WCIM 2014 SEOUL KOREA 193
Poster Session
The Korean Journal of Internal Medicine Vol. 29, No. 5 (Suppl. 1)
PS 0569 Oncology
Pancreatic Cancer Causing Heart Failure
Armando LOPES BRAZ1, Tiago MASCARENHAS1, Conceição QUADRADO1, José BRAZ NOGUEIRA1
Hospital Santa Maria, Portugal1
A 67-year-old patient was sent to the internal medicine consultation due to dyspnea, orthopnea and lower limb edemas for 6 month, which got worse in the past 2 weeks, with diffi cult stabilization and control, even with intense therapy for heart failure.
The therapy was improved and an echocardiogram was requested. One month later she was reevaluated showing no clinical improvement, so she was admitted in the internal medicine ward. The echocardiogram showed an ejection fraction of 21%, increased right chambers, severe pulmonary hypertension and left ventricle dilatation with depressed cardiac function. The therapy for heart failure was optimized and a ventilation-perfusion scyntigraphy was performed to evaluate the respiratory system.
It revealed areas of pulmonary collapse and pulmonary embolism. On the ward she suffered a sudden episode of dyspnea and left leg edema and experienced severe pain.
An ultrasound of the lower limbs proved the existence of bilateral severe deep venous thrombosis. For a further investigation the patient did a body CT-scan and cancer markers were searched. The CA19.9 was 253679 and there were several metastatic lesions on the liver and an infracentrimetic mass on the pancreatic tail on the CT- Scan. She started anticoagulation for prevention of other pulmonary embolism, while waiting for a pancreatic biopsy. The patient died 3 month after the diagnosis due to a sudden Myocardial infarction. The symptoms of heart failure dominated the whole clinical picture, being the DVT the wind of change to establish the diagnosis of pan- creatic cancer, a scary disease that was silent for so long. This case shows the impor- tance of the paraneoplastic symptoms such the bilateral DVT which was the important milestone for a further investigation and the fi nal diagnose.
PS 0570 Oncology
Another Case of Atypical Chest Pain?
Si Yong Ivan CHUA1 Changi General Hospital, Singapore1
Acute central chest pain accounts for 20-30% of all emergency department diagnosis, and at least half of them are labelled as atypical chest pain upon discharge. Atypical chest pain is a non-specifi c diagnosis and the lack of a fi rm diagnosis may lead to recurrent symptoms, anxiety or depression. A 59 year old chinese male with hyper- tension and hyperlipidemia presented to our Emergency Department with complaints of central chest pain for 4 days with radiation to right lateral chest wall with similar episodic symptoms since April 2014. It was associated with 4 kg of weight loss over 3 months. Physical examination was unremarkable apart from marked conjunctiva pallor. There was no jaundice. ECG showed RBBB and a shortened Qtc interval. CXR was normal. An i-stat was ordered in view of pallor and Hb was 9 with an incidental fi nding of hypercalcemia. A liver panel was subsequently ordered that showed a raised ALP with normal bilirubin and transaminases. The patient was admitted to the medical unit with a CT scan of the abdomen performed revealing a mass in the liver suspicious for cholangiocarcinoma. A biopsy was done for confi rmation of disease.
PS 0571 Oncology
Gastric Metastasis of Lung Adenocarcinoma - A Rare Presentation of a Common Neoplasia
Miguel BIGOTTE VIEIRA1, Nuno GAIBINO1, Marco FERREIRA, Anabela OLIVEIRA1 Centro Hospitalar Lisboa Norte - Hospital Santa Maria, Portugal1, Centro Hospitalar Lisboa Norte, Portugal2 Background: Gastrointestinal metastasizing of primary lung cancer is not common.
Gastric metastasis from lung cancer and, in particular from adenocarcinoma is rare with only few cases described in the literature.
Methods: A 64-year-old man was admitted to the hospital for progressive asthenia, anorexia and weight loss. During the previous month the patient had been admitted to another hospital for left inferior limb deep vein thrombosis (DVT) while being treated with warfarin. Anticoagulation had been started after the diagnosis of right inferior limb DVT had been made two months before. The patient had history of triple bypass heart surgery, dyslipidemia, dyspepsia, depression and had smoke during adolescence.
On examination the patient was tachycardic, pulmonary auscultation presented dimin- ished vesicular breath sounds and bilateral inferior limb swelling was apparent.
Results: Laboratory workup revealed anemia (erythrocytes 8.7 g/dL), elevated C reac- tive protein (6.4 mg/dL) and elevated international normalized ratio (4.09). Immuno- logical tests including lupus anticoagulant, anti-cardiolipin, anti-ß2-glycoprotein-Ian- tibodies were negative. A full body CT scan revealed bilateral primitive iliac veins DVT, chronic and subacute bilateral PE, small sized pleural effusion, bronchovascular bundle thickening and multiple milimetric mediastinal lymphadenopathies with the widest measuring 1.2 cm. The patient developed hematemesis and endoscopy was performed revealing an 8 mm sessile polyp localized at the stomach that was excised. Gastric biopsy revealed metastasis from primary lung adenocarcinoma positive for TTF-1 by immunohistochemistry. Fiberoptic bronchoscopy demonstrated pulmonary median lobe thickening with hyperemic and thickened mucosa. Bronchoalveolar lavage and biopsies were performed revealing pulmonary adenocarcinoma positive for TTF-1, CK7, Napsin A and negative for CK5, CK20, p63 by immunohistochemistry. During hospitalization the patient clinical situation deteriorated and the patient died.
Conclusions: Gastric metastasis from primary lung adenocarcinoma constitutes a rare presentation of this neoplasia which may be associated with serious clinical complications.
PS 0572 Oncology
Lung Cancer with Revealing Skin Metastasis
Miguel ARDÉRIUS1, Nayive GÓMEZ1, David FORTES1, Alda JORDÃO1, Glória SILVA1 Centro Hospitalar Lisboa Norte, Portugal1
Introduction: Skin metastization is an uncommon manifestation of carcinomas (3-4%
incidence in some series). Lung origin is more common in men (24 versus 4% in wom- en, in recent meta-analysis), being the fi rst manifestation in 0.8% of cases. It appears in advanced stage and has poor prognosis.
Case Presentation: 78 year old man, smoker, went to the ER because of the appear- ance, in the last 3 months, of 2 cutaneous nodules in the thorax, with progressive enlargement and infl ammatory signs. Concomitantly, he showed asthenia, adynamia, anorexia, exertional dyspnea and weight loss (10kg), symptoms the patient didn’t quite value, showing a very good Performance Status (Karnofsky scoring 70%). In observa- tion, 2 solid subcutaneous nodules (3cm), parasternal, violaceous, ulcerated, non ad- herent, painful; and 2 similar nodules, smaller and non ulcerated, palpable in the ingui- nal regions. In the thorax radiography, peribronchial mass on the right, with irregular contour. Thoraco-abdomino-pelvic CT showed a perihilar mass (8cm) in the right lung, obliterating the anterior segment of the superior lobe; pulmonary artery compression;
mediastinal pleura invasion; multiple adenomegalies; adrenal gland metastization; and subcutaneous masses in the anterior thoracic wall, abdominal wall and gluteal region.
Analytically, elevated NSE (142μg/L). Bronchofi broscopy revealed complete bronchial obstruction, with the biopsy confi rming a Small Cell Carcinoma. The biopsies from the skin lesions had a mixed pattern (Combined Small Cell and Large Cell Neuroendocrine Carcinoma). He was discharged to Pneumological Oncology, where he started chemo- therapy.
Conclusion: Despite the fact that skin metastasis are rare, it’s timely recognition may be critical to the prognosis. The Internist should therefore be aware of its existence. In this case, the patient kept a good performance status despite the advanced disease.
