Recent Weight Loss Research Articles

INTERESTING CASES OF LARGE CELL NEUROENDOCRINE LUNG CARCINOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Large-cell neuroendocrine carcinoma (LCNEC) is a rare form of pulmonary tumors with features of small cell lung carcinoma and non-small cell lung cancer. Due to its rarity, there is little known about its presentation and prognosis. We review 2 cases of LCNEC with different outcomes which will help contribute to the current literature of LCNEC. CASE PRESENTATION: Patient A was a 76-year-old male who presented to the Emergency Department with chief complain of dyspnea and shortness of breath. Patient had a history of COPD with 4-5L of home oxygen, hypertension, and a right lung mass. Patient A is a current smoker with 100 pack-year history. He had reported a recent unintentional weight loss of 40 pounds. CT Chest demonstrated a right chest mass measuring 11.9cm. Patient B is a 43-year-old male with no prior smoking history who presented to the ED with complaints of myalgias, sore throat, fevers, and shortness of breath. Patient A also began having generalized weakness, unintentional weight loss of 20lbs, and hoarseness which increased over the past month. Chest CTA demonstrated a large multi-spatial mediastinal mass with confluent adenopathy extending to the left hilum. Both patients underwent endobronchial ultrasound-guided biopsy with bronchioalveolar lavage that demonstrated large cell neuroendocrine carcinoma of the lung. Patient A underwent diagnostic studies 4 month after the mass was detected and Patient B underwent diagnostic studies the following day after mass detection. Patient A experiences an extended stay in the medical intensive care unit and was ultimately admitted to hospice. Patient A expired 24 hours after admission to hospice. Patient B began systemic chemotherapy and radiation with and oncologist and is currently improving. DISCUSSION: Further studies are aimed towards finding similarities in symptoms or laboratory values in order to identify this aggressive carcinoma earlier in its course. Our case reports highlight the aggressive nature of LCNEC. It reveals that advanced age, pulmonary comorbidities and delayed diagnosis all feed into a poor prognosis for LCNEC. CONCLUSIONS: LCNEC is an aggressive cancer that warrants an expediated work-up and early treatment. With time as we analyze more cases of LCNEC, our understanding of the cancer will improve. This will pave the way for better treatment and better prognosis in patients suffering from LCNEC. REFERENCE #1: Berry, M. F. (2020). Approach to the adult patient with a mediastinal mass. UpToDate. https://www-uptodate-com.mwu.idm.oclc.org/contents/approach-to-the-adult-patient-with-a-mediastinal-mass?search=Approach%20to%20the%20adult%20pateint%20with%20a%20mediastinal%20mass&source=search_result&selectedTitle=1˜150&usage_type=default&display_rank=1 REFERENCE #2: Glisson, B. S. (2020). Large cell neuroendocrine carcinoma of the lung. UpToDate. https://www-uptodate-com.mwu.idm.oclc.org/contents/large-cell-neuroendocrine-carcinoma-of-the-lung?search=Large Cell Neuroendocrine Carcinoma of the Lung&source=search_result&selectedTitle=1˜16&usage_type=default&display_rank=1 REFERENCE #3: Tazelaar, H. D. (n.d.). Pathology of lung malignancies. UpToDate. https://www-uptodate-com.mwu.idm.oclc.org/contents/pathology-of-lung-malignancies?search=Pathology of lung malignancies&source=search_result&selectedTitle=1˜150&usage_type=default&display_rank=1 DISCLOSURES: No relevant relationships by Andriana Saric, source=Web Response

