Adrenal Angiosarcoma: A Diagnostic Dilemma.

Primary angiosarcoma of the adrenal gland is both a rare and aggressive malignancy. Differentiating it from more common adrenal masses such as adrenal adenomas, adrenal cortical carcinomas, and metastatic carcinomas is one of several diagnostic challenges. Immunohistochemical analysis is imperative to arrive at the correct diagnosis. Treatment typically involves surgery and adjuvant chemotherapy, but prognosis remains poor.

The concurrence of granulomatous inflammation in intrathoracic lymph nodes with regional metastasis from primary lung cancer in surgically resected specimens.

INTRODUCTION: Granulomatous inflammation has been associated with malignancies such as breast, testicular, renal cell, and lymphoma. The coexistence of granulomatous inflammation in mediastinal/hilar lymph node with primary lung malignancy has been described in case reports. Our goal was to examine the frequency of granulomatous reaction in mediastinal/hilar lymph node in the patients who had undergone surgical resection of lung cancer. MATERIAL AND METHODS: We performed a retrospective analysis of 40 patients (1) aged ≥ 18 years and (2) who underwent lobectomy or pneumonectomy from August 1, 2012 to October 31, 2016 at Saint Louis University Hospital and (3) had pathology suggestive of cancer. RESULTS: Of those 40 patients, 3 (7.5%) had granulomatous inflammation in the lymph nodes. None of these 3 individuals had evidence of metastasis in the particular lymph nodes with granulomatous inflammation. CONCLUSION: Our small cohort revealed that the presence of granulomatous inflammation in a lymph node can be safely taken as an evidence of the absence of metastasis to the lymph node. This finding can obviate the need for further sampling for the particular lymph node with granulomatous inflammation and can decrease the sampling time.

Impact of an Inpatient Palliative Care Consultation in Terminally Ill Cancer Patients.

Limited data are available to guide the timing of palliative care involvement in the treatment of cancer. We describe the referral patterns of inpatient palliative care consultations(IPCC) in advanced cancer patients in a tertiary care center. METHODS: A retrospective review was performed of IPCC for cancer patients from January 1, 2014, to December 31, 2014. Descriptive statistics are reported. RESULTS: IPCCs were requested for 245 cancer inpatients, of which 130 were male (53.1%) and 115 (46.9%) were female; 128 (52.2%) were Caucasian, 114 (46.5%) were African American, and 3 (1.2%) were another race. Of the 245 patients, 79 (32.2%) were newly diagnosed during the current admission, and the remaining 146 (67.8%) had been diagnosed previously. Fifty-seven (23.3%) patients were admitted to the intensive care unit (ICU) during hospitalization. Of the 39 patients (15.9%) who died during their hospital stay, 34 (87.0%) had an ICU stay during the hospitalization or died in the ICU. The most common malignancies were lung (71; 29.0%), pancreatic-biliary (33; 13.4%), lymphoma and leukemia (22; 8.9%), hepatocellular (18; 7.3%), head and neck (16; 6.5%), and upper gastrointestinal tract(GI) (16; 6.5%). CONCLUSIONS: Our data show that 15.9% of terminally ill cancer patients with IPCC died in the hospital, the majority of whom died in the ICU. This was likely due to delays in the initiation of outpatient palliative care consultation, leading to an increased strain on tertiary referral centers. Our study highlights a racial disparity in the rate of IPCC in African Americans, compared to historical data.

Correction to: Hepatocellular Carcinoma with Bone Metastases: Incidence, Prognostic Significance, and Management-Single-Center Experience.

The original version of this article unfortunately contained a mistake in the Author group section. Author first names and family names were interchanged.

Gastric Spindle Cell Neuroendocrine Tumor Mimicking Gastrointestinal Stromal Tumor: Unique Morphology and Diagnostic Pitfall.

Gastric neuroendocrine tumors (GNETs) with spindle cell morphology are extremely rare. We present a case of a 49-year-old female patient with a history of systemic lupus erythematosus, Sjogren's syndrome, and gastroesophageal reflux disease. She was initially thought to have a spindle cell gastrointestinal stromal tumor per histological studies of the fundic polypectomy samples. Immunohistochemically, the tumor cells were negative for CD117, and CD34, but positive for chromogranin, synaptophysin, and CD56 with a 6% Ki-67 index, consistent with a spindle cell-type well differentiated neuroendocrine tumor, World Health Organization (WHO) Grade 2. To the best of our knowledge, this is the first case report of a gastric spindle cell neuroendocrine tumor in the English literature.

Hepatocellular Carcinoma with Bone Metastases: Incidence, Prognostic Significance, and Management-Single-Center Experience.

