Localized Colitis Associated With Cholecystectomy in Multiple Sclerosis Patient Treated With Ocrelizumab.

Our understanding of multiple sclerosis (MS) has led to the development of new therapeutic strategies, including ocrelizumab, a third-generation humanized anti-CD20 antibody. Ocrelizumab is largely well tolerated with favorable effectiveness, however, it has been associated with reports of colitis presenting weeks to months following infusion. We present a case of severe localized colitis in the setting of recent surgery and chronic ocrelizumab use. High-dose IV hydrocortisone was initiated, and the patient showed gradual improvement. Repeat imaging after discharge showed near-complete resolution of the patient's condition. This case aims to increase awareness of possible postoperative severe localized colitis in MS patients on Ocrevus.

An Unusual Presentation of Occult Small-Cell Neuroendocrine Carcinoma as Acalculous Cholecystitis With Widespread Liver Metastasis.

Small-cell neuroendocrine carcinoma, often classified as small-cell lung carcinoma (SCLC) type, is an aggressive neuroendocrine tumor with early metastatic potential that can lead to unexpected patient presentations. We report the case of a 69-year-old man who presented to the emergency department with worsening right upper abdominal pain, nausea, and vomiting for the past several days. The clinical picture and the workup, including the complete metabolic panel and complete blood count, were highly suggestive of acute cholecystitis with transaminitis and direct hyperbilirubinemia. The ultrasound and magnetic resonance cholangiopancreatography of the abdomen revealed a diffusely hyperdense and hypertrophic liver without evidence of choledocholithiasis. After initial resuscitation, the patient underwent laparoscopic cholecystectomy. Intraoperative findings were consistent with diffuse miliary liver metastatic disease of unknown etiology, rigid liver parenchyma, an extremely frail gallbladder wall, and mild ascites. A biopsy of the liver and cholecystectomy were performed. The final pathology revealed metastatic SCLC to the liver and widespread intravascular tumor emboli, causing diffuse ischemia of the entire gallbladder wall. The patient's postoperative course was marked by the development of foudroyant liver insufficiency and worsening severe type B lactic acidosis.

Gallbladder Cancer or Diffuse Xanthogranulomatous Cholecystitis: A Case of Management Dilemma During Elective Cholecystectomy With Unexpected Severe Mass-Like Pericholecystic Fibrosis and Inflammation.

A 52-year-old man was scheduled to undergo an elective laparoscopic cholecystectomy for an increasingly symptomatic cholelithiasis. The pre-operative diagnosis was established clinically and confirmed with ultrasonography (US), showing gallstones and thickened gallbladder wall. Intraoperatively, extensive dense adhesions of the omentum to the entire subdiaphragmatic surface of the liver and the diaphragm were encountered. The adhesions of the omentum and colon were completely obscuring the Morrison's space with cartilage-like consistency at the supposed anatomical projection of the gallbladder fundus. Due to these unexpected pathological findings and uncertain disease biology, a decision was made to abort and re-schedule the surgery after obtained tissue biopsy results, magnetic resonance cholangiopancreatography (MRCP), and tumor markers carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and alpha fetoprotein (AFP) were available. CA 19-9 was found elevated 10-fold, while AFP and CEA levels were within normal limits. A follow-up cholecystectomy was performed, and final pathology revealed diffuse xanthogranulomatous cholecystitis (XC) and extensive inflammatory changes, adhesions, and fibrosis and no malignancy. The patient tolerated the procedure well and was discharged home on day two after surgery. His follow-up examination was unremarkable. Distinguishing between XC and gallbladder carcinoma is important to appropriately guide management and treatment.

Synchronous Acute Appendicitis and Acute Cholecystitis: A Case Report.

