Graves disease and metastatic hormonal-active Hürthle cell thyroid cancer: A case report

Rationale:A hormone-active metastatic Hürthle cell thyroid carcinoma (HCTC) and Graves disease (GD) present a therapeutic challenge and is rarely reported.Patient concerns:We present a 64-year-old male patient, who had dyspnea and left hip pain lasting 4 months. He had clinical signs of hyperthyroidism and a tumor measuring 9 cm in diameter of the left thyroid lobe, metastatic neck lymph node and metastases in the lungs, mediastinum, and bones.Diagnosis:Laboratory findings confirmed hyperthyroidism and GD. Fine-needle aspiration biopsy and cytological investigation revealed metastases of HCTC in the skull and in the 8th right rib. A CT examination showed a thyroid tumor, metastatic neck lymph node, metastases in the lungs, mediastinum and in the 8th right rib measuring 20 × 5.6 × 4.5 cm, in the left acetabulum measuring 9 × 9 × 3 cm and parietooccipitally in the skull measuring 5 × 4 × 2 cm. Histology after total thyroidectomy and resection of the 8th right rib confirmed metastatic HCTC.Interventions:The region of the left hip had been irradiated with concomitant doxorubicin 20 mg once weekly. When hyperthyroidism was controlled with thiamazole, a total thyroidectomy was performed. Persistent T3 hyperthyroidism, most likely caused by TSH-R-stimulated T3 production in large metastasis in the 8th right rib, was eliminated by rib resection. Thereafter, the patient was treated with 3 radioactive iodine-131 (RAI) therapies (cumulative dose of 515 mCi). Unfortunately, the tumor rapidly progressed after treatment with RAI and progressed 10 months after therapy with sorafenib.Outcomes:Despite treatment, the disease rapidly progressed and patient died due to distant metastases. He survived for 28 months from diagnosis.Lessons:Simultaneous hormone-active HCTC and GD is extremely rare and prognosis is dismal. Concomitant external beam radiotherapy and doxorubicin chemotherapy, followed by RAI therapy, prevented the growth of a large metastasis in the left hip in our patient. However, a large metastasis in the 8th right rib presented an unresolved problem. Treatment with rib resection and RAI did not prevent tumor recurrence. External beam radiotherapy and sorafenib treatment failed to prevent tumor growth.     

Treatment of end-stage lymphedema following radiotherapy for lymphoma: A case report

Rationale: Despite significant advances in microsurgical techniques, simultaneous vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) surgeries may be effective for treatment of end-stage lymphedema. This case report describes the successful treatment of end-stage lymphedema with VLNT and LVA.Patient Concerns:A 72-year-old patient with bilateral lower extremity lymphedema was referred to our lymphedema clinic. This patient had a history of lymphoma and treated with radiotherapy on right inguinal area 26 years ago. Interestingly, the patient developed lymphedema on both the right and left lower extremities although she had radiotherapy on her right inguinal area.Diagnosis:According to the indocyanine green lymphography, lymphoscintigraphy, and magnetic resonance lymphangiography, the patient was diagnosed with end-stage lymphedema (International Society of Lymphology stage 3).Intervention:The patient underwent simultaneous VLNT and LVA for treatment of end-stage lymphedema.Outcomes:Significant reduction in circumference and volume of lower extremity was achieved following simultaneous VLNT and LVALessons:Simultaneous VLNT and LVA surgeries may be effective in patients with end-stage lymphedema.     

Cerebral large artery occlusion in chronic graft-versus-host disease: A case report

Rationale:Cerebral large artery occlusion in chronic central nervous system graft-versus-host disease after allogeneic hematopoietic stem cell transplantation (allo-HSCT) was very scarce. We described a young patient with bilateral white matter lesions and symptomatic internal carotid artery occlusion after allo-HSCT with the history of aplastic anemia.Patient concerns:A 17-year-old girl with the history of aplastic anemia developed recurrent headache and sudden hemiplegia of right limbs 2 years after allo-HSCT.Diagnoses:She was diagnosed with skin chronic graft-versus-host disease 19 months after allo-HSCT. Brain magnetic resonance imaging showed bilateral subcortical white matter abnormal signals and hyperintensity of left fronto-parietal lobe on diffusion weighted imaging and corresponding hypointense apparent diffusion coefficients indicating acute infarction. CT angiography revealed thrombosis in left internal carotid artery. Carotid plaque high-resolution magnetic resonance imaging showed annular enhancement of vascular wall revealing signs of vasculitis.Interventions:Intravenous immunoglobulin, methylprednisolone, and anticoagulant therapy were used to treat the patient.Outcomes:The patient''s symptoms gradually resolved and she could walk with assistance after 3 weeks before returned home.Lessons:Chronic graft-versus-host disease-associated vasculitis could involve cerebral large vessels which warrants further study.     

