Association of right breast cancer and ileal gastrointestinal stromal tumor in a patient with type I neurofibromatosis: Case report and review of the literature

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The association of breast cancer and ileal GIST in Neurofibromatosis type 1 is extremely rare.

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Laparoscopy is associated with better perioperative outcomes and shorter hospital stay.

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Laparoscopic resection of small bowel GIST has shown in some studies to have oncological outcomes comparable to laparotomy.

Introduction

The Neurofibromatosis type I (NF1) is an autosomal dominant syndrome that affects 1/3000–1/4000 individuals. Patients with this condition are predisposed to different tumors, like neurofibromas, optic nerve gliomas, gastrointestinal stromal tumors (GIST) and breast cancers.

Presentation of case

A 78-year-old female patient affected by NF1 in May 2018 during follow-up for a carcinoma of the right breast had persistent anemia requiring regular blood transfusions. She presented with NF 1 with disseminated cutaneous neurofibromas, asthma, hypothyroidism, arterial hypertension and uterine prolapse.

She had performed gastroscopy and colonoscopy both negative for neoplastic lesions. She was subjected to chest and abdomen CT which revealed the presence of an ileal lesion of 6.5 × 4 cm suspected of GIST.

The patient underwent laparoscopic ileal resection in 120 min and was discharged on the sixth postoperative day.

Discussion

NF1 is caused by biallelic loss of a tumor suppressor gene. Most GISTs are localized in the stomach and small intestine. Surgery is the first line of treatment for localized disease. The main goal of surgery is complete excision with negative margins. The association between breast cancer and intestinal GIST in NF1 is reported only from two previous studies.

Conclusion

It is a rare case of association of breast cancer and ileal GIST in NF1. Laparoscopic resection of intestinal GIST has shown in some studies to have oncological outcomes comparable to laparotomy. Furthermore, laparoscopy is associated with better perioperative outcomes and shorter hospital stays. Further studies with a higher level of evidence are needed.

Increased breast cancer risk in women with neurofibromatosis type 1: a meta-analysis and systematic review of the literature

BACKGROUND

Neurofibromatosis type 1 (NF1) is a cancer predisposing syndrome. Studies suggest that women < 50 years old (y.o.) with NF1 have an increased breast cancer (BC) incidence and BC associated mortality. However, this has not been widely recognized secondary to small study populations.

METHODS

A systematic literature review was conducted through database searches for BC and NF1: 3456 articles identified, 166 reviewed, 58 used for descriptive analysis and 4 utilized for meta-analysis. Fisher's exact tests, Kaplan-Meier curves and random-effects meta-analysis models were used for analysis.

RESULTS

Two hundred eighty-six cases of NF1 and female BC were identified with a median age of 46 years at diagnosis; 53% were <  50. Peak age of BC diagnosis was between 34 to 44 years. Women < 50 y.o. presented with more advanced disease vs. those ≥50 (56% vs. 22% stage III-IV, respectively; p = 0.005). Median survival for the entire cohort was 5 years vs. the reported median BC survival of over 20 years in the general population using the SEER database. Median age at BC death was 48.5 years; 64% of deceased patients were <  50. Meta-analysis of a total of 4178 women with NF1 revealed a BC standardized incidence ratio (SIR) of 3.07 (95%CI 2.16-4.38) for women with NF1 vs. the general population. Women < 50 y.o. demonstrated a higher SIR of 5.08 (95%CI 3.77-6.81) compared to 1.92 (95%CI 1.40-2.63) if ≥50 y.o.

CONCLUSIONS

This systematic literature review and meta-analysis suggests that women with NF1 <  50 y.o. have a five-fold increased risk of BC, present with more advanced disease, and may have an increased BC related mortality. Increased awareness and implementation of recent National Comprehensive Cancer Network early BC screening guidelines for this high-risk patient population is essential. Additional evaluation on the influence of NF1 gene mutations identified in patients undergoing hereditary cancer genetic testing on breast cancer risk in individuals without clinical evidence of NF1 is needed.

Evaluation of the most commonly used (semi-)quantitative parameters of 18F-FDG PET/CT to detect malignant transformation of neurofibromas in neurofibromatosis type 1

In patients with neurofibromatosis type 1, transformation of neurofibromas into a malignant peripheral nerve sheath tumor (MPNST) is a severe complication of the disease. Fluorine-18-fluorodeoxyglucose PET/computed tomography (PET/CT) is a viable option for detecting malignant tumors in neurofibromatosis type 1 patients. The aim of this review was to assess the diagnostic performance of the most frequently used parameters of PET/CT in detecting MPNST. An extensive computer search was performed using the Cochrane Library, Pubmed, and Medline/Embase databases. Two reviewers independently extracted data of relevant studies and assessed the methodological quality (QUADAS-2). The diagnostic performance of PET/CT parameters in individual studies was determined by calculating a diagnostic odds ratio (DOR) using the absolute numbers of true-positive, true-negative, false-positive, and false-negative test results. A total of eight studies were included, of which three evaluated the standardized uptake value as a diagnostic parameter, two assessed the tumor-to-liver (T/L) ratio, and three articles described both parameters. The cut-off values for maximum standardized uptake value (SUVmax) ranged from 3.2 to 4.5; for the T/L ratio, the cut-off values were between 1.0 and 4.3. The sensitivity and specificity ranged from 90 to 100% and from 80 to 100%, respectively (SUVmax). T/L ratios were associated with 92-100% sensitivity and 72-94% specificity. The corresponding DORs ranged from 57 to 145 (SUVmax) and 35 to 655 (T/L ratio). Both the SUV and the T/L ratio are associated with high sensitivity combined with acceptable specificity in detecting MPNST. There is a tendency toward higher DORs using the T/L ratio, but the number of studies is limited.

