Cholecystectomy clip-induced biliary stone: Case report and literature review.

ABSTRACT: Migration of cholecystectomy surgical clip into the common bile duct with subsequent stone formation is a rare phenomenon, one which may lead to complications including obstruction, pain, nausea, vomiting and fever. The mechanism of migration is largely unknown but may result from a combination of factors including necrosis, intra-abdominal pressure or poor surgical technique with migrated clip serving as a nidus for stone formation. We present a 55-year-old woman with clip-induced stone impacted at the distal common bile duct 12 years post-cholecystectomy and a review of the literature related to cholecystectomy clip stone formation. In addition, we reviewed relevant English language case reports and literature reviews by searching PubMed using search terms 'stone', 'clip', 'cholecystectomy' and 'biliary'. There was no limit to the date of publication. Our study found 68 unduplicated cases of clip-induced stones which had a wide range of onset and presenting systems. Further research is needed to identify risk factors, methods of prevention and benefits of early detection screening.

Association of Programmed Cell Death 1 Inhibitor with Circumorificial Plasmacytosis.

Introduction: The development of immune checkpoint inhibitors is considered one of the most important advances in cancer treatment. Pembrolizumab is an immune checkpoint inhibitor against programmed death-1 (PD-1) receptors that has demonstrated antineoplastic activity against various malignancies, including non-small cell lung cancer, melanoma, and triple-negative breast cancer. Pembrolizumab is associated with numerous adverse reactions including mucosal and cutaneous reactions referred to as immune-related adverse events. These events can impact patient quality of life and lead to dose reduction or discontinuation of the medication. A comprehensive understanding of pembrolizumab's toxicities is crucial for the initiation of treatment. Case Presentation: We present the case of a 27-year-old man with stage IVB thymic carcinoma with a bulky anterior mediastinal mass, bilateral jugular, bilateral peritracheal, and bilateral cardiophrenic lymphadenopathies, and a small pericardial effusion. He received pembrolizumab IV every 3 weeks for 53 cycles over 39 months. The patient developed bleeding oral lesions approximately 38 months after treatment with pembrolizumab. Conclusion: The patient's pembrolizumab treatment was not interrupted and the perioral rash ultimately improved after treatment with steroids.

Modified Docetaxel, Cisplatin, and Fluorouracil (mDCF) as a Neoadjuvant Chemotherapy for Non-metastatic Esophageal Cancer (nMEC).

Objective: Perioperative chemotherapy can potentially downstage esophageal cancer, reducing the risk of early systemic dissemination. One recommended neoadjuvant regimen for managing gastroesophageal junction and esophageal cancer is docetaxel, cisplatin, and 5-fluorouracil (DCF). To address the high toxicity profile of DCF, modifications in dosages and treatment intervals have been studied. We integrated a modified DCF regimen (mDCF) into a multimodal treatment approach for non-metastatic esophageal cancer (nMEC). Retrospectively, we sought to describe our community experience of administrating neoadjuvant mDCF to patients with nMEC.Design: Patients diagnosed with nMEC between August 2008 and November 2017 and prescribed mDCF were identified for retrospective review. Outcomes of interest included disease-free survival (DFS), overall survival (OS), and hematologic toxicities. Analyses were performed using SAS 9.4.Results: Thirty patients met inclusion criteria with a median age of 64.9 years; 90% were male. The 2-year and 5-year DFS was 60.8% and 41.7%, respectively, for adenocarcinoma and 71.4% and 71.4% for squamous cell carcinoma (SCC). The 2-year and 5-year OS was 64.9% and 44.5%, respectively, for adenocarcinoma and 71.4% and 71.4% for SCC. Both DFS and OS decreased with increasing disease stage, histology (adenocarcinoma versus squamous), esophageal compared to esophagogastric-junction involvement, and without surgical intervention. Frequent toxicity grades for leukopenia and thrombocytopenia were Grades I and II.Conclusion: Using an mDCF regimen in combination with chemoradiation +/- surgical resection in a community setting appears to have an acceptable toxicity profile as well as DFS and OS outcomes compared to chemotherapeutic regimens reported in other similar studies.

Cinacalcet for the Treatment of Humoral Hypercalcemia of Malignancy: An Introductory Case Report with a Pathophysiologic and Therapeutic Review.

Hypercalcemia is an ominous development in the course of malignancy associated with a mean survival of only several months. A majority of cases of hypercalcemia are related to humoral hypercalcemia of malignancy (HHM), where hypercalcemia is caused by increased levels of circulating parathyroid hormone-related protein (PTHrP). Mainstay treatments in the management of HHM are intravenous fluids, intravenous bisphosphonates, and subcutaneous denosumab, although hypercalcemia oftentimes recurs despite these efforts. We present a case of advanced non-small cell lung cancer with PTHrP-mediated hypercalcemia that proved resistant to standard therapy. A trial of oral cinacalcet was initiated and improved calcium levels for 2 months despite a progressive rise in PTHrP and prior to subsequent disease progression. Based on the current body of literature, we propose that this calcium-lowering effect of cinacalcet occurs due to a potential effect on renal calcium excretion.

