Case Reports in Oncological Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Morbid Obesity as Early Manifestation of Occult Hypothalamic-Pituitary LCH with Delay in Treatment Mon, 30 Nov 2015 15:31:33 +0000 Morbid obesity presents unique challenges in managing additional disease processes. A 16-year-old male with a history of central diabetes insipidus (DI) and hypothyroidism developed destructive lesions in both his right mandible and brain, which were not discovered until the patient presented for tinnitus, 8 years after his initial diagnosis with DI. Langerhans cell histiocytosis (LCH) was diagnosed on pathologic biopsy. The patient’s initial body mass index (BMI) was 54.5 kg/m2 so a unique treatment approach with single agent cladribine (2-CdA) was offered as traditional steroid therapy could worsen his endocrine dysfunction. The patient presented with neurodegenerative sequelae from the central LCH, possibly due to a delay in diagnosis and therapy. This case highlights difficulties in managing obese patients in an oncology setting and provides an illustrative case of how obesity may mask other comorbid conditions. Close supervision of complex obese patients with coordinated endocrinology and oncology care is vital. For the primary care practitioner, monitoring abrupt changes in BMI with serial cranial imaging may lead to a prompt diagnosis and prevention of further neurodegenerative effects. The use of 2-CdA was found to successfully bring the patient’s LCH into remission without the additional risks of steroid therapy in a morbidly obese patient. Jennifer Keates-Baleeiro and Marielisa Rincon Copyright © 2015 Jennifer Keates-Baleeiro and Marielisa Rincon. All rights reserved. Chemoradiotherapy in a Case of Malignant Syringocystadenocarcinoma Papilliferum of Vulva with Locoregional Failure Mon, 30 Nov 2015 06:45:50 +0000 Introduction. Syringocystadenocarcinoma papilliferum (SCACP) is an extremely rare malignant adnexal tumor, which arises from syringocystadenoma papilliferum. To date, less than 30 cases of malignant SCACP have been reported, of which locoregional metastases were found in only four cases. Case Report. A 57-year-old female patient who presented to our Oncology Department with a recurrent malignant SCACP of the left labia along with right inguinal lymphadenopathy. Pathological examination confirmed the diagnosis of malignant SCACP with right inguinal lymph node metastases. Due to the fixity of the right inguinal nodes, neoadjuvant chemotherapy was administered with Cisplatin and 5-Fluorouracil for four cycles, following which the primary tumor and the contralateral inguinal nodes regressed completely. Then definitive chemoradiation was delivered with five cycles of weekly Cisplatin and external beam pelvic irradiation up to a dose of 59.4 Gy. Patient is disease-free 11 months after treatment. Discussion. We here report the fifth case of malignant SCACP with locoregional metastases. This is the first case of malignant SCACP which has been treated with neoadjuvant chemotherapy followed by concurrent chemoradiation. Although surgery has been used most commonly, chemoradiation may also have a role in the treatment of malignant SCACP, especially in cases of locoregional metastases. Pamidimukkala Bramhananda Rao, Saptarshi Ghosh, Manisha Mohapatra, N. Pramod Philip, P. Ravindra Kumar, Surendra Manam, Pradeep Karra, and Vijay Krishna Jasti Copyright © 2015 Pamidimukkala Bramhananda Rao et al. All rights reserved. Poorly Differentiated Neuroendocrine Tumor of the Rectum Coexistent with Giant Rectal Villous Adenoma Presenting as McKittrick-Wheelock Syndrome Sun, 22 Nov 2015 11:06:15 +0000 McKittrick-Wheelock Syndrome is a rare disorder, noted for electrolyte and fluid depletion caused by secretory colorectal adenomas and carcinomas. We report here the first reported case of a 55-year-old man with a large rectal villous adenoma coexistent with a poorly differentiated neuroendocrine tumor of rectum presenting with McKittrick-Wheelock Syndrome. Palliative chemotherapy resulted in complete resolution of symptoms and improved quality of life. Sammy G. Nakhla, Traci T. Murakami, and Srinath Sundararajan Copyright © 2015 Sammy G. Nakhla et al. All rights reserved. Scalp Melanoma Diagnosed by Fine Needle Aspiration Cytology in a Tertiary Health Center Tue, 17 Nov 2015 14:23:35 +0000 Melanoma is one of the most aggressive malignant skin neoplasms worldwide with more than 20% of world melanoma seen in black Africa and Asia. Late presentation due to ignorance, poverty, and lack of adequate health facility in Nigeria is always the norms. We present this case report because of precision in diagnosis, using fine needle aspiration cytology (FNAC) to reemphasize that the technique is cheap, cost effective, and quick that can reduce the burden of