Human chorionic gonadotropin 116 (N < 5) and CA 15.3 = 74.4 U/ml (N < 31); all other tumour markers (PSA, α-fetoprotein, CA 19.9 and CEA) within normal range. Normal urinalysis. Cardiac tests showed the following: (1) EKG – normal; (2) cardiac ultrasound displaying good left ventricle global systolic function; diastolic dysfunction; no valve abnormalities; mild biatrial dilation; dilated right ventricle with preserved systolic function; IVC within normal limits, preserved inspiratory collapse; no intra-chamber

thrombi or tumour. PI3K assay Radiologic exams revealed: (1) chest radiograph – normal; (2) venous ultrasound and Doppler of the lower limbs; (3) thoracic CT-angiogram and (4) abdominal and pelvic CT scan. The last three exams lead to the following

diagnoses: (A) residual superficial venous thrombosis of the right basilic vein, maintaining deep venous (humeral and axillary) system permeability; (B) deep venous thrombosis of the right posterior tibial and calf veins, with normal popliteal, common femoral, superficial femoral vein, great saphenous and small saphenous vein permeability; left lower limb venous system with no lesions; (C) anterior segmental pulmonary embolism in the right upper lobe and the internal segmental branch of the ipsilateral inferior lobe; (D) enlarged liver with several images compatible with metastases (Fig. 1); and (E) infiltrative lesion of the pancreatic uncinate process, involving the superior mesenteric vessels and thus becoming inoperable (Fig. 2). He was treated with subcutaneous XL184 chemical structure enoxaparin 60 mg bid, q12 h, with subsequent improvement. The patient was then transferred to the Lisbon Portuguese Oncology Institute, where he had an endoscopic ultrasound guided fine-needle aspiration biopsy of the liver and pancreas that confirmed a pancreatic adenocarcinoma (Fig. 3) with hepatic metastases (Fig. 4). In order to safely undergo these biopsies enoxaparin was withheld during 24 h. About 3 days after low-molecular-weight heparin (LMWH) was stopped the patient suffered a severe ischaemic

stroke leaving him with right-side hemiplegia. Progressive deterioration in neurologic status quickly ensued and the patient eventually GABA Receptor died a few days afterwards. No autopsy was made. The combination of conventional tumour markers, endoscopic methods and the most recent radiologic means including positron-emitting tomography (PET scan) allow us to correctly diagnose the malignancy behind TS in about 85–95% of cases.9 We stress the pivotal need – as we approach these patients in medical wards – to quickly and correctly identify the origin and histology of the underlying neoplasm, because TS is a quite serious clinical condition, and even though it is usually associated with advanced-stage cancer, there are also rare events when it helps to uncover cancer in an early phase and treat it, allowing for a better prognosis.