SESSION TYPE: Cancer Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Leiomyosarcoma is a rare malignancy which responds poorly to systemic chemotherapy and radiation. Dew, et al. demonstrated a 5 year survival rate of 31% after surgical resection of the primary tumor. We present a 48 yo patient with leiomyosarcoma metastases to the lung treated with transpulmonary chemoembolization (TPCE).

CASE PRESENTATION:

A 48 year old man presented with lower extremity edema and was diagnosed with leiomyosarcoma of the IVC. After surgical resection of the primary tumor and systemic chemotherapy and radiation, the patient developed lung and liver metastasis not amenable to surgical resection. His liver metastases are well controlled with transarterial chemoembolization. His lung metastases continue to progress despite systemic chemotherapy. He has undergone two treatments of segmental TPCE using doxorubicin beads (image 1). He had minimal fatigue the week after the second procedure. He had no other systemic side effects such as nausea, vomitting, or mucositis. He has no worsening cough or chest pain related to embolization of the pulmonary artery. Image 2 demonsrates post-procedural appearance of his left lung. He will undergo further TPCE for continued treatment.

DISCUSSION:

Leiomyosarcoma of the IVC is a rare malignancy with less than 300 cases reported. Our patient in this study has disease recurrence to the lungs and liver after primary surgical resection and systemic chemotherapy administration. Given the poor response of leiomyosarcoma to chemotherapy and radiation, alternate therapies were considered to treat his nonresectable pulmonary disease. Vogl, et al. performed a study from 2001-2005 demonstrating the use of TPCE for pulmonary metastatic disease in 52 patients. 27 of the 52 cases demonstrated partial response or stable disease and all patients had minimal side effects from the procedure. Our patient has undergone 2 treatments of TPCE for his pulmonary disease. The patient has experienced no significant side effects from the embolization or local chemotherapy administration; he has had no complications since his initial treatment approximately 45 days ago.

CONCLUSIONS:

TPCE is a promising treatment option for patients with unresectable pulmonary metastatic disease. Our patient has had no significant complications or side effects after treatment. Although no conclusions can be drawn on one case, the lack of significant side effects after local doxorubicin administration suggests that further research is warranted using TPCE as a tolerable treatment for nonresectable pulmonary metastatic disease.1) J. Dew, K. Hansen, J. Hammon, T. McCoy, E. A. Levine, and P. Shen, "Leiomyosarcoma of the inferior vena cava: surgical management and clinical results," American Surgeon, vol. 71, no. 6, pp. 497-501, 2005.2) Vogl TJ, Lehnert T, Zangos S, Eichler K, Hammerstingl R, Korkusuz H, Lindemayr S. Transpulmonary chemoembolization (TPCE) as a treatment for unresectable lung metastases. Eur Radiol. 2008;18:2449-2455.DISCLOSURE: The following authors have nothing to disclose: Andrew West, Drew Sessions, Mollie MeekTranspulmonary Chemoembolization of pulmonary metastases is a procedure that has been rarely reported in literature. It is still likely considered a research procedure/technique. This will not discuss any products used.UAMS, Little Rock, AR.

IMPORTANCE Ablative therapies extend the capability of delivering potentially curative treatment for bilateral hepatic colorectal metastases.

OBJECTIVE

To compare the long-term effectiveness of ablation with that of resection in patients with bilateral hepatic colorectal metastases. DESIGN Review of a prospective database of 2123 operative cases of hepatic colorectal metastases. SETTING A large institution with expertise in ablation and resection. PATIENTS Patients with bilateral colorectal liver metastases undergoing operation with a curative intent. A total of 141 patients had been treated with bilateral resection (BR) and 95 had undergone ablation. INTERVENTIONS Radiofrequency or microwave ablation alone or in combination with resection (A/R) compared with BR. MAIN OUTCOMES AND MEASURES We compared tumor characteristics and operative and postoperative outcomes using χ2 or Wilcoxon tests as appropriate and assessed overall survival differences between the 2 groups using the log-rank test.

RESULTS

During the study, 141 patients were treated with BR and 95 patients with A/R. The A/R group was a significantly poorer prognostic group than the BR group as judged by the Clinical Risk Score (P < .01). There was no difference in median operative time (A/R: 280 minutes, BR: 282 minutes; P = .52), but a lower blood loss (A/R: 300 mL, BR: 500 mL; P < .01) and a shorter length of stay (A/R: 7 days, BR: 9 days; P < .01) was achieved in the A/R group. Long-term outcome was not significantly different between the groups (5-year overall survival, A/R: 56%, BR: 49%; P = .16).

