Pretty easy, isn't it? Lung cancer is the most frequent cause of brain metastases and in 20-30% of cases it is as a result of them that the primary tumor is diagnosed (as here).

A 60-year-old man comes to the emergency department for a coma crisis. Ex-smoker for 3 years, with no other history of interest. A CT scan shows multiple metastases. What is the most probable origin?

Clinical characteristics of patients with lung cancer and metachronous or synchronous tumours with other locations.

Lung cancer is the leading form of cancer death worldwide. Cancer patients are at a high risk of developing a second cancer. The present study attempts to determine the characteristics of a population with lung cancer diagnosed with another cancer. We analysed records of patients from the Department of Lung Oncology of our hospital from 2000 to 2007 who were identified as having two or more tumours. We found 4.2% (n=44) multiple cancers among the registered cases (n=1046), 88.6% males, (high) mean age 70.1+/-10 years old. About 86% (n=38) of the patients were smokers or ex -smokers. From the patients with record of family history, 65.4% (n=17) had relevant family history of cancer. The majority of the first malignancy diagnosed was prostate, colon, head and neck and bladder. Lung cancer was essentially the second malignancy. The mean time lag between the two diagnoses was 62.9+/-64.9 months (max. 240, min. 0), with the second cancer usually detected at an advanced stage. The mean survival of patients who had a second primary lung cancer was 8.6+/-8.24 months (max. 32, min. 1), with four patients still surviving. Our results suggest that extended follow -up is needed in these patients, using screening strategies which follow international recommendations, and with control of carcinogenic risk factors such as smoking. We suggest a tailored risk algorithm and a further study to assess if there are particular molecular markers in these patients.

Unusual Case of Pancreatic Adenocarcinoma with Bladder Metastasis.

<iBackground</i: The pancreas can be the site of neoplasms of several histogenetic origins; in most cases, tumors derive from the exocrine component, and ductal adenocarcinoma certainly prevails over the others. This tumor displays remarkably aggressive behavior, and it is often diagnosed at a late stage of disease. <iCase presentation</i: We discuss the rare case of a 76-year-old male with locally advanced pancreatic head adenocarcinoma who developed uncommon metastatic disease. The bladder constitutes a very rare site of metastases, mostly deriving from melanoma, gastric, lung and breast cancers. The bladder's secondary involvement in pancreatic malignancies represents an extremely unusual occurrence, and there are very few cases described in the literature to date. <iConclusions:</i The finding of pancreatic adenocarcinoma metastases leads to a poor prognosis, and patients who are diagnosed at this stage constitute 53% of cases, with a 5-year survival of 3%. Although rare, therefore, the diagnostic hypothesis of pancreatic ductal adenocarcinoma (DAC) metastases to the bladder must, in some cases, be considered, especially if accompanied by a clinical picture that may suggest it.

Carcinoma of sigmoid colon after ureterosigmoidostomy.

An unusual case of adenocarcinoma of the colon in a 49-year-old man is described. The patient underwent ureterosigmoidostomy at the age of 3 years after a traffic accident. At the age of 49 years, he was admitted to a Department of Urology for treating urinary lithiasis. A chest x-ray and thoracic computed tomography (CT) showed some nodules in both pulmonary fields, while an abdominal CT was normal. The previous patient's history was ignored, the patient underwent thoracoctomy and a nodule was removed. The histology revealed a metastatic, moderately differentiated mucinous adenocarcinoma, probably of the bowel. A sunsequent colonoscopy was non-disclosing and the patient was thought to suffer from a carcinoma of unknown origin and received 6 cycles of chemotherapy with carboplatin and 5-fluorouracil. Five months after the end of chemotherapy he presented with an uncerated mass in the lower abdominal wall. A new CT scan revealed a solid mass in the pelvis with infiltration of the suprapubic region while a repeat colonoscopy showed an infiltrating mass in the sigmoid. Biopsies were obtained from both lesions and the histology was similar with that of the pulmonary nodule.

[Clinicopathological study on multiple primary malignant neoplasms, related to the oral-maxillofacial region].

The present study consists of a clinical and histopathological analysis of those cases which were diagnosed as multiple primary malignant neoplasms of the oral-maxillofacial region and the other organs. 9 patients of those multiple primary malignant neoplasms out of 261 patients of malignant neoplasms in the oral-maxillofacial region, who visited in out department from 1975 to 1986, were detected. 3.4% of the incidence rate was calculated. All the cases were male, and these included each 1 case of triple and quadruple. 7 cases were detected prior in the oral-maxillofacial region to the other organs. There seemed to be a preponderance to early detection of a neoplasm in the oral-maxillofacial region. Therefore, the possibility of multiple primary malignant neoplasms should be kept in mind in the routine clinical activities. 2 cases were synchronous, 6 months or less interval between the first and the second neoplasms, the others were metachronous, averaged 5-year interval. The primary sites in the oral-maxillofacial region were tongue (3 cases), floor of the mouth (2), buccal mucosa (2), lower gingiva (1), maxillary sinus (1), all of them were diagnosed as squamous cell carcinomas, histopathologically. The other organs were esophagus (3 cases), stomach (2), colon (2), lung (2), liver (1), urinary bladder (1), hypopharynx (1). Histopathological diagnoses of them were squamous cell carcinomas (3 cases of esophagus, each 1 case of lung, urinary bladder, and hypopharynx), adenocarcinomas (2 cases of stomach and colon, and 1 case of lung), and a hepatoma. It's necessary to differentiate the multiple primary malignant neoplasms from metastases when each of them were diagnosed as squamous cell carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

