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Case Report TRACO November 20, 2012 Oluwadamilola Olaku MD, MPH. NCI/DCTD/OCCAM
Objectives ●Describe the history of cancer case reports.●Recognize potential roles of case reports.●Describe case reports.●Outline pertinent information for a good case report.
Definition Case reports are brief reports describing an isolated clinical case or a small number of cases. They may describe new or uncommon diagnoses, unusual outcomes or prognosis, new or infrequently used therapies and side effects of therapy not usually discovered in clinical trials. (Khalid Khan, PeterThompson)
‘…Any patient that goes through the door of this hospital is a potential case report…’ Anonymous (The Montreal General Hospital)
History There has been a long descriptive history of case reporting in cancer patients.In the book titled Clinical Case Reporting in Evidence-Based Medicine, Milos Jenicek eloquently describes case reports as the first line of evidence, where everything begins.
CASE REPORTSSome of the earliest case reports describing individual patients afflicted with cancer can be traced back to the papyrus records of Ancient Egyptian medicine of approximately 1600 B.C.. These reports were the first recorded incurable tumors of the breast. Farrow JH
Case reports- New diagnosis ●Historically case reports were the subject of letters between colleagues that ultimately became the origin of journals.●Case reports of melanoma were described by Hippocrates in the fifth century B.C. and also by Rufus of Ephesus, a Greek physician, in the first century A.C. (Urteaga et al)●In January 1832, Thomas Hodgkin reported six cases to the Medical-Chirurgical Society of London, two of which were what we know today as Hodgkin’s lymphoma. (Altschuler EL)
Case report-New Diagnosis ● In1957, Dennis P. Burkitt described a tumor that presented as a growth in the angle of the jaw of African children. ●In 1990, Farcet et al. described two patients with a new type of lymphoma, called Hepatosplenic T-Cell lymphoma leading to more focused research of this new entity.
Case report-unusual response to treatment. More recently researchers have used the case report format to share unusual treatment combinations or responses. For example, Treon et al reported in 2004 about an interesting clinical response to sildenafil in Waldenstrom’smacroglobulinemia.
Case Report of Gastric Cancer 82 year old female patient diagnosed with gastric cancer via an abdominal computed tomography (CT) scan in September 2006. The CT detected a gastric mass in the gastric antrum and the small gastrohepatic lymph nodes without metastasis to any other organ. Her past medical history included hypertension, osteoarthritis and allergic rhinitis. She had a family history of gastric cancer.
Case report 1 She had a gastroscopy in October 2006 which revealed a polypoid gastric mass approximately 25mm in diameter at the middle body portion of the lesser curvature and a flat elevated lesion 50mm in diameter at the prepyloricantrum. Endoscopic biopsy confirmed well differentiated adenocarcinoma with a mutation in p53 that showed a high nuclear activity of more than 80%.
Case report 1 Surgery was recommended but not performed because of her age and concerns about quality of life after gastrectomy. She had daily therapy with 900mg of orally administered Rhusverniciflua Stokes (RVS) extract from September 2006. Five months later the gastroscopy and abdominal CT scans demonstrated that the polypoid mass in the mid body had markedly decreased
Case report 1 and the flat elevated lesion in the prepyloricantrum had shrunk slightly, although the gastrohepatic lymph nodes were not changed. The biochemical parameters associated with liver and renal function were within the normal range and no significant side effects from her RVS treatment were observed. Lee et al
Sustained Partial Remission of Metastatic Pancreatic Cancer following Systemic Chemothearpy with Gemcitabine and Oxaliplatin plus adjunctive treatment with Mistletoe extract ●A 43-year old woman was admitted to hospital following several weeks of abdominal pain and progressive weight loss (5kg in 3months). Initial computed tomography (CT) scan examination revealed a mass of 2x2cm in the pancreatic head infiltrating the surrounding connective tissue.
Case report 2. ● Furthermore, diffuse hepatic lesions of up to 3.5cm in diameter were detected in both hepatic lobes, and serum CA 19-9 levels were as high as 1136 U/l (normal range:<37U/l). Explorative surgery was performed for suspected metastatic pancreatic cancer.● Intraoperative histological evaluation of the pancreatic mass confirmed the presence of pancreatic adenocarcinoma.
Case report 2. The patient underwent a pylorus-preserving pancreatic head resection, including dissection of regional lymph nodes and atypical resection of a single liver segment. Based on the final histological evaluation, the tumor was classified as pT3, pN1(8/24), pM1hep, L1, V1, G2, corresponding to an International Union against Cancer (UICC) stage IV.
Case report 2 3 weeks post op, palliative chemotherapy with a combination of gemcitabine (cumulative dose 1600mg/week over 2 weeks) and oxaliplatin (cumulative dose 160mg every 3 weeks) was initiated over 9 cycles ( administered over a total period of 37 weeks due to treatment-associated side effects)
Case report 2. Restaging examination 9 weeks after initiation of chemotherapy showed a partial remission of hepatic metastases. At the same time the serum levels of CA19-9 decreased to 34U/ml. 10 months after finishing systemic chemotherapy, the patient still showed no evidence of tumor progression and CA 19-9 levels continued to be completely normalized.
