Hilar Mass Research Articles

The clinical value of CT-guided percutaneous needle biopsy in the diagnosis of pulmonary hilar masses

The clinical value of CT-guided percutaneous needle biopsy in the diagnosis of pulmonary hilar masses

Complicaciones del tratamiento con anticoagulantes orales en mayores de 65 años, a propósito de un caso

Descripción del caso: Mujer de 79 años con antecedentes de hipertensión arterial, fibrilación auricular (FA) permanente anticoagulada (acenocumarol) e insuficiencia mitral. Barthel 90, Lowton-Brody: 2. Acude a urgencias por dolor costal (osteomuscular) de dos semanas de evolución, sin otros síntomas, siendo dada de alta y acudiendo nuevamente por epistaxis y disnea. Exploración y pruebas complementarias: destacar en la auscultación cardio-pulmonar: tonos arrítmicos con soplo sistólico en reborde esternal izquierdo, crepitantes hasta campos medios, con murmullo vesicular disminuido. Radiografía de tórax: masa hiliar derecha con engrosamiento pleural derecho, e infiltrado bilateral. Hemograma: hemoglobina 7.9 g/dl (previa 11.6 g/dl), leucocitos 11.57x10l. Bioquímica: PCR 72.90mg/l, urea 85 mg/l. Coagulación: INR indeterminado, actividad protrombina <12.5%. Juicio Clínico: Hemorragia alveolar bilateral. Diagnóstico diferencial: Hemorragia alveolar bilateral, neumonía bilateral, insuficiencia cardiaca congestiva (Edema Agudo de Pulmón). Conclusión: El 0.5% de la población usa anticoagulantes orales, entre el 6.8-11.1% por FA, un INR>4 aumenta el riesgo de sangrado. Se trata de un paciente pluripatológico, dependiente moderada, con mal cumplimiento tratamiento y de control de anticoagulación. Ante estos datos (anemización, ausencia de signos de infección o insuficiencia cardiaca), y los resultados de las pruebas, nos decantamos por la hemorragia alveolar como primera posibilidad diagnostica.

Primary Pulmonary Synovial Sarcoma: An Exceedingly Rare Pulmonary Malignancy Presenting as an Obstructing Endobronchial Mass

SESSION TITLE: Lung Cancer Case Report Posters II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Primary pulmonary synovial sarcomas (PPSS) are exceedingly rare tumors. We report a case of PPSS presenting as an obstructing endobronchial lesion. This case highlights the importance of appropriate cytogenetic testing in the diagnosis of this rare tumor. CASE PRESENTATION: An 83-year-old Caucasian female presented to her primary care physician with a 3-week history of progressive dyspnea and hemoptysis. Medical history was significant for a prior stable pulmonary nodule and previous pontine stroke. Vital signs were notable for a respiratory rate of 26 and oxygen saturations of 82% on room air. Physical examination revealed reduced air entry on the right, with occasional wheezing. Cardiac and abdominal examination was unremarkable. She underwent chest radiography that showed right lower lobe collapse. She then proceeded to a computed tomography (CT) scan of the chest that showed a right hilar mass causing right mainstem obstruction, right lower lobe atelectasis and a presumed post-obstructive pneumonia (Figure 1). She proceeded to bronchoscopy where a large endobronchial mass was noted near the take off of the superior segment of the right lower lobe (Figure 2). Biopsies showed sarcoma cells. Fluorescent in-situ hybridization (FISH) testing showed rearrangement of the gene SS-18 at 18q11.2, indicating a primary pulmonary synovial sarcoma. Thorough focused physical examination and full body CT/PET demonstrated no other lesions. She underwent radiation therapy with 6600 cGys in 33 fractions with curative intent. At 1-year follow-up she is in complete remission. DISCUSSION: Synovial sarcomas (SS) are uncommon, accounting for 10% of all sarcomas. Synovial sarcomas typically occur in soft tissues and extremities. Definitive diagnosis of SS requires cytogenetic demonstration of SS-18 genetic rearrangement at 18q11.2 by FISH, present in 90% of synovial sarcomas. PPSS is rare, but is increasingly recognized with improvements and wider availability of cytogenetic testing. PPSS presenting as an obstructing endobronchial tumor has only been reported on few occasions previously. CONCLUSIONS: Primary pulmonary synovial sarcomas are rare malignancies that may present as obstructing endobronchial lesions. Wider availability of cytogenetic testing may lead to an increased recognition of this entity. Radiation therapy with curative intent is a viable treatment option. Reference #1: Primary pulmonary synovial sarcoma: a rare primary pulmonary tumor. Falkenstern-Ge RF et al. Lung. 2014 Feb;192(1):211-4. DISCLOSURE: The following authors have nothing to disclose: Hemang Yadav, Rodrigo Cartin-Ceba No Product/Research Disclosure Information

