Direct Tumor Invasion Research Articles

Liver Stem/Progenitor Cells in the Canals of Hering: Cellular Origin of Hepatocellular Carcinoma with Bile Duct Tumor Thrombi?

It is generally believed that the invasion of hepatocellular carcinoma (HCC) into the biliary tree ultimately leads to the formation of bile duct tumor thrombi (BDTT). However, recent studies revealed that primary tumor might be small, even undetectable, and there was no histopathologic evidence of direct tumor invasion into bile duct wall in some patients. During the last decade, efforts on stem cell biology may shed light on the pathogenesis of BDTT. Presently, accumulating evidence supports the following notions: (1) the canals of Hering (CoH) are the most likely origin of liver stem/progenitor cells (LSPCs) in adult livers; (2) similar signalling pathways may regulate self-renewal in LSPCs and liver cancer cells, and a substantial proportion of liver tumors may often originate from the transformation of LSPCs; and (3) liver cancer contains rare cells with stem cell-like properties, which could derive from malignant transformation of LSPCs. Herein, we propose that HCC with BDTT, especially with small or undetectable primary lesion and/or no histopathologic evidence for bile duct invasion, might arise from LSPCs residing in the CoH and, possibly, some primary lesions are formed firstly within the intrahepatic biliary tree. When "tumor thrombi" extends mainly along bile duct, there might be "BDTT" alone; when it invades into surrounding parenchyma, there might often be small "primary tumor" with "BDTT". If this holds true, the putative type may be a particular subset of HCC, and most importantly it would facilitate our understanding of stem-cell origin of HCC.

Unusual Presentation of Urothelial Carcinoma of the Bladder With Noncontiguous Rectal and Diffuse Muscular Skeletal Metastases

AN 83-year-old man presented with frequent bowel movements and weight loss in the last 6 months. History was remarkable for hypertension and diabetes mellitus. Digital rectal examination revealed a tumor 3 cm from the anal verge, which was subsequently confirmed by rectoscopy. Biopsy revealed poorly differentiated carcinoma. The tumor cells stained strongly positive for CK7, weakly positive for CK20, and negative for CDX-2 and S-100. Therefore, primary adenocarcinoma of the colon was less likely and tumor growth of urothelial origin was suspected. Subsequent computerized tomography (CT) of the abdomen showed thickening of the right posterior wall of the bladder and noncontiguous circumferential thickening of the rectal wall (figs. 1 and 2). CT also revealed extensively infiltrative, strong enhancing lesions in multiple skeletal muscles, including bilateral psoas major, quadratus lumborum, iliacus, gluteus medius/minimus, obturator externus, quadratus femoris and adductor brevis/magnus. Cystoscopic biopsy of the bladder tumor confirmed high grade urothelial carcinoma. Ultrasound biopsy was performed for the skeletal muscle lesion and the result was consistent with metastatic urothelial carcinoma. The patient was treated with chemotherapy. Bladder urothelial carcinoma often metastasizes to regional lymph nodes, liver, lung and bone. The lower gastrointestinal tract is usually involved by direct tumor invasion. Noncontiguous rectal metastasis from urothelial carcinoma presenting as an annular rectal tumor is rare. 1 This case had concomitant diffuse skeletal muscle metastasis, which is an even rarer presentation of urothelial carcinoma. 2 Metastatic muscular lesions of urothelial carcinoma origin usually show low density and ring enhancement on CT. 3 However, in

Airway stent improves outcome in intubated oesophageal cancer patients: Table 1–

To the Editors: Advanced, unresectable oesophageal cancer with airway invasion has a very poor prognosis. For tumours extending into the airway lumen, the primary goals of therapy are for the palliative relief of the malignant obstruction of the oesophageal lumen and central airway and to close the fistula between the oesophagus and central airway. Palliative options include mechanical core-out, dilatation, laser ablation, electrocautery, cryotherapy, photodynamic therapy and brachytherapy 1, 2. However, satisfactory results may not be immediate or lasting. Endoscopic stenting is effective for airway stenosis from both extrinsic compression and direct tumour invasion, and has also been shown to be useful in the treatment of tracheo-oesophageal fistulas 3. …

