br Case report The patient then achieved disease free
Case report The patient then achieved disease-free status as noted in a series of routine image studies during regular follow-up at our oncology clinic. In November 2011, she presented due to hematuria for several days. Diagnostic cystoscopy showed a mass lesion on the urinary bladder. Whole body computed tomography (CT) scan revealed an isolated 2.6 × 2 cm tumor in the right posterior lateral wall of the urinary luteolin (Fig. 1). Cystoscope-assisted biopsy showed a poorly differentiated adenocarcinoma with signet ring appearance arising from the submucosa of the urinary bladder. A metastatic cancer rather than primary urinary bladder cancer was impressed according to microscopic morphology of tumor and intact mucosa of urinary bladder. Immunohistochemical (IHC) profiles of the urinary bladder tumor revealed the expression pattern as CK7+, CK20+, CDX2−, ER− and scattered expression of PR. Colon origin was excluded due to different morphologic appearance and IHC profiles comparing to previous colon cancer specimen, which had strong CDX-2 expression. Recurrent breast cancer was found to be unlikely due to different ER and PR expression patterns compared to the primary breast cancer. Under the preliminary diagnosis of recurrent gastric cancer with solitary urinary bladder metastasis, she received palliative chemotherapy with weekly high-dose 5-fluorouracil followed by radiotherapy (5040 centi-Gray divided into 28 fractions) for the isolated metastatic tumor. Complete tumor response was achieved and there was no evidence of residual tumor by subsequent tumor marker (Fig. 2) and imaging follow-up. The patient experienced abdominal distension and bilateral leg edema in September 2013. A subsequent CT scan showed multiple metastatic lymph nodes over para-aortic areas (Fig. 3). Palliative chemotherapy with docetaxel + cisplatin regimen was administered as a second line palliative chemotherapy for recurrent gastric cancer with lymph node metastasis based on previous urinary bladder tumor scenario. Nevertheless, in May 2014, she complained of progressive enlarged left neck lymph nodes within half a year. Images showed the tumor had progressed with multiple lymph nodes metastases mainly involving left supra-clavicle, and mediastinum areas. The patient received neck lymph node biopsy because of the bizarre growth rate of her neck lymph node, and the pathologic report confirmed metastatic carcinoma. However, the microscopic appearance and IHC profiles of neck lymph node tumor were distinct to the urinary bladder tumor. A complementary pathologic review for a series of tumors in this patient is mandatory to confirm the origin of metastatic neck tumor, and to provide important guidance to best choose further chemotherapeutic regiments.
Pathologic finding We reviewed specimens microscopically and immunohistochemically with a pathologist, and the urinary bladder lesion disclosed signet ring cell appearance (Fig. 1) with CK7 (+). We preliminarily determined that the cancer had originated from the stomach. However, in the following lymph node lesion, we compared samples of these recurrent lymph nodes with original gastric, breast and colon cancer tissue. Microscopically, lymph node tissue showed compact sheets and nests of carcinomatous cells displaying round nuclei, distinct nucleoli and pink cytoplasm without obvious ductal or glandular structure. IHC stain showed ER (6F11) (faint +), PR (1A6) (−), CDX2 (−), CK20 (+), CK7 (+) and HER-2-neu(polyclone): negative (1+) (shown in Fig. 4A). Tracing back previous pathologic reports from gastric, breast and colon cancer, gastric tissue disclosed signet ring cells and some poorly differentiated cells scattered microscopically. IHC stain showed ER (−), PR (−), Her2 (−), CK7 (+), CK20 (+, partial) and CDX2 (−) (shown in Fig. 1). The patient\'s breast tissue revealed poorly differentiated cells diffusely infiltrating into the fibrous stroma and between the benign mammary glands. IHC stain showed ER (++, 100%), PR (++, 100%), HER-2-NEU (++, 100%), CK7 (+), CK20 (−) and CDX2 (−) (shown in Fig. 4B). IHC stains from breast, gastric, urinary bladder and lymph node tissue were summarized in Table 1. The colon cancer presented in cribriform appearance with moderately glandular differentiation. Morphologically, colon cancer as the originating site was initially excluded. Due to the ambiguous result comparing lymph node tissue with gastric and breast tissue, we checked further breast cancer-specific IHC stain – GCDFP-15 (gross cystic disease fluid protein-15), which showed a positive predicted value for breast cancer up to 99%. In this case, GCDFP was both positive at breast and lymph node tissue. Furthermore, we traced back to the urinary bladder pathologic specimen, which also showed GCDFP-15(+). Thereafter, we overruled our previous conclusion based upon this new information. The lymph node and previous urinary bladder lesions were both favored to be of breast cancer origin. Clinically, CK7+/CK20+ can be observed in approximately 11% of breast cancer cases, and the new evidence supported our final diagnosis.