A rare case report of anal canal adenocarcinoma

Rationale:Anal canal adenocarcinoma is a kind of rare malignant tumor of the intestinal tract with a low incidence rate.Patient concerns:A 42-year-old man came to our department with anal tenderness accompanied by intermittent drainage of mucus discharge for 2 weeks.Diagnoses:The computer tomography showed a strip-shaped high-density shadow in the rectal wall. The magnetic resonance imaging showed a cyst-like mass of about 33 × 57 × 30 mm in the anal area. The lesion penetrated the anal canal, and plaque-shaped high signal shadow can be seen in the left side of the anus. The intraoperative pathology indicated the mass as anal canal adenocarcinoma.Interventions:The abdominal perineal resection was performed for this patient. The postsurgical pathology showed that the tumor was anal canal adenocarcinoma with large amounts of mucus.Outcomes:The patient recovered well and was discharged from our department at 12th day post-surgery. This patient received further pelvic radiotherapy.Lessons:Anal canal adenocarcinoma is a kind of malignant tumor that is extremely rare clinically. Computer tomography, magnetic resonance imaging, coloscopy, and histopathology are vital for the diagnosis of anal canal adenocarcinoma. Comprehensive treatment, including abdominal perineal resection, radiotherapy, and chemotherapy, is important for the treatment of anal canal adenocarcinoma.     

Favorable response to multimodal treatment in hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus and left adrenal gland metastasis: A case report and literature review

Rationale:Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-related deaths and the sixth most commonly diagnosed cancer globally. Interdisciplinary and multimodal treatment strategies are essential for a successful therapy in HCC. Established therapies for HCC treatment include surgical resection, liver transplantation, local ablative therapies, transarterial chemoembolization (TACE), tyrosine kinase inhibitors (TKIs), immunotherapy, and radiotherapy (RT).Patient concerns:A 52-year-old male patient did an ultrasound scan and found a large mass within the right lobe of the liver and gallstones in December 2018. He had a history of chronic hepatitis C virus infection (30 years) and was treated with sofosbuvir (400 mg, q.d.) for 1 year. The patient never had any symptoms of gallstones. Enhanced abdominal computed tomography of this patient showed a heterogeneous irregular mass with the largest measurement of up to 13.7 × 11.1 cm in size in the right lobe of the liver, meanwhile also had inferior vena cava (IVC) tumor thrombus, right atrial (RA) tumor thrombus, and left adrenal gland metastasis. The laboratory test data revealed that the serum tumor marker α-fetoprotein was 2.63 ng/mL, cancer antigen 19-9 (CA 19-9) was 34.40 U/mL, and protein induced by Vitamin K absence was 391.94 mAU/mL.Diagnosis:HCC with IVC tumor thrombus, RA tumor thrombus, and left adrenal gland metastasis, and gallstones.Interventions:He was hospitalized and received TACE treatment, oral TKIs, intravenous drip programmed cell death-1 (PD-1) inhibitor and RT.Outcomes:The patient showed a favorable response after consecutive treatment with TACE, TKIs, PD-1 inhibitor, and RT. Until now, the patient has survived 34 months since the diagnosis of the disease.Lessons:Our case suggests that TACE combined with TKIs, PD-1 inhibitor, and RT may be a suitable treatment option for advanced HCC patients with IVC tumor thrombus and/or RA tumor thrombus, and/or adrenal gland metastasis.     

