Paraneoplastic Cushing syndrome in neuroendocrine tumor

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Abstracts

neoplasy and suspicion of relapse or other primary neoplasm, should be made a exhaustive investigation up to the finally diagnosis. doi:10.1016/j.ejim.2013.08.386

ID: 626 Lung carcinoma or tuberculosis: Which came first? A. Hipólito-Reisa, D. Libânioa, T. Amarob, R. Môçoa

additional diagnosis work-up should be performed in order to exclude malignancy. doi:10.1016/j.ejim.2013.08.387

ID: 648 Prostatic adenocarcinoma resembling lymphoma J. Cochicho, D. Perdigoto, R. Mamede, E. Louro, A. Carvalho, J. Nascimento Costa

a

Internal Medicine Service, Department of Medicine, Pedro Hispano Hospital - ULSM, Porto, Portugal b Pathology Department, Pedro Hispano Hospital - ULSM, Porto, Portugal

Several reports have shown a significantly increased risk of lung carcinoma associated with pre-existing pulmonary tuberculosis (TB). Given the huge health impact of TB and lung cancer, the association of these two entities has serious implications. Biological plausibility of this association has been demonstrated as continuous inflammatory process might predispose to the development of cancer. In fact, inflammatory environment induces the production of nitric oxide and reactive oxygen species by activated neutrophils, leading to DNA damage. Tissue repair, as well as angiogenesis, as part of the inflammatory process, also contributes to carcinogenesis. The inverse relation has also been described, as reactivation of pulmonary TB can follow the onset of an immunosuppression state induced by the cancer. As the signs, symptoms and radiologic findings can be masked by pre-existing disease, diagnosis of lung cancer superimposed on pulmonary TB is difficult and, in most cases, delayed until an advanced stage. We report the case of a 53-year-old HIVnegative male patient being treated for a pulmonary TB that in the tenth month of treatment presented with further weight loss, fatigue, hemoptysis and pleuritic chest pain, signs and symptoms interpreted as secondary to the TB itself. Since the beginning of TB treatment acid-fast bacilli (AFB) were being persistently detected in sputum smears, although culture samples became negative after the third month of treatment, documenting adequate response. Nevertheless a bronchoalveolar lavage (BAL) was performed and was negative for malignant cells and Koch's bacillus. The patient fulfilled a year of directly observed therapy (DOT) with a combined antituberculous regimen. Three months after stopping TB treatment the patient was admitted to our hospital after a self-limited seizure. Some weeks before patient had complained of nausea, severe headache and worsening insomnia. Physical examination was normal, as were blood analysis. Brain CT showed nodular lesions with ring-enhancing contrast and an extensive area of vasogenic edema, confirmed by magnetic resonance imaging (MRI). Lumbar puncture revealed no signs of infection and AFB staining, polymerase chain reaction (PCR) and cultures of cerebrospinal fluid (CSF) were negative for tuberculosis. Thoraco-abdominal CT documented volumetric progression of two large pulmonary masses, one posteriorly in the right lobe and the other in the subcostal slope of the left superior lobe (both regarded the year before as tuberculous lesions) and identified a new lesion in the left adrenal gland (7 cm width). A CT-guided percutaneous biopsy of one of the pulmonary lesions was performed. The histology confirmed the presence of pulmonary adenocarcinoma. There was no isolation of Koch's bacillus in direct staining nor in culture of the biopsy fragment. He started dexamethasone with symptomatic and radiological improvement, and was proposed for palliative radiotherapy of the brain. As this case shows, clinical and radiographic similarities between TB and lung cancer may mislead the diagnosis of the latter. This suggests that in patients with TB in whom a growing nodule is present or who show little improvement of symptoms despite anti-tuberculous therapy,

