Anterior Exenteration Research Articles

Oncologic Outcomes after Anterior Exenteration for Muscle Invasive Bladder Cancer in Women

We investigated oncologic and urinary outcomes after anterior exenteration for urothelial cell carcinoma in females, identifying tumor characteristics associated with female pelvic organ involvement. We hypothesized that a lack of trigonal or bladder floor tumor, intraoperative palpable posterior mass and clinical lymphadenopathy is associated with a lack of female pelvic organ involvement. We retrospectively reviewed the charts of female patients who underwent radical cystectomy at our institution from 1999 to 2014. Patient and operative characteristics were extracted from the electronic medical record, and performance of hysterectomy was tested for association with disease recurrence. Categorical and continuous variables were analyzed with the chi-square and Student t-test, and Kaplan-Meier analysis was performed to determine recurrence-free survival according to hysterectomy performance. Women who had neobladder creation were additionally evaluated for an association between hysterectomy status, and nighttime wetting and catheter use. Of 322 eligible patients 160 with urothelial cancer did not have a hysterectomy before cystectomy. Mean followup was 2.2 years (SD 2.8). There were 22 patients (13.8%) who had recurrence during followup. No patient or surgical factor other than use of adjuvant chemotherapy or radiation (p <0.01) was associated with recurrence. Of 139 women 32 (23.0%) who underwent exenteration had female pelvic organ involvement. At least 1 of the 3 characteristics of interest were present in 28 of 99 (28.3%) women with any genitourinary organ involvement compared to only 4 of 40 (10.0%) of those who did not (p=0.01). Nighttime continence ranged between 21.9% and 48% but there was no significant association with continence and hysterectomy status. Lack of trigonal/bladder floor tumor, palpable posterior mass and clinical lymphadenopathy is associated with the absence of pelvic organ involvement. Individualized risk assessment using these factors along with patient preferences should be used to guide surgical planning.

Pelvic Exenterations for Advanced and Recurrent Endometrial Cancer: Clinical Outcomes of 40 Patients.

The aim of this study was to analyze the clinical experience and outcome of patients who have undergone pelvic exenteration for primary advanced or recurrent endometrial cancer. We analyzed the medical records of 40 women who underwent pelvic exenteration to treat primary advanced or recurrent endometrial cancer. Pelvic exenteration was performed in 40 patients with primary advanced or recurrent endometrial cancer. Three patients (8%) underwent a primary exenteration, and 37 patients (92%) underwent a secondary exenteration. A total exenteration, anterior exenteration, and posterior exenteration was performed in 85%, 5%, and 10% of patients, respectively.In 31 cases, exenteration was performed with a curative aim, and in 9 cases, exenteration was performed with a palliative aim. The overall survival rates were 61.4% at 5 years and 51.1% at 10 years. For the 31 patients who underwent pelvic exenteration with a curative aim, the overall survival rates were higher than those for the entire study population and were 72.6% at 5 years and 59.4% at 10 years. For the 9 patients who underwent a palliative exenteration, the overall survival rates were 19.1% at 5 years and 0% at 10 years. This is to the best of our knowledge the biggest study of pelvic exenteration in patients with endometrial cancer. Our data show that pelvic exenterations are a valid therapeutic option with long-term survival in select patients.

Our Experience of Laparoscopic Anterior Exenteration in Locally Advanced Cervical Carcinoma

Study ObjectiveTo show the feasibility, technique, and results of laparoscopic anterior exenteration in selected patients. DesignA retrospective cohort study. SettingGalaxy Care Laparoscopy Institute, Pune, India. PatientsSeventy-four of 85 patients who underwent laparoscopic anterior exenteration for stage IVA carcinoma of the cervix from January 2005 to January 2015 were analyzed; the median follow-up was 30 months. Contrast-enhanced computed tomographic imaging of the abdomen and pelvis was performed for all patients. InterventionsThe same surgeon and team performed all the operations for uniformity in 10 operative steps. Measurements and Main ResultsThe mean operative time was 180 minutes, and the mean blood loss was 160 mL. The mean hospital stay was 6 days. The average number of lymph nodes removed was 21.4. Surgical margins were negative in all patients. Forty-two patients had positive lymph nodes. Chemoradiation was given to those with positive lymph nodes. Perioperative complications occurred in 15 (20.27%) patients including deep vein thrombosis, urinary tract infection, ureterosigmoid leak (n = 2/74), and so on. Positron emission tomographic imaging and computed tomographic scanning were performed at 6 months after surgery and 6 months after adjuvant therapy in those with positive lymph nodes. There was no immediate postoperative mortality. The overall survival rate at 5 years was 25%. ConclusionLaparoscopic anterior exenteration is feasible in cases of advanced carcinoma of the cervix. Results have shown that in selected patients this procedure is associated with good long-term survival.

Our experience of Laparoscopic Anterior Exenteration in Locally Advanced Cervical Carcinoma

To demonstrate the feasibility, technique and results of laparoscopic anterior exenteration in selected patients.

Salvage Surgery for Cervical Cancer Recurrences.