IgA vasculitis mimicking drug-induced skin reaction and infectious colitis in an elderly patient: A case report

Rationale:Immunoglobulin A vasculitis (IgAV) in adults is rare and shows worse symptoms and prognosis. In real-life clinics, IgAV in elderly patients may be difficult to diagnose because of its rarity and other common diseases to consider. This study reports a case of IgAV mimicking drug-induced skin reaction in an elderly patient.Patient concerns:A 74-year-old female without any underlying disease presented to our emergency department as she was suffering from lower abdominal pain and diarrhea for 3 weeks. The patient was diagnosed with infectious colitis, and antibiotic treatment was administered at a local clinic. At presentation, the patient had rashes on both lower legs that developed after the antibiotic treatment, which was assumed as a drug eruption. Although antibiotic treatment was continued, the patient had persistent abdominal pain, diarrhea, hematochezia, and rashes. Proteinuria was developed on urinalysis.Diagnoses:Infectious colitis, IgAV.Interventions:Sigmoidoscopy revealed easily bleeding erythematous mucosal lesions from the descending colon to the rectum. IgAV was suspected, and thus skin biopsy was performed. Histological findings of the skin biopsy showed leukocytoclastic vasculitis, which is compatible with IgAV. A nonsteroidal anti-inflammatory drug was administered for abdominal pain. The patient showed persistent proteinuria and a systemic steroid (prednisolone 50 mg [1 mg/kg]) was started.Outcomes:After administration of the nonsteroidal anti-inflammatory drug, the patient''s abdominal pain was resolved rapidly. Under systemic steroid treatment, the patient showed significant symptomatic improvements, and after 2 weeks, the skin and colonic mucosal lesions were completely resolved.Lessons:We present a case of adult-onset IgAV, which was initially diagnosed with infectious colitis and drug eruption. The history of skin reaction development after antibiotic treatment and the rarity of IgAV in elderly patients masked the diagnosis of IgAV. Despite its rarity, IgAV should be highly suspected in elderly patients with rashes, proteinuria, and signs of colitis.     

Long-term survival in a patient with advanced non-smoking lung adenocarcinoma and no EGFR mutation after comprehensive therapy with EGFR-TKI-based therapy: A case report

Rationale:This is the first known report to describe a case of advanced non-smoking lung adenocarcinoma with no epidermal growth factor receptor mutation after comprehensive epidermal growth factor receptor-tyrosine kinase inhibitor-based therapy that survived for nearly 12 years.Patient concerns:A 48-year-old Chinese woman that came to our hospital with a left supraclavicular mass.Diagnosis:The final diagnosis was left lung adenocarcinoma with left supraclavicular lymph node metastasis, cT1N3M0 IIIB (International association for the Study of lung cancer 6th version).Interventions:After 4 months of 4 cycles of chemotherapy, gefitinib was administered alone for 5.5 years. Local radiotherapy (40GY/20F) was administered for 1 month, and osimertinib alone was followed for 4.5 years. A combination of pemetrexed with oxaliplatin and hyperthermia at the same time was administered for 4 cycles. Toripalimab and anlotinib were administered for 3 months. Since then, the patient had been taking a double dose of icotinib herself.Outcomes:The patient has survived for nearly 12 years since diagnosis of lung cancer.Lessons:Our case is of significant importance to clinicians involved in the treatment of patients with advanced nonsmoking lung adenocarcinoma and no epidermal growth factor receptor mutations.     

Angiosarcoma secondary to postirradiation and chronic lymphedema: Case reports

Introduction:Angiosarcoma secondary to post-irradiation and lymphedema is rare, but it is aggressive with a poor prognosis. It is essential to understand these patients’ clinical features and distinguish them from benign diseases or other malignant tumors.Patient concerns:Three patients who had radiotherapy for cancer treatment and chronic lymphedema admitted to the hospital with specific skin lesions at upper or lower extremities.Diagnosis:Excisional biopsies revealed prominent, highly atypical cells with a vasoformative area, composed of atypical, large epithelioid cells with vesicular nuclei, prominent nucleoli, and mitoses. Immunohistochemistry revealed diffuse expression of endothelial cell markers suggestive of angiosarcoma.Interventions:One patient had shoulder disarticulation with wide excision with adjuvant radiotherapy and chemotherapy and other 2 discontinued the treatment.Outcomes:After the treatment, one patient was transferred to rehabilitation department for shoulder disarticulation prosthesis fitting without recurrence sign for 1 year. Two patient refused further treatment and was lost to follow-up.Conclusion:In cases of patients with irratiation and chronic lymphedema, clinical findings suggestive of angiosarcoma, biopsy and imaging studies should be performed as soon as possible.     

