First Sign Of Malignancy Research Articles

Extrauterine Malignancies Detected on Papanicolaou Smear: the clinical and cytomorphological features of eight patients

Abstract
 Background: Papanicolau smear (Pap) is an effective technique for the diagnosis of cervix cancer. Atypical glandular cells may be revealed in this examination and occasionally may be the first sign of extratuerine malignancy. The 8 cases presented in this study are uncommon cases of previously unknown extrauterine tumors all detected on classical Pap smears.
 Patients and Method: A retrospective analysis of the clinical database identified eight women with previously undiagnosed extrauterine tumor detected on standard Pap smear. Clinical data were obtained from patient files and microscopic examination was repeated on the material obtained from the cytology archives. Cellblock and cytomorphology examinations were made, and clinical data were reviewed together with histopathology. 
 Results: Pap smear was the first sign of malignancy in all cases. The patients were asymptomatic or had non-specific symptoms. Definitive diagnosis was made after adequate radiological work up and biopsy. All eight cases had similar cytomorphological features of a histologically proven primary tumor. Atypical glandular cell groups were the most remarkable sign in six patients. In the other two patients, cells of lymphatic origin and atypical lymphocytes were detected. Cellblock with immunohistochemistry confirmed the diagnosis in three cases. 
 Conclusion: Pap smear is a worldwide accepted method for cancer screening. Although it has high specificity and sensitivity for cervical cancers, the results of this study highlight that rigorous examination of Pap

Evaluation of thromboembolic event, basic coagulation parameters, and associated factors in patients with colorectal cancer: a multicenter study.

Patients with colorectal cancer are at an increased risk of hemostatic disturbances, and recent studies have shown that coagulation disorders could be the first sign of malignancy. Although coagulopathy is a significant cause of cancer-related death and disability, it is usually underestimated, and there has been no recent scientific evidence regarding the exact burden and its specific determinants. Moreover, the public health importance of the risk of coagulopathy among patients with colorectal polyps has not been addressed. An institution-based comparative cross-sectional study was conducted on a total of 500 study participants (250 colorectal cancer patients, 150 colorectal polyp patients, and 100 controls) from January to December 2022. Venous blood was collected for basic coagulation and platelet analysis. Descriptive statistics and non-parametric tests (Kruskal-Wallis and Dunn-Bonferroni pairwise comparisons) were used to compare study parameters among the groups. The test results were expressed as medians and interquartile ranges. Binary logistic regressions were fitted, and statistical significance was declared at a p-value of less than 0.05, with 95% CI. The prevalence of coagulopathy among colorectal cancer patients was 198 (79.2%; 95% CI: 73.86, 83.64), while the prevalence was 76 (50.7%; 95% CI: 45.66, 54.34) among colorectal polyp patients. From the final model, age between 61 and 70 (AOR = 3.13: 95% CI: 1.03, 6.94), age > 70 years (AOR = 2.73: 95% CI: 1.08, 4.71), hypertension (AOR = 6.8: 95% CI: 1.07, 14.1), larger tumor size (AOR = 3.31: 95% CI: 1.11, 6.74), metastatic cancer (AOR = 5.8: 95% CI: 1.1, 14.7), and BMI ≥30 kg/m2 (AOR = 3.8: 95% CI: 2.3, 4.8) were positively associated with coagulopathy. This study showed that coagulopathy is a major public health concern among patients with colorectal cancer. Therefore, existing oncology care efforts should be strengthened to prevent coagulopathy among patients with colorectal cancer. Moreover, patients with colorectal polyps should receive more attention.

