Glucagonoma Syndrome: A Rare Paraneoplastic Disorder due to Neuroendocrine Tumor of the Pancreas.

Glucagonoma syndrome is an extremely rare paraneoplastic disorder. The key presenting feature is a rash (necrolytic migratory erythema) which can easily be misdiagnosed as a primary skin disorder. Moreover, 50 to 80 % of patients already have metastatic disease at diagnosis. We report a case of a 38-year female presenting with epigastric pain and a skin rash all over the body. Workup revealed a neuroendocrine tumor (NET) of the pancreas, for which she underwent resection, resulting in a complete cure. A follow-up MRI after 8 months showed a hyperintense and arterially enhancing nodular liver lesion which did not show any uptake on the octreotide scan. However, a subsequent biopsy revealed a recurrence of the tumor. This was a unique finding in our case where a highly sensitive octreotide scan failed to identify metastasis, emphasising the importance of biopsy in such cases. Key Words: Glucagonoma, Necrolytic migratory erythema, Alpha-cell adenom.

Gastric Lymphoma: Severe Gastric Outlet Obstruction Warranting Stent Placement.

Primary gastric lymphoma is an uncommon entity accounting for <5% of primary gastric neoplasms and 10-15% of all non-Hodgkin lymphomas. It may present with nonspecific symptoms or features of gastric outlet obstruction (GOO). GOO can develop prior to or during treatment due to disease or post-treatment scarring. The obstruction can be both intrinsic or extrinsic. Endoscopic balloon dilatation and surgical gastrojejunostomy have been tried with variable success. Gastroduodenal stenting with self-expanding metal stents (SEMS) has been used lately with excellent results but mainly in the palliative management of gastric carcinoma with GOO or in benign GOO. We present a case of gastric diffuse large B cell lymphoma on RCHOP chemotherapy who developed severe GOO leading to profound metabolic alkalosis and electrolyte imbalances, ultimately warranting an enteral stent. Key Words: Primary gastric lymphoma, Gastric outlet obstruction, Diffuse large B cell lymphoma, Enteral stent.

Control of Oesophageal Tumour-related Bleeding with a Fully Covered Self-expandable Metallic Stent (SEMS) Insertion.

The role of metallic stents in the management of refractory variceal bleeding is now well established however, they have been rarely used in the treatment of malignant gastrointestinal (GI) tract bleeding. To our knowledge, there are only three case reports in this regard, where fully covered self-expandable metallic stents (SEMS) were placed for the treatment of bleeding duodenal tumours. We have shared an experience of a novel and successful treatment of the oesophageal tumour-related bleeding with a fully covered SEMS. The 49-year male with oesophageal cancer presented with haematemesis and had received neo-adjuvant chemotherapy 3 weeks back. Upper GI endoscopy revealed an obstructing distal oesophageal tumour with the diffuse oozing of blood. While injection of adrenaline over a large ulcerated surface area was not possible, an attempt to treat it with hemospray was also unsuccessful. Thus, a temporary fully covered SEMS was inserted across the tumour to create a tamponade effect which resulted in the immediate cessation of the bleeding. This was endoscopically removed after a week and there was no further bleeding in one-month follow-up. Key Words: Upper gastrointestinal bleeding, Metallic stent, Oesophageal cancer.

A Case of Esophageal Squamous Papilloma: An Unusual Cause of Dysphagia and Hematemesis in a Patient with Concurrent Malignancies.

Introduction: The esophageal squamous papilloma (ESP) is a rare cause of dysphagia and hematemesis. The malignant potential of this lesion is uncertain; however, the malignant transformation and concurrent malignancies have been reported in the literature. Case Description: We report a case of esophageal squamous papilloma in a 43 years old female who had a background diagnosis of metastatic breast cancer and liposarcoma of the left knee. She presented with dysphagia. Upper gastrointestinal (GI) endoscopy showed a polypoid growth, and its biopsy confirmed the diagnosis. Meanwhile, she presented again with hematemesis. A repeat endoscopy showed that the previously seen lesion had likely broken off, leaving behind a residual stalk. This was snared and removed. The patient remained asymptomatic, and a follow-up upper GI endoscopy at six months did not show any recurrence. Practical Implications: To the best of our knowledge, this is the first case of ESP in a patient with two concurrent malignancies. Moreover, the diagnosis of ESP should also be considered when presenting with dysphagia or hematemesis.