Internal Medicine, Hospitais da Universidade de Coimbra, Coimbra, Portugal

Background: Prostate cancer was the most frequent cancer in men from the European Union in 2012, with an estimated mortality of 10.04% according to the World Health Organization. Bone and regional lymph nodes are the predominant sites of disseminated prostate cancer in patients who present with metastatic disease. Generalized lymphadenopathy is a very unusual manifestation of prostatic cancer, but frequently associated to other diseases such as lymphoma, especially in the elderly. Case presentation: Male, 87 years, presented with asthenia and muscle strength loss in the lower limb which had worsen in the past two months, leading to impaired mobility. He also complained of anorexia, weight loss and recently started constipation and urinary retention. Physical examination revealed he was sub febrile and had distal paraparesis. At the emergency department, laboratory exams showed normocytic anemia, thrombocytopenia, elevated CRP, DHL, GGT and ALP and on abdominal ultrasound he was found with multiple lomboaortic lymph nodes. The study of the spine showed lytic and blastic bone lesions with possible infiltration of the spinal cord and on the body scan there were supra and infradiaphragmatic lymph nodes, enlarged and heterogeneous prostate and a perirectal mass. The PSA value was 7166 ng/ml (N b 4) and it was decided to start cyproterone. A few days after, it was known the result of bone marrow biopsy which described infiltration of the bone marrow by a prostatic adenocarcinoma. The patient, whose general status markedly declined during the hospital stay, died from nosocomial pneumonia, 30 days after admission. Conclusions: There must be a high suspicion of prostate carcinoma in men with cancer of unknown origin, even in patients with generalized lymphadenopathy that suggests lymphoma at first. Treatment of bone metastasis is palliative, and in cases in which complications such as pathologic fractures and spinal cord compression have already occurred at presentation, relieving pain is the main goal. doi:10.1016/j.ejim.2013.08.388

ID: 660 Paraneoplastic Cushing syndrome in neuroendocrine tumor N. Jacinto, C. Madaleno, P. Rocha, J. Meneses Santos Medicine 2, Hospital Universitário de Santa Maria, CHLN/FML Lisboa, Lisbon, Portugal

Cushing's syndrome describes the signs and symptoms that result from excessive chronic tissue exposure to glucocorticoids. Iatrogenic exogenous cortisol represents 60% of Cushing's, the remainder is due to pituitary (75%) or adrenal (15%) dysfunction or ectopic adenocortocotrophic hormone (ACTH) and corticotropin-releasing hormone secretion (10%). The authors present the case of a 57 year old woman, smoker (35 pack-year), admitted with fever, cough and purulent sputum for seven days. She had hirsutism, buffalo hump,

Abstracts

two pink papular lesions in the left breast and right scapular region, purple breast and abdomen striae, decreased breath sounds and inspiratory crackles in the lower right lung. Blood tests revealed leukocytosis (16050 × 106/L), aspartate aminotransferase 43 U/L, alanine aminotransferase 113 U/L, gamma-glutamyltransferase 128 U/L, alkaline phosphatase of 47 IU/L, and total bilirubin 0.7 mg/dL, hypoxemia (PaO2 47 mm Hg), metabolic alkalosis with hypochloraemic hypokalemia (pH 7.61, PaCO2 47 mm Hg, HCO3− 47.6, K+ 1.9, Cl− 89 mEq/L). Serum ACTH was 303 pg/mL, with elevated serum and urinary free cortisol. Further test didn't show circadian variation or suppression with low and high dose dexamethasone test confirming ACTH dependent Cushing. Chest X-ray showed lower right lung consolidation. CT scan confirmed right lower lobe atelectasy due to a 4 cm mass in the main right bronchus, with mediastinal lymphadenopathy and multiple liver nodules. Histological analysis of the skin lesion was compatible with neuroendocrine tumour. The patient died of sepsis after therapy with cisplatin and etoposide. The bronchial neuroendocrine tumours can be classified in carcinoid both typical and atypical, small-cell lung carcinoma and large-cell neuroendocrine lung carcinoma, representing 25% of all neuroendocrine tumours. Thoracic neuroendocrine tumours responsible for ectopic ACTH production represent up to 2% of all Cushing's syndrome. doi:10.1016/j.ejim.2013.08.389

ID: 694 Ascites as presentation of prostate cancer A. Sanches, S. Martins, M. Carvalho Medicina, CHMT - Centro Hospitalar do Medio Tejo, Abrantes, Portugal

