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NF-1 and optic nerve glioma – additional opinion

5-year-old boy with diagnosis of neurofibromatosis type 1 underwent ophthalmological evaluation that showed reduction in visual acuity and reduction of the bilateral visual field. MRI showed presence of a big expansive lesion and of temporopolar arachnoid cyst. The treating doctors recommended an urgent surgery in order to reduce the cerebral hypertension. In the expert's opinion, after having seen the images, the arachnoid cyst has not changed that much, and probably has little impact or effect, and therefore meanwhile no surgery is warranted.

Papillary Carcinoma of Thyroid with Multiple and Diffuse Nodular Secondarisms of the Pulmonary Parenchyma

78-year-old female with history of diabetes, and meningioma complicated by neurologic deficits following surgery, was diagnosed with progressive iodine-refractory metastatic papillary thyroid carcinoma (PTC). Her initial work-up revealed lung metastasis. She underwent a right thyroidectomy and then left thyroidectomy and laryngectomy, and subsequently received I-131 on 8 occasions. She had a drop in thyroglobulin levels to the early treatments, but most recently, thyroglobulin has steadily increased.

Child suffering from NF-1 and optic nerve glioma

5-year-old boy with diagnosis of neurofibromatosis type 1 underwent ophthalmological evaluation that showed picture of slight reduction in visual acuity of the right eye and severe hypovision of the left eye with slight reduction of the bilateral visual field. MRI showed presence of a big expansive lesion and of right temporopolar arachnoid cyst. The treating doctors recommended an urgent surgery in order to reduce the cerebral hypertension.

Stage 4 Neuroblastoma

1.5-year-old male suffered from eye swelling. His MRI revealed expansive lesion of left lateral orbital wall origin, with compression on the lateral rectus muscle. Later he was hospitalized due to fever and vomiting in left orbital lesion, suspecting a metastatic neuroblastoma. His eye examination revealed exophthalmus of the eye with exophoria and light dysfunction of the lateral rectus. His biopsies were indicative of stroma-poor neuroblastoma.

Pulmonary heteroplasia_3

66-year-old female was diagnosed, following persistent cough, with non-operable tumor of her lung with satellite nodules, and chemotherapy was initiated (first Cisplatin and Gemcitabine, and then switched to Tarceva). Response evaluation following the fourth cycle of chemotherapy showed either stability or an initiation of tumor response, but bone scintigraphy that was performed 6 months later revealed an area of increased uptake in the left hemithorax which could be suggestive of a secondary bone lesion.

 

Endometrial Cancer

52-year-old female with a diagnosis of stage IIIC Grade 3 endometrial cancer. Following the adequate surgery she was started on a chemotherapy protocol, including Taxol, Epirubicin and Cisplatinum. However the first course caused severe toxicity and was switched to Taxol and carboplatinum. One treatment option is by intense combination chemotherapy, and therefore the expert supports the protocol used by this case. Another option is endocrine manipulation by hormone therapy.

Pulmonary Heteroplasia – additional opinion

66-year-old female was diagnosed, following persistent cough, with lung tumour with concomitant pulmonary nodules and a measurable enlargement of lymph nodes. FBS was positive for well differentiated neuroendocrine carcinoma and a needle biopsy revealed adenocarcinoma with associated neuroendocrine differentiation.

Pulmonary heteroplasia_2

66-year-old female was diagnosed, following persistent cough, with non-operable tumor of her lung with satellite nodules, and chemotherapy was initiated (first Cisplatin and Gemcitabine, and then switched to Tarceva). Response evaluation following the fourth cycle of chemotherapy showed either stability or an initiation of tumor response, but bone scintigraphy that was performed 6 months later revealed an area of increased uptake in the left hemithorax which could be suggestive of a secondary bone lesion.

Cystic Pleuro-Pulmonary Blastoma – additional opinion

2-year-old girl was diagnosed with pleuropulmonary blastoma (PPB). She presented with cough and fever which was treated as pneumonia. When her symptoms did not improve, a chest X-ray showed a right lower lobe infiltrate with pleural effusion and a cystic lesion superiorly. She was further treated with antibiotics and improved clinically, but follow-up with chest CT showed a persistent cystic area in the right lower lobe and pneumothorax. She thus underwent pleural drainage and thoracoscopic biopsy, revealing a diagnosis of "cystic pleuropulmonary blastoma".

Stage I Uterine Leiomyosarcoma

38-year-old female was diagnosed with stage I uterine leiomyosarcoma with high mitotic count and infiltrative-type growth margins. The expert recommends to give her adjuvant chemotherapy after the surgery - 6 courses of Adriamycin + Ifosfamide chemotherapy and consider radiotherapy afterwards for local control. An alternative treatment is with the combination of Gencitabine + Taxotere. Her prognosis depends on recurrence.