CONCLUSIONS

AND RELEVANCE Treatment of bilateral, multiple hepatic metastases with combined resection and ablation was associated with improved perioperative outcomes without compromising long-term survival compared with bilateral resection. Ablative therapies extend the capability of delivering potentially curative treatment for bilateral hepatic colorectal metastases.

SESSION TYPE: Cancer Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Malignant neoplasms are the third leading cause of mortality in the Philippines. Lung cancer is the leading cause of cancer-related mortality throughout the world. However, there are variants to this disease that are rarely seen. Presented is a case of a 75 year old male who was diagnosed with pulmonary sarcomatoid carcinoma at the Philippine Heart Center.

CASE PRESENTATION:

A 75 year old male, heavy smoker, presented 6 months prior with non-productive cough, chest x-ray showed a nodule on the left upper lobe. Persistence of cough, associated with anorexia and weight loss prompted consult. Upon admission, chest x-ray showed a mass on the left upper lobe. Chest CT scan with contrast was done which revealed a left upper lobe mass with surrounding lymphangitic spread and nodules on the left hilar and right lower lobe. Consideration was malignancy. CT guided fine needle aspiration biopsy of the left upper lobe mass was done. Metastatic work-ups were requested. Cranial CT scan showed enhancing nodules in the subcortical and cortical region of the left frontal lobe. Whole abdominal CT scan revealed enhancing nodules in the liver, bilateral adrenal glands, bilateral subcutaneous abdominal wall, and left gluteal region, also indicative of metastasis. Histopathologic findings were cytomorphologic features and immunohistochemical profile consistent with Sarcomatoid Carcinoma, of Lung Primary. Patient was diagnosed as stage IV disease and palliative treatment was recommended. Patient underwent whole brain radiation therapy and was started on chemotherapy with Gemcitabine then discharged.

DISCUSSION:

Pulmonary sarcomatoid carcinomas are poorly differentiated non-small cell carcinomas that contain at least 10% of sarcoma or sarcoma-like elements. These tumors are believed to arise from epithelial to mesenchymal transition of cells and and represent only 0.1% to 0.4% of all cases of non-small cell lung cancer. There is no record of a previous case of sarcomatoid carcinoma in our center. Average age of diagnosis for these patients is about 60 years of age, with a male preponderance of 4:1. The disease is noted to be more prevalent in patients with history of smoking. It is said to present more commonly as a mass in the upper lobes, as was noted in our patient. Median size is 4.5 cms, but diameters of up to 19 cms have been noted. They can invade adjacent structures by forming large necrotic and hemorrhagic masses and can metastasize to conventional sites such as the brain bone adrenals and liver, but may also include unusual locations such as the skin, as noted in our patient, as well as the esophagus, stomach, pancreas and heart. Treatment of localized disease relies on surgical resection, with adjuvant chemotherapy and radiation for patients with bulky tumors, or nodal involvement. Those with stage III or stage IV sarcomatoid carcinomas are managed non-operatively and given palliative treatment. However, cases show consistent poor response to systemic chemotherapy. These patients are said to have poorer prognosis compared with conventional NSCLCs, with a 5-year survival of only 24.5% versus 46.5% for other NSCLC. Future goals may be to target the epithelial mesenchymal transition pathways of these sarcomatoid carcinomas to eliminate surviving cancer cells in order to prevent recurrence and improve survival.

CONCLUSIONS:

Pulmonary sarcomatoid carcinoma is a rare variant of non-small cell lung carcinoma, seen to have a sarcomatoid component. It commonly presents as advanced disease, and combined with aggressive metastases, as well as poor response to conventional chemotherapeutic agents, makes it a uniquely lethal disease and thus leads to poorer outcomes in our patients. Our only hope is to better understand the epithelial-mesenchymal transition pathways of these cancer cells and hopefully develop targeted therapies, that will improve the survival for these patients.1) L. Martin, et al. Sarcomatoid Carcinoma of the Lung: A Predictor of Poor Prognosis. Ann Thorac Surgery. 2007;84:973-980.2) Pelosi G, et al. Pleomorphic carcinomas of the lung show a selective distribution of gene products involved in cell differentiation, cell cycle control, tumor growth, and tumor cell motility: a clinicopathologic and immunohistochemical study of 31 cases. Am J Surg Pathol 2003;27:1203-15.3) Vibha T. Thomas, Stacy Hinson and Kartik Konduri. Epithelial - mesenchymal transition in pulmonary carcinosarcoma. Therapeutic Advances in Medical Oncology. 2012 4: 31.DISCLOSURE: The following authors have nothing to disclose: Jessamine Dacanay, Fernando AyuyaoNo Product/Research Disclosure InformationPhilippine Heart Center, Quezon, Philippines.

