Modesto D'Aprile

Gastric stump lymphoma five years after distal gastrectomy.

We report the case of a 77-year-old man who developed low grade B cell non-Hodgkins lymphoma of the gastric stump 5 years after undergoing a distal gastrectomy for benign gastric ulcer. Lymphoma occurring in the post-operative stomach would appear to be very rare, with only 14 previously recorded cases. The median period of lymphoma onset after ulcer surgery is about 20 years (range 9-43 years) and gastric remnants of lymphoma are generally diagnosed in low stage, when surgery is possible and makes the prognosis good. The clinical case presented herein is quite different from the others. The patient developed lymphoma within 5 years of the ulcer surgery, thus, earlier than generally reported in literature; he presented with massive regional and extra-regional nodes involvement and liver metastases and he poorly responded to antiblastic chemotherapy. The pathogenetic role of Helicobacter pylori (HP) infection and the possibility of malignant lymphoma developing in the gastric stump are discussed.

Breast cancer metastatic to the choroid in a male patient: case report.

Choroidal metastases have been observed in about 8% of patients with metastatic breast cancer, even if their true incidence is likely to be higher, as they are not routinely investigated in the absence of symptoms. Radiotherapy is the treatment of choice for symptom palliation. The prognosis is traditionally poor, with a reported average survival of one year. Here we describe the third case reported in the literature of a metastatic tumor to the choroid from a male breast carcinoma.

Rapidly Progressive Coma in Leptomeningeal Carcinomatosis From Undiagnosed Bronchioloalveolar Carcinoma

A hypertensive, nonsmoking 55-year-old woman presented for presyncope associated with spatial and temporal disorentation, dysarthria, headhache, and a 1-month history of intermittent vomiting and headhache. Four years previously, patient was diagnosed with stage II Hürtle cell follicular carcinoma of the thyroid gland, treated with total thyroidectomy followed by adjuvant radioiodine therapy. At the admission, her blood pressure was 170/100 mmHg. Neurologic examination showed normal symmetric reflexes, intact cranial nerves function, and absence of meningeal signs. Initial brain computed tomography (CT) scan was unremarkable for any acute process. Blood count; renal, liver, and thyroid function tests; vasculitic screen; and viral serology were normal. The serum carcinoembryonic antigen level was elevated at 99.3 ng/mL. During the next 2 days, patient underwent both gadolinium-enhanced brain magnetic resonance imaging (MRI), which documented only mild enlargement of ventricles, and intracranial MRI angiography, which was negative. A CT scan of thorax revealed a focal area of increased lung opacity in the right lower lobe of about 1 cm in diameter consistent with a neoplastic process (Fig 1, arrow). CT scan of abdomen showed no evidence of metastases. Research of urinary catecholamine was negative. A lumbar puncture was performed. CSF study showed clear CSF with normal protein, decreased glucose, leukocyte count of 20/mm, no RBCs, and normal opening pressure. A cytological examination did not reveal the presence of neoplastic cells. Microbiological tests, including polymerase chain reaction for Mycobacterium tuberculosis, excluded a viral or bacterial meningitis. Seven days after admission, patient presented diplopia and lower extremity weakness. Although dexamethasone and mannitol were administered intravenously, the patient’s neurological status continued to deteriorate with severe headhache, clonic seizures, continuous decrease in general responsiveness, and coma. She died 12 days after the admission. Postmortem examination was performed. Macroscopically, whitish patches were noted on the leptomeninges, particularly on the base of the brain; the spinal cord appeared normal. An area of consolidation of about 2 cm in diameter in the right lower lobe of the lung was observed. The sampling of leptomeningeal revealed a picture of neoplastic carcinomatosis (Fig 2A). By immunohistochemistry, the cells were focally positive for thyroid transcription factor 1 (TTF-1; Fig 2B) and heavily for cytokeratin 7 (CK7; Fig 2C). Histologic samples of right lower lobe of the lung disclosed a nonmucinous bronchioloalveolar carcinoma (BAC; Fig 3); sometimes neoplastic cells were associated with granulocytic inflammatory cells (Fig 3, insert). The immunohystochemical stains was positive for CK7 and negative for CK20 and thyreoglobulin. Cellular morphology of leptomeningeal metastases (Fig 4A) looked strongly like that of lung cancer (Fig 4B), thus confirming the diagnosis of leptomeningeal carcinomatosis from nonmucinous BAC. Metastatic involvement of pia and arachnoid mater (leptomeninges) is found at autopsy in 5% of patients with systemic cancer. Neverthless, an antemortem diagnosis is much less commonly confirmed, reflecting the difficulty in making the diagnosis clinically or with laboratory studies. If leptomenigeal metastases is suspected, the diagnosis should be based on the complementary combination of neuroimaging and CSF studies. A gadolinium-based MRI is more sensitive than CT scan for the assessment of the brain. Overall, it might disclose meningeal lesions in nearly 70% of patients. The most useful laboratory test in the diagnosis of leptomeningeal metastases is the

