A Rare Case of Abdominal Wall Skeletal Muscle Metastasis From Adenocarcinoma of the Pancreatic Head.

Pancreatic cancer can be aggressive and commonly metastasizes to various organs. Most commonly, pancreatic cancer metastasizes to the lung, liver, bones, and peritoneum, but very rarely does it spread to the abdominal wall or skeletal muscle. In this case, we discuss a patient who initially presented with weight loss and jaundice from a pancreatic head adenocarcinoma that later metastasized to the rectus abdominis muscle. A 63-year-old female presented with jaundice and weight loss. CT imaging revealed a 2.8 cm pancreatic head mass with pancreatic and biliary ductal dilation. Carbohydrate antigen 19-9 (CA 19-9) level was also found to be elevated to 1810 U/mL. An endoscopic ultrasound-guided biopsy was later performed and confirmed pancreatic adenocarcinoma. The patient underwent a Whipple pancreatoduodenectomy following initial treatment with neoadjuvant FOLFIRINOX chemotherapy. Following the Whipple procedure, she received adjuvant chemotherapy and subsequent imaging revealed no recurrence and decreased CA 19-9 level to 46 U/mL. Eight months afterward, the patient presented once again with lower abdominal pain. Repeat CA 19-9 level was found to have increased to 1503 U/mL. Repeat positron emission tomography scan imaging was performed and showed a 4.7 cm left rectus abdominis muscle mass. The mass was later biopsied, and pathology revealed recurrent, metastatic pancreatic adenocarcinoma. The patient was restarted on chemotherapy with paclitaxel and gemcitabine leading to a reduction in tumor size and CA 19-9 levels of 135 U/mL. However, surgical resection was later pursued due to increased tumor size only four months later. At this time, limited literature is available reporting the occurrence of pancreatic cancer metastasizing to the abdominal wall. Upon literature review, only five cases have been reported to date, and only two of the cases involved the skeletal muscle. Our rare case is the first-time documentation of rectus abdominis metastasis from pancreatic adenocarcinoma arising from the pancreatic head.

Esophageal Neuroendocrine Carcinoma Presenting After Definitive Chemoradiation of Squamous Cell Carcinoma in the Same Location.

Esophageal neuroendocrine carcinoma is very rare and highly aggressive. An 85-year-old man with a history of esophageal squamous cell carcinoma in remission presented 4 years after definitive chemoradiation with new-onset dysphagia. Endoscopy with biopsy revealed high-grade malignancy consistent with neuroendocrine carcinoma. Treatment options were limited to chemotherapy because of his metastatic disease, and he unfortunately died 14 months after diagnosis. The occurrence of esophageal neuroendocrine carcinoma in a site of prior squamous cell carcinoma is very uncommon, and this likely represents a case of radiation-induced malignancy. Therefore, when undergoing radiotherapy, patients and providers should discuss the possibility of this life-threatening complication.

A Rare Case of Synchronous Intraductal Papillary Mucinous Neoplasm-Associated Pancreatic Adenocarcinoma and Signet Ring Cell Gastric Adenocarcinoma.

BACKGROUND Synchronous malignancies are primary cancers that are diagnosed in a single individual within a 2-month period. Synchronous malignancies are uncommon, involving only 2.4-8% of all cancer cases, with a very low number of cases of simultaneous gastric and pancreatic cancer. Although cases of synchronous malignancies do exist, synchronous pancreatic adenocarcinoma and signet ring cell (SRC) gastric adenocarcinoma have not been documented. CASE REPORT A 76-year-old woman with a previously diagnosed intraductal papillary mucinous neoplasm (IPMN) presented with left-sided abdominal pain. Initial workup, including computed tomography imaging and endoscopic ultrasound with biopsy, led to the diagnosis of pancreatic adenocarcinoma. Within 1 month of diagnosis, the patient underwent an extended Whipple procedure and was also found to have a primary SRC gastric adenocarcinoma on evaluation of the gastric tissue margins that were removed during the procedure. The patient was initiated on chemoradiation therapy with 5-fluorouracil. However, following a subsequent decline in performance status and multiple hospitalizations, she could not tolerate further cancer treatment and died soon afterwards. CONCLUSIONS Few cases of synchronous malignancies involving the stomach and pancreas have been reported. Because gastric cancer could easily be missed on screening endoscopy; physicians must have a high index of suspicion. In those patients with a prior history of cancer, biopsies should be performed to aid in early diagnosis. To our knowledge, only metachronous cases of SRC gastric and pancreatic adenocarcinoma have been documented. Therefore, this report represents the first case of synchronous SRC gastric adenocarcinoma and IPMN-associated pancreatic adenocarcinoma in the literature.