A mimicker of acute myocardial infarction

In April, 2009, a 33-year-old man visited our emergency room complaining of sudden chest tightness, dyspnoea, left shoulder pain, and cold sweats while sleeping. He had intermittent chest discomfort, mild fever, and fl u-like symptoms about 1 month ago and had visited the outpatient clinic at that time. During the previous visit, his electrocardiogram (ECG) showed widespread borderline ST elevation over praecordial and inferior leads, but echocardiography showed no typical fi ndings of pericarditis. His medical history was otherwise unremarkable. On examination, blood pressure was 123/75 mmHg and heart rate was 70 beats per min. Compared with previous data, ECG showed progressive ST elevation, particularly over inferior leads. Chest radiography showed a mass superimposed over the left hilum. 3D echocardiography showed a large heterogeneous mass encroaching on the lateral aspect of the left ventricle and pulmonary artery (fi gure A). To exclude acute coronary syndrome, emergency coronary angiography was done, which showed patent vessels. CT of the chest showed a 7cm×5 cm×6 cm lobulated heterogeneous mass occupying the left anterior mediastinum adjacent to the pericardium with multifocal central-low density. Laboratory tests were all within normal range except for high concentratons of α-fetoprotein (13 ng/ml) and βHCG (57 mIU/ml). Thoracotomy showed direct tumour invasion from the mediastinum into the left lung, aorta, anterior chest wall, and main pulmonary arterial trunk. Excisional biopsy (fi gure B, C) confi rmed seminoma. We started bleomycin, etoposide, platinum (BEP) chemotherapy at the 20th day of hospitalisation. Follow-up echocardiogram 2-days later showed partial shrinkage of the tumour. ECG showed no more ST elevation. Six more courses of BEP chemotherapy were given from June to August, 2009. Follow-up chest CTs at 4 and 6 months after initial diagnosis showed no recurrent tumour. When seen in December, 2009, the patient was symptom-free and there was no evidence of recurrence. The mediastinum is the most common extragonadal primary site for germ cell tumours. The most common type of mediastinal germ cell tumour is mature teratoma, followed by seminoma, the latter accounting for most of the malignant subtypes (25–40%). Symptomatic patients can experience substernal chest pain, dyspnoea, weight loss, dysphagia, or fever. Tumour extension to the pericardium or mediastinum can produce pericardial eff usions along with changes on ECG. Although the radiology and pathology of primary cardiac tumours are well known, detailed understanding of extracardiac masses have mostly been limited to single case reports. The echocardiographic features of mediastinal tumours has been reveiwed, although there was no reference to germ cell tumours. Transthoracic and transoesophageal echocardiography are the mainstay in identifying mediastinal masses. A quick diagnosis by bedside echocardiography is crucial in emergency situations where the tumour causes compression or even pericardial tamponade. More complete imaging by CT or MRI is usually required. In cases of uncertain fi ndings, 3D echocardiography might be used to further identify the texture of the tumour and its association with adjacent structures. With advances in multidimensional echocardiographic imaging, visualisation of cardiovascular structure, function, and haemodynamics has greatly improved. Our patient had a primary mediastinal seminoma with extension to major cardiac structures. In our case, we successfully showed the detailed texture, character, and associations of the seminoma. Although treatable, therapeutic recommendations for this class of germ cell tumour are in constant evolution. Early diagnosis is paramount to long-term survival.