 

Small Cell Neuroendocrine Tumor of the Cervix – additional opinion

36-year-old otherwise healthy female presented with an atypical pap smear. Biopsy of cervix revealed poorly Differentiated Neuroendocrine Carcinoma. Immunohistochemical staining showed the cells positive for NSE, SYN, CHR, and 90% positive for Ki67 (proliferative index). The findings of the PET-FDG test showed pathological absorption of FDG as a primary tumor of the cervix, towards the left side of the body. Moreover, evidence is seen of nodal metastatic spread in the retroperitoneum and pelvis, mainly on the left.

Stage 4 Neuroblastoma – additional opinion

1.5-year-old male suffered from eye swelling. His MRI revealed expansive lesion of left lateral orbital wall origin, with compression on the lateral rectus muscle. Later he was hospitalized due to fever and vomiting in left orbital lesion, suspecting a metastatic neuroblastoma. His eye examination revealed exophthalmus of the eye with exophoria and light dysfunction of the lateral rectus. His biopsies were indicative of stroma-poor neuroblastoma.

Neurofibromatosis type 1 - Ophthalmologic Exam is recommended

5-year-old boy was diagnosed with neurofibromatosis type 1 (NF1) eight months after birth. He has displayed café-au-lait spots, axillary freckling, macrocephaly, sphenoid dysplasia, brain hamartomas, right temporal arachnoid cyst, and optic glioma. Visual evoked potentials showed evidence of bilateral functional deficit.

Non Small Cell Lung cancer, Stage 4, S/P Right Pneumonectomy

A 74 years old male was diagnosed 3 years ago with non small cell lung carcinoma. Accordingly, it was decided that no chemotherapy should be given at that stage. Year and a half later, a new SOL was found in right lung, and right pneumonectomy was performed. On pathology a well to moderately differentiated adenocarcinoma was found. Lymphatic invasion was identified in lung and mediastinum. A revision on previous specimen was performed and it was concluded that the tumor was morphologically different from the previous specimen.

Metastatic Heteroplasia of the Lung

70-year-old male underwent epileptic seizures. A brain CAT scan showed a space occupying lesion with surrounding edema in his left frontal lobe. A subsequent MRI examination enabled the demonstration of four separated lesions in his brain consistent with metastases. A total body CAT scan demonstrated a mass in the right lung. The diagnosis of poorly differentiated squamous cell carcinoma of the lung was established by bronchoscopy and transbronchial biopsy. The patient was treated by brain irradiation.

Adeno Carcinoma of Lung

45-year-old male with stage 4 Adeno carcinoma of the lung. The tumor was found to obstruct the left superior lobe bronchus with subsequent subtotal athelectasis and retracted left hemi-thorax. The exam found diffuse thickening of the mediastinal pleura, lymphadenopathy and analogous formations of probable secondary nature. In the expert's opinion, if the patient is already at stage IV, he should not undergo surgery. He recommends combined endobronchial and external irradiation together with chemotherapy.

Neuroroendocrine neoplasia with hepatic secondary lesions_2

39-year-old male was diagnosed to have a neuroendocrine tumour with synchronic liver metastases. The disease was treated with an etoposide-carboplatin combination, Interferon A, somatostatin analogue and Zebra fish egg derived dietary supplements. In early 2008, a tumour progression was noted in that the disease started to produce the epithelial tumour markers CEA and CA 19-9.

Small Cell Neuroendocrine Tumor of the Cervix

36-year-old otherwise healthy female underwent routine tests that found atypical cells in Pap smear. Her cervix was biopsied, and found poorly differentiated neuroendocrine carcinoma. The findings of the PET-FDG test showed pathological absorption of FDG as a primary tumor of the cervix, towards the left side of the body. Moreover, evidence is seen of nodal metastatic spread in the retroperitoneum and pelvis. In the expert's opinion the patient has locally extensive small cell neuroendocrine carcinoma of the cervix with extensive pelvic and PA adenopathy.

Operated breast cancer with metastases

A 55 years old female was diagnosed with infiltrating ductal carcinoma of the right breast 7 years ago. The patient underwent a right quadrantectomy and axillary lymph nodes removal, adjuvant chemotherapy and radiation therapy. 5 years ago, after diagnostic finding of reappearance of infiltrating ductal carcinoma of the right breast, the patient underwent right mastectomy and revisional surgery of axillary armpit, and another adjuvant chemotherapy. 

Rectal Carcinoma, Gastric Carcinoma, Metastases.

52-year-old male was diagnosed in 2004 with a carcinoma of the lower rectum and underwent surgical anterior resection of the rectal tumor which was a well differentiated adenocarcinoma. In 2008 he underwent emergency operation for a perforated pyloric ulcer and then a radical resection of a gastric tumor which infiltrated the entire thickness of the gastric wall. It was a G3 diffuse type adenocarcinoma with signet ring cells, at pT3N2 stage.