CLOT OR NOT? AN UNUSUAL CTEPH MIMIC

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of severe pulmonary hypertension (PH) resulting from pulmonary thromboembolic events with subsequent remodeling of pulmonary vasculature. As one of the few forms of PH with potentially definitive management via pulmonary thromboendarterectomy (PTE), it is imperative that the diagnosis of CTEPH involves careful assessment of the patient's history and available studies, including echocardiograms, ventilation-perfusion (V/Q) scans, computed tomography (CT) scans, right heart catheterizations, and pulmonary angiography. This is especially true when considering other conditions that may mimic the presentation of CTEPH. Herein, we discuss a rare instance of pulmonary artery sarcoma (PAS) mimicking CTEPH in a patient with progressive shortness of breath. CASE PRESENTATION: A 53-year-old female with past medical history remarkable for breast cancer status-post lumpectomy and radiation on adjuvant anastrazole monotherapy presented to an outside hospital for progressive shortness of breath and weight loss. CT chest angiography suggested large pulmonary embolism clot burden, and the patient subsequently underwent catheter-directed thrombolysis with tissue plasminogen activator in bilateral pulmonary artery catheters for 24 hours, with minimal change in mean pulmonary artery pressures between times of insertion and removal. The patient subsequently transferred institutions for consideration of PTE.Review of her CT scans and a new V/Q scan suggested a more lobulated, large volume appearance of the obstructing material in her pulmonary vasculature, raising concern for malignant obstruction as opposed to CTEPH. Subsequent positron emission tomography (PET) CT scan showed equivocal fluorodeoxyglucose (FDG) uptake. The patient was brought to surgery, wherein bilateral intravascular tumor involving the main pulmonary artery extending into both branches was discovered consistent with PAS. The mass was extracted, and the patient was eventually discharged with oncologic follow-up, with post discharge course complicated by metastatic disease currently undergoing her third line of therapy. DISCUSSION: This case demonstrates the complexity diagnosing CTEPH. Important mimics of CTEPH outside of PAS include fibrosing mediastinitis, sarcoidosis, large vessel vasculitis, amongst others. Early clinical clues suggesting against the patient's initial diagnosis include recent weight loss and the lobulated appearance of the pulmonary arterial mass. The prognosis of PAS is extremely poor, due to diagnostic and management delays given the stark similarity to CTEPH, with mean survival rates between 12 and 18 months. (1,2) CONCLUSIONS: Diagnosis and management of CTEPH requires expert, multidisciplinary care, especially with the complexity of properly diagnosing the condition amidst other possible mimicking conditions. REFERENCE #1: Bandyopadhyay D, et al. Primary pulmonary artery sarcoma: a close associate of pulmonary embolism-20-year observational analysis. J Thorac Dis 2016; 8: 2592–2601. REFERENCE #2: Wong HH, et al. Presentation and management of pulmonary artery sarcoma. Clin Sarcoma Res 2015; 5: 3. DISCLOSURES: No relevant relationships by Adam Custer, source=Web Response No relevant relationships by NEVEEN El-Farra, source=Web Response No relevant relationships by Jane Wang, source=Web Response No relevant relationships by Alexander Yuen, source=Web Response

Patient-Generated Subjective Global Assessment (PG-SGA) predicts length of hospital stay in lung adenocarcinoma patients.

The prevalence of malnutrition is high among oncology patients in Northern China. Malnutrition is related to the longer hospital stay, and it can be used to predict the prognostic outcome of patients. This work focused on investigating the relationship of nutritional condition with the length of hospital stay (LOS) in Northern Chinese patients with lung adenocarcinoma (LUAD). The Patient-Generated Subjective Global Assessment (PG-SGA), Nutritional Risk Screening 2002 (NRS 2002) score, recent weight loss and BMI were assessed in a probabilistic sample of 389 LUAD patients without epidermal growth factor receptor (EGFR) mutations. This study collected the demographic and clinical features of patients in a prospective manner. Then, we examined the association of nutritional status with LOS among the population developing LUAD. According to the PG-SGA, 63 (16·3 %), 174 (44·7 %) and 78 (20·1 %) patients were at risk for undernutrition, moderate undernutrition and severe undernutrition, respectively. Nutritional risk was found in 141 (36·2 %) patients based on the NRS 2002. The average LOS for tumour patients in Northern China was 12·5 d. At admission, a risk of undernutrition or undernutrition according to the PG-SGA (P < 0·001), NRS 2002 (P < 0·001) and latest weight loss (P < 0·001) predicted the longer LOS. LOS was related to nutritional status and hospitalisation expenses (P < 0·001). LUAD patients who stayed in the ICU had a poorer nutritional status and a longer LOS (P < 0·001). In Northern Chinese patients with LUAD, a risk for undernutrition evaluated by the PG-SGA, the NRS 2002 and recent weight loss, but not BMI, could predict a longer LOS.