incisional biopsy before definitive surgery and improve early detection of the disease especially in developing countries. A. B. Zarami, N. A. Satumari, and M. Ahmed Copyright © 2015 A. B. Zarami et al. All rights reserved. A Literature Review and Case Report of Metastatic Pure Choriocarcinoma Mon, 16 Nov 2015 16:17:11 +0000 In 2012, testicular cancer was estimated to account for 940 disability adjusted life years in Australia; of these, 450 were years lost due to premature death and 500 were years of healthy life lost due to disease, disability, or injury (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 2012). Testicular choriocarcinoma is one of the rarest variants of testicular germ cell tumours, accounting for less than 1% of testicular germ cell tumours and only about 0.19% of all testicular tumours. Management involves radical orchidectomy and chemotherapy. Even then, prognosis is poor. This case report describes a 20-year-old male with pure testicular choriocarcinoma with pulmonary metastases which showed sustained and complete response to adjuvant chemotherapy consisting of bleomycin, etoposide, and cisplatin. Diwei Lin, Amanda Jia Hui Tan, and Rajinder Singh-Rai Copyright © 2015 Diwei Lin et al. All rights reserved. Recurrent Renal Cell Carcinoma with Synchronous Tumor Growth in Azygoesophageal Recess and Duodenum: A Rare Cause of Anemia and Upper Gastrointestinal Bleeding Thu, 12 Nov 2015 11:45:54 +0000 Renal cell carcinoma (RCC) has potential to present with distant metastasis several years after complete resection. The common sites of metastases include the lungs, bones, liver, renal fossa, and brain. RCCs metastasize rarely to the duodenum, and duodenal metastasis presenting with acute gastrointestinal bleed is infrequently reported in literature. We present a case of synchronous presentation of duodenal and azygoesophageal metastasis manifesting as acute upper gastrointestinal bleeding, four years after undergoing nephrectomy for RCC. The patient underwent further workup and was treated with radiation. The synchronous presentation is rare and stresses the importance of searching for recurrence of RCC in patients presenting with acute gastrointestinal bleeding. Vamshidhar R. Vootla, Muhammad Kashif, Masooma Niazi, and Suresh K. Nayudu Copyright © 2015 Vamshidhar R. Vootla et al. All rights reserved. Multiple Bone Metastases as the First Manifestation of Hepatocellular Carcinoma in Patient with Noncirrhotic Liver Mon, 09 Nov 2015 13:04:57 +0000 Hepatocellular carcinoma (HCC) generally occurs on the background of chronic liver disease. Chronic hepatitides B and C and alcoholic liver disease are well-known risk factors for HCC, and it is uncommon in noncirrhotic liver. Extrahepatic metastasis seldom occurs in patients with early stage intrahepatic HCC and isolated bone metastases as a first documented extrahepatic metastasis is unusual presentation. In this report, we present a rare case of small solitary HCC (<3 cm) in noncirrhotic liver, presenting isolated bone metastases as a sole manifestation in patient with no well-known risk factors. This case suggests that HCC should be considered as one of differential diagnoses in patient presenting with multiple bone metastases, even in the absence of liver cirrhosis. Soo Ya Bae, Hyun Jung Kim, Hyun Ho Oh, Min Kwan Kwon, Jong Ho Lee, Moon Park, and Byeong Seok Sohn Copyright © 2015 Soo Ya Bae et al. All rights reserved. Urothelial Superior Vena Cava Syndrome with Limited Response to Radiation Therapy Sun, 08 Nov 2015 13:32:19 +0000 Radiation therapy (RT) is the standard of care for cases of superior vena cava (SVC) syndrome secondary to metastatic adenopathy. Histologies vary in radiosensitivity and response time, making alternative therapies such as chemotherapy and/or intravenous stenting preferable alternative options for certain diagnoses. Metastatic urothelial carcinoma is a particularly rare cause of SVC syndrome with only 3 cases reported in the literature. Consequently, optimal management remains challenging, particularly in cases of high tumor burden. Here we present a case of highly advanced metastatic urothelial cancer with SVC syndrome and tracheal compression. The patient started urgent RT but expired midway through her treatment course due to systemic progression of disease, requiring SVC and tracheal stenting. The authors review the literature including discussion of the few other known cases of SVC syndrome due to urothelial carcinoma and a review of this histology’s response to RT. This experience suggests, that in cases of SVC syndrome with widespread advanced disease, stenting and chemotherapy with or without RT may be the most important initial treatment plan, depending on goals of care. Nishan Bingham, H. James Wallace III, Joanne Monterroso, Claire Verschraegen, Brenda