First_Aid_Step1

Natural history of lobar pneumonia Lung cancer Leading cause of cancer death. Presentation: cough, hemoptysis, bronchial obstruction, wheezing, pneumonic “coin” lesion on CXR or noncalcified nodule on CT. Sites of metastases from lung cancer: Liver (jaundice, hepatomegaly), Adrenals, Bone (pathologic fracture), Brain; “Lung ‘mets’ Love Affective Boneheads and Brainiacs.” In the lung, metastases (usually multiple lesions) are more common than 1° neoplasms. Most often from breast, colon, prostate, and bladder cancer. SPHERE of complications: Superior vena cava/thoracic outlet syndromes Pancoast tumor Horner syndrome Endocrine (paraneoplastic) Recurrent laryngeal nerve compression Risk factors include smoking, secondhand smoke, radon, asbestos, family history. Squamous and Small cell carcinomas are Sentral (central) and often caused by Smoking.

[Small cell carcinoma of the urinary bladder with synchronous esophageal cancer and incidental lung cancer: a case report].

We present a case of triple primary cancers occurring synchronously in the urinary bladder, esophagus, and incidentally in the lung. A 65-year-old man with a chief complaint of gross hematuria was admitted to our hospital. Cystoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a non-papillary broad-based bladder tumor. Histological diagnosis was transitional cell carcinoma of the urinary bladder and he underwent one course of neoadjuvant chemotherapy (M-VAC) with the preoperative diagnosis of T3bN0M0. After one course of chemotherapy, chest CT, lymph node biopsy and esophagoscopy revealed squamous cell carcinoma of the esophagus. He first underwent radiochemotherapy (total 70 Gy, CDDP 5 mg x 41, 5-FU 250 mg x 24) for esophageal cancer and achieved complete remission. Then, he underwent radiotherapy for a total of 60 Gy for bladder cancer. However, his general condition gradually became worse and he died from metastatic cancer. The autopsy proved that he died from multiple metastases of small cell carcinoma of the urinary bladder and incidentally squamous cell carcinoma of the lung was identified.

Brain metastasis

Causes The most common sources of brain metastases in a case series of 2,700 patients undergoing treatment at the Memorial Sloan–Kettering Cancer Center were: Lung cancer, 48% Breast cancer, 15% Genitourinary tract cancers, 11% Osteosarcoma, 10% Melanoma, 9% Head and neck cancer, 6% Neuroblastoma, 5% Gastrointestinal cancers, especially colorectal and pancreatic carcinoma, 3% Lymphoma, 1% Lung cancer and melanoma are most likely to present with multiple metastasis, whereas breast, colon, and renal cancers are more likely to present with a single metastasis. Diagnosis Brain imaging (neuroimaging such as CT or MRI) is needed to determine the presence of brain metastases. In particular, contrast-enhanced MRI is the best method of diagnosing brain metastases, though detection is primarily done by CT. Biopsy is often recommended to confirm diagnosis.

[Carcinoma of unknown origin. Diagnostic study of 48 cases and its clinical yield].

Forty-eight patients fulfilling the criteria for carcinoma of unknown origin (CUO) between April 1983 and December 1987 were retrospectively analyzed. Mean age was 62 (33-83). Twenty-seven were males (56%) and 21 females (44%). The most common site of metastasis was the bone (35%), followed by the liver (19%) and lymph nodes (19%). 58% of cases were adenocarcinomas. Overall 274 studies for the detection of the primary tumor were carried out, the diagnosis being achieved in 10 cases (3.65%) which corresponded to lung neoplasms (5 cases), prostatic adenocarcinoma with negative markers (2 cases), bile duct neoplasms (2 cases) and pancreatic carcinoma (1 case). In our series, the most useful studies were computed tomography (CT) and fibrobronchoscopy. The necropsy, carried out in 11 patients, yielded 8 additional diagnoses: pulmonary neoplasm (one case), gastric adenocarcinoma (2 cases), malignant melanoma (2 cases), small intestine neoplasm (one case), parotid cancer (one case) and hepatocarcinoma (one case). Thirty-five patients were treated with chemotherapy and/or radiation; 12 objective responses (3 complete and 9 partial) were achieved, with a median duration of the response of 10 months (range 0.2-78 +). In view of the low diagnostic yield of the studies in patients with CUO we feel that the diagnostic study may be limited to CT scan with evaluation of the possible usefulness of bronchoscopy in individual patients. Regarding therapy, it is to be noted that there was a tendency for a longer survival in patients who responded.

Post-traumatic seizure with an unexpected finding.