Venous thromboembolism as the first sign of malignancy

BackgroundVenous thromboembolism (VTE) is commonly associated with hypercoagulability in patients with cancer; however, there have been few investigations of VTE as the first sign of malignancy and even fewer performed in the United States. The aim of our study was to evaluate the incidence and predictors of unrecognized malignancy in patients presenting with VTE. MethodsWe performed a 1-year retrospective analysis of the Nationwide Readmission Database, including patients aged 18 years or older, presenting with a primary diagnosis of deep vein thrombosis (DVT) or a pulmonary embolism (PE). Patients known to have preexisting malignant diseases were excluded. Outcomes included the rate of newly diagnosed malignancy within 6 months from the discovery of VTE and demographic or associated illness predictors for the diagnosis of malignancy. A regression analysis was performed, based on which a VTE malignancy score was developed. ResultsA total of 116,048 patients were identified with VTE (49.8% DVT, 41.7% PE, 8.6% DVT and PE), 16% (n = 18,294) with malignancy. Of the remaining 97,754 patients, 31% were readmitted within 6 months. The incidence of newly diagnosed malignancy within 6 months was 2.4% (n = 2354). The most common malignancies were gastrointestinal in origin (29.2%). Demographic and diagnostic predictors for malignancy included age 65 years or older, female sex, inferior vena cava (IVC) thrombus, upper extremity thrombus, and a Charlson Comorbidity Index score of 5 or more. Receiver operating characteristic curve analysis found a cutoff VTE Malignancy score of 3 (sensitivity, 86%; specificity, 89%) to be predictive of an increased risk of a newly discovered malignancy within 6 months. ConclusionsVTE can be a risk indicator of underlying malignancy. Validation of a patient risk stratification score using multiple demographic or comorbid predictors for VTE on index admission may offer an opportunity for earlier diagnosis of occult malignancy.

The Burden of Metastatic Lymphadenopathy in Jammu Region - An Observational Study

Background: Lymphadenopathy may be the first sign of malignancy and use of FNA in the diagnosis of metastatic disease is well established. In patients with enlarged lymph nodes and previously documented malignancy, FNAC can obviate further surgery performed merely to confirm the presence of metastasis. Aim: The objective was to study the relative frequency of various metastatic lymph node lesions in hospital based population in Jammu region. Material and Methods: In this study, we analysed the clinicopathological features of metastatic lymphadenopathy, diagnosed on FNAC in the Jammu region of Jammu and Kashmir Union Territory of India over a period of three years. Interpretation and Results: A total of 190 lymph nodes were labelled as metastatic on FNAC. The age of the patients ranged from 12 to 95 years, with maximum number of cases in 51-60 years age group. Male predominance was seen with a male: female ratio of 2.3:1.The cervical lymph nodes were involved most commonly (48.42%). The most common metastatic malignancy reported was squamous cell carcinoma (115 cases, 60.50%) with oral cavity being the most common primary site of malignancy. Conclusion: In the present study FNAC proved to be a useful diagnostic modality in the diagnosis of metastatic malignancies due to its rapidity of diagnosis, ease of performance and minimal complications. Keywords: Fine needle aspiration cytology, FNAC, Jammu, Lymphadenopathy, Metastatic.

CMET-10. INTRACRANIAL SOLITARY PITUITARY METASTASIS: THE IMPLICATIONS FROM FIVE CASES

Abstract BACKGROUND Pituitary gland metastasis is a rare disease which represents only 1% of pituitary gland lesions. Intracranial solitary pituitary metastasis tends to be misdiagnosed as pituitary adenoma, resulting in a delayed anti-tumor treatment. METHODS Five cases of patients with pituitary gland metastasis recorded between 2014 and 2018 in our hospital were investigated with reference to patient demographics, symptoms at presentation, radiological and histological findings, management and outcomes. RESULTS Five patients (4 male and 1 female) were included and the median age was 48 years (range: 21 to 66). In those five cases, central nervous system related symptoms were the first sign of malignancy, including visual loss (5 in 5 patients), visual field defects (5 in 5 patients), apituitarism (5 in 5 patients), headache (4 in 5 patients), hypothroidism (4 in 5 patients) and diabetes insipidus (2 in 5 patients). All patients received total or partial hypophysectomy and pathologically revealed metastatic adenocarcinoma in 4 patients and metastatic squamous carcinoma in 1 patient. Further examinations by Computed Tomography (CT) or Positron Emission Computed Tomography (PET) indicated lung as primary site in five cases. EGFR mutation and ROS1 fusion were found in 3 and 1 adenocarcinoma patient, respectively, through gene detection of tissue. Postoperative radiotherapy (5 patients), target therapy (4 patients) and chemotherapy (1 patient) were given as subsequent treatment. During the follow-up, four patients died and the overall survival was 2, 8, 28 and 30 months, respectively. CONCLUSION We found that pituitary symptoms usually presented as the first sign of malignancy in intracranial solitary pituitary metastasis. Lung is the most frequently primary site, particularly in adenocarcinoma with driver gene mutation. Patients may benefit from multidiscipline treatment, including resection of pituitary metastasis combined with radiotherapy and targeted therapy.