Re-irradiation of multiple brain metastases using CyberKnife stereotactic radiotherapy: Case report

Introduction:Brain metastasis (BM) is the commonest adult intracranial malignancy and many patients with brain metastases require two course radiotherapy. Re-irradiation is frequently performed in Radiotherapy (RT) departments for multiple brain metastases.Patient concerns:We present a case of a 55-year-old male patient suffering from brain metastases, who had previously received whole-brain radiotherapy (WBRT) and first CyberKnife Stereotactic Radiotherapy (CKSRT) for metastases, presented with a recurrence of metastasis and new lesions in the brain.Diagnoses:An enhanced computed tomography (CT) scan of the brain revealed abnormalities with double-dosing of intravenous contrast that identified >10 lesions scattered in the whole brain.Interventions:Re-irradiation was performed using CKSRT. The patient was treated with 30 Gy in 5 fractions for new lesions and 25 Gy in 5 fractions for lesion that were locally recurrent and close to brainstem lesions.Outcome:The lesions were well-controlled, and the headache of the patient was significantly relieved one month after radiotherapy. The total survival time of the patients was 17 months from the beginning of the Cyberknife treatment.Conclusion:The present case report demonstrates that CyberKnife therapy plays a significant role in the repeated radiotherapy for multiple metastatic brain tumors. CKSRT can be used as a salvage method in recurrent multiple brain metastases.     

Compressive optic neuropathy (CON) in Graves’ disease caused by hypertrophy of levator and superior rectus muscles: A case report

Rationale:Enlargemento of the medial rectus is the most predominant factor of compressive optic neuropathy (CON) in Graves‘ disease. This case report indicates that CON could develop only from the hypertrophic superior levator and superior rectus (SL/SR) muscle in a patient with poorly controlled Graves‘ disease, and described the possible risk of FT₃-thyrotoxicosis with a prominent goiter to develop the current rare case with a review of the literature.Patient concerns:A 66-year-old woman undergoing endocrine management of hyperthyroidism with prominent goiter visited the Department of Ophthalmology due to right-eye upper-eyelid retraction.Diagnoses:At initial presentation, the right and left margin reflex distance-1 (MRD-1) was 3.2 mm and 2.1 mm, respectively, and no proptosis or visual dysfunction was observed. Despite insufficient hormonal regulation, she refused to undergo goiter removal. The upper eyelid retraction gradually worsened to 7.7 mm of MRD-1, followed by the onset of 20 prism diopters (PD) of the right hypertropia, resulting in right-eye CON after 6 months. Her free thyroxin level was 3.88 ng/dl and free triiodothyronine was 24.90 pg/ml. Computed tomography and magnetic resonance imaging showed only SL/SR enlargement in the right orbit.Interventions:Intravenous steroid and radiation therapy resulted in visual improvement; however, a prominent upper eyelid retraction and 35PD of hypertropia remained in her right eye. Orbital decompression, upper retraction repair, and superior rectus recession were performed to prevent the recurrence of CON and correct any disfigurement.Outcomes:The combination of conventional intravenous steroid pulse therapy, radiotherapy, and orbital decompression was effective, and no recurrence was observed for more than 1.5-years postoperatively.Lessons:Enlargement of the SL/SR muscle complex may independently induce the CON. We believe that strict attention should be paid to patients with triiodothyronine thyrotoxicosis with progressive eyelid retraction and hypertropia.     

A case report of PR-3-ANCA-positive glomerulonephritis with histological features of GPA associated with infectious endocarditis

Rationale:Several renal diseases are associated with infectious endocarditis. However, there are few reports on patients with granulomatosis with polyangiitis (GPA) associated with infectious endocarditis, and there is no consensus for appropriate treatment.Patients concerns:A 35 -years-old man with congenital ventricular septal defect presented severe anemia, hematuria and proteinuria. The blood and urine examinations showed elevated white blood cells (12,900 cells/μL), C-reactive protein level (13.1 mg/dL) and proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA) level (11.0 IU/mL), severe anemia (hemoglobin: 6.1 g/dL) and renal dysfunction [estimated glomerular filtration rate (eGFR): 12.7 ml/min.1.78 m² with hematuria and proteinuria].Diagnoses:The patient was diagnosed with crescentic glomerulonephritis with histological features of GPA associated with infectious endocarditis by renal biopsy and transthoracic echocardiography.Interventions:Antibacterial drugs (ampicillin-sulbactam) were administrated. No immunomodulating agents were used because immunosuppressive drugs may worsen infectious endocarditis. Subsequently, renal function and urinary findings improved. However, infectious endocarditis was not improved. Therefore, valve replacements and ventricular septal closure surgery were conducted.Outcomes:Thereafter, his postoperative course was uneventful, renal function improved (eGFR: 64.3 ml/min.1.78 m²), and PR3-ANCA level normalized.Lessons:We reported a case report of PR3-ANCA positive glomerulonephritis with histological features of GPA associated with infectious endocarditis. Physicians might note this renal complication when they manage infectious endocarditis.     