Primary lung cancer presenting as spontaneous pneumothorax

Pneumothorax is a rare manifestation of lung cancer. The mechanism by which pneumothorax occurs in lung cancer is not clear, and differing views have been expressed. Among 180 adults who presented with spontaneous pneumothorax from 1980 to 1992, eight had lung cancer: seven had squamous cell carcinoma and one had adenocarcinoma. All were men between 50 and 81 years old (average age, 66 years). In all patients, the pneumothorax occurred on the same side as the carcinoma. Thoracotomy was done in four patients. The results obtained by surgery indicated that pneumothorax may be caused by: 1) direct invasion of tumor into the pleura (patient 1); 2) rupture into the pleural space of dilated alveoli that are distal to the site of stenotic bronchial cancer (patient 7); 3) rupture into the pleural space of alveoli that had become distended to compensate for atelectasis due to obstructive bronchial cancer (patient 6); and 4) unknown (patient 2). These results suggest that lung cancer should always be considered as a possible cause of spontaneous pneumothorax in older patients.

Necrotizing Fasciitis Originating from Metastatic Colorectal Tumor Invasion-Case Report

Background: Retroperitoneal necrotizing fasciitis is a rare, fulminate disease, and is often fatal. The etiology of retroperitoneal necrotizing fasciitis may be the result of pelvic or perirectal infection, including those of the gynaecologic and obstetric origin, colonic inflammatory disease, or even due to a ruptured appendix. Aim and Objectives: We present two cases with retroperitoneum and lower extremities necrotizing fasciitis and diagnosed as caused by colorectal adenocarcinoma invasion. We aim to discuss the rare etiology, clinical presentation, diagnosis and treatment. Materials and Methods: We present two cases report with initial presentation of retroperitoneal necrotizing fasciitis, and diagnosed as caused by colorectal adenocarcinoma invasion. Due to severe sepsis, the first patient died on day 73 after emergent fasciotomy and debridement. The second patient who received left hemicolectomy, several courses of debridement, and skin graft was discharged in good health after 60 days. Results: In a review of the current literature, only a few reported cases have presented with retroperitoneal necrotizing fasciitis directly caused by the colorectal cancer. Almost all of the patients in the previously published reports expired during the fulminate course of infection. Our second patient was one of the few cases who successful survived after cancer treatment and reconstruction. Conclusion: Extended necrotizing fasciitis including Fournier's gangrene is a potentially lethal infectious disease. Direct tumor invasion is a rare cause, but results in higher mortality from the disease. If we can provide an early diagnosis via tumor markers, image, or biopsy, we may treat the underlying disease, thereby reducing the number of operations and further improving the outcome. We also should keep in mind that extended necrotizing fasciitis of the groin areas, abdominal wall, and perineum may be related to metastatic tumor invasion.

Sleeve lobectomy for patients with non-small cell lung cancer

Purpose A sleeve lobectomy for lung cancer is a procedure intended both for the maintenance of lung function and for radical treatment. We investigated the clinico-pathological features and treatment responses of lung cancer patients who underwent sleeve lobectomy in our department. Subjects Among the 984 patients with non-small cell lung cancer who underwent resection in our department between 1994 and 2007, the subjects were 24 patients in whom a sleeve lobectomy was performed. Results There were 18 male and 6 female patients, with a mean age of 65 years. The histological type was diagnosed as squamous cell carcinoma in 14 patients, and adenocarcinoma in 10. Patients with either mucoepidermoid carcinoma ( n = 1) or carcinoid tumor ( n = 1) were excluded. The pathological stage was evaluated as IA, IB, II, IIIA, IIIB, and IV in 4, 1, 8, 8, 2, and 1 patient, respectively. Regarding post-operative complications, 4 patients required sputum aspiration with a bronchoscope from the 2nd to 7th post-operative day due to sputum retention. The 5-year survival rate in patients who underwent sleeve lobectomy was 70.0%. According to the pathological nodal status, the 5-year survival rates of N0, N1, and N2 were 100.0%, 87.5%, and 41.7%, respectively. The 5-year survival rates in squamous cell carcinoma and adenocarcinoma were 83.0% and 45.7%, respectively. Conclusion Sleeve lobectomy facilitated the maintenance of residual lung function without serious perioperative complications. This finding suggests that patients with direct tumor invasion to the bronchus might be good candidates for a sleeve lobectomy, but not those with extra-nodal invasion.

