What Lurks Beneath: Lacrimal Gland Adenocarcinoma Dedifferentiation to Sarcomatoid Carcinoma

This was a case of a young lady presenting with 10 year history of a mass in the right eye. It was found to be an adenocarcinoma of the lacrimal gland from histopathological biopsy. She underwent wide excision, orbital exenteration and reconstruction with a free rectus abdominis flap. Unfortunately, she had a tumour recurrence which was not controlled by radiotherapy and a second excision. The behavior of the tumour was aggressive, resulting in widespread metastases. She passed away within a year of her presentation. Of note, the histopathology report from the second excision turned out to be sarcomatoid carcinoma. This is described in the literature as dedifferentiation, or high grade transformation (HGT). Occurrence of dedifferentiation in salivary gland tumours is well-established, but not as well-described in lacrimal gland tumours. In this case, there was a severely delayed presentation of a lacrimal gland adenocarcinoma in a young person, which underwent dedifferentiation into a sarcomatoid carcinoma. This phenomena is associated with aggressive tumour biology behavior and poor prognosis, despite surgery and radiotherapy.

Recurrence of a nasopharyngeal carcinoma manifesting as a cerebellopontine angle mass.

As many as 31% of patients with nasopharyngeal carcinoma present with intracranial extension. Despite this high percentage, extension to the cerebellopontine angle is rare. The mechanism of tumor spread to the cerebellopontine angle is not completely understood. The most likely mechanism is direct extension to the skull base with involvement of the petrous apex and further extension posteriorly via the medial tentorial edge. We report the case of a 46-year-old woman with nasopharyngeal carcinoma who had been treated initially with chemoradiation and subsequently with stereotactic radiosurgery for residual tumor. One year later, she presented with an intracranial recurrence of the nasopharyngeal carcinoma in the cerebellopontine angle; the recurrence mimicked a benign tumor on magnetic resonance imaging. The tumor was ultimately diagnosed as an undifferentiated carcinoma of nasopharyngeal origin. She was treated with palliative chemotherapy.

Coma due to malplaced external ventricular drain.

Ventriculostomy or external ventricular drain (EVD) placement by free-hand technique has a high malplacement rate. It is a blind procedure that often requires multiple attempts and revisions. To date, no neurological complication due to EVD malplacement has been reported in the literature. In this report, we present the first case of coma induced by a malplaced EVD and the patient regained consciousness after the drain was adjusted. Our discussion focused on various techniques that can improve the accuracy of EVD insertion. EVD insertion under image guidance provides better accuracy with limited disadvantages. We hypothesized that the patient's coma was due to the mass effect and irritation of the malplaced EVD exerted onto the ventral periaqueductal grey matter and the ascending neurons from upper brainstem.