Numb chin syndrome- The first finding in metastatic malignancy

Numb chin syndrome (NCS) is a sensory neuropathy of the mental nerve, which is accompanied by hypoesthesia and paresthesia of the jaw and lower lip. Although being well known in neurology practice, most of the physicians who have not experienced this phenomenon are unaware of this phenomenon since it is rare and can be confused with somatic complaints. This case report aims to point out that NCS may be the first sign and symptom of metastatic cancers in patients who are not diagnosed. We report a 52-year-old man who presented to our outpatient clinic with numbness on his right jaw for 1 month. He had a history of renal transplantation and used immunosuppressive therapy. He was diagnosed as metastatic lung cancer when he was investigating the etiology and died within a month. Patients presenting with numb chin syndrome are diagnosed late because of being rare. 75% of the patients presenting with this complaint are due to malignant metastasis and maybe the first sign of malignancy in a significant rate of them, as presented here. Many malignant and metastatic neoplasms may cause this neuropathy. In most cases, life expectancy is short and is considered as a sign of poor prognosis. Numb chin syndrome is a lesser known symptom of mental nerve neuropathy. In case dental and jaw-related pathologies cannot be detected, it should be kept in mind that this may be the first sign of malignancy and all detailed investigations should be planned for this purpose.

Twelve cases of pituitary metastasis: a case series and review of the literature.

The pituitary gland is an unusual site for metastatic spread, but as patients with metastatic malignancy are living longer, it may become more prevalent. Compression of important anatomy adjacent to the sella may produce disabling symptoms and endocrine derangement, leading to significant morbidity. An ambispective review of patient records between 2013 and 2017 from three neurosurgical centres was performed. After identifying cases, further investigation was performed to evaluate patient demographic, symptoms at presentation, radiological and histological findings, management, and outcome. Our investigation identified 12 patients with pituitary metastasis. The average age of the cases was 63.4years, with breast (n = 4) and lung (n = 4) being the most common primary cancers. In half the cases there was a history of metastatic disease, while in one-quarter of cases, pituitary symptoms were the first sign of malignancy. Adenohypophyseal dysfunction (83%), diabetes insipidus (DI) (75%), headache (67%) and visual field defects (67%) were the most common findings at presentation. Glucocorticoid replacement increased the sensitivity for diagnosis of DI. All cases were contrast enhancing on MRI and the endoscopic trans-sphenoidal approach was preferred for biopsy and debulking. The pituitary should not be overlooked as a site of metastasis and sellar symptoms may be the first presentation of neoplastic disease. Any biochemical or clinical sign of pituitary pathology in a patient with known cancer should raise suspicion for sellar metastasis. Moreover, the development of DI or ophthalmoplegia from any pituitary lesion is suggestive of metastatic disease even in patients with no known primary.