L. Waters, and Christopher J. Anker Copyright © 2015 Nishan Bingham et al. All rights reserved. Clinicopathological and Targeted Exome Gene Features of a Patient with Metastatic Acinic Cell Carcinoma of the Parotid Gland Harboring an ARID2 Nonsense Mutation and CDKN2A/B Deletion Sun, 08 Nov 2015 13:16:22 +0000 We describe the presentation, treatment, clinical outcome, and targeted genome analysis of a metastatic salivary acinic cell carcinoma (AciCC). A 71-year-old male presented with a 3 cm right tail of a parotid lesion, first detected as a nodule by the patient seven months earlier. He had a right total parotidectomy with cranial nerve VII resection, right facial nerve resection and grafting, resection of the right conchal cartilage, and right modified radical neck dissection. The primary tumor revealed AciCC with two distinct areas: a well-differentiated component with glandular architecture and a dedifferentiated component with infiltrative growth pattern associated with prominent stromal response, necrosis, perineural invasion, and cellular pleomorphism. Tumor staging was pT4 N0 MX. Immunohistochemistry staining showed pankeratin (+), CD56 (−), and a Ki67 proliferation index of 15%. Upon microscopic inspection, 49 local lymph nodes resected during parotidectomy were negative for cancer cells. Targeted sequencing of the primary tumor revealed deletions of CDKN2A and CDKN2B, a nonsense mutation in ARID2, and single missense mutations of unknown significance in nine other genes. Despite postoperative localized radiation treatment, follow-up whole body PET/CT scan showed lung, soft tissue, bone, and liver metastases. The patient expired 9 months after resection of the primary tumor. Wayne A. Warner, Deborah J. Wong, Fernando Palma-Diaz, Terry Y. Shibuya, and Jamil Momand Copyright © 2015 Wayne A. Warner et al. All rights reserved. Left Vocal Cord Paralysis Detected by PET/CT in a Case of Lung Cancer Tue, 03 Nov 2015 06:41:40 +0000 We report a patient with lung cancer. The first PET/CT imaging revealed hypermetabolic mass in the left aortopulmonary region and hypermetabolic nodule in the anterior segment of the upper lobe of the left lung. After completing chemotherapy and radiotherapy against the primary mass in the left lung, the patient underwent a second PET/CT examination for evaluation of treatment response. This test demonstrated, compared with the first PET/CT, an increase in the size and metabolic activity of the primary mass in the left lung in addition to multiple, pathologic-sized, hypermetabolic metastatic lymph nodes as well as multiple metastatic sclerotic areas in bones. These findings were interpreted as progressive disease. In addition, an asymmetrical FDG uptake was noticed at the level of right vocal cord. During follow-up, a laryngoscopy was performed, which demonstrated left vocal cord paralysis with no apparent mass. Thus, we attributed the paralytic appearance of the left vocal cord to infiltration of the left recurrent laryngeal nerve by the primary mass located in the apical region of the left lung. In conclusion, the knowledge of this pitfall is important to avoid false-positive PET results. Ali Ozan Oner, Adil Boz, Evrim Surer Budak, and Gulnihal Hale Kaplan Kurt Copyright © 2015 Ali Ozan Oner et al. All rights reserved. Prostate Cancer-Associated Disseminated Intravascular Coagulation with Excessive Fibrinolysis Treated with Degarelix Tue, 03 Nov 2015 06:37:46 +0000 Disseminated intravascular coagulation (DIC) with excessive fibrinolysis (XFL) is a rare and acute life-threatening variant of DIC in patients with prostate cancer. Patients present with coagulopathy, hypofibrinogenemia, and systemic bleeding. We describe a case of DIC XFL caused by prostate cancer (PC) successfully treated with a single injection of degarelix, a gonadotropin-releasing hormone (GnRH) receptor antagonist. This led to prompt control of the patient’s coagulopathy within ten days of treatment. Our case highlights features of this rare and devastating hemorrhagic complication of PC along with a fast-acting and effective therapeutic drug option. Shawn Y. Ong, Josephine Taverna, Clint Jokerst, Thomas Enzler, Emad Hammode, Elisa Rogowitz, Myke R. Green, and Hani M. Babiker Copyright © 2015 Shawn Y. Ong et al. All rights reserved. A Rare Case of Paclitaxel and/or Trastuzumab Induced Acute Hepatic Necrosis Thu, 29 Oct 2015 14:16:02 +0000 Paclitaxel induced mild derangement of liver functions including bilirubin, alkaline phosphatase, and AST has been infrequently noticed in clinical trials. Contrary to Paclitaxel, hepatocellular injury, hepatitis, and liver tenderness are common laboratory and clinical findings with Trastuzumab. However, hepatic failure/necrosis secondary to Paclitaxel or Trastuzumab has never been reported in literature. A 62-year-old