A positron emission tomography was performed and revealed a small solid nodular lesion in the left breast and homolateral axillary adenopathy. no evidence of disease recurrence. INTRODUCTION Breast cancer is the most common cancer in women in Europe which has been increasing with mammographic screening and continues to grow as population ages. The risk of breast cancer is usually age-dependent, with a quarter of breast cancers occurring before age 50, and 5% before age 35 [1]. The other most important risk factors paederoside include: genetic predisposition, exposure to estrogens, ionizing radiation, low parity, obesity and alcohol consumption [2]. In countries with screening programs, breast cancer is usually often detected before clinical symptoms are apparent, but occasionally the occurrence of paraneoplastic syndrome precedes the identification of the tumor. Paraneoplastic neurologic syndromes are rare immune mediated syndromes defined by the presence of neurological paederoside symptoms associated with the diagnosis of cancer within 4 years from the onset of the non-metastatic neurological manifestations and implies the exclusion of other neurological disorders [3]. The precise immunological mechanism is not well understood, however, specific autoantibodies, such as anti-Ri, anti-Yo and anti-Hu may be detected in the serum and cerebrospinal fluid of affected patients. In spite of the diagnosis of a paraneoplastic syndrome continues to be challenging, requiring an elevated degree of suspicion, due the heterogeneity in timing, symptomatology and the underlying cancer is only found in 20C40% of cases. Breast cancer related neurologic paraneoplastic syndromes includes sensory and motor-type neuropathies, paraneoplasic cerebellar degeneration, opsoclonusCmyoclonus syndrome (OMS), stiff person paederoside syndrome, encephalomyelitis and paraneoplastic retinopathy [4, 5]. OMS associated with breast cancer is usually infrequent and is characterized by spontaneous, arrhythmic, conjugate saccades of eyes in all directions of gaze without a saccadic interval (opsoclonus) and brief, shock-like, involuntary movements caused by muscular contractions or inhibitions (myoclonus). Additional clinical features such as ataxia, tremors, dysarthria and psychiatric symptoms are usually observed. The most frequent tumor associated with OMS is usually small cell lung cancer, but other tumors, along with breast cancer, have been reported including ovarian teratoma and other gynecologic cancers, gastric adenocarcinoma, malignant melanoma and bladder cancer [5C7]. CASE REPORT A 49-year-old woman with a past medical history of depressive disorder and bilateral breast reduction mammoplasty was admitted to anal sphincteroplasty for the treatment of fecal incontinence as a labor complication. During the post-operative period she presented a subacute onset of opsoclonus, mioclonus, ataxia, sleep disturbance and irritability. Neurologic examination revealed spontaneous, involuntary, FASLG arrhythmic and conjugate rapid eye movements; facial, axial and appendicular myoclonus and gait ataxia. Her motor strength and deep tendon reflexes were normal. Sensation was intact in all modalities. For etiological clarification, a full workup was conducted with blood assessments, including tumor markers and serology for human immunodeficiency virus, cytomegalovirus and Epstein paederoside Barr virus; brain magnetic resonance imaging (MRI), CT scan of the chest, abdomen and pelvis, thyroid and breast ultrasound and all revealed normal. Her cerebrospinal fluid (CSF) showed normal cell counts and protein values, and unfavorable cytology and viral markers. For further investigation of the clinical hypothesis of idiopathic opsoclonusCmyoclonus syndrome, the patient was transferred to Neurology Department. Electroencephalogram was unfavorable for epileptiform activity. The CSF was tested for presence of paederoside onconeural antibodies and anti-Ri was positive. A positron emission tomography was performed and revealed a small solid nodular lesion in the left breast and homolateral axillary adenopathy. Breast screen with mammography and ultrasound, followed by MRI showed a nodular opacity under the left nipple and axillary adenopathy. MRI guided core biopsy of the breast lesion revealed an invasive ductal carcinoma (IDC) luminal A type. The left axillary node biopsy confirmed lymph node metastasis. Meanwhile, patient received immunotherapy with a combination of corticosteroids and rituximab. Symptomatic medication as clonazepam, levetiracetam, thiamine was prescribed. An intensive rehabilitation program.
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