE) delivers brief electric pulses to attain nonthermal focal ablation that spares vasculature and other sensitive systems. It is a promising prostate cancer treatment due to sparing of the tissues associated with morbidity risk from conventional therapies. IRE effects depend on electric field strength and tissue properties. These characteristics are organ-dependent, affecting IRE treatment outcomes. This study characterizes the relevant properties to improve treatment planning and outcome predictions for IRE prostate cancer treatment. METHODS. Clinically relevant IRE pulse protocols were delivered to a healthy canine and two human cancerous prostates while measuring electrical parameters to determine tissue characteristics for predictive treatment simulations. Prostates were resected 5hr, 3 weeks, and 4 weeks post-IRE. Lesions were correlated with numerical simulations to determine an effective prostate lethal IRE electric field threshold. RESULTS. Lesions were produced in all subjects. Tissue electrical conductivity increased from 0.284 to 0.927S/m due to IRE pulses. Numerical simulations show an average effective prostate electric field threshold of 1072 � 119V/cm, significantly higher than previously characterized tissues. Histological findings in the human cases show instances of complete tissue necrosis centrally with variable tissue effects beyond the margin. CONCLUSIONS. Preliminary experimental IRE trials safely ablated healthy canine and cancerous human prostates, as examined in the short- and medium-term. IRE-relevant prostate properties are now experimentally and numerically defined. Importantly, the electric field required to kill healthy prostate tissue is substantially higher than previously characterized tissues. These findings can be applied to optimize IRE prostate cancer treatment protocols.

Cutaneous endometriosis that arises de novo, without a prior history of surgery, is a rare phenomenon. The clinical diagnosis of cutaneous endometriosis remains challenging due to the variable clinical appearance and symptoms of the condition, and therefore must be considered in the differential diagnosis of any umbilical lesion. We report a 31-year-old woman who presented with spontaneous cutaneous endometriosis of the umbilicus.

A 42-year-old woman presented with a rapidly enlarging right-sided thyroid mass and underwent hemithyroidectomy. Riedel's thyroiditis was only diagnosed upon surgical decompression of the right carotid artery 2 years later. She became more symptomatic as Riedel's thyroiditis progressed, and mediastinal fibrosclerosis developed over the next 12 months. Oral prednisolone failed to improve her condition, and she was commenced on tamoxifen. Despite initial improvement, her symptoms recurred 2 years later, mainly arising from compression of the trachea and esophagus at the thoracic inlet. Fluorodeoxyglucose positron emission tomographic scan showed locally advanced active invasive fibrosclerosis in the neck and mediastinum. An elevated activin-A level of 218 pg/mL was consistent with active inflammation. IgG subtypes (including IgG4) were normal. Two courses of iv methylprednisolone were given but only produced transient improvement. Subsequently, the patient received 3 doses of i.v. rituximab at monthly intervals and had prompt sustained symptomatic improvement. Activin-A level decreased to 122 pg/mL 10 months after rituximab therapy. Fluorodeoxyglucose positron emission tomographic scan 6 weeks after therapy showed reduction in inflammation. A further scan at 10 months demonstrated ongoing response to rituximab. This is a case of refractory Riedel's thyroiditis with symptomatic, biochemical, and radiological improvement that has persisted 14 months after rituximab. The likelihood and duration of response to rituximab in Riedel's thyroiditis requires further study.