PD07-06 PREDICTING OUTCOMES AFTER ADRENALECTOMY USING THE 5-ITEM FRAILTY INDEX (5I-FI) IN THE ACS-NSQIP DATABASE

You have accessJournal of UrologyAdrenal (PD07)1 Sep 2021PD07-06 PREDICTING OUTCOMES AFTER ADRENALECTOMY USING THE 5-ITEM FRAILTY INDEX (5I-FI) IN THE ACS-NSQIP DATABASE Krishna Ravivarapu, Evan Garden, Alexander Small, Osama Al-Alao, and Michael Palese Krishna RavivarapuKrishna Ravivarapu More articles by this author , Evan GardenEvan Garden More articles by this author , Alexander SmallAlexander Small More articles by this author , Osama Al-AlaoOsama Al-Alao More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001975.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To evaluate the condensed 5-item frailty index (5i-FI) as a predictor of postoperative complications as well as healthcare resource utilization (HCRU) outcomes in a contemporary cohort of adrenalectomy patients. METHODS: All MIS and open adrenalectomy cases recorded in the National Surgical Quality Improvement Program database (2015-2018) were analyzed. Primary outcomes of interest were postoperative complications, classified as Clavien-Dindo (CD) I/II or CD IV, and increased HCRU. HCRU outcomes were prolonged (>75th percentile) length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). 5-iFI score was calculated for each patient by adding one point for each of the following: impaired functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure within 30-days of surgery, and hypertension requiring medication. Multivariate logistic regressions were used to evaluate 5-iFI score groups (0, 1, 2, ≥3) as independent predictors of clinical and HCRU outcomes, adjusting for age, sex, BMI, race, hispanic ethnicity, smoking status, immunosuppressant use, MIS approach, malignant neoplasm, disseminated cancer, recent ascites, dialysis status, recent weight loss, and bleeding disorders. RESULTS: A total of 4358 patients were included, of which 3578 (82.1%) underwent MIS adrenalectomy. Higher 5i-FI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p <0.05). Multivariate analysis controlling for available demographic, surgical, and pathologic factors showed that several 5i-FI scores are independent predictors of adverse clinical and HCRU outcomes (Table 1). CONCLUSIONS: The 5i-FI has potential as a practical frailty-based preoperative risk assessment tool in adrenalectomy. Understanding frailty is important for preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions to minimize postoperative burdens. Further work is needed to balance the practicality, scope, and predictive accuracy of frailty assessment tools. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e107-e107 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Krishna Ravivarapu More articles by this author Evan Garden More articles by this author Alexander Small More articles by this author Osama Al-Alao More articles by this author Michael Palese More articles by this author Expand All Advertisement Loading ...

Development and Validation of a Nutritional Risk Screening Scale for Stroke Patients

IntroductionStroke is a global health problem, and around 62% of stroke patients suffer from malnutrition due to dysphagia, eating speed, or stress response. This study aimed to develop a Nutritional Risk Screening Scale for Stroke Patients (NRSS-SP).Material and methodsIn the current study we construct a theoretical framework by combining stroke characteristics, the risk factors of malnutrition in stroke patients, and clinical experience. Then, using the Delphi method, we formed a pool for entries and combined the opinions and suggestions discussed by experts in a research team. Next, we collected all of the data and information, categorized, merged, and split the pool of entry items' contents. Finally, we formed a pretest scale comprising 11 items after scoring their importance.ResultsThe pretest NRSS-SP comprised 10 items in three fields: physical, psychological, and independence. The score was assigned to each factor according to the evaluation results. (e.g., Disease severity, serum albumin and dysphagia: Score 3, age ≥70 years: Score 1). The cumulative effect of four factors (depression, anxiety, serum level of albumin, and body mass index (BMI)) was 65.512%. The item-level Content Validity Index (CVI) of the NRSS-SP ranged from 0.081 to 1.000, and the scale-level CVI was 0.912. The coefficient of Cronbach’s α ranged from 0.822 to 0.911.ConclusionsAn NRSS-SP (including National Institutes of Health Stroke Scale score, BMI, serum level of albumin, recent weight loss, recent food intake, dysphagia, age, depression, anxiety, and Barthel Index) score ≥6.5 was classified as a malnourishment risk; an NRSS-SP score &lt;6.5 denoted normal nutrition.

NRS-2002 components, nutritional score and severity of disease score, and their association with hospital length of stay and mortality

Malnutrition is a substantial issue in hospitals, leading to prolonged length of hospital stay, increased perioperative morbidity and increased mortality. There are several validated screening tools for malnutrition, one of which is the Nutritional Risk Screening 2002 (NRS). It screens patients based on recent weight loss, reduction of recent food intake, body mass index (BMI), severity of disease and age. Higher NRS scores have been shown to be negatively associated with patients&rsquo; outcomes such as increased morbidity and mortality. The aim of the study was to evaluate how the two NRS components Nutritional Score (NS) and Severity of Disease Score (SDS) are associated with patients&rsquo; length of hospital stay and mortality. All patients admitted to the medical department of a large community hospital in Switzerland were screened for malnutrition using the nutrition screening NRS during the years 2014 to 2017. Data on patients&rsquo; NRS, primary diagnosis, number of secondary diagnoses, mortality, length of stay (LOS), discharge, sex and age were collected. The association between the NRS components and LOS/mortality was estimated using a linear mixed-effects regression model and a logistic regression model, respectively, with adjustment for confounders (age, sex, comorbidity, diagnosis group, mode of discharge and year of hospitalisation). The evaluation of the outcomes of 21,855 hospitalisations demonstrated that the NS was associated with an increment in the LOS of 5.5&ndash;12.3% per score point, depending on the diagnosis group. An increase in the SDS by one point was associated with an increase in the LOS of 2.2&ndash;11.3%. The odds for all-cause in-hospital mortality were increased by 44.1% (95% confidence interval [CI] 33.7&ndash;55.2%) per point in the NS, and by 73% (95% CI 57.5&ndash;90.1%) per point in the SDS. Increases in both components of the NRS are associated with longer LOS. The NS has a slightly stronger impact on LOS compared to the SDS and its effect is dependent on the patient&rsquo;s diagnosis group. Increases in the SDS are linked to a higher mortality than increases in the NS.

