Clear cell variant of epithelioid mesothelioma is an extremely rare tumor with only isolated cases reported so far in the peritoneum. Here, we report a case of peritoneal epithelioid mesothelioma, clear cell variant, in a 63-year-old female patient with a novel VHL gene mutation and an unusual indolent clinical course. The patient, who has no clinical history of asbestos exposure, presented with a 27.2 cm upper abdominal mass and a 5.5 cm liver lesion. Retrospective review of the patient's abdominal CT scan 4 years ago showed two small abdominal lesions that were felt clinically to represent hemangiomas. These were retrospectively considered to have grown in size and represented the current abdominal mass. Both masses were subsequently biopsied and showed a proliferation of monomorphic epithelioid cells with distinct cell membranes, fine chromatin and clear to finely vacuolated pale eosinophilic cytoplasm arranged in nests and solid sheets. Immunohistochemical staining confirmed it to be malignant mesothelioma. Clear cell variant of peritoneal epithelioid mesothelioma should always be considered in patients with an abdominal or pelvic mass with clear cell features. Given the rarity of such entity, its clinical course and prognosis remains unclear.

The anti-inflammatory properties of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) may reduce the risk of developing sepsis in surgical intensive care patients and improve outcomes in those who do become septic. The objective of this study was to assess whether surgical intensive care unit (SICU) patients with prior exposure to HMG-CoA reductase inhibitors had a lower incidence of developing sepsis and improved outcomes. A retrospective cohort study was conducted. Patient demographic data, statin use, sequential organ failure assessment (SOFA) scores, vasopressor requirements, ventilator days, length of SICU stay, and mortality in septic patients were collected. Incidence of development of sepsis was determined using systemic inflammatory response syndrome criteria. Patients were grouped into cohorts based on whether they met the sepsis criteria and if they had previously received statins. Cohorts of patients who did and did not become septic with prior statin exposure were compared and an odds ratio was calculated to determine a protective effect. The setting was a SICU. The study comprised of 455 SICU patients and had no interventions. Among the 455 SICU patients, 427 patients were included for the final results. Patients receiving statins verses not receiving statins were similar in demographics. Previous statin exposure had a protective effect in the development of sepsis (9.77% on statins vs. 33.6% without statins; odds ratio 0.203, confidence interval 0.118-0.351). Of those patients who developed sepsis, there was a statistically significant decrease in 28-day mortality in patients with prior statin exposure (P = 0.0341). No statistical difference was noted in length of stay, vasopressor requirements, or days on mechanical ventilation. Prior exposure to statins may have a protective effect on the development of sepsis and decrease mortality in critically ill surgical patients.

A 66-year-old woman presented to the hospital with a one-month history of shortness of breath, fatigue, and postmenopausal vaginal bleeding and a one-week history of chest pain. This case report discusses the rare synchronous occurrence of two different malignancies in the setting of non-ST segment elevation myocardial infarction and the relation between these unfortunate events. Besides the case presented in this report, there have been only 13 reported cases of synchronous chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) associated with metastatic squamous cell carcinoma. While it is well known that malignancy causes a hypercoagulable state, there are other mechanisms which may have contributed to the patient's myocardial ischemia including external vascular compression, tumor lysis syndrome, and anemia. This case report discusses the rarity of synchronous malignancies but the importance of understanding and consideration of cardiac events in this population.

Our case highlights renal cell carcinoma with metastases to the gastric body and rectum presenting as melena and dyspnea. Renal cell carcinoma frequently metastasizes to the lungs, lymph nodes, bones, and liver; gastrointestinal metastasis is rare.

INTRODUCTION: Renal Cell Carcinoma (RCC) frequently metastasizes to the lungs, lymph nodes, bones, and liver via lymphatic, hematogenous, or direct invasion. Gastrointestinal metastasis is rare. We present a case of metastatic RCC to the gastric body and rectum presenting as melena and shortness of breath. CASE DESCRIPTION/METHODS: Patient is a 68-year-old male with a history of stage IV RCC to the skin and lung status post right total nephrectomy and right upper lobe wedge resection, who presented to the hospital with a one-month history of shortness of breath and 10–15 episodes of melena per day. On presentation, his heart rate was 121 bpm and blood pressure quickly dropped from 131/81 mmHg to 110/61 mmHg. Physical exam demonstrated abdominal tenderness and cachexia. Labs demonstrated hemoglobin 6.7 g/dL, which was 4 points lower than baseline and hyponatremia of 128 mmol/L. Other labs including hepatic panel and coagulation parameters were within normal limits. Hemoccult testing was positive. The patient was started on intravenous fluids, pantoprazole infusion, and blood transfusion (2 units). CT scan of the abdomen demonstrated a metastatic lesion in the sigmoid colon suggestive of an invasive metastatic lesion. Endoscopy revealed a nodule in the duodenum and mass was visualized on the greater curvature of the gastric body. Colonoscopy revealed a single polyp in the rectum, 10 mm in size. These lesions were biopsied and treated with bipolar cauterization. Pathological reports demonstrated metastatic carcinoma consistent with a renal primary source. DISCUSSION: RCC involves malignant cell proliferation in the proximal convoluted tubules of the kidney. Post-nephrectomy, there is still an approximate 20–40% chance of distal metastasis or locally recurrent disease. Thus, strict follow up is vital. While primary colorectal cancer is common, metastasis to this site is rare. There have been approximately 10 cases reported of metastasis of RCC to the rectum. Only 0.2–0.7% of RCC cases have been found to have metastasized to the stomach. This is the first case reported of synchronous metastasis of RCC to the rectum and gastric body presenting as melena as opposed to hematochezia. Although rare, clinicians should be mindful of this scenario and this case provides a clinical reminder.