It is best heard at the right upper sternal border (aortic area). It sometimes radiates to the carotid arteries. In mild aortic stenosis, the crescendo-decrescendo is early peaking. Whereas in severe aortic stenosis, the crescendo is late-peaking. In severe cases, obliteration of the S2 heart sound may occur. Stenosis of Bicuspid aortic valve is like the aortic valve stenosis heart murmur. But, one may hear a systolic ejection click after S1 in calcified bicuspid aortic valves. Symptoms tend to present between 40 and 70 years of age. Mitral regurgitation is a holosystolic murmur. One can best hear it at the apex location and it may radiate to the axilla or precordium. When associated with mitral valve prolapse, one may hear a systolic click. In this scenario, valsalva maneuver will decrease left ventricular preload. This will move the murmur onset closer to S1. Isometric handgrip will increase left ventricular afterload. This will increase murmur intensity. In acute severe mitral regurgitation, one may not hear a holosystolic murmur. Pulmonary valve stenosis is a crescendo-decrescendo systolic murmur. One can hear it best at the left upper sternal border. It has association with a systolic ejection click that increases with inspiration. This finding results from an increased venous return to the right side of the heart. Pulmonary stenosis sometimes radiates to the left clavicle. Tricuspid valve regurgitation is a holosystolic murmur. It presents at the left lower sternal border with radiation to the left upper sternal border.
Endodermal sinus tumor (EST) is a member of the germ cell tumor group of cancers. It is the most common testicular tumor in children under three, and is also known as infantile embryonal carcinoma. This age group has a very good prognosis. In contrast to the pure form typical of infants, adult endodermal sinus tumors are often found in combination with other kinds of germ cell tumor, particularly teratoma and embryonal carcinoma. While pure teratoma is usually benign, endodermal sinus tumor is malignant. Cause
Causes for this cancer are poorly understood. Diagnosis
The histology of EST is variable, but usually includes malignant endodermal cells. These cells secrete alpha-fetoprotein (AFP), which can be detected in tumor tissue, serum, cerebrospinal fluid, urine and, in the rare case of fetal EST, in amniotic fluid. When there is incongruence between biopsy and AFP test results for EST, the result indicating presence of EST dictates treatment. This is because EST often occurs as small "malignant foci" within a larger tumor, usually teratoma, and biopsy is a sampling method; biopsy of the tumor may reveal only teratoma, whereas elevated AFP reveals that EST is also present. GATA-4, a transcription factor, also may be useful in the diagnosis of EST.Diagnosis of EST in pregnant women and in infants is complicated by the extremely high levels of AFP in those two groups. Tumor surveillance by monitoring AFP requires accurate correction for gestational age in pregnant women, and age in infants.