Plant Based Foods to Improve Metabolic Health in Prediabetics – Protocol for a Randomized Controlled Trial

ObjectivesThe study will investigate the effectiveness of an Asian food based intervention to improve metabolic health, notably glucose homeostasis in a prediabetic population. MethodsA parallel design randomized controlled trial will be conducted in Chinese prediabetics aged 45–75 years, BMI 19.5–32 kg/m2. Prediabetes defined according to the American Diabetes Association guideline: fasting blood glucose 5.6–6.9 mmol/l or hemoglobin A1c 5.7–6.4% or 2-hr oral glucose tolerance test 7.8–11.0 mmol/l. Major exclusion criteria were: smoking, food allergies or intolerances to common food ingredients, dietary restrictions, sustained hypertension (>160/95 mmHg), history of metabolic, cardiac, liver or kidney disorders, thyroid dysfunction and recent weight loss. The dietary intervention will last for 16 weeks, where volunteers will consume 2 specially formulated main meals per day, provided as pre-cooked, frozen, ready-meals (approximately 400 kcal each). The treatment group (TG) meals will be prepared with legumes, low GI rice or noodles, blended vegetable oil and added mixed herbs and spices. The control group (CG) meals, isocaloric, will consist of a portion of chicken, a portion of vegetables, medium to high GI rice or noodles and negligible herbs and spices. The male volunteers will be provided additional 100 kcal snacks containing either wholegrain cereals and nuts/seeds (TG) or refined cereal snack products (CG). The daily meals and snacks for rest of the day will be chosen freely, while a dietitian limits the total average calorie consumption to ensure around 5% weight loss in both groups. The effects of dietary interventions on metabolic health will be assessed at every 4 week intervals. The primary outcome measures will include several markers of glucose homeostasis (including HbA1c, fasting glucose, fasting insulin and a 2-hr oral glucose tolerance test [OGTT]). The secondary outcomes will include lipid profile, fructosamine, adiponectin, markers of oxidative stress and chronic inflammation. ResultsThe recruitment for the study has been completed (n = 256 screened, n = 123 suitable). The dietary intervention will commence in March 2021 and expected to be completed in July 2021. ConclusionsN/A. Funding SourcesJointly funded by the National University of Singapore, Agency of Science Technology and Research, Singapore, and Wilmar International Limited.

Female cancer survivors are more likely to be at high risk of malnutrition and meet the threshold for clinical importance for a number of quality of life subscales.

The present study aimed to explore malnutrition risk, handgrip strength and quality of life (QOL) in cancer survivors. In total, 232 individuals completed a demographic questionnaire, Patient-Generated Subjective Global Assessment Short Form and the European Organization for Research and Treatment of Cancer QOL Questionnaire (EORTC QLQ-C30). Handgrip strength was determined using a spring-loaded handgrip dynamometer and anthropometric measurements were taken by an oncology nurse. Frequencies and distribution data, analysis of variance and chi-squared tests were then conducted. The majority of the cohort were female (n=141; 60.8%) had breast cancer (n=62; 26.7%) and the mean±SD body mass index (BMI) was 26.6±6.2kgm-2 . Less than a one-third reported seeing a dietitian (n=68; 29.3%). Over one-third reported recent weight loss (n=88; 37.3%). Some 40.9% (n=95) were at moderate to high risk of malnutrition, with women more likely than men to be classified as high risk (p<0.05). Mean±SD handgrip strength was 25±15kg and this differed significantly by gender (p=0.00), cancer type (p=0.01) and BMI classification (p=0.01). One-fifth of individuals were classified as having dynapenia (n=48; 21.1%). Median (interquartile range) QOL score was 66.7 (33.3). The proportion of individuals meeting the threshold for clinical importance for QOL subscales ranged from 12.5% (constipation) to 42.7% (physical functioning). Females were more likely than males to meet the threshold for physical functioning (p=0.00), fatigue (p=0.02) and pain (p=0.01). Females are more likely than males to be at high risk of malnutrition and meet the threshold for clinical significance for several QOL subscales.

Nutritional status and symptom burden in advanced non-small cell lung cancer: results of the dietetic assessment and intervention in lung cancer (DAIL) trial

IntroductionEuropean Society for Clinical Nutrition and Metabolism guidelines recommend that patients with cancer should be screened for malnutrition at diagnosis. The dietetic assessment and intervention in lung cancer study investigated...

Primary laparoscopic repair of perforating fishbone injury of the small bowel

A 69-year-old man presented to the emergency department with a 2-day history of worsening right iliac fossa pain. He denied any associated nausea, fevers, change in bowel habit, urinary symptoms...