Paraneoplastic Cushing Syndrome: A Sign of Occult Malignancy

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Cushing Syndrome (CS) results from prolonged hypercortisolism. While often caused by iatrogenic administration of exogenous steroids or Cushing Disease, CS is also rarely caused by secretion of ACTH from ectopic sources, such as malignancies. Though rare - with ectopic ACTH secretion (EAS) accounting for only >15% of endogenous CS cases - diagnosis of CS can lead to earlier discovery of occult malignancy and increase potential for successful treatment. Clinicians therefore need a high degree of suspicion when faced with such presentations. CASE PRESENTATION: 57-yo man with CKD, CAD, HTN, DM and a long smoking history was admitted with respiratory failure due to CAP with dyspnea, weight gain, abdominal distention, and extremity weakness x 1 month. Physical exam showed reduced breath sounds over his right lower lung fields and abdominal obesity, but no Cushingoid appearance. He had marked refractory HTN. Labs showed profound hypokalemia with metabolic alkalosis, hypoxemia, hypercapnia and leukocytosis. CXR showed a right pleural effusion and basilar infiltrate. Elevated serum cortisol and ACTH levels helped diagnose CS. Abdominal CT showed no adrenal mass. Lab tests ruled out pheochromocytoma. A negative dexamethasone suppression test led to suspicion for EAS. CT Chest showed a mass with RML bronchial obstruction, mediastinal LAD and bilateral noncalcified lung nodules concerning for metastatic disease. While pleural fluid analysis showed a transudative effusion and microbiology was negative, cytology showed atypical cells suspicious for malignancy. Biopsy of the RML mass allowed for a unifying diagnosis of small cell carcinoma (SCLC) as the cause of the paraneoplastic CS. Chemotherapy was promptly started. DISCUSSION: Current standard practice for CS diagnostic work-up includes 8 mg dexamethasone suppression and CRH stimulation tests, inferior petrosal sinus sampling (IPPS), and imaging including CT, MRI, octreotide scans and venous sampling. In cases of EAS, the majority did not respond to CRH stimulation or dexamethasone suppression. IPPS was found most likely to identify the disease. Hypercortisol control treatments range from medications such as ketoconazole, metyrapone, or etomidate to surgical bilateral adrenalectomy. The highest rate of cure, up to 65%, came with the surgical removal of the ectopic ACTH-secreting neoplasm though recurrence was a possible complication. While cure in nonsurgical candidates is relatively rare, survival was common except in those cases of paraneoplastic CS caused by aggressive diseases. CONCLUSIONS: Though rare and difficult to recognize, Paraneoplastic CS may be the first sign of malignancy. While the source of EAS may be benign, it can be seen with SCLC, gastrinoma, medullary thyroid cancer and other such aggressive malignancies. Early identification may be lifesaving. Reference #1: Bertherat J. Cushing syndrome due to ectopic ACTH secretion. Orpha Net. 2012; ORPHA:99889 DISCLOSURE: The following authors have nothing to disclose: Vandana Pai, Kim Phung Nguyen, Jennifer Treece, Badar Siddiqui, Lisa McKinney-Smith No Product/Research Disclosure Information

Metastatic spinal cord compression as the first sign of malignancy

Background and purpose — Metastatic spinal cord compression (MSCC) as the initial manifestation of malignancy (IMM) limits the time for diagnostic workup; most often, treatment is required before the final primary tumor diagnosis. We evaluated neurological outcome, complications, survival, and the manner of diagnosing the primary tumor in patients who were operated for MSCC as the IMM.Patients and methods — Records of 69 consecutive patients (51 men) who underwent surgery for MSCC as the IMM were reviewed. The patients had no history of cancer when they presented with pain (n = 2) and/or neurological symptoms (n = 67).Results — The primary tumor was identified in 59 patients. In 10 patients, no specific diagnosis could be established, and they were therefore defined as having cancer of unknown primary tumor (CUP). At the end of the study, 16 patients were still alive (median follow-up 2.5 years). The overall survival time was 20 months. Patients with CUP had the shortest survival (3.5 months) whereas patients with prostate cancer (6 years) and myeloma (5 years) had the longest survival. 20 of the 39 patients who were non-ambulatory preoperatively regained walking ability, and 29 of the 30 ambulatory patients preoperatively retained their walking ability 1 month postoperatively. 15 of the 69 patients suffered from a total of 20 complications within 1 month postoperatively.Interpretation — Postoperative survival with MSCC as the IMM depends on the type of primary tumor. Surgery in these patients maintains and improves ambulatory function.

Cutaneous metastasis to the scalp as the primary presentation of colorectal adenocarcinoma

Eruptaneous metastasis is an uncommon presentation of colorectal adenocarcinoma that can occur years after diagnosis of the primary cancer or manifest as the first sign of malignancy. It is essential to diagnose these metastases immediately, as this late-stage development carries a poor prognosis. The scalp is one of the less common sites for skin metastases and nodules may be mistaken for benign entities. In this case report, we report on the case of a 61-year-old woman with CREST syndrome who presented with a cutaneous metastasis to the scalp as the first sign ofcolorectal adenocarcinoma.

How not to miss metastatic spinal cord compression.