Rare Malignancies in Eastern India, Socio-Economic Impact

The etiology of cancer is multifactorial. Various factors, including physical carcinogens, chemicals and viral carcinogens affect patients with known predisposing factors who subsequently develop malignancies. Here is a retrospective study of 18 patients who developed rare malignancies in clinical situations like xeroderma pigmentosum, tuberous sclerosis, neurofibromatosis, hereditary multiple exostosis, second malignancies due to radiotherapy and chronic irritation. The predisposing factors like chronic infection in leprosy, filariasis, poverty and ignorance leading to the chronicity of the lesion, lack of available health care facilities and socio-cultural background, i.e. consanguinity marriage in some community are responsible for the development of these rare malignancies. They were treated at A.H Regional Cancer Centre, Cuttack, Odisha, which is located at Eastern part of India for various malignancies, between January 1989 and January 2008. Malignancies that developed in patients with the above predisposing factors are being reported here due to their rarity and to highlight the impact of socio cultural background in developing these malignancies. Patients with above clinical situations should be kept under close observation for early detection of malignancy so their chances of survival can be improved. In addition, those oncogenic stimuli that initiated or propagated the malignancies, due to socio-economic factors, should be addressed promptly to prevent their eventual development.

Association between Neurofibromatosis Type 1 and Breast Cancer: A Report of Two Cases with a Review of the Literature

Neurofibromatosis type 1 (NF1) is one of the most common genetic diseases in humans and is associated with various benign and malignant tumors, including breast cancer. However, an increased risk of breast cancer in NF1 patients has not been widely recognized or accepted. Here, we report two cases of breast cancer in NF1 patients and review the literature on the association between NF1 and breast cancer.

Oral metastasis of metaplastic breast carcinoma in a patient with neurofibromatosis 1

Neurofibromatosis type 1 (NF1) has been associated with an increased risk for development of malignancy, especially malignant peripheral nerve sheath tumors. In addition, recently, literature has demonstrated an increased risk of breast cancer in women with NF1. The present paper shows a 53-year-old woman with NF1 who presented with metaplastic breast carcinoma and developed multiple metastases, including mandible. Furthermore, we reviewed the English literature, found 63 cases showing the association between NF1 and breast cancer, and added one more case. The present study demonstrated an important association between NF1 and breast cancer. Until the present time, there has been only one case of metaplastic breast carcinoma associated with NF1. Curiously, in our case the oral metastasis corresponded to sarcomatous component of metaplastic breast carcinoma.

Gastrointestinal stromal tumors associated with neurofibromatosis 1: a single centre experience and systematic review of the literature including 252 cases

AIMS

The objectives of this study were (a) to report our experience regarding the association between neurofibromatosis type 1 (NF1) and gastrointestinal stromal tumors (GISTs); (b) to provide a systematic review of the literature in this field; and (c) to compare the features of NF1-associated GISTs with those reported in sporadic GISTs.

METHODS

We reported two cases of NF1-associated GISTs. Moreover we reviewed 23 case reports/series including 252 GISTs detected in 126 NF1 patients; the data obtained from different studies were analyzed and compared to those of the sporadic GISTs undergone surgical treatment at our centre.

RESULTS

NF1 patients presenting with GISTs had a homogeneous M/F ratio with a mean age of 52.8 years. NF1-associated GISTs were often reported as multiple tumors, mainly incidental, localized at the jejunum, with a mean diameter of 3.8 cm, a mean mitotic count of 3.0/50 HPF, and KIT/PDGFR α wild type. We reported a statistical difference comparing the age and the symptoms at presentation, the tumors' diameters and localizations, and the risk criteria of the NF1-associated GISTs comparing to those documented in sporadic GISTs.

CONCLUSIONS

NF1-associated GISTs seem to have a distinct phenotype, specifically younger age, distal localization, small diameter, and absence of KIT/PDGRF α mutations.

Synchronous gastrointestinal stromal tumors (GIST) and other primary cancers: case series of a single institution experience

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasm affecting the gastrointestinal tract. The incidental occurrence of mesenchymal tumors and other primary tumors has not been well described in literature.

OBJECTIVE

The aim of this study was to evaluate the clinical and pathologic features of GIST occurring synchronously with other primary tumors.

METHODS

Forty-three patients with diagnosis of GIST treated surgically with curative intent at our institution from 1998 to 2006 were included. The patient clinical data and pathological reports were reviewed.

RESULTS

Of the 43 patients, there were 6 (14%) cases of synchronous GIST and other primary tumors discovered as coincidental findings. The synchronous GISTs analyzed were located in the stomach (50%) and small intestine (50%), size ranging from 0.7 to 7.6 cm (median 3.35 cm). Five (83%) of the concurrent primary tumors were from gastrointestinal origin and only one (17%) patient presented with concurrent breast cancer and GIST. The synchronous GISTs immunofenotype shows positivity for CD117 and CD34 (100%), smooth-muscle actin (SMA) (67%), S100 (50%) and desmin (33%). Whereas staining for cytokeratin AE1/AE3 and PDGF were all negative. According to GIST risk category for aggressive behavior three were classified as very low, one intermediate and two high.

CONCLUSIONS

The synchronous occurrence of GISTs and other primary neoplasm is not an uncommon entity and usually they are discovery incidentally. Epithelial tumors of the gastrointestinal tract are the most associated with concomitant GISTs. Further studies are required to clarify the molecular and genetic mechanisms of carcinogenesis and progression associating GIST and synchronous tumors.