bluuebunny/crossref_metadata_2025_split huggingface dataset:
1657 Acute Drop in Hemoglobin Requiring Transfusion an Odd Presentation of Metastatic Breast Cancer to the Colon in Form of Colon Polyps
Authors: Harris Elizabeth , Boktor Moheb , Burstein Ezra , Hammer Suntrea 
Published: October 2019

INTRODUCTION:
Breast cancer (BC) is the leading cancer and second most common cause of cancer deaths in women. It can present with metastases to other organs. However, BC metastases to the colon are uncommon. Lobular carcinoma, comprising 10% of BC, is most commonly spread to gastrointestinal tract (GIT). We present a case of a patient whose recurrent metastatic lobular adenocarcinoma presented as colon polyps.

CASE DESCRIPTION/METHODS:
A 59-year-old female was diagnosed in 2006 with stage IIIC grade 1 estrogen (ER+), progesterone receptor positive (PR+), and HER-2/neu negative (Her2-) invasive lobular BC of left breast and treated with left modified radical mastectomy, chemo and radiation therapy to left chest wall. She was in remission since 2007 and on maintenance hormonal therapy. She presented in late 2018 with shortness of breath and fatigue secondary to anemia. She had a history of roux and Y gastric bypass. She was admitted to the hospital with symptomatic anemia, drop in HGB 8.3 to 5.5 though she received blood transfusion a week prior. A full hematologic workup was unrevealing including bone marrow biopsy. She required multiple transfusions and hospitalization in 2019. CT scan of abdomen and pelvis revealed no abnormality in the colon. She underwent EGD and colonoscopy. EGD revealed esophagitis and prior gastric bypass without evidence of bleeding. Colonoscopy revealed numerous polyps throughout colon, all removed. Pathology on these polyps showed metastases of ER+, PR+, HER2- BC. She underwent re-staging with biopsy of a para-aortic lymph node and skeletal survey, both of which showed metastatic disease. After colonoscopy with polypectomy her anemia improved. She has subsequently been started on palliative chemotherapy.

DISCUSSION:
This is a unique case of metastatic BC with severe anemia due to colonic metastases. To our knowledge, only a handful of case reports exist describing similar presentations. BC rarely metastasizes to GIT and when it does it spreads to the stomach as linitis plastica. Metastases of BC to the colon are less common, although there is a case reports metastatic BC being diagnosed based on a single colon polyp and colonic obstruction due to large metastatic masses. Our case highlights the importance of screening for GIT metastases that may not occur until many years after the initial BC diagnosis. Moreover, given the propensity of lobular BC to metastasize to GIT, more frequent screening endoscopies may be beneficial to these patients.
1658 Colonic Metastatic Disease Masquerading as Immune Checkpoint Inhibitor-Mediated Colitis
Authors: Hastie Elizabeth , Rubin Joshua 
Published: October 2019

INTRODUCTION:
The use of immune-checkpoint inhibitors (ICIs) in the treatment of advanced cancer has increased exceptionally since ipilimumab was first approved for melanoma in 2011. As the prevalence of patients being treated with ICIs rises so too have their immune related adverse events (irAEs). Clinicians are now faced with the challenge of accurately and promptly recognizing irAEs. With immune-mediated diarrhea and colitis being two of the most common irAEs, an algorithm for their treatment has already been established; however, it is important for clinicians to maintain a broad differential diagnosis when caring for a patient on an ICI with colitis symptoms.

CASE DESCRIPTION/METHODS:
A 48-year-old woman with a history of metastatic, refractory, triple negative, BRCA positive breast cancer was started on pembrolizumab four years after being diagnosed with breast cancer. 18 months after initiating treatment with pembrolizumab, she developed loose, watery stools. Cross sectional imaging revealed mild, circumferential wall thickening of the proximal ascending colon. A gastrointestinal pathogen nucleic acid detection test was negative, and she was started on a two-week course of budesonide for presumed immune checkpoint inhibitor-mediated colitis (IMC). Her symptoms progressed with bright red blood per rectum and abdominal cramping. Treatment for IMC was escalated with a prednisone taper followed by infliximab infusion. 6 weeks after being treated for IMC, her hemoglobin was 7.6 and ferritin 4. She was referred to gastroenterology for iron deficiency anemia. Repeat abdominal CT revealed increased colonic wall thickening. Colonoscopy revealed an obstructing, ulcerated mass in the ascending colon. Pathology identified poorly differentiated adenocarcinoma consistent with a breast cancer metastasis. She underwent right hemicolectomy 6 months after the initial CT showed colonic thickening.