BACKGROUND: Hepatocellular carcinoma (HCC) represents one of the most common causes of cancer-related deaths worldwide, with rising incidence in the USA. Bone metastases with HCC, in particular, have an extremely poor prognosis. We present prevalence, treatment, and survival of patients with bone and more specifically spinal metastases from HCC. METHODS: A retrospective analysis was done at a single tertiary care institution of patients with bone metastases from HCC between January 2005 and December 2015. RESULTS: Among 1017 patients with HCC, 20 were found to have bone metastases of which 11 had spinal metastases. Seventeen (85%) were male, with median age of 58 years at time of HCC diagnosis. Systemic chemotherapy and sorafenib were used in 12 (60%) patients, and 12 (60%) received radiation therapy. Among patients who did not receive therapy, median survival was 76 days. Median survival after diagnosis of metastasis in patients on sorafenib and radiation were 106 and 100 days, respectively. CONCLUSION: Bone metastases in HCC are very rare and aggressive. Due to its rarity, optimal treatment strategies are not well defined. Early diagnosis is important for optimal therapy and improved survival.

All That Glitters Is Not Gold" - A Case of an Occult Foreign Body in the Lung with Elevated 2-[18F]-Fluoro-2-deoxy-D-glucose (FDG) Uptake Mimicking Bronchogenic Carcinoma.

Combined positron emission tomography/computed tomography (PET/CT) using the glucose analogue 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) has become the standard of care in oncological patients. However, due to the non-specific nature of FDG uptake, there are many physiological variants and benign pathological entities that also demonstrate augmented glucose metabolism, such as inflammatory and infective processes. Undiagnosed and retained foreign bodies (occult foreign bodies) in the lung can induce inflammatory reaction consisting of polymorphonuclear neutrophils, macrophages, and granulation tissue resulting in intense FDG uptake because of high metabolic activity and cell turnover. Here, we present a case of an occult foreign body imitating a tumor on PET/CT.

Synchronous Ileal Neuroendocrine Tumor and Ovarian Steroid Cell Tumor Present in a Female With Hyperandrogenism.

Well-differentiated neuroendocrine tumors (NET) of the ileum are generally slow-growing tumors with metastatic potential that may cause systemic symptoms from the secretion of serotonin, cortisol, and other biologically active substances. Likewise, steroid cell tumors of the ovary are slow-growing tumors that cause systemic symptoms from the functional production of androgens, estrogens, and other hormones. To the best of our knowledge, synchronous ileal NET and ovarian steroid cell tumors have not been previously reported in the English literature. We present a case of a 59-yr-old woman with 2 primary tumors that were found incidentally: a Stage III (T2N1M0) 1.6 cm well-differentiated NET (NET G2) of the terminal ileum with metastasis to a mesenteric lymph node and a 2.4 cm steroid cell tumor of the left ovary. The patient had suffered from hyperandrogenism for several years before diagnosis of an ovarian steroid cell tumor, but had no symptoms attributable to the NET. From review of the literature, this is the first case description of these 2 primaries arising in the same individual.

Synchronous quadruple primary neoplasms: glioblastoma, neuroendocrine tumor, schwannoma and sessile serrated adenoma in a patient with history of prostate cancer.

Quadruple synchronous primary neoplasms are exceedingly rare with only one case reported in the English literature. We herein report a case of synchronous quadruple primary neoplasms in a 70-year-old Arabic male with a history of prostate cancer who presented to our hospital for work-up of a brain mass found at an outside hospital. Subsequent (18)Fluorodeoxyglucose (FDG) positron emission tomography demonstrated a 5.9-cm temporoparietal mass and three additional lesions, each with increased maximum standardized uptake value (SUV(max)). Histologic examination, immunohistochemistry and cytogenetic analyses of the lesional tissue revealed four primary neoplastic lesions: primary glioblastoma, inguinal schwannoma, well-differentiated neuroendocrine tumor of the terminal ileum and an appendiceal sessile serrated adenoma/polyp. This case is unique among previous reports as our patient presented with four primary neoplasms synchronously. To the best of our knowledge, this combination of synchronous multiple primary neoplasms has not been reported in the English literature.

A unique case of a patient with rectal cancer who developed benign esophageal stenosis after localized rectal radiation and systemic chemotherapy.

Acute esophagitis and esophageal strictures typically occur after local radiation therapy to the thoracic field. Toxicity is usually limited to the field of radiation and potentially augmented by concomitant use of chemotherapy, however esophageal stricturing due to chemotherapy alone is exceedingly rare. Gastrointestinal toxicity has been previously reported in the setting of 5-fluorouracil (5-FU)-based chemotherapy with abnormal thymidylate synthase or dihydropyrimidine dehydrogenase activities. We present a unique case of isolated chemotherapy-induced esophageal stricture in the setting of stage IIIa rectal adenocarcinoma which presented shortly after initiation of treatment with 5-FU-based chemotherapy in a patient with normal thymidylate synthase and dihydropyrimidine dehydrogenase assays. These findings prompt further investigation of pathways and potential risk factors leading to esophageal toxicity in patients treated with 5-FU-based chemotherapy.

