Pheochromocytoma with IVC Invasion: Case Report & Systematic Review of Literature

Surgical management and outcome of pheochromocytoma with invasion of the inferior vena cava (IVC) has not been thoroughly reported or widely available in the literature. As determining the malignancy of pheochromocytoma has yet to be clearly defined and the experience of surgical resection of this condition is underrepresented, we include a case report and a systematic literature review on this condition. A literature search in PubMed was performed based on a recent review article by Kassahun et al. (2016). The search yielded 13 case reports between 1988 and 2014 from which data was extracted based on the following variables: patient’s age, gender, comorbidities, laboratory tests for pheochromocytoma diagnosis, size and laterality of the tumor, diagnostic test for IVC invasion, preoperative treatment and imaging, perioperative procedures, and oncological outcomes. The mean age of the patients was 49.4 years, with 38.5% being female (n=5) and 53.3% being male (n=8). 92% (n=12) of the cases were right-sided pheochromocytomas that invaded the IVC, with only one case of pheochromocytoma localized in the organ of Zuckerkandl. Only 46.7% (n=7) of the cases reported using laboratory tests to diagnose pheochromocytoma while only 53.3% (n=8) specifically reported using imaging techniques (CT, MRI, ultrasound, CTA, inferior venacavogram, MIBG-scintigraphy) to diagnose IVC invasion. Four of the surgical cases were performed without cardiopulmonary bypass while three specifically mentioned the use of the bypass technique. There was also further variance in surgical approach as some were performed via sternotomy, thoracophrenolaparotomy, or thoracoabdominal approach to completely resect the tumor and IVC, or to perform a cavotomy with no reconstruction of the IVC necessary. Follow-up of only 8 patients were noted, all of which revealed no evidence of disease, although at different time points post-op. The lack of a thorough and consistent report on pheochromocytoma cases with IVC invasion makes it difficult to compare the management of this condition. We hope a comprehensive review of these patient cases provides greater insight into the diagnosis of pheochromocytoma with IVC invasion and the characteristics and surgical procedure of this tumor invasion that would eliminate recurrence

Mixed Goblet Cell Carcinoid-Adenocarcinoma: A Case Series

INTRODUCTION: Mixed goblet cell carcinoid-adenocarcinoma (GCC) tumors are a group of rare heterogenous neoplasms of the appendix accounting for \u3c 5% of all primary appendiceal tumors. They are characterized as an intermediate between classic carcinoid tumors and appendiceal adenocarcinomas, exhibiting both neuroendocrine and glandular/mucinous morphology that most commonly presents in Caucasian females in the fifth and sixth decades. We present three cases of mixed GCC presenting as acute appendicitis. CASE PRESENTATION: Case #1 A 65-year-old male presented with RLQ pain, nausea, emesis, and leukocytosis. CT of the abdomen revealed perforated appendicitis. The patient underwent a laparoscopic appendectomy. Pathology revealed a high-grade adenocarcinoma ex goblet cell carcinoid, signet ring type extending through the muscularis propria into the mesoappendix measuring \u3e3cm. The patient subsequently underwent a colonoscopy that revealed diverticulosis, but was otherwise normal. Patient then underwent a right hemicolectomy and partial omentectomy. Pathology revealed normal ileal, omental, and colonic tissue without evidence of carcinoma. 0/12 nodes were positive. Case #2 A 49-year-old male presented with periumbilical pain, nausea, emesis, and leukocytosis. CT of the abdomen revealed appendicitis. The patient underwent a laparoscopic appendectomy. Pathology revealed a high-grade, poorly differentiated, adenocarcinoma ex goblet cell carcinoid invading through the muscularis propria into the periappendiceal soft tissue measuring 1.5cm. The patient subsequently underwent a colonoscopy that revealed diverticulosis, but was otherwise normal. Patient then underwent a laparoscopic right hemicolectomy. Pathology revealed normal ileal and colonic mucosa without evidence of carcinoma. 0/14 nodes were positive. Case #3 A 70-year-old female presented with periumbilical pain. CT of the abdomen revealed appendicitis. The patient underwent a laparoscopic appendectomy. Pathology revealed a high-grade adenocarcinoma ex goblet cell carcinoid extending through the muscularis propria into the mesoappendix measuring 4cm. Patient then underwent an exploratory laparotomy with a right hemicolectomy. Pathology revealed normal ileal and colonic mucosa without evidence of carcinoma. 0/21 nodes were positive. CONCLUSION: Mixed GCC tumors are rare tumors that tend to present at an advanced stage and most commonly spread via direct extension. Surgical resection with a right hemi-colectomy after an appendectomy has been shown to improve the prognosis. HIPEC and adjuvant chemotherapy are other therapeutic options, but have not been shown to improve survival. In the current age of increasing rates of managing acute appendicitis non-operatively we strongly encourage surgical appendectomy in patients older than 45 years of age to avoid missing this important diagnosis and the opportunity to treat it in a timely manner

Thromboelastography Following Liver Resection

BACKGROUND: This study was aimed at examining the predominant coagulation profile following liver resection. OBJECTIVE: Study the TEG profile following liver resection. METHODS: Patients undergoing liver resection were prospectively enrolled in the study. Perioperative variables were obtained and the TEG AND PT/INR were obtained preoperatively, post-operatively, and on POD# 1, 3, and 5. RESULTS: 17 patients were enrolled with a median age of 61, 35.3 % were female undergoing resection for either primary or metastatic disease. 35.3% underwent major hepatectomy, median EBL was 350mL, and the median LOS was 6 days, with a morbidity of 35.3% and no mortality. Post-operatively the TEG profile demonstrated a hypercoagulable profile in 92.8%, 64.2%, 57.1% and 42.8% of patients immediately post-operatively, and on POD# 1, 3, and 5 respectively. Despite multiple elevations in PT/INR in all the time points there was no concordance with the TEG profile. CONCLUSION: The TEG profile demonstrated a hypercoagulable profile in majority of patients undergoing liver resection despite an elevated PT/INR