A 5-year-old boy of non-consanguineous Indian descent presented to the emergency department (ED) following a prolonged seizure, preceded by a minor head injury from a low-level unwitnessed fall. The seizure was described as focal with head and neck version to the right. There was urinary and faecal incontinence and foaming at the mouth. The seizure lasted for 30 min, following which the child made a rapid recovery and had no neurological deficit when examined in the ED. His initial observations were unremarkable, with him being afebrile, normotensive and having a blood sugar of 4.6 mmol/L. QUESTION 1: Which imaging modality, if any, should be performed? QUESTION 2: Initial imaging showed two parenchymal lesions, one within the left frontal lobe and the other in the right parietal lobe with possible areas of blood or calcification. MRI (figure 1A,B) was urgently undertaken and reported as likely to be either haemorrhage into cavernomatous malformations, haemorrhagic metastases or haemorrhage within infected lesions such as tuberculomas.What would be the most useful next step in view of the differential diagnosis?CT chest and abdomenPerform a C-reactive proteinPerform a Mantoux testRefer to neurosurgeryTake a detailed family history QUESTION 3: As the patient remained stable on the ward, with no signs of focal neurology and no mass effects on MRI, a lumbar puncture was performed the following day to exclude tuberculosis (TB) (table 1). What cell appearance would indicate TB infection? QUESTION 4: A review of the mother's medical records and MRI scans revealed her to have multiple discrete cerebral cavernous malformations (CCMs) (figure 2).In view of this new information, what is the next step in investigating this child?

Metastatic spread and common symptoms. Part six: Advanced cancer of the pancreas, prostate, stomach, and uterus.

This is the last article in a six-part series on metastatic spread and natural history of the 18 most lethal tumors. The articles summarize symptom/problem anticipation, cancer metastasis, and the 18 tumors that each cause more than 6000 deaths/year in the United States. Bladder and brain cancer were discussed, with information given on tumor types, metastatic spread and invasion, and common symptoms. Parts II, III, IV, and V charted the natural histories, problems, and assessment parameters of advanced cancers of the breast, colon and rectum, esophagus, kidney, liver, and lung; and leukemia, melanoma, multiple myeloma, non-Hodgkin's lymphoma, and cancers of the oral cavity (and pharynx) and ovary. Part VI finishes the series with discussions of cancers of the pancreas, prostate, stomach, and uterus. Each of these cancers is presented separately, with information given on mortality rates, the most common tumor types, sites of metastases, common problems, and common oncology emergencies. Sites of spread, resulting problems (including site-specific symptoms), and assessment parameters are presented as tables. Material is presented so that clinicians are able to anticipate the spread of these cancers and can thus identify problems early in their development so that the problems are more easily managed.

Pancreatic metastasis arising from a BRAF(V600E)-positive papillary thyroid cancer: the role of endoscopic ultrasound-guided biopsy and response to sorafenib therapy.

Lungs and bones are the most common sites for distant metastases from papillary thyroid cancer (PTC). Metastases to the pancreas are extremely rare. Here we present a man with pancreatic metastases from PTC, report our experience with sorafenib therapy, and discuss the role of endoscopic ultrasound (EUS)-guided biopsy in its diagnosis. A 56-year-old man underwent total thyroidectomy, right-modified neck dissection, and radioactive iodine (RAI) remnant ablation for PTC at age 47 years (in 2002). Between 2002 and 2007, he had three more neck surgeries, two RAI therapies, and external beam radiotherapy for persistent and subsequently metastatic PTC. In 2008, a computed tomography/positron emission tomography (CT/PET) scan showed an 18F-fluorodeoxyglucose (FDG)-avid pancreatic focus. Magnetic resonance imaging (MRI) revealed a pancreatic nodule at the same location. An EUS-guided biopsy confirmed the diagnosis of pancreatic metastasis from PTC, and molecular studies showed positive BRAF(V600E) mutation. He was treated with sorafenib for 6 months. Although a lung CT scan done 2 months after initiation of sorafenib suggested stability of the disease, MRI studies done at 3 and 6 months showed clear progression with an increase in the size of the lung and pancreatic metastases. Subsequently, he developed liver, bone, and omental metastases. He died in July 2011, 9 years and 8 months after the initial diagnosis of PTC and 20 months after discovery of the pancreatic metastasis. A middle-aged man with PTC developed lung metastases despite multiple surgeries and RAI therapies. Seven years after the initial diagnosis, a pancreatic metastasis was accidentally discovered. Both the metastasis and the primary thyroid tumor are positive for BRAF(V600E) mutation. The lung and pancreatic metastases progressed while the patient was receiving sorafenib for 6 months, and the patient died 20 months after diagnosis of pancreatic metastasis. PTC rarely metastasizes to the pancreas. In this patient, an FDG PET scan and EUS-guided biopsy played important roles in the diagnosis. PTC metastases to the pancreas usually occur in otherwise advanced disease. In the patient presented here, sorafenib may have slowed disease progression but the overall utility of tyrosine kinase inhibitors in pancreatic metastases from PTC is not clear.

Familial and personal history of cancer in bronchogenic carcinoma--frequency and clinical implications.

A familial and personal history of cancer might be associated with a more aggressive cancerous disease. This study was carried out on 1277 consecutive lung cancer (LC) patients, seen from January 1989 to October 2002 in a single institution. A set of 31 clinical laboratory, radiological and pathological variables was recorded prospectively for all patients. In addition, both the number of first-degree blood-relatives with cancer (lung and non-lung cancers) and the personal history of previously cured cancers were noted. There were 368 patients (28.8% of the sample) who had one first-degree relative with cancer (112, 8.7% of the sample with LC), 100 (7.8%) had two first-degree relatives (six with LC) and 31 (2.4%) had three or more relatives affected (four with LC). In total, 1142 patients (89.4% of the sample) have never been treated for another cancer; the remaining 135 patients (10.6%) had already been diagnosed with a variety of tumours, including head and neck cancer (36 patients, 2.8%), bladder cancer (33 patients, 2.6%), colorectal cancer (24 patients, 1.9%), breast cancer (seven patients, 0.6%), melanoma (five patients, 0.4%), skin (five patients, 0.4%) and prostate cancer (five patients, 0.4%). Among the variables studied, none was found to be significantly associated with a personal and/or family history of cancer. Survival expectancy was similar among patients with or without a familial or personal history of cancer. A familial and a personal history of cancer are common features in LC, but are not of clinical significance.