Acute cholecystitis (AC) and acute appendicitis (AA), independently, are among the most commonly diagnosed conditions in the emergency department (ED). However, their synchronous presentation is very rare. Here, we present a 31-year-old man with worsening right flank abdominal pain, nausea, and vomiting. Physical examination results were significant for moderate to severe right upper abdominal quadrant pain with a positive Murphy's sign and right lower quadrant pain with rebound. Workup in the ED revealed leukocytosis with a left shift, and the abdominal ultrasound and computerized tomography scan showed AA and AC. A literature review revealed a paucity of publications on concomitant AA and AC. Reporting new cases will contribute to improving our understanding of the biology, natural history, and management of this rare pathological combination.

Hypothyroidism Presenting as Adynamic Ileus Mimicking a Mechanical Small Bowel Obstruction: A Diagnostic and Management Dilemma.

Patients who present with nausea, vomiting, constipation, and abdominal pain typically undergo workups for small bowel obstruction (SBO). SBO is commonly caused by mechanical obstruction due to adhesions, inflammatory conditions, or malignancies. Hypothyroidism is primarily associated with decreased basal metabolic rate and rarely, in severe cases, gastrointestinal motility dysfunction. We report a case of a 44-year-old man who presented to the emergency department with abdominal pain, nausea, and vomiting. The workup, including computed tomography, showed a small bowel feces sign, highly suspicious for a mechanical SBO. His past medical history was significant for a poorly controlled hypothyroidism due to Hashimoto's thyroiditis with a markedly elevated thyroid stimulating hormone (TSH) level. He had no prior surgical history, and his family history was significant for a suspected inflammatory bowel disease (IBD) in his son. The patient failed initial resuscitative nonoperative management and underwent exploratory laparoscopy that revealed diffusely dilated small bowel loops with no obvious cause of mechanical obstruction. Inflammatory markers for IBD were found to be negative, and the patient's gastrointestinal motility gradually improved with daily intravenous levothyroxine.

Small Bowel Perforation Due to Rare Metastasis From Stage IV Lung Adenocarcinoma.

Lung adenocarcinoma commonly metastasizes to the lymph nodes, bone, nervous system, liver, respiratory system, and adrenal gland. Metastasis to the small bowel is extremely rare and the literature deals mostly with few published case reports. We present a case of a 70-year-old male with a previous history of stage IV lung adenocarcinoma with brain and liver metastases treated with radiotherapy and chemotherapy. He presented to the emergency department with peritonitis and sepsis due to bowel perforation. He underwent an emergency exploratory laparotomy and small bowel resection. Surgical pathology revealed metastatic lung adenocarcinoma as the cause of bowel perforation. He tolerated and recovered from surgery well and was discharged on postoperative day 7. On one-month follow-up as an outpatient, he was doing well and had no complications or complaints from his recent surgery.

Synchronous papillary-medullary thyroid microcarcinoma: a case report.

Background: Papillary thyroid carcinoma is the most common type of thyroid carcinoma, making up 85-90% of all thyroid carcinomas. Medullary thyroid carcinoma is the third most common type of thyroid carcinoma, making up less than 5% of all thyroid carcinomas. However, synchronous papillary-medullary thyroid carcinoma is exceedingly rare and has not been well described historically. There have been fewer than 40 cases reported in the current literature. Case Description: In this case report we present a 65-year-old man with synchronous papillary-medullary thyroid carcinoma. A 65-year-old man presented with a symptomatic multinodular thyroid goiter. Ultrasound (US) confirmed bilateral thyroid nodules, and he was initially managed nonoperatively. Fine needle aspiration (FNA) biopsy of the left dominant nodule revealed atypia of undetermined significance (AUS) (Bethesda class III). Further assessment of the FNA specimen with ThyGeNEXT® (mutation panel) revealed no mutations and the ThyraMIR® (microRNA risk classifier) was negative, which classified the results as very highly likely to be benign. Due to worsening local compressive symptoms, a total thyroidectomy was performed. Final surgical pathology revealed incidental multicentric, multifocal micropapillary carcinoma foci from (0.1 to 0.5 cm), and a 0.3 cm medullary carcinoma in the left thyroid lobe on the background of nodular hyperplasia. Conclusions: Synchronous papillary-medullary thyroid carcinoma is a rare finding that should be considered in patients with symptomatic multinodular thyroid goiters. It is important to report this case to increase awareness and improve our understanding and management of these unusual carcinomas in the future.