A Case of Cholangiocarcinoma Diagnosed by Skin Biopsy

A 72-year-old man presented to an outside hospital with abdominal pain, jaundice, and a 30 lb weight loss. CT showed choledocholithiasis and suspected cholecystitis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) which revealed stones in the common bile duct (CBD). Sphincterotomy and stone extraction with stent placement was performed. A laparoscopic cholecystectomy was done, revealing a hydropic gallbladder (GB) that was pierced open, suctioned and subsequently removed in an endobag. A JP drain was left in the GB bed and pulled through a port site. The patient's jaundice did not improve and he was transferred to another facility where endoscopic ultrasound demonstrated a hilar mass with an associated CBD stricture. An ERCP with brush and biopsy of the CBD stricture was also done, and cytology returned showing only atypia. Both procedures were repeated two weeks later and results were again negative. In the interim, the patient underwent skin biopsy of an enlarging subcutaneous nodule located at a previous surgical port site and the results returned as metastatic adenocarcinoma. A GI pathologist re-examined the GB specimen obtained during the laparoscopic cholecystectomy and noted that there was evidence of cholangiocarcinoma (CCA) within the GB wall. CCA carries a dismal prognosis when detected in an advanced stage and early diagnosis is a challenge. The prevalence of incidental GB carcinoma is between 1% and 2% of all cholecystectomies performed with some studies reporting an incidence as high as 7.4%. Removal of unsuspected GB carcinoma laparoscopically can lead to seeding of tumor cells into the abdominal wall. Incidence of port site recurrence after laparoscopic cholecystectomy for unsuspected GB cancer can be as high as 14%. Intraoperative GB perforation can raise this rate of recurrence to 40%. Recurrences usually occur 6 to 16 months after the operation as was seen in this case. There are several proposed mechanisms of port site recurrence, the most popular of which include: direct wound contamination from laparoscopic instruments; the bile itself containing exfoliated tumor cells which can spread with bile spillage; and also, whether insufflation of the peritoneum can enhance wound metastases. In this case, JP drain placement along with GB perforation may also have been a route of seeding. Physicians should be aware of the risk of tumor seeding when CCA is a possibility in order to avoid the acceleration of metastatic disease.

A Rare Case of Intraductal Papillary Mucinous Neoplasm of Biliary Duct in a Patient With Prostate Adenocarcinoma

A 80-year-old male was evaluated for elevated prostate specific antigen (PSA) level and biopsy of prostate gland revealed Adenocarcinoma. Patient underwent cross sectional tomography (CT) imaging of abdomen which showed 2.3 x 2.7 cm soft tissue mass centered at porta hepatis with diffuse dilatation of left intrahepatic biliary ductal system and mild prominence of right intrahepatic ductal system. On physical examination, head, eyes, ears, nose and throat were normal. There was no jaundice. Abdomen was soft, non-tender, non-distended, no masses or free fluid and normal bowel sounds. Laboratory evaluation showed normal liver enzymes, lipase and amylase. Carbohydrate Antigen (CA 19-9) was 35.2 units/ml. The patient underwent endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreaticography (ERCP). EUS showed 2 adjacent hilar masses involving common hepatic duct and left hepatic duct with protrusion of the tissue into the lumen of the duct and upstream ductal dilatation with parenchymal atrophy. ERCP revealed a large filling defect in the common hepatic duct extending into the left hepatic duct. A large amount of clot and soft tissue with a fish-egg appearance was retrieved. Two pigtail biliary stents were placed into the left hepatic duct upstream from soft tissue mass. The biopsy of the soft tissue revealed intraductal papillary neoplasm of the bile duct with diffuse high-grade dysplasia and intramucosal carcinoma. The patient underwent radical resection of common hepatic duct, left hepatic lobectomy with Roux-en Y hepaticojejunostomy to the right hepatic duct. Histopathological examination of the resected specimen revealed intraductal papillary neoplasm with diffuse high-grade dysplasia. The surgical margins and lymph nodes were negative for carcinoma. Post-operative course was complicated by intra-abdominal abscesses and pneumonia requiring intravenous antibiotics and CT guided drainage. Follow up CT scan, 2 months after the surgery was negative for any masses. Patient feels well and is asymptomatic 12 months since surgery. Intraductal Papillary Mucinous Neoplasms (IPMNs) are intraductal mucin-producing tumors arising from epithelial cells and have malignant potential. It usually arises from the pancreatic duct. It can lead to cyst formation or papillary proliferation and may have varying degrees of cellular atypia. The malignant potential rises with increasing size (> 3cm). Multiple genetic mutations have been described. IPMN of the biliary tract are rarely reported in literature. It is more often associated with higher levels of CA 19-9 and Carcinoembryonic antigen (CEA). Most IPMNs are benign and non invasive, however due to increasing size and malignant potential, surgical resection is the treatment of choice. Our patient's IPMN was 2.7 cm with high-grade dysplasia that was treated with surgical resection.

