Initial Presentation Of Malignancy Research Articles

Pericardial Effusion as Initial Presentation of Malignancy

Pericardial effusion describes accumulation of fluid in the pericardial space. When it happens with malignancy, it incurs poor prognosis. Most often lung, hematological or breast carcinomas form the background. It may cause hemodynamic instability and cardiac tamponade and require prompt invasive management. This is elaborated by this article. This is a case report of 55 year old Asian man who presented with a month history of lethargy fever, sweating and worsening dyspnea. He was assessed in the Triage room and some imaging was performed. Pericardial effusion was found and emergency pericardiocentesis performed. The patient was managed through multidisciplinary approach.It is, thus, recommended to set a low threshold for diagnosis and management for pericardial effusion.Keywords: Cardiac Tamponade, Case Report, Pericardial Effusion, Pericardiocentesis.

LOW-PRESSURE CARDIAC TAMPONADE: A RARE COMPLICATION IN THOSE UNDERGOING HEMODIALYSIS WITH KNOWN PERICARDIAL EFFUSION

LOW-PRESSURE CARDIAC TAMPONADE: A RARE COMPLICATION IN THOSE UNDERGOING HEMODIALYSIS WITH KNOWN PERICARDIAL EFFUSION

Hemophagocytic Lymphohistiocytosis as Initial Presentation of Malignancy in Pediatric Patients: Rare but Not to Be Ignored.

It is complicated to establish a consensus on the management and diagnosis of malignancy-triggered hemophagocytic lymphohistiocytosis (M-HLH) in children, as an initial presentation of malignancy is complicated. In this paper, we analyze the clinical characteristics and outcomes of eight pediatric patients in which M-HLH was the initial presentation of malignancy. All patients had hematologic malignancies: three subcutaneous panniculitis-like T-cell lymphomas, two acute lymphoblastic leukemias, two anaplastic large cell lymphomas, and a systemic EBV + T-cell lymphoma of childhood. The incidence rate of M-HLH among leukemia and malignant lymphoma patients in our institution was 1.9%. From the initial diagnosis of HLH, the median time taken to be diagnosed as a malignancy was about 1.3 months. The majority of patients received HLH-targeted immunosuppression and/or etoposide at first. The patients’ clinical response to treatment for HLH and malignancies were varied. Five out of the eight patients died, one of whom died due to HLH-related cerebral edema after the initiation of chemotherapy. The median overall survival was 1.6 years. In order to improve the survival rate, the early detection of M-HLH, rapid screening for malignancy, and complete control of M-HLH with HLH-directed therapy followed by a thorough response monitoring are required.

BE CAREFUL, THAT CARDIAC TAMPONADE MAYBE MALIGNANT

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac tamponade results from the accumulation of pericardial fluid under pressure which causes impaired cardiac filling and hemodynamic compromise. The causes of cardiac tamponade include infection, inflammation, autoimmune diseases, malignancy, drugs, and radiation. Malignancies including lungs, breast, gastrointestinal and hematological may lead to pericardial effusion with or without tamponade. Cardiac tamponade as an initial presentation of malignancy is rare. CASE PRESENTATION: A 63-year-old male presented with altered mental status for 2 weeks, intermittent cough for 6 months, and unintentional weight loss of about 20 lbs. His vitals were blood pressure 125/86, MAP 94, HR 100, and RR 18. He has a medical history of Type 2 diabetes mellitus, hypertension, dyslipidemia, depression, anxiety, tuberculosis (treated in 1970), exposure to radiation during military service, and a family history of multiple malignancies. CT head showed no acute intracranial abnormality. Chest X-ray showed right perihilar pneumonia and the patient was started on antibiotics. CT chest showed multilobar pneumonia, underlying nodularities within the right lung, diffuse sclerotic lesions throughout the skeleton suggestive of metastatic disease, right small pleural effusion, large pericardial effusion. TTE showed moderate to large pericardial effusion with tamponade physiology. He underwent an urgent pericardial window to relieve cardiac tamponade. On analysis, pericardial fluid was malignant. It showed metastatic adenocarcinoma, consistent with lung primary. Immunohistochemical stains show that tumor cells are positive for Ber-EP4, CD15, CK7, and TTF-1. DISCUSSION: There are three routes through which the malignancies involve pericardium – local extension, hematogenous and lymphatic. Pericardial effusion is common in malignancy and when present associated with poor prognosis and can be fatal. Cardiac tamponade is however a rare initial presentation of malignancy. EKG findings in tamponade include low voltage QRS, PR segment depression, electrical alternans, and sinus tachycardia. Diagnosis can be made by echocardiography. CONCLUSIONS: Pericardial effusion with cardiac tamponade may be malignant. Pericardiocentesis in cardiac tamponade has therapeutic efficacy including high diagnostic yield. Pericardial fluid cytology should be examined even if the malignancy is not suspected, especially if the chest x-ray is abnormal. REFERENCE #1: Pericardial diseases in patients with cancer: contemporary prevalence, management, and outcomes. BMJ Volume 106 Issue 8 https://doi.org/10.1136/heartjnl-2019-315852 REFERENCE #2: Cardiac tamponade as the initial presentation of malignancy: is it as rare as previously supposed? BMJ Volume 70 Issue 828 https://doi.org/10.1136/pgmj.70.828.703 REFERENCE #3: Relation of Acute Pericardial Disease to Malignancy. American Journal of Cardiology https://doi.org/10.1016/j.amjcard.2005.01.094 DISCLOSURES: No relevant relationships by Nimesh Adhikari, source=Web Response No relevant relationships by Nouran Eshak, source=Web Response No relevant relationships by Kenneth Iwuji, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response No relevant relationships by Upama Sharma, source=Web Response No relevant relationships by Anupama Sharma, source=Web Response