DISCUSSION:
Pembrolizumab is one of many ICIs that have been developed for the treatment of advanced-stage malignancies. The gastrointestinal side effects of this class of medications pose a challenge for physicians as IMC is nearly indistinguishable from many other etiologies of diarrhea clinically, and the onset of gastrointestinal symptoms ranges widely from 1 to 32 weeks after starting the medication. As the use of ICIs becomes more widespread, quick and accurate differentiation of an irAE from other life threatening pathology is of vital importance, and early colonoscopy should be considered to rule out metastatic disease.
1671 Neuroendocrine Tumours of the Anal Canal: A Catastrophic Culprit
Authors: Aujla Amreet K. , Desai Aakash , Delasos Lukas , Hong Timothy 
Published: October 2019

INTRODUCTION:
Neuroendocrine (NE) tumors within the gastrointestinal (GI) tract are a rare type of GI malignancy with an estimated incidence of 2.5–5 per 100,000 people per year. 45% NE tumors arise in the small intestine, with the incidence decreasing throughout distal portions of the GI tract. Anal NE tumors represent 1% of all malignancies of the anal canal and are found incidentally on endoscopy. The rarity of this disease has led to a lack of sufficient data available to help guide therapy. Thus, the prognosis associated with NE tumors has remained poor throughout all stages of the disease. We present a case of anal NE carcinoma with disease recurrence after multiple lines of systemic treatment and salvage immunotherapy.

CASE DESCRIPTION/METHODS:
A 58-year-old female presented with complaints of constipation and mild rectal bleeding. She underwent a colonoscopy that revealed a 2 cm mass about 1 cm from the anal verge. Biopsy of the anal mass demonstrated high-grade NE carcinoma with small cell features. Staging computed tomography (CT) scan showed no metastases. Magnetic resonance imaging (MRI) of the brain was negative for metastasis. She underwent 4 cycles with cisplatin and etoposide as well as prophylactic cranial irradiation. Follow up CT scan showed an adequate response to initial therapy. However, three months later, repeat imaging showed new left retroperitoneal lymphadenopathy with biopsy revealing recurrent NE carcinoma. She again underwent therapy with cisplatin and etoposide as well as radiation therapy to the area of local recurrence. Repeat imaging showed absence of disease recurrence. The patient remained disease free for the next six months, until follow up imaging revealed a new left adrenal mass and retroperitoneal nodule. MRI of the brain showed brain metastasis. She began therapy with topotecan and cranial radiation, but due to a mixed response to treatment she was transitioned to temozolomide. Therapy continued but ended soon after progression of disease was noted. As a last attempt, she underwent immunotherapy with pembrolizumab but was transitioned to hospice care after the onset of rapid clinical progression of her disease.

DISCUSSION:
There remains a lack of treatment options beyond standard chemotherapy for this disease. Although she had an initial response to treatment, prognosis for anal NE carcinoma remains grim. This case illustrates the difficulty in management of this disease. Novel approaches in treatment are much needed.
1675 A Rare Case of Rectal Adenocarcinoma With Isolated, Asynchronous Metastasis to the Temporal Bone
Authors: Gajula Prianka , Mahmood Ali 
Published: October 2019

INTRODUCTION:
Metastatic disease only to the bone without other organ involvement in colorectal cancer patients is extremely rare. Isolated, asynchronous metastasis to the temporal bone, without involvement of the liver or lung is an even further deviation from the traditional presentation. We present the case of a 56-year-old lady with a history of rectal cancer in remission presenting with hearing loss, facial swelling, and facial droop.

CASE DESCRIPTION/METHODS:
The patient presented with a stage 3C rectal cancer pT3N2bM0 and received adjuvant chemotherapy based on her pathology. The disease was in complete remission, without evidence of any CT, PET, or endoscopic findings of disease recurrence. Three years after her initial diagnosis, the patient began to develop swelling, with associated myalgia and hearing loss on the ipsilateral side. CT and MRI imaging revealed a mass in the right temporal bone, eroding into the bony architecture with peri-orbital and temporal swelling, with inflammatory changes of the right mandibular process. A subsequent biopsy of the cranial mass was consistent with metastatic rectal adenocarcinoma. Repeat imaging had not shown any evidence of abdominal or chest disease.