A successful approach for angiosarcoma of the scalp using helical tomotherapy and customized surface mold brachytherapy: A case report

Rationale:Angiosarcoma of the scalp (ASS) is a rare solid tumor with a high risk of local recurrence. Effective treatment strategies are not currently available for angiosarcoma of the scalp (ASS). The aim of this study was to report the utility of high-dose-rate brachytherapy (HDRBT) as a boost treatment for ASS following total scalp irradiation using helical tomotherapy (HT). This is the first report of successful treatment of ASS using HT and HDRBT.Patient concerns:An 81-year-old woman presented with hemorrhagic nodular skin tumors of the scalp. The patient first noticed the scalp mass 3 months before consultation, which became significantly enlarged within a short period. The tumor was positioned mostly in the parietal area, although the skin color change was widely spread to the surrounding scalp.Diagnosis:The patient underwent biopsy of the skin lesion at the right parietal region, which revealed the presence of angiosarcoma on pathological examination. There was neither regional lymphadenopathy nor distant metastases on PET/CT.Interventions:Considering the patient''s old age and poor performance status because of a history of cerebral infarction, we considered that she was eligible for definitive chemoradiotherapy of the scalp. We adopted an individual surface mold HDRBT boost of 18 Gy in three fractions following total scalp irradiation with 50 Gy in 25 fractions delivered using HT. Docetaxel (40 mg/m²) was administered every 4 weeks, concurrently with radiotherapy.Outcomes:Treatment tolerance was good, and severe toxicity has not been observed to date. At 18 months after radiotherapy, the patient does not have any evidence of recurrence.Conclusion:Customized surface mold HDRBT following total scalp irradiation using HT resulted in excellent disease control and minimal toxicity; thus, it may be a promising therapeutic option for ASS.     

Giant cell tumor of the cervical spine treated by carbon ion radiotherapy: A case report

Introduction:Giant cell tumor (GCT) of the bone is a benign–malignant intermediate tumor with locally destructive growth and a relatively high local recurrence rate. Neurological symptoms may develop in patients with GCT of the spine, and surgical treatment is prioritized in cases where resection is possible. However, the local recurrence rate of GCT of the bone is higher than that of GCT at other sites owing to the associated surgical challenges, and treatment is often difficult. No study to date has reported long-term remission of recurrent tumors for more than 5 years by treatment with carbon ion beam radiotherapy after resection of GCT of the cervical spine.Patient concerns:A 14-year-old boy who experienced recurrence after surgery for GCT of the cervical spine.Diagnosis:The patient presented with cervical pain, and computed tomography revealed a mass of the C2 vertebral body. He underwent surgery for tumor resection and autologous bone grafting, and the final pathological diagnosis was GCT. The transplanted bone exhibited gradual progression of resorption, and recurrent tumors were observed on computed tomography and magnetic resonance imaging 1 year and 4 months after surgery.Interventions:The patient was started on denosumab at 15 years of age and received carbon ion beam therapy with 70.4 Gy administered in 32 sessions over 7 weeks.Outcomes:No progressive tumor growth was observed, there were no neurological symptoms such as paralysis or pain were noted, and the patient was in remission for 5 years after irradiation.Conclusion:These findings suggest that carbon ion radiotherapy is a safe and effective therapeutic option for patients with recurrent GCT of the cervical spine.     

A rapid response of lung squamous cell carcinoma following treatment with sintilimab combined with recombinant humane endostatin injection and nab-paclitaxel in an elderly patient: A case report

Rationale:At present, the prognosis of patients with giant lung squamous cell carcinoma (LSCC) is poor, and there is no safe and effective treatment for elderly patients with large LSCC.Patient concerns:Here, we reported a 77-year-old man admitted to the hospital with cough for 3 months and significant chest pain. Computed tomography (CT) imaging showed a large mass in the left lung with pleural effusion.Diagnoses:Chest CT scan revealed a 12.5 cm × 7.3 cm mass in the left upper lobe adjacent to the pulmonary vein, with left pleural effusion. Pulmonary tumor markers were significantly elevated, and CT-guided percutaneous lung mass biopsy specimens showed LSCC.Interventions:After diagnosis, the patient was treated with sintilimab combined with endostar and nab-paclitaxel. After 2 cycles of treatment, the lung mass in the patient shrank rapidly and the clinical symptoms were relieved.Outcomes:The patient''s tumor dramatically shrank, and the pleural effusion was decreased after 4 cycles of treatment without any adverse effects. Meanwhile, the high-level tumor marker resumed normal.Lessons:Sintilimab combined with endostar and nab-paclitaxel may be a good treatment option for lung squamous cell cancer, especially for that in elderly patients.     

