Nishant Poddar

Hepatocellular Carcinoma Presenting as an Incidental Isolated Malignant Portal Vein Thrombosis

IntroductionPortal 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 ReportA 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.DiscussionThis 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.

Unusual Case of Squamous Cell Carcinoma of Pancreas with Review of Literature.

Primary squamous cell carcinoma (SCC) arising from the pancreas is a rare entity with an incidence of 0.5 to 4 % [1]. What makes this tumor so unique and rare is that squamous cells are absent in the normal pancreas [2]. Squamous cell carcinoma, also called epidermoid carcinoma, is often present in the tissue, such as the surface of the skin and the lining of the digestive and respiratory tracts. Since primary SCC of the pancreas is very rare, an extensive workup is necessary to exclude other primary metastatic sites. Currently, there are no standard treatments or guidelines due to the rarity of this disease. However, the treatments of such cases are extrapolated from data of squamous cell carcinomas of other sites and adenocarcinoma of the pancreas. This cancer has an aggressive course and has poor prognosis like adenocarcinoma of the pancreas.

Adenocarcinoma Ex Goblet Cell Carcinoid (GCC) of the Appendix: Report of Five Cases and Pitfalls in Diagnosis of GCC

Neoplasm of the appendix is relatively rare. Only 0.9-1.4% of all appendectomy specimens is found to have it. One in particular is the adenocarcinoma ex goblet cell carcinoid. The exact histopathogenesis and pathologic classification of this neoplasm are yet to be elucidated. Herein we report five cases to emphasize the importance of meticulous sampling and the possibility of misdiagnosis due to the presence of diverticulitis and acute appendicitis in some of these patients. All of our patients initially were presented with symptoms of or mimicking appendicitis, with radiology imaging suggestive of acute appendicitis or an appendiceal abscess. The pathologic examination of the appendectomy specimen revealed the incidental finding of the adenocarcinoma ex goblet cell carcinoid with focal positivity of synaptophysin and chromogranin. Two of our patients had diverticulitis and perforated appendicitis, which may lead to a misdiagnosis of the goblet cell carcinoid due to the absence of a discrete mass formation and focal localization of these tumor cells. Therefore, meticulous sampling is imperative in the diagnosis of this entity

Hepatocellular Carcinoma with Orbital Metastasis: a Unique Multidisciplinary Case Report

Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the second most common cause of cancerrelated mortality worldwide. Higher prevalence is seen in Asia and other developing countries [1]. Both the incidence and the mortality from this cancer are increasing in the USA [2]. Metastasis to the orbit is rare in hepatocellular carcinoma, with infrequent mention in the literature to date [3–5]. Approximately 50% of these unusual cases represent the initial diagnosis of metastatic disease. Treatment is challenging and generally requires a multimodal treatment plan to optimize both outcomes and quality of life. Our review of the literature notes radiation and systemic therapies to be the mainstay, but there is rare mention of more invasive treatments such as surgery and radioembolization, likely because such patients often have impaired functional status and are poor surgical candidates. Here, we report a case of orbital metastasis as the initial presentation of metastatic HCC in a 60-year-old male of Chinese descent with previously treated hepatitis C virus (HCV) infection, successfully treated with a multimodal approach including radioembolization, surgery with reconstruction, external beam radiotherapy, and systemic therapy, whose right orbit remains free of disease over 1 year after treatment initiation. Case Presentation

Perianal Basal Cell Carcinoma: a Case Report

Basal cell carcinoma (BCC) is the most commonly diagnosed skin cancer and highest incidence of any malignancy in theUSA [1]. It usually arises in the elderly on sun-exposed areas, such as the head and neck [2]. The most important etiologic factor for the development of BCC is ultraviolet light exposure; thus, it is very rare for BCC to arise within the anogenital region or other non-UV-exposed areas. Here, we describe a case of a 49-year-old patient with a perianal skin lesion that presented with painless bleeding. Immunohistochemical staining for Ber-EP4 and BCL2 was positive which demonstrated that the lesion was BCC and not a basaloid squamous cell carcinoma. There have only been a few previously published reports of perianal BCC. While very rare, it is important to highlight this case as it demonstrates the necessity to biopsy suspicious perianal lesions and how to distinguish between basaloid squamous cell carcinoma and BCC.

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

Abstract: 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.

Extrahepatic metastasis of hepatocellular carcinoma arising from a hepatic adenoma without concurrent intrahepatic recurrence

Hepatocellular carcinoma (hcc) arising from a hepatic adenoma is a rare phenomenon accounting for fewer than 5% of hcc cases; it seldom recurs after resection of the primary tumour. We report a case of extrahepatic metastasis of hcc arising from a hepatic adenoma that presented as a solitary sternal metastasis without any evidence of intrahepatic recurrence. Our patient was initially treated with radiation therapy and bland embolization, without response. Subsequently, the patient developed progressive disease while taking sorafenib. He later received chemotherapy with docetaxel and gemcitabine, with the development of multiple pulmonary and splenic nodules. However, he remained free of intrahepatic recurrence. To the best of our knowledge, this is the first case of extrahepatic metastasis of hcc arising from a hepatic adenoma without evidence of intrahepatic recurrence.

Impact of an inpatient palliative consultation in terminally ill cancer patients.

77 Background: Terminally ill cancer patients have complex medical and psychosocial needs at the end of life. Given these complexities, limited data is available to suggest the appropriate timing of palliative care involvement in the treatment of cancer. Our study aims to describe the referral patterns of inpatient palliative care consultations in advanced cancer patients in a tertiary care center. METHODS A retrospective review was performed. Inpatient palliative consultation was obtained in cancer patients from January 1, 2014 to December 31, 2014. Descriptive statistics are used in data analysis. RESULTS Inpatient palliative care consults (IPCC) were obtained for 245 cancer patients admitted to Saint Louis University Hospital. Of the 245, 130 were male (53.06%), 115 were female (46.93%), 128 were White (52.24%), and 114 were Black (46.53%). Newly diagnosed patients with cancer during the current admission were 79(32.24%). 57 (23.26%) patients were admitted to the Intensive care unit during hospitalization. A total of 39(15.91%) patients died in the hospital; among those who died in the hospital 34 had ICU stay during the hospitalization or died in the ICU (87%). Malignancies most common were lung 71(28.97%) followed by pancreatic-biliary 33(13.4%), lymphoma and leukemia 22(8.9%), hepatocellular carcinoma 18(7.34%), head and neck 16 (6.5%), and upper GI 16 (6.5%). Disposition at discharge included home hospice 67 (28.3%), hospice in facility 27(11%), home without hospice 71(28.9%), facility without hospice 39(15.9%). CONCLUSIONS According to the National Hospice and Palliative Care Organization as of 2013, 7.0% hospice patients die in acute care hospitals. Our data shows 15.9% who received IPCC died in the hospital with 87% dying in ICU. This is likely due to delays in the initiation of palliative care consultation as outpatient leading to increase strain on tertiary referral centers. In another study 22% of eligible Black patients received IPCC. Our rate of IPCC in Blacks was 46.5%. This highlights the disparity in access to outpatient palliative care in this population. Future efforts should be made to promote early outpatient palliative services to reduce ICU admissions, hospital re-admissions and healthcare costs.

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.