The National Institute for Health and Care Excellence (NICE) estimates that each year in the UK around 2.5 million people will approach their GP with back pain. Fortunately most cases are due to non-specific causes and are often self-limiting. Metastatic spinal cord compression (MSCC) is one of the ominous causes of back pain where there is a compression of the thecal sac and its components by tumour mass. This is a true spinal emergency, and if the pressure on the spinal cord is not relieved quickly, it may result in irreversible loss of neurologic function. The most important prognostic factor for functional outcome is neurologic function before treatment.1 Hence, any delay could result in poorer functional outcome and decreased quality of life, with increased dependence on healthcare resources. There is a need for improving awareness among all clinicians so as to make prompt diagnosis and referral of MSCC a reality.2 Bone is the third most common site of metastases after the liver and the lung. MSCC is seen in up to 5% of cancer patients; however, in up to 20% of MSCC cases, cord compression may be the first sign of malignancy.3 Although the exact incidence of MSCC is not known, intelligent estimates put the number at about approximately 4000 cases in England and Wales.4 The most common primary tumours that metastasize to the spine are breast, lung, prostate, and kidney tumours. Tumours may spread to the …

Metástasis cutáneas de tumores sólidos. Estudio descriptivo retrospectivo

IntroductionCutaneous metastases are a rare event compared with other metastases. Their incidence is estimated between 0.7% and 9% of patients with cancer. Their presence always indicates a disseminated malignant disease and could also be the first manifestation of a tumor, appearing simultaneously or after a diagnosis of cancer. ObjectivesTo describe the epidemiological and clinical characteristics of cutaneous metastases in our hospital. Material and methodWe performed an observational retrospective study. We included all patients with cutaneous metastases diagnosed in the Dermatology Service of our hospital during a 7-year period. Patients with metastases from sarcomas, melanomas and hematologic malignances were excluded. ResultsWe studied 102 patients with cutaneous metastases. The primary tumor was identified in 87 patients (85%). The most frequent tumors were breast cancer in women (48%) and lung cancer in men (11%). Cutaneous metastases were the first sign of malignancy in 12 patients (11%). The predominant clinical form was the nodular form. The most common localization of the metastases was the thoracic region. The most common histologic diagnosis was adenocarcinoma. The mean survival after the development of metastases was 22.1 months. ConclusionThere is an association between the frequency of cutaneous metastases and the most frequent malignancies in each sex.Our results were similar to those of other studies regarding age, sex distribution, the predominant clinical form, location, and histological diagnosis of cutaneous metastases.

Advances on mechanisms of coagulation with non-small cell lung cancer

近来研究越来越多地发现凝血功能紊乱通常是恶性肿瘤的首发迹象。现在已经证实，肿瘤导致血栓形成的风险增加，而凝血功能的过度激活也极大地影响肿瘤的进展。在肺癌患者中，存在着持续的凝血刺激。癌细胞通过组织因子（tissue factor, TF）的表达激活凝血功能；通过凝血酶的表达和促凝血微粒的释放等影响凝血功能。凝血功能也通过介导血小板释放其颗粒内容物、抑制自然杀伤细胞和募集巨噬细胞而促进肿瘤的进展。非小细胞肺癌（non-small cell lung cancer, NSCLC）占肺癌的80%-85%，本文就凝血系统各个组分在NSCLC发生发展中的病理生理学机制的最新研究进展进行综述。

Paraneoplastic syndromes

AbstractNeuro‐ophthalmologic disorders in the patient with cancer Paraneoplastic syndromes Background: Paraneoplastic syndromes are caused by remote effect of cancer rather than direct invasion. Objective: Review of paraneoplastic neuro‐ophthalmic manifestations, differential diagnosis, diagnostic workup and proposed pathophysiology will be presented. Methods: Literature review along with representative case presentations. Results: Overall incidence of remote effect of cancer is 10‐15 % of all cancers. The number of autoantibodies in association with paraneoplastic syndromes is accumulating. Conclusion: Paraneoplastic syndrome with ocular manifestation may be the first sign of malignancy, and therefore ophthalmologist may play a crucial role in early detection and timely treatment with potential improvement of the disease course.

Meningeal carcinomatosis

AbstractNeuro‐ophthalmologic disorders in the patient with cancer Meningeal carcinomatosis Background: Meningeal carcinomatosis may be the first sign of malignancy, although usually represents widespread disease, and occurs most frequently in association with lung, breast and gastrointestinal cancer. Objective: To review the ophthalmological symptoms, signs, imaging appearance and differential diagnosis of meningeal carcinomatosis. Methods: Retrospective literature review and case reports. Results: Ocular manifestations are reported in 91% of patients with meningeal carcinomatosis. These include visual loss, diplopia, papilloedema, optic atrophy, and pupillary abnormality. Conclusion: Ophthalmologists and other eye care providers play a crucial role in the early detection of meningeal carcinomatosis.