DISCUSSION:
More than 90% of colorectal carcinomas are adenocarcinomas originating from epithelial cells of the colorectal mucosa. Approximately 10% of all colorectal carcinomas are mucinous carcinomas. The metastatic pattern of colorectal carcinomas is well known. In a study using more than 49,000 patients with colorectal cancer, it was found that the most common sites of metastasis involved the thoracic organs, the liver, the nervous system, and the peritoneum. Literature review reveals an overall incidence of 5–11% of bony metastasis. This figure includes both isolated skeletal metastases and those with coinciding liver and lung spread. Isolated skeletal metastases are even more infrequently seen, occurring at an estimated frequency of 1–2%. Asynchronous and isolated metastasis to the temporal bone is rare. Assi R, Mukherji D, Haydar A, Saroufim M, Temraz S, Shamseddine A. Metastatic colorectal cancer presenting with bone marrow metastasis: a case series and review of literature. J Gastrointest Oncol. 2016;7(2):284–297.
1692 Retrieval of Impacted Extraction Balloon: A Rare Complication of ERCP for Choledocholithiasis
Authors: Ali Saad Emhmed , Frandah Wesam , Mardini Houssam , Gabr Moamen 
Published: October 2019

INTRODUCTION:
ERCP is an essential tool in the management of biliary disorders. A large variety of rare ERCP related complications have been reported such as an impacting a retrieval basket, and colonic perforation. We report an unusual complication of ERCP with a retained balloon and a successful endoscopic removal at subsequent ERCP.

CASE DESCRIPTION/METHODS:
A 61-year-old man was transferred from a local hospital after undergoing an ERCP for choledocholithiasis. The ERCP balloon became lodged in the bile duct during stone extraction. The endoscopist tried to retrieve the balloon by pulling on the external part of the balloon catheter, but the catheter broke. He aborted the procedure and removed the ERCP scope by cutting the balloon catheter from outside and pulled the scope out. The patient was left intubated with the balloon catheter in his mouth and was transferred to our facility. Upon arrival, the patient was taken for ERCP. A fluoroscopic film showed the extraction balloon in the right upper quadrant of the abdomen (Figure 1). The duodenoscope was introduced through the mouth next to the balloon catheter. The impacted balloon was seen emerging from the major papilla (Figure 2). It was compressing the upper ampulla, duodenum, and stomach leading to linear pressure erosions (Figure 2). We used the Spyglass direct visualization system ((Boston Scientific, Marlborough, Mass, USA) to visualize the balloon impaction site, which was obstructed by the balloon catheter and the stone (Figure 3). The bile duct was then cannulated using a 0.025-inch × 270 cm angled ERCP guidewire (Olympus VisiGlide) through a 3.9 Autotome sphincterotome (Boston Scientific). The CBD was moderately and diffusely dilated. The impacted balloon catheter was pulled using the external part of the catheter, and it was successfully removed. We placed one fully covered self-expandable metal stent (FCSEMS) (Wallflex, Boston Scientific)10 mm by 4 cm with one 7 Fr by 10 cm double pigtail plastic stent into the CBD to maintain adequate drainage. The ERCP was accomplished without difficulty. The patient was extubated, liver function test improved. He was discharged home in a stable condition. He will have repeated ERCP in 8 weeks to remove the stents.

DISCUSSION:
Retaining ERCP balloon during stone extraction is extremely rare because it is easy to deflate and remove. Up to our knowledge, it has not been reported in the literature. We have demonstrated a successful retrieval of retained ERCP balloon during stone extraction.
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1711 An Esophageal Mass Masquerading as Asthma Exacerbation: An Unfortunate Outcome
Authors: Chan Matthew , Patel Akash , Bowers Jacqueline 
Published: October 2019

INTRODUCTION:
Esophageal masses can present in a variety of ways, such as a result of mediastinal mass effect leading to cough, hoarseness, and/or dysphagia, or they can be incidental findings on imaging as part of the evaluation of an unrelated condition. A definitive diagnosis generally requires tissue sampling. We present a case of a woman with a recent diagnosis of asthma unresponsive to standard therapies who was found to have an esophageal mass that unfortunately led to respiratory arrest.