Perforated Colon Cancer Associated With Post-operative Recurrent Bowel Perforations.

Colon perforation is a major life-threatening condition associated with high morbidity and mortality, which often develops secondary to complicated diverticulitis and, less commonly, colon cancer. We describe the case of a 51-year-old female who had perforated colon cancer with concurrent diverticulosis. Based on history, physical exam, laboratory, and computed tomography (CT) findings on initial presentation, the patient was diagnosed with acute complicated diverticulitis. Despite medical treatment, the patient's condition worsened, warranting exploratory laparotomy and a left hemicolectomy with transverse end colostomy creation. Surgical pathology revealed stage IIIC colon cancer without evidence of diverticulitis. The patient underwent eight cycles of adjuvant chemotherapy with FOLFOX (folinic acid, fluorouracil, and oxaliplatin). Over the next year, the patient experienced recurrent bowel perforations requiring repeated surgeries. Perforations were identified in both the small and large bowel on different occasions. Even though neither presented with a clear etiology, possible ischemic, infectious, erosive, and iatrogenic etiologies were on the differential. Our case exemplifies the mounting complications we should be wary of when performing repeated invasive abdominal operations.

Digital angiolipoma: uncommon location and presentation of a common tumour.

A 56-year-old woman presented with an enlarging soft-tissue mass of the left ring finger, causing worsening range of motion in the metacarpophalangeal and interphalangeal joints. Excision of the mass was performed and a 3.5×3.5×3 cm lipoma was found displacing the digital neurovascular bundles laterally and posteriorly. Surgical pathology revealed a rare angiolipoma. This case was unusual because of the location of the mass, and the fact that it was non-tender, and larger than the typical angiolipoma presentation. Definitive identification of angiolipomas, especially those without gross vascularisation, as in this case, is often delayed until final pathology. Reporting cases of angiolipoma of the finger will increase awareness of this rare lesion and broaden the differential diagnosis to improve identification and management in future cases. We discuss a surgical approach which successfully increased range of motion of the hand and preserved neurovascular integrity.

Prospects for Radiopharmaceuticals as Effective and Safe Therapeutics in Oncology and Challenges of Tumor Resistance to Radiotherapy.

The rapid advances in nuclear medicine have resulted in significant advantages for the field of oncology. The focus is on the application of radiopharmaceuticals as therapeuticals. In addition, the latest developments in cell biology (the understanding of the cell structure, function, metabolism, genetics, signaling, transformation) have given a strong scientific boost to radiation oncology. In this regard, the article discusses what is soon going to be a new jump in radiation oncology based on the already accumulated considerable knowledge at the cellular level about the mechanisms of cell transformation and tumor progression, cell response to radiation, cell resistance to apoptosis and radiation and cell radio-sensitivity. The mechanisms of resistance of tumor cells to radiation and the genetically determined individual sensitivity to radiation in patients (which creates the risk of radiation-induced acute and late side effects) are the 2 major challenges to overcome in modern nuclear medicine. The paper focuses on these problems and makes a detailed summary of the significance of the differences in the ionizing properties of radiopharmaceuticals and the principle of their application in radiation oncology that will shed additional light on how to make the anti-cancer radiotherapies more efficient and safe, giving some ideas for optimizations.

Primary versus secondary nature of mesenteric neuroendocrine tumours.

