Complete remission of refractory small cell carcinoma of the pancreas with cisplatin and etoposide

Review of Merkel cell carcinoma with solitary pancreatic metastases mimicking primary neuroendocrine tumor of the pancreas

OBJECTIVE/BACKGROUND

Merkel cell carcinoma (MCC) but metastases to the pancreas are very rare. There are only a few cases of isolated metastases of MCC to the pancreas. Because of this rarity, it can be wrongly diagnosed as a neuroendocrine tumor of the pancreas(pNET), especially the poorly differentiated neuroendocrine carcinoma (PNEC) subtype, in which the treatment is vastly different than that of MCC with isolated metastases of the pancreas.

METHODS

An electronic search of the PubMed and google scholar databases was performed to obtain the literature on MCC with pancreatic metastases, using the following search terms: Merkel cell carcinoma, pancreas, and metastases. Results are limited to the following available article types: case reports and case series. We identified 45 cases of MCC with pancreatic metastases from the PubMed and Google Scholar database search and examined their potential relevance. Only 22 cases with isolated pancreatic metastases were taken for review including one case that we encountered.

RESULTS

The results from our review of cases of isolated pancreatic metastases of MCC were compared to the characteristics of the poorly differentiated pancreatic neuroendocrine tumor (PNEC). We found the following: (a) MCC with isolated pancreatic metastases occurred at an older age than PNEC and with male gender predominance (b) Most of the metastases occurred within 2 years of initial diagnosis of MCC (c) Resection of pancreatic mass was the first line treatment in case of resectable PNECs whereas resection of metastases was infrequently performed in MCC with pancreatic metastases.

Long-Lasting Complete Remission of Small-Cell Carcinoma of the Pancreas with Carboplatin and Etoposide Complicated by Gallbladder Adenocarcinoma Diagnosed during Follow-Up

Small-cell carcinoma of the pancreas (PSCC) is a highly aggressive neoplasia with a dismal prognosis. It is extremely rare, with only a few cases reported in the literature. There is a paucity of clinical data to guide management and since the disease is mainly diagnosed at an advanced stage standard treatment consists of chemotherapy based upon treatment protocols used for small-cell lung cancer. We report the case of a female diagnosed with PSCC who achieved complete clinical remission after treatment with carboplatin and etoposide. During a 3-year follow-up the patient developed a gallbladder adenocarcinoma that was treated by surgical resection but relapsed within 20 months with widespread hematogenous metastasis.

Pancreatic small cell cancer

Small cell carcinoma (SCC) is most commonly associated with lung cancer. Extra-pulmonary SCC can originate in virtually any organ system, with the gastrointestinal tract being the most common site of involvement. We review the clinical presentation, pathogenesis, histology, imaging modalities and optimal therapeutic management of PSCC in light of available evidence.

Pathology, genetics and precursors of human and experimental pancreatic neoplasms: An update

Over the past decade, there have been substantial improvements in our knowledge of pancreatic neoplasms and their precursor lesions. Extensive genetic analyses, recently using high-throughput molecular techniques and next-generation sequencing methodologies, and the development of sophisticated genetically engineered mouse models closely recapitulating human disease, have improved our understanding of the genetic basis of pancreatic neoplasms. These advances are paving the way for refined, molecular-based classifications of pancreatic neoplasms with the potential to better predict prognosis and, possibly, response to therapy. Another major development resides in the identification of subsets of pancreatic exocrine and endocrine neoplasms which occur in the context of hereditary syndromes and whose genetic basis and tumor development have been at least partially defined. However, despite all molecular progress, correct and careful morphological characterization of tissue specimens both in the context of experimental and routine diagnostic pathology represents the basis for any further genetic investigation or clinical decision. This review focuses on the current and new concepts of classification and on the current models of tumor development, both in the field of exocrine and endocrine neoplasms, and underscores the importance of applying standardized terminology to allow adequate data interpretation and promote scientific exchange in the field of pancreas research.

Poorly differentiated neuroendocrine carcinomas of the pancreas: a clinicopathologic analysis of 44 cases

BACKGROUND

In the pancreas, poorly differentiated neuroendocrine carcinomas include small cell carcinoma and large cell neuroendocrine carcinoma and are rare; data regarding their pathologic and clinical features are very limited.