Arthritis as an initial presentation of malignancy: two case reports

BackgroundArthritis is rarely reported as a paraneoplastic manifestation of occult malignancy. We report herein two cases of paraneoplastic arthritis due to occult malignancy.Case 1The patient was a 65-year-old woman of asian descent who was a former smoker with a history of spine surgery performed for L4/L5 degenerative disc disease. She presented with a 1-month history of oligoarthritis affecting both ankle joints and early morning stiffness of about 3 hours. Laboratory tests were positive for antinuclear antibody at a titer of 1:320 (speckled) but negative for rheumatoid factor. She was treated for seronegative spondyloarthritis and started on prednisolone without much improvement. A routine chest radiograph incidentally revealed a right lung mass which was found to be adenocarcinoma of the lung. She was treated with gefitinib and her arthritis resolved.Case 2The patient was a 64-year-old woman of asian descent, nonsmoker, who presented with a chief complaint of asymmetrical polyarthritis involving her right wrist, second and third metacarpophalangeal joints, and first to fifth proximal interphalangeal joints. She was treated for seronegative rheumatoid arthritis (RA) and started on sulfasalazine, with poor clinical response. Six months later, she developed abdominal pain which was diagnosed as ovarian carcinoma by laparotomy. Her arthritis resolved following treatment of her malignancy with chemotherapy.ConclusionIn summary, paraneoplastic arthritis usually presents in an atypical manner and responds poorly to disease-modifying antirheumatic drugs. Accordingly, we recommend screening for occult malignancy in patients presenting with atypical arthritis.