Concomitant tuberculosis and lung cancer diagnosed by bronchoscopy

INTRODUCTION: Tuberculosis (TB) in patients with lung cancer may be masked by cancer symptoms; in the Health District of South Granada (HDSG), as part of the TB monitoring programme, samples of bronchial secretions for studies for TB were obtained in all fibre-optic bronchoscopies (FBS) performed for all indications. The objective was to determine the existence of any association between TB and lung cancer in our area. METHODS: This was a prospective study of all cases of TB diagnosed in the HDSG between 1st January 2003 and 31st December 2010. Absolute and relative frequencies were calculated for qualitative variables and mean and standard deviation were calculated for quantitative variables. Data analyses was performed using the IBM SPSS Statistics 19 software. RESULTS: TB was diagnosed in 319 cases, 272 (85,2%) of which were pulmonary (PTB); the diagnosis was made by FBS in 33 cases. Concomitant TB and lung cancer were diagnosed in 15 cases (5.7% of cases of PTB in patients over 20 years of age). Radiological findings included atelectasis and/or pulmonary infiltrates in 13 cases, cavitated mass and hilar mass associated with milliary pattern in one patient each. Lung cancer stage was III-IV in 9 cases (all died) and I-II in 6 cases, in which both diseases were considered cured. CONCLUSIONS: The high association between TB and lung cancer found in our sample (4.7% of all cases of TB) compared with other studies (1,9%) suggests that it would be advisable to exclude TB in all cases of lung cancer; this is particularly important in areas with a high prevalence of TB, especially because the same FBS can obtain samples for both pathological and microbiological studies.

Convex probe endobronchial ultrasound: applications beyond conventional indications.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is maturing and gaining acceptance by more and more clinicians for lymph node staging of lung cancer and diagnosis of mediastinal and hilar masses or lymph node enlargement by convex probe endobronchial ultrasound (CP-EBUS). The application of CP-EBUS, however, is not limited to conventional indications. Diagnostically, elastography is a new technology for the differentiation of benign and malignant lymph nodes before aspiration. CP-EBUS can also be used for pulmonary vascular diseases, such as pulmonary embolism (PE) and non-thrombotic endovascular lesions (NELs). Therapeutically, CP-EBUS can be used for cyst drainage and drug injections. CP-EBUS is not limited to observation and aspiration of mediastinal masses and lymph nodes, but is also suitable for exploration of other tissues external to the central airway, which necessitates unprecedented skills for the bronchoscopist.

A surgical case of eosinophilic angiocentric fibrosis of the lung.

Eosinophilic angiocentric fibrosis (EAF) is an uncommon inflammatory disease that develops from the respiratory organs and affects them. Almost all reports about EAF describe lesions affecting the upper respiratory tract. We present the first case of EAF of the lung treated by surgical excision. A 69-year-old female consulted our hospital following the detection of an abnormal chest shadow with chronic cough. Chest computed tomography showed a pulmonary growing mass in the right hilar area, which corresponded to an enhanced accumulation on positron emission tomography. We doubted a pulmonary malignant tumor and performed a right upper lobectomy. Pathological and other clinical presentations revealed EAF of the lung without coexisting systemic diseases. The patient had an uncomplicated postoperative course, and the presenting cough had improved. EAF can involve the lung and cause symptomatic airway obstruction. For a hilar region mass with imaging characteristics similar to those of lung cancer, a differential diagnosis must be considered.