Gangliocytic paraganglioma, a rare ampullary tumour treated with open transduodenal resection and sphincteroplasty.

Gangliocytic paragangliomas are rare neuroendocrine tumours residing in the gastrointestinal tract, most commonly the periampullary region. Most are benign tumours with a low malignancy rate. We report a 50-year-old man who presented with acute onset of left-upper quadrant abdominal pain with radiation to the back. An intraluminal mass at the junction of the duodenum with normal pancreatic/hepatic parenchyma was discovered on abdominal CT. Following upper endoscopy and MRI revealing a periampullary lesion, fine-needle aspiration and biopsies were. Immunohistochemistry was positive for synaptophysin and S100HU, consistent with gangliocytic paraganglioma. The benign nature of this tumour and unique anatomy of a separate opening of the pancreatic and common bile ducts led to transduodenal excision with sphincteroplasty, thereby avoiding extensive surgery. Surveillance CT every 6 months and upper endoscopy initially every 6 months (now yearly) revealed no evidence of endoscopic or histological recurrence at 3 years follow-up.

Oesophageal papillomatosis, not amenable to endoscopic therapies, treated with oesophagectomy.

Oesophageal papillomatosis is a very rare entity, with only 10 cases (including ours) reported in the literature. We report a 51-year-old man with a 25-year history of dysphagia with solids and liquids who failed a trial of proton pump inhibitors and fluticasone. His initial endoscopy revealed a viliform mass with dense eosinophilic infiltrate without neoplasia. Endoscopic ultrasound examination revealed a 4×1.6×0.7 cm mucosal hemicircumferential lesion without regional adenopathy. Pathological findings from the oesophagectomy specimen confirmed oesophageal papillomatosis with no malignancy. Surveillance endoscopy 4 months later revealed the lesion had increased in size. Additional ablative therapies failed, and the patient underwent oesophagectomy. Surveillance CT of the chest and abdomen at 3 months and oesophagogastroduodenoscopy at 6 months were negative. This case illustrates that oesophageal squamous papillomatosis not amenable to medical therapy requires surgical treatment.

Adenomyomatous hyperplasia of the ampulla of Vater presenting as acute pancreatitis.

We report an interesting and rare case of a man with adenomyomatous hyperplasia of the ampulla of Vater presenting as acute pancreatitis, which to our knowledge, is only the second reported case in the English literature. The patient presented with an acute onset of abdominal pain, nausea and vomiting, without fever, chills or rigours. CT of the abdomen revealed changes of acute pancreatitis with a peripancreatic adenopathy, and abdominal ultrasound revealed a slightly hyperechoic and oedematous head of the pancreas, consistent with acute pancreatitis. Endoscopic retrograde cholangiopancreaticography revealed an ampullary lesion. Pathology of the ampullary lesion revealed an inflammatory polyp. Endoscopic ultrasound with endoscopic mucosal resection of the lesion revealed an adenomyomatous hyperplasia. The patient recovered well postendoscopic resection without recurrent pancreatitis or cholestasis.

Peripancreatic cystic lymphangioma diagnosed by endoscopic ultrasound/fine-needle aspiration: a rare mesenchymal tumour.

A 73-year-old man presented with a 5-month history of intermittent nausea, vomiting, central abdominal discomfort and a 17-pound weight loss over the past year. Laboratory testing, including a complete blood count with differential, liver function testing, amylase and lipase studies were normal. A CT scan showed a bilobed cystic lesion inferior to the body of the pancreas. An endoscopic ultrasound revealed a 5.3×3.9 cm, anechoic, bilobed cystic lesion, extrinsic to the body of the pancreas with a 1-2 mm septation and a normal pancreas. Fine-needle aspiration revealed a milky-white aspirate with negative cytology. Laboratory assessment of the cystic aspirant revealed carcinoembryonic antigen 1.7 ng/mL, amylase 148 units/L, cholesterol 300 mg/dL, and carbohydrate antigen 19-9 3 units/mL. He underwent resection of the mass, with the histopathology confirming a diagnosis of peripancreatic lymphangioma. He did well after the surgery with interval resolution of his symptoms.

Anthracosis and large mediastinal mass in a patient with healed pulmonary tuberculosis.

A Mexican woman, aged 71 years, with life-long exposure to soot from a wood cook stove in a closed environment, who was treated for tuberculosis 4-years prior, presented with prominent mediastinal lymphadenopathy with anthracosis. Mediastinal lymphadenopathy is a common presentation of diverse granulomatous, malignant and infectious conditions like tuberculosis. Anthracotic pigment is found in different conditions such as tuberculosis or domestically acquired particulate lung disease. Accurate assessment of chronology and causative factors presents a challenge. Recognizing that pneumoconiosis can mimic or coexist with other granulomatous, infectious and malignant conditions presenting as mediastinal lymphadenopathy is important. Misdiagnosis may result in under- or over-treatment of potentially curable conditions such as tuberculosis, under-treatment of a lethal condition such as melanoma, or exposure of patients to inappropriate administration of costly therapy with potential untoward effects.