DESIGN

A total of 107 pancreatic resections originally diagnosed as poorly differentiated neuroendocrine carcinomas were reassessed using the classification and grading (mitotic rate/Ki67 index) criteria put forth by the World Health Organization in 2010 for the gastroenteropancreatic system. Immunohistochemical labeling for neuroendocrine and acinar differentiation markers was performed. Sixty-three cases were reclassified, mostly as well-differentiated neuroendocrine tumor (NET) or acinar cell carcinoma, and eliminated. The clinicopathologic features and survival of the remaining 44 poorly differentiated neuroendocrine carcinomas were further assessed.

RESULTS

The mean patient age was 59 years (range, 21 to 82 y), and the male/female ratio was 1.4. Twenty-seven tumors were located in the head of the pancreas, 3 in the body, and 11 in the tail. The median tumor size was 4 cm (range, 2 to 18 cm). Twenty-seven tumors were large cell neuroendocrine carcinomas, and 17 were small cell carcinomas (mean mitotic rate, 37/10 and 51/10 HPF; mean Ki67 index, 66% and 75%, respectively). Eight tumors had combined components, mostly adenocarcinomas. In addition, 2 tumors had components of well-differentiated NET. Eighty-eight percent of the patients had nodal or distant metastatic disease at presentation, and an additional 7% developed metastases subsequently. Follow-up information was available for 43 patients; 33 died of disease, with a median survival of 11 months (range, 0 to 104 mo); 8 were alive with disease, with a median follow-up of 19.5 months (range, 0 to 71 mo). The 2- and 5-year survival rates were 22.5% and 16.1%, respectively.

CONCLUSIONS

Poorly differentiated neuroendocrine carcinoma of the pancreas is a highly aggressive neoplasm, with frequent metastases and poor survival. Most patients die within less than a year. Most (61%) are large cell neuroendocrine carcinomas. Well-differentiated NET and acinar cell carcinoma are often misdiagnosed as poorly differentiated neuroendocrine carcinoma, emphasizing that diagnostic criteria need to be clearly followed to ensure accurate diagnosis.

Combination of irinotecan and a platinum agent for poorly differentiated neuroendocrine carcinomas

Extrapulmonary poorly differentiated neuroendocrine carcinoma (PDNEC) is a rare and highly aggressive neoplasm for which the optimal chemotherapy remains unclear. The objective of this study was to evaluate the outcomes of patients with PDNEC treated with cisplatin and irinotecan (IP) and perform a review of the literature. From 2008 to 2012, patients with advanced PDNEC (Ki67≥20%) who received the IP combination were selected for analysis. Radiologic responses were determined through Response Evaluation Criteria In Solid Tumors criteria. Twenty-eight patients were included. The median age at diagnosis was 57 years and the most common presentation was pancreatic PDNEC. Twenty-five patients (89%) received chemotherapy with cisplatin and irinotecan and three received carboplatin and irinotecan. Forty-six percent of the patients achieved objective response and the median time to tumor progression was 3.7 months. The median overall survival was 11.7 months. Thirteen patients (46%) had treatment interruptions or dose reductions due to grade 3/4 toxicity. This retrospective cohort of advanced extrapulmonary PDNEC patients suggests that the IP combination is feasible and resulted in similar response rate and median survival to other treatments previously reported.

Primary small cell carcinoma of the pancreas: rare type of pancreatic cancer and review of the literatures

Back ground

Primary small cell carcinoma of the pancreas (SCCP) is a rare malignancy with an extremely poor prognosis which accounts for 1 to 1.4 percent of all pancreatic malignancies.

Case presentation

We present the case of a 62-year-old man with a half-month history of upper abdominal discomfort who was diagnosed with SCC of the pancreatic tail. A Chest X-ray showed no evidence of primary lung tumor. The diagnosis of a SCCP was confirmed by post-surgery pathology and immunohistology. In our review of the published reports of SCCP, we only found a few cases reported in the literatures. The diagnosis of SCCP needs the post-surgery pathology and immunohistology and the prognosis of SCCP is extremely poor. There was a significant increase in median survival, from 1 to 6 months, in treated patients compared to patients treated only by symptomatic management. Chemotherapy was the most common treatment and the combination of cisplatin/etoposide was most frequently prescribed.