Surgery_Schwartz

carcinoids, and tumors <1 cm in diameter), as well as false-positive results (because of confusion with other infectious or inflammatory processes).Metastatic Lesions to the LungThe cause of a new pulmonary nodule(s) in a patient with a previous malignancy can be difficult to discern.29 Features sug-gestive of metastatic disease are multiplicity; smooth, round borders on CT scan; and temporal proximity to the original pri-mary lesion. One must always entertain the possibility that a single new lesion is a primary lung cancer. The probability of a new primary cancer vs. metastasis in patients presenting with solitary lesions depends on the type of initial neoplasm. The highest likelihood of a new primary lung cancer is in patients with a history of uterine (74%), bladder (89%), lung (92%), and head and neck (94%) carcinomas.Surgical resection of pulmonary metastases has a role in properly selected patients.30 The best data regarding outcomes of resection of pulmonary metastases come

Cardiac metastasis of head and neck squamous cell carcinoma.

Two patients with cardiac metastasis from head and neck cancer are reported. Cardiac metastasis located in the left atrium was detected on a follow-up computed tomography (CT) scan 15 months after partial glossectomy for a tongue carcinoma in a 60-year-old man. The diagnosis was confirmed as cardiac metastasis of squamous cell carcinoma (SCC) by surgical excision of the cardiac lesion. The patient died 3 weeks after surgery. In a 69-year-old man with a partial maxillectomy for primary soft palate cancer, a follow-up CT scan 5 months after surgery revealed a mass in the right atrium and ventricle, and multiple lung metastases. He died of heart failure 3 weeks after the diagnosis of cardiac metastasis. Information on these cases should add to knowledge about rarely encountered cardiac metastasis.

The value of postmortem examination in cases of metastasis of unknown origin-20-year retrospective data from a tertiary care center.

Metastasis of unknown origin (MUO) is a diagnostic challenge in clinical practice even with the state of current advanced diagnostic technology. To evaluate the value of autopsy in determining the primary site of MUO, this study reviewed the Hamilton experience-over the last 20 years-with patients autopsied with clinical diagnosis of MUO. All autopsy diagnoses from cases performed at the Hamilton Health Sciences Center and St Joseph's Healthcare from 1980 to 2000 were reviewed. Fifty-three cases of MUO were identified (MUO was defined as a patient with pathological and/or radiological diagnosis of a metastatic tumor for which the primary site of malignancy was unknown). The clinical history and gross and microscopic diagnoses for these cases were reviewed. There were 31 men (58.5%) and 22 women (41.5%) in the study. Their mean age was 66 years. Pathological diagnoses at autopsy were adenocarcinoma (n = 37), small cell carcinoma (n = 6), anaplastic carcinoma (n = 3), and undifferentiated carcinoma (n = 3). Primary tumors were identified in 27 patients (51%), most commonly in the lung (n = 8), large bowel (n = 6), and pancreas (n = 4). Histochemical and immunohistochemical stains were helpful in reaching the diagnosis of a primary tumor in 4 of 27 cases. The following were observed: (1) in this series, autopsy was helpful in establishing the diagnosis of a primary tumor in 51% of the cases, reaffirming the value of postmortem examination in these instances; (2) adenocarcinoma was the most frequent tumor presenting as MUO; (3) the lung and the large bowel were the most frequent sites for primary tumors; and (4) careful gross and histological examinations remain the most important tools in identifying the primary site.

Desmoplastic Melanoma as a Diagnostic Pitfall.

