[ ISSN : 2573-3680 ]
Parkinsonism; Central nervous system (CNS); Metastasis; Breast cancer
We present a case of a woman with progressive parkinsonistic features, and a previous history of breast cancer with no recurrence since 20 years.
We present a 76-year-old Caucasian woman who was admitted to our Acute Neurology Ward. She had a previous history of hypertension, hypercholesterolemia, GERD, and non-metastatic HER2 positive breast cancer. The breast cancer successfully had been treated radically with left-sided mastectomy, axillary evacuation of nodules with no nodular spreading and no cancer recurrence since 20 years. The treatment was felt to be curative at the time of diagnosis and no concomitant radiation, chemotherapy or anti-HER-2 treatment was offered. Her oncological treatment and follow-up terminated one year after diagnosis of the localized breast cancer. The patient’s primary care provider had first referred her to an outpatient Clinic for Memory and Cognitive disorders due to restless legs syndrome, locomotor and progressive cognitive problems suggestive of dementia. Prior to referral, she presented with bradykinesia during 6 months and for one year she had been on medication for restless legs syndrome with pramipexol in the primary care sector. Both the patient and relatives had noted decreased locomotor speed and difficulty walking. The patient accepted giving-up driving a car. She was still responsible for financial matters with a previous job in bookkeeping, her husband, however, complained of new episodes of miscalculations. Due to progression in visuospatial dysfunction and visual hallucination within one year of diagnosis of Parkinsonism, a diagnosis of Dementia with Lewy Bodies was suspected and the patient instead was admitted to an acute Neurology ward prior to her scheduled outpatient Memory Clinic appointment. On neurological evaluation she presented with non-tremor dominant parkinsonistic features including oligomimia, stooping shuffling gait, movement en-bloc, cork-wheel rigidity of upper limbs and positive pull-test. Finger-tapping bilaterally with decrement, left more than right, alternating movement with bradykinesia but without dysdiadokinesia, saccades were hypometric. There was no evidence of gaze palsy, retrocollis or frontal hyperactivity suggestive of Progressive Supranuclear Palsy. No spasticity or alien limb phenomenon was evident suggestive of Corticobasal degeneration. A bilateral proximal paresis of the hip was noted, however, deep tendon reflexes were normal. Of note, no signs of Babinski were present neither left nor right. Furthermore, the patient appeared moderately cognitively impaired with apraxia, visuospatial dysfunction, impaired immediate recall and memory. She also revealed signs of executive dysfunction including perseveration, disinhibition and poor judgement. Left-sided visual neglect was noted. Complaints had worsened within weeks including leg cramps and headache. Acute CT head, followed by MRI headand spine (Figure 1) were requested suspecting an expansive process, which was confirmed. MRI spine showed widespread leptomeningeal carcinomatosis throughout the spinal canal, with several intramedullary metastases. Whole-body FDG-PET CT confirmed widespread involvement as seen on MRI scans (Figure 1) but was negative for breast cancer recurrence and showed no additional lung or visceral cancer-spread.
Figure 1: MRI brain reveals a large contrast-enhancing expansive process involving the right basal ganglia and frontal lobe edema, mass-effect and midline shift (A, B). MRI spine (C) and whole body FDG-PET CT with intramedullary metastasis (arrows).
A neurosurgical procedure was performed with stereotactic biopsy of the solitary brain right basal ganglia tumor, suspecting a brain neoplasm, possibly lymphoma due to patient age and medullary seeding, less likely an ependymoma with seeding. Neuropathological evaluation of the brain biopsy, excluded the tumor process to be due to malignant melanoma, glioma, lung cancer, colo-rectal-, bladder cancer or clear cell carcinoma, Surprisingly, the histopathological evaluation revealed a metastatic process which could clearly be distinguished from the surrounding brain tissue and revealed recurrence of the previous HER-2 positive adenocarcinoma (Figure 2). The patient received five sessions of palliative whole brain radiotherapy and was started anti-hormonal treatment. Her performance score, however, was already severely impaired at treatment initiation and the patient was not considered a candidate for adjuvant chemotherapy or antibody treatment. She was released to a hospice, still on anti-hormonal treatment and expired about one month after the diagnosis of breast-cancer brain metastasis.
Figure 2: A right frontal biopsy was performed showing a disorganized tumoral process with no clear evidence of glandular arrangement (A). Cells revealed pleomorphic nuclei and mitotic figures. Stains were negative for melan A, CD45, GFAP, TTF-1, CK-20, p40 and napsin (not shown). The tumor stained positive for CK7 (B), estrogen-receptor (C) and HER-2 (D) antibodies consistent with a metastatic process from previous breast cancer.
This case report presents the rare case of a woman with isolated CNS involvement from a previous localized primary breast cancer. In concordance with the stage at initial breast cancer diagnosis, the patient was a disease-free survivor and had had no recurrence or metastatic disease during the past 20 years prior to admission. It is well known that HER-2 positive breast-cancer frequently metastasizes to the brain [1]. Several studies demonstrate a correlation with tumor stage and risk of brain metastasis [2]. However rare, it has been shown that HER-2 brain metastasis may occur even at 20 years of followup low-grade HER-2 positive breast-cancer [3,4]. In accordance with this, our patient had been diagnosed with grade II HER2- positive breast cancer 20 years prior to diagnosis of breast-cancer brain metastasis. Renewed mammography was not requested by the oncologist prior to the patient´s death, due to rapid deterioration at time of relapse. At time of breast cancer diagnosis the patient solely, underwent left-sided mastectomy and axillary evacuation of lymph nodes revealing no metastatic spread to any lymph-node station (n=11) and no adjuvant treatment was initiated. Isolated widespread CNS involvement with no obvious evidence of tumor recurrence extracranially 20 years after initial breast cancer diagnosis is unusual. One may hypothesize that a HER-2 positive low malignant cancer cell clone might have nested in the CNS and escaped immunosurveillance being trapped behind a closed blood-brain barrier.
Although, rapid progression of Parkinsonism with progressive cognitive symptoms such as hallucination is highly consistent with a clinical diagnosis of dementia with Lewy body, any neurological symptoms in patients with previous HER-2 positive breast-cancer irrespective of previous tumor grade and disease-free interval should prompt consideration of requesting an immediate brain scan in order to exclude CNS metastasis. Of note, the patient did not have any complaints of headache in the months ahead of admission, a red-flag which would otherwise guard most health care providers, and possibly correlated to the development of mass effect seen on MRI scans (Figure 1). This case highlights the need for awareness of long-term breastcancer brain metastasis, even in low-grade HER-2 positive patients.
The widespread metastatic disease of brain and spinal cord at time of diagnosis in our patient was rapidly fatal. Long-term survival (>5 yrs) of metastatic HER-2 brain metastasis has been reported, especially in patients receiving adjuvant treatment [5]. Although, speculative, a scan of both brain and spinal cord at time of prodromal Parkinsonian symptoms such as restless legs syndrome or at time of presentation of Parkinsonism, might have led to a more favorable outcome in our patient.
Consent was obtained from the patient and relatives prior to the patient’s death.
Saidane HA, Hansen MV, Scheie D and Roemer SF. A Rare Cause of Parkinsonism. SM J Clin Med. 2018; 4(2): 1035.
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH