Melanoma of Unknown Primary Presenting as a Single Back Mass

In this report, we present a case involving the discovery of metastatic melanoma within a mid-right back mass with the clinical presentation of an epidermoid cyst, but the histological qualities of a lymph node. A 43-year-old male presented with a 5 cm x 5 cm cyst-like mass on his mid-right back that had become painful over the last year and consequently underwent three surgical procedures. First, initial excision of the back mass and histological examination resulted in a diagnosis of metastatic melanoma without epidermal involvement. This was followed by re-excision of the back mass site and sentinel node excision, and finally, lymph node dissection of the right axilla. Of the lymph nodes examined, the sentinel node in the right axilla alone showed evidence of melanoma. The absence of a primary lesion or any histological evidence of regression in a presumed primary site resulted in a diagnosis of melanoma of unknown primary, or occult primary melanoma. To our knowledge, this is the first documented case of an occult primary melanoma presenting as a single mass representing a lymph node in the back

Hepatic Cyst Compressing The Right Atrial and Ventricular Inflow Tract: An Uncommon Cardiac Complication

Commonly reported complications of hepatic cysts are spontaneous hemorrhage, rupture into the peritoneal cavity, infection and compression of the biliary tree however cardiac complications are not commonly reported. We are presenting a case of a large liver cyst presenting with right atrial and ventricular inflow tract impingement resulting in cardiac symptoms. A 68 year-old Hispanic female presented with one month of fatigue and shortness of breath after household work and walking less than one block, right upper quadrant pain and weight loss. She had history of multiple hepatic cysts for more than 12 years, well-controlled diabetes and hypertension. Examination of the heart revealed tachycardia with regular heart sounds. There were no murmurs. She had tenderness in her right upper quadrant on palpation and an enlarged smooth liver. Rest of physical examination was unremarkable. CT scan of the abdomen showed multiple non-enhancing liver cysts in both lobes, with the largest measuring 12 x 15 x 17 cm which was significantly increased from her baseline of 7 x 8 x 10 cm in 2003. Echocardiogram showed normal left ventricular ejection fraction, grade 1 diastolic dysfunction and a hepatic cyst impinging RA and RV inflow tract. She had successful laparoscopic enucleation of liver cyst and subsequent relief from tachycardia, fatigue and shortness of breath. In conclusion, this case illustrates that hepatic cysts may become symptomatic after remaining quiescent for an extended period. They may present with unusual symptoms and clinicians should be mindful of rare complications, such as in this case

A Rare Triad of Appendiceal Diverticula, Appendiceal Carcinoid, and Colonic Diverticula

Appendiceal diverticulosis is a rare finding associated with appendiceal neoplasms. Both can masquerade as appendicitis in patients and are overlooked in differentials of right upper quadrant pain. A 37-year-old African American female presented with appendicitis-like symptoms to the emergency room with fever and leukocytosis. Appendectomy was performed with pathological evaluation revealing coexisting appendiceal diverticula and carcinoid of the appendix with lymphovascular invasion and mesoappendiceal involvement. In line with the National Comprehensive Cancer Network guidelines, right hemicolectomy with lymph node dissection was performed which was negative for neoplastic invasion but positive for colonic diverticulosis. While there have been many case reports of appendiceal diverticula with coexisting appendiceal carcinoid, a concurrent colonic diverticulum in the right hemicolectomy specimen during the oncologic resection of the appendiceal carcinoid has not been previously reported. We propose colonic diverticula as another possible feature that may be associated with appendiceal diverticula especially with an underlying appendiceal neoplasm

Nanda Kumar

Abstract Congress is considering proposals to improve its financing of long-term care. The key issue is whether it should support a social insurance program or a pro-gram targeted to a population group defined by income and assets. Social insurance is expensive, costing between $15 and$20 billion. For the most part, it provides benefits-primarily asset protection-to middle- and upper-income individuals. An improved Medicaid program, costing about $8 billion, benefits lower-income indi-viduals but does not protect those with higher incomes. These two options cannot be viewed independently from trends in the private market. Sales of private long-term care policies have grown and between 30 percent and 40 percent of the elderly can be considered potential buyers. If private alternatives are available for those individuals who need asset protection, the case for a more targeted public approach-along with reliance on the private sector-becomes more compelling. Congress should consider a program that enhances Medicaid; improves consumer education; assists states in regu-lating long-term care policies, so as to enhance consumer protection and confidence; and clarifies taxes on long-term care insurance to encourage workers and the elderl

Sclerosing Mesenteritis in a Patient Heterozygous for Factor V Leiden

BACKGROUND Sclerosing mesenteritis is an inflammatory and fibrotic disease that affects the mesentery of the small intestine. This condition is non-neoplastic, although it is frequently associated with underlying malignancies. The overall etiology is unclear because of the limited number of cases available for review, yet a number of possible mechanisms have been described, including ischemia. Factor V (FV) Leiden is a hereditary condition causing hypercoagulability, thrombosis, and ischemia. Because ischemia is one of the proposed mechanisms for the fibrosis and sclerotic findings of sclerosing mesenteritis, this case explores a possible association between FV Leiden and sclerosing mesenteritis. CASE REPORT Herein, we describe a case of sclerosing mesenteritis in a patient heterozygous for FV Leiden, with a strong personal and family history of venous thromboembolism. This patient presented with acute worsening of chronic abdominal pain and was found to have a small bowel obstruction requiring acute surgical intervention. Imaging findings and pathologic examination of the ileum and mesentery conclusively diagnosed sclerosing mesenteritis. CONCLUSIONS This case serves to highlight a possible association between mesenteric ischemia secondary to chronic thrombotic activity and sclerosing mesenteritis. This patient\u27s virgin abdomen and lack of additional risk factors for sclerosing mesenteritis make this case a unique presentation of the disorder. This case serves to update the literature at large, as only one prior case in a FV Leiden patient has been described, in which the patient had the additional risk factor of previous abdominal surgery

Hepatic Cyst Compressing The Right Atrial and Ventricular Inflow Tract: An Uncommon Cardiac Complication

Commonly reported complications of hepatic cysts are spontaneous hemorrhage, rupture into the peritoneal cavity, infection and compression of the biliary tree however cardiac complications are not commonly reported. We are presenting a case of a large liver cyst presenting with right atrial and ventricular inflow tract impingement resulting in cardiac symptoms. A 68 year-old Hispanic female presented with one month of fatigue and shortness of breath after household work and walking less than one block, right upper quadrant pain and weight loss. She had history of multiple hepatic cysts for more than 12 years, well-controlled diabetes and hypertension. Examination of the heart revealed tachycardia with regular heart sounds. There were no murmurs. She had tenderness in her right upper quadrant on palpation and an enlarged smooth liver. Rest of physical examination was unremarkable. CT scan of the abdomen showed multiple non-enhancing liver cysts in both lobes, with the largest measuring 12 x 15 x 17 cm which was significantly increased from her baseline of 7 x 8 x 10 cm in 2003. Echocardiogram showed normal left ventricular ejection fraction, grade 1 diastolic dysfunction and a hepatic cyst impinging RA and RV inflow tract. She had successful laparoscopic enucleation of liver cyst and subsequent relief from tachycardia, fatigue and shortness of breath. In conclusion, this case illustrates that hepatic cysts may become symptomatic after remaining quiescent for an extended period. They may present with unusual symptoms and clinicians should be mindful of rare complications, such as in this case