Conclusion

The accurate diagnosis of (SCCP) is necessary for determining prognosis and deciding appropriate therapy.

Mayo Clinic experience with very rare exocrine pancreatic neoplasms

OBJECTIVES

Limited data are available to guide the management of very rare exocrine neoplasms of the pancreas (VREP). Available evidence suggests that VREP have different risk factors and prognoses from those of adenocarcinoma of the pancreas. The primary objectives for this study were to determine the survival, comorbidities, and response to treatment of patients seen at Mayo Clinic with VREP.

METHODS

We reviewed patients from 1975 to 2005 who had VREP and compared them to patients with adenocarcinomas that were matched for TNM, grade, and decade of treatment.

RESULTS

Sixty-six patients with VREP were identified. The most commonly identified neoplasms were acinar cell carcinoma (n = 15), small cell carcinoma (n = 12), and squamous cell carcinoma (n = 8). Abdominal discomfort and jaundice were the most common presenting symptoms. The median overall survival for patients with VREP, 10.4 months (range, 3.7-23 months), was better than that for matched controls, 8.2 months (range, 4-15.4 months) (P = 0.01). There was no difference in the survival of patients with stage 4 disease between cases, 8 months (range, 2.3-21.8 months), and controls, 6.7 months (range, 2.3-10.8 months) (P = 0.17).

CONCLUSIONS

We present one of the largest series of VREP to date. The overall survival of all patients with VREP was better than matched controls, but no statistical difference was seen between the groups with stage 4 disease.

Small cell carcinoma of the pancreas: role of EUS-FNA and subsequent effective chemotherapy using carboplatin and etoposide

BACKGROUND

Small cell carcinoma (SCC) of the pancreas is a rare entity, with only a few cases reported in the literature. The aim of this study was to evaluate the effectiveness of combination chemotherapy with carboplatin and etoposide (CE) in SCC of the pancreas.

METHODS

We performed a retrospective analysis of four patients diagnosed with SCC among 279 patients with malignant pancreatic tumors treated between 2000 and 2007. All patients were treated with combination chemotherapy using a schedule consisting of intravenous (IV) carboplatin (150 mg/m(2)) on day 1 and IV etoposide (80 mg/m(2)) on days 1, 2, and 3 every 28 days.

RESULTS

Pathological diagnosis was confirmed by endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) in all patients. Three patients treated with the combination chemotherapy achieved remission, two with a complete response and one with a partial response. The remaining one patient showed no change. One of the two patients with a complete response survived for 56 months following the diagnosis.

CONCLUSIONS

Combination chemotherapy with CE may be effective for the treatment of SCC of the pancreas; EUS-FNA plays an important role in distinguishing SCC from other pancreatic malignancies, leading to the appropriate treatment being given.

A case of long survival in poorly differentiated small cell carcinoma of the pancreas

Small cell carcinoma (SCC) of the pancreas is rare. It has similar histological features to pulmonary small cell carcinoma and is equally aggressive. Most patients with SCC in the pancreas reported in case studies died within 1 year after diagnosis. We present a case of unusually long-term survival after surgery and combined chemotherapy for SCC of the pancreas. A 62-year-old woman presented with epigastric pain and jaundice. Computed tomography revealed dilated common bile duct caused by external compression of the mass in the pancreatic head. Exploratory laparotomy and pancreaticoduodenectomy (PPPD) was performed with histopathological analysis confirming a primary small cell carcinoma of the pancreas. After an uneventful postoperative recovery, the patient was treated with 6 cycles of combined chemotherapy consisting of cisplantin and ectoposide. During the follow-up, there was no evidence of recurrence and the patient has remained in a good health condition for 36 mo since the diagnosis.

The pathology of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinomas (EPSCCs) are uncommon malignant neoplasms with a reported incidence of 0.1% to 0.4% in the United States. Since their first description in 1930, they have been seen in nearly every organ system. Like their more common pulmonary counterparts, EPSCCs are thought to arise from a multipotential stem cell. However, there is recent molecular evidence that small cell elements may arise as a late-stage phenomenon in the genetic progression of more organ-typical carcinomas. The morphologic, immunohistochemical, and ultrastructural features are similar to those described in pulmonary small cell carcinomas (PSCCs). The differential diagnosis of EPSCC includes PSCC, other neuroendocrine tumors, small round blue cell tumors, metastatic melanoma, lymphoma, and poorly differentiated non-small cell carcinomas. Molecular alterations reported to occur in EPSCCs include abnormalities described in PSCC and changes found in carcinomas more typically encountered in the organ from which they arise. In this article we discuss the pathology of EPSCC with a review of theories of histogenesis, sites of occurrence, diagnostic features, differential diagnosis, molecular alterations, and clinical behavior.