BackgroundChemotherapy has in some series been linked with increased morbidity after a hepatectomy. Hepatic injuries may result from the treatment with chemotherapy, but can also be secondary to co-morbid diseases. The aim of the present study was to draw correlations between clinical features, treatment with chemotherapy and injury phenotypes and assess the impact of each upon perioperative morbidity.Patients and methodsRetrospective samples (n= 232) were scored grading steatosis, steatohepatitis and sinusoidal injury (SI). Clinical data were retrieved from medical records. Correlations were drawn between injury, clinical features and perioperative morbidity.ResultsInjury rates were 18%, 4% and 19% for steatosis, steatohepatitis and SI, respectively. High-grade steatosis was more common in patients with diabetes [odds ratio (OR) = 3.33, P= 0.01] and patients with a higher weight (OR/kg = 1.04, P= 0.02). Steatohepatitis was increased with metabolic syndrome (OR = 5.88, P= 0.02). Chemotherapy overall demonstrated a trend towards an approximately doubled risk of high-grade steatosis and steatohepatitis although not affecting SI. However, pre-operative chemotherapy was associated with an increased SI (OR = 2.18, P= 0.05). Operative morbidity was not increased with chemotherapy, but was increased with steatosis (OR = 2.38, P= 0.02).ConclusionsDiabetes and higher weight significantly increased the risk of steatosis, whereas metabolic syndrome significantly increased risk of steatohepatitis. The presence of high-grade steatosis increases perioperative morbidity, not administration of chemotherapy per se.

This case details the decline in lung function due to bronchial webs in a lung transplant recipient. The decline occurred 2 years after transplantation and, despite therapy, the webs, which had an inflammatory component, became treatment resistant. We outline the pathological findings and management strategies used, discuss the evidence in the literature, and offer possible causes for these unusual clinical findings.

IntroductionChemotherapy-induced hepatic injuries (CIHI) are an increasing problem facing hepatic surgeons. It may be possible to predict the risk of developing CIHI by analysis of genes involved in the metabolism of chemotherapeutics, previously established as associated with other forms of toxicity.MethodsQuantitative reverse transcriptase-polymerase chain reaction methodology (q-RT-PCR) was employed to quantify mRNA expression of nucleotide excision repair genes ERCC1 and ERCC2, relevant in the neutralization of damage induced by oxaliplatin, and genes encoding enzymes relevant to 5-flurouracil metabolism, [thymidylate synthase (TS), thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD)] in 233 hepatic resection samples. mRNA expression was correlated with a histopathological injury scored via previously validated methods in relation to steatosis, steatohepatitis and sinusoidal obstruction syndrome.ResultsLow-level DPD mRNA expression was associated with steatosis [odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.53–10.19, P < 0.003], especially when stratified by just those patients exposed to chemotherapy (OR = 4.48, 95% CI = 1.31–15.30 P < 0.02). Low expression of ERCC2 was associated with sinusoidal injury (P < 0.001). There were no further associations between injury patterns and target genes investigated.ConclusionsPredisposition to the development of CIHI may be predictable based upon individual patient expression of genes encoding enzymes related to the metabolism of chemotherapeutics.

Chronic cardiac dysfunction in patients with chronic liver disease (CLD) in the absence of alcohol consumption or other cardiac disease is well described. Whilst functional and morphological features of this condition remain unclear, diastolic dysfunction has been implicated by echocardiography. We aimed to evaluate myocardial structure, function and tissue composition with cardiac magnetic resonance (CMR) imaging in patients with hepatitis C and histological evidence of liver disease on biopsy. Contrast-enhanced CMR imaging for morphological, functional and tissue characterization was performed on 16 patients with CLD and 21 healthy controls. Cardiac structure and function was assessed with standard cine imaging, with Late Gadolinium Enhancement (LGE) and myocardial T1 mapping (pre- and post-contrast) performed to evaluate regional and diffuse myocardial fibrosis respectively. Compared to controls, patients with CLD demonstrated lower left ventricular end-diastolic volume (LVEDV) (138 ± 36 vs. 167 ± 44 mL, p

