Unexplained isolated acute severe thrombocytopenia after surgery for a recurrent malignant retroperitoneal tumor presenting with colon perforation: A case study of a disastrous complication.

INTRODUCTION: Tumor- or treatment- induced thrombocytopenia in solid cancer patients is common. In the postoperative setting, diagnosis of thrombocytopenia become more complex as infection, sepsis, drugs and transfusion come also into the equation. PRESENTATION OF CASE: Herein, the case an otherwise-healthy 71-year-old male patient with a sizable recurrent malignant retroperitoneal tumor under pazopanib admitted with colon perforation and submitted to emergency left colectomy with end transverse colostomy is presented. Immediate postoperative period characterized by massive primary tumor growth and isolated acute severe thrombocytopenia. The patient treated with combined prednisone, IVIg and platelets transfusion along with medication discontinuation with no response. DISCUSSION: Sepsis-, drug- and heparin-induced thrombocytopenia, disseminated intravascular coagulopathy and secondary (sepsis-, drug-, transfusion- or tumor-induced) immune thrombocytopenia (ITP) were included in the differential diagnosis. Based on exclusion, secondary drug- or tumor-induced ITP was the most prominent diagnosis. Concomitant presentation of thrombocytopenia along with massive primary tumor growth made Kasabach-Merritt syndrome also a probable diagnosis. However, neither secondary ITP nor Kasabach-Merritt syndrome has previously been associated with a retroperitoneal tumor in the literature. CONCLUSION: Although management of thrombocytopenia depends on etiology, in our patient's case the diagnosis of secondary ITP and directed management did not result in a successful outcome.

Extensive colonic pneumatosis in a patient on adjuvant chemotherapy after right colectomy for primary terminal ileum lymphoma: A decision-making process between surgical and non-surgical management.

INTRODUCTION: Pneumatosis intestinalis is a rare condition that may be idiopathic or a sign of numerous underlying gastrointestinal, pulmonary and systemic diseases. PRESENTATION OF CASE: Herein, the case an otherwise-healthy 82-year-old female patient with vague abdominal pain due to total colonic pneumatosis 20 days after completion of R-CHOP chemotherapy for a stage IIE primary non-Hodgkin's lymphoma of the terminal ileum submitted to right hemicolectomy and ileal resection 6 months previously is presented. As no evidence of intramural bowel gas was present on pre-operative CT, pneumatosis coli considered to be secondary. As no worrisome clinical, laboratory and imaging findings were present, pneumatosis coli seemed to be benign. As no other etiologic factors identified, pneumatosis coli considered to be chemotherapy-induced. The patient treated conservatively with cessation of enteral nutrition and broad spectrum antibiotics with uneventfull recovery. DISCUSSION: Pneumatosis intestinalis can be benign or life-threatening. Bowel obstruction, perforation, ischemia and severe colitis represent the most life-threatening causes. In clinical practice it is often challenging to distinguish between life-threatening and benign pneumatosis intestinalis, a decision which should be based on the presence or absence of worrisome clinical, laboratory and imaging findings. CONCLUSION: In analogous cases, the main dilemma for the physicians is to identify whether surgical intervention is required or not. Given the potential severity of pneumatosis intestinalis, early diagnosis and recognition of its severity is critical as it would dictate surgical or non-surgical management.

Obstructive jaundice as primary presentation of a stage IIE Non-Hodgkin lymphoma: A decision making process between advanced lymphoma and locally advanced/metastatic pancreatic adenocarcinoma.

INTRODUCTION: Secondary pancreatic tumors are uncommon and account for 2-5% of pancreatic cancer. Tumors characterized most commonly with pancreatic involvement are lymphoma, renal cell and lung carcinomas. PRESENTATION OF CASE: A 76-year-old female patient with obstructive jaundice as the primary symptom and inguinal lymphadenopathy is presented. Imaging revealed a bulky solitary solid pancreatic head mass along with paraaortic and mesenteric lymphadenopathy. The absence of a previous history of malignancy and the presence of a dominant pancreatic mass along with distal lymphadenopathy confined differential diagnosis to advanced secondary pancreatic lymphoma, which is the most common secondary pancreatic tumor, and locally advanced/metastatic pancreatic adenocarcinoma. Pathologic confirmation with excisional biopsy of an enlarged inguinal lymph node and EUS-FNB of the pancreatic head mass confirmed the diagnosis of secondary Non-Hodgkin pancreatic lymphoma allowing initiation of induction chemotherapy. DISCUSSION: Secondary pancreatic lymphoma can be seen up to 30% of patients with advanced lymphoma; although the head of the pancreas is the most common location, obstructive jaundice is not the predominant symptom as obstruction of the common bile duct is usually absent. In the setting of a solitary nodular type pancreatic mass, key imaging findings highly suggestive of secondary pancreatic lymphoma and not of adenocarcinoma are the absence of vascular invasion, bile and pancreatic duct obstruction, and the presence of lymphadenopathy below the level of the left renal vein. CONCLUSION: When a secondary pancreatic tumor is highly suspected pathologic confirmation is always needed before initiation of induction or palliative chemotherapy.

The isoattenuating pancreatic adenocarcinoma: Review of the literature and critical analysis.

Dynamic CT has a reported sensitivity of as high as 97% in the detection of pancreatic cancer. Consequently, a substantial number of pancreatic tumors can still escape detection. The isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on dynamic CT as its attenuation is indistinguishable from the attenuation of the pancreatic parenchyma. 88% and 100% of the isoattenuating adenocarcinomas <20 mm and >20 mm respectively are recognized only by the presence of secondary imaging findings highly suggestive of malignancy. Dynamic MRI can unmask 80% of the isoattenuating pancreatic adenocarcinomas. If MRI fails to unmask the mass, EUS-biopsy is not mandatory to be performed as biopsy proof is not required for solid pancreatic masses suspicious for malignancy before proceeding to surgery. The isoattenuating adenocarcinomas should not be regarded as early cancers as less than one-third of them are stage T1 tumors. After curative intent surgery, isoattenuating pancreatic adenocarcinoma patients have a significantly longer median survival than usual pancreatic adenocarcinoma patients associated with the higher rate of well differentiated tumors among isoattenuating tumors. The more favorable postsurgical survival of the isoattenuating pancreatic adenocarcinoma patients makes it even more imperative to correctly diagnose their cases at a resectable stage.

Connecting tube colonic erosion and gastrocolic fistula formation following late gastric band erosion.

Band erosion is a rare complication of laparoscopic adjustable gastric banding (LAGB) with a reported prevalence varying from 0.3% to 14%. Intraluminal colonic erosion of the connecting tube is very rare, as only isolated cases have been described. Consequently, simultaneous gastric band erosion and connecting tube colonic erosion is an extremely rare event. Herein, we present a case of a woman with morbid obesity, who submitted to LABG 4 years ago. The patient presented with symptoms and signs of right lower quadrant peritonitis. Computed tomography (CT) demonstrated migration of the band into the gastric lumen, inflammation around the intra-abdominal course of the connecting tube and an inflammatory mass surrounding the tube at the right lower quadrant. Laparotomy revealed the eroded band, the eroded transverse colon from the connecting tube, a gastrocolic fistula along the course of the tube and a right lower quadrant phlegmon. The connecting tube was mobilized from the surrounding adherent tissues, the gastric band removed, the stomach and colon walls closed, and the gastrocolic fistula excised. To our knowledge this is the second case of concurrent band erosion and connecting tube colonic erosion along with gastrocolic fistula formation in a patient with morbid obesity treated with LAGB.