Small cell carcinomas of the gastrointestinal tract: clinicopathological features and treatment approach

Small cell undifferentiated carcinoma (SmCC) of the gastrointestinal tract (GIT) is a rare and highly aggressive malignancy. To date, fewer than 1,000 cases have been reported, with an estimated prevalence of 0.1% to 1% of all gastrointestinal (GI) tumors. Data on the disease are scarce due to its rarity and the fact that most authors have focused on one site within the GIT. In light of the limited data and its perceived similarity to SmCC of the lung, the disease has usually been treated as the latter. Nevertheless, recent clinicopathologic and molecular data imply several differences between the two entities, questioning the extent to which extrapolations from one to the other can be made. We review the available data on GI SmCC with emphasis on outlining its clinicopathologic features and the recommended treatment approach.

Primary small cell carcinoma of the pancreas with an unusual sonographic appearance

We present a case of primary pancreatic small cell carcinoma with an unusual sonographic feature. A 75-year-old woman presented with poor appetite and weight loss. Abdominal sonographic examination revealed a diffusely enlarged pancreas with relative increased echogenicity and smooth contour. CT also confirmed the diffuse infiltrative pattern of the tumor. The diagnosis was confirmed via sonographically guided biopsy. The tumor was composed of small cells with hyperchromatic nuclei and scanty cytoplasm infiltrating the pancreatic tissue, consistent with small cell carcinoma of the pancreas. Primary pancreatic small cell carcinoma rarely presents as the diffuse infiltrating type. These unusual sonographic features must be differentiated from other pancreatic tumors presenting as diffuse pancreatic enlargement.

Curative resection of a small cell carcinoma of the pancreas: report of a case of long survival without chemotherapy

A 41-year-old asymptomatic man was, by chance, diagnosed as having a mass in the left upper quadrant of the abdomen by ultrasound. Computed tomography and magnetic resonance imaging showed a slightly enhanced heterogeneous mass, measuring about 5 cm in diameter, adjacent to the pancreas tail and spleen. On abdominal angiography the tumor was found to be fed by the splenic artery, and no encasement was observed. At operation the tumor was connected to the pancreas tail and attached to the spleen, and no metastasis was evident. As a result of these observations, a curative resection was performed. On histological examination the tumor cells had no ductal or architectural organization and were continuous to the normal pancreatic tissues. The cells were negative for Grimelius argylphile and the periodic acid schiff stain. Immunohistochemistry indicated that the tumor cells were positive for keratin and epithelial membrane antigen, but negative for chromogranin A, vimentin, alpha1-antitrypsin and alpha1-antichymotrypsin. The tumor was diagnosed as a small cell carcinoma of the pancreas, which is a rare disease. In previously reported cases curative resection of the tumor had not been possible because of its rapid progression and metastasis, and the prognosis is generally very poor. In our case, however, curative resection of the tumor was done, and the patient is healthy with no signs of recurrence for 56 months after the operation and with no additional therapy.

Poorly differentiated small cell carcinoma of the pancreas. A case report and review of the literature

Small cell carcinoma (SCC) of the pancreas is a rare malignancy with an extremely poor prognosis. We present the case of a 74-year-old man with a 2-month history of upper abdominal discomfort who was diagnosed with SCC of the pancreas tail, involvement of peripancreatic and mesenteric lymph nodes and multiple liver metastases (extended disease). A CT scan and a positive somatostatin receptor scintigraphy showed no evidence of a primary lung tumour. The diagnosis of a SCC was confirmed by biopsy. Local tumour control could be achieved by gemcitabine once a week and a long-acting somatostatin analogue once a month, but liver metastasis showed progress. Thus, 5-fluorouracil on a weekly basis was started. The patient died 8 months after diagnosis and had not been hospitalised in the meantime.

Small-Cell Carcinomas of the Gastrointestinal Tract: A Review

Purpose

To improve our understanding of the entity of small-cell carcinoma (SmCC) of the gastrointestinal (GI) tract.