A spontaneous bilateral fallopian tube pregnancy with didelphic uterus: A case report

Rationale:In this article, we report interesting clinical manifestation of spontaneous bilateral fallopian tube pregnancies in a patient with a didelphic uterus.Patient concerns:A 26-year-old female patient, gravida 2, para 0 + 1, suffered from progressive abdominal pain and vaginal bleeding. A laboratory exam revealed a human chorionic gonadotropin level of 1091 IU/L. Transvaginal ultrasound detected no embryo sacs in the uterus but revealed a didelphic uterus, and a mass measuring 39 mm x 32 mm in the left adnexa region with another mass measuring 42 x 28 mm in the right adnexa region.Diagnoses:An ectopic pregnancy in the left adnexa region and a corpus hemorrhagicum in the right adnexa region were suspected.Interventions:Laparoscopic exploration operation confirmed a didelphic uterus, and pathological biopsy revealed bilateral fallopian tube pregnancies.Outcomes:The patient made a good recovery and the human chorionic gonadotropin became normal within the following 2 months.Lessons:To the best of our knowledge, clinical manifestation of spontaneous bilateral fallopian tube pregnancies in a patient with a didelphic uterus has never been reported before. Based on the experience with this case, we suggest that if a gestational sac is found in 1 fallopian tube, the contralateral fallopian tube needs to be examined for an ectopic pregnancy during surgery.     

Primary hyperparathyroidism presenting as a brown tumor with hypercalcemia crisis in a second-trimester pregnant woman: A case report

Introduction:Primary hyperparathyroidism (PHPT) in pregnancy is rare and unrecognized because the maternal physiological adaptations blurs the symptoms. There is no standard treatment strategy for maternal PHPT. Early diagnosis and interventions can prevent catastrophic consequences to the mother and fetus.Patient concerns:A 31-year-old Chinese woman was admitted, due to a lump on the left lower leg for 4 months. The patient complained of mild pain in the left lower leg following exercise that could be relieved after a short rest. The patient was at 18 weeks of gestation, and the growth of the fetus was normal. The patient has a 3-year history of hypercalcemia and a 2-year history of nephrolithiasis. No family history of hypercalcemia and endocrine tumors were present.Diagnosis:Laboratory tests demonstrated high serum calcium level of 3.84 mmol/L, parathyroid hormone 1393 pg/mL, alkaline phosphatase 488 μ/L. Ultrasound showed a 22.4 mm × 7.8 mm solid nodule in the left lower lobe of the thyroid gland. Based on these findings, the patient was diagnosed with PHPT.Interventions:The patient accepted continuous renal replacement to reduce ironized calcium level. Parathyroidectomy was performed at the 19th week of gestation. Threatened abortion occurred 2 days after the surgery, and magnesium sulfate was used to prevent the abortion. Calcium gluconate, calcium carbonate and vitamin D3 were used to treat the hypocalcemia that occurred 5 days after the surgery.Outcomes:Pathology examination demonstrated the parathyroid adenoma. Abortion was prevented using magnesium sulfate and hypocalcemia was cured with calcium gluconate, calcium carbonate and vitamin D3. At 38-week of gestation, the patient (ionized calcium level: 2.16 mmol/L) delivered a healthy female baby weighing 2700 g with 10/10 Apgar. Till now, both the mother and infant showed no complications.Conclusion:Maternal PHPT is rare and challenging to diagnose, causing life-threatening complications to mother and fetus. Any decision regarding surgery for a pregnant woman with primary hyperparathyroidism is more complex than in men or nonpregnant women. The decision should be made based on the severity of hypercalcemia and symptoms.     

