Malignant Granular Cell Tumor of the Back: A Case Report and Review of the Literature

Malignant granular cell tumors are rare, intensely aggressive entities. This paper presents a case of a large rapidly recurrent malignant granular cell tumor with regional and distal metastases on the back of a 54-year-old Cuban man. The primary tumor recurred within six months of the original wide local excision and with satellite lesions apparent at twelve months, and the mass was diagnosed using the histological criteria established by Fanburg-Smith et al. for malignant granular cell tumors. By fifteen months, right axillary lymphadenopathy, multiple satellite lesions, pulmonary nodules, and distant metastasis in the right thigh were present. At sixteen months, wide local excision of recurrent mass and local satellite masses along with right axillary dissection and placement of Integra with subsequent split-thickness skin graft were performed by surgical oncology and plastic surgery teams. The surgical specimen measured 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses with the largest mass 22.0 × 9.0 × 4.6 cm. Following surgery, patient was started on Pazopanib 800 mg/day based on phase III randomized trial data in the treatment of soft tissue sarcomas showing this as a potential novel therapy for malignant granular cell tumors

Inflammatory Breast Cancer in Pregnancy and Lactation

Inflammatory breast cancer (IBC) represents only 1% to 5% of all breast malignancies and is an extremely aggressive subtype. At time of diagnosis, up to 85% of patients will present with regional nodal metastases and up to 30 % will have metastasis to distant organs. There is limited medical literature describing treatment guidelines for IBC during gestation. The best diagnostic tools are core needle and full-thickness skin punch biopsies to assess presence of dermal lymphatic invasion. Breast Ultrasound is preferred to mammogram, but mammography could still be done with proper fetal shielding. Ultrasound and Magnetic resonance imaging are used for staging. Pregnant patients should be managed with special attention to the health of the fetus by a multidisciplinary team. Treatment based on current guidelines consist of a sequence of systemic chemotherapy followed by mastectomy with axillary dissection (modified radical mastectomy), and even if good clinical nodal response to neoadjuvant therapy is obtained, sentinel node biopsy is not recommended. Radiation therapy is to be given once the baby has been delivered. Chemotherapy is not recommended in the first trimester, and anti-estrogen hormonal therapy, as well as targeted Her2-neu therapies are contraindicated during the length of the pregnancy. There is no evidence that early termination improves the outcome. However, given the poor prognosis of IBC, patients should be fully counseled on the risks and benefits of continuing or terminating an early pregnancy

Toxicities associated with hyperthermic isolated limb perfusion and isolated limb infusion in the treatment of melanoma and sarcoma

Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) may play a significant role in the treatment of patients with recurrent or in transit extremity melanoma or sarcoma that is unresectable. These procedures may be indicated when patients are otherwise faced with the possibility of a debilitating amputation. Not entirely benign treatment modalities, HILP and ILI can be associated with regional and systemic toxicities. We conducted a literature search of published studies using HILP and ILI for the treatment of extremity sarcomas and melanomas, and associated toxicities was performed. The regional toxicities of HILP and ILI are similar. The most common toxicities reported are mild to moderate. However, when severe regional toxicity occurs, albeit infrequently (<5%), fasciotomies or even amputation may be necessary. Some studies have showed a relationship between acute regional toxicities and long term regional morbidity. Systemic toxicity appears to be more frequent when TNF- is used in combination with other drugs during HILP, however the use of TNF- in the United States is limited to trials. Although regional toxicities are similar, systemic toxicity of ILI is minimal compared to HILP. ILI is easier to repeat, technically less complex, and may be more acceptable in infirmed patients. Long term morbidity and outcomes for ILI are still being evaluated. Both of these techniques may be suitable options in patients with unresectable advanced or recurrent, or in transit extremity melanoma or sarcoma