Methods

A MEDLINE search was done, using the terms “small cell carcinoma” or “oat cell carcinoma” combined with “gastrointestinal” or with any of the GI sites, for the period 1970 to 2003. The 138 eligible reports identified in this way were reviewed for clinical data.

Results

To date, approximately 544 cases of GI SmCC have been reported. The disease represents 0.1% to 1% of all GI malignancies, with the esophagus being the most common primary site. A majority of patients present with overt distant metastases. Systemic symptoms are common; ectopic hormonal secretion may occur. By light microscopy, GI SmCCs are essentially indistinguishable from primary pulmonary SmCC. The presence of non-SmCC components is common. Data from molecular analysis of the disease has identified some similarities to pulmonary SmCC. Chemotherapy represents the main treatment option, with modest impact on survival. In locoregional disease, the literature suggests that treatment be initiated using chemoradiotherapy and then, if metastatic disease is still excluded, surgical resection be considered. The disease is highly aggressive, and survival is in the range of several weeks for untreated patients and of 6 to 12 months for those receiving therapy.

Conclusion

SmCC of the GI tract is a rare and lethal disease. Although there are many similarities to pulmonary SmCC, some differences between the two entities are suggested. While chemotherapy can achieve significant palliation, surgery may have a potential impact on long-term survival of patients with locoregional disease.

The treatment of undifferentiated neuroendocrine tumors

The aggressiveness of poorly-differentiated neuroendocrine tumors is similar to small-cell lung cancer within a median survival of 6 months without treatment. Most patients have metastatic disease and poor condition at the time of diagnosis, and cannot be approached surgically with curative intent. Moertel et al. [Treatment of neuroendocrine carcinomas with combined etoposide and cisplatin, Cancer 1991;68:227--232] reported an objective response rate of 67% with a chemotherapy regimen combining etoposide plus cisplatin, with a median survival of 19 months and a median time to progression of 11 months. Since this publication, this regimen has been considered as the reference treatment for poorly-differentiated neuroendocrine tumors. A French retrospective study has recently confirmed the high chemosensitivity of those tumors. However, the prognosis remains poor with a 2-year survival lower than 20% and other therapeutic approaches should be developed.

Small cell carcinoma of the gallbladder

BACKGROUND AND OBJECTIVES

Small cell carcinoma of the gallbladder is rare with only 36 cases reported in the literature. Early reports demonstrated an extremely poor prognosis for this histologic type. Five new cases are reported and the previous experience in the literature is reviewed to further clarify the clinical behavior of this malignancy.

METHODS

A retrospective analysis is performed on 5 new cases. An extensive review of the literature is also performed.

RESULTS

Twenty-eight pure small cell carcinomas and 8 combined small cell carcinomas with adenocarcinoma are reported in the literature. Conclusions from the literature review reveal that small cell carcinoma of the gallbladder affects an elderly patient population (median age 65 years), has a female preponderance (76%), is associated with cholelithiasis (72%), metastasizes to nodes (88%), liver (88%), lung (23%), and peritoneum (19%), and has a median survival of 4 months. Pure tumors had median survivals of 9 months and combined tumors had median survivals of 4.5 months. The 5 patients in the literature treated with surgery and chemotherapy had improved median survival of 13 months. The 5 newly reported cases had similar epidemiological characteristics to the literature data, however, these cases were managed aggressively with surgery and chemotherapy, demonstrating a median survival of 31 months.

CONCLUSIONS

Although small cell carcinoma of the gallbladder is a distinct histologic and clinical entity, it has many clinical characteristics similar to adenocarcinoma of the gallbladder including comparable natural history and tendency for locoregional spread. Aggressive multimodality therapy, especially the combination of surgery and chemotherapy, may improve survival.

Small cell undifferentiated carcinoma of the pancreas

Small cell undifferentiated carcinoma of the pancreas is a rare neoplasm: Only 12 cases have previously been documented. This paper describes the clinical evolution, immunohistochemical profile, and ultrastructural features of a case occurring in a 37-year-old woman.