Dear Editor, Desmoplastic melanoma (DM) is a rare histological subtype of melanoma, usually presenting as a slowly-growing, amelanotic, discoid, and/or firm lesion composed of spindle cells with abundant collagen (1). It is more common on sun-exposed areas, especially on head and neck in elderly patients (2). Regional lymph node involvement is reported to be less frequent than in other cutaneous melanomas (3). Desmoplastic melanoma can clinically mimic a wide spectrum of benign and malignant lesions, including Bowen's disease, desmoplastic nevus, basal cell carcinoma, squamous cell carcinoma, lentigo maligna, dermatofibrosarcoma protuberans, peripheral nerve sheath tumors, cysts, or hypertrophic/keloid scars (4). Regarding its appearance, at the time of diagnosis DM frequently presents as advanced lesions with deep infiltration. A 60-year-old man presented with an one-year history of an asymptomatic, erythematous, well-defined plaque in the right lumbar region (Figure 1). Dermatological examination revealed a 5×5 cm, pink/red infiltrated plaque accompanied by a 6 mm dark-brown melanocytic lesion. Dermoscopically, atypical vascular structures in the form of linear, irregular, and dotted vessels, milky-red areas, and atypical pigment network, and streaks were observed near the melanocytic lesion (Figure 2). A 4 mm punch biopsy was performed on the erythematous plaque next to the melanocytic lesion, and a dermal-based, paucicellular proliferation of atypical spindle cells without melanin in a sclerotic stroma was found histologically (Figure 3, a). Immunohistochemically, dermal spindle cells were stained with S-100 and HMB45 antibodies (Figure 3, b). The patient was histologically diagnosed with melanoma, of the desmoplastic subtype. The lesion was totally excised with 2 cm clear margins. A diagnosis of nonulcerated nodular melanoma with a Breslow thickness of 4 mm and a mitotic index 1/mm2 was established. Sentinel lymph node biopsy revealed no metastases. No systemic metastases were detected in PET-CT scanning and cranial magnetic resonance imaging. The patient remained under follow-up and has been free of any local recurrence or primary or systemic metastasis for 3 years. Dermoscopic characteristics of DM are not well known, probably due to it not being considered a melanocytic lesion. Debarbieux et al. first reported the dermoscopic features of desmoplastic melanoma in six cases (5). They found that only half of the cases presented one classical feature of a melanocytic lesion, whereas the other cases were diagnosed based on the presence of figures of regression such as white scar-like and "peppering", multiple (>4) color, and melanoma-related vascular patterns (five out of six) such as linear-irregular vessels and milky-red areas (5). In the largest DM case series, Jaime et al. reported that all DM featured at least 1 melanoma-specific structure, with atypical vascular structures being the most common (6). Similarly, in our patient dermoscopy showed an atypical pigment network and streaks, atypical vascular structures, and milky-red areas, which is predictive for melanoma. We reported this case to serve as a reminder to consider desmoplastic melanoma in the differential diagnosis of pink tumoral lesions despite its rarity and atypical localization.

[Prevalence, rate of correct clinical diagnosis and mortality of cancer in 4,894 elderly autopsy cases].

The prevalence, rate of correct clinical diagnosis and mortality of cancer were analyzed in 4,894 consecutive autopsies at the Tokyo Metropolitan Geriatric Hospital from 1972 to 1990. average age and standard deviation of patients was 78.1 +/- 9.1 years. Cancer was found in 45.5% of patients of 60 years and over, and in 49.1% in men and 41.9% in women (p < 0.001). Cancer prevalence decreased with advance in age; 50.0% in the sixties, 47.9% in the seventies, 43.2% in the eighties and 39.3% in the nineties and over. Multiple cancer was found in approximately 12% of patients of 70 years and over. The top three cancer incidences were gastric cancer, 15.0%, lung cancer, 10.7% and colon cancer, 5.9% in both genders. In men, prostate cancer was next common, followed in orderly hepatic cancer, esophageal cancer, gall bladder-bile duct cancer, pancreas cancer, renal cancer and urinary bladder cancer. In women, the following order of frequency was gall bladder-bile duct cancer, uterus cancer, pancreas cancer, hepatic cancer, breast cancer, thyroid cancer, esophageal cancer, renal cancer and urinary bladder cancer. The prevalence of gastric cancer, lung cancer, hepatic cancer and esophageal cancer was significantly higher in men, while that of gall bladder-bile duct cancer was higher in women. The age-related tendencies varied among cancers of different organs. Gastric cancer increased up to the sixties in men and up to the seventies in women and leveled off after those ages. Lung cancer revealed peak prevalence in the sixties and seventies and decreased after the age of eighty.(ABSTRACT TRUNCATED AT 250 WORDS)

[A Case of Synchronous Multiple Metastases in which the Origin Could Not Be Identified by Routine Examination].

A 67-year-old man presented at our hospital with severe edema on the left side of his neck, chest and brachial regions. He had a history of right radical nephrectomy due to renal cell carcinoma (RCC, clear cell subtype, stage II) 15 years earlier. Thereafter, metastases to the pancreatic tail and right lung, and left lung metastasis were removed at 8 years and 11 years, respectively, after the nephrectomy. Four years earlier, he had also undergone total gastrectomy for gastric carcinoma (poorly differentiated adenocarcinoma, stage IV) and subsequent maintenance chemotherapy for gastric carcinoma. Follow-up computed tomography (CT) disclosed bilateral lung metastases and a pancreatic head metastasis. Cytology of pleural effusion on admission suggested pleuritis carcinomatosa from RCC. Clinical diagnosis was bilateral lung and pancreatic head metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to RCC metastasis. Maintenance chemotherapy for gastric carcinoma was replaced by Sunitinib 50 mg for RCC but he died of progressive disease 20 days later. Immunohistochemical study of the tissue from autopsy revealed lung metastasis and pancreatic head metastasis from both RCC and gastric carcinoma as well as multiple visceral metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to gastric carcinoma. Cause of death was acute respiratory failure due to pulmonary tumor embolism and pulmonary edema. Immunohistochemical study from autopsy was able to reveal the exact diagnosis, and immunohistochemical studies may be helpful in diagnosing the exact origin of metastasis and selecting appropriate treatmentsin patientswith multiple cancers.

A case report of primary signet ring cell carcinoma of the lung: imaging study and literature review.