Spectrum of 18F-FDG PET/CT Findings in Oncology-Related Recurrent Laryngeal Nerve Palsy

The objective of our study was to review recurrent laryngeal nerve (RLN) anatomy and describe the typical (18)F-FDG (FDG) PET/CT appearance of vocal cord paresis due to oncology-related RLN injury including a spectrum of presentations, causes, and sites of nerve injury. Oncology-related RLN palsy may be caused by direct tumor invasion or its therapy. FDG PET/CT findings should be recognized to avoid misdiagnosis. Laryngoscopy confirms the suspected diagnosis and excludes primary vocal cord neoplasm.

CT-Diagnosed Mesenteric Alterations in Patients with Non-Hodgkin’s Lymphoma: A Population-Based Study

Background: Mesenteric alterations are associated with non-Hodgkin’s lymphoma (NHL), but the frequency and prognostic value of mesenteric alterations are unknown in patients with NHL. Patients and Methods: We retrospectively screened 120 patients that were treated for NHL between January 1996 and December 2001 for the presence of mesenteric alterations, defined on computed tomography (CT) scans as nodular or diffuse infiltration of the abdominal mesentery with increased density of mesenteric fat. Results: 21 patients (17.5%) had radiological findings of mesenteric alterations at the time of the initial NHL diagnosis. Mesenteric alterations were significantly associated with mesenteric lymphadenopathy (p = 0.01). In about 50% of the patients, mesenteric alterations could not be explained by direct mesenteric tumour invasion or overt lymphatic obstruction. Patients with initial findings of mesenteric alterations tended to have a better 4-year survival as compared to patients without such findings (79 vs. 43%, p = 0.11). The International Prognostic Index (IPI) score was the only independent predictor of survival in the multivariate analysis. Conclusion: This retrospective screening study found a moderate prevalence of mesenteric alterations in patients with various subtypes of NHL. The diagnostic and prognostic value of mesenteric alterations should be further assessed in prospective studies.

Cancer Pain and Analgesia

Pain ranges in prevalence from 14-100% among cancer patients and occurs in 50-70% of those in active treatment. Cancer pain may result from direct invasion of tumor into nerves, bones, soft tissue, ligaments, and fascia, and may induce visceral pain through distension and obstruction. Cancer pain is multifaceted. Clinicians may describe cancer pain as acute, chronic, nociceptive (somatic), visceral, or neuropathic. Despite implementation of the WHO guidelines, reports of undertreatment of cancer pain persist in various clinical settings and in spite of decades of work to reduce unnecessary discomfort. Substantial obstacles to adequate pain relief with opioids include specific concerns of patients themselves, their family members, physicians, nurses, and the healthcare system. The WHO analgesic ladder serves as the mainstay of treatment for the relief of cancer pain in concert with tumoricidal, surgical, interventional, radiotherapeutic, psychological, and rehabilitative modalities. This multidimensional approach offers the greatest potential for maximizing analgesia and minimizing adverse effects. Primary therapies are directed at the source of the cancer pain and may enhance a patient's function, longevity, and comfort. Adjuvant therapies include nonopioids that confer analgesic effects in certain medical conditions but primarily treat conditions that do not involve pain. Nonopioid medications (over-the-counter agents) are useful in the management of mild to moderate pain, and their continuation through step 3 of the WHO ladder is an option after weighing a drug's risks and benefits in individual patients. Symptomatic treatment of severe cancer pain should begin with an opioid, regardless of the mechanism of the pain. They are very effective analgesics, titrate easily, and offer a favorable risk/benefit ratio. Cancer pain remains inadequately controlled despite the diagnostic and therapeutic means of ensuring that patients feel comfortable during their illness. Therefore, all practitioners need to make control of cancer pain a professional duty, even if they can only use the most basic and least expensive analgesic medications, such as morphine, codeine, and acetaminophen, to reduce human suffering.