Wilkie’s Weight Loss Wonder: A Case Series

INTRODUCTIONWilkie’s Syndrome, also known as Superior Mesenteric Artery Syndrome (SMAS), is a rare cause of bowel obstruction that can contribute to vague abdominal symptoms on clinical presentation. This syndrome occurs when the aortomesenteric angle decreases, compressing the third portion of the duodenum between the aorta and the superior mesenteric artery. An acute decrease in the mesenteric fat pad cushion between these two blood vessels is the primary etiology, although other causes (e.g., anatomical, postoperative, functional, and pubescent etiologies) have also been described.CASE PRESENTATIONIn the present cases, 2 females with a common history of recent weight loss presented to our institution with similar symptoms of abdominal pain, nausea and vomiting. Each patient was subsequently diagnosed with SMAS following imaging studies. Both patients experienced successful resolution of symptoms with conservative nutritional management.DISCUSSIONCommon presenting complaints of SMAS include nausea, vomiting, early satiety and postprandial pain. These symptoms overlap with other gastrointestinal disorders (i.e., mesenteric ischemia, intestinal volvulus, peptic ulcer disease) making diagnosis difficult. SMAS can be identified through imaging modalities including barium studies and computer tomography. First line therapies typically include conservative nutritional support and promotion of weight gain. If conservative therapies fail, various surgical procedures can be pursued. Delayed diagnosis can lead to further pathological sequelae, including duodenal compromise, ischemia and necrosis. As the syndrome progresses, success of conservative nutritional support is less likely, and surgical correction becomes increasingly necessary.CONCLUSIONTherefore, a clinical goal for SMAS should include as swift a recognition and diagnosis as possible.

Association Between Patient-Reported Frailty and Non-Home Discharge Among Older Adults Undergoing Surgery.

Identifying surgical patients at risk for discharge to a post-acute facility has the potential to reduce hospital length of stay, improve postoperative planning, and increase patient satisfaction. We sought to examine the association between a positive response to a preoperative patient-reported frailty screen and non-home discharge (NHD). Prospective cohort. Urban tertiary academic preoperative evaluation center. Convenience sample of patients aged 60 and older evaluated from November 2018 to August 2019) undergoing one of 14 major elective general and vascular operations with an expected length of stay of 3 days or longer. Items from the previously validated Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL) screen were modified, and patients were queried on fatigue, activity against resistance, ambulation, and weight loss. Multivariable logistic regression adjusting for age and sex was used to determine the association between patient-reported items and NHD. A total of 230 patients were included for analysis. The average age of the cohort was 70.1 (standard deviation = 7.1); 91.7% were White, and 52.4% were female. There were 24 patients (10.4%) who were not discharged home. They were more likely to report fatigue (54% vs 29%; P = .01), weight loss (58% vs 21%; P < .01), and difficulty with activity against resistance (33% vs 7%; P < .01) before surgery. In adjusted analysis, patients who self-reported frailty (FRAIL screen ≥2) were significantly more likely to have an NHD (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 1.7-11.7; P < .01), as were patients who responded "yes" to any question from the FRAIL screen (OR = 2.5; 95% CI = 1.7-3.5; P < .01). A positive response to difficulty with activity against resistance or recent weight loss showed similar odds of NHD (OR = 7.6; 95% CI = 2.6-23.9; P < .01; and OR = 7.9; 95% CI = 2.9-21.6; P < .01, respectively). Patient response to screening questions on the FRAIL screen identified those at highest risk of NHD. The FRAIL screening tool is practical, easy to apply, and could be used during preoperative counseling to identify patients likely to have increased discharge planning needs.

Peptide receptor radionuclide therapy controls inappropriate calcitriol secretion in a pancreatic neuro-endocrine tumor: a case report

BackgroundHypercalcemia of malignancy is not uncommon in patients with advanced stage cancer. In rare cases the cause of the hypercalcemia is excessive production of calcitriol, the active form of vitamin D. Although inappropriate tumoral secretion of calcitriol is typically associated with lymphomas and some ovarian germ cell tumors, we present a case of calcitriol overproduction-induced hypercalcemia due to a pancreatic neuroendocrine tumor. The high expression of somatostatin receptors on this neuroendocrine neoplasm opened up the opportunity to treat the patient with radiolabelled somatostatin analogs, which successfully controlled the refractory hypercalcaemia and calcitriol levels. This case documents a rare finding of refractory hypercalcaemia of underlying malignancy due to a calcitriol-producing pancreatic neuroendocrine tumor, responding to peptide receptor radionuclide therapy (PRRT).Case presentationA 57 years-old patient presented with back pain, general discomfort, polydipsia, polyuria, fatigue and recent weight loss of 10 kg. Clinical examination was normal and there was no relevant medical history. Biochemical evaluation showed hypercalcemia with markedly increased calcitriol levels. CT-thorax-abdomen and ultrasound guided biopsy revealed a pancreatic neuroendocrine tumor with multifocal liver metastases, suggesting that excessive overproduction of calcitriol by this neuroendocrine tumor was the cause of the refractory hypercalcemia. The patient was eligible for PRRT. Four cycles of 177Lu-DOTATATE PRRT resulted in a morphological response and a normalization of serum calcium levels, confirming the hypothesis of a calcitriol producing pancreatic neuroendocrine tumor. Progression of liver metastases warranted further therapy and temozolomide-capecitabine was started with morphological and biochemical (serum calcium, calcitriol) stabilization.ConclusionAlthough up to 30–40% of gastroenteropancreatic neuroendocrine tumors are known to be functional (i.e. producing symptoms associated with the predominant hormone/peptide secreted), calcitriol secreting pancreatic neuroendocrine tumors are very rare. However, treatment with PRRT resulted in normalization of calcium and calcitriol levels, strongly supporting the hypothesis of a calcitriol-producing pancreatic neuroendocrine tumor.