SESSION TYPE: Cancer Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

The incidence of solid organ cancer with metastasis to bones of the digits (acrometastasis) is exceedingly rare, occurring in only 0.1% of cases with osseous involvement. We describe a 52 year-old female who was found to have metastatic lung adenocarcinoma with acrometastasis during evaluation of left thumb pain.

CASE PRESENTATION:

A 52 year-old female with history of migraines and 20 pack-year smoking was evaluated by orthopedics for left thumb swelling, pain, and absent flexion, and determined to have a trigger finger. Hand radiographs revealed no osseous abnormalities. She received a flexor sheath injection of corticosteroids, with subsequent improvement in pain and range of motion. However, 6 weeks later she developed new thumb erythema, relapse of symptoms, and a palpable mass. Surgical exploration revealed complete destruction of the proximal phalanx and no viable bone remaining. Histologic evaluation of the mass revealed a poorly differentiated adenocarcinoma, suggestive of a primary lung tumor by immunohistochemical staining. Survey imaging with CT chest revealed a large left upper lobe mass, extensive adenopathy of the mediastinum and left hilum, and suggestion of lymphangitic carcinomatosis. Additionally, PET imaging illustrated widespread disease, with involvement of the brain, adrenal glands, pelvis, and spine.

DISCUSSION:

Bony metastases are common and frequently occur from a wide array of primary tumors, including lung, prostate, kidney, breast, and gastrointestinal. However, bones of the hand rarely harbor metastatic disease, accounting for only 0.1% of metastatic osseous involvement. Acrometastasis was first identified in 1906 in a female with breast cancer and metastases to the metacarpals. The etiology of acrometastasis is almost exclusively a lung primary tumor, accounting for approximately 44% of all reported cases. The mechanism of spread to the digits is unknown, but hypotheses include increased blood flow and chemotaxis of prostaglandins during trauma. The high predilection towards a primary lung tumor among acrometastases is thought to be secondary to direct systemic arterial supply, whereas tumor emboli of other primary malignancies must first pass through capillary beds of the liver or the lung.

CONCLUSIONS:

Acrometastasis is a rare occurrence, and typically suggests concomitant widespread malignancy with poor prognosis. Our patient presented with thumb pain, and subsequent evaluation revealed metastatic lung adenocarcinoma. She died 6 weeks later. This emphasizes the importance of identifying non-benign causes of finger symptoms in a timely manner.1) Flynn CJ, et al. Two Cases of Acrometastasis to the Hands and Review of the Literature. Current Oncology 2008;15(5):51-58.DISCLOSURE: The following authors have nothing to disclose: David Ferraro, Pedro LuceroNo Product/Research Disclosure InformationSan Antonio Military Medical Center, Fort Sam Houston, TX.

SESSION TYPE: Cancer Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Non-small cell lung cancers (NSCLC) constitute between 85 to 90 % of all lung cancers; the rest 10 to 15 % are small cell lung cancers. Extrathoracic metastasis to brain, bones, liver, bone marrow, lymph nodes & adrenal glands is well known in case of non-small cell lung cancer (1).

CASE PRESENTATION:

A 56-year-old African American gentleman with no past medical history presented with complaint of constipation associated with progressively worsening left periumbilical pain and one episode of vomiting undigested food material. He reported decreased appetite and 15 pounds weight loss in last few months. He had 40 pack year history of smoking and occasional alcohol intake. On physical examination he was afebrile with stable vital signs, had mild tenderness in the left periumbilical location with no guarding or rigidity. CT scan of abdomen revealed a long segment of intussusception involving proximal jejunal loop in left hemiabdomen leading to proximal small bowel obstruction secondary to a submucosal mass. CT scan of the chest revealed severe emphysema with bullous changes and a 1.4 cm spiculated mass in left apex along with bilateral necrotic appearing hilar lymphadenopathy (Image 1). Patient underwent exploratory laparotomy during which the diseased part of small intestine (fungating, friable mass measuring 6.0 x 4.2 x 3.8 cms) and part of the attached mesentery (with multiple lymph nodes enlargement) were resected. Histopathology revealed poorly differentiated neoplasm and immunohistochemical markers (positive for CD34, cytokeratin & vimentin, negative for CD117, CK20) were consistent with a metastatic non-small cell carcinoma (Image 2). An MRI of the brain also revealed vasogenic edema with five enhancing lesions compatible with metastatic disease. Patient was started on palliative chemotherapy and radiotherapy (whole brain irradiation) and discharged from the hospital with outpatient follow ups.

