Tumor lysis syndrome (TLS) occurs when tumor cells lyse and empty their contents into the bloodstream. TLS can occur in response to therapy or spontaneously, and it is most commonly seen in high-grade lymphomas, acute leukemias, and other rapidly proliferating tumors. For multiple myeloma (MM), the risk of RLS is less than one percent, and the risk of spontaneous TLS is even rarer. Therefore, we present a rare case of spontaneous TLS in MM. This case met the 2004 Cairo-Bishop laboratory criterion as well as the clinical TLS criterion for diagnosis and was treated with rasburicase as per guideline recommendations. We hope to educate others on such a presentation especially given the emergent nature of treatment and the increasing incidence of this disease.

A Rare Case of Spontaneous Tumor Lysis Syndrome in Multiple Myeloma

**Scoring is only possible in the semifinals hall**

**Abstract:**



Rare Presentation of HPV-related Retroperitoneal Squamous Cell Carcinoma of Unknown Primary: A case report

Background
Routine hepatic ultrasonography is the most used clinical imaging study in diagnosing chronic liver diseases (CLDs), including assessing hepatic steatosis, a common presentation of CLDs. However, data remain lacking on the performance of hepatic ultrasonography in assessing steatosis and factors that may impact the quality of its performance. This study evaluated the association of hepatic ultrasonography for the assessment of hepatic steatosis with histological hepatic steatosis and other related factors.
Methods
A single-center retrospective study of 188 patients with various CLDs, regular follow-ups, and liver biopsy at the UCIMC Liver Clinic.
Results
The mean age±SD was 57±13 years old. 93 patients were male (49.5%), and 44 (23.4%) had a BMI ≥ 30. Chronic hepatitis C (CHC, 20.8%) and B (17.5%), and non-alcoholic fatty liver disease (NAFLD, 29.0%) were the main CLDs. In this cohort, 89/187 (47.6%) patients had biopsy-proven hepatic steatosis (i.e., ≥ 5% of hepatocytes), 129/188 (68.6%) had ultrasonographic reports of hepatic steatosis, and 67/184 (36.4%) had ultrasonographic reports of hepatomegaly (i.e., ≥ 16.5 cm). The sensitivity and specificity of hepatic ultrasonography for assessing hepatic steatosis, compared to histological steatosis ≥ 5% (gold standard), was 85.4% (76/89 patients) and 46.9% (46/98 patients), respectively. Chi-square analysis showed that hepatic steatosis on ultrasonography was significantly associated with biopsy-proven hepatic steatosis (76/128, 59.4%, p<.01). Hepatic steatosis on ultrasonography was also significantly associated with age ≥ 65 years old (48/129, 37.2%, p=.02), histological evidence of ballooning degeneration (57/86, 66.3%, p<.01), Mallory-Denk bodies (20/60, 33.3%, p<.01), and portal/periportal fibrosis (66/98, 67.3%, p<.03). The frequency of hepatic steatosis diagnosed on ultrasonography was higher in those with NAFLD (45/92, 48.9%) than those with CHC (25/92, 27.2%) or CHB (22/92, 23.9%), but the difference was not significant (p=.08). Ultrasonographic-diagnosed hepatic steatosis was not significantly associated with BMI ≥ 30 (31/129, 24%, p=.76), elevated AST or ALT to ≥ 35 IU/L for males or ≥ 25 IU/L for females (90/111, 81.1%, p=.06 or 84/111, 75.7%, p=.77, respectively). In multivariate analysis, ultrasonographic-diagnosed hepatic steatosis was significantly associated with the presence of ballooning degeneration (95% CI: 1.25-20.72; p=.02) and portal/periportal fibrosis (95% CI: 1.29-11.14; p=.02) on liver biopsy, but not biopsy-proven hepatic steatosis (95% CI: 0.17-1.94; p=.37) or hepatomegaly on ultrasonography (95% CI: 0.71-7.33; p=.17).
Conclusion
Routine hepatic ultrasonography has good sensitivity, but low specificity in the assessment of hepatic steatosis. Histological hepatocytic ballooning degeneration and portal/periportal fibrosis were independently associated with hepatic steatosis detected by ultrasonography.

