case № 0009

MPMT (multiple primary malignant tumors). Peripheral cancer of the lower lobe of left lung cT1bN0M0. Condition after lobectomy in 2012. Prostate cancer T3bN1M0.Condition after surgery in August 2013.The progression of disease with metastases in the upper lobe of the left lung. Condition after marginal resection in 19.08.2015. Relapse in remaining lobe? Granulation tissue?


Concomitant diseases: Hypertensive disease II st., Ischemic heart disease, atherosclerotic cardiosclerosis. Diabetes mellitus type II. Chronic obstructive lung disease of moderate severity, emphysematous type.Cyst of the right kidney.

Case description:

Patient is 74 years old.

Date of birth - 05.02.1941

Blood group - A (II) Rh (+)

In 2012, in the patient was diagnosed - peripheral tumor of the lower lobe of the left lung.

04.07.2012 to the patient was provided operation – thoracotomy from the left side, the radical lower lobectomy, lymph node dissection, drainage of pleural cavity. The Type R 0.

Histological examination of the operational material -  in the lower lobe of the left lung - moderately differentiated squamous cell carcinoma with necrotic areas 2.5 cm in diameter. Bronchopulmonary lymph nodes and lymph nodes groups 6,7,8,11 – without  metastases. Separately marked area in the lower lobe - fibrosis. Edge of  resection - without tumor.

The postoperative period was without complications.

For several  years patient was under the supervision of an urologist because of the increase in PSA levels. During the biopsy (05.08.2013) - diagnosed cancer of the prostate.

19.11.2013 to the patient was provided operation - a radical prostatectomy with saving of nervous innervation.

Histological examination of the surgical material – small acinar prostate adenocarcinoma, Gleason score - 3 + 4 = 7, 30% of the lesions, mainly on the periphery from the left side with perivascular proliferation on the background of glandular - stromal hyperplasia with multiple foci of PIN - 2, chronic prostatitis with pronounced inflammatory component.

19.08.2015 to the patient was provided operation –rethoracotomy from the left side. Marginal resection of the left upper lobe with resection of the adventition of the aorta.

The next examinations of lung tissue show different results:

Pathomorphological examination(04.09.2015) - peripheral adenocarcinoma G3 (tumor cells CK7, TTF1,CK18 - positive, CK5/6,synaptofizyn,chromohranin, PSA, PSMA - negative, p63 - weak focal positive) of upper lobe of left lung, 3,5 cm in widest dimension. Margin of the resection - beyond the tumor. Primary operating material for comparative analysis is not delivered.

Pathomorphological examination (18.09.2015) - low differentiated squamous keratinized lung cancer. 9 lymph nodes - without metastases.

Cytology (16.10.2015)blood,fibroblastic and histiocytic - macrophage cells. Tumor cells are not found.

Pathomorphological examination (29.10.2015) - small areas of lung parenchyma with focal fibrosis. Morphological studies of previously removed lung tumor tissue are not delivered.

Patient - Chmelevsky Vladymyr.

The patient needs a qualified diagnostics and the final establishment of the correct diagnosis.

case № 0407

Cr of ascending colon IV st. (locally disseminated). Acute intestinal obstruction.

Case description:

Patient was admitted to the hospital with signs of intestinal obstruction. When colonoscopy was provided – was found constrictive Cr.

Conservative treatment was ineffective.

17.12.2015 was operation was provided - laparotomy, was formated ileotransversoanastomosis. During revision - liver metastases were NOT found. Tumor is large, sprouting all walls of intestine, invades the retroperitoneal space, motionless. The large metastases in the mesentery roots of the small intestine. Patohistology – 25.12.2015, the small pieces of intestine with the growth of mucusproducing adenocarcinoma (G3), intestinal type with ulceration and necrosis.