S3450 Metastatic Diffuse B-Cell Lymphoma Presenting With Gastrointestinal (GI) Bleeding

INTRODUCTION: Diffuse B-Cell Lymphoma (DBCL) is an aggressive, high-grade cancer that arises from neoplastic proliferation of B cells. Primary gastrointestinal (GI) lymphoma is the most common type of extranodal lymphoma and occurs in 30-40% cases. This case report is unique in that it highlights a patient who presented with GI bleeding due to metastatic DBCL. CASE DESCRIPTION/METHODS: A 64 yearold male with a history of coronary artery disease (CAD) status and atrial fibrillation on apixaban, clopidogrel, and aspirin presented to the emergency room with a one day history of hematemesis and melena. He denied a loss of consciousness, fall, chest pain, headache, fevers, or recent weight loss. Patient had no endoscopic history. The patient was tachycardic, hypotensive, and tachypneic on presentation. Physical exam was notable for diffuse lymphadenopathy. Lab findings included an initial hemoglobin of 9.4 g/dL, a blood urea nitrogen (BUN) of 62 mg/dL, and creatinine of 1.51 mg/ dL. Computed tomography (CT) abdomen and pelvis showed extensive lymphadenopathy, multiple small splenic lesions, and pulmonary nodules concerning for lymphoma (Figure 1). Esophagogastroduodenoscopy (EGD) showed a medium-sized ulcerated bleeding mass on the greater curvature of the stomach (Figure 2a). Hemostasis was achieved with epinephrine and two hemostatic clips (Figure 2b). Gastric ulcer biopsy showed diffuse large B-cell lymphoma. Excisional biopsy of a left axillary lymph node showed large B-cell lymphoma. The patient received chemotherapy with rituximab, cyclophosphamide etoposide, vincristine, and prednisone (R-CHOP) with plans for continued oncology treatment and follow-up. DISCUSSION: Cases of gastric DBCL are rare.This case report highlights a patient who presented with gastrointestinal bleeding due to metastasis of DBCL to the stomach. DBCL is aggressive and first line treatment is with R-CHOP. Surgery is second-line treatment for cases with perforation and severe bleeding. Clinicians should consider metastatic DBCL as a rare cause of GI bleeding with other supportive findings such as lymphadenopathy. Earlier diagnosis and treatment of DBCL will lead to improved prognosis.Figure 1.: CT abdomen and pelvis shows extensive adenopathy.Figure 2.: Figure 2a. Bleeding ulcer on greater curvature of stomach.Figure 3.: Figure 2b. Hemostasis of ulcer with clips.

Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery.

To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events. The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy. A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations (P = 0.020), higher length of hospitalization (P < 0.001), and higher mortality (P = 0.027) and readmission rates (P = 0.023). Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.

S1455 A Rare Case of Poorly Differentiated Metastatic Extra-Pulmonary Neuroendocrine Tumor in an HIV Patient