Neuroendocrine tumours (NETs) are rare group of malignancy that originate from neuroendocrine cells present throughout the body. Most patients with NET first present with symptoms associated with metastasis, and up to 20% of patients have unknown primary site of tumour. Most common metastatic sites for small intestine NETs (SI-NETs) are the locoregional lymph nodes and liver. Although mesenteric metastasis through direct extension or lymphatic spread from SI-NETs is common, mesenteric extranodal involvement is extremely rare, and its biology and primary versus secondary nature are not well understood. Due to their small size and location, SI-NETs are frequently undetected on anatomical imaging or indium-111-pentetreotide single-photon emission computed tomography/CT (Octreoscan) and are difficult to be found via endoscopy. Gallium-68-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid-octreotate positron emission tomography (68Ga-DOTATATE PET)/CT has been increasingly used for accurate staging, unknown primary tumour site localisation and appropriate management planning. We present a case of an incidentally found mesenteric NET with occult SI-NETs localised preoperatively by 68Ga-DOTATATE PET/CT.

Incidental Adrenal Mass in a Patient With Surgically Treated Lung Adenocarcinoma.

Adrenal metastases are not uncommon in patients with widespread metastatic lung cancer. Isolated metachronous adrenal metastases in cases of surgically treated lung cancer without long-term evidence of disease are rare and may pose a diagnostic and treatment dilemma. The current literature suggests that in such cases, adrenalectomy provides better median and overall survival rates. This case presents an incidentally discovered isolated adrenal mass in a patient with a past medical history of lung adenocarcinoma that was surgically removed three years before metastasis discovery. The patient successfully underwent adrenalectomy and was disease-free with no apparent complications at her three-month follow-up visit. The case highlights the importance of long-term radiographic surveillance after surgical resection of lung adenocarcinoma for the prompt diagnosis and timely treatment of metachronous metastases.

Accessory Liver Lobe Attached to the Wall of the Gallbladder.

A 47-year-old woman with a history of known gallstone disease presented with worsening post-prandial right upper abdominal pain radiating to the back, abdominal bloating, and nausea. An ultrasound of the abdomen confirmed the diagnosis of cholelithiasis. During laparoscopic cholecystectomy, an accessory liver lobe attached to the anterior wall of the gallbladder was incidentally found. An accessory liver lobe is a rare anatomical variation that mostly remains clinically asymptomatic. Since hepatocellular carcinoma can rarely develop in an accessory liver lobe, intraoperative complete resection should be considered for both therapeutic and diagnostic purposes.

A Unique Combined Ganglioneuroma Schwannoma Tumor Mimicking Adrenal Malignancy.

A 28-year-old woman with a past medical history significant for cervical cancer was diagnosed with a 2.5 cm adrenal tumor but was lost to follow-up. Two years later, she presented to the emergency room with worsening right upper abdominal and flank pain. The computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen and pelvis revealed that the right adrenal mass had nearly doubled in size (4.3 cm), was heterogeneous with calcifications, central necrosis and actively uptaking the intravenous (IV) contrast with a delayed washout. The biochemical workup was negative for hyperaldosteronism, hypercortisolism, and pheochromocytoma. She reported an unintentional body weight loss of 40 pounds. Adrenocortical carcinoma or a metastatic malignancy was high on the differential diagnoses list. She underwent a successful laparoscopic adrenalectomy, and final pathology revealed a benign extra-adrenal combined ganglioneurofibroma and schwannoma. These rare benign malignancies alone or in combination may closely mimic the clinical and imaging characteristics of adrenal malignancy and pose a diagnostic and therapeutic dilemma to surgeons as well as cause a significant distress to patients and their families. Thus, it is important to thoroughly document and report these cases in order to increase awareness and improve our understanding of the biology, natural history and management of these extremely rare tumors.

Acute Granulomatous Appendicitis and Lower Gastrointestinal Bleeding as the Presenting Features of Crohn's Disease.