Regional spread of cutaneous squamous cell carcinoma of the face via facial vein tumor thrombus: a case report

Cutaneous squamous cell carcinoma of the head and neck most often spreads via direct extension or through lymphatics to regional lymph nodes. This is a unique case of a cutaneous squamous cell carcinoma of the nasal dorsum with direct vascular invasion of the facial vein. This was initially incorrectly identified as a regional level Ib lymph node metastases, and the intervening venous structures were neither extirpated during an initial surgery nor recognized during subsequent radiation therapy. The patient then presented with a sizable recurrence in the right suborbital subcutaneous tissue region extending into the neck and internal jugular vein. During further resection, direct tumor invasion into the facial vein was pathologically confirmed. This unusual involvement is presented as the first documented report of regional spread via tumor thrombosis within the facial vein as demonstrated in the facial vein with a tumor thrombus, as demonstrated by computed tomography and microscopic findings.

Direct Tumor Invasion in Colon Cancer: Correlation with Tumor Spread and Survival

This study examined the correlation between depth of local invasion in colon cancer and tumor spread and patient survival. A cohort of 796 patients with a complete set of TNM staging information following an elective resection for colon cancer was selected. The rates of lymph node and distant metastasis, tumor differentiation, and extramural venous invasion for different tumor (T) categories were compared. The effects of initial tumor (T) category on overall patient survival were studied. The depth of local tumor invasion correlated strongly with nodal involvement (P = 0.0001), rates of extramural venous invasion (P = 0.0002), poor differentiation (P = 0.0001), and distant metastasis (P = 0.0001). Fifty-seven percent of the patients remained lymph node-negative and distant metastasis-negative irrespective of their depth of tumor invasion had no impact on overall survival (P = 0.49). For patients with lymph node or distant metastasis (43 percent), depth of tumor invasion had significant impact on overall survival (P = 0.001). Thirteen percent of T3N1, 33 percent of T3N2, 40 percent of T4N1, and 68.percent of T4N2 cases had distant metastasis at presentation. Two types of colon cancer were observed: locally active and tendency to metastasize. For the latter, overall mortality and the risk of metastasis increased with depth of tumor invasion.

Focal Paraneoplastic Syndrome associated with small cell carcinoma of the lung

Sirs: Paraneoplastic neurological disorders (PND) are rare diseases, which are associated with systemic malignancy but are not caused by direct tumour invasion, infection, metabolic derangements or antineoplastic treatment. They are usually multi-focal but often comprise a number of distinct clinicopathological syndromes [1]. PND are most commonly associated with small cell lung cancer (SCLC). Other tumours include gynaecological cancers, lymphomas (especially Hodgkin’s disease), prostate, testicular, oesophageal and gastric cancers. Here we report a case of a focal paraneoplastic motor neuronopathy in association with SCLC. A 63 year-old right-handed female presented with loss of power and grip in the right hand, which rapidly became severe over a period of a few weeks. Her symptoms continued to worsen slowly for a total period of eight months. She had no pain or sensory loss in the right hand and no symptoms in the left hand or legs. Her neurological symptoms started 20 months after she was diagnosed with SCLC involving the left main bronchus, which was treated successfully with cryotherapy, local radiotherapy and cyclophosphamide, vincristine and etoposide chemotherapy. Her symptoms have been stable for the last 11 years. On examination there was gross wasting in the right hand with profound paralysis of all finger movements with normal upper limb reflexes. Routine blood tests were unremarkable. Antineuronal antibodies at first presentation were positive for the Hu antigen (1/500). CSF analysis showed intrathecal IgG synthesis but was otherwise normal. CT chest and bronchoscopy post-treatment did not show evidence of tumour recurrence. The Gadolinium enhanced MRI scan of the cervicalspine and brachial plexus was also normal. Neurophysiological studies are summarised in Table 1. Electromyography showed partial denervation and reinnervation in the C8, T1 segments. In summary, these results are consistent with a severe C8/T1 and moderate C7 segmental cord lesion which has been unchanged on repeated studies. PND typically but not necessarily precede the presentation of overt malignancy [1]. Here, we have described a case of unusual segmental cord damage at C7 to T1, which developed after the presentation and successful treatment of SCLC. Neurological involvement in this context is more commonly due to either tumour infiltration or a side effect of treatment. However, this is unlikely to be the case in our patient. Firstly, follow-up imaging and bronchoscopy excluded local tumour recurrence. Furthermore, contrast enhanced MR imaging of the cervical spine and brachial plexus did not show evidence of tumour infiltration. Secondly, the development of neuropathy outside the radiotherapy zone suggests that radiotherapy is unlikely to account for this presentation. Finally, vincristine neurotoxicity causes an early-onset dose-related sensorimotor neuropathy, which reverses with discontinuation [2] whereas etoposide causes a sensory-predominant or occasionally autonomic neuropathy [3]. SCLC is the commonest tumour found in association with PND, in the majority of cases with positive anti-neuronal antibodies [1]. Motor neuronopathy has been described mainly in Hodgkin’s disease and a case report of thymoma but not SCLC as a progressive, painless asymmetric weakness beginning in the legs associated with diminished or absent reflexes and lack of corticospinal tract signs [4, 5] which LETTER TO THE EDITORS

A "Benign" Sphenoid Ridge Meningioma Manifesting as a Subarachnoid Hemorrhage Associated with Tumor Invasion into the Middle Cerebral Artery

Meningioma rarely manifests as a subarachnoid hemorrhage (SAH), and invasion directly into a major intracranial artery is extremely rare. To the best of our knowledge, meningioma presenting with an SAH associated with major intracranial arterial invasion has never been reported. We present a case of sphenoid ridge meningotheliomatous meningioma manifesting as an SAH without pathologically atypical or malignant features, due to direct tumor invasion into the middle cerebral artery.

Survival benefits of pancreatoduodenectomy for gastric cancer: relationship to the number of lymph node metastases

Pancreatoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high frequency of associated morbidity and mortality. The aim of this study was to determine the limited indication of PD for advanced gastric cancer. From January 1984 and December 2005 patient's charts were reviewed and outcomes after PD for gastric cancer were compared between two subgroups; those with a 'high' number (7<or= group) of lymph node metastases and those with 'low' numbers (6>or= group). PD was intraoperatively selected because of direct tumor invasion into the pancreas (52.2% of the 7<or= group vs 12.5% of the 6>or= group) or pancreatic lymph node infiltration (47.8% of the 7<or= group vs 87.5% of the 6>or= group; P = 0.058). The postoperative histological analysis showed 22 cases from 23 (95.7%) in 7<or= group with T3 or T4 tumor, compared with only 4 cases (50%) in 6>or= group (P = 0.014). The 5-year survival rates were significantly better in the 6>or= group compared with the 7<or= group (P = 0.014). The indication for PD in advanced gastric cancer should consider the degree of extensive lymph node metastases and incurable factors.