Response of small cell carcinoma of pancreas to a small cell lung cancer regimen: a case report

Small cell carcinoma of the pancreas is a very rare malignancy with 18 cases reported in the literature, of which only 3 were treated with chemotherapy. A 52-year-old man was diagnosed with small cell carcinoma originating in the head of the pancreas and invading the duodenum. He was treated with a similar approach as for localized small cell lung cancer, with six cycles of combination chemotherapy and local radiotherapy, and went into complete remission. After 3 months, he developed liver metastases along with an enlarged left supraclavicular lymph node. He was treated with two cycles of CVA, but developed lung metastases and was treated with ifosfamide/mesna. However, his overall condition deteriorated and hospice care was instituted until the patient's demise. The patient survived 14 months following diagnosis, significantly longer than the 15 reported patients with small cell pancreatic carcinomas not treated with chemotherapy. Combination chemotherapy and radiation therapy as it is utilized for small cell lung cancer appear to be beneficial for small cell carcinoma of the pancreas.

Extrapulmonary small cell cancer

Extrapulmonary small cell cancer is rare, but it occurs in a wide variety of sites, where it has a behaviour quite different from the tumours normally found at those sites. Prognosis is generally poor, but combined modality treatment with combination chemotherapy can often achieve useful palliation and, occasionally, long term remission and cure.

A metastatic neuroendocrine anaplastic small cell tumor in a patient with multiple endocrine neoplasia type 1 syndrome. Assessment of disease status and response to doxorubicin, cyclophosphamide, etoposide chemotherapy through scintigraphic imaging with 111In-pentetreotide

Extrapulmonary small cell and small cell neuroendocrine tumors of unknown primary site are, in general, aggressive neoplasms with a short median survival. Like small cell lung cancer (SCLC), they often are responsive to chemotherapy and radiotherapy. Small cell lung cancer and well differentiated neuroendocrine carcinomas of the gastrointestinal tract and pancreas tend to express somatostatin receptors. These tumors may be localized in patients by scintigraphic imaging using radiolabeled somatostatin analogues. A patient with anaplastic neuroendocrine small cell tumor arising on a background of multiple endocrine neoplasia type 1 syndrome is reported. The patient had a known large pancreatic gastrinoma and previously treated parathyroid adenopathy. At presentation, there was small cell cancer throughout the liver and skeleton. Imaging with a radiolabeled somatostatin analogue, 111In-pentetreotide (Mallinckrodt Medical B. V., Petten, Holland), revealed all sites of disease detected by routine biochemical and radiologic methods. After six cycles of chemotherapy with doxorubicin, cyclophosphamide, and etoposide, there was almost complete clearance of the metastatic disease. 111In-pentetreotide scintigraphy revealed uptake consistent with small areas of residual disease in the liver, the abdomen (in mesenteric lymph nodes), and posterior thorax (in a rib). The primary gastrinoma present before the onset of the anaplastic small cell cancer showed no evidence of response to the treatment. The patient remained well for 1 year and then relapsed with brain, lung, liver, and skeletal metastases. Despite an initial response to salvage radiotherapy and chemotherapy with carboplatin and dacarbazine, the patient died 6 months later.

Primary small cell carcinoma of the pancreas

A 59 yr old male presented with abdominal pain and jaundice. CT scan showed a tumor in the pancreas with secondaries in the liver, peri-pancreatic lymph nodes, vertebral bone marrow and subcutaneous tissue of the neck together with a cervical lymph node. The patient died after 2 wks and autopsy revealed complete replacement of the pancreas by tumor. Careful dissection of both lungs failed to show any tumor. A diagnosis of primary small cell carcinoma of the pancreas was made. Review of the literature indicates that this type of carcinoma accounts for about 1% of all pancreatic cancers and is commoner in elderly males who have a history of cigarette smoking. There is usually a rapid progression of disease and widespread dissemination, especially if untreated. Some success has been obtained with chemotherapy.

Small cell undifferentiated carcinoma of the pancreas. Report of a patient with tumor marker studies

BACKGROUND

Small cell undifferentiated carcinoma of the pancreas is a rare type of pancreatic neoplasm.

METHODS

The authors report the clinical and pathologic aspects of a patient with this malignant lesion and an extensive serologic and immunohistochemical survey of potential ectopically produced hormones or tumor markers.

RESULTS

Neuron-specific enolase (NSE) emerged as a tumor marker.

CONCLUSIONS

NSE could be valuable in the diagnosis and management of other patients with this rare disease.