DISCUSSION:

Intussusception is an "internal prolapse" of the bowel that leads to obstruction and compromise of mesenteric blood flow, with resultant inflammation and the potential for ischemia of the bowel wall (2). Surgical resection is recommended because of the high percentage of associated malignancy (3).

CONCLUSIONS:

Adult intussusception is rare accounting for 1 to 5% of bowel obstruction and commonly involves a distinct pathologic lead point, which is malignant in over half of the cases (3). Hence, adult patient with intussusception should be evaluated for underlying malignancy.1) Kuo CW et al. Non-small cell lung cancer in very young and very old patients. Chest 2000; 117:354.2) Marinis A et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009; 15:407.3) Nagorney DM et al. Surgical management of intussusception in the adult. Ann Surg 1981; 193:230.DISCLOSURE: The following authors have nothing to disclose: Vipin Mittal, Anish Shah, Arya Karki, Muhammad Ali, Amer Akmal, Walid BaddouraNo Product/Research Disclosure InformationSt Joseph's Regional Medical Center, Paterson, NJ.

SESSION TYPE: Pleural Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Temsirolimus is a novel highly specific inhibitor of the mammalian target of rapamycin (mTOR), a regulator of tumor cell growth and angiogenesis. It has demonstrated efficacy in both untreated and previously treated patients with advanced renal cell carcinoma (ARCC). Although temsirolimus has an overall acceptable safety profile, one of its most concerning adverse events is pulmonary toxicity traditionally manifested as pneumonitis. Furthermore, respiratory symptoms of any grade have been reported in up to half of treated patients.

CASE PRESENTATION:

We present the case of a 53 year-old man with a 5-year history of ARCC with metastases to the lung, liver, brain, omentum and retroperitoneum who had disease progression on multiple chemotherapeutic regimens. He was subsequently started on intravenous temsirolimus 25 mg once weekly. A routine surveillance chest CT done 8 weeks after the initiation of therapy showed new small bilateral pleural effusions. The patient was kept on temsirolimus as he was clinically stable but later developed a progressively worsening dyspnea. Another chest CT done 6 weeks after the previous one showed a new moderate free-flowing right pleural effusion and a new small loculated left pleural effusion with no evidence of pneumonitis. 1450 cc of serosanguinous fluid were removed during a right thoracentesis. Analysis of the fluid showed an exudate, with negative cultures and cytology. Temsirolimus was subsequently discontinued with significant clinical and radiographic improvement of both pleural effusions.

DISCUSSION:

Although pneumonitis has been reported in up to 36% of patients treated with temsirolimus, this is to our knowledge the second case report of temsirolimus-related pleural effusion and the first one involving a thoracentesis. The pleural effusion in our patient is very likely due to temsirolimus given the onset and resolution of the effusions and symptoms with the initiation and discontinuation of therapy, respectively. Moreover, other etiologies such as a parapneumonic effusion (negative pleural fluid cultures), malignant effusion (negative pleural fluid cytology) and subdiaphragmatic irritation due to metastatic liver disease (not temporally related to the effusion) are less likely. The mechanism of temsirolimus-induced pleural effusion is unclear but may involve an inflammatory process given the abundance of neutrophils (61%) in the removed pleural fluid.

CONCLUSIONS:

We have described a case of temsirolimus-related pleural effusion. Patients with an effusion and concurrent respiratory symptoms would benefit from discontinuation of the drug.1) Drug-related pneumonitis in patients with advanced renal cell carcinoma treated with temsirolimus. Maroto JP et al. J Clin Oncol. 2011 May 1;29(13):1750-6.2) Temsirolimus in renal cell carcinoma with sarcomatoid differentiation: a report of three cases. Areses MC et al. Med Oncol. 2011 May 11. [Epub ahead of print]DISCLOSURE: The following authors have nothing to disclose: Wassim Labaki, Eric AndersonNo Product/Research Disclosure InformationGeorgetown University Hospital, Washington, DC.