Fatal thrombocytopenia and thrombocytopathia: An unusual onset of non small cell lung cancer

Background: Although bone marrow is a common site of micrometastases for non-small cell lung cancer (NSCLC), thrombocytopathia and hemorrhagic diathesis are rare causes of death. Case Report: A 57-year-old patient was admitted to the emergency room because of massive nosebleeding and hemoptysis. Routine blood analysis showed thrombocytopenia and prolonged bleeding time; results of functional platelet tests suggested concomitant thrombocytopathia. Routine chest X-ray revealed an 18 mm large spot in the right superior lobe. During the first hour of recovery the patient had another episode of nosebleeding. A bone marrow biopsy showed a wide infiltration with neoplastic cells. Histology was compatible with NSCLC. The clinical conditions and hematological parameters progressively deteriorated, and on the third day the patient died because of hypovolemic shock. Conclusion: This is a very rare clinical presentation of NSCLC characterized by massive bleeding due to thrombocytopenia and thrombocytopathia secondary to wide bone marrow infiltration.

Long-term follow-up in breast cancer survivors: A single institution survey

599 SURVIVAL FROM BREAST CANCER has improved over the last few years, but scanty information is available on the long-term follow-up. Follow-up is performed periodically, with the aim of early detection of local recurrences, distant metastases, and new primary cancer. We, therefore, considered data on women with breast cancer diagnosed and treated in the rural province of Latina, central Italy, who had survived for at least 10 years. Few similar population studies have been reported in Italy to date.1,2 The dormancy of breast cancer after mastectomy and the causes of death of breast cancer survivors have been investigated recently in the United States3 and in the Netherlands4 in order to ascertain when excess mortality from breast cancer disappears and what would be the appropriate length of follow-up for investigational purposes. However, the preceding studies1,2 focused on populations treated before the introduction of chemoand hormono-therapy into the clinical practice that have markedly affected the outcome of breast cancer patients in the last three decades. This is the first report focusing on long-term survivors of breast cancer living in a rural community and treated either with surgery alone or with surgery plus adjuvant therapy. The records of patients who had breast cancer between 1973 and 1989 were reviewed from the database of S. Maria Goretti Hospital, Latina, Italy. All breast cancer patients not known to be dead were matched against death records. A total of 100 long-term survivors was collected. The duration of the observation time ranged from 12 to 28 years, with a median follow-up of 14 years. Median age at diagnosis and median age at follow up were 49 years (range 28–74 years) and 68 years (range 50–84 years), respectively. According to the TNM classification, 39 patients were initially stage I, 35 were stage IIA, 17 were stage IIB, 6 were stage IIIA, and 3 were stage IIIB. The primary tumors were all #4 cm in size. All patients underwent surgery (89 mastectomy, 11, conservative surgery). Adjuvant chemotherapy was prescribed in 41% of women, and of these 80% were given six courses of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). The rest received anthracyclinebased regimens. Adjuvant tamoxifen alone was given to 17% of patients, and only 3% of patients received chemotherapy plus tamoxifen. Women were followed with physical examination and regular laboratory tests (blood cell count, chemistry profile, liver function tests, and tumor markers) every 3 months for the first 3 years, every 6 months for the next 2 years, and then annually. Yearly mammography of the contralateral and preserved breast, bone scan, and gynecological examination together with 6-monthly chest x-ray and liver sonogram were performed. Overall, relapses and contralateral breast cancers were detected in 11% and 5% of patients after a median follow-up of 12 years (range 2–15