Signet ring cell carcinoma (SRCC) is a subtype of adenocarcinoma with characteristics of strong invasion and a poor prognosis. While it can occur in various organs, including the stomach, colon, esophagus, bladder, prostate, pancreas, and breast, primary lung SRCC is rare, and most SRCC found there are from gastrointestinal metastasis. Reports on primary lung SRCC are few and the aim of this study is to describe the imaging, histopathological, and immunohistochemical characteristics of a case of primary lung SRCC in our hospital. A 68-year-old female with no smoking history was admitted with recurrent cough, chest pain, and dyspnea of 2 months duration. Computed tomographic (CT) chest showed multiple solids nodules of different sizes and mass in the left upper lobe, lower lobe, and subpleural region. Multiple enlarged lymph nodes were seen in the mediastinum and left hilum. The aim of this paper is to improve the understanding of this tumor. A literature review identified 15 cases of primary lung SRCC with available CT imaging. Except for two patients with multiple ground glass nodules and multiple small nodules, the rest were solid, and ranged in size from 1.0 to 8 cm. Only one patient had a cavity in the solid lesion. Immunohistochemical stains for thyroid transcription factor-1 (TTF-1) (13/13) and CK7 (12/12) showed positive reaction in all cases evaluated, and napsin A (3/4) were also positive, while all cases including CK20 (12/12) and CDX2 (6/6) were negative.

Multiple polypoid colonic metastases from rectal adenocarcinoma with signet ring cells features: a case report.

Multiple polypoid colonic metastases are very rare which mainly originated from gastric carcinoma or melanoma. For rectal cancers, liver, lung and peritoneum are the most common metastatic sites. Here we present an unusual case with rectal adenocarcinoma and metachronous multiple colonic polypoid metastases. A 53-year-old man who underwent radical resection for rectal cancer 2 years ago was admitted to our department for an elevation of CEA level of 18.4 ng/ml. Colonoscopy revealed ten ivory rubbery colonic polypoid lesions (about 5 mm in diameters) in the large bowel which were confirmed as signet ring cell carcinomas (SRCC) by biopsy, but full-body contrast enhanced CT and PET-CT showed no other suspicious lesion. Seven weeks later, a laparoscopic total colectomy was performed and more than 50 polypoid lesions were observed throughout the mucosal surface of the large intestine which were confirmed as metastatic SRCC by postoperative pathological examination. All the 34 paracolic lymph nodes retrieved were involved. After 4 months, diffuse abdominopelvic and multiple bone metastases were identified by CT and the patient died of the disease 1 month later. Here we present an unusual case of multiple colonic polypoid metastases of rectal adenocarcinoma. For SRCC that is prone to have disseminated micrometastases, colonic 'polyps' may be the early noticeable sign of undetectable and extensive tumor spread. Instead of surgical resection of 'the confined disease in colon', systemic treatment maybe a more appropriate choice.

Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy.

We carried out a prospective study of the effectiveness of a diagnostic strategy in forty consecutively seen patients who had skeletal metastases of unknown origin. The diagnostic strategy consisted of the recording of a medical history; physical examination; routine laboratory analysis; plain radiography of the involved bone and the chest; whole-body technetium-99m-phosphonate bone scintigraphy; and computed tomography of the chest, abdomen, and pelvis. After this evaluation, a biopsy of the most accessible osseous lesion was done. The laboratory values were non-specific in all patients. The history and physical examination revealed the occult primary site of the malignant tumor in three patients (8 per cent): one patient who had carcinoma of the breast; one, of the kidney; and one, of the bladder. Plain radiographs of the chest established the diagnosis of carcinoma of the lung in seventeen patients (43 per cent). Computed tomography of the chest identified an additional six primary carcinomas of the lung (15 per cent). Computed tomography of the abdomen and pelvis established the diagnosis in five patients (13 per cent): three patients who had carcinoma of the kidney; one, carcinoma of the liver; and one, carcinoma of the colon. Examination of the biopsy tissue established the diagnosis in only three additional patients (8 per cent) and confirmed it in eleven others. On the basis of the biopsy alone, we were unable to identify the primary site of the malignant tumor in twenty-six (65 per cent) of the patients. In thirty-four (85 per cent) of the forty patients, the primary site was identified with the use of the diagnostic strategy described here, and only two additional occult malignant tumors were found on follow-up studies. Our diagnostic strategy was simple and highly successful for the identification of the site of an occult malignant tumor before biopsy in patients who had skeletal metastases of unknown origin.

Assessment of Cost-Effectiveness of Computerized Cranial Tomography in Children with Mild Head Trauma.

Pediatric head traumas constitute the majority of admissions to emergency departments (ED) due to trauma. This study aims to draw attention to the use of cranial computerized tomography (CT) scans in the evaluation of children with head trauma under the age of 18, and to determine CT scans' usefulness in terms of cost-effectiveness. Age, gender, mechanism of trauma and Glasgow Coma Scale (GCS), diagnosis, time of admission to hospital, hospitalization and operation, cranial computerized tomography and hospitalization costs of all cases were retrospectively analyzed. A total of 26,412 patients younger than 18 years old who were admitted to the emergency department due to head trauma and who had a cranial tomography were analyzed. They had a mean age of 7.74 ± 5.66 years. In total, 26,363 (99.8%) of these patients had a GCS greater than 14. Out of these patients, only 402 (1.5%) had brain injury revealed by cranial CT, 41 (0.2%) of these patients were operated and 3 of the patients lost their lives. The total cost of patients admitted to the emergency department with a head injury amounts to USD 583,317. Furthermore, 75.78% of this cost comes from negative cranial CTs. A cost analysis according to different age groups did not show a meaningful difference between 0-2 years and 3-5 years (<ip</i = 1.000), but there was a meaningful difference for all the other age groups. Our findings show that applying algorithms to predict traumatic brain injury in children with mild head injury rather than scanning all patients with cranial CT will enable more reliable and cost-effective patient care. Current practices should be reviewed to avoid unnecessary radiation exposure and expense in the ED. It is also necessary to inform and educate parents about the risk/benefit ratio of cranial CT scans.