CARDIAC TAMPONADE AS A PRESENTATION OF AN ASYMPTOMATIC EXTRACARDIAC MALIGNANCY

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pericardial tamponade is a life-threatening event secondary to inhibition of passive diastolic filling by rapid accumulation of fluid leading to right atrioventricular diastolic collapse. Patients with pericardial metastasis showing symptoms of cardiac tamponade as the first presenting sign of extracardiac malignancy is very uncommon. CASE PRESENTATION: A 24-year-old female presented to the hospital with progressive dyspnea and lower extremity swelling that started 3 days ago. She had no significant past medical history and was taking no prescription medications. She denied illicit drug use or smoking. There was no family history of malignancy or autoimmune disorder. Her vital signs were: afebrile, blood pressure 90/60 mmHg, heart rate140bpm, respiratory rate 30/min, oxygen saturation 95% on 10 liters of a nonrebreather mask. On physical examination jugular venous distention was 2 cm.Decreased breath sounds on the right hemithorax. Heart sounds were muffled, tachycardia, with a regular rhythm. The patient had 1+ edema bilaterally in the lower extremities. Other exams were unremarkable. CT angiogram of chest found a large right pleural effusion, 2.6 cm pulmonary nodule at right lower lobe,mediastinal lymphadenopathy, and a large pericardial effusion (Fig.1). An echocardiogram showed signs of pericardial tamponade(Fig.2). Cardiology team was consulted and took the patient for an urgent pericardiocentesis with pericardial chest tube placement which drained 650 mL of hemorrhagic fluid. Pulmonology service was consulted for right-sided chest tube placement which drained 600 mL of straw-colored fluid. The patient was then returned to MICU with significantly improvement in vital signs. Pericardial cytology demonstrated malignant cells positive for BerEP4, CK-7, and TTF-1 indicating pulmonary adenocarcinoma, stage 4 given the pericardial tamponade. DISCUSSION: In a young patient without any recent cardiac procedures, history of heart disease or renal failure, other possibilities for hemorrhagic pericardial effusion should be considered such as metastatic cancers including lymphoma, autoimmune disorders, and infectious causes such as tuberculosis and HIV. The treatment of pericardial tamponade in the setting of non-small cell lung cancer is urgent pericardiocentesis, followed by pericardial window if effusion is recurrent. The overall survival in patients with malignant pericardial effusion is dictated by histological type of the underlying malignant process. CONCLUSIONS: Cardiac metastasis is mostly asymptomatic, and pericardium is most common site of metastasis. Pulmonary adenocarcinoma involves lymphatic drainage of the heart and presents with signs of cardiac tamponade even before signs of pulmonary disease. A careful physical exam, imaging, surgical intervention and critical care management were crucial as demonstrated in our case. Reference #1: Fraser, R.S., Viloria, J.B. and Wang, N.-S. (1980), Cardiac tamponade as a presentation of extracardiac malignancy. Cancer, 45: 1697-1704. doi:10.1002/1097-0142(19800401)45:7<1697::AID-CNCR2820450730>3.0.CO;2-J Reference #2: Muir, Keith & Rodger, J. (1994). Cardiac tamponade as the initial presentation of malignancy: Is it as rare as previously supposed?. Postgraduate medical journal. 70. 703-7. 10.1136/pgmj.70.828.703. Reference #3: Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol. 2007;60(1):27-34. doi:10.1136/jcp.2005.035105 DISCLOSURES: No relevant relationships by Kanak Parmar, source=Web Response No relevant relationships by Wasawat Vutthikraivit, source=Web Response

ATRIAL FIBRILLATION WITH CARDIAC TAMPONADE AS A FIRST SIGN OF UNDERLYING MALIGNANCY

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: While cardiac tamponade is unusual as the initial presentation of malignancy, malignant pericardial tamponade presenting as atrial fibrillation is even rarer. We present a case of atrial fibrillation with cardiac tamponade who was subsequently diagnosed with pulmonary adenocarcinoma CASE PRESENTATION: A 65-year-old woman presented with concerns of exertional shortness of breath for 1 week with dry cough, fatigue, and chest tightness, with a sudden worsening of respiratory symptoms and palpitations. She was hypotensive, tachycardic, and afebrile. Auscultation revealed muffled heart sounds and she had jugular venous distension. Her electrocardiogram showed atrial fibrillation with rapid ventricular response and no acute ST-segment changes. Chest x-ray showed blunting of her bilateral costophrenic angles with cardiomegaly, but no acute infiltrate. Computed tomography (CT) revealed moderate bilateral pleural effusions, moderate pericardial effusion (2-cm thickness), and bilateral noncalcified pulmonary nodules, with the largest measuring 1.7 x 2.4 cm at the left upper lobe (Image 1). Transthoracic echocardiogram revealed moderate to large pericardial effusion with early tamponade physiology (Image 2). She received emergent pericardial window surgery with drainage of exudative pericardial fluid. Cytological analysis revealed tumor cells positive for Ber-EP4, CK-7, and TTF-1 and negative for CK-20, PAX-8, and calretinin, consistent with metastatic adenocarcinoma likely from the lung. The patient had marked symptomatic improvement after the procedure, and her cardiac rhythm reverted to sinus rhythm. DISCUSSION: Nearly 18%–20% of autopsies performed on cancer patients show involvement of the heart or pericardium. Malignant pericardial effusions can occur by direct invasion of cancer or by metastatic invasion via the lymphatics or hematogenous spread. Tamponade physiology in patients with malignant pericardial effusion is associated with immediate mortality in up to 85% of cases. The association of atrial arrhythmias with cardiac tamponade is rare in the literature, and the association with malignant pericardial effusion is even rarer. Two cases in the literature report cardiac tamponade with atrial fibrillation as the first manifestation of malignancy—both were lymphoid in origin. This is the first case of newly diagnosed solid pulmonary tumor manifesting as atrial fibrillation with malignant pericardial tamponade. CONCLUSIONS: Despite its rarity, malignant pericardial tamponade with atrial fibrillation and rapid ventricular rate should be recognized and managed promptly to mitigate a potentially life-threating condition. Reference #1: Krisanda TJ. Atrial fibrillation with cardiac tamponade as the initial manifestation of malignant pericarditis. Am J Emerg Med. 1990;8(6):531–533. doi:10.1016/0735-6757(90)90157-u Reference #2: Refaat MM, Katz WE: Neoplastic pericardial effusion. Clin Cardiol. 2011;34:593–598. DISCLOSURES: No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by Amr Ismail, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Ximena Solis, source=Web Response No relevant relationships by Victor Test, source=Web Response