The importance of antibody-mediated rejection (AMR) following lung transplantation remains contentious. In particular, the diagnostic criteria suggested to define AMR, namely the presence of donor-specific antibodies (DSA), C4d immunoreactivity, histological features and allograft dysfunction are not always readily applicable or confirmatory in lung transplantation.In a retrospective single-center study of 255 lung transplant recipients (LTR), we identified 9 patients in whom a clinical diagnosis of AMR was made within 12months of transplant, and define the immunological, histological, clinical features, as well as the therapeutic response of this cohort.Nine LTR with AMR underwent combination therapy with high-dose intravenous corticosteroid, intravenous immunoglobulin, plasmapheresis and rituximab. Following therapy, while the total number of the original DSA dropped by 17%, and the median value of the mean fluorescence intensity (mfi) of the originally observed DSA decreased from 5292 (IQR 1319-12,754) to 2409 (IQR 920-6825) (p0.001), clinical outcomes were variable with a number of patients progressing to either chronic lung allograft dysfunction or death within 12month.AMR in lung transplantation remains both a diagnostic and therapeutic challenge, but when clinically suspected is associated with a variable response to therapy and poor long-term outcomes.

Diagnosis: Tuberculosis cutis miliaris acuta generalisata in the context of advanced human immunodeficiency virus (HIV) infection. Histopathological findings on the skin biopsy (Figure 1) revealed superficial dermal granulomatous inflammation (Figure 2) and acid-fast bacilli (Figure 3). Empirical treatment for tuberculosis and Mycobacterium avium complex (MAC) infection was commenced with rifampicin, isoniazid, pyrazinamide, ethambutol, and clarithromycin. Mycobacterium tuberculosis complex (MTB) polymerase chain reaction (PCR) performed on the skin biopsy specimen was positive and clarithromycin was discontinued. The fever defervesced within 48 hours. Over the subsequent weeks, fully sensitive MTB was cultured from blood cultures, sputum, bronchoalveolar lavage fluid, and urine from the acute admission. Cutaneous tuberculosis has long been recognized as a clinical syndrome having been first described by Laennec in 1826. It continues to be an important but rare clinical manifestation of tuberculosis in a resource-rich setting [1] with highly variable skin findings. Direct inoculation from an exogenous source, Figure 1. Multiple pustular skin lesions on upper limb (arrows). Figure 2. Hematoxylin-eosin stain of skin biopsy (×100 magnification) showing superficial dermal granulomatous inflammation (arrow).

Irreversible electroporation (IRE) delivers brief electric pulses to attain non-thermal focal ablation that spares vasculature and other sensitive systems. It is a promising prostate cancer treatment due to sparing of the tissues associated with morbidity risk from conventional therapies. IRE effects depend on electric field strength and tissue properties. These characteristics are organ-dependent, affecting IRE treatment outcomes. This study characterizes the relevant properties to improve treatment planning and outcome predictions for IRE prostate cancer treatment.Clinically relevant IRE pulse protocols were delivered to a healthy canine and two human cancerous prostates while measuring electrical parameters to determine tissue characteristics for predictive treatment simulations. Prostates were resected 5 hr, 3 weeks, and 4 weeks post-IRE. Lesions were correlated with numerical simulations to determine an effective prostate lethal IRE electric field threshold.Lesions were produced in all subjects. Tissue electrical conductivity increased from 0.284 to 0.927 S/m due to IRE pulses. Numerical simulations show an average effective prostate electric field threshold of 1072 ± 119 V/cm, significantly higher than previously characterized tissues. Histological findings in the human cases show instances of complete tissue necrosis centrally with variable tissue effects beyond the margin.Preliminary experimental IRE trials safely ablated healthy canine and cancerous human prostates, as examined in the short- and medium-term. IRE-relevant prostate properties are now experimentally and numerically defined. Importantly, the electric field required to kill healthy prostate tissue is substantially higher than previously characterized tissues. These findings can be applied to optimize IRE prostate cancer treatment protocols.