Insight into Sweet’s syndrome and associated-malignancy: A review of the current literature

Sweet's syndrome (acute febrile neutrophilic dermatosis) is an infrequent skin disease characterized by sudden onset of fever, leucocytosis and erythematous plaques or nodules infiltrated by neutrophils. There are three main clinical settings in which Sweet's syndrome has been described: classical or idiopathic Sweet's syndrome, malignancy-associated Sweet's syndrome and drug-induced Sweet's syndrome. Classical Sweet's is often preceded by an upper respiratory tract infection and may be associated with inflammatory bowel disease and pregnancy. Approximately 21% of patients have an associated malignancy, most commonly hematological disease. The syndrome may occur as a paraneoplastic accompaniment to established cancer or may be a first sign of malignancy or its recurrence. The incidence is said to be increasing in recent years due to the frequent use of growth factors in cancer patients. Several anticancer agents including all-trans-retinoic acid proteosome inhibitors, hypomethylating agents, tyrosine kinase inhibitors and lenalidomide are potential harbingers of Sweet's syndrome. Unfortunately, little is known about the pathophysiology of Sweet's syndrome and there are no established guidelines for treatment of malignancy-associated Sweet's syndrome. Systemic corticosteroids are the mainstay of treatment. Sweet's syndrome caused by anticancer agents sometimes involves withdrawal or temporary discontinuation of anticancer agents, use of systemic corticosteroids and/or rechallenge with either with the same anticancer agents or different agents. This report provides insights into the pathophysiology, clinical presentation, diagnostic work, differential diagnosis and management of malignancy-associated Sweet's syndrome published in reported cases.

Cutaneous metastasis as the first sign of lung cancer

Cutaneous metastases of lung tumors are occurring in 1-12% of cases. High prevalence of lung cancer increases the likelihood of finding these changes in clinical practice. They are usually in the form of a firm, mobile and painless nodule on the head, neck and chest, and their appearance is a sign of advanced disease. Cutaneous metastases are rarely the first sign of malignancy. A 62-year-old patient presented to her doctor a fast-growing nodule on the forehead. Extirpation of the nodule and further diagnosis showed that it was a metastasis of small cell lung cancer localized in the right lung with extensive metastases to the contralateral lung, liver and spine. Cutaneous metastases may be the first sign of malignancy or the first sign of progression of already diagnosed malignancy. A diagnosis of metastatic disease should be considered in patients with risk factors or a known cancer. The presence of a skin metastasis in a patient with a lung cancer indicates poor prognosis.

Spinal Cord Stimulation in the Treatment of Cancer-Related Pain: “Back to the Origins”

Spinal cord stimulation (SCS) has been used in the treatment of chronic pain for more than 40 years. The most common indication for SCS in the USA is failed back surgery syndrome (FBSS). Interestingly, the first two spinal cord stimulators ever implanted were in patients suffering from bronchogenic carcinoma and pelvic cancer, respectively. While cancer accounts for millions of deaths each year in the USA, pain is often the first sign of malignancy. An increasing number of people suffer from cancer-related pain each year and many receive suboptimal relief. Given the demonstrated value of spinal cord stimulation in the treatment of neuropathic pain, spinal cord stimulation should be considered "earlier" as an adjunct to the treatment of cancer-related pain. In addition, with the improving survival rates associated with advances in cancer treatment, spinal cord stimulation may help reduce the risk of development of chronic neuropathic pain in survivors.

Malignant pericardial effusion and cutaneous metastasis - an initial presentation of adenocarcinoma of lung

Cardiac tamponade is a life threatening condition. It is rarely the first sign of malignancy which can be diagnosed by cytological examination of pericardial fluid. Subcutaneous metastatic nodules also are an uncommon first sign of underlying cancer. In this report we present a 62 years old case of lung cancer who initially presented with the above two rare clinical signs. He was admitted with cardiac symptoms, chest pain and dyspnea since last 6 months. Chest radiographs showed cardiomegaly and diagnosis of cardiac tamponade was made. Pericardiocentesis showed malignant cells, morphologically suggestive of an adenocarcinoma. Fine needle aspiration of the subcutaneous nodules showed a similar picture. Search for the primary revealed a mass in the lung on computed tomography.

Knee Pain in a 13-Year-Old Boy

Knee Pain in a 13-Year-Old Boy