Case Reports in Oncological Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Progression of an Invasive ACTH Pituitary Macroadenoma with Cushing’s Disease to Pituitary Carcinoma Thu, 20 Aug 2015 09:44:25 +0000 Pituitary carcinomas are very rare tumors that in most cases produce prolactin and adrenocorticotropic hormone (ACTH). It is a challenge to diagnosis of a pituitary carcinoma before disclosed symptomatic metastasis. We report the case of a female patient with Cushing’s disease who underwent three transsphenoidal surgeries, with pathological findings of common ACTH pituitary adenoma including Ki-67 expression <3%. She achieved hypocortisolism after the 3rd surgery although ACTH levels remained slightly elevated. The patient returned some time later with fast worsening of hypercortisolism. Magnetic resonance imaging showed clivus invasion, which led to a fourth surgery and radiation. This time, immunohistochemistry revealed strong Ki-67 (10% to 15%) and p53 expression. Liver and lumbar spine metastases were found on workup. The patient died after few months due to lung infection. Pituitary carcinomas are rare, and the transformation of an ACTH-secreting pituitary adenoma into a carcinoma is exceptional. The difficulty of defining markers for the diagnosis of carcinoma, before metastasis diagnosis, in order to change the management of the disease, is a challenge. Clarissa Groberio Borba, Rafael Loch Batista, Nina Rosa de Castro Musolino, Vanielle Carvalho Machado, Ana Elisa Evangelista Alcantara, Gilberto Ochman da Silva, Valter Angelo Sperling Cescato, and Malebranche Berardo Carneiro da Cunha Neto Copyright © 2015 Clarissa Groberio Borba et al. All rights reserved. Nontargeted Effect after Radiotherapy in a Patient with Non-Small Cell Lung Cancer and Bullous Pemphigoid Sun, 09 Aug 2015 11:55:38 +0000 Purpose. To describe tumor shrinkage of nonirradiated lung metastases in a patient with non-small cell lung cancer. Case Report. The patient had a concurrent autoimmune condition, bullous pemphigoid, which was clinically exacerbated during radiotherapy of mediastinal and axillary lymph node metastases. He also developed a series of infections during and after irradiation, and we hypothesize that the immunological events during this phase might have influenced the size of the nonirradiated metastases. Conclusion. Ionizing radiation generates inflammatory signals and, in principle, could provide both tumor-specific antigens from dying cells and maturation stimuli that are necessary for dendritic cells’ activation of tumor-specific T cells. Even if the detailed mechanisms causing nontargeted immune modulatory effects in individual patients are poorly understood, clinical development of radioimmunotherapy is underway. Carsten Nieder, Khalid Al-Shibli, and Terje Tollåli Copyright © 2015 Carsten Nieder et al. All rights reserved. A Rare Case of Metastatic Desmoplastic Small Round Cell Tumour: Diagnosis and Management Sun, 09 Aug 2015 08:52:20 +0000 A 26-year-old male without any significant past medical history presented to the hospital with shortness of breath, cough, pleuritic chest pain, and weight loss for the past 3 months. On chest CT, he was found to have extensive mediastinal and hilar lymphadenopathy and multiple pulmonary nodules. On physical examination, a right groin mass was noted which had been slowly growing for the past 2 years. Ultrasound of the groin showed complex solid mass with internal vascular channels. CT guided biopsy of the mass showed desmoplastic small round cell tumour. His hospital course was complicated by hypoxic respiratory failure requiring emergent intubation and ICU admission where he completed one cycle of vincristine, cyclophosphamide, and doxorubicin with subsequent improvement, followed by extubation. His condition continued to improve after second cycle of chemotherapy and he was ultimately discharged in a stable condition to continue outpatient chemotherapy after a 2-month inpatient stay. Shahzaib Nabi, Abhijit Saste, and Rohit Gulati Copyright © 2015 Shahzaib Nabi et al. All rights reserved. Metastasis of Gastric Signet-Ring Cell Carcinoma to the Urinary Bladder: A Case Report and Review of the Literature Tue, 04 Aug 2015 11:26:50 +0000 Although signet-ring cell (SRC) adenocarcinoma is commonly seen in the stomach, it is a very rarely seen histologic entity in the bladder. It is difficult to distinguish primary SRC adenocarcinoma of the bladder from bladder metastasis of SRC carcinoma of the stomach only based on histological findings. In such cases, clinical findings and immunohistochemical studies may be helpful. We present here a 48-year-old male patient presenting with hematuria and abdominal pain. Computerised tomography of the patient revealed a gastric mass, peritoneal involvement, and thickening of the bladder wall, and histopathological analysis revealed SRC adenocarcinoma in both of the endoscopic biopsies taken from the stomach and bladder. Immunohistochemical analyses confirmed the diagnosis of SRC adenocarcinoma of the bladder secondary to gastric cancer. Kerem Okutur, Orhan Onder Eren, and Gokhan Demir Copyright © 2015 Kerem Okutur et al. All rights reserved. Reconstruction of Radiated Gluteal Defects following Sarcoma Resection with Pedicled Sensate Tensor Fascia Lata Flaps Mon, 03 Aug 2015 07:28:51 +0000 Sarcomas of the gluteal region often result in sizable defects following resection that are challenging to reconstruct due to their location, particularly in patients who have received radiation therapy. Reconstruction of these defects has been seldom discussed in the literature. We present two patients with large radiated gluteal defects following sarcoma resection, of which one patient received neoadjuvant radiation and the other received intraoperative radiation therapy. As a result of the resection and radiation, local tissues and recipient vessels were unsuitable for use in reconstruction. A pedicled tensor fascia lata (TFL) flap was therefore performed in both cases, which resulted in durable sensate reconstruction with good functional outcomes and no complications. We believe the pedicled TFL flap represents an important option for the reconstruction of oncologic gluteal defects that provides well-vascularized and sensate tissue from outside the zone of radiation without the need for microsurgical techniques. Albert H. Chao and Patrick N. Kearns Copyright © 2015 Albert H. Chao and Patrick N. Kearns. All rights reserved. Primary Intracranial Melanoma with Early Leptomeningeal Spread: A Case Report and Treatment Options Available Wed, 29 Jul 2015 12:56:04 +0000 Primary CNS melanomas are rare and they constitute about 1% of all cases of melanomas and 0.07% of all brain tumors. These tumors are aggressive in nature and may metastasise to other organs. Till date less than 25 cases have been reported in the literature. The primary treatment for local intraparenchymal tumours is complete resection and/or radiotherapy and it is associated with good survival. However once there is disease spread to leptomeninges the overall median survival is around 10 weeks. In this case report we describe a primary intracranial melanoma without any dural attachment in 16-year-old boy who had radical excision of the tumor followed by radiotherapy who eventually had rapidly developed leptomeningeal disease and review the literature with a focus on the clinic pathological, radiological, and treatment options. Rajesh Balakrishnan, Rokeya Porag, Dewan Shamsul Asif, A. M. Rejaus Satter, Md. Taufiq, and Samson S. K. Gaddam Copyright © 2015 Rajesh Balakrishnan et al. All rights reserved. Two Cases of Pneumatosis Intestinalis during Cetuximab Therapy for Advanced Head and Neck Cancer Wed, 29 Jul 2015 06:40:20 +0000 Pneumatosis intestinalis is a rare but known potential complication of treatment with cetuximab. Here we present two cases of pneumatosis intestinalis occurring in patients who were receiving cetuximab as treatment for advanced head and neck cancer. In both cases, cetuximab was discontinued after discovery of the pneumatosis intestinalis. James A. Miller, Daniel J. Ford, Mohamed S. Ahmed, and Thom R. Loree Copyright © 2015 James A. Miller et al. All rights reserved. Small Bowel Adenocarcinoma as the Cause of Gastrointestinal Bleeding in Celiac Disease: A Rare Malignancy in a Common Disease Tue, 28 Jul 2015 10:22:00 +0000 Introduction. Celiac disease is associated with an increased risk of small bowel malignancies, particularly lymphoma. Its association with small bowel carcinoma is less known. Case Description. We report a case of an 89-year-old woman with celiac disease who experienced recurrent episodes of gastrointestinal bleeding and was ultimately found to have adenocarcinoma of the small intestine. Discussion and Evaluation. Diagnosis of small bowel adenocarcinoma is often delayed because of the need for specialized modalities, which are often deferred in the inpatient setting. Although resection is the modality of choice for small bowel tumors, a majority is either locally advanced or metastatic at diagnosis, and even localized cancers have worse prognosis than stage-matched colorectal tumors. The role of adjuvant chemotherapy is uncertain, but it is often offered extrapolating data from other gastrointestinal cancers. Small bowel carcinomas occurring in the context of celiac disease appear to be associated with higher rates of microsatellite instability than sporadic tumors, although other specific genomic abnormalities and mechanisms of carcinogenesis in celiac disease remain unknown. Conclusion. Recurrent episodes of gastrointestinal bleeding in a patient with celiac disease should prompt an early evaluation of the small bowel to assure timely diagnosis of carcinoma at an early curable stage. Jaleh Fallah, Maxwell Eyram Afari, Alfredo C. Cordova, Adam J. Olszewski, and Taro Minami Copyright © 2015 Jaleh Fallah et al. All rights reserved. Alveolar Rhabdomyosarcoma in a 69-Year-Old Woman Receiving Glucagon-Like Peptide-2 Therapy Wed, 22 Jul 2015 11:30:30 +0000 A 69-year-old woman was diagnosed with alveolar rhabdomyosarcoma (ARMS) of the nasopharynx. She has a history of catastrophic thromboembolic event in the abdomen that caused short-gut syndrome and dependence on total parenteral nutrition (TPN) twelve hours per day. She was treated for short-gut syndrome with teduglutide, a glucagon-like peptide-2 (GLP-2) analog, which led to reduction of TPN requirements. However, a few months later, she developed metastatic alveolar rhabdomyosarcoma. Though a causative relationship is unlikely between the peptide and ARMS due to the brief time course between teduglutide therapy and sarcoma diagnosis, neoplastic growth may have been accelerated by the GLP-2 analog, causing release of IGF-1. The transmembrane receptor for IGF-1 is frequently overexpressed in ARMS and is implicated in cell proliferation and metastatic behavior. This case describes a rare incidence of metastatic alveolar rhabdomyosarcoma in a sexagenarian and possibly the first case reported associated with the use of teduglutide. Teduglutide was discontinued due to a potential theoretical risk of acceleration of sarcoma growth, and the patient’s rhabdomyosarcoma is in remission following sarcoma chemotherapy. Laura E. Zyczynski, Jonathan B. McHugh, Thomas E. Gribbin, and Scott M. Schuetze Copyright © 2015 Laura E. Zyczynski et al. All rights reserved. A Case of Primary Breast Diffuse Large B-Cell Lymphoma Treated with Chemotherapy Followed by Elective Field Radiation Therapy: A Brief Treatment Pattern Review from a Radiation Oncologist’s Point of View Mon, 13 Jul 2015 13:25:47 +0000 We here report a case of primary breast lymphoma (PBL). A 44-year-old woman presented with a painless mass in the right breast. Fine needle aspiration cytology and excisional biopsy were performed. Excisional biopsy revealed low grade lymphoma, which was subsequently confirmed with histopathology and diagnosed as diffuse large B-cell lymphoma (DLBCL). A chest computed tomography scan revealed a 3.5 cm sized breast mass with skin thickening and a small sized lymphadenopathy in the ipsilateral axilla. Radiation therapy including the right whole breast and ipsilateral axilla and supraclavicular lymph node was performed after the patient received four courses of R-CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone plus rituximab) chemotherapy. At the follow-up period of 42 months, the patient is surviving with no evidence of disease. No morbidities occurred in this patient during the follow-up period. We also briefly review the current practice pattern in PBL patients with DLBCL. Kyu Chan Lee, Seung Heon Lee, KiHoon Sung, So Hyun Ahn, Jinho Choi, Seok Ho Lee, Jae Hoon Lee, Junshik Hong, and Sang Hui Park Copyright © 2015 Kyu Chan Lee et al. All rights reserved. Small Cell Lung Cancer Patient with Profound Hyponatremia and Acute Neurological Symptoms: An Effective Treatment with Fludrocortisone Thu, 09 Jul 2015 11:09:20 +0000 Hyponatremia is a frequent electrolyte abnormality in patients with small cell lung cancer (SCLC). Being usually asymptomatic, hyponatremia may cause symptoms like nausea, fatigue, disorientation, headache, muscle cramps, or even seizures, particularly if severe and rapid decrease of serum sodium levels occurs. Here we report a case of SCLC patient with severe hyponatremia and acute neurological symptoms that developed 2 days after the first course of second-line chemotherapy, most probably due to the release of antidiuretic hormone (ADH, also known as arginine vasopressin) during lysis of the tumour cells. Initial treatment consisted of continuous administration of hypertonic saline that resulted in improvement of patient’s neurological status. However, to obtain a persistent increase in serum sodium level, pharmacological intervention with oral fludrocortisone 0.1 mg twice daily was needed. We can therefore conclude that mineralocorticoids may be used to correct hyponatremia in SCLC patients when appropriate. Jana Jaal, Tõnu Jõgi, and Alan Altraja Copyright © 2015 Jana Jaal et al. All rights reserved. Denileukin Diftitox (Ontak) as Maintenance Therapy for Peripheral T-Cell Lymphomas: Three Cases with Sustained Remission Thu, 09 Jul 2015 10:21:58 +0000 Peripheral T-cell lymphomas (PTCL) are rare but markedly aggressive forms of non-Hodgkin’s lymphoma (NHL). They carry a poor prognosis, with current therapeutic approach being generally ineffective. The most employed first-line treatment is CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), which still results in high rates of relapses. Denileukin diftitox is a fusion protein combining the cytotoxic portion of the diphtheria toxin and the receptor-binding domain of the interleukin-2 (IL-2) molecule, thereby targeting cells expressing the IL-2 receptor, including both T-cell and B-cell lymphomas. It has been approved for the treatment of cutaneous T-cell lymphomas, and it has documented activity in PTCL both as a single agent and as part of combination therapy. This report documents three cases of PTCL where denileukin diftitox has been used as long-term maintenance therapy after complete remission was achieved. While the overall survival rate of patients with advanced stage, refractory PTCL is generally poor (with median overall survival of 5.5 months), the three patients described in this report are all experiencing an ongoing complete remission for more than four years. Alejandra C. Fuentes, Ellen Szwed, Cathy D. Spears, Sandeep Thaper, Long H. Dang, and Nam H. Dang Copyright © 2015 Alejandra C. Fuentes et al. All rights reserved. Lung Metastasis Mimicking Fingertip Infection Tue, 07 Jul 2015 10:47:56 +0000 Metastasis fingers (acral metastasis) are finding a poor prognosis. Past medical history should be questioned and metastasis from primary tumor should be kept in mind in patients with pain, swelling, and hyperemia in fingers. Successful surgical treatment on acral metastasis does not extend the life expectancy; however, it reduces the patient’s pain during his terminal period, saves the functions of the limb, and increases life comfort. Salih Soylemez, Murat Demiroglu, Mehmet Ali Yayla, Korhan Ozkan, Bugra Alpan, and Harzem Ozger Copyright © 2015 Salih Soylemez et al. All rights reserved. Secretory Carcinoma of the Breast: Report of Two Cases and Review of the Literature Sun, 05 Jul 2015 08:03:09 +0000 Secretory carcinoma of the breast is an extremely rare subtype of breast cancer characterized by intracellular or extracellular secretion and granular eosinophilic cytoplasm of the neoplastic cells. The disease which was considered to be predominant in younger age group has been recognized in adult population too and tends to show slow growth and indolent behavior. The disease occurs preferentially in females and only 27 cases have been reported amongst males. An optimal treatment for the disease subtype has been debated because of the paucity of data. We report two cases (one female and one male) of this rare disease that underwent treatment at our institution. Vivekanand Sharma, Gajendra Anuragi, Suresh Singh, Pinakin Patel, Arpita Jindal, and Raj Govind Sharma Copyright © 2015 Vivekanand Sharma et al. All rights reserved. Antiangiogenic Therapies and Extracranial Metastasis in Glioblastoma: A Case Report and Review of the Literature Tue, 23 Jun 2015 08:57:58 +0000 We present a case report of a patient with glioblastoma multiforme (GBM) complicated by extracranial metastasis (ECM) whose survival of nearly four years surpassed the anticipated life expectancy given numerous negative prognostic factors including EGFRvIII-mutation, unmethylated MGMT promoter status, and ECM. Interestingly, while this patient suffered from locally aggressive disease with multiple intracranial recurrences, the proximal cause of death was progressive extracranial disease and complications related to pulmonary metastases. Herein, we review potential mechanisms of ECM with an emphasis upon glioblastoma molecular and genetic profiles and the potential implications of targeted agents such as bevacizumab. Mohamed H. Khattab, Ariel E. Marciscano, Simon S. Lo, Michael Lim, John J. Laterra, Lawrence R. Kleinberg, and Kristin J. Redmond Copyright © 2015 Mohamed H. Khattab et al. All rights reserved. Embryonal Carcinoma in Cryptorchid Abdominal Testis of an Infant Sun, 07 Jun 2015 08:19:33 +0000 Cryptorchidism is a known predisposing factor for the development of testicular tumors in adults. Age of patient at the time of treatment of undescended testes has some bearing on the risk of neoplasia. Testicular neoplasia at the time of primary surgery for cryptorchidism has been reported rarely in prepubertal period. We report a case where embryonal carcinoma was detected in a cryptorchid testis of an infant. Atia Zaka-ur-Rab, Zeeba Zaka-ur-Rab, and Kafil Akhtar Copyright © 2015 Atia Zaka-ur-Rab et al. All rights reserved. Malignant Triton Tumors in Sisters with Clinical Neurofibromatosis Type 1 Sun, 31 May 2015 14:07:18 +0000 Malignant triton tumors (MTTs) are rare and aggressive sarcomas categorized as a subgroup of malignant peripheral nerve sheath tumors (MPNSTs). MTTs arise from Schwann cells of peripheral nerves or existing neurofibromas and have elements of rhabdomyoblastic differentiation. We report the occurrence of MTTs in two sisters. The first patient is a 36-year-old female who presented with left sided chest wall swelling. She also had clinical features consistent with neurofibromatosis type 1 (NF-1). Debulking of the mass showed high-grade malignant peripheral nerve sheath tumor with skeletal muscle differentiation (MTT). The patient was treated with ifosfamide and adriamycin along with radiation. Four years after treatment, she still has no evidence of disease recurrence. Her sister subsequently presented to us at the age of 42 with left sided lateral chest wall pain. Imaging showed a multicompartmental retroperitoneal cystic mass with left psoas involvement. The tumor was resected and, similarly to her sister, it showed high-grade malignant peripheral nerve sheath tumor with rhabdomyoblastic differentiation (MTT). The patient was started on chemotherapy and radiation as described above. Basnet Alina, Jofre A. Sebastian, and Capo Gerardo Copyright © 2015 Basnet Alina et al. All rights reserved. Synchronous Multicentric Giant Cell Tumour of Distal Radius and Sacrum with Pulmonary Metastases Wed, 27 May 2015 09:03:38 +0000 Giant cell tumour (GCT) is an uncommon primary bone tumour, and its multicentric presentation is exceedingly rare. We report a case of a 45-year-old female who presented to us with GCT of left distal radius. On the skeletal survey, osteolytic lesion was noted in her right sacral ala. Biopsy confirmed both lesions as GCT. Pulmonary metastasis was also present. Resection-reconstruction arthroplasty for distal radius and thorough curettage and bone grafting of the sacral lesion were done. Multicentric GCT involving distal radius and sacrum with primary sacral involvement is not reported so far to our knowledge. Varun Sharma Tandra, Krishna Mohan Reddy Kotha, Moorthy Gadisetti Venkata Satyanarayana, Kali Varaprasad Vadlamani, and Vyjayanthi Yerravalli Copyright © 2015 Varun Sharma Tandra et al. All rights reserved. Primary Mediastinal Synovial Sarcoma Presenting as Superior Vena Cava Syndrome: A Rare Case Report and Review of the Literature Mon, 25 May 2015 06:52:21 +0000 Primary mediastinal sarcomas are aggressive tumors with a very rare incidence. This report describes the case of a 35-year-old male patient who presented with acute symptoms of dyspnoea, facial puffiness, voice-hoarseness, and engorged neck veins. With the clinical picture consistent with the superior vena cava (SVC) syndrome, the patient was investigated with computed tomography of the chest. This revealed a large soft tissue density mass lesion compressing the SVC along with other critical superior mediastinal structures. Histopathological evaluation of the mass revealed features consistent with a soft tissue sarcoma and positive staining was observed for vimentin and S-100. Cytogenetic analysis by fluorescent in situ hybridisation (FISH) demonstrated the t(X:18) translocation. Thus diagnosis was established as primary mediastinal synovial sarcoma. Patient was treated with three cycles of neoadjuvant chemotherapy, to which there was a partial response as per the RECIST criteria. Surgical excision of the mediastinal mass was performed, and further postoperative treatment with adjuvant chemoradiotherapy was provided. Patient currently is free of disease. This is to the best of our knowledge the first report in the world literature of a successfully treated case of “primary mediastinal sarcomas presenting as SVC syndrome.” Patient is under regular surveillance at our clinic and remains free of recurrence one year after treatment completion. Irappa Madabhavi, Pritam Kataria, Apurva Patel, Swaroop Revannasiddaiah, Asha Anand, Harsha Panchal, Sonia Parikh, Malay Sarkar, Gaurang Modi, Rahul Kulkarni, and Sandip Shah Copyright © 2015 Irappa Madabhavi et al. All rights reserved. Chemotherapy in the Setting of Severe Liver Dysfunction in Patients with Metastatic Colorectal Cancer Thu, 21 May 2015 11:39:12 +0000 The liver is the dominant site of metastases for patients with metastatic colorectal cancer (mCRC). Depending on the timing of diagnosis and the biology of the disease, it is not uncommon for these patients to present with visceral crisis in the form of severe liver dysfunction. Treatment of these individuals is, however, difficult and challenging. The decision to consider chemotherapy in these dire circumstances entails consideration of numerous factors. If we were to focus on just the metabolism of the different drugs and biologic agents available to treat mCRC, both 5-fluorouracil and oxaliplatin alone or in combination with a monoclonal antibody are reasonable choices. Specifically, FOLFOX is a feasible and safe option in patients with mCRC with severe liver dysfunction. Choice of the biologic agent to add to the doublet chemotherapy could be individualized based on the RAS status and the clinical scenario. Based on the divergent experience of treating 2 cases and other prior reports, a summary of recommendations with a model in the form of a “therapeutic triad” is presented. The paper highlights the therapeutic challenges in patients with mCRC and severe liver dysfunction. The choice of chemotherapeutic agents and reports of other cases/series is also presented. Pashtoon Murtaza Kasi, Gita Thanarajasingam, Heidi D. Finnes, Jose C. Villasboas Bisneto, Joleen M. Hubbard, and Axel Grothey Copyright © 2015 Pashtoon Murtaza Kasi et al. All rights reserved.