Robotic-assisted laparoscopic partial nephrectomy for small renal cell carcinoma: Chi Mei Medical Center experience

Robotic-assisted laparoscopic partial nephrectomy for small renal cell carcinoma: Chi Mei Medical Center experience

Clinical Features And Outcomes Of Patients With Small Cell Lung Carcinoma; Retrospective Analysis

Objectives: Lung cancer is the leading cause of cancer-related mortality in both men and women worldwide. Small cell lung cancer (SCLC) represents 15-20 % of all lung cancers. The aim of this study was to evaluate the clinical features of small cell lung cancer (NSCLC) cases that were diagnosed in our clinic. Methods: The patients who were diagnosed as SCLC in our clinic were comprised the study group. The files and records of the study group were retrospectively reviewed to identify patients. The study group included 64 patients (59male, 5 female). Results: The mean age was 57.5 ±8.1 years. All patients were current smokers ( 50,3 pack-year). The most frequent symptoms on admission were chest pain, cough and weight loss. The most common radiologic finding was a hilar solid mass and hilar lymphadenopathies. The diagnosis was established by histopathologic examination of biopsy specimens obtained by various means, in which bronchoscopy was the sole means of diagnosis in 92,2 % of the patients. The stages of SCLC were limited disease in 26(29,7 %) and extensive disease in 38 (59,3%) patients. Metastasis was most frequently to the liver followed by bone and brain. Five (7,8%) patient had complete response (CR). forty nine (76,5%) patients had partial response. The median survival was 309 days, 210 days and 270 days for LS, ES and overall patients, respectively. Conclusions: In conclusion, demographic and clinical features of the patients were similar with the literature. Due to the high rates of extensive disease, the median survival rates and responses were lower than the previous series.

Surgical specimen histology revealed inadequacy of conventional transbronchial needle aspiration sample in the diagnosis of adenosquamous lung carcinoma.

We retrospectively reviewed the accuracy of conventional transbronchial needle aspiration (cTBNA) in the subtyping of lesions located in or around central airways by comparing the histological diagnosis based on TBNA and surgical specimens. cTBNA was conducted in consecutive patients with lesions located in or around the central airways (trachea, left and right primary bronchi, hilar and mediastinal masses or lymph nodes) between October 2012 and May 2014 in Wuhan No. 1 Hospital. The aspirated specimens in all patients were performed cytological and/or histopathological examination. Of these patients, some were subjected to surgical resection and histopathological examination was performed by the Department of Pathology. In the patients with gross specimens, the final diagnosis was established based on histopathological results from these specimens. In 63 patients diagnosed with cTBNA for the lesions located in or around the central airways, 23 patients with a diagnosis of lung cancer or atypical hyperplasia underwent surgery. The final diagnosis based on histopathology of surgery specimen was lung cancer in 22 patients [3 small cell lung cancer (SCLC), 9 squamous cell carcinoma (SCC), 5 adenocarcinoma (ADC), 4 adenosquamous carcinoma (ADS) and 1 neuroendocrine carcinoma], and inflammatory pseudotumor in 1 patient. The overall diagnostic yield of cTBNA for lung cancer was 95.7% (22/23), but the accuracy for histological typing of lung cancer is only 63.6% (14/22), for adenosquamous lung carcinoma was only 25% (1/4). cTBNA is a safe and effective procedure that can be used for the diagnosis of central lung cancer. However, the accuracy of TBNA for the histological classification of lung cancer is relatively low, especially for adenosquamous lung carcinoma.

V7-02 ROBOTIC PARTIAL NEPHRECTOMY FOR A COMPLEX HILAR MASS IN A 14 YEAR OLD BOY

You have accessJournal of UrologyPediatrics1 Apr 2015V7-02 ROBOTIC PARTIAL NEPHRECTOMY FOR A COMPLEX HILAR MASS IN A 14 YEAR OLD BOY Abhishek Srivastava, Aryeh Keehn, Amanda North, and Reza Ghavamian Abhishek SrivastavaAbhishek Srivastava More articles by this author , Aryeh KeehnAryeh Keehn More articles by this author , Amanda NorthAmanda North More articles by this author , and Reza GhavamianReza Ghavamian More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1933AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic surgery still poses many challenges in pediatric patients and there has been limited use of minimally invasive approaches for treatment of renal masses in pediatric population. We present a case of 14 year old boy with history of recurrent urinary tract infections and bilateral hydronephrosis, who underwent bilateral pyeloplasty several years ago and presented to the emergency room after a right renal mass was seen on a follow-up renal ultrasound. METHODS CT scan showed 4.2cm, infrahilar renal mass. Renal scan revealed a split differential function of 42% on the right and 52% on the left. Serum creatinine was 1.1. Given the patient's young age, prior history of bilateral renal surgery on both kidneys, the increased risk of CKD in the long-term and the equivalent oncologic efficacy of partial vs. radical nephrectomy, we considered nephron-sparing surgery. Plan was for a Robotic Right Partial Nephrectomy with intraoperative ultrasonography. If partial nephrectomy was not deemed possible, we would have proceeded with radical nephrectomy. RESULTS We were able to successfully perform Robotic partial nephrectomy without any complications. Pathology revealed Renal cell carcinoma, unclassified type, 5.5 × 5.4 × 3.4 cm (High Grade). Postoperative creatinine was 1.3. Surgical resection margins were negative for tumor. Patient was discharged on postoperative day 4. CONCLUSIONS Robotic partial nephrectomy is feasible in complex hilar mass and in pediatric population. It should be attempted if nephron sparing is indicated. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e659 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abhishek Srivastava More articles by this author Aryeh Keehn More articles by this author Amanda North More articles by this author Reza Ghavamian More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Anaplastic lymphoma kinase-positive lung adenocarcinoma patient with development of sick sinus syndrome while on targeted treatment with crizotinib.