Glioblastoma

55-year-old female was diagnosed with glioblastoma after suffering increasing headaches, and was treated with radiation with concurrent Temodal. MRI exam that was performed after 2 additional cycles of CCNU showed tumor progression. The expert recommends different further treatment options.

Advanced Metastatic Colon Cancer

58-year-old male suffers from advanced metastatic colon cancer with weakness, severe anemia and synchronic liver metastases. A good partial response has been accomplished by the combination chemotherapy and the antiangiogenic antibody Avastin. In the meantime, the patient has been started on a therapeutic protocol based on hyperthermia. In the expert's opinion, There is no evidence that hyperthermia is of any benefit in this patient.

MDS – Myelodysplastic Syndrome

74-year-old male with gradual pan-cytopenia with predominant thrombocytopenia underwent a bone marrow biopsy that confirmed the diagnosis of Myelodysplastic syndrome (MDS). He is currently in good general health except for slowly progressive weakness and being constantly tired. In the expert's opinion, there is no indication for therapy at this time, since the counts are satisfactory for every-day living. Nevertheless, the treating options are erythopoietin injections, lenalidomide, Vidaza or Dacogen therapy, or stem cell transplantation.

Myelodysplastic syndrome (MDS), with kariotype del(11)q(11)

A 74 year-old male, that was diagnosed as suffering from myelodysplastic syndrome (MDS) with kariotype del(11)q(11) by a bone marrow biopsy, following a gradual pancytopenia. The patient complains about slowly progressive weakness and being constantly tired.He was offered chemotherapy, but he declined this treatment because of fear that it would worsen his already severe weakness.

Peripheral T-cell lymphoma

51-year-old male with past medical history that is remarkable for Sino-nasal adenocarcinoma which was resected 13 years ago, and a recurrent local tumor which was re-operated. Since late 2007, the patient has been noticed to have mild macrocytic anemia and leucopenia, and the hematologist thought it might represent a myelodysplastic syndrome.

Glioblastoma of the right temporal occipital region

A 61 year old male who presented with an epileptic episode was evaluated. A temporo-parietal-occipito mass was detected on MRI and PET CT. A follow-up MRI one year later showed progression of the lesion. One month later he had a craniotomy and what seems to be a partial removel of the mass. The pathology revealed glioblastoma. He was scheduled for radiotherapy two months later. The post operative MRI showed post operative changes including blood at the surgical cavity. However, there is a significant residual tumor present which is enhancing following administration of contrast.

IgG Multiple Myeloma

57-year-old male who was found to have back pain and hyperglobulinemia approximately. Marrow biopsy was consistent with IgG myeloma. He was treated with steroids and local radiotherapy with improvement in symptoms and a modest reduction in the M-component. He received melphalan-based autologous stem cell transplantation, which was complicated by reversible respiratory failure. Unfortunately, he relapsed and was treated with bortezomib and steroids for 6 cycles followed by thalidomide. The disease has responded to therapy.

Anaplastic Astrocytoma in the left temporal lobe

65-year-old male experienced loss of consciousness, and a CT scan showed a left temporal mass which was confirmed by MRI. The patient underwent Stereotacti biopsy of mass, and Histological examination gave a diagnosis of anaplastic astrocytoma. He started chemoradiation with fotemustine (nitrosourea alkylating agent). Repeated MRI showed progression with mass effect, mild uncal herniation and enlarging ventricles. He has stable expressive aphasia and hemisyndrome, lethargy and decreased motivation. His treatment was switched from phenobarbital to levetiracetam.

 

Multirelapse Squamed Carcinoma of the Skin

75-year-old male with a cutaneous squamous cell carcinoma resected from the right eyebrow in 2003. In 2006, the patient underwent resection of an ipsilateral squamous cell carcinoma in the parotid bed that was presumably a nodal metastasis. He then experienced local relapse treated with resection and adjuvant radiotherapy. There was recurrent disease involving the right cheek excised in 2008. In 2009, another recurrence led to resection with orbital exenteration. Pathology showed squamous cell carcinoma, with perineural invasion, and extension into the orbital muscles.

Cystic Pleuro-Pulmonary Blastoma

2-year-old female had been diagnosed with Pleuropulmonary Blastoma. The disease extent included the lung and pleura with no signs of metastatic spread. It was decided to start with 3 cycles of chemotherapy and afterwards to carry out a CT scan reassessment and surgical operation. The expert agrees that patients treated with combination of chemotherapy and complete surgical resection do better. Achieving total resection of the tumor results in a significantly better prognosis, whereas extrapulmonary involvement at diagnosis results in worse prognosis.