Сountry in which the patient wants to be treated - Israel.

case № 0406

Cr of the left breast pT2pN2M1, clinical group II, st. IV, liver MTS.  Condition after left-side mastectomy, hysterectomy with appendages, left hemihepatectomy of the left lobe of liver and thermal ablation of the right lobe of liver, removal of gallbladder.

Case description:

Date of birth - 01.09.1970

Main points:

10.09.2007  - diagnosed infiltrative ductal carcinoma with a predominance of intraductal component 

Operations: 04.09.2007 -  mastectomy of the left breast

24.12.2007 -  supravaginal amputation of uterus with appendages

04.09.2012 year - resection of the left lateral section of the liver, removal of the gallbladder

12.09.2013 - Radiofrequency thermoablation of liver

07.08.2015 year - Radiofrequency thermoablation of liver

Chemotherapy - 12 courses, the last - in December 2012

Radiation therapy - not performed.

In 2007 to the patient was diagnosed cancer of the left breast ER (-) PR (+) HER -2n (+). 04.09.2007 was provided operation - sectoral resection of the left breast. The operation expanded to radical subcutaneous mastectomy of the left breast by Madden. Was diagnosed infiltrative ductal carcinoma with a predominance of intraductal component. In 2 of 4 th lymph node were detected massive metastases . Immunohistochemical examination - 80% of malignant cells express progesterone receptors, estrogen receptor expression in the studied tumors cells is absent. Expression of Her2 / neu is determined in 50% of the tumor cells (1+). The test material does not express glutathione - S- transferase and P - glycoprotein, which indicates the sensitivity of tumors to the drug cisplatin, and a number of anthracycline antibiotics. The proliferative potential of the tumor is low (30-40% of Ki-67 positive cells). There was started chemotherapy: doxorubicin 100 mg and cyclophosphamide 1.2 (3 blocks).
24.12.2007 was provided operation. Histological examination: The endometrium is proliferative. Bilateral follicular cysts. Postoperatively, the patient received 6 cycles of chemotherapy (2 of them - paclitaxel). From 2008 to 2012 woman received tamoxifen 20 mg / per day.
In 2012, during the ultrasound examination, in the left lobe of the liver was diagnosed formation 20 mm in diameter, low echogenicity. Tamoxifen has been canceled. 04.09.2012 was provided operation - resection of the left lateral section of the liver. During revision of Sg3 of liver was palpated tight - elastic neoplasm up to 7 cm in diameter. Histopathological examination: poorly differentiated adenocarcinoma with infiltrative anaplasia , multiple sclerosis. Patohistochimical research: morphological changes and immunophenotype of metastases of breast - carcinoma with loss of receptors TR / PR.
During 2012 woman received chemotherapy (carboplatin , taxoter). Ambulatory received Faslodex - 500 mg 1 time per month. During ultrasound examination of liver in 4-5 segments was visualized tumor, with reduced echogenicity, heterogeneous structure with size 22 × 24 mm, with a clear irregular contour.
Continues to receive Faslodex. 09.12.2013 was provided operation: Radiofrequency thermoablation of metastatic breast cancer in  Sg 5 of liver. 03.12.2013 was repeated burning of place of thermoablation. During the histopathological examination - microscopic description - signs of liver carcinoma and psevdopapilar microalveolar structure. Tumor cells have an extensive eosinophilic cytoplasm in some cells there are signs of apocrinisation which is characteristic of the breast parenchyma.
The results of immunohistochemical study:
Estrogenreceptor (1D5) - negative reaction
Progesteronreceptor (636) - negative reaction
Cytokeratin 7 (OV-TL 12/30) - negative reaction
Cytokeratin 20 (k 20.8) - negative reaction
Cytokeratin 17 - negative reaction
Cytokeratin 19 - negative reaction.
Bone scan - a bone scan - signs of focal lesions of the skeleton were not found.
09.06.2014 - molecular - cytogenetic analysis - identified gene amplification HER-2 / neu.   ER + (5), PR + (5), HER- neu2 + (status uncertain). Conclusion: Determined gene amplification HER - 2 / neu.
Prolonged administration of Fazlodex 500 mg.
06.07.2015 on MRI in the projection of the 6 segment  of the liver was found the round formation with high MR - signal with size about 1.27 cm.
07.08.2015 was provided thermoablation on the affected area of 6 segment of liver.
07.09.2015 at the histopathological examination - liver tissue with irregularly expressed (moderate) protein degradation, small and large centers of high- drop fatty degeneration, focal necrosis, small foci of inflammatory infiltration in the parenchyma - fibrosis in the portal tracts. The nature of the changes suggests herpetic character.
Revealed positive DNA of TTV (TT hepatitis virus), PCR - identified CMV Ig G - 8.5 positive and herpes I type Ig G 21.2 - positive.
Recommended antiviral therapy, to continue taking Fazlodex.