SESSION TYPE: Bronchology Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

We present a case of a middle aged woman with chronic cough who was found to have cavitating lung lesions on CT thorax. We describe the bronchoscopic techniques employed to clinch the diagnosis.

CASE PRESENTATION:

A 56-year-old Chinese housewife, previously healthy and a life-long non-smoker consulted her family physician for fever and prolonged cough productive of greenish sputum with occasional episodes of hemoptysis. She did not complain of dyspnea, chest discomfort, night sweats or weight loss. She was prescribed several courses of antibiotics and her chest radiograph showed several ill-defined nodular infiltrates over the right mid and lower lung zones. Pulmonary metastases were suspected and she was referred to Medical Oncology. CT thorax, abdomen and pelvis showed two thin walled cavities in the right lower lobe, one measuring 11 x 18 mm in size and the other measuring 16 x 26 mm. A tiny7 x 7 mm sized cavity was also seen in the right upper lobe in the periphery. Both lungs showed scattered tree in bud type of opacities in almost all lobes in a peripheral distribution. The inferior aspect of the lingula and the medial segment of the right middle lobe also revealed cicatrization bronchiectasis. She was hospitalized for further work up. She had low grade fever and her nutrition was fair. There were no clubbing of fingers or cervical lymphadenopathy, and examination of the abdomen, breasts and neurological system was unremarkable. Auscultation only revealed scattered crackles over the lower third of the right hemithorax. Complete blood count, urea and electrolytes, liver function and calcium level were normal. Three induced sputum samples for acid fast bacilli and TB molecular (GeneXpert test) were negative. Bronchoscopy with washing of the right middle lobe followed by bronchoscopic lung biopsy of the right lower lobe cavitatory nodule, aided by navigational bronchoscopy and radial endobronchial ultrasound (EBUS) was performed. Bronchoscopy revealed a normal tracheobronchial tree. Bronchial washing of the right middle lobe was sent for cytology, bacterial and mycobacterial cultures. The right laterobasal bronchial segment B9(a) leading to the largest cavitating lesion was accurately localized by navigational bronchoscopy and confirmed real time by EBUS radial probe and fluoroscopy. Bronchoscopic lung biopsies and brushing were performed using guide-sheath method. Histology of bronchoscopic lung biopsy showed an area of central caseous necrosis with positive Ziehl Neelson stain for numerous acid fast bacilli. No malignant cells were detected. Culture of lung tissue yielded Mycobacterium Kansasii, while the bronchial aspirate and induced sputum cultures were sterile. She was started on rifampicin, isoniazid and ethambutol, and her symptoms had completely resolved at the last clinic review.

DISCUSSION:

The combination of bronchoscopic techniques allows precise targeting of peripheral lung lesions, which would otherwise been traditionally approached via CT-guided transthoracic needle aspiration. This reduces the risk of pneumothorax, which is more common with the latter approach.

CONCLUSIONS:

In the last decade, there has been tremendous advances in bronchoscopic techniques to achieve higher yields for both central and peripheral lung lesions. Our case illustrates the strategy of combination techniques to arrive at the diagnosis.1) Hergott CA, Tremblay A. Clin Chest Med. 2010 Mar;31(1):49-6DISCLOSURE: The following authors have nothing to disclose: Melvin Tay, Kay Leong Khoo, Pyng LeeNo Product/Research Disclosure InformationNational University Hospital, Singapore, Singapore.

SESSION TYPE: Cancer Cases IPRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION:

Prostate is a rare site for Extra Pulmonary Small Cell Carcinoma (EPSCC). We report the first case of Tumor Lysis Syndrome (TLS) that developed in Prostatic EPSCC. This case was complicated by methemoglobinemia and severe hemolytic anemia after rasburicase (recombinant urate oxidase) use.