Cervical cancer usually presents in advanced stages and is treated with chemoradiation. About 15-20% patients present with local recurrence after chemoradiation. Radical surgical resection is the only treatment modality offering long term survival benefit in recurrent cervical cancer. The most common surgical option for these patients is pelvic exenteration. Radical hysterectomy may be done for patients with a small centrally located recurrence in the cervix with no infiltration of adjacent structures. The aim of this study was to evaluate the morbidity and survival outcome following radical hysterectomy and pelvic exenteration for recurrent cancer cervix. We retrospectively reviewed the medical records of our patients who underwent surgery for cancer cervix recurrence from January 2010 to December 2014. The postoperative morbidity was considered early if it happened in the initial 30days of surgery and late if it occurred after 30days. All patients were followed up till February 2015. Survival analysis was done using Kaplan- Meir method. Between January 2010 and December 2014, 20 patients with recurrent cervical cancer underwent radical surgical resection. The median age of the study group was 43years (range 28-63years). Seventeen patients had squamous cell carcinoma and 3 had adenocarcinoma. 13 underwent pelvic exenteration and 7 patients underwent radical type 2 hysterectomy with bilateral pelvic lymphnode dissection. In the exenteration group, 8 patients had anterior exenteration, 4 had total exenteration and one had posterior exenteration. Urinary diversion was done by ileal conduit in 8 patients, double barrel colostomy in two and wet colostomy in two patients. There were no immediate postoperative deaths. Operating time, blood transfusions needed and hospital stay was more in the exenteration group compared to radical hysterectomy patients. After pelvic exenteration post-operative complications were seen in 76.9% of which the most common was of the urinary tract including 3 patients with pyelonephritis, 5 had renal insufficiency and 2 patients developed urinary fistulae. Post-operative morbidity was lower in radical hysterectomy patients. There were two patients in the hysterectomy group who developed vault recurrence while none in the exenteration group had local recurrence. The median follow up time was 19months (range 9-53months).Three year overall survival for the entire cohort was 43%. Median survival time for the exenteration group was 28months which was significantly higher than 14months for the radical hysterectomy group. This study shows that radical surgical resection is feasible with good survival outcome and acceptable morbidity in recurrent cancer cervix patients. Radical hysterectomy can be done in selected patients but pelvic exenteration has better long-term survival but with the potential for both short- & long-term complications.

Role of MR Imaging and FDG PET/CT in Selection and Follow-up of Patients Treated with Pelvic Exenteration for Gynecologic Malignancies.

Pelvic exenteration (PE) is a radical surgical procedure used for the past 6 decades to treat locally advanced malignant diseases confined to the pelvis, particularly persistent or recurrent gynecologic cancers in the irradiated pelvis. The traditional surgical technique known as total PE consists of resection of all pelvic viscera followed by reconstruction. Depending on the tumor extent, the procedure can be tailored to remove only anterior or posterior structures, including the bladder (anterior exenteration) or rectum (posterior exenteration). Conversely, more extended pelvic resection can be performed if the pelvic sidewall is invaded by cancer. Preoperative imaging evaluation with magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is central to establishing tumor resectability and therefore patient eligibility for the procedure. These imaging modalities complement each other in diagnosis of tumor recurrence and differentiation of persistent disease from posttreatment changes. MR imaging can accurately demonstrate local tumor extent and show adjacent organ invasion. FDG PET/CT is useful in excluding nodal and distant metastases. In addition, FDG PET/CT metrics may serve as predictive biomarkers for overall and disease-free survival. This pictorial review describes different types of exenterative surgical procedures and illustrates the central role of imaging in accurate patient selection, treatment planning, and postsurgical surveillance.

Synchronous ipsilateral renal cell carcinoma and urothelial carcinoma of kidney or ureter: Cases report and literature review

Synchronous ipsilateral renal cell carcinoma and urothelial carcinoma of kidney or ureter: Cases report and literature review

Continent urinary diversion following anterior exenteration

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Laparoscopic Anterior Exenteration With Intracorporeal Uretero-Sigmoidostomy

To demonstrate the feasibility of laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy. After Institutional Review Board approval was obtained, patients who had undergone laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy were analyzed. Fifty-seven patients with advanced cervical carcinoma, stage IV A, since 2005 were analyzed retrospectively. The preoperative workup was done with contrast-enhanced computed tomography abdomen-pelvis and positron emission tomography (PET) scans. Patients were analyzed for operative time, blood loss, and complications. Patient follow-up was done monthly for the first 3 months, every 3 months for 1 year, and then every 6 months for 3 years. Postoperative follow-up was done with PET scans. Galaxy Care Laparoscopic Institute, Pune, India. Operative steps were as follows: The mean operative time was 180 minutes (range, 140-240 minutes), and mean blood loss was 100 mL (range, 50-200 mL), as measured by the amount of blood in the suction machine. The median duration of hospital stay was 4 days (range, 3-7 days). The mean number of lymph nodes retrieved was 12 (range, 9-21). Surgical margins were negative in all patients with a lateral margin >2 cm. Twenty-eight patients had positive lymph nodes. Chemoradiotherapy was given to the patients with positive lymph nodes. Minor leak was present in 11 patients in the immediate postoperative period, for which no active intervