Iman Mohamed

Local therapy in metastatic breast cancer is associated with improved survival.

Patients presenting with stage-IV breast cancer are usually offered systemic chemotherapy to control metastatic tumor burden and palliative radiation therapy to manage the symptomatic primary tumor. The aim of this study was to assess the result of local therapy on the overall outcome of patients with metastatic breast cancer. We reviewed medical records of all patients with metastatic breast cancer that presented to our institution between 2000 and 2009. Based on the treatment received, the patients were grouped as follows: group 1 included patients who underwent surgery and also received radiotherapy and chemotherapy/hormonal therapy, group 2 included patients who received radiotherapy and chemotherapy/hormonal therapy only, and group 3 included patients who received chemotherapy/hormonal therapy alone. Of the 37 patients included in the study, 10 patients were placed in group 1, 17 patients in group 2, and 10 patients in group 3. About 38% had high to anaplastic tumor grade, and 48% had ≥2 metastatic sites in the body. Overall, the average survival time was 3.13 years (range: 0–17 years). A significant difference in survival estimates was noted between groups 1, 2, and 3 with mean survival times of 8.83, 4.9, and 2.26 years, respectively (log rank &khgr;2 = 10.44, P = 0.005). In age-adjusted multivariate Cox regression model (&khgr;2 = 21.729, P= 0.001), high/anaplastic tumor grade (P = 0.036), African American race (P = 0.009), central nervous system metastasis (P = 0.003), group 2 (P = 0.006), and group 3 (P = 0.002) were associated with poor survival. Survival was not associated with estrogen and progesterone receptor and visceral or bone metastases. We conclude that aggressive local control of primary tumor in patients presenting with stage-IV breast cancer is associated with improved survival.

Bilateral Myeloid Sarcoma of the Breast and Cerebrospinal Fluid As a Relapse of Acute Myeloid Leukemia After Stem-Cell Transplantation: A Case Report

Case Report A 47-year-old woman with an insignificant past medical and family history was diagnosed with acute myeloid leukemia (AML) M1 in April 2009. The patient was treated with induction chemotherapy with daunorubicin and cytarabine followed by consolidation chemotherapy with cytarabine. One year later, the patient had a bone marrow relapse and underwent a second induction chemotherapy, after which she went into complete remission. In April 2010, the patient had allogenic stem-cell transplantation. A bone marrow biopsy 3 months later showed complete morphologic remission. In March 2011, the patient developed sudden onset of rapidly enlarging bilateral breast masses. She denied any trauma to the breast before the development of the masses. On physical examination, no lymphadenopathy was noted in the cervical, clavicular, and left axillary areas. However, a firm lymph node was palpated in the right axilla. A breast examination demonstrated the near complete replacement of breast tissue with multiple firm, mobile masses. A bilateral diagnostic mammogram and breast ultrasound were carried out. Mammogram images showed heterogeneous dense breast tissue with multiple masses (Figs 1A and 1B). On the ultrasound, there were numerous masses throughout both breasts. The largest mass in the left breast measured 4.2 cm, and the largest mass in the right breast measured 6.2 cm (Figs 2A and 2B). A complete blood count revealed a WBC count of 3600/ L, hemoglobin concentrations of 12.4 g/dL, and platelet count of 197,000/ L. The patient underwent a core biopsy of both breasts. The histomorphology, cytologic features, and immunoprofile using flow cytometry of both biopsies were consistent with myeloid sarcoma (Figs 3A through 3D; hematoxylin and eosin stain; Figs 3A and 3C, 40 magnification; Figs 3B and 3D, 4 magnification). Immunophenotypic analysis demonstrated a population of abnormal myeloblasts of similar phenotype to that of the bone marrow that expressed CD13, CD33, and CD34 (Fig 4) with aberrant expression of mature myeloid markers CD15 and CD11b and dim aberrant expression of T-cell marker CD7. Myeloperoxidase stain was positive. The proliferation marker Ki-67 revealed that the tumor cells displayed nuclear immunoreactivity. This indicates a high proliferative index for this neoplasm. Fine-needle aspiration of the right axillary lymph node showed a cytomorphology similar to that seen on breast biopsies. At that time,

A case report of complete remission of pulmonary metastases from epithelioid sarcoma to navelbine chemotherapy.

Management of soft tissue sarcomas can be very challenging because they have a high rate of metastasis, especially to the lungs, and respond very poorly to the currently available chemotherapeutic drugs. We present a case of epithelioid sarcoma in which complete remission of pulmonary metastases was observed after treatment with a single agent, navelbine, a vinca alkaloid, and a potential therapeutic agent. The patient has been persistently free of metastases for 4 years since treatment with navelbine. Further studies are warranted to establish the role of navelbine for the treatment of soft tissue sarcoma and their metastases.

Skin lesions with Lynch syndrome could represent Muir-Torre syndrome.

We report a case of a 46-year old gentleman who was initially found to have stage II B Colorectal cancer at the age of 35 years in 2002 treated with colon resection. Afterwards, he underwent annual colonoscopy surveillance and had a removal of one tubular adenoma in 2005. Rest of screening colonoscopies remained normal. At the time of his colorectal cancer diagnosis, he was found to have a strong family history of malignancies which included colorectal cancer in father at the age of 42 and pancreatic cancer at the age of 62. Paternal uncle had colon cancer at the age of 56, paternal grandmother brain tumor at the age of 66 years indicating a possibility of Lynch syndrome. Subsequently, he underwent MLH1 and MSH2 sequencing and was found to have an MSH2 mutation known as 1003insA. He is one of the five children, all his siblings underwent MSH2 site-specific testing with two siblings testing positive for familial MSH2 mutation. In 2013, he presented to a dermatologist for an ulcerating lesion on the right side of the nose present for 6 months .The biopsy of the lesion came back positive for sebaceous carcinoma, and he underwent Mohs surgical resection. With a history of colorectal cancer, MSH2 mutation, and the development of sebaceous carcinoma, he was diagnosed to have Muir–Torre syndrome.

A case of life-threatening retinoic acid syndrome and review of literature.

All-trans-retinoic acid represents a major progress that has made acute promyelocytic leukemia the most curable subtype of acute myeloid leukemia in adults. Although all-trans-retinoic acid is usually well tolerated, some patients develop the retinoic acid syndrome, characterized by unexplained fever, weight gain, respiratory distress, interstitial pulmonary infiltrates, pleural and pericardial effusions, episodic hypotension, and acute renal failure. Further studies of growth factor expression and modulation of adhesion molecules are warranted to provide further insights into the pathogenesis of the syndrome and may lead to its prevention.

Metastatic renal extraskeletal Ewing sarcoma in complete remission for the last 8 years.

Primary renal extraskeletal Ewing sarcoma (EES) is rare but well known to be aggressive, less responsive to the treatment, and has early predilection for metastases. Metastases at the time of diagnosis to the lungs or bones are associated with poor outcome. We present a case of primary renal EES in 57-year-old woman with multiple metastases to the lungs at the time of diagnosis with complete remission of the disease for the last 8 years following multimodality treatment Multidisciplinary approach for the management of EES has definitely improved the quality of life and the survival of the patients.

Gastrointestinal stromal tumor with primary resistance to imatinib and extensive bone metastases.

Gastrointestinal stromal tumors (GISTs) are the most common nonepithelial tumors of gastrointestinal tract characterized by mutations activating c-KIT or platelet-derived growth factor receptor alpha. GISTs frequently metastasize to liver and peritoneum, but rarely to the bones. Imatinib, a tyrosine kinase inhibitor, has revolutionized the treatment of advanced and metastasized GISTs by both slowing down the disease progression and prolonging the survival. Occasionally, patients with GISTs can develop primary or secondary resistance to imatinib monotherapy. We are presenting an interesting case of metastatic GISTs with extensive bone lesions and primary resistance to imatinib. Efforts to identify bone metastases using appropriate imaging modalities are highly recommended in patients diagnosed with GISTs. Also, alternate strategies to overcome the emerging resistance with single agent imatinib chemotherapy are warranted.

Association of hyperplastic polyposis syndrome, colorectal cancer and meningioma

Recent research has provided compelling evidence that a subset of hyperplastic polyps may be associated with a risk of colorectal cancer. Colorectal cancer with extracolonic manifestation is usually seen in a hereditary syndrome setting, but some association with meningioma has been reported. The association of colorectal cancer with hyperplastic polyposis and meningioma is extremely rare. This report in a 57-year-old female with no family history of colon cancer or polyps, could be the first case of hyperplastic polyposis syndrome, colorectal cancer and meningioma. Hyperplastic polyposis syndrome was diagnosed as per WHO criteria at the time of colon cancer diagnosis. Within 4 months of colon cancer diagnosis she developed seizures. Imaging of the brain revealed meningioma of the left cerebellopontine angle. The patient underwent surgery followed by chemotherapy.

Carboplatin-induced hematuria in a patient of breast carcinoma. A case report.

Platinum-based antineoplastic drugs are widely used in the treatment of solid tumors. Carboplatin, a second generation platinum compound, was developed to have less nonhematologic toxicity, in comparison with cisplatin. We report on a 34-year-old woman with breast cancer who developed gross hematuria after initiation of carboplatin-based chemotherapy. To our knowledge, there are very few cases reports of carboplatin-associated gross hematuria.

Cost-benefit of recurrence score–guided treatment using an Oncotype DX 21-gene assay: A single institution analysis.

29 Background: In 2010 the National Comprehensive Cancer Network recommended a 21-gene assay recurrence score (RS) to aid in the adjuvant treatment decision among patients with estrogen receptor positive, lymph node negative early stage breast cancer. Early-decision impact studies show that the RS can reduce overall chemotherapy use by 27%. This study was performed to assess the cost-benefit of the test for the patients diagnosed and treated an academic institute before 2010. METHODS Data from early breast cancer estrogen-receptor-positive and lymph-node-negative patients (n = 87), who were diagnosed and treated at our center from 2004-2010 were analyzed. All patients had the 21-gene recurrence test done to guide in their management. Cost of chemotherapy, adverse effects, and supportive care costs were calculated from previously published articles. RESULTS 66 patients with stage I breast cancer and 21 patients with stage II were analyzed. All but one patient had a tumor size more than 5mm. In total, 27 patients received chemotherapy. Characteristics of patients receiving chemotherapy are shown in the table. Cost of 21 gene recurrence score assay was