INTRODUCTION: HIV infected individuals have an increased risk of malignancies such as Kaposi sarcoma, primary central nervous system lymphoma, non-Hodgkin lymphom, and cervical cancer. The incidence of non-AIDSdefining tumors such as Neuroendocrine Tumor (NET) has not been well reported in the literature. Majority of NETs occur in the gastrointestinal tract (almost 68%) and bronchopulmonary tree (about 25%). Of the GI NETs, most are in the small intestine with less than 1% of pancreatic origin. We present an HIV patient with primary pancreatic NET with metastasis to the liver. CASE DESCRIPTION/METHODS: A 56-year-old African American male with history of HIV currently on antiretrovirals presented with complaints of non-radiating chest pain, shortness of breath, back pain, dizziness, night sweats, nausea, constipation, and recent weight loss. Patient is a current non-smoker with 30 pack year history, no recent travel or sick contacts. Initial workup, including CBC, CMP, EKG, and chest x-ray on admission were unremarkable. Physical exam and vital signs were within normal limits; however, due to the presenting symptoms, CTA of the chest was obtained revealing an incidental finding of a hypodense soft tissue mass highly suspicious for lymphoma. Follow up CT Abdomen and Pelvis with contrast revealed retroperitoneal and periportal lymphadenopathy along with a 3.7 cm Liver mass, suggestive of lymphoma with soft tissue metastasis. In view of these findings the primary working diagnosis was HIV associated lymphoma. However, CT guided liver and lymph node biopsy pathology favored metastatic large cell neuroendocrine carcinoma, most probable primary in pancreas. DISCUSSION: Even though there are malignancies commonly associated with HIV and AIDS, it is important to keep a broad differential when working up a patient with HIV. The incidence of ADC decreased 2-3 folds since 1998 while NADC increased in incidence but no variance of standardized in the same time frame. This has been attributed to the introduction of combination antiretroviral therapies that increased HIV patients life expectancy and allowing them to be at the same risk of developing age-related cancers as the general population. NET in HIV positive patients in sites other than lungs and skin has not been well characterized. Previous study has shown a correlation between Merkel Cell carcinoma and concurrent HIV infection, and it is unclear if our pancreatic cancer is sporatic or associated with HIV infection.

S1774 Primary Anorectal Malignant Melanoma: Rare and Fatal

INTRODUCTION: We present an uncommon diagnosis of primary anorectal malignant melanoma (ARMM) in a patient with anemia and altered bowel habits. Primary ARMM accounts for less than 4% of anorectal malignancies and less than 1.5% of all melanomas. ARMM can often go undiagnosed, which is detrimental to patients due to its aggressive nature. CASE DESCRIPTION/METHODS: 63 y.o. African American male with a history of ascending colon resection for colon adenocarcinoma 8 years prior was referred for change in bowel habits and nausea with eating. He had worsening intermittent constipation, but denied melena or blood in his stool. He had nausea 45 minutes after eating but no vomiting. He denied recent weight loss. His last colonoscopy was a year after colon resection. The ileocolonic anastomosis was at 70 cm from anal verge, there was a 3 mm hyperplastic polyp in the sigmoid and repeat colonoscopy was recommended in a year. Physical exam was negative for skin hyperpigmentation, moles or lesions. Abdominal exam was negative for tenderness, guarding or rebound. Labs showed normocytic anemia, Hgb 8.1 g/dl from 12 g/dl the year prior. Digital rectal exam revealed a firm immobile mass, 3 cm from anal verge. Colonoscopy showed a fungating, ulcerated, non-obstructing 3 cm mass in the rectum. Biopsies were done with cold forceps for histology. Pathology noted the mass had brownish pigmentation and extensive necrosis, consistent with malignant melanoma. Immunohistochemical staining was positive for S-100, HMB-45, Melan-A and SOX-10 supporting the diagnosis. A diagnosis of primary anorectal malignant melanoma was made as patient had no evidence of cutaneous or ocular melanoma. PET scan showed metastasis to a large pelvic lymph node so patient was not a surgical candidate. Oncology started patient on immunotherapy with ipilmumab and nivolumab. DISCUSSION: Primary ARMM is a rare malignancy, especially in African Americans such as our patient, with a poor prognosis. As with our case, presenting symptoms can be unspecific such as anemia. Often patients with ARMM present with rectal bleeding that is attributed to hemorrhoids and endoscopic intervention is not pursued. This is detrimental as it causes a delay in diagnosis. Our patient’s mass was pigmented, but in 29% of cases the mass may be amelanotic resulting in misdiagnosis. Treatment is abdominoperineal resection if there is no evidence of metastasis. Our case highlights the importance of recognizing primary ARMM as a cause of rectal bleeding in patients with an anorectal mass.Figure 1.: Retroflexed view in the rectum revealing the pigmented, ulcerated, non-obstructing 3 cm mass at 3 cm from anal verge.Figure 2.: The mass is composed of melanoma cells that formed irregular nests and cords, and manifested enlarged and hyperchromatic nuclei with irregular nuclear contours and prominent nucleoli. The pigments were finely granular and brownish. (H&E, x200).Figure 3.: Immunohistochemistry demonstrated the tumor cells to be positive for S-100 (Fig. A, cytoplasmic stain, fast red; X100), HMB-45 (Fig. B, cytoplasmic stain, fast red; X100) and SOX-10 (Fig. D, nuclear stain, fast red; X100). They were negative for expression of pan-cytokeratin, the brown granules in the background are melanin pigments (Fig.C, AE1/3, lack of cytoplasmic stain, DAB; X100).