Combined therapy for thyroid carcinoma invading the oesophagus

The midline viscera in the neck are predisposed by anatomic proximity to the invasion of thyroid gland carcinoma. The literature is replete with reports focusing on thyroid cancer involving invasion of the trachea, but offers few articles documenting involvement of the oesophagus. This tubular passageway is invaded less often than the trachea 1� 3 perhaps due to its posterior location. The oesophageal musculature becomes involved through direct tumour invasion or extracapsular extension of affected paratracheal lymph nodes. The oesophageal mucosa being a tough barrier to penetrate accounts for the rare neoplastic extension to the luminal surface. 2 The observed incidence of thyroid cancer invading the oesophagus (TCIE) has ranged from less than 1 to 22%. 1� 3 Owing to the paucity of outcome data, we followed up three cases of TCIE (Table 1; Figure 1) in which thyroidectomy with tumour shaved off the muscular layer of the oesophagus was the primary treatment. All patients received adjuvant postoperative radioactive iodine therapy ± external beam irradiation. In case 1, external beam irradiation was given to the entire anterior portion of the neck and also to the upper mediastinum because of the presence of tumour in the resection margin following completion thyroidectomy and a second dose of radioiodine. Subsequent doses of radioiodine were given for residual disease in the thyroid bed, metastatic spread to the lungs and suspected occult recurrent neoplasm. After a median follow-up of 53 months, all patients were alive and free of local disease. One individual was asymptomatic from imaging scan-shown pulmonary metastases. Our patients were submitted for follow-up procedures such as periodic clinical examination, plasma thyroglobulin level determination, 131 Iodine total body scintigraphy and thyroid hormone suppressive therapy.

Dysfunction of the Recurrent Laryngeal Nerve and the Potential of Gene Therapy

Injury to the recurrent laryngeal nerve causes vocal fold paresis or paralysis resulting in poor voice quality, and possibly swallowing dysfunction and/or airway compromise. Injury can occur as part of a neurodegenerative disease process or can be due to direct nerve trauma or tumor invasion. Management depends upon symptoms, the cause and severity of injury, and the prognosis for recovery of nerve function. Surgical treatment techniques can improve symptoms, but do not restore physiologic motion. Gene therapy may be a useful adjunct to enhance nerve regeneration in the setting of neurodegenerative disease or trauma. Remote injection of viral vectors into the recurrent laryngeal nerve is the least invasive way to deliver neurotrophic factors to the nerve's cell bodies within the nucleus ambiguus, and in turn to promote nerve regeneration and enhance both nuclear and nerve survival. The purpose of this review is to discuss the potential role for gene therapy in treatment of the unsolved problem of vocal fold paralysis.

Isolated paraneoplastic optic neuropathy associated with small-cell lung cancer and anti-CV2 antibodies