CASE DESCRIPTION/METHODS:
A 32-year-old African American female with history of G6PD deficiency, alpha thalassemia, GERD, morbid obesity, and recent diagnosis of asthma presented with dyspnea. A month prior, she was seen in the ER on two separate occasions for similar symptoms and treated for asthma exacerbations and subsequently discharged home. Chest x-rays performed then were unremarkable. Upon further history, the patient also had progressive dysphagia from solids to liquids and globus pharyngis. There was no history of tobacco or alcohol use, and no family history of malignancy. On admission, vitals were unremarkable. Exam revealed hoarseness, biphasic stridor greater upon inspiration, and expiratory wheezing throughout lung fields. Labs showed a chronic microcytic anemia, and chest x-ray was again unremarkable. She was treated for presumed asthma exacerbation and started on IV PPI and IV steroids for possible airway edema due to GERD. ENT was consulted to assess for any airway obstruction. Flexible nasopharyngolaryngoscopy showed paralysis of the left true vocal cord, and a CT with IV contrast of the neck and chest was performed that showed a large mass involving the mid-thoracic esophagus compressing the trachea. Gastroenterology and Cardiothoracic Surgery were consulted, and the patient was transferred to an outside hospital for emergent tracheal stenting. Unfortunately, the patient had respiratory arrest prior to intervention. Family declined autopsy studies to determine the etiology of the mass.

DISCUSSION:
This case illustrates that careful history and physical examination clues be obtained in cases of asthma unresponsive to standard therapy. A low threshold for obtaining further dedicated imaging such as chest CT can help with prompt identification and management of life-threatening processes such as respiratory compromise. Some differentials for esophageal masses include squamous cell cancer, adenocarcinoma, and lymphoma among others, and this case highlights that everything that wheezes is not asthma.
1720 A Case of Sunitinib-Induced Necrotizing Esophagitis
Authors: Bertran-Rodriguez Carlos E. , Mony Shruti , Slone Samuel , Arroyo Yadis , Pagan Andrea , Rabbanifard Roshanak 
Published: October 2019

INTRODUCTION:
Acute esophageal necrosis (AEN), also known as “black esophagus” or “acute necrotizing esophagitis”, is a rare entity thought to be caused by a known ischemic insult from a low perfusion state. Etiologies include multi-organ dysfunction, hypoperfusion, vasculopathy, sepsis, among others. Sunitinib, a chemotherapeutic agent for renal cell cancer and gastrointestinal stromal tumors, has common gastrointestinal (GI) side effects of diarrhea and vomiting but severe GI side effects are rare. We present a unique case of Sunitinib-induced AEN.

CASE DESCRIPTION/METHODS:
A 72-year-old man presented to the hospital for a two days history of epigastric abdominal pain, bilious vomiting, and multiple episodes of non-bloody diarrhea. His medical history was significant for metastatic papillary renal cell carcinoma on Sunitinib. On presentation, his blood pressure was 74/52 mm Hg and heart rate 107 beats per minute. He exhibited generalized abdominal tenderness without rebound or guarding. His hemoglobin was 15 g/dL. He was admitted to the ICU for hypovolemic shock thought to be secondary to severe gastroenteritis requiring the use of vasopressors. He later developed ongoing melena and his hemoglobin decreased to 10.8 g/dl requiring urgent Endoscopy. The examination revealed circumferential, black, necrotic mucosa in the lower one-half of the esophagus with a sharp demarcation of healthy mucosa at the level of gastroesophageal junction without any active bleeding. Findings were consistent with AEN. The patient remained hypotensive despite aggressive resuscitation and the use of vasopressors. Unfortunately, the patient died several days later.

DISCUSSION:
AEN is characterized by the classic endoscopic image of diffuse, circumferential, black-appearing necrotic mucosa. The exact etiology leading to the hypoperfusion state in our case is unclear and could be attributed to Sunitinib. The most common adverse GI reactions to Sunitinib include diarrhea (53%), nausea (44%), and vomiting (24%) which were intractable in the above case. This medication has also been linked to severe GI hemorrhage. Sunitinib inhibits platelet-derived growth factors and vascular endothelial growth factors which play a major role in angiogenesis and apoptosis. We believe that by inhibiting these cellular processes, the patient was predisposed to development of AEN which was potentiated by the patient’s hypovolemic state.
1746 A Surprising Case of Boerhaave's Syndrome Successfully Treated With a Single Hemostatic Clip
Authors: Collins Kelsey , Herman Michael , Blank Andrew 
Published: October 2019

INTRODUCTION:
Boerhaave’s Syndrome (BS), defined as transmural esophageal perforation, is rare and associated with 35% mortality. Patients with BS can develop associated mediastinitis, sepsis, and septic shock. Patients require urgent management, usually with volume resuscitation, antibiotics, surgical intervention, or occasional endoscopic placement of a metallic stent. There are few reported cases demonstrating successful repair of esophageal perforation with hemostatic clips alone. We present a case of direct repair of BS with a single hemostatic clip.