Characteristics of lung cancer after a previous malignancy.

In the era of improving overall survival rates of malignant diseases, the impact of a previous malignancy (PM) on treatment and outcome of lung cancer (LC) remains unclear. We reviewed all LC patients from our institution that were treated from 2004 to 2006 for the occurrence of LC with PM excluding patients with multiple primary LC. A total of 444 and 2698 LC patients with and without a history of a PM were identified (prevalence of 14.1%). PM were most often located in breast (15.5%), prostate (14.9%), bladder (9.0%) and kidney (8.8%). Compared to never smokers, patients with nicotine consumption had more often a cancer history of prostate, gastrointestinal, and the head-neck region. The median interval until diagnosis of LC was 72.2 months (range 0-537 months) with most LC diagnosed 5 years after PM diagnosis. With a similar distribution of histology, stage and localization compared to controls, NSCLC patients with PM and stage IV disease showed a favorable overall survival (p < 0.0001). In contrast, SCLC patients had similar survival curves (n.s.). A considerable subgroup of LC patients has a history of PM that may indicate a favorable prognostic factor. However, these patients should be treated similar to other LC patients.

Sister Mary Joseph's nodule as a presenting sign of internal malignancy.

CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I.

[Bronchopulmonary adenocarcinomas of apparently primary origin. A retrospective study of sixty-six patients (author's transl)].

A retrospective study of sixty-six case-reports confirmed the traditional factors described in this histological type of cancer, particularly the age, a slight predominence of males, and the very poor prognosis. A selection was made of 42 cases in which extensive investigations had been carried out to search for a possible extrapulmonary primary adenocarcinoma, but only one case of renal cancer and one of thyroid cancer were demonstrated. Autopsy had revealed the presence of 3 prostatic lesions and their relation to the pulmonary affection is discussed. Thyroid cancer had been found in 2 cases, which emphasizes the value of scintigraphy for this organ, whereas the authors felt that other investigations were of no value in the absence of clinically oriented signs.

Inflammatory myofibroblastic tumor of urinary bladder with severe hematuria: A Case report and literature review.

Inflammatory myofibroblastic tumor (IMT) is a rare intermediate soft tissue tumor. Rarely occurring in the urinary bladder, MTs is composed of myofibroblast differentiated spindle cells and accompanied by numerous inflammatory cells, plasma cells and/or Lymphocytes. A 28-year-old female, with history of 2 cesarean sections 8 years ago and 2 years ago, was admitted to the emergency department for a 7-day ongoing gross hematuria with clots. A cystoscopy showed a tumor near the bladder neck, computed tomography (CT) showed a mass and massive blood clots in the bladder. Finally, postoperative pathological examination confirmed a diagnosis of inflammatory myofibroblastic tumor of bladder. The patient was given rehydration and blood transfusion to improve the general condition. Then, emergency transurethral resection of the bladder tumor was performed. No metastases to lymph nodes and other organs were found, and no tumor progression was revealed during 3-months of follow-up. IMTs rarely occur in the urinary bladder. Due to the lack of specificity in clinical symptoms, it's difficult to arrive at a definite diagnosis before operation. Therefore, usually, the final diagnosis depends on histomorphological features and the immunohistochemical profile. Further case studies are required to study the biological behavior of this condition.

Prostate sarcoma: report of 2 cases and bibliographic review.

To report two cases of prostate sarcoma and perform a review of the published literature. The first case is a 21 year old patient who presented acute urine retention and lung metastases on diagnosis. He was diagnosed by TURP of rhabdomyosarcoma of the prostate dying 1 month after surgery. The second case was a 33 years old male who presented to the emergency room with anal pain, urinary symptoms, hematochezia and loss of 20 kg over the past 3 months. Abdominal CT scan showed an 11 x 10 x 9 cm mass in the lower pelvis that infiltrated the bladder and rectum, being unable to define its origin. CA 19.9, CEA and PSA were normal. The suspected diagnosis was a prostate sarcoma infiltrating rectum and bladder. A pelvic exenteration was performed with a wet colostomy. The pathologic diagnosis was a high grade sarcoma not clearly identified of the prostate. He was treated with adriamycin as adjuvant chemotherapy, having local recurrence, nodal involvement and multiple pulmonary metastases after 3 months of follow up Prostate sarcomas are rare tumors. This makes difficult to know their natural history. Their rapid progression and systemic spread, despite multimodal treatment, gives a mean survival of 24 months. Main survival factors are grade, a complete resection of the tumor and a low local stage. There is a need to find new chemotherapy protocols to increase survival rates as it has been shown in extremities sarcomas.

Are patients with non-muscle-invasive bladder cancer a suitable population for a lung cancer screening trial?