Metastatic non small cell lung Cancer

67 year old male, previously a heavy smoker, suffering for 2 months from weakness, diminished appetite and weight loss. Tests showed a mass in right arm, possibly attached to muscle, and tenderness in right ribs. Chest CT showed a mass in LLL, lung foci, suspected secondary spread and masses in upper abdomen. CT guided biopsy from right lung mass was consistent with non small cell carcinoma with extensive necrosis. SPECT bone scan showed many focal findings in the vertebrae L,D2,7, most of the ribs bilaterally and in the limbs- suspected for secondary pathology.

Left frontotemporal craniolacunia

11-months-old male showed signs of tumefaction in the left frontotemporal region. An ultrasound showed a solid noncalcified neoformation, and a brain CAT scan showed a small solid lesion resulting in erosion of the cranial theca both in the external and internal table. Based on clinical status and tomodensitometric appearance, the diagnosis of suspected eosinophilic granuloma or hystiocytosis X was made, and a surgical curettage of the craniolacunia was recommended in order to comfirm the diagnosis.

B-cell lymphoma

59-year-old-male underwent biopsy, after founding epigastric mass, and was diagnosed with B-cell lymphoma. He was treated as an aggressive lymphoma with R-CHOP. Because of neurtopenia, the planned 6 cycle regimen was not completed and a radiation course was administered. Since then the patient feels well, but continues to have prolonged and persistent neutropenia with mild thrombocytopenia. The expert suggests differential diagnosis of the bone marrow problem, and recommends additional diagnostic workup.

Prostatic adenocarcinoma – additional information

78-years-old male with poorly differentiated hormone resistant prostate cancer. The expert recommends treatment with Ketoconazole as a "second line" hormonal treatment, together with LHRH agonist that he currently takes.

Infiltrating Duct Carcinoma of Breast

51-year-old female underwent Lumpectomy and sentinel lymph node biopsy for infiltrating duct carcinoma of her left breast. The tumor was completely excised and concluded as stage I. The estrogen and progesterone receptor status were optimal, and therefore the expert recommends hormone therapy. He also recommends to complete the ongoing adjuvant irradiation program, to complete staging procedures, and to undergo genetic counseling.

Demyelinizing Disease

47-year-old female with a diagnosis of Multiple Sclerosis ,who suffers from progressive tetraparesis, more pronounced in the lower extremities. Her treatment included mitoxantrone and Interferon-beta treatment, both were discontinued because of side effects. Her movement difficulties, due to the left lower limb rigidity, are increasing progressively.

Symptomatic Pancytopenia

74-year-old male has suffered over six months from pancytopenia. The main problem has been the symptomatic anemia, which required blood transfusions. Bone marrow aspiration revealed some myelodysplasia, and immune therapy has been prescribed. The expert suggests possible differential diagnosis of pancytopenia and recommends to establish a definite diagnosis before discussing treatment.

PANCYTOPENIA OF UNKNOWN ETIOLOGY

74-year-old female evaluated for pancytopenia of unknown etiology, which required blood transfusions. Bone marrow aspirate and biopsy showed a hypocellular bone marrow with trilineage maturation. The treatment include immunosuppressive agents and erythropoietin.

Metastatic, Non Small Cell Lung Cancer – further opinion

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.

Hepatic metastases from prostatic adenocarcinoma

A 66 year old man that was diagnosed with prostate cancer underwent radical prostatectomy 2 years ago. Pathology result of the surgical specimen revealed poorly differentiated prostate carcinoma with positive surgical margins. He was treated with antiandrogens and adjuvant radiation therapy. Since the beginning of the last year and under hormonal monotherapy with Casodex his PSA levels doubled. PET CT of the abdomen and the pelvis revealed hepatic lesion.

Axonal and Demyelinative Sensorimotor Neuropathy

66-year-old male with a 6-year history of sensory symptoms in the feet and hands. He describes a sensation of cold and stinging in the feet; and numbness in the hands, especially at night. Nerve conduction and EMG demonstrated axonal and demyelinative sensorimotor neuropathy with neurogenic changes in muscles. Follow-up nerve conduction testing that was performed 2 years later showed similar findings.

Portosystemic Encephalopathy in Hepatocellular Carcinoma

Adult male with a history of hepatitis C, non-Hodgkin’s lymphoma (NHL) and hepatocellular carcinoma. Patient treated for NHL with CHOP-R 4 years ago. However, post-treatment, he had continued presumed bone marrow suppression. He was diagnosed 2 years later with HCC and underwent TACE with good effect. Since the TACE, the patient has had persistent and worsening hepatic dysfunction with portal hypertension and ascites. Recently, the patient developed encephalopathy and was treated, as described below, with fast return to consciousness.

Metastatic, Non Small Cell Lung Cancer

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.