59 year old male with a history of non-ischemic cardiomyopathy, status post AICD/pacemaker insertion, presented with generalized weakness and confusion. He was diagnosed with diffuse B-cell lymphoma and underwent bone marrow transplant about a year ago.

The patient was on Warfarin (Coumadin) for his cardiomyopathy. Three days prior to admission he fell in the bathroom and hit his head. On presentation to the Hospital his INR was elevated at 4.1 with the platelet count of 17,000 (normal>150,000). He had low grade fever and normal white count. Cultures were obtained.

CT head showed a lesion in the right frontal area. MRI is not possible due to the AICD. CT Chest revealed multiple pulmonary nodules (see the image above).

The patient is a farmer and was working with hay several days prior to admission. He was started on an antifungal agent (voriconazole) for possible fungal infection. Bronchoscopy and biopsy was scheduled.

What is the likely etiology of the lesion in the brain and in his lungs?

This is the most unusual and bizarre cancer case I have ever seen.

69 year old female with no previous medical history presented to her gynecologist with vaginal bleeding. Pelvic ultrasound reveled an abnormal endometrial thickening. Endometrial biopsy confirmed the diagnosis of endometrial cancer.

The patient underwent uneventful laparoscopic hysterectomy and salpingo-oophorectomy. The post-op pathology revealed a surprise – in addition to the endometrial cancer the patient also had grade 1 ovarian papillary serous carcinoma.

A PET scan revealed areas of increased intake in the pelvis. Very shortly after the first surgery she underwent exploratory laparotomy and restaging including pelvic/periaortic lymphadenectomy, omentectomy and multiple biopsies. The final pathology – no cancer, just reactive changes after the first procedure.

Five weeks later the patient gets readmitted with abdominal distention and a sepsis like picture. CT abdomen/pelvis showed multiple abdominal and pelvic masses. CT chest shows multiple pulmonary nodules (see the images above). Broad spectrum IV antibiotics started. The patient was getting progressively worse.

The biggest question was: what were we dealing with? It would be unlikely for stage 1 endometrial or ovarian cancer to progress so rapidly just a few weeks after a complete restaging.

Some reports in the medical literature indicate that a laparoscopic approach for hysterectomy could promote retrograde dissemination of the cancer cells through the fallopian tubes into the peritoneal cavity. These concerns were not substantiated in the bigger studies.

The patient was taken back to OR for an exploratory laparotomy. Intraoperative findings – abdomen and pelvis are packed with cancer. The preliminary pathology – high grade sarcoma. The biopsy specimens were sent to New York to a sarcoma specialist.

The patient continued to deteriorate and Hospice care was initiated.

All the pathology slides beginning with the first surgery are going to be re-looked at and reviewed again. Regardless of what the final pathological diagnosis is, this is the most explosive presentation of cancer I have ever seen.

There are very few oncologic emergencies. Neoplastic epidural spinal cord compression is one of them. The delay in diagnosis and treatment is often explained by the non-specific nature of the presenting signs and symptoms.

The patient developed urinary retention a couple of weeks prior to presentation. On the morning of admission he was fully functional. Later he sat down to have a cup of coffee and boom – he couldn’t feel his legs. He couldn’t get up either.

Ideally, this patient should be rushed to the Hospital with an emergent neurosurgery consult. Prompt surgical decompression of the spinal cord or radiation treatment could improve his chances for functional recovery.

The patient lives on a 500 acre farm in a remote part of the country and getting to the closest ER took some time. It did not take the ER physician a long time to recognize the potential problem. Intravenous steroids were administered. MRI of the spine clearly showed an epidural mass with spinal cord compression at T6 level (see the image above).

No neurosurgeon was available in the small outlying hospital. That means that the patient had to be transferred to a bigger hospital. More time spent on arranging the transfer and getting the patient to the neurosurgeon.

All in all, it took 12 hours from the onset of symptoms to the neurosurgical evaluation. The patient had an urgent laminectomy with spinal cord decompression. The likely diagnosis is metastatic prostate cancer with T6 epidural metastasis and spinal cord compromise.

Despite the treatment with steroids and an “emergent” surgical decompression the patient remains paraplegic. His PSA is > 300. The final pathology is yet pending.

This is an unfortunate case. Despite appropriate actions and management, the patient did not receive the needed care for 12 hours after the onset of symptoms. Had he lived closer to an urban area and a bigger hospital, he might have been able to walk.

This is true not only for trauma and oncology patients. Same goes for the patients with coronary conditions and other emergencies. The unfortunate truth is that access to medical care often decreases the further you go from a major urban center.

We have come a long way since the old days when ground ambulance was the only way to transport critically ill patients. Helicopters and fixed-wing aircrafts are readily available now for transfer.

Everything takes time, though. Packing the patient for the ambulance ride or even picking up the phone and waiting for the answer on the other end wastes the precious time that could make a big difference in the patient’s outcome. The bottom line is - in the case of a medical emergency the distance from the Hospital could be a deciding factor between life and death.

79 year old female with stage 4 metastatic breast cancer and poor prognosis presented with progressively worsening shortness of breath. Chest XR revealed evidence of left-sided pneumonia with lung consolidation(click on image above). The patient requested a "full code" including intubation.