Association of Ultrasonographic Assessment of Hepatic Steatosis with the Presence Of Histological Steatosis and the Related Factors

Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare autoimmune disorder related to aquaporin-4 IgG (AQP4-IgG) antibody. Sometimes, NMOSD patients don't have this antibody, called seronegative NMOSD. Extremely rarely, this condition presents as a paraneoplastic syndrome. This presentation illustrates a case of paraneoplastic AQP4-IgG seronegative NMOSD.

A Rare Case of Paraneoplastic AQP4-IgG Negative Neuromyelitis Optica Spectrum Disorder

Background

Tumor-to-tumor metastasis (TTM) is an exceptionally rare phenomenon, especially so when involving cutaneous neoplasms. Therefore, they may present a diagnostic conundrum for pathologists.

TTM are defined by the following criteria:

1- More than one primary tumor must exist.

2- The host tumor is a true neoplasm.

3- The primary tumor shows growth inside the secondary tumor, not just transitional growth indicative of collision.

4- The host tumor cannot be a lymph node affected by leukemia or lymphoma.

This systematic review aims to characterize the cutaneous TTM as both donor and recipient tumors. This will provide information for pathologists to consider in the diagnosis of TTM. Additionally, these events may provide insight into underlying mechanisms of tumor tropism in metastatic disease.

Methods

PubMed, Embase, Medline, and ScienceDirect were searched using the terms “tumor-to-tumor metastasis” and “cutaneous””. Titles and abstracts were reviewed independently by 2 reviewers (NC, MRM). Inclusion criteria required English language and peer-reviewed studies. Consensus was reached for all articles. Furthermore, citations of all included studies were

reviewed to find further cases. The following data were extracted: title, patient age, sex, race, donor and recipient tumor type, size, location, subtype, and special features, treatment history, and metastatic burden.

Results

13/673 articles met inclusion criteria and were further reviewed. The most common donor cutaneous malignancy was melanoma (7/13), The most common recipient tumor of cutaneous metastatic melanoma was basal cell carcinoma (2/13). Lipomas and basal cell carcinomas(BCCs) were the two most common recipient cutaneous tumors (2/13 each), and the phenomena often occurred in the setting of widespread metastasis (7/13 cases).

Conclusion

While uncommon, tumor-to-tumor metastasis should be considered as an important differential diagnosis that may have profound implications for treatment and prognosis. Melanomas were implicated in cutaneous TTM more often than any other tumor. This information will be useful for pathologists to consider in working up challenging cases suggestive of tumor-to-tumor metastasis.

Characteristics of TTM identified in this study may elucidate mechanisms underlying metastatic tropism. It is unclear to what degree TTM occurs from chance, or how the host tumor microenvironmental milieu affects the probability of metastasis. Our findings suggest host tumor microenvironment plays an important role in TTM, as only 7/13 of cases occurred in patients with diffuse metastatic burdens. Additional studies teasing apart the seed-and-soil hypothesis of TTM are needed to understand this phenomenon use it to improve diagnosis, prognosis, and treatment of patients with metastatic disease.

Cutaneous Neoplasms as Donors and Recipients in Tumor-to-Tumor Metastasis: A Systematic Review of the Literature

There is a role for the gut virome in numerous dysbiosis-associated states including obesity, inflammatory bowel diseases, and C. difficile infection. These findings are likely related to the ecological function of bacteriophages (phages) in regulating the structure, composition, and diversity of the gut microbiome. Dysregulation in the gut phage community may therefore lead to microbiome dysbiosis. To study whether exogenous phage administration may have therapeutic potential as a treatment for dysbiosis, our lab purified phages from lactic acid bacteria-fermented sauerkraut to test the effect of sauerkraut phages in a mouse model for stress-induced dysbiosis. Stress is strongly associated with dysbiosis, decreased microbiome diversity, and the growth of pro-inflammatory bacteria in the gut microbiome. Sauerkraut and other fermented foods have been shown to promote microbiome diversity and our lab hypothesized that phages may have a role in mediating this effect.

