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Tonic pupil, or Adie’s pupil, is an autonomic disorder due to a loss of function of parasympathetic ciliary ganglion cells. Upon examination, the pupil appears tonically dilated and shrinks poorly to light, while reacting better to accommodation stimulus. The denervated iris sphincter is very sensitive to topical parasympathomimetic pilocarpine drops. Indeed, if Adie is present, the dilated pupil will constrict more than the normal pupil. Most cases are idiopathic or due to a viral infection and have a benign course. They usually occur in women between 20 and 40 years of age. Other reported causes of tonic pupils can be vascular, traumatic, inflammatory, paraneoplastic, and neoplastic. Breast cancer generally metastasizes to the brain in advanced stages and orbital localizations have sometimes been reported. In our case, a meningeal and retro-orbit cancer invasion caused a dysfunction of the parasympathetic fibers which lead to the pupil through the optical foramen. Indeed, first ophthalmic symptoms were only an enlarged pupil poorly responsive to light. This unusual clinical sign led to the discovery of an unknown breast cancer in an advanced stage. In young adult women, unilateral tonic pupils are considered a benign parasympathetic ocular disorder that is rarely observed in clinical practice. However, it can be found in numerous systemic diseases; thus instrumental and laboratory findings are mandatory. Tumors can also represent etiologic agents and secondary localizations from breast cancer to extra parenchymal CNS structures should be considered in differential diagnosis hypothesis.

The aim of this study was to determine the activity and toxicity of two sequential chemotherapy regimens in the first-line treatment of advanced non-small-cell lung cancer (NSCLC).Eighty-eight chemonaive patients with stage IIIB/IV NSCLC were randomised to receive either three cycles of 75 mg/m(2) cisplatin plus 75 mg/m(2) docetaxel, both administered on day 1 every 21 days, followed by three cycles of 1,200 mg/m(2) gemcitabine on days 1 and 8 every 3 weeks (arm A), or three cycles of 25 mg/m(2) cisplatin plus 25 mg/m(2) docetaxel on days 1, 8 and 15 every 28 days, followed by three cycles of 1,200 mg/m(2) gemcitabine on days 1 and 8 every 3 weeks (arm B).Of the evaluable patients, 61% in arm A (n = 41) and 36% (n = 44) in arm B completed treatment as per the protocol. The best tumour response rates were as follows (arm A and arm B): complete response: 2.4 and 2.3%; partial response: 39 and 20.4%; stable disease: 26.8 and 13.6%; and progressive disease: 31.8 and 45.4%. The median progression-free and overall survival were 3.9 and 12.3 months in arm A, respectively, 3.1 and 7.7 months in arm B. Grade 3-4 adverse events were more common in arm A. Grade 3-4 neutropenia was the main toxicity observed (56.1% in arm A and 11.4% in arm B).Our data demonstrate the feasibility of a sequential approach of cisplatin plus docetaxel followed by single-agent gemcitabine. Weekly administration of platinum-docetaxel is associated with an improved safety profile but lower efficacy than the conventional three-weekly schedule (registration ID 2004-001044-72).

Background Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer. Case presentation A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater’s papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater’s papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis. Conclusions This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.