Synchronous Tumors: Adenocarcinoma of the Esophagus and Clear Cell Renal Carcinoma.

Synchronous cancers in patients with esophageal cancer are rare. We present a female nonsmoker with gastrointestinal symptoms that led to the diagnosis of HER-2/neu positive esophageal adenocarcinoma. During the staging workup, she was found to have a synchronous early-stage clear cell renal carcinoma. The patient underwent an esophagogastrectomy and radical nephrectomy and remains disease-free at a 12-month follow-up visit. We offer a detailed literature review on esophageal cancer and second primary malignancies seen in this context. Our case is unique as the literature suggests more advanced staging at diagnosis and poorer prognosis in persons with synchronous or metachronous cancers of esophagus and kidney. We believe that studies involving more patients are needed for the long-term prognosis assessment in these patients.

Skin necrosis: a rare complication of protein S deficiency.

Hereditary protein S deficiency is an autosomal dominant disorder leading to recurrent venous thrombosis and, less commonly, to arterial thrombosis. Cases of skin necrosis have been documented in patients with protein C or S deficiency while being treated with warfarin. We describe herein a patient with protein S deficiency who developed significant skin necrosis without being exposed to warfarin. She had a protracted clinical course resulting in gangrene and transmetatarsal amputation. Recognition of this rare complication and an earlyhematology referral may prevent dismal outcomes in patients with protein S deficiency.

Western variant of brain intravascular lymphoma displaying three distinct evolutive radiologic stages.

Intravascular lymphoma is a rare type of extranodal diffuse large B-cell lymphoma characterized by proliferation of clonal lymphocytes within small- and medium-sized blood vessels and a relative sparing of surrounding tissues. It commonly affects the central nervous system (CNS), but its atypical presentation often leads to a delayed diagnosis. We report a unique case of a 53-year-old man presenting with confusion and ataxic gait. The initial magnetic resonance imaging (MRI) of the brain showed multifocal plaque-like CNS lesions suggestive of multiple sclerosis. His condition worsened rapidly, accompanied by persistent low-grade fever and further alteration in mental status. Follow-up MRI studies suggested new parenchymal brain lesions consistent with multiple evolving embolic strokes and subsequently with brain infarcts. Biopsy showed intravascular lymphomatous brain involvement. His condition continued to deteriorate, resulting in multiorgan failure and demise. To the best of our knowledge, these clear-cut MRI stages of brain intravascular lymphoma have not been previously reported in the scientific literature. Our findings are important as the diagnosis intravascular lymphoma is commonly made postmortem, given its rapidly progressive course and lack of typical symptomatology.

An unusual presentation of a carcinoid tumor of the common bile duct.

CONTEXT: Carcinoid tumors arising from the bile ducts account for only a small fraction of biliary tract cancers. CASE REPORT: We report herein a 42-year-old man with a carcinoid tumor of the common bile duct. He presented with abdominal pain, bloating and dyspepsia. Clinicolaboratory and imaging studies suggested a probable obstructive common bile duct lesion. The patient underwent an endoscopic retrograde cholangiopancreatography with a stent placement in view of common bile duct decompression. Persistence of symptoms prompted a laparotomy and pancreaticoduodenectomy that revealed a well-differentiated carcinoid tumor originating in the common bile duct. CONCLUSION: Clinician's familiarity with the unusual sites of origin of neuroendocrine tumors and/or atypical presentation of such tumors may facilitate their early recognition and allow for a timely intervention.

A 64-year-old woman with a left upper-lung field lobulated mass.

Pulmonary mucinous cystic neoplasia (PMCN) is an uncommon primary lung malignancy. Approximately 80 cases have been reported in the literature. We describe a case and review the literature on this malignancy. Our patient was asymptomatic and presented with a left upper-lung field lobulated mass. Primary PMCN is a spectrum of mucinous cystic lesions that should be considered as a separate lung tumor entity due to its unique morphologic features and its distinct clinical behavior. Prognosis is generally better than other more common lung malignancies.

Chronic lymphocytic leukemia presenting with cholecystitis-like symptoms and gallbladder wall invasion.

Although infiltration of the gallbladder by lymphoma is rare, it has to be considered in the differential diagnosis of patients presenting with cholecystitis-like symptoms. The most common lymphomas masquerading as acute cholecystitis are mucosa-associated lymphoid tissue lymphoma and large B-cell lymphoma. We describe a 75-year-old patient who presented with an acute cholecystitis-like picture, featuring chronic lymphocytic leukemia (CLL) with gallbladder wall involvement as the initial disease presentation. The cholecystectomy specimen showed perineural invasion present within the gallbladder wall, which likely accounted for the patient's right upper quadrant abdominal tenderness. In this way, we would like to alert clinicians and pathologists alike to CLL as yet another cause of a cholecystitis-like symptomatology.

Squamous cell lung cancer presenting with pulmonary lymphangitic carcinomatosis.

Pulmonary lymphangitic carcinomatosis (PLC) refers to the infiltration of lung lymphatic channels with metastatic carcinoma and is associated with a dismal prognosis. PLC accompanies circa 7% of all pulmonary metastases and is most commonly caused by various metastatic adenocarcinomas. Only two cases of PLC due to squamous cell lung carcinoma have been reported to date in the English literature. We report herein a unique case of squamous cell lung carcinoma with lymphangitic spread, displaying bilateral and diffuse bronchial tree involvement that might have been a result of invasion from the pulmonary lymphatics into the bronchial lumen.

Breast Cancer Metastasis Masquerading as Primary Colon and Gastric Cancer: A Case Report.

BACKGROUND Breast cancer is the most common malignancy in women worldwide. Despite treatment, recurrence and metastasis are common. Lobular breast cancer most commonly metastasizes to the lungs, liver, lymph nodes, and sites in the brain. Metastasis to the gastrointestinal tract is rare, with few cases reported to date. CASE REPORT This report describes a patient with late colon and gastric metastases from lobular breast cancer mimicking primary colon and gastric cancers. CONCLUSIONS Immunohistochemical methods can help differentiate metastatic breast disease to the gastrointestinal tract from primary gastrointestinal malignancy.

Synchronous tumors: adenosquamous carcinoma of pancreas and GIST of stomach.

We report herein a unique case of an adenosquamous carcinoma (ASC) of the pancreas and a synchronous gastrointestinal stromal tumor (GIST) of stomach in a 75-year-old Caucasian male. He presented with painless jaundice and generalized pruritus and was found to have a pancreatic head mass. Whipple's procedure was performed and yielded the above diagnoses. Ductal pancreatic adenocarcinoma, not a much rarer and more aggressive ASC subtype, has previously been shown to co-exist with GIST in some surgical series. In addition, the incidentally discovered GIST in our patient involved the stomach and not the small intestine, which is the predominant GIST location when concurrently diagnosed with other GI tumors. At the time of this publication, our patient, who received adjuvant chemoradiotherapy, remains disease-free 14 months after the abdominal surgery.