lady, previously healthy, was treated with adjuvant therapy for left breast stage II, high grade invasive ductal carcinoma which was node negative, oestrogen receptor negative, progesterone receptor positive, and HER2 receptor positive. After modified radical mastectomy and axillary clearance, she finished four cycles of Doxorubicin/Cyclophosphamide chemotherapy and then commenced on Paclitaxel/Trastuzumab combination chemotherapy. Within twelve hours of first dose of Paclitaxel/Trastuzumab therapy, patient required hospital admission for acute onset respiratory failure. Patient died within 36 hours of therapy and autopsy was suggestive of acute hepatic necrosis without any other significant findings. Detailed investigations were not carried out as event was quick with rapid deterioration. There was no history of prior liver pathology/injury and preliminary investigations for major organ involvement were unremarkable. As per our knowledge, Paclitaxel and/or Trastuzumab induced acute hepatic necrosis has never been reported in literature before, hence difficult to predict. Hiren Mandaliya, Pinky Baghi, Amy Prawira, and Mathew K. George Copyright © 2015 Hiren Mandaliya et al. All rights reserved. Successful Intravascular Correction of Intratumoral Pseudoaneurysm by Erosion of the Aorta in a Patient with Thoracic Giant Cell Tumor of Bone Responding to Denosumab Tue, 27 Oct 2015 09:50:16 +0000 Giant cell tumor of bone (GCT) is a rare, locally aggressive neoplasm characterized by the presence of giant cells with osteoclast activity. Its biology involves the overexpression of the Receptor Activator of Nuclear Factor kB Ligand (RANKL) by osteoclast-like giant cells and tumor stromal cells, which has been shown to be an actionable target in this disease. In cases amenable to surgical resection, very few therapeutic options were available until the recent demonstration of significant activity of the anti-RANK-ligand monoclonal antibody denosumab. Here we present a case of a patient with advanced GCT arising in the spine, recurring after multiple resections and embolization. Following initiation of denosumab, which resulted in unequivocal clinical improvement, computed tomography of the chest done for reassessment purposes revealed an intratumoral pseudoaneurysm by erosion of the aorta, further corrected by endovascular approach and stent placement. Patient had an unremarkable recovery from the procedure and continued benefit from therapy with denosumab and remains on treatment 24 months after the first dose. Natalia M. P. Fraile, Diego Toloi, Ceci O. Kurimori, Adriana R. B. Matutino, Alberto Codima, Veridiana P. Camargo, Olavo Feher, and Rodrigo R. Munhoz Copyright © 2015 Natalia M. P. Fraile et al. All rights reserved. Diaphragmatic Amyloidosis Causing Respiratory Failure: A Case Report and Review of Literature Mon, 26 Oct 2015 07:36:18 +0000 Neuromuscular respiratory failure is a rare complication of systemic immunoglobulin light chain amyloidosis. We describe a case of a 70-year-old Caucasian man with multiple myeloma who presented with worsening dyspnea. The patient was diagnosed with and treated for congestive heart failure but continued to suffer from hypercapnic respiratory insufficiency. He had restrictive physiology on pulmonary function tests and abnormal phrenic nerve conduction studies, consistent with neuromuscular respiratory failure. The diagnosis of systemic immunoglobulin light chain amyloidosis was made based on the clinical context and a cardiac biopsy. Despite treatment attempts, the patient passed away in the intensive care unit from hypercapnic respiratory failure. Autopsy revealed dense diaphragmatic amyloid deposits without phrenic nerve infiltration or demyelination or lung parenchymal involvement. Only 5 cases of neuromuscular respiratory failure due to amyloid infiltration of the diaphragm have been described. All cases, including this, were characterized by rapid progression and high mortality. Therefore, diaphragmatic amyloidosis should be on the differential for progressive neuromuscular respiratory failure in patients with multiple myeloma or any other monoclonal gammopathy. Given its poor prognosis, early recognition of this condition is essential in order to address goals of care and encourage pursuit of palliative measures. Aleksey Novikov, Horatio Holzer, Robert A. DeSimone, Ghaith Abu-Zeinah, David J. Pisapia, Tomer M. Mark, and Raymond D. Pastore Copyright © 2015 Aleksey Novikov et al. All rights reserved. Endometrioid Paraovarian Borderline Cystic Tumor in an Infant with Proteus Syndrome Mon, 19 Oct 2015 09:57:42 +0000 Ovarian and paraovarian neoplasms are uncommon in children, mainly originating from germ cell tumors and, least frequently, epithelial tumors. There is an association between genital tract tumors and Proteus syndrome, a rare, sporadic, and progressive entity, characterized by a postnatal overgrowth in several tissues caused by a mosaic mutation in the AKT1 gene. We describe a 20-month-old asymptomatic infant with Proteus syndrome who developed an endometrioid paraovarian borderline cystic tumor. This is the youngest patient so far reported in the literature with this rare syndrome and an adnexal tumor of borderline malignancy. A total of nine patients have been described with female tract tumors and associated Proteus syndrome, which includes bilateral ovarian cystadenomas and other benign masses. A paraovarian neoplasm is extremely rare in children and could be considered a criterion for Proteus syndrome. Standardized staging and treatment of these tumors are not well established; however, most authors conclude that these neoplasms must be treated as their ovarian counterparts. Liliana Vasquez, Mariela Tello, Ivan Maza, Monica Oscanoa, Milagros Dueñas, Haydee Castro, and Alan Latorre Copyright © 2015 Liliana Vasquez et al. All rights reserved. Migrating Polyarthritis as a Feature of Occult Malignancy: 2 Case Reports and a Review of the Literature Mon, 19 Oct 2015 08:45:31 +0000 Malignant disease may be associated with a wide variety of musculoskeletal syndromes. Rarely the musculoskeletal system can be indirectly affected by paraneoplastic phenomena, such as carcinomatous polyarthritis (CP). The differential diagnosis for CP is broad and is often a diagnosis of exclusion. CP often presents similarly to other forms of inflammatory arthritis, and a detailed history and physical examination can often distinguish CP from other more common causes of polyarticular arthritis. However serological tests such as rheumatoid factor (RF) and anti-citrullinated peptide (anti-CCP) antibody positivity, while rare, can be misleading. Clinical awareness and suspicion are paramount in achieving an accurate diagnosis and early detection of an occult neoplasm is critical for prompt management and therapy. We report two cases presenting with this unique clinical phenotype associated with paraneoplastic polyarthropathy and review the literature. Geoffrey Alan Watson, Lorraine O’Neill, Ruth Law, Geraldine McCarthy, and Douglas Veale Copyright © 2015 Geoffrey Alan Watson et al. All rights reserved. Rhabdomyolysis due to Trimethoprim-Sulfamethoxazole Administration following a Hematopoietic Stem Cell Transplant Sun, 18 Oct 2015 15:33:34 +0000 Rhabdomyolysis, a syndrome of muscle necrosis, is a life-threatening event. Here we describe the case of a patient with chronic myeloid leukemia who underwent a haploidentical stem cell transplant and subsequently developed rhabdomyolysis after beginning trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis therapy. Rechallenge with TMP/SMX resulted in a repeat episode of rhabdomyolysis and confirmed the association. Withdrawal of TMP/SMX led to sustained normalization of creatine kinase levels in the patient. A high index of suspicion is necessary to identify TMP/SMX as the cause of rhabdomyolysis in immunocompromised patients. Alexander Augustyn, Mona Lisa Alattar, and Harris Naina Copyright © 2015 Alexander Augustyn et al. All rights reserved. Mucoepidermoid Carcinoma of the Palatine Tonsil Thu, 15 Oct 2015 12:31:11 +0000 Mucoepidermoid carcinoma (MEC) is the most common primary salivary gland malignancy in both adults and children. It has a slight female predilection and usually presents as a painless, rubber-like or soft mass, which may be fixed or mobile. Histologically, MEC is comprised of a mixture of cell types including mucous, epidermoid, and intermediate cells that can be arranged in solid nests or cystic structures. In the oral cavity, it most frequently occurs at the palate or buccal mucosa. The present paper aimed to describe an unusual case of MEC arising in the palatine tonsil. Lucas Novaes Teixeira, Victor Angelo Martins Montalli, Luiz Carlos Santana Teixeira, Fabrício Passador-Santos, Andresa Borges Soares, and Vera Cavalcanti de Araújo Copyright © 2015 Lucas Novaes Teixeira et al. All rights reserved. An Unusual Case of Invasive Kaposi’s Sarcoma with Primary Effusion Lymphoma in an HIV Positive Patient: Case Report and Literature Review Thu, 15 Oct 2015 08:42:52 +0000 We report a case of AIDS-related Kaposi’s sarcoma (KS) with Primary Effusion Lymphoma (PEL) in a 28-year-old, African American male. Kaposi’s sarcoma is an AIDS defining disease and typically will disseminate early in the course of the disease affecting the skin, mucous membranes, gastrointestinal tract, lymph nodes, and lungs. This case reports an unusual presentation of the disease along with primary effusion lymphoma. Although the most common organ systems affected by KS are the respiratory and the gastrointestinal systems, the lungs of this patient did not show any evidence of KS. Additionally, the patient demonstrates the rarely seen liver and unique pancreatic involvement by KS along with unusual synchronous bilateral pleural and peritoneal cavity involvement by PEL, adding to the distinct pattern of invasive AIDS-related Kaposi’s sarcoma. Alexandra Millet, Sanmeet Singh, Genelle Gittens-Backus, Kim Ann Dang, and Babak Shokrani Copyright © 2015 Alexandra Millet et al. All rights reserved. Is It Safe to Restart Antivascular Endothelial Growth Factor Therapy in Patients with Renal Cell Carcinoma after Cardiac Ischemia? Tue, 13 Oct 2015 11:15:46 +0000 Agents targeting vascular endothelial growth factor (VEGF) represent active drugs in treating patients with advanced renal cell carcinoma (RCC). Studies have shown that sunitinib and axitinib can be associated with cardiac toxicity. Whether these agents should be restarted in patients who experience cardiac ischemia remains uncertain. Here, we present three patients with metastatic RCC who restarted sunitinib or axitinib after intervention of active ischemic cardiac disease without causing subsequent relevant cardiac events. This experience suggests that these agents can be continued after management of cardiac ischemia. Bo Zhao, Laura S. Wood, Karen James, and Brian I. Rini Copyright © 2015 Bo Zhao et al. All rights reserved. Combination Trimodality Therapy Using Vismodegib for Basal Cell Carcinoma of the Face Sun, 04 Oct 2015 14:54:32 +0000 Background. For large basal cell carcinomas (BCCs) of the head and neck, definitive surgery often requires extensive resection and reconstruction that may result in prolonged recovery and limited cosmesis. Vismodegib, a small-molecule inhibitor of the hedgehog pathway, is approved for advanced and metastatic BCCs. We present a case of advanced BCC treated with combination of vismodegib, radiotherapy, and local excision resulting in excellent response and cosmesis. Case Presentation. A 64-year-old gentleman presented with a 5-year history of a 7 cm enlarging right cheek mass, with extensive vascularization, central ulceration, and skin, soft tissue, and buccal mucosa involvement. Biopsy revealed BCC, nodular type. Up-front surgical option involved a large resection and reconstruction. After multidisciplinary discussion, we recommended and he opted for combined modality of vismodegib, radiotherapy, and local excision. The patient tolerated vismodegib well and his right cheek lesion decreased significantly in size. He was then treated with radiotherapy followed by local excision that revealed only focal residual BCC. Currently, he is without evidence of disease and has excellent cosmesis. Conclusions. We report a case of locally advanced BCC treated with trimodality therapy with vismodegib, radiotherapy, and local excision, resulting in excellent outcome and facial cosmesis, without requiring extensive resection or reconstructive surgery. Alec M. Block, Fiori Alite, Aidnag Z. Diaz, Richard W. Borrowdale, Joseph I. Clark, and Mehee Choi Copyright © 2015 Alec M. Block et al. All rights reserved. Oxaliplatin-Induced Tonic-Clonic Seizures Wed, 30 Sep 2015 11:12:45 +0000 Oxaliplatin is a common chemotherapy drug used for colon and gastric cancers. Common side effects are peripheral neuropathy, hematological toxicity, and allergic reactions. A rare side effect is seizures which are usually associated with posterior reversible leukoencephalopathy syndrome (PRES). A 50-year-old male patient presented with severe abdominal pain. CT scan of the abdomen showed acute appendicitis. Appendectomy was done and pathology showed mixed adenoneuroendocrine carcinoma. Adjuvant chemotherapy was started with Folinic acid, Fluorouracil, and Oxaliplatin (FOLFOX). During the third cycle of FOLFOX, the patient developed tonic-clonic seizures. Laboratory workup was within normal limits. EEG and MRI of the brain showed no acute abnormality. The patient was rechallenged with FOLFOX but he had tonic-clonic seizures for the second time. His chemotherapy regimen was switched to Folinic acid, Fluorouracil, and Irinotecan (FOLFIRI). After 5 cycles of FOLFIRI, the patient did not develop any seizures, making Oxaliplatin the most likely culprit for his seizures. Oxaliplatin-induced seizures rarely occur in the absence of PRES. One case report has been described in the literature. We present a rare case of tonic-clonic seizures in a patient receiving Oxaliplatin in the absence of PRES. Ahmad K. Rahal, Phu V. Truong, and K. James Kallail Copyright © 2015 Ahmad K. Rahal et al. All rights reserved. Dysphagia and Neck Swelling in a Case of Undiagnosed Lhermitte-Duclos Disease and Cowden Syndrome Thu, 10 Sep 2015 13:33:42 +0000 We report a case of a 37-year-old woman presenting with dysphagia and thyroid masses who was subsequently diagnosed with Lhermitte-Duclos disease (LDD) based on MRI scan and histopathology. Additional imaging subsequently revealed the presence of thyroid nodules and bilateral breast cancers. Genetic testing later confirmed the diagnosis of Cowden syndrome. This case illustrates the importance of the overlap between LDD, Cowden syndrome, thyroid disease, and breast cancer. Zishuo Ian Hu, Lev Bangiyev, Roberta J. Seidman, and Jules A. Cohen Copyright © 2015 Zishuo Ian Hu et al. All rights reserved. Malignant Mesothelioma Mimicking Invasive Mammary Carcinoma in a Male Breast Thu, 10 Sep 2015 07:11:10 +0000 Malignant mesothelioma is an uncommon tumor with strong association with asbestos exposure. Few cases of malignant pleural mesothelioma metastatic to the female breast have been reported. Herein, we presented, for the first time, a case of locally infiltrating malignant pleural mesothelioma forming a mass in the breast of a male as the first pathologically confirmed manifestation of the disease. Breast ultrasound revealed an irregular mass in the right breast which involves the pectoralis muscle. Breast core biopsy revealed a proliferation of neoplastic epithelioid cells mimicking an infiltrating pleomorphic lobular carcinoma. IHC studies showed the cells to be positive for calretinin, CK5/6, WT1, and CK7. The cells were negative for MOC-31, BerEp4, ER, and PR. A final diagnosis of malignant mesothelioma, epithelioid type, was rendered. This case demonstrates the importance of considering a broad differential diagnosis in the setting of atypical presentation with application of a panel of IHC markers. Mohamed Mokhtar Desouki and Daniel Jerad Long Copyright © 2015 Mohamed Mokhtar Desouki and Daniel Jerad Long. All rights reserved. PD-1 Blockade in Advanced Melanoma in Patients with Hepatitis C and/or HIV Thu, 10 Sep 2015 06:30:23 +0000 On the basis of remarkable antitumor activity, programmed death receptor-1 (PD-1) inhibitors pembrolizumab and nivolumab were approved for the treatment of advanced melanoma in the second-line setting following progression on either CTLA-4 inhibitor ipilimumab or BRAF/MEK inhibitors (for BRAF mutated melanoma). Given hypothesized risk of triggering exacerbations of autoimmune diseases and/or chronic viral infections, clinical trials (including regulatory studies) evaluating checkpoint blocking antibodies PD-1 and CTLA-4 have excluded patients with autoimmune diseases, chronic hepatitis B/C virus (HBV/HCV), and/or human immunodeficiency virus (HIV) infections. Herein, we describe two patients with advanced melanoma and concomitant HCV/HIV infections treated with PD-1 inhibitor pembrolizumab. Patient 2 with HIV/HCV coinfection progressed after 2 doses of pembrolizumab. Patient 1 who had HCV alone was treated with pembrolizumab with initial partial response. HCV viral load remained stable after 9 cycles of pembrolizumab following which 12-week course of HCV-directed therapy was commenced, resulting in prompt reduction of HCV viral load below detectable levels. Response is ongoing and HCV viral load remains undetectable. In both patients, no significant toxicities were observed when pembrolizumab was initiated. We argue for the further investigation of checkpoint inhibition in cancer patients with underlying chronic viral infections in the context of carefully designed clinical trials. Diwakar Davar, Melissa Wilson, Chelsea Pruckner, and John M. Kirkwood Copyright © 2015 Diwakar Davar et al. All rights reserved. Innovative Approaches to Radiation Treatment for Mycosis Fungoides in the Setting of Collagen Vascular Disease Thu, 27 Aug 2015 12:46:24 +0000 Patients with connective tissue disorders are clinically challenging for radiation oncologists as these patients may be at increased risk for radiation-related skin toxicity. A clinical dilemma presents itself in a patient with lupus who presents with confluent skin lesions from mycosis fungoides requiring radiotherapy. In this report, we discuss an innovative technique used to develop an immobilization device that also effectively functioned as a uniform bolus with distinct dosimetric advantages to the use of a facial moulage. Stephanie A. Terezakis, George C. Bohle III, Ying-Chun Lo, Sean L. Berry, and Joachim Yahalom Copyright © 2015 Stephanie A. Terezakis et al. All rights reserved. Systemic Chemotherapy for Progression of Brain Metastases in Extensive-Stage Small Cell Lung Cancer Wed, 26 Aug 2015 09:51:16 +0000 Lung cancer is the most common cause of cancer related mortality in men and women. Approximately 15% of lung cancers are small cell type. Chemotherapy and radiation are the mainstay treatments. Currently, the standard chemotherapy regimen includes platinum/etoposide. For extensive small cell lung cancer, irinotecan and cisplatin have also been used. Patients with relapsed