Prognosis (case series) Level of Evidence 4. To estimate the relative risk of developing a second primary neoplasm, in particular lung cancer, after having non-muscle-invasive bladder cancer (NMIBC). Patients were included in the study if they had developed NMIBC between 1995 and 2003. All clinical data were extracted from the medical records of our institution's database. The interval between neoplasms, smoking habits, histological subtypes and survival were also analysed. Patient follow-up was >or=5 years. We found 231 patients with NMIBC, 39 of which had a second primary neoplasm: 10 lung cancer, one pancreas, one gastric, one pharynx, one liver, one parathyroid, one oesophageal, five basal cell carcinoma, three larynx, two colon, three rectal and 10 prostate. In patients with lung cancer, NMIBC was the first primary tumour. Overall, the median (range) interval between occurrence of NMIBC and lung cancer was 54.2 (8-168) months. For the relationship between the observed and expected cases of lung cancer, after normalizing our frequencies to the sex ratio and age of our group of patients, the risk of lung cancer was 10.27-fold higher in patients with NMIBC as compared with the general population of Catalonia (95% confidence interval 4.92-18.88). We consider that an annual examination for the detection and prevention of lung cancer must be included in clinical guides for patients with NMIBC. This proposal is reinforced by the finding that death in our group of patients with both tumours was always derived from lung cancer and not from bladder cancer.

A Rare Case of Thyroid Metastasis Secondary to Hidden Undiagnosed Lung Adenocarcinoma.

The majority of thyroid lesions are primary in origin while secondary metastases to thyroid are considered a rare incidence. However, presentation of such cases with no signs of lung cancer can be extremely challenging to diagnose. Here, we present a 64-year-old man, an ex-smoker of 70 pack-years, who presented with a complaint of hoarseness of voice with associated dyspnea, choking episodes, weight loss, and hemoptysis. With no investigation abnormalities indicating lung adenocarcinoma, he was transferred to the Otolaryngology Department as being suspicious of thyroid cancer. A laryngoscopy demonstrated an immobile right vocal cord and pooling of secretions while a computed tomography (CT) scan showed a right thyroid lobe nodule, upper mediastinal lymphadenopathy, and pleural effusion. The patient underwent a total thyroidectomy. Biopsies from the lymph nodes and lung were obtained, and all demonstrated lung adenocarcinoma. Thus, a diagnosis of primary lung adenocarcinoma with thyroid and mediastinal lymph nodes metastases was established. Despite being a rare clinical presentation, thyroid metastasis should be considered and evaluated for a primary origin according to the associated clinical history and presentation.

[Adenocarcinomas of unknown origin. Study of 17 autopsies (author's transl)].

This article reports on the autopsy results of 17 patients with adenocarcinomas from occult primary tumours: 10 are of bronchial origin, 3 of renal origin, 1 of hepatic origin, 1 of ovarian origin, and 1 of pancreatic or bronchial origin. In one case no primary tumour was found. Factors which can lead the clinicians toward further investigations are the location or nature of the first clinical signs (neurological and respiratory for bronchial cancers, subdiaphragmatic for primary abdominal tumours) and smoking habit (bronchial carcinoma in smokers).

Stroke Mimic Caused by Acetazolamide.

To describe a case of a stroke mimic caused by iatrogenic ataxia due to acetazolamide. An 86-year-old man with a history of gout and glaucoma, presented to the emergency department with progressive confusion, dizziness, disequilibrium and slurred speech, 3 days after he had started acetazolamide following ocular surgery. Physical examination showed he was hypertensive and had dysarthria; it was not possible to observe his gait due to pain in the right foot presumed to be due to a gout crisis. A stroke was thought to be the cause of these neurological deficits so a head CT scan was performed but did not show any alterations. During a stay in the stroke unit the neurological deficits remained unchanged and so, after review of the history, neurological side effects due to acetazolamide were suspected and the drug was suspended. A head MRI was performed to rule out stroke and the patient gradually improved. In the meanwhile, the patient was observed by an ophthalmologist and repeat surgery was proposed because of increased intraocular pressure. Neurological deficits with a normal head CT scan in the emergency department pose many difficulties and require extensive knowledge of brain vascular anatomy and the differential diagnoses for stroke. Not all focal neurological deficits are strokes.The need to diagnose stroke very quickly in order that effective treatment can be started can obscure the actual diagnosis so the differential diagnoses should always be carefully considered.Even though the sudden onset of focal neurological deficits suggests a stroke, a careful history should indicate the correct diagnosis.

Multiple and incidentally found cancers detected by 18F-FDG positron emission tomography/CT at one examination.

During the initial 8 months period of 18F-FDG PET/CT examination in our institution eleven cases of double cancers were detected. Eight cases were simultaneous second cancers and 3 cases are consecutive cancers. All cases are clinical ones and were referred from both outside hospitals and our own hospital. 18F-FDG PET/CT examination were utilized either to determine the extent of tumor or to stage the cancer or to detect recurrent tumors during the follow-up period. During the 8-months period 964 cases were studied. Therefore, the detection rates of simultaneous and consecutive cancers are 0.83% and 0.31% respectively. All together the detection rate of double cancer was 1.14%. To gain the general conception of double cancers the authors reviewed the autopsy registry of Japanese Society of Pathology during the four years from 2000 through 2003, and tabulated the combination of primary and second cancers. Frequently found combination of cancers were cancers of the thyroid, lung, stomach, liver, biliary tract, colon, rectum, and prostate. 18F-FDG PET/CT examination seems to be very useful in the management of cancer patients in terms of whole patient care.