Bone metastases in HCC are very rare and aggressive. Due to its rarity, optimal treatment strategies are not well defined. Early diagnosis is important for optimal therapy and improved survival.

Cancers of the small bowel are relatively rare and account for approximately 1–2% of all gastrointestinal neoplasms. The most common histologic subtype – adenocarcinoma – constitutes 40% of all cases. These cancers generally present with vague abdominal discomfort and are often diagnosed at a late stage and carry a poor prognosis. The treatment of choice of early-stage small bowel adenocarcinoma is surgical resection. No standard treatment protocol has been defined for unresectable or metastatic disease. Here, we report a case of a 56-year-old woman who presented with unexplained iron deficiency anemia. Extensive initial studies with serial CT scans of the abdomen, esophagogastroduodenoscopy, small bowel capsule endoscopy and colonoscopy were noncontributory. She was later found to have a metastatic small bowel adenocarcinoma and treated with palliative chemotherapy. She achieved a modest response to the treatment. Interestingly, in our case, the sole presentation was unexplained iron deficiency anemia. Physician’s awareness regarding the possibility of small bowel cancer especially in the setting of iron deficiency and its workup has been emphasized. This enhances the chance of early detection and hence better survival.

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This unusual case of hepatocellular carcinoma presenting as an incidental malignant portal vein thrombosis without any primary liver lesion is extremely rare. Other reported cases of malignant portal vein thrombosis have been in patients with underlying hepatoma, cirrhosis, or with intrabiliary hepatocelluar carcinoma. In the clinical setting of portal vein thrombosis, imaging studies showing enhancement of the thrombus in the arterial phase are important in leading to the diagnosis of malignancy.

Limited data are available to guide the timing of palliative care involvement in the treatment of cancer. We describe the referral patterns of inpatient palliative care consultations(IPCC) in advanced cancer patients in a tertiary care center.Methods: A retrospective review was performed of IPCC for cancer patients from January 1, 2014, to December 31, 2014. Descriptive statistics are reported.Results: IPCCs were requested for 245 cancer inpatients, of which 130 were male (53.1%) and 115 (46.9%) were female; 128 (52.2%) were Caucasian, 114 (46.5%) were African American, and 3 (1.2%) were another race. Of the 245 patients, 79 (32.2%) were newly diagnosed during the current admission, and the remaining 146 (67.8%) had been diagnosed previously. Fifty-seven (23.3%) patients were admitted to the intensive care unit (ICU) during hospitalization. Of the 39 patients (15.9%) who died during their hospital stay, 34 (87.0%) had an ICU stay during the hospitalization or died in the ICU. The most common malignancies were lung (71; 29.0%), pancreatic-biliary (33; 13.4%), lymphoma and leukemia (22; 8.9%), hepatocellular (18; 7.3%), head and neck (16; 6.5%), and upper gastrointestinal tract(GI) (16; 6.5%).Conclusions: Our data show that 15.9% of terminally ill cancer patients with IPCC died in the hospital, the majority of whom died in the ICU. This was likely due to delays in the initiation of outpatient palliative care consultation, leading to an increased strain on tertiary referral centers. Our study highlights a racial disparity in the rate of IPCC in African Americans, compared to historical data.

Primary angiosarcoma of the adrenal gland is both a rare and aggressive malignancy. Differentiating it from more common adrenal masses such as adrenal adenomas, adrenal cortical carcinomas, and metastatic carcinomas is one of several diagnostic challenges. Immunohistochemical analysis is imperative to arrive at the correct diagnosis. Treatment typically involves surgery and adjuvant chemotherapy, but prognosis remains poor.

Neoplasm of the appendix is relatively rare. Only 0.9-1.4% of all appendectomy specimens is found to have it. One in particular is the adenocarcinoma ex goblet cell carcinoid. The exact histopathogenesis and pathologic classification of this neoplasm are yet to be elucidated. Herein we report five cases to emphasize the importance of meticulous sampling and the possibility of misdiagnosis due to the presence of diverticulitis and acute appendicitis in some of these patients. All of our patients initially were presented with symptoms of or mimicking appendicitis, with radiology imaging suggestive of acute appendicitis or an appendiceal abscess. The pathologic examination of the appendectomy specimen revealed the incidental finding of the adenocarcinoma ex goblet cell carcinoid with focal positivity of synaptophysin and chromogranin. Two of our patients had diverticulitis and perforated appendicitis, which may lead to a misdiagnosis of the goblet cell carcinoid due to the absence of a discrete mass formation and focal localization of these tumor cells. Therefore, meticulous sampling is imperative in the diagnosis of this entity.

A 74-year-old white male was diagnosed with squamous cell carcinoma in 2013. Six months after Mohs surgery, he underwent a left superficial parotidectomy, left neck dissection, and excision of the left postauricular lymph node after confirmation of lymphatic spread. Pathology from the left parietal scalp lesion revealed multifocal invasive squamous cell carcinoma. Extranodal tumor extension was noted in a postauricular lymph node and left parotid gland, and he was diagnosed with stage IV squamous cell carcinoma.Despite receiving adjuvant radiation therapy from December 2013 to March 2014 to the right neck and scalp, a skin graft after 5 months was confirmed to have squamous cell carcinoma. Positron emission tomography-computed tomography showed metastatic disease at the level of cricoarytenoid cartilage and bilateral parotid glands. Cetuximab was discontinued, as he had an anaphylaxis episode after the first dose, and he later underwent localized radiation to his left temple.He returned after a year with multiple cutaneous nodular masses over the left face and neck, with a large ulcerated necrotic area over the left temporal region (Figure). Due to the lack of further chemotherapy options, he was started on pembrolizumab.Anti-programmed death ligand 1 testing from the tumor showed a staining distribution of 1%-24% and a staining intensity of 1þ, with a low positive result. Next-generation sequencing assay showed genomic alterations in AKT3 E17K,