A 46-year-old woman with a history of hemorrhoids presented with right-sided abdominal pain and rectal bleeding. Preoperative imaging and intraoperative observations were suggestive of acute appendicitis. The surgical pathology of removed appendix was consistent with granulomatous appendicitis. The patient was evaluated again in two months due to persistent hematochezia and new onset of left lower quadrant abdominal pain. A diagnostic colonoscopy revealed mildly edematous mucosa in the descending colon, sigmoid colon, and rectum, and a rectal biopsy revealed patchy chronic proctitis. The biopsy of anal canal mucosa showed acute and chronic granulomatous inflammation. Based on her clinical presentation and pathology results, the diagnosis of chronic active proctitis secondary to Crohn's disease (CD) was made. There is a debate on necessity of follow-up on patients with appendiceal CD after appendectomy as previously reported appendiceal CD usually follows a benign course post-appendectomy. However, our patient's case progressed from granulomatous appendicitis to CD with severe GI bleeding and proctitis within only two months post-appendectomy. A high index of suspicion is needed in patients with a history of granulomatous appendicitis and lower GI bleeding to ensure prompt diagnosis and timely treatment.

Endosalpingiosis of the Gallbladder: A Unique Complication of Ruptured Ectopic Pregnancy.

A 60-year-old woman with a history of a ruptured ectopic pregnancy and subsequent salpingo-oophorectomy presented with clinical signs. Pre-operative imaging and intra-operative observations were highly suggestive of acute on chronic cholecystitis. A laparoscopic cholecystectomy was performed. In addition to confirming calculous cholecystitis, final pathology revealed endosalpingiosis on the serosal surface of the gallbladder. Endosalpingiosis is a rare, benign presence of glands lined by tubal-like epithelium, and the few case reports describe it on the surface of the female reproductive organs or seeded on the pelvic peritoneum. We hypothesize that, in this unique case, the endosalpingiosis is due to patient's ruptured ectopic pregnancy, which allowed tubal epithelial cells to spread to the gallbladder. The only documented cases of endosalpingiosis outside the pelvic and lower abdominal organs have been congenital choristomas. To our knowledge, this is the first documented case of acquired endosalpingiosis of the gallbladder.

Low-grade Appendiceal Mucinous Neoplasm in the Context of Acute Appendicitis.

A 49-year-old woman presented with clinical signs, pre-operative imaging, and intra-operative findings suggestive of acute appendicitis. A laparoscopic appendectomy was performed. Final pathology revealed a low-grade appendiceal neoplasm with serrated architecture, and secondary acute inflammation of the appendix (5 cm in length x 0.7 cm in diameter) with a congested and hemorrhagic serosal surface. The main concern in the management of patients with low-grade appendiceal mucinous neoplasm (LAMN) is that these dysplastic tumors share such similar clinical, imaging, and intraoperative features with simple acute appendicitis, which is deemed definitively cured following surgical removal of the appendix. A definitive diagnosis of LAMN is often delayed until the final pathology report; however, this finding can have implications on the further management of the patient, especially with the risk of recurrence in situations of peritoneal dissemination or positive surgical margins. Reporting LAMN cases will increase awareness of this rare disease and will contribute to improved management in the future.

ONCOGENE PANEL SEQUENCING ANALYSIS IDENTIFIES CANDIDATE ACTIONABLE GENES IN ADVANCED WELL-DIFFERENTIATED GASTROENTEROPANCREATIC NEUROENDOCRINE TUMORS.