Sirs: Paraneoplastic neurological syndromes (PNS) are disorders that occur in patients with systemic cancer, which are not due to direct tumour invasion or metastasis, chemotherapy or radiotherapy-induced neurotoxicity, coagulopathy, infection or metabolic or nutritional deficits. They are mediated by immunological mechanisms related to onconeural antigens expression by cancer cells [1]. Paraneoplastic optic neuropathy is an uncommon disorder [2–8]. We describe a patient with an isolated optic neuropathy associated with small-cell lung cancer and anti-CV2 antibodies. The patient was a 64-year-old heavy-smoker male who developed painless, progressive vision loss in his left eye, with only perception of movement 5 days after onset and mild visual loss in his right eye 2 days later. General and neurological examination revealed no abnormalities. Visual acuity was 0.4 in the right eye and only movement perception in the left one; a left relative afferent pupillary defect was present. Funduscopy showed right eye papilledema, whereas the left papilla was pale. Fluorescein angiography showed vitreous turbidity and dye enhancement in both papillae; no signs of retinitis or vasculitis were found. Blood analysis, including ESR, thyroid function tests, angiotensin-converting enzyme levels, autoantibodies and tumour markers (including neuron-specific enolase), were negative. CSF showed five mononuclear cells/ mm, a protein level of 78 mg/dl and no oligoclonal bands. Cytological examination was negative. Anti-CV2 antibodies were found in serum (1/8,000) and CSF (1/400), but not in aqueous humour. Brain MRI showed no abnormalities. Visual evoked potentials showed reduced amplitudes and mildly prolonged P100 latencies. Electroretinography was normal. A thorax CT scan revealed a 3-cm cystic nodule in the right superior lobe. Video-assisted thoracoscopy with lung biopsy was done; smallcell lung cancer was diagnosed. Methylprednisolone (1 g iv. daily for 5 days) was given and chemotherapy (cisplatin plus etoposide) was started after diagnosis of limited-stage disease. Fifteen months after diagnosis visual acuity was 0.7 in both eyes and no further relapses nor new neurological symptoms or signs developed over follow-up. Anti-CV2 antibodies remained in the serum sample at the same titer of 1/8,000. We report a patient with a seven-day history of painless, progressive, asymmetric, optic neuropathy as the only manifestation of small-cell lung cancer associated with anti-CV2 antibodies. Anti-CV2 (also called CRMP5-IgG) is an IgG autoantibody specific for the 62 kDa collapsing response-mediator protein 5 (CRMP-5) [9, 10]. Both the retina and the optic nerve contain full-length CRMP-5 protein. AntiCV2/CRMP-5 antibodies are markers of paraneoplastic autoimmunity related to lung cancer (mainly small-cell type) or thymoma [9, 10]. Graus et al. [11] have recently recommended diagnostic criteria for PNS. Although optic neuropathy is not a classical syndrome, our patient fulfills criteria for PNS as a non-classical syndrome with onconeural antibodies (anti-CV2/CRMP-5) and cancer (small-cell carcinoma). Response to therapy (steroids and chemotherapy) can be interpreted as an additional data supporting the diagnosis. Optic neuropathy is an uncommon paraneoplastic manifestation of cancer. Up to date, only 42 patients with paraneoplastic optic neuropathy have been reported in the English literature. However, nearly always patients had other neurological symptoms or signs, such as neuropathy, cerebellar ataxia, dementia, other cranial nerve abnormalities, A. Ares-Luque (&) L.A. Garcia-Tunon AE B.C. Cabezas L.E. Hernandez-Echebarria AE J. Tejada Neurology Dept. Hospital de Leon C/ Altos de Nava sn. 24071 Leon, Spain Tel.: +34-98/7237400 Fax: +34-98/7240503 E-Mail: adrianares@telefonica.net

Cerebral Lipiodol Embolism: A Complication of Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

We report a case of cerebral lipiodol embolism following transcatheter chemoembolization (TACE) for hepatocellular carcinoma. A 70-year-old woman with a large unresectable hepatocellular carcinoma underwent TACE. Her level of consciousness deteriorated after the procedure, and magnetic resonance imaging and non-contrast computed tomography revealed a cerebral lipiodol embolism. Despite intensive care, the patient died 2 weeks later. The complication might have been due to systemic-pulmonary shunts caused by previous surgeries and/or direct invasion of the recurrent tumor.

Survival in Colorectal Cancer Patients With Urinary Tract Invasion

We compared overall survival and disease-free survival in colorectal cancer patients with and without invasion of urinary organs. We clarified the potential predictors of the overall and disease-free survivals after surgery, the factors associated with direct tumor invasion of the urinary organs, postoperative complications, recurrence sites, and survival in patients with and without urinary organ resection in 171 patients with Stage III colorectal cancer who underwent surgery, including 23 patients with tumor invasion of the urinary organs and 148 patients without invasion. Old age (65 years or older), rectal cancer, and macroscopic Type 3 and 4 disease were found to be independent poor prognostic factors for the overall and disease-free survivals in all patients. The overall and disease-free survivals in patients with direct tumor invasion of the urinary organs were not shorter than those in patients without invasion. A large extent of tumors located in the cross-sectional circumference of the bowel (> or =72 percent) and a large maximum tumor size (>50 mm) were significant tumor characteristics associated with positive direct tumor invasion of the urinary organs by sigmoid and rectal cancers. Although the local recurrence of patients with tumor invasion of the urinary organs occurred more frequently in patients without invasion, there were no differences in the overall and disease-free survivals between the patients without a urinary organ resection and those with a local resection of urinary bladder or ureter. The survival of patients with a urinary invasion was not shorter than that of patients without urinary invasion.