The anaplastic lymphoma kinase (ALK) positive non-small cell lung cancer (NSCLC) patients are younger and have never smoked, while pathologically are predominately adenocarcinomas. Crizotinib as an ALK inhibitor has been used in treating ALK positive NSCLC patients for several years and some adverse effects should be paid attention to. We now describe a case of ALK positive NSCLC patient with development of sick sinus syndrome (SSS) while on targeted treatment with crizotinib. A 46-year-old non-smoking woman with right hilar mass and underwent transesophageal endoscopic ultrasonography lymph node biopsy showed low differentiation adenocarcinoma, immunohistochemistry (IHC) of tumor samples revealed the ALK overexpression. The severe sinus bradycardia and RR interval prolongation were detected 3 months after crizotinib treatment, she underwent pacemaker implantation. Although the severe sinus bradycardia and RR interval prolongation were unusual adverse effects, physicians should be aware of these side effects when using crizotinib.

Respiratory failure with hilar mass: Role of endobronchial ultrasound-guided transbronchial needle aspiration in the medical intensive care unit.

We report the case of a 58-year-old man on chronic steroid therapy, who developed a rapidly progressive right upper lobe infiltrate/mass that extended into the right hilum. Respiratory failure necessitated endotracheal intubation. Broad spectrum antibiotics were initiated without clinical improvement and because of his immunosuppressive therapy opportunistic pathogens were considered. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed in the Medical Intensive Care Unit (MICU) with rapid onsite evaluation. Specimens obtained from the right hilar mass revealed organisms suspicious for cryptococcal infection, subsequently confirmed via a culture. No complications occurred during the EBUS procedure despite the patient requiring vasopressor support and 100% inspired oxygen. Little data exists regarding the use of EBUS in patients admitted to the MICU with respiratory failure of unknown etiology and mediastinal/hilar lymphadenopathy. This case illustrates the potential safe use of EBUS-TBNA in patients presenting with respiratory failure, with a mediastinal or hilar mass and suspected infectious etiology.

Multidetector Row Computed Tomography(MDCT) Evaluation of Bronchogenic Carcinoma and Histopathological Correlation

Bronchogenic carcinoma is one among the leading causes of death in males in India and globally. Multidetector row Computed Tomography is a non-invasive technique for evaluation of bronchogenic carcinoma. Aims and objections: To document imaging characteristics of various histopathological cell types of bronchogenic carcinoma by MDCT and to correlate with histopathology. A prospective study was done on 60 patients with clinical or radiological suspicion of bronchogenic carcinoma undergoing MDCT. The final diagnosis was established by histopathology. Study duration was for 2 years from January 2013 to December 2014. Results: MDCT is a promising tool in evaluation of bronchogenic carcinoma. Squamous cell carcinoma is the most common histological celltype, closely followed by adenocarcinoma. Hilar mass was the predominant presentation followed by lung mass.

Atypical presentation of bronchogenic carcinoma with humeral metastasis

Bronchogenic carcinoma often manifests with some atypical symptoms which delay the diagnosis of malignancy. The primary manifestation of lung cancer with pathological fracture of humerus due to skeletal metastasis is very rare. We hereby report such a case in an elderly nonsmoker male who initially presented with nontraumatic painful swelling of right arm which was found to be due to humeral fracture. However, initial management by the orthopedic surgeon over 3 months did not provide adequate relief. On subsequent evaluation, chest X-ray showed a right hilar mass. Further radiologic imaging and a guided biopsy from lung mass confirmed an adenocarcinoma. Fine needle aspiration from humeral osteolytic lesion also confirmed metastatic deposit. This case highlights the importance of suspecting pathological fracture while dealing with nontraumatic fracture, especially in elderly patients, which avoids the diagnostic delay.