Objective: To report the rate of candidate actionable somatic mutations in patients with locally advanced and metastatic gastro-enteropancreatic (GEP) neuroendocrine tumors (NET) and of other genetic alterations that may be associated with tumorigenesis. Methods: A phase II mutation targeted therapy trial was conducted in patients with advanced well-differentiated G1/G2 GEP-NET. Mutations found in the mTOR pathway-associated genes led to treatment with the mTOR inhibitor everolimus, and were defined as actionable. Tumor deoxyribonucleic acid (DNA) from GEP-NET were sequenced and compared with germline DNA, using the OncoVAR-NET assay, designed for hybrid capture sequencing of 500 tumor suppressor genes and oncogenes. Somatic variants were called and copy-number (CN) variant analysis was performed. Results: Thirty patients (14 small-intestine, 8 pancreatic, 3 unknown primary NET, and 5 of other primary sites) harbored 37 lesions (4 patients had DNA of multiple lesions sequenced). Only 2 patients with sporadic NET (n = 26) had an actionable mutation leading to treatment with everolimus. Driver somatic mutations were detected in 18 of 30 patients (21/37 lesions sequenced). In the remaining samples without a driver mutation, CN alterations were found in 11/16 tumors (10/12 patients), including CN loss of chromosome (Chr) 18 (P<.05), CN gain of Chr 5, and loss of Chr 13. CN losses in Chr 18 were more common in patients without driver mutations detected. Pronounced genetic heterogeneity was detected in patients with multiple lesions sequenced. Conclusion: Genome-wide DNA sequencing may identify candidate actionable genes and lead to the identification of novel target genes for advanced well-differentiated GEP-NET. Abbreviations: Chr = chromosome; CN = copy number; DNA = deoxyribonucleic acid; FDA = Food and Drug Administration; GEP = gastro-enteropancreatic; MEN-1 = multiple endocrine neoplasia syndrome type 1; mTOR = mammalian target of rapamycin; NET = neuroendocrine tumor; PFS = progression-free survival; PNET = pancreatic neuroendocrine tumors; SINET = small-intestine neuroendocrine tumor.

Diffuse Xanthogranulomatous Cholecystitis: Master of Disguise.

A 67-year-old woman presented with clinical symptoms, radiological findings, and preoperative work-up highly suggestive of advanced stage IV carcinoma of the gallbladder (CG). An extended cholecystectomy with the excision of adjacent liver segments and loco-regional lymphadenectomy was performed. Final pathology results revealed diffuse xanthogranulomatous cholecystitis (XG) with ruptured Rokitansky-Aschoff sinuses with tumor-resembling adenomyosis without atypical or malignant cells. There was a reactive inflammatory and fatty degeneration of the adjacent hepatic tissue and a nonspecific inflammatory reaction of the enlarged periportal lymph nodes. The main concern in the management of patients with mass-forming XG is that this benign condition shares strikingly similar clinical, imaging, biochemical, and intraoperative features with advanced CG, which has one of the poorest overall survival rates. Misdiagnosis is not uncommon, which causes significant distress for patients and their families and, in some cases, may result in erroneous treatment. Although the presence of some preoperative imaging findings and/or intraoperative frozen section biopsies may be helpful in suspecting XG, definitive diagnosis is usually delayed until the final pathology result that may come as a surprise. Increasing awareness of this rare, insidious disease will contribute to a better understanding of its biology and natural history and, eventually, help improve management.

Non-surgical Pneumoperitoneum in the Setting of Gram-negative Sepsis.

Pneumoperitoneum is described as the presence of free air in the peritoneal cavity. In the majority of cases, it is the manifestation of abdominal viscus perforation, requiring an emergent surgical exploration. In rare cases, however, no evidence of perforation of the gastrointestinal or genitourinary tracts can be found at exploration, and in such cases, the pneumoperitoneum is referred to as non-surgical pneumoperitoneum. We present a case of an 87-year-old man who developed a non-surgical pneumoperitoneum in the setting of gram-negative sepsis. The patient was admitted for treatment of obstructive uropathy and sepsis secondary to a gram-negative urinary tract infection. Despite the initial resuscitation and antibiotic therapy, his hospital course was complicated by worsening abdominal discomfort, and a chest radiograph revealed free air under the diaphragm. He was taken to the operating room for an emergent surgical exploration that revealed no visceral perforation or other possible surgical causes. He tolerated and recovered from surgery well, and had a complete resolution of pneumoperitoneum in the early post-surgery period, per radiographic imaging. This interesting case highlights a rare case of idiopathic nonsurgical pneumoperitoneum in the setting of gram-negative sepsis. Additionally, we discuss considering non-surgical etiologies for patients without clinical signs or surgical evidence of perforation.