Malignant tumors in hernia sac: Clinicopathological and immunohistochemical studies of 21 cases at a single institution.

Malignant tumors presented in hernia sac are very rare and the clinicopathological features are not well studied. We retrospectively reviewed 21 patients with cancers identified in surgically resected hernia sac specimens at our institution, including 14 males and 7 females, with a median age of 65 years (range 35-93). Fourteen patients (66.7%) carried a synchronous or metachronous cancer diagnosis elsewhere and the tumors in hernia sac were proven to be metastasis. Of the remaining seven (33.3%) cases, hernia sac tumors were the initial presentation of malignancy, and a panel of immunohistochemistry markers were applied in combination with clinical information to identify tumor origin. The final classification of all 21 cases was as follows: 11 gastrointestinal tract tumors including 10 adenocarcinomas and 1 gastrointestinal stromal tumor, 5 pancreatobiliary adenocarcinomas and 5 gynecological serous carcinomas. Compared to other tumor types, pancreatobiliary adenocarcinomas were more likely to involve hernia sac as initial presentation before a primary site was identified (P = 0.0307) and had worse survival (P < 0.005). As the first and largest cohort of malignant tumors in hernia sac, our study provides critical data on frequency, distribution, clinicopathological features and applicability of immunohistochemical markers to determine tumor origin in cases with unknown primary.

Which patients with ischaemic priapism require further investigation for malignancy?

Ischaemic priapism (IP) is characterised by a persistent, painful penile erection lasting for >4 h. Many causes of IP have been identified including haematological dyscrasias (particularly, sickle cell disease), drugs and rarely malignancy. There are also a large proportion of men, in which no aetiology is identified. Identification of men at risk for malignancy provides a diagnostic challenge to the clinicians looking after these patients. All cases of IP between 2007 and 2017 at a single tertiary andrology unit were identified. The case notes and electronic records of these patients were reviewed to identify cases of malignant priapism. Men with idiopathic IP were used as a control group for comparative statistics. In total, 412 men with IP were identified, 202 of which had idiopathic IP. Within this group, the prevalence of malignant priapism was 3.5% (n = 11). MP secondary to local invasion or penile metastases occurred in seven of the 11 men (bladder × 3, prostate, lung, urethral and chondrosarcoma of the pelvis). MP secondary to haematological malignancy occurred in the remaining four (chronic myeloid leukaemia × 2, chronic lymphocytic leukaemia, and myelodysplasia). IP was the initial presentation of malignancy in seven of the patients (64%). An abnormally low haemoglobin value (reference range 130-180 g/dl) was found in 82% (n = 9) of the men with MP. The mean haemoglobin value in men with MP was 109.64 ± 20.30 g/dl compared to the control of 131.87 ± g/dl. This difference was considered highly significant p = 0.0046. Men with MP also appear to have a very poor prognosis with an 18-month mortality of 64% (n = 7). Malignancy is a rare and important cause of IP. A low haemoglobin is a predictor of malignancy and warrants further investigation in IP.

Rheumatic manifestations as initial presentation of malignancy: A case series from a tertiary care center in India.

ObjectiveMalignant neoplasms can be associated with a wide variety of rheumatological manifestations that may be caused by direct tumor invasion into bones and joints, as a paraneoplastic syndrome, and through altered immune surveillance. To identify the relationship between rheumatic manifestations in various malignancies.MethodsTwenty patients with various malignancies presenting with rheumatic conditions in our tertiary medical care were studied retrospectively from case records at the Kalinga Institute of Medical Sciences from 2013 to 2018.ResultsIn the present study, total of 20 patients including 12 males and 8 females with mean age at diagnosis of was 46.3±22.2 years with various malignancy associated rheumatic diseases were included. In total 20% of patients with were current smokers. Seven (35%) had hematological malignancies whereas 13 (65%) had solid malignancies. Most common presenting feature was arthritis (40%), followed by weight loss (20%), skin rash (10%), fever (15%) and muscle weakness (10%) at the time of diagnosis. All of them developed malignancy within 24 months of diagnosis. Among the autoantibodies, only 6 patients (30%) were positive for both ANA (n= 4, 20%) and RF (n=2, 10%), other antibodies were negative. The patients in the hematological malignancies had significantly higher serum levels of LDH, Mean±SD U/L compared to solid malignancy group (716.8±169.6 vs. 249.9±161.6, p<0.001).ConclusionIn our cohort, all the patients developed malignancies within 2 years of diagnosis of rheumatic condition. Higher serum LDH levels helpful to differentiates between hematological and solid malignancies. Hence early detection of malignancy is of major importance in these patients.

Adenocarcinoma of the colon presenting with scrotal metastasis: case report and review of the literature

The scrotum is an uncommon site for cutaneous metastases from visceral malignancies. A man with colon cancer, which subsequently developed cutaneous metastasis to the scrotumis described. PubMed medical database was used to search the following terms separatelyand in combination: cutaneous metastasis, skin metastasis, scrotal metastasis, scrotum, rectalcancer, and colon cancer. Cutaneous metastasis most frequently occur in the vicinity of the primary tumor. Skinsites of metastatic cancer may include the abdomen, back, chest, face, scalp, and genitalia. Thereported patient developed metastatic cutaneous lesions of his colon cancer not only on the abdomenbut also on the scrotum. Including our patient, 9 men have been described with metastatic colon orrectal carcinoma localized to the scrotum. The lesions were the presenting sign of malignancy inone man and in the others, the lesions appeared within 24 months of their initial diagnosis ofcancer. The skin metastases were pleomorphic; they appeared as papules, nodules and/or cutaneousinduration. Survival data was only reported in five of the patients. However, colon or rectalmetastases to the scrotum is a poor prognostic sign with a mean survival time of 11 months. Scrotal metastases from carcinoma of the colon or rectum may be the initialpresentation of malignancy or herald the discovery of recurrent disease. The morphology of themetastatic tumor is variable: papules, nodules and/or sclerosis. The development of scrotalmetastases from colon or rectal carcinoma portends a poor prognosis. Most of the patients succumbto theirmetastatic disease within a year.