Left Hilar Mass Image Forming of Idiopathic Pulmonary Artery Aneurysm

Left Hilar Mass Image Forming of Idiopathic Pulmonary Artery Aneurysm

Potential influence of automated volumetry on treatment response classifications in lung cancer lesions

Material and methods 60 patients (41 men, 19 women, mean age 61.8 ± 9.4 years) with histopathologically verified lung cancer were included in this retrospective study. For each patient, up to 2 target lesions were quantitatively evaluated in a baseline and two follow-up CT scans (77 lesions, 154 response classifications) by two independent radiologists. Hilar and mediastinal masses, as well as lesions surrounded by atelectasis were excluded. For each lesion a unidimensional diameter measurement, as well as an automated CT-volumetry was performed. In the follow-up studies, the response evaluation was assessed using RECIST compared to volume equivalents of RECIST with converted thresholds (-65/+73%).

P3-30-3 - Combination of Repeated Surgery and Perioperative Chemotherapy for Metachronous Double Bile Duct Cancer

A 69-year-old woman was admitted due to jaundice. Enhanced CT scan showed advanced gallbladder cancer invading the liver parenchyma. After three courses of gemcitabine (GEM) therapy were administered as neoadjuvant chemotherapy, extended right hemihepatectomy was performed. Postoperative adjuvant chemotherapy was canceled due to the patient's refusal. Nine months after the surgery, CA19-9 level was increased and follow-up CT detected hilar lymph node swelling, which strongly suggested recurrence of the disease. Chemotherapy using S-1 was introduced but was stopped because of progressive disease response. Instead, GEM therapy was administered and a partial response was observed which persisted for about five years thereafter. However, 76 months after the operation, jaundice was noted and solitary hilar mass lesion was detected by a follow-up CT and FDG-PET, without any other distant metastasis. The patient underwent extrahepatic bile duct resection with partial resection of the portal vein due to direct tumor invasion, and pathologically the tumor was diagnosed hilar cholangiocarcinoma. Since cancer infiltration of the intrahepatic bile duct stump was histologically positive, combination chemotherapy using GEM plus CDDP was administered. The patient is currently 76 years of age, 7 years after the initial surgery, and she is still doing well without any signs of recurrence. Metachronous multiple carcinomas of the biliary system are relatively uncommon due to the rarity of cholangiocarcinoma and its poor prognosis. Although some selected patients with bile duct cancer have a chance of long-term survival thanks to recent advances in both surgical resection and combination chemotherapy, standardization of chemotherapy or other therapeutic modalities has not been established for the treatment of such critical patients. We discussed feasibility and safety of multidsciplinary treatment for metachronous multiple bile duct cancers with the review of the literature.

Complications of Oral Anticoagulant Therapy in over 65 Years, a Case Report

Case description: Woman, 79 years old. Medical history: hypertension, Atrial fibrillation (AF) permanent treated with acenocoumarol and mitral insufficiency. Barthel 90, Lowton-Brody. 2. The patient came to the emergency room for rib pain (musculoskeletal) in last two weeks, without other symptoms. We initiated analgesia and the patient was discharged. She came back with new symptoms: epistaxis and dyspnea. Exploration and complementary tests: cardio-pulmonary auscultation arrhythmic tones with sternal border systolic murmur left, crakling sounds in the lungs, with decreased breath sounds. Chest x-ray: right hilar mass with right pleural thickening, and diffuse bilateral infiltration. CBC: hemoglobin 7.9 g/dl (First: 11.6 g/dl), WBC 11.57x10l. Biochemistry: PCR 72.90 mg/l, urea 85 mg/l. Coagulation: INR undetermined, activity prothrombin <12.5%. Diagnosis: bilateral alveolar hemorrhage. Diagnosis Differential: bilateral alveolar hemorrhage, bilateral pneumonia, heart failure congestive (Acute Lung Edema). Conclusion: 0.5% of the population uses oral anticoagulants, between 6.8-11.1% by FA an INR>, increases the risk of bleeding. This is a patient with multimorbidity, moderately dependent, with poor treatment compliance and anticoagulation control. Given these data (anemia, no signs of infection or heart failure), and the test results, we opted for the first possibility alveolar hemorrhage diagnosed.