CASE PRESENTATION:

A 56-year-old African American with a metastatic small cell cancer of the prostate developed TLS within 2 day of initiation of chemotherapy. 15 days prior to admission, he had a biopsy of a 1.7 cm hypodense nodule in the left lobe of the prostate that demonstrated poorly-differentiated small cell cancer (immunostain negative for PSA and TTF-1, positive for chromogranin, synaptophysin and CD56). His Serum PSA was 6.1. Extensive metastases to pelvic lymph nodes, liver (despite advanced alcoholic liver cirrhosis), lumber spine and lungs were noted, all with significant uptake on PET CT. Despite intravenous hydration and steroids, his serum creatinine, phosphate and uric acid increased from normal to 4.0, 7.4 and 16 respectively. On day 5, he received a dose of rasburicase. After rasburicase, his uric acid and phosphorus started to decline. However he became tachycardiac, tachypneic and hypoxemic (oxygen saturation in mid-80s on room air). He was noted to have methemoglobinemia (5.9%) for which he was given a dose of methylene blue and was transferred to intensive care unit. His hemoglobin dropped from 13 to 6.6 gm/dl with peripheral smear demonstrating numerous bite cells. Bilirubin increased to 21, LDH peaked at 3234 (baseline 160), haptoglobin <30, absolute reticulocyte count and reticulocyte index peaked at 206 and 82.4, respectively. He received 11 units via red cell exchange transfusion. Patient condition was stabilized and he was transferred to floor with Hemoglobin of 13 g/dl, total bilirubin of 4.4, methemoglobin of 0.6 and creatinine of 4.0.

DISCUSSION:

TLS has not been reported in EPSCC of Prostate. This case highlights several important issues in prevention and treatment of TLS. Although our patient had normal baseline Creatinine, LDH and Uric Acid levels, he was at intermediate to high risk for developing TLS due to bulky tumor mass, extensive metastasis, urinary outflow-tract obstruction, high proliferative rate of malignant cells, chemo-sensitive malignancy and acidic urine. At risk patients should receive allopurinol or rasburicase prior to chemotherapy. Rasburicase treatment can induce hemolytic anemia in G6PD deficient cases but its routine measurement is not currently recommended. Methylene blue is not helpful in G6PD deficient cases and should not be used.

CONCLUSIONS:

: Tumor Lysis Syndrome should be anticipated and treated with cautions in high risk patients.1) Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med 2011; 364:1844-18542) Bauters T, Mondelaers V, Robays H, et al. Methemoglobinemia and hemolytic anemia after rasburicase administration in a child with leukemia. Int J Clin Pharm 2011; 33:58-6DISCLOSURE: The following authors have nothing to disclose: Sikander Zulqarnain, Terrence Bradley, Spiro DemitisNo Product/Research Disclosure InformationSUNY Downstate Medical Center, Brooklyn, NY.

SESSION TYPE: Cancer Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Lung cancer is the leading cause of cancer death in both male and female. Overall survival is around 15% at 5 years including all stages. The primary risk factor is smoking tobacco which accounts for 85% of all cancer-related deaths. Around 36% of patients are initially diagnosed as having stage IV disease, which includes most frequently liver (33%-40%), brain (15-43%), adrenal glands (18-38%) and bone (19-33%) metastases. Metastatic disease involving the gastrointestinal tract is uncommon being the small bowell the most common site. No cases of synchronous rectal and brain metastasis have been reported.

CASE PRESENTATION:

A 58 years old female was initially evaluated for presenting with left body hemiparesis. Brain MRI showed nodular cortical lesion in the temporoparietal area with cerebral edema. Surgical resection was then performed. CT of the chest revealed a lesion located in the right upper lobe which was biopsied. At the same time the patient developed hematochezia, sigmoidoscopy showed a lesion 5 cm. from the anal margin which was also biopsied. After neurosurgery treatment with phenytoin, dexametasone and whole brain radiation therapy was begun. The patient died 3 months later because of brain disease progression.

DISCUSSION:

Pathologic review revealed that the 3 lesions resected and/or biopsied were adenocarcinoma poorly differentiated with a immunohistochemisty profile that showed TTF1 (thyroid transcription factor) and CK 7 possitivity with CK 20, CDX-2 and thyroglobulin negativity. This immunohistochemisty profile lead to a diagnosis of primary lung adenocarcinoma with rectal and brain metastases.

CONCLUSIONS:

We report a rare case of synchronous rectal and brain metastasis from primary lung adenocarcinoma. Even though lung cancer metastases to the gastrointestinal tract are uncommon in the literature no rectal metastases have been described to date. In the case we present immunohistochemisty played an important role in defining the organ site of origin of the primary tumor.1) Schwartz AM, Henson DE; American College of Chest Physicians, Diagnostic surgical pathology in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):78S-93S.DISCLOSURE: The following authors have nothing to disclose: Pablo Romero, Carolina Barciocco, Mariano DiocaNo Product/Research Disclosure InformationInstituto Roffo, Buenos Aires, Argentina.