Case report 2. Upon recommendation of her homeopathist , the patient had undergone adjunctive therapy with mistletoe extracts (Iscador 5mg thrice weekly) which was initiated concurrently with the systemic chemotherapy 3 weeks after pancreatic surgery.Ritter et al.
Case report 2. Fig. 1. Histological sections through the pancreas (a) and the liver (b) of the patient, showing diffuse pancreatic infiltration by the carcinoma and hepatic metastatic spreading.
Case report 2. (a) Abdominal CT scans of the patient prior to surgery, showing multiple liver metastases of up to 3.5 cm in diameter. (b) Abdominal CT scan of the same patient following resection of liver segment IV and 37 weeks of systemic chemotherapy with gemcitabine and oxaliplatin, showing sustained partial remission.
Rare cases In rare cases, a series or more definitive study may be impossible.The reporting of similar rare cases, affords the clinician an opportunity to read this discontinuous “case series” and inform a rational approach to disease.
Rare cases ● A well-written case report or small uncontrolled series of cases is often the first step in the discovery of new diseases and treatments.(Albrecht et al, Ruben RJ)● A good case report has the element of surprise
Case Report 3. A ● 54-year old man presented with a palpable mass in the right breast. No history of familial breast cancer, gynecomastia, solid organ tumors or hormonal medication.● He was not a heavy drinker and had a smoking history of 20 pack years.Body mass index (BMI) was 24.5.
Case report 3 The right nipple was retracted and bilateral axillary accessory breasts with nipples present.
Case report 3. Figure 1. A mass (arrowheads) with nipple retraction was detected in the right breast. Bilateral accessory breasts in the axilla with nipples (arrows)were also present. (A) Right. (B) Left.
Case report 3. ● On physical examination, a 2cm-sized mass was palpated just under the right nipple.● Bloody discharge developed with squeezing from a single duct of the left nipple.● There was no palpable mass in the left breast and axillary nodes were not palpable.
Case report 3. Physical examination of the external genitalia revealed unilateral undescended testis which was small (7-8ml) and located in the left inguinal canal. The size of the right testis was normal (15ml).
Case report 3. ● Patient’s hormonal profiles, including testosterone, prolactin and thyroid function tests were normal.● Estradiol 58.9pg/ml (NR 15-47), luteinizing hormone (LH) 6.3 m/U/ml (NR 1.0-5.3), and follicular stimulating hormone (FSH) 10.9m/U/ml (NR 1.0-5.3) were slightly increased.
Case report 3. ● Chromosomal studies revealed a normal male karyotype of 46XY, and genetic analyses for BRCA1/2 genes were normal.● CXR, Liver US, PET/CT showed no evidence of metastatic disease.● Mammography and ultrasonography showed a mass (BIRADS 5) in the subareolar area of both breasts.
Case report 3 Mammography. Mammography showed a mass in the subareolar area of both breasts. (A) Right. (B) Left.
Case report 3. Ultrasonography showed a hypoechoic breast mass (BIRADS Category 5) in the subareolar area of both breasts. (A) Right. (B) Left.
Case report 3. ●In preoperative PET/CT, bilateral uptake in the subareolar area of SUVmax 6.8 in the right breast and 5.2 in the left breast, and mild uptake in both axillaes.●Core needle biopsy revealed invasive ductal carcinoma in the right breast and ductal carcinoma insitu in the left breast.
Case report 3 ●Fine needle aspiration of the right axillary lymph node was negative.●Bilateral total mastectomy, sentinel lymph node biopsy and excision of the accessory breasts in the axilla were performed.●Histopathological examination revealed invasive ductal carcinoma of the right breast and solid papillary carcinoma in situ in the left breast.
Case report 3. (A) The invasive ductal carcinoma in the right breast was mainly composed of micropapillary components (H&E stain, ×200). The tumor cells were suspended in a clear space. (B) The solid papillary carcinoma in the left breast showed solid tumor cell nests with focal necrosis (H&E stain, ×100). Woo-Young et al.
Case Report 4. ●A 65 year old woman underwent surgery for papillary serous ovarian adenocarcinoma involving both ovaries and with extensive metastases (stage IIIC).●Exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with cancer staging was performed.
Case report 4 ●Chemotherapy- carboplatin, paclitaxel, and cisplatin.●CA-125 level was normal and no evidence of disease progression.●Presented with progressive neurological symptoms two years later starting with dysesthesias and numbness and progressing to quadriparesis with urinary retention.
Case report 4. ●Imaging studies of her spine revealed an enhancing heterogeneous C2-C5 intramedullary lesion with cord expansion and edema extending into the medulla and to the thoracic spinal cord.●CA-125 was normal, CT scan of chest, abdomen, and pelvis were negative for other lesions. Infection screen was negative.
Case report 4. ●C2-C5 laminectomies were performed for planned ultrasound guided dorsal midline biopsy and debulking of the intramedullary mass.●Post-operative MRI scan showed the expected post-laminectomy changes without any associated hematoma.●Pathologic analysis revealed histological and cytological features consistent with papillary serous ovarian adenocarcinoma.