We evaluated long-term safety and lung function outcomes in a cohort of patients with severe upper-zone heterogeneous emphysema who underwent bronchoscopic lung volume reduction (BLVR) performed with the Emphasys one-way valve.A retrospective cohort study was undertaken to assess long-term outcomes in 23 consecutive patients who underwent upper lobe BLVR between July 2001 and November 2003 as part of a first-in-humans study. Long-term follow up (12 months) was available in 16/23 patients (median duration of follow up 64 months (range 15-90 months)). Both unilateral (n=4) and bilateral (n=12) BLVR procedures were performed with a mean of 6 (range 3-11) valves being inserted. Changes in pulmonary function tests were assessed longitudinally following the procedure.13/16 and 11/16 patients showed post-procedure improvements in FEV1 and DL(CO) , respectively. However, early improvements in pulmonary function were not sustained with only 6/16 patients still showing improved lung function at the end of follow up. There were no significant improvements in other indices of pulmonary function. Three patients, in the absence of clinical benefit, proceeded to lung transplantation at 15, 16 and 44 months post BLVR. Four patients died during the course of the study at 27, 29, 39 and 50 months post procedure.BLVR with the Emphasys one-way valve has an acceptable safety profile and in select patients may achieve long-term sustained improvements in pulmonary function.

Dear Editor, We read with great interest the recent study by Beilfuss et al ,1 which found vitamin D supplementation to ameliorate transforming growth factor-β-induced fibrogenesis in human hepatic stellate cells. Vitamin D is an important secosteroid hormone with pleiotropic effects that extend well beyond its established regulatory role in calcium and bone homeostasis. These include its recently described involvement in the regulation of immunomodulation, cell proliferation and differentiation, as well as anti-inflammatory and anti-fibrotic properties.2 Subjects with non-alcoholic fatty liver disease (NAFLD) have a lower 25-hydroxyvitamin D [25(OH)D] level,3 which is …

Aim To describe two cases of anaplastic large cell lymphoma, and to demonstrate the disease histologically at numerous extra-nodal sites. Methods Patient A is a 67-year-old male with malena and B-symptoms, and extensive lymphadenopathy. Patient B is a 55-year-old HIV-infected male with malaise and B-symptoms, and acute renal failure due to obstructive nephropathy, secondary to extensive retroperitoneal lymphadenopathy. Results Histopathological specimens from both patients will be shown, demonstrating disease involvement in peripheral blood, bone marrow aspirate and trephine, lymph nodes, urine cytology and also invading skeletal muscle. PET imaging for one patient is included, remarkable for the extent of disease involvement. The poster presentation will demonstrate photos of these specimens, and will incorporate a suggested algorithm for the histopathological diagnosis of anaplastic large cell lymphoma. Conclusion These two cases demonstrate two different presentations of anaplastic large cell lymphoma, with different ALK-mutation status, variable degrees of extranodal disease involvement demonstrated on peripheral blood, bone marrow aspirate and trephine, urine cytology and infiltrating skeletal muscle, in addition to PET imaging.

Primary angiosarcoma of the spleen is a rare tumour with aggressive behaviour. We present an unusual case of metastatic angio-sarcoma of splenic origin, initially diagnosed by bone marrow trephine for investigation of anaemia. The patient had chronic liver disease secondary to alcohol and hepatitis C infection and died after developing haematemesis with anaemia and acute renal failure. At post-mortem examination, metastatic angiosarcoma was found in the bone marrow, spleen, liver and brain. The greatest volume of tumour was present in the spleen, which was the presumed site of origin. We present a review of the literature on splenic angiosarcoma, and discuss the interaction of this rare malignancy with chronic liver disease.

Introduction Keratoacanthoma (KA) and squamous cell carcinoma (SCC) are both uncommon subungual lesions. The histological diagnosis of subungual KA and subungual SCC is sometimes difficult, especially on small biopsy specimens. Correctly distinguishing these two lesions is important for both therapeutic and prognostic reasons. Case history We report a case of a 45-year-old Caucasian man, who presented with a rapidly growing lesion at the nail bed of the index finger, which showed radiologic osteolytic change in the underlying distal phalanx. An initial nail bed biopsy of the lesion was diagnosed as SCC. An amputation of the distal phalanx was later performed, which showed the lesion to be a subungual KA. Discussion We discuss subungual KA and the histological features used to distinguish subungual KA and subungual SCC. In many cases, the diagnosis will require close correlation with clinical and radiological findings.