Bacteriophages derived from fermented food increase cecal microbiome diversity in the setting of stress-induced dysbiosis

Advancing Cancer Diagnostics with Artificial Intelligence (AI): A Comprehensive Systematic Review

Numerous Recurrent Venous Thromboembolisms in the Setting of Severe Obesity and Anticoagulation: A Case Report

Background
The choroid, due to its rich vascular supply, is the most commonly affected ocular site for metastatic diseases. 
Most common cancers that result in choroidal metastasis are breast cancer (46-47% of cases) and lung cancer (21-29%). 
The most common type of lung cancer responsible for metastatic spread to choroid is adenocarcinoma. Small-cell lung cancer is a rare cause of choroidal metastasis.

Case Presentation
A 69-year-old male with history of COPD and heavy tobacco smoking initially presented with right-sided blurred vision and flashes of light. In the oncologist’s office, the patient was also found to have dyspnea, fatigue, anorexia and significant unintentional weight loss.
Fundus examination revealed irregular creamy white lesion and sub retinal fluid. 
The optical coherence tomography (OCT), ultrasound and fluorescein angiography of right eye showed vitreous detachment and a 10 mm x 10 mm x 3 mm irregular choroidal mass consistent with amelanotic metastatic choroidal disease.
CT scan of the chest W/WO contrast revealed a 5 cm x 4 cm right lower lobe mass, multiple bilateral pleural-based nodules, left lobe satellite nodules, subcarinal and anterior tracheal lymphadenopathy. CT scan of the abdomen and pelvis were negative for metastatic disease.
CT-guided biopsy of the right lower lobe mass showed high-grade tumor cells and immunohistochemistry showed positive staining for synaptophysin, CD56, TTF-1, and AE1/AE3 consistent with small-cell lung cancer.

Discussion
Lung cancer is a very uncommon cause of choroidal metastasis. Among all lung neoplasms, adenocarcinoma of the lung is the most common type which account for choroidal metastasis. 
SCLC is rarely reported to have spread to choroid. Most patients with SCLC with intraocular metastasis also had evidence of spread to bones and abdominal organs. Our patient did not show metastasis to solid organs or bones, but had widespread metastatic lesions in the thoracic cavity. Treatment of metastatic SCLC includes systemic therapy and local therapy. Systemic therapy includes chemotherapy with platinum-based regimens and target therapy e.g. atezolizumab or durvalumabc etc. Local radiotherapy also helps increase tumor response rate significantly.


Unilateral Choroidal Metastases as An Unusual Presentation for Small Cell Lung Cancer


Background
Drug-induced hypersensitivity syndrome (DIHS) is a severe, potentially life-threatening drug reaction with cutaneous and internal organ involvement. DIHS can lead to various autoimmune conditions, occurring in about 10% of patients, including thyroiditis. This case highlights the need for post-DIHS thyroiditis screening.

Case Presentation
A 32-year-old woman presented to the emergency department with fever, morbilliform eruption, facial swelling, lymphadenopathy, and laboratory studies notable for atypical lymphocytes (4%), eosinophilia (1400), and aminotransferase abnormalities (AST 61, ALT 265). Two weeks prior, she initiated a course of oral trimethoprim-sulfamethoxazole. History, clinical exam, and laboratory findings were consistent with DIHS. She was treated with high-dose corticosteroids with a resolution of the eruption and stabilization of hepatic enzymes. At follow-up in an outpatient dermatology clinic four weeks after discharge, she was noted to have clinically painful thyromegaly, fever, tachycardia, and palpitations. She was referred to the ED to expedite workup for suspected symptomatic hyperthyroidism. Workup revealed TSH of 0.01 (L), FT4 >7.7 (H), TSI <0.10, TRAb negative, and TPO Ab 202 (H). Thyroid ultrasound showed enlarged thyroid with heterogenous echotexture. Endocrinology diagnosed her with thyroiditis and prescribed atenolol for symptom management. She continued to have heat intolerance, palpitations, and faint pink macules on her lower legs. She initiated low-dose methimazole with a resolution of symptoms.

Discussion

One of the most common drug classes to cause post-DIHS autoimmune thyroiditis are sulfa drugs and antiepileptics. The most commonly seen issues that arise in the thyroid post-DIHS are Hashimoto’s thyroiditis and Graves’ disease, which have been observed to occur between 2 months and 3 years after the diagnosis of DIHS. As seen in this case, the patient experienced debilitating symptoms of thyroiditis within 1 month, which could have been minimized with early screening and recognition. This case emphasizes the importance of dermatologic follow-up for patients diagnosed with DIHS and the role of post-DIHS screening for autoimmune thyroid disease, as missed diagnosis of delayed sequelae can lead to significant morbidity.

