Firugre 1 : Magnification of 40x, staining with : Synaptophysin-positive (A), CK 20-positive (B), CK AE1 / AE3-positive (C)
After initial excision patient was not reffered to an oncologist. After two months she developed symptoms of an infection and pain in the anal region and was admitted to a hospital . She was operated on and extirpation of the reamining tumor was performed. Pathohistological examination of sample was described as: ADENOCARCINOMA (GRADUS III). Immunohistochemistry: CK PAN-positive, CK 20-positive, S-100-negative, VIMENTIN-negative, LCA-negative, CK7-negative, CK 5/6-negative.
She was refferd to the oncologist, two months after the initial diagnosis. At first appointment her ECOG PS was 0 . An ultrasound examination (US) of the abdomen, small pelvis and inguinal regions was performed and it confirmed metastatic disease ; left iliac lymph node 4.7 cm in size and a conglomerate of pathologicaly altered lymph nodes in the ingunal region on the left 10 x 8 cm in size. A biopsy was performed and the pathological report showed that the sample morphologically and immunohistochemically corresponds to the previously diagnosed tumor: MIXED ADENONEUROENDOCRINE CARCINOMA-MANEC, Synaptophysin-positive, Chromogranin A-positive, CD56-positive, CK 20-positive, NSE-positive, CK7-negative, Ki67-about 90% of tumor cells show nuclear positivity. Patient was presented to the MDT and the desicion was made to start with PE regimen in the first line of treatment . After two cycles , there was an evident clinical progression and she started to have difficulty walking Lab reports showed elevated levels of CYFRA 21-1 5.3 ng / ml , LDH 444 U / L and NSE 140,2 ng / ml. Progression-free survival (PFS) for the first-line of chemotherapy was 1 month. In the second line patient was treated with paclitaxel and ifosfamide (PI) combination chemotherapy.After three cycles of therapy initial responce was stable disease . Patient progressed after six cycles CT showed enlargement of the mass in the left ingunal region , now 10x9x6.5 cm in size , mass in the pelvis now 10 cm in size (Figure 2) , onset of peritoneal carcinomatosis and cutaneous and subcutaneous metastatic deposits . She had worsening of her previous condition , limited movement in her left leg and developed DVT . She started LMWH for treatment of DVT . Her ECOG PS was 3.PFS for second-line of therapy was 4 months.