A CURIOUS CASE OF PERICARDIAL EFFUSION IN METASTATIC CLEAR CELL RENAL CARCINOMA Shidestini Martinez, Fereshteh Yazdi, Maamannan Venkataraj, Jonathan Packer, Laurie Grier; Department of Medicine, Louisiana State University, Shreveport, LA.
Introduction: Immune modulators such as nivolumab, a programmed death-1 (PD-1) inhibitor, and ipilimumab, cytotoxic T-lymphocyte associated antigen 4 binder are commonly used in the treatment of renal cell carcinoma, non- small cell lung malignancies and malignant melanoma. Rare cases of myocarditis have been associated with this class of immune therapy and even more rarely cases of pericardial effusion. Case: This is a 65-year-old male with history of Renal Cell Carcinoma (RCC) diagnosed in 2019 now s/p radical nephrectomy and surgical resection of right frontal lobe brain metastasis. Patient received three doses of nivolumab and ipilimumab and then presented to outside hospital for worsening shortness of breath He was treated with vancomycin and Zosyn for suspected pneumonia. The patient became increasingly hypotensive and hypoxic requiring intubation. This was thought to be secondary to septic shock and he was accepted for acute hypoxemic
respiratory failure to our facility. Patient was started on levophed, vasopressin and hydrocortisone infusions. Bedside echo was performed demonstrating a pericardial effusion. Cardiology was able to perform bedside pericardiocentesis with aspiration of 200cc of serosanguineous fluid. Patient initially improved following pericardiocentesis however ultimately succumbed to an acute GI bleed with unknown source. Discussion: We present a case of pericardial effusion in metastatic clear cell renal carcinoma with no malignant cells in pericardial fluid. Although a rare occurrence, prior case reports of pericardial effusion caused by nivolumab/ ipilimumab were reported only in metastatic NSCLC. Mechanisms of immune related cardiac effects of nivolumab and ipilimumab remain unclear. Immunotherapy in the treatment of malignancies is associated with a wide spectrum of life-threatening immune related adverse events. Non- specific symptoms such as dyspnea should alert the clinician to look for immune-related cardiac toxicities.
A ROUNDABOUT WAY TO GASTRIC ADENOCARCINOMA DIAGNOSIS AFTER ROUX-EN-Y BYPASS Ebiai Ruona, William Song; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Gastric cancer is the 5th most common type of malignancy world-wide. Obesity has been associated with an increased risk of gastric cancer and Roux-en-Y is the most commonly performed surgical weight-loss procedure in the US. Gastric adenocarcinoma in the remnant stomach after Roux-en-Y is rare, with only a few cases reported in literature. We present a case of a gastric adenocarcinoma in the excluded stomach, 20 years after gastric bypass surgery. Case: A 50-year-old woman with remote history of breast cancer and Roux-en-Y gastric bypass surgery who presented with five weeks of nausea, vomiting, constipation, abdominal pain and significant weight loss with inability to tolerate solid food. She developed ascites and bilateral pleural effusions. Thoracentesis and paracentesis showed non-cancerous cells. Her abdomen was globose, soft and massless with diffuse tenderness to palpation. Diagnostic laparoscopy and intraoperative
esophagogastroduodenoscopy revealed intact post Roux-en-Y anatomy and no obvious cause for her symptoms. The procedure showed extensive peritoneal adhesions and diffuse small bowel inflammation. Spontaneous bacterial peritonitis secondary to extensive adhesions and inflammation was considered but her symptoms continued despite appropriate treatment. Subsequent CT abdomen revealed diffuse peritoneal carcinomatosis. Given her breast cancer history, there was concern for ovarian malignancy, but transvaginal ultrasound revealed no adnexal masses. Her tumor markers CEA and CA-125 were elevated. Double balloon endoscopy was performed to evaluate for malignancy of a different origin and revealed an ulcerated pylorus as well as irregular appearing mucosa in the remnant stomach. Biopsies taken revealed poorly differentiated gastric adenocarcinoma, diagnosed as stage IV gastric adenocarcinoma with diffuse peritoneal carcinomatosis. Her symptoms remained intractable. She was transferred to an 28
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