Gastrointestinal duvar kalınlığına yaklaşım: Prospektif tek merkezli çalışma

Giriş ve Amaç:Çeşitli abdominal şikayetler ile başvuran hastalarda ultrasonografi ve bilgisayarlı tomografi yaygın olarak kullanılmaktadır. Radyolojik yöntemlerde saptanan gastrointestinal sisteme ait duvar kalınlaşması sapta-nan olgularda yaklaşım ve algoritma ile ilgili ortak kabul görmüş bir konsen-sus yoktur.Gereç ve Yöntem:Ocak 2010- Temmuz 2012 tarihleri arasında Ankara E¤itim ve Araştırma Hastanesi Gastroenteroloji Bölümünde, herhangi bir nedenden dolayı abdominal ultrasonografi veya bilgisayarlı tomografi çe-kilen ve gastrointestinal sistem luminal kalınlaşma rapor edilerek endoskopi veya kolonoskopi yapılan hastaların verileri prospektif olarak toplandı. Has-taların yaşları, cinsiyetleri, hematolojik parametreleri, radyolojik incelemede-ki kalınlaşma tespit edilen bölgenin lokalizasyonu, endoskopi ve kolonosko-pi bulguları, patoloji sonuçları ve elde edilen tanıları not edildi.Bulgular: Gastrointestinal sistem duvar kalınlı¤ı saptanan ve takibinde endoskopik in-celeme yapılabilen toplam 129 hasta (49 erkek, 80 kadın) çalışmaya dahil edildi. Hastaların ortalama yaşı 59.78 (20-90,±16.13) idi. Ortalama hemog-lobin düzeyi 12.31 mg/dl (5.8-16.9, ±2.35) olarak bulundu. 60 hastada üst gastrointestinal sistem (özofagus, mide), 69 hastada ise alt gastrointestinal sis-tem (ileum, kolon) duvar kalınlı¤ı saptandı. Üst gastrointestinal sistemde du-var kalınlı¤ı saptanan hastaların 17'sinde (%28.3), alt gastrointestinal sistem-dekilerin ise 32'sinde (%46.4) malign hastalıklar saptandı. Mide adenokarsi-nomlarının %92.9'u (13/14), kolorektal adenokarsinomlarının %96.9'u (31/32) 50 yaşın üzerindeydi. Hemoglobin düzeyi 12.0 mg/dl'nin altında olan olgular incelendi¤inde, üst gastrointestinal sistem duvar kalınlı¤ı sapta-nanların %73,3'ünde, alt gastrointestinal sisteme ait duvar kalınlı¤ı saptanan-ların %72.3'ünde adenokarsinom tespit edilmiştir. Sonuç:Gastrointestinal sistem duvar kalınlı¤ı önemli bir radyolojik bulgu olup özellikle 50 yaşın üze-rinde ve hemoglobin düzeyi 12'nin altında olan hastalarda neoplastik hasta-lıkların ilk bulgusu olabilir. Radyolojik yöntemlerde gastrointestinal sistem duvar kalınlı¤ı saptanan hastalara mutlaka endoskopik de¤erlendirme öneril-melidir.

Palpable Penile Metastases: A Bizarre Presentation of Rectal Adenocarcinoma.

Metastasis to the penis is an uncommon occurrence, with only about 370 cases reported in the literature to date. The majority of the primary tumors are genitourinary in origin. We report on a patient with undiagnosed disseminated rectal adenocarcinoma, who first presented with lesions of the corporal bodies. A review of the literature indicates that corporeal metastasis as an initial presentation of malignancy is an extremely rare occurrence and carries a very poor prognosis.

The Clinical Significance of Incidental Computer Tomography Finding of Gastrointestinal Luminal Wall Thickening as Evaluated by Endoscopy

The widespread use of computerized tomography in evaluating patients with various abdominal complaints gave rise to reports of incidental gastrointestinal luminal wall thickening (GILWT), the clinical significance of which remains uncertain. In order to determine the endoscopic significance of GILWT we reviewed 1609 abdominal and/or pelvic CT scans. Ninety-two patients with GILWT were identified. Patients with obvious clinical cause of this abnormality were excluded from the study. The median age of the patients was 58 years, with no significant difference in gender distribution. The GILWTs were distributed along the GI tract as follows: 24 upper (esophageal, gastric, and duodenum), 13 small intestine (jejunum and ileum), 3 combined small and large intestine, and 52 colon. Fifty of these patients underwent endoscopic evaluation. Six patients (12%) had cancer, all of which involved the colon. The endoscopy was unremarkable in 19 (38%) and revealed a nonmalignant finding in the remaining 25 patients (50%). None of the upper GI or small bowel GILWTs were malignant, while 6 of the 34 colonic GILWTs (18%) were malignant. The mean age of the colonic GILWT group was 59. None of the patients younger than 50 had cancer, while 6 of the 24 older patients (25%) had colon cancer. We conclude that as GILWT is not a common finding and could be the initial presentation of malignancy, particularly when involving the colon in patients older than 50, endoscopic evaluation should be strongly recommended in patients who do not have an alternative diagnosis that can satisfactorily explain GILWT.

P109 Trousseau's syndrome as initial presentation of malignancy. Report of two clinical cases

P109 Trousseau's syndrome as initial presentation of malignancy. Report of two clinical cases

Paraparesia secundaria a metástasis intramedular como manifestación inicial de un carcinoma microcítico de pulmón

Intramedullary metastases (IM) are uncommon and rarely considered the initial presentation of malignancy. Lung and breast cancer account for most of the primary tumors. Magnetic resonance imaging may facilitate recognition of IM in patients with clinical features of myelopathy. A case of a unique intramedullary metastases as the presenting feature of an occult lung cancer is described.