Introduction: Prostate cancer is the second cause of death in men. In Portugal we estimate an incidence of 82/100,000 inhabitants and a mortality rate of 3.5%. The usual clinical presentation is urinary dysfunction. There are only few cases reported of ascites as presentation of prostate cancer. The gold standard treatment is surgery, however hormonal therapy is sometimes chosen. Objectives: Differential diagnosis of ascites with recent presentation. Case presentation: 75-year old male patient, with a personal history of prostate cancer (diagnosed in 2004 and treated with nilutamide annually followed by attending Urologist), severe aortic stenosis and atrial fibrillation, admitted into the Internal Medicine Ward with a two-week history of ascites. The physical examination revealed gynecomastia, aortic systolic murmur grade III/VI. Abdomen without collateral circulation, oedema of abdominal wall, ascites, without palpable masses or abdominal pain. Laboratory findings demonstrated cholestasis, elevation tumor markers alpha-fetoprotein and Ca 19.9 and a normal PSA. Prostatic echography was normal. Abdominal echography, CT and MRI revealed an “abdominal mass between the liver and the right kidney of unknown origin (renal? hepatic?) and portal vein thrombosis” reason why he began enoxaparin in therapeutic doses. To clarify the diagnosis, the patient underwent CTguided biopsy of the abdominal mass. On the 12th day of admission the patient died. After his death, the histology of the abdominal mass revealed “epithelial malignant neoplasia-metastatic carcinoma, prostatic primary neoplasia”. Discussion: The authors consider this case interesting due to the fact that even though PSA and prostatic echography are normal, there was metastization of the primary tumor as abdominal mass, clinically manifested by ascites. There are few cases describing ascites as manifestation of primary or secondary of prostatic cancer moreover with normal PSA. doi:10.1016/j.ejim.2013.08.390

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ID: 728 Muscular metastization—A rare form of neoplasia appearance S. Estrela, H. Moreira, V. Mendes, J. Silvestre, C. Tapadinhas, P. Póvoa Intensive Care, Centro Hospitalar de Lisboa Central, Lisboa, Portugal

Introduction: Malignant neoplasia with an unknown primary site is part of a heterogeneous group with several clinical manifestations, impairing its diagnosis and staging. The case presented is of a 76-yearold female, with unknown pathological background that appealed to the Emergency Service (ES) due to an abscess after tooth extraction a month prior, having been treated with analgesic drugs. Twenty days later she returned to the ES due to prostration, inability to walk and anorexia. Spatial disorientation, hypotension and generalized hypotonia stood out upon physical examination. Laboratory tests showed leukocytosis (18.100 × 109/L), neutrophilia (89%), PCR = 5 mg/dL, urea = 120 mg/dL and creatinine = 1.17 mg/dL. Arterial blood gases showed metabolic acidosis with lactate = 3.5 mmol/L. The chest X-ray showed opacity on the right base. Cervical and Thoracic CT revealed small collection of liquid net septa adjacent to the left mandible, cardiomegaly, bilateral pleural effusion and parenchymal condensation in the lower right lobe. Echocardiography revealed an intrauricular image suggestive of thrombus. The patient stayed in the ES, remaining hypotensive and oliguric, with worsening lactic acidosis, being admitted to the Intensive Care Unit for multiorgan failure. She was ventilated and subjected to renal replacement technique. Abdominal CT performed that displayed uretrohidronefrose on the left and nodular lesions scattered in the muscle masses, which were subject to biopsy where the pathological examination revealed it to be an adenocarcinoma. The patient had no clinical improvement and died on the 12th day of hospitalization. Clinical autopsy was performed that revealed early pancreatic neoplasia, not described in previous studies with tumor infiltration present in the endocardium, myocardium and pericardium. Conclusion: The authors describe this situation by its paucity of findings from examination, which contrasts with the aggressiveness of this neoplasm. doi:10.1016/j.ejim.2013.08.391

ID: 741 Levels of survivin in lung cancer patients G. Kapellosa, K. Polonifia, D. Farmakisa, N. Alevizopoulosb, E. Spartalisc, P. Tomosc, H. Gogasa, A. Aessoposa, A. Polizosa, M. Mantzourania a

First Department of Internal Medicine, Laiko Hospital, University of Athens Medical School, Athens, Greece b Department of Oncology, Evangelismos Hospital, University of Athens Medical School, Athens, Greece c Second Department of Propaedeutic Surgery, Laiko Hospital, University of Athens Medical School, Athens, Greece

Objective: Survivin, an apoptosis inhibitor protein, has multiple functions that favor cancer cell survival. We sought to determine survivin levels in blood samples and biopsies from patients with lung cancer compared to normal individuals and healthy lung tissues respectively. Methods: Blood samples were obtained from 32 patients with non-small-cell lung cancer (NSCLC) and 49 healthy individuals. Tissue samples were also collected, 15 NSCLC biopsies and 15 histopathologically normal lung tissues. For quantitative evaluation of survivin mRNA expression levels, hybridization Polymerase Chain Reaction (PCR) method was used. Results: Overexpression of survivin was detected in all malignant samples. In