Primary Splenic Epidermoid Cyst: A Case Report.

Primary splenic epidermal cysts, a type I splenic lesion, are very uncommon and usually found coincidentally. In this report, we present a primary splenic epidermal cyst that presented as a mass in the left upper quadrant associated with sharp pain, early satiety, and constipation. We review the classification of splenic cysts with a detailed look into the causes and types of type I cysts. We discuss the different treatment options, how current and past surgical options are controversial, and indications for splenectomy in spleen cysts. We explore how percutaneous drainage as a bridge to splenectomy may have been beneficial in a splenic cyst of great size. This splenic cyst was attempted laparoscopically but converted to an open splenectomy after complications. The patient recovered with no difficulties postoperatively.

Primary Lung Adenocarcinoma Presenting as Cardiac Tamponade in a 40-Year-Old Non-Smoker.

Lung cancer is the number one cause of cancer-death in the world with the majority of cases directly attributable to smoking. The diagnosis is mostly made following evaluation for either an incidental lung nodule or respiratory signs and symptoms such as cough and hemoptysis. This is a review of a young never-smoker who presented predominantly with gastrointestinal symptoms, which is an uncommon initial presentation of lung cancer associated with malignant pericardial effusion. A 40-year-old male without a history of smoking presented with epigastric pain associated with nausea and vomiting. He denied significant cardio-respiratory or systemic symptoms. Physical examination was unremarkable besides tachycardia of 111 beats per minute, blood pressure of 108/65 mmHg, and mild generalized direct abdominal tenderness. EKG showed electrical alternans. CXR demonstrated a prominent cardiac silhouette leading to evaluation with echocardiography, which revealed a large pericardial effusion and signs of cardiac tamponade. 1200 ml of serosanguinous fluid was removed by pericardiocentesis with significant clinical improvement. The basic workup of infectious and immunologic causes was negative, which prompted a contrasted CT scan of the chest. This revealed a left upper lobe mass measuring 3.6 x 2.8 cm without mediastinal or hilar lymphadenopathy. CT-guided biopsy was performed and was consistent with pulmonary adenocarcinoma but was negative for molecular drivers and programmed cell death ligand 1 (PD-L1). Pericardial fluid cytology also confirmed the presence of malignant cells. The patient complained of mild dyspnea and chest pain before discharge which led to a repeat echocardiogram and identification of a recurrent large pericardial effusion. Cardiothoracic surgery consultation was obtained, and the patient underwent subxiphoid pericardial window placement. Learning points from this case report include: First, non-smoking-related lung cancer is still among the top ten causes of cancer death in the US. It should remain in the differential diagnosis of patients presenting with pertinent signs and symptoms, even in non-smokers. Secondly, malignancy, most importantly primary lung cancer, is a common cause of a large symptomatic pericardial effusion in patients who have a non-revealing basic workup. In such patients, a detailed evaluation for undetected underlying malignancy is important. Thirdly, colchicine and non-steroidal anti-inflammatory drugs are commonly used for the treatment of painful malignant pericardial effusion; however, there is a lack of data to support this practice. Finally, pre-discharge screening echocardiography in patients with new or recurring cardiorespiratory symptoms following initial pericardiocentesis could be important because recurrent large pericardial effusion is a common and potentially fatal complication of malignant pericardial effusion.

Poorly Differentiated Large Cell Neuroendocrine Carcinoma of the Colon: A Case Report.

Colon cancer is one of the most common diagnoses of cancer and a leading cause of death in America. Large cell neuroendocrine tumors are a very uncommon type of colon cancer that tends to have a poor prognosis. Usually, these tumors are only found at the time of metastasis making them even more difficult to treat. A 65-year-old female presented with worsened generalized abdominal pain associated with abdominal distention. She had not had a bowel movement in over a week and did not have any flatulence. She had a colonoscopy four years prior that was normal. Physical examination was significant for abdominal distention and a large right-sided palpable mass in her abdomen with generalized tenderness. A CT scan showed a large irregular mass at least 9.8 x 10.5 cm at the mid to distal ascending colon resulting in significant colonic narrowing significant for a large bowel obstruction. The CT also demonstrated suspicious nodules in the lung, lesions in the liver, and lymphadenopathy. She had an exploratory laparotomy with an extended hemicolectomy to remove the mass. Pathology revealed the mass was neuroendocrine carcinoma, a large cell subtype, that was poorly differentiated with involvement of at least 32 of 34 lymph nodes. This tumor was positive for AE1/AE3, CEA, CK20, and synaptophysin. Ki-67 showed 70% positivity. TTF1 was negative and ruled out a primary lung tumor. Microsatellite immunostains were positive for MLH-1, MSH-2, MSH-6, and PMS2. The patient was started on Carboplatin AUC6 and Etoposide 100mg/m2 in three-week intervals. Pegfilgrastim was also added to her treatment plan every 21 days. This is a review of a female who presented with colonic obstruction that was found to be poorly differentiated large cell neuroendocrine carcinoma after a previous negative colonoscopy.

Virilizing Adrenocortical Carcinoma Resected With Negative Margins Treated With Surgery Alone.

Adrenocortical carcinoma is a rare malignancy. A virilizing adrenocortical carcinoma is even more unique of a diagnosis. In this report, we present a rare case of this uncommon tumor with an interesting presentation, clearly documented physical exam changes over a span of at least 8 years, and a technically challenging case. We also briefly review the management of adrenocortical carcinoma. The tumor was successfully resected with no planned adjuvant treatment at this time. The patient had recurrence of menstrual cycle post-operatively and required no steroid supplementation.