S3447 Atypical Symptomatology, a Call to Keep an Open Differential List

INTRODUCTION: Appropriate suspicion with atypical presentations can serve as a screen for dangerous conditions, especially important as these conditions may have grim outcomes. This case depicts a primary mediastinal choriocarcinoma (CCA) in a male; a rare tumor often with complicated diagnosis and treatment. According to reported cases, these neoplasms often metastasize early and can be rapidly fatal even with treatment. Of note, this malignancy was detected via thorough history taking at a gastrointestinal (GI) clinic visit. We would like to highlight the importance of maintaining awareness for rarer entities while pursuing the more common differentials. CASE DESCRIPTION/METHODS: The patient is a 42 year old male who was referred to a GI clinic for symptoms including epigastric pain and hematemesis with positive H. pylori stool antigen and initiation on quadruple therapy for the H. pylori. At the GI appointment, he reported persistent symptoms despite treatment. Upon further questioning, he also reported recent weight loss and clarified he had hemoptysis rather than hematemesis. In response to his atypical symptoms, a more ominous disease process was considered with ordering of a chest x-ray. Unfortunately, this imaging demonstrated a mediastinal lung mass with metastases. The patient was referred for further evaluation at an emergency department. A CT scan confirmed the findings and alpha-fetoprotein and beta-HCG levels were markedly elevated suggesting CCA. Testicular ultrasound did not show a primary testicular mass. Due to long term GI symptoms, the patient had endoscopic studies performed with benign results. Initial biopsies of a pulmonary mass were read as squamous cell carcinoma but repeat biopsies yielded results consistent with stage IIIC CCA. Chemotherapy was promptly initiated and now four months post-initiation of treatment, he has had improvement in symptoms, labs, and imaging markers. DISCUSSION: Primary mediastinal CCAs are exceedingly rare tumors often with poor prognoses. In this case, the malignancy was detected by a gastroenterologist recognizing an atypical presentation. The patient is now showing improved symptoms after treatment initiation. The patient could have had rapid deterioration and an ultimately fatal outcome in these past few months following had his atypical symptoms not elicited suspicion with further investigation. This report is meant to serve as a call to action to keep a broad differential when evaluating patients keeping in mind that while rare, zebras do exist.

Factors Contributing to Extended Hospital Length of Stay in Emergency General Surgery†

Background Emergency general surgery (EGS) is a field characterized by disproportionately high costs, post-operative mortality, and complications. We attempted to identify independent factors predictive of an increased postoperative length of stay (LOS), a key contributor to economic burden and worse outcomes. Methods The ACS-NSQIP database was queried for data from2005 to 2017. Current procedural terminology (CPT) codes were used to identify the most commonly performed EGS procedures: appendectomy, bowel resection, colectomy, and cholecystectomy. Cohorts above and below 75th percentile LOS were determined, compared by preoperative variables, and evaluated with univariate and multivariate logistic regression to quantify risk. Results Of 267,495 cases, 70,703 cases were above the 75th percentile for LOS. A larger proportion of patients in the extended LOS group were 41 years or older (88.6% vs 45.7%). More Blacks (10.3% vs 6.7%) were observed in the extended LOS group. Age, race, cardiopulmonary, hepatic, and renal disease, diabetes, recent weight loss, steroid use, and sepsis history were significant factors on multivariate analysis but varied in terms of risk proportion by procedure. Age (61+), Black race, hypertension, sepsis, and cancer were significant for all 4 procedures. Conclusions Several factors are independently associated with extended LOS for those undergoing the most common EGS procedures. Five of these were associated with an increased LOS for all four procedures. These included, age (61+), hypertension, sepsis, cancer, and Black race.

Fat density is a novel prognostic marker in patients with esophageal cancer.

While long-term obesity is a well-known risk factor for esophageal adenocarcinoma (ADC), recent weight loss represents a significant concern in esophageal cancer (EC), in relation with dysphagia and disease aggressiveness. These phenomenons may diversely impact the adipose tissue density, suggested in other cancer settings as an important prognostic biomarker. The analysis of body mass composition (BMC) parameters, including adipose tissue attenuation is studied here in a population of EC operated with curative intent. BMC was retrospectively evaluated on Computed-Tomography (CT)-scan images from fluorodeoxyglucose (FDG)-positron-emitting (PET)/CT scans performed as a diagnostic procedure in a cohort of 145EC patients operated with curative intent The mean subcutaneous (SFD) and visceral fat (VFD) density along with the index (area/height2) (SF index (SFI), VF index (VFI)) were assessed on two adjacent slides at the third lumbar vertebra level by two independent investigators. Overall survival (OS) was calculated from the date of the baseline FDG-PET/CT scan. Inter-observer correlations are excellent for all BMC parameters (r=0.94-0.99). As expected, weight loss is associated with worse outcome. We show that low SFD (HR 0.5 (95% CI: 0.3-0.7), p<0.001) and low VFD (HR 0.6 (95% CI: 0.4-0.9), p=0.04) at diagnosis are associated with better OS. In contrast, body mass index (BMI) fails to show any relevance in predicting survival. Adipose tissue density is an important prognostic factor in EC.