A Rare Presentation of Dual Ovarian Pathologies: Small Cell Carcinoma of the Ovary and Mucinous Ovarian Cancer.

The small cell carcinoma of ovaries co-occurring with mucinous ovarian cancer is a rare event. We report a 21-years-old lady with a composite tumour comprising small cell carcinoma and mucinous carcinoma of ovaries. The incidental finding of the left ovarian cyst led to further workup and revealed a solid cystic mass in the left adnexal area pathologically proven to be mucinous ovarian carcinoma. The initial surgery was deferred upon the patient's request. After a few more cycles of chemotherapy, at the completion of surgery as per ovarian protocol, the pathological evaluation showed small cell carcinoma in the left ovary with a residual focus of mucinous carcinoma. In contrast, the right ovary also showed surface deposits of small cell carcinoma. The patient's clinical condition deteriorated very rapidly after that, and she passed away. Early recognition of small cell carcinoma in a composite tumour is critically essential for timely intervention.

An Unusual Occurrence of Uterine Metastases in a Case of Invasive Ductal Breast Carcinoma.

Breast cancer is the most frequent cancer in women and has a high proclivity for metastasizing, yet it seldom affects gynaecological organs. We present a case of invasive ductal carcinoma of the breast that metastasized to the uterus following initial curative treatment. Our patient was taking tamoxifen, which can induce endometrial hyperplasia and make diagnosis more complicated.

Skull Base Osteomyelitis: A Single-Center Experience.

Background Skull base osteomyelitis (SBO) is an uncommon entity and carries a high mortality rate. It can be be odontogenic, sinogenic, or otogenic in origin, in addition to being a complication of skull surgery/trauma. Pseudomonas is one of the most commonly identified pathogen. The goal of the study is to describe the clinical spectrum, microbiologic characteristics, treatment, and its response among different patients with SBO. In addition, we compared the outcomes of bacterial and fungal osteomyelitis. Methodology This is a single-center retrospective analysis of patients with SBO who presented to Shaukat Khanum Memorial Cancer Hospital & Research Centre Lahore, Pakistan between January 1998 and September 2019. A total of 15 patients with SBO were identified. Results SBO was common in males (79.9%) with a high body mass index. Diabetes mellitus was the most common co-morbid condition (46.62%). Bacterial etiology was seen in 46.62% and fungal isolate was detected in 6.66% of the patients; 26.64% were culture-negative and the remaining had a mixed culture. The mean duration of treatment was 17.58 ± 10.85 weeks. Overall, five (33.3%) patients were cured and did not have a recurrence of symptoms at six months, while three (19.98%) had a recurrence of symptoms at six months from the end of the treatment; six (39.96%) patients were lost to follow-up. Conclusions Patients with SBO can present with various conditions, and early identification of the condition and a positive culture growth can guide optimal treatment.

Achieving Complete Radiological and Bio-Chemical Response as a Predictor of Long-Term Survival in Stage IV Epithelial Ovarian Cancer.

Objective Epithelial ovarian cancer (EOC) is common among ovarian cancers. The majority of existing literature shows combined data of stage III and stage IV. Therefore, we aimed to look for whether achieving complete radiological and biochemical response after initial treatment of stage IV epithelial ovarian cancer as a predictor of long-term survival in the Pakistani population. Methods A cross-sectional study was conducted of patients with stage IV epithelial ovarian cancer diagnosed and treated from 2006-2013 at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Overall survival was defined as the number of months between patients' diagnosis at the hospital and any cause of death or last follow-up date. Kaplan Meier curve was used to report the overall survival. The log-rank test was used to distinguish the survival difference in complete and no complete response. P-value <0.05 was considered statistically significant. Result A total of fifty patients of stage IV epithelial ovarian carcinoma, with a mean age of 53 ± 2 received neoadjuvant chemotherapy and suitable patients underwent interval-debulking surgery. Among these fifty patients, twenty-one (42%) patients who achieved complete radiological and biochemical response had a median survival of greater than five years. Patients without co-morbidities (46%) and having good performance status (52%) showed better results of the treatment. Patients' tolerance to chemotherapy with good response and fit enough to undergo interval-debulking surgery, achieving complete radiological and biochemical response after initial induction therapy were significantly associated with long-term survival (P<0.05). Conclusion Outcomes of patients who present with stage IV EOC remains dismal. Patients who achieved complete radiological and biochemical response after neoadjuvant chemotherapy and interval-debulking surgery was significantly associated with long-term survival.