small cell lung cancer have a very poor prognosis, and the morbidity increases with brain metastases. Approximately 10%–14% of small cell lung cancer patients exhibit brain metastases at the time of diagnosis, which increases to 50%–80% as the disease progresses. Mean survival with brain metastases is reported to be less than six months, thus calling for improved regimens. Here we present a case series of patients treated with irinotecan for progressive brain metastases in small cell lung cancer, which serves as a reminder of the role of systemic chemotherapy in this setting. Nagla Abdel Karim, Ananta Bhatt, Lauren Chiec, and Richard Curry Copyright © 2015 Nagla Abdel Karim et al. All rights reserved. Primary Mesenteric Undifferentiated Pleomorphic Sarcoma Masquerading as a Colon Carcinoma: A Case Report and Review of the Literature Wed, 26 Aug 2015 08:29:18 +0000 Undifferentiated pleomorphic sarcoma (UPS) is the most common sarcoma that appears in older patients, usually in the extremities and the retroperitoneum. Other locations are rare. By definition, in UPS, although the malignant cells tend to appear fibroblastic or myofibroblastic, they should not show differentiation towards a more specific line of differentiation. In this sense, we report the case of an 80-year-old patient with an initial clinical diagnosis of a locally advanced colonic neoplasm that was later confirmed as a primary mesenteric UPS. Primary mesenteric UPS are extremely rare with less than 20 cases reported. We also review the pathologic and radiologic diagnostic criteria and the natural history of these tumours. Robert Diaz-Beveridge, Marcos Melian, Carlos Zac, Edwin Navarro, Dilara Akhoundova, Melitina Chrivella, and Jorge Aparicio Copyright © 2015 Robert Diaz-Beveridge et al. All rights reserved. Primary Cutaneous Peripheral T-Cell Lymphoma Not Otherwise Specified: A Rapidly Progressive Variant of Cutaneous T-Cell Lymphoma Wed, 26 Aug 2015 08:13:03 +0000 Primary Cutaneous Peripheral T-Cell Lymphoma NOS (PTL-NOS) is a rare, progressive, fatal dermatologic disease that presents with features similar to many common benign plaque-like skin conditions, making recognition of its distinguishing features critical for early diagnosis and treatment (Bolognia et al., 2008). A 78-year-old woman presented to ambulatory care with a single 5 cm nodule on her shoulder that had developed rapidly over 1-2 weeks. Examination was suspicious for malignancy and a biopsy was performed. Biopsy results demonstrated CD4 positivity, consistent with Mycosis Fungoides with coexpression of CD5, CD47, and CD7. Within three months her cancer had progressed into diffuse lesions spanning her entire body. As rapid progression is usually uncharacteristic of Mycosis Fungoides, her diagnosis was amended to PTL-NOS. Cutaneous T-Cell Lymphoma (CTCL) should be suspected in patients with patches, plaques, erythroderma, or papules that persist or multiply despite conservative treatment. Singular biopsies are often nondiagnostic, requiring a high degree of suspicion if there is deviation from the anticipated clinical course. Multiple biopsies are often necessary to make the diagnosis. Physicians caring for patients with rapidly progressive, nonspecific dermatoses with features described above should keep more uncommon forms of CTCL in mind and refer for early biopsy. Kimberly Aderhold, Lisa Carpenter, Krysta Brown, and Anthony Donato Copyright © 2015 Kimberly Aderhold et al. All rights reserved. High-Grade Leiomyosarcoma Arising in a Previously Replanted Limb Sun, 23 Aug 2015 11:18:37 +0000 Sarcoma development has been associated with genetics, irradiation, viral infections, and immunodeficiency. Reports of sarcomas arising in the setting of prior trauma, as in burn scars or fracture sites, are rare. We report a case of a leiomyosarcoma arising in an arm that had previously been replanted at the level of the elbow joint following traumatic amputation when the patient was eight years old. He presented twenty-four years later with a 10.8 cm mass in the replanted arm located on the volar forearm. The tumor was completely resected and pathology examination showed a high-grade, subfascial spindle cell sarcoma diagnosed as a grade 3 leiomyosarcoma with stage pT2bNxMx. The patient underwent treatment with brachytherapy, reconstruction with a free flap, and subsequently chemotherapy. To the best of our knowledge, this is the first case report of leiomyosarcoma developing in a replanted extremity. Development of leiomyosarcoma in this case could be related to revascularization, scar formation, or chronic injury after replantation. The patient remains healthy without signs of recurrence at three-year follow-up. Tiffany J. Pan, Liron Pantanowitz, and Kurt R. Weiss Copyright © 2015 Tiffany J. Pan et al. All rights reserved.