CASE DESCRIPTION/METHODS:
A 44-year-old male presented to the ED for food impaction with subsequent development of large volume hematemesis. He was stable, with no sign of respiratory distress. However, given his persistent hematemesis, he was intubated for airway protection. Initial labs were remarkable for leukocytosis to 14.8 and hemoglobin of 18.4. A Mallory Weiss tear was expected, but his CT chest showed inflammation in the mediastinum associated with debris in the esophagus and esophageal wall thickening. His clinical picture and imaging were consistent with BS complicated by mediastinitis and esophagitis with superimposed esophageal perforation. He was given one dose of both Zosyn and a PPI and was taken for emergent EGD. Red blood and clots were seen throughout his esophagus, and a large non-bleeding tear with stigmata of recent bleeding was seen in the distal esophagus. One hemostatic clip was placed with successful resolution of the defect. He was then admitted to the medical ICU for further management. Over the next 24 hours, he developed melena and became tachycardic. His leukocytosis peaked at 21, and his hemoglobin gradually decreased to 8.9. Repeat CT chest was obtained due to worsening symptoms, but imaging showed that the esophageal clip was in place, and there was improvement in prior esophageal wall thickening, but there was a new small left pleural effusion. Cardiothoracic Surgery evaluated the patient and recommended an esophagram, which showed no evidence of esophageal contrast extravasation. He was successfully extubated and was discharged home the following day.

DISCUSSION:
BS is often a medical emergency requiring urgent intervention. Most cases are treated surgically with direct repair of the rupture via thoracotomy or laparotomy. Although there is a known role for endoscopic management using a metallic stent, there is an evolving role for treatment of more mild cases of BS with clip placement alone.
1750 Bevacizumab-Induced Esophageal Perforation: A Case Report
Authors: Abidian Mohamed Modar , Nath Anand , Shafa Shervin 
Published: October 2019

INTRODUCTION:
Esophageal perforation can range from micro perforation to full wall thickness rupture. Patient symptoms can vary based on the injury extent. Common causes of perforation include iatrogenic (endoscopy), traumatic, peptic ulceration and/or foreign body ingestion. Rarely, spontaneous perforation (Boerhaave’s syndrome) occur as a result of sudden increase in the intraesophageal pressure from severe vomiting. The management depends on the severity of the rupture and includes conservative therapy, endoscopy and/or surgery. We present a rare incidence of spontaneous esophageal perforation in the setting of bevacizumab therapy.

CASE DESCRIPTION/METHODS:
Our patient is a 57 year-old female with past medical history of colorectal cancer diagnosed in 2002. Since then, patient had undergone partial resection of the colon, radiotherapy and multiple courses of chemotherapy. However, her colorectal cancer had metastasized to retroperitoneal and pelvic lymph node, skeletal bones and lungs. Her last chemotherapy regimen included FOLFIRI (Fluorouracil, Leucovorin, Irinotecan) plus Bevacizumab, which was started 8 days prior to admission. The patient had also complained of persistent nausea and recurrent vomiting prior to admission. She had also reported lower abdominal pain, prompting a CT of the abdomen. The CT showed small pneumomediastinum in the posterior mediastinum located between the distal esophagus and the descending thoracic aorta (Figures 1 and 2). The patient had remained hemodynamically stable without any other clinical features of active perforation. The decision was made to forego endoscopic diversion and to continue with conservative management. She remained nothing per mouth and received antibiotics and intravenous fluids. A follow-up esophagram did now show evidence of contrast leak at the site of perforation (Figure 3).

DISCUSSION:
Bevacizumab has shown improved outcomes in patients with metastatic colorectal However, gastrointestinal perforation is an adverse event reported in 0.3–3.2% of patients. The mechanism by which bevacizumab induces perforation has not been determined, but may be associated with delayed wound healing. Moreover, Bevacizumab is frequently combined with cytotoxic regimens, including taxanes, which may be associated with gastrointestinal wall inflammation and necrosis. It is possible that her episodes of emesis may have contributed to this microperforation. As more cases are reported, clinicians can gain better understanding of related adverse effects of this medication.