Intramedullary spinal cord metastases: clinical features and treatment outcome.

Our objective was to delineate clinical features and treatment outcome of patients with intramedullary spinal cord metastasis (ISCM). There are no reports of a large experience with this rare cancer complication. We reviewed records retrospectively from 1980 to 1993 to identify patients with histologically confirmed systemic cancer, clinical features of myelopathy, and either tissue-proven ISCM or abnormal neuroimaging findings consistent with ISCM. We identified 40 patients who fulfilled these criteria. In nine, ISCM was the initial presentation of cancer. Nineteen patients had lung primaries (small cell in 12). Twenty-one patients had pain, 35 had demonstrable sensory loss, 37 had weakness, and 25 had urinary incontinence at presentation. Nine patients had true Brown-Séquard syndrome and nine others had pseudo-Brown-Séquard syndrome. Median duration of symptoms at diagnosis was 28 days (range 3 days to 18 months). Thirteen patients had prior brain metastasis, nine had brain metastasis simultaneous with ISCM, and one had brain metastasis after ISCM; 11 had concomitant leptomeningeal metastases. Spinal magnetic resonance findings were abnormal in 30/30 patients, myelographic results were abnormal in 16/20, and eight had pathologic confirmation of ISCM. Thirty-five patients had radiotherapy and five had surgery; four were untreated or treated elsewhere. Median survival was 4 months for patients receiving radiotherapy and 2 months for patients not receiving radiotherapy. Eleven patients survived > 6 months. Twenty-three were ambulatory at ISCM diagnosis, and 21 were ambulatory at letest follow-up. We conclude that ISCM as the initial presentation of malignancy is not rare, and hemicord syndromes occur frequently. Although long-term survival is poor, treatment preserves ambulation in most patients still ambulatory at diagnosis. Focal radiotherapy is indicated in most patients.

Cardiac tamponade as the initial presentation of malignancy: is it as rare as previously supposed?

Advanced malignant disease frequently involves the heart and pericardium, and pericardial effusion is a common postmortem finding in such patients. Identification of pericardial effusions in life is uncommon, however, even when symptomatic. Cardiac tamponade occurring as the first presentation of malignancy appears to be uncommon. We present five cases of cardiac tamponade due to undiagnosed malignancy which presented to a general medical unit over 18 months. The availability of echocardiography was an important factor in correct diagnosis, since clinical features were non-specific. Bronchial adenocarcinoma was the cause in three of the five cases. Review of the literature confirms adenocarcinomas of the bronchus as the most common cause of this complication. The majority of cases have presented with large volume, haemorrhagic effusions, and cytology (with or without carcinoembryonic antigen measurement) was diagnostic in most patients. Immediate treatment with subxiphoid pericardiotomy is recommended; the role of balloon catheter pericardiotomy remains to be established. Combined chemotherapy and radiotherapy appears to extend survival, which in some cases may be prolonged. We recommend that early echocardiography should be obtained in all patients presenting with apparent cardiac failure, since early treatment of malignant effusions provides symptomatic relief.

Cardiac tamponade as the initial presentation of malignancy

We describe a series of five patients who had cardiac tamponade at the time of initial presentation as a result of extracardiac malignancy. Three cases had adenocarcinoma and two had squamous cell carcinoma. The diagnosis of bronchogenic carcinoma was established after appropriate investigations in three cases. One patient possibly had a primary malignancy of the gastro-intestinal tract. The relevant literature is reviewed.

Cardiac Tamponade as the Initial Presentation of Malignancy

Although neoplastic involvement of the pericardium frequently is present postmortem, cardiac manifestations before death are uncommon, and cardiac tamponade as the initial presentation of cancer is rare. In this study, a malignancy was first recognized in eight of 23 patients (35 percent) who presented with cardiac tamponade. Seven of these eight patients had lung and one patient thyroid carcinoma. The prognosis of these eight patients was poor with seven of eight patients dead within a mean of seven weeks (range 2.5 to 16). Overall, pericardial fluid cytology demonstrated a specific diagnosis of malignancy in 14 of 19 patients (74 percent). Earlier recognition of the possibility of malignancy may allow initiation of appropriate local or systemic treatment to lessen the probability of cardiac tamponade and improve survival. We recommend that all patients who present with tamponade have cytology performed on the pericardial fluid, even if malignancy is not suspected initially.