Alla Tkachenko
The wishes of the patient - Consultation
- Direction of future treatment
- Life extension

case № 0405

Chondroid chordoma of middle cranial fossa with dissemination to posterior cranial fossa, extracranial. Condition after operation (22.09.2015) - resection of chordoma of middle cranial fossa from the left side.

Case description:

Patient is sick since 2011.
Before the operation, in September 2015, there were complaints on headache, exophthalmos from the left side.

22.09.15 - was provided operation -  resection of chordoma of middle cranial fossa from the left side.

Histological examination of operational material - chondroid chordoma.

The patient's condition before surgery was moderate severity. Heart sounds are resonant. Blood pressure - 135/70  Hg mm. HR - 84 beats/min. Vesicular breathing. BR - 18 / min. Abdominal palpation is painless. Stool and urine are not affected.

Consciousness is clear. Glasgow coma scale - 15 points. Verbal contact is available. The photoreaction is saved. The sensitivity and movement are saved. The function of pelvic organs are controled.

Laboratory Methods:

General blood count - RBC - 3.47 * 1012/ L, WBC - 12.8 * 109/ L, hemoglobin - 111 g / l.

Urinalysis: leucocytes 1-2 in the field of view.

Biochemical analysis of blood: total protein - 68 g / l, total bilirubin - 10.3 mkmol / l, urea - 4.8 mmol / l.

Deleted only part of the tumor. Radiation therapy patient did not receive. To the patient Ukrainian doctors recommend chemotherapy.
Distantly patient was consulted at Massachusetts General Hospital (Boston) - was recommended after re-operation to conduct proton therapy.

Matviiv Oleg

Patient needs:

- the final removal of the tumor

- conducting proton therapy

Please write what are the proposals for the treatment of this patient. To the offers attach resume of the doctor who will treat the patient and the estimated cost of the treatment.

P.S. If you can not open a file with MRI - you must download the program Radiant DICOM Viewer.

case № 0402

Malignant tumour of basis of the skull (cranio - fascial hemangiopericytoma) with extra – intracranial dissemination (clinoid space, ethmoid bone, maxillary sinus)

Case description:

Patient is sick since 2008, when appeared complaints of headaches and fits of unmotivated irritation.There was diagnosed tumor of of basis of the skull. 02.07.08 patient had an operation - partial removal of extracerebral tumor of anterior cranial fossa from the right side.During the operation developed massive parenchymal bleeding from tumor vessels. Because of severe bleeding and hemodynamic infringement operation was stopped. After stabilization of condition was performed second operation 22.07.08 - total removal of extracerebral tumor of anterior cranial fossa from the right side. On histological examination was observed anaplastic hemangiopericytal meningioma with extensive areas of necrosis. Subsequently, MRI found that tumor growth is continuing. 06.04.2011 because of this, next operation was done. 12.12.2014 to patient was performed one more operation - subtotal removal of extracerebral tumor of anterior cranial fossa from the right side. Radiological therapy was used in 2011 - without the desired effect.