Primary vaginal malignant melanoma: A rare case report of successful treatment with nivolumab

Rationale:Primary vaginal malignant melanoma is a sporadic and very aggressive tumor that is treated through surgery or radiotherapy combined with chemotherapy. Since most cases are diagnosed at an advanced stage, the operation range is extensive, the quality of life is poor, and the prognosis is gloomy.Patient concerns:A 58-year-old woman presented irregular water-like leukorrhea for 1 month after 6 years of menopause. Positron emission tomography-computed tomography revealed a 3.1 × 2.6 × 3.2 mass on the middle and lower part of the right vaginal wall. A gynecological examination revealed a 2 to 3 cm exophytic black mass in the lower-right part of the vaginal orifice. This mass was 2 cm from the urethral orifice. Furthermore, the mucosa of the anterior inferior vaginal wall had blackened and thickened, and there were some scattered black dots at the medial labia minora.Diagnosis:Due to the patient''s symptoms with radiographic findings, the postmenopausal woman was diagnosed with primary vaginal malignant melanoma.Interventions:Surgery was done to remove the mass. The patient also underwent inguinal lymph node dissection, received immunotherapy, and was treated with nivolumab.Outcomes:After a 6-month follow-up period, the patient underwent a routine gynecological examination with negative radiological results. Moreover, no local recurrence or distant metastases were found.Lessons:This patient showed a good response to immunotherapy. With this treatment method, the prognosis is better for advanced-stage women, especially those who cannot endure the surgery. Local lesion resection and inguinal lymph node dissection combined with immunotherapy are recommended. The case reported here may help treat similar clinical cases.     

Primary cutaneous apocrine carcinoma of the scalp: Two case reports and literature review

Rationale:Apocrine carcinoma is a rare malignant sweat gland tumor that has been reported in approximately 200 cases. This tumor usually occurs in the axilla, but in rare cases, it can also develop in the scalp. In the present work, we report 2 cases of cutaneous apocrine carcinoma of the scalp.Patient concerns:Two men visited our outpatient clinic with recurrence of tumor after undergoing surgery for scalp tumor at another hospital.Diagnoses:Brain magnetic resonance imaging of a 56-year old man showed the presence of a 5.0 × 4.5 × 4.4 cm scalp mass in the right parietal region, invading the skull and dura mater and a 2.2 × 2.0 × 0.7 cm bony mass without any skin lesions right next to the scalp mass. Neck magnetic resonance imaging of a 76-year-old man revealed the presence of a well-defined oval mass in the subcutaneous layer of the left occipital scalp and 2 enlarged lymph nodes in the left neck. Definite diagnoses were made postoperatively. The patients were diagnosed with cutaneous apocrine carcinoma. The diagnosis was confirmed through histopathological and immunohistochemical staining tests.Interventions:The tumors were removed with a wide safety margin and reconstructive surgery was performed.Outcomes:Additional radiotherapy or chemotherapy was performed. Follow-up more than 6 months revealed no recurrence or metastasis.Lessons:If accurate diagnosis and treatment had taken place at the initial stages of the primary cutaneous apocrine carcinoma, it would have been possible to prevent recurrence and intracranial invasion. As recurrent primary cutaneous apocrine carcinoma can become aggressive and difficult to treat, even a small mass on the scalp must be evaluated carefully and treated properly.     

Breast osteosarcoma originating from a malignant phyllodes tumor: A case report of a rare neoplasm

Rationale:Malignant phyllodes tumors with osteosarcomatous transformation are exceedingly rare. The clinical manifestations are similar to those associated with benign giant calcification, resulting in nonspecific and complex clinical symptoms.Patient concerns:A 59-year-old woman presented with a firm, painless, movable, 5.0 × 4.0 cm lump in the lower inner quadrant of the left breast that she had detected 1 month prior.Diagnoses:Breast osteosarcoma originating from a malignant phyllodes tumor was confirmed by histopathologic and immunohistochemical evaluation.Interventions:The patient underwent a wide local excision.Outcomes:The patient recovered uneventfully and was discharged after the operation. The 6-month postoperative follow-up assessment revealed no evidence of recurrence.Lessons:Diagnosing malignant phyllodes tumors with osteosarcomatous transformation requires a high level of suspicion and awareness by both surgeons and pathologists. They should be aware of the extent of such disease, which might be mistaken as benign giant calcification. Medical history and imaging findings are important for accurate diagnosis. Phyllodes tumor with an osteosarcomatous component is an aggressive neoplasm associated with distant metastasis. Delayed diagnosis and insufficient excision might negatively impact both treatment and survival.