Thrombotic thrombocytopenic purpura in a patient with interferon treated hepatitis C successfully treated with rituximab.

Thrombotic thrombocytopenic purpura (TTP) is a life threatening condition associated with formation of platelet thrombi. Deficiency of ADAM TS 13 with presence of inhibitory anti-ADAM TS 13 Immunoglobulin G antibody is seen in patients with acquired TTP. TTP in patients on interferon therapy for chronic hepatitis C has rarely been reported. Furthermore, successful treatment of an initial episode of acute refractory acquired TTP, in a patient of chronic hepatitis C during interferon therapy with Rituximab, has not been previously reported. Here we describe a case of acute refractory acquired TTP associated with pegylated interferon therapy for her chronic hepatitis C infection. Initially refractory to plasmapheresis and steroids, she was successfully treated with Rituximab and plasmaphersis without any evidence of reactivation of hepatitis.

Hepatocellular carcinoma presenting as an incidental isolated malignant portal vein thrombosis.

INTRODUCTION: Portal vein thrombosis is frequently associated with hepatocellular carcinoma (HCC). Tumor invasion into the portal vein by direct venous extension or metastasis occurs in up to 70% of HCC patients (Cedrone et al., Liver 16:94-8, 1996). However, presentation as an isolated malignant portal vein thrombosis without any evidence of obvious hepatoma-like lesions in the liver by imaging studies is extremely uncommon. We present an unusual case of HCC presenting as a malignant portal vein thrombus, proven on biopsy of the thrombus without any evidence of primary liver lesion. This, to our knowledge, is the first case of HCC presenting as an incidental isolated malignant portal vein thrombosis. The importance of doing delayed enhancement imaging studies to rule out malignant portal vein thrombosis is emphasized. CASE REPORT: A 60-year-old man presented with acute substernal chest pain. Physical examination revealed icterus. Examination of the abdomen did not reveal any organomegaly. Liver function test revealed a predominantly conjugated bilirubinemia. Abdominal sonogram revealed thrombosis and occlusion of the posterior right portal vein. Liver parenchyma was homogenous with no intrahepatic mass. Computed tomography (CT) of the abdomen and pelvis after administration of oral and intravenous contrast with delayed views revealed arterial enhancement of the right portal vein thrombus with delayed washout. MRI of the abdomen with gadolinium confirmed the right portal vein thrombus without focal hepatic mass. Aspiration of the right portal vein thrombus under CT guidance revealed hepatocellular carcinoma which was confirmed by immunohistochemistry. Serum alpha-fetoprotein level was very high. Patient was started on sorafenib with subsequent decrease in alpha-fetoprotein level. He was doing well till the date of this report. DISCUSSION: This unusual case of hepatocellular carcinoma presenting as an incidental malignant portal vein thrombosis without any primary liver lesion is extremely rare. Other reported cases of malignant portal vein thrombosis have been in patients with underlying hepatoma, cirrhosis, or with intrabiliary hepatocelluar carcinoma. In the clinical setting of portal vein thrombosis, imaging studies showing enhancement of the thrombus in the arterial phase are important in leading to the diagnosis of malignancy.

Small bowel adenocarcinoma presenting with refractory iron deficiency anemia - case report and review of literature.

Cancers of the small bowel are relatively rare and account for approximately 1-2% of all gastrointestinal neoplasms. The most common histologic subtype - adenocarcinoma - constitutes 40% of all cases. These cancers generally present with vague abdominal discomfort and are often diagnosed at a late stage and carry a poor prognosis. The treatment of choice of early-stage small bowel adenocarcinoma is surgical resection. No standard treatment protocol has been defined for unresectable or metastatic disease. Here, we report a case of a 56-year-old woman who presented with unexplained iron deficiency anemia. Extensive initial studies with serial CT scans of the abdomen, esophagogastroduodenoscopy, small bowel capsule endoscopy and colonoscopy were noncontributory. She was later found to have a metastatic small bowel adenocarcinoma and treated with palliative chemotherapy. She achieved a modest response to the treatment. Interestingly, in our case, the sole presentation was unexplained iron deficiency anemia. Physician's awareness regarding the possibility of small bowel cancer especially in the setting of iron deficiency and its workup has been emphasized. This enhances the chance of early detection and hence better survival.