Proton pump inhibitor therapy usage and associated hospitalization rates and critical care outcomes of COVID-19 patients.

Proton Pump Inhibitors (PPI) are one of the most prescribed medications in the United States. However, PPIs have been shown to increase the risk of enteric infections. Our study aims to evaluate the correlation between PPI and COVID-19 severity. We performed a retrospective cohort study on patients who tested positive for SARS-CoV-2 from March to August 2020. Patients were categorized based on PPI user status. Primary outcomes included need for hospital or ICU admission and 30-day mortality. Secondary outcomes looked to determine the severity of COVID-19 infection and effect of comorbid conditions. 2,594 patients were reviewed. The primary outcomes of our study found that neither active nor past PPI use was associated with increased hospital admission or 30-day mortality following completion of multivariate analysis. Additionally, there was no association between COVID-19 infection and the strength of PPI dosing (low, standard, high). However, the following covariates were independently and significantly associated with increased admission: age, male gender, diabetes, COPD, composite cardiovascular disease, kidney disease, and obesity. The following covariates were associated with increased mortality: age, male gender, COPD, and kidney disease. In conclusion, the high risk features and comorbidities of PPI users were found to have a stronger correlation to severe COVID-19 infection and poor outcomes as opposed to the use of PPI therapy.

Comparison of the impact of chronic corticosteroid therapy on critical care outcomes of COVID-19 patients with and without history of chronic liver disease.

There is a paucity of studies investigating the impact of chronic corticosteroid use for coexisting conditions in patients with Coronavirus Disease 2019 (COVID-19). Additionally, the information regarding the impact of chronic liver disease (CLD) on COVID-19 outcomes is evolving. Our study aims to investigate hospitalization outcomes of patients with COVID-19 on long term corticosteroids for coexisting conditions while also seeking to compare outcomes between such patients with a history of CLD to analyze the impact on mortality. We conducted a retrospective chart review across our 10-hospital network identifying patients on chronic corticosteroids (Prednisone ≥ 5 mg daily dose or equivalent dose of another steroid, for a duration of 30 days or more) who were hospitalized with COVID-19 from March 1, 2020 to June 30, 2020. Of these patients who met inclusion criteria, patients were then divided into groups based upon their history of CLD. Primary outcomes of the study looked to investigate the hospitalization outcomes of patients with a history of CLD and comorbid conditions requiring chronic corticosteroid use. Secondary outcomes sought to further investigate risk factors for mortality in our study sample. 837 charts were reviewed. 139 patients met inclusion criteria of which 34 patients had a history of CLD. Statistical analysis demonstrated no difference in length of hospital stay but increased ICU admission rate in the CLD group (41.2% vs 23.8%). No statistically significant difference was seen in between the CLD and non-CLD groups in term of complication rates and 28-day mortality. However, chronic corticosteroids patients were found to have higher rates of ICU admission and overall 28-day and ICU mortality in comparison to patients who were not on chronic corticosteroids prior to COVID-19 hospitalization. The larger contributor to COVID-19 severity was likely chronic corticosteroid use rather than CLD and thus chronic corticosteroid use should be limited throughout the COVID-19 pandemic especially in patients with additional speculated risk factors for COVID-19 such as CLD.

High-Dose Prednisone for Treatment of Autoimmune Pancreatitis in a Patient with Coronavirus Disease 2019 (COVID-19) due to Infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

BACKGROUND Autoimmune pancreatitis (AIP) is a rare, steroid-responsive disease of the pancreas. Concurrent treatment with immunosuppressants, including corticosteroids, increases the risk of developing a severe form of coronavirus disease 2019 (COVID-19) due to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The World Health Organization (WHO) advises against the use of corticosteroids in patients with SARS-CoV-2 due to their poor outcomes in patients with SARS-CoV and Middle East respiratory syndrome (MERS-CoV), unless these patients require steroid treatment for a coexisting disease. CASE REPORT A 53-year old patient was admitted with symptoms and diagnostic findings consistent with AIP. Thorough etiological workup revealed an elevated IgG4 level of 361 mg/dL and significant clinical response to corticosteroid treatment, leading to a diagnosis of AIP. After finishing steroid treatment at home, the patient was readmitted with another episode of AIP complicated by development of acute necrotic collection and COVID-19 while taking a second course of high dose prednisone. The patient was continued on high dose prednisone, started on azathioprine and intravenous meropenem, and underwent CT guided percutaneous drainage. He also received supportive care for COVID-19. After significant clinical improvement, the patient was discharged to quarantine at home, which he completed uneventfully. CONCLUSIONS Despite the use of corticosteroids due to AIP, this high risk patient recovered from COVID-19 without complications. These findings support the use of corticosteroids when necessary for treatment of coexisting conditions in COVID-19 patients.