Importance of Post-Drug Induced Hypersensitivity Syndrome Thyroiditis Screening

We present a patient with antiphospholipid syndrome and thrombocytopenia that was found to have a rare mutation in the Vitamin K epoxide reductase complex subunit 1 which altered his response to Warfarin therapy. The patient had experienced multiple prior thrombolic events, however his low platelet count put him in danger of having a severe bleeding event. We describe below how we found a balance in managing both his clotting and bleeding risks.

Management of Recurrent Arterial Clots in Antiphospholipid Syndrome with Thrombocytopenia and Warfarin Resistant Gene

Background 
Radiation therapy (RT) serves as the mainstay adjuvant therapy in patients that underwent breast-conserving surgery for the management of breast cancer. Radiation induced rib fracture is a rare complication of radiotherapy. 


Case Presentation 
A 57-year-old African American female presented to the hospital after an abnormal screening mammogram demonstrated left breast calcifications. A left breast core biopsy revealed an intermediate- to high- grade ductal carcinoma in situ. The mass was excised. On immunohistochemical receptor assay, the mass was found to be estrogen receptor (+) and progesterone receptor (+). The patient was counselled on the initiation of adjuvant radiotherapy as part of the treatment regimen. 

Six months after her radiotherapy, the patient presented with a month-long discomfort on the left lower quadrant of her left breast, which aggravated with movement, despite the absence of trauma or falls. An X-ray demonstrated a subtle fracture of the tip of the left 10th rib and the lateral aspect of the left 7th rib, and the patient was treated conservatively. 

A PET-CT scan a month later showed a minimally displaced fracture of the left anterolateral 7th rib. The previously noted subtle fracture on the 10th rib was not appreciated on this examination. The patient returned to the clinic reporting a decreased pain intensity. A month later, the patient no longer had chest pain or discomfort and was informed that her subtle fractures have healed. 


Discussion 
Radiation-induced rib fractures (RIRF) refer to the occurrence of rib fractures after radiotherapy to the region close to a rib or within a path of a rib. They are considered pathological fractures, as they happen in underlying abnormal bone affected by radiation therapy. 

RIRFs are rare especially after hypofractionated stereotactic body radiation therapy (SBRT). It was reported that the incidence of RIRF with whole breast dose <50 Gy was 1.5% and >50 Gy was 5.3%. High-dose volume and the maximum dose have a direct relationship with RIRF. The toxic effects of radiation reduce osteoblast function and therefore, decreases bone matrix production leading to pathological fractures. The bones within the radiation portal are weakened, particularly if the primary irradiated tumor is close to the chest wall.

These patients may be asymptomatic or symptomatic and present with chest discomfort or pain after a few months of radiation. These symptoms usually resolve conservatively; therefore, a follow up of the patient and imaging should be considered.


Underline digital video library

A Rare Case of Spontaneous Tumor Lysis Syndrome in Multiple Myeloma

Rare Presentation of HPV-related Retroperitoneal Squamous Cell Carcinoma of Unknown Primary: A case report

Association of Ultrasonographic Assessment of Hepatic Steatosis with the Presence Of Histological Steatosis and the Related Factors

A Rare Case of Paraneoplastic AQP4-IgG Negative Neuromyelitis Optica Spectrum Disorder

Cutaneous Neoplasms as Donors and Recipients in Tumor-to-Tumor Metastasis: A Systematic Review of the Literature

Bacteriophages derived from fermented food increase cecal microbiome diversity in the setting of stress-induced dysbiosis

Advancing Cancer Diagnostics with Artificial Intelligence (AI): A Comprehensive Systematic Review

Numerous Recurrent Venous Thromboembolisms in the Setting of Severe Obesity and Anticoagulation: A Case Report

Unilateral Choroidal Metastases as An Unusual Presentation for Small Cell Lung Cancer

Importance of Post-Drug Induced Hypersensitivity Syndrome Thyroiditis Screening

Management of Recurrent Arterial Clots in Antiphospholipid Syndrome with Thrombocytopenia and Warfarin Resistant Gene

Radiation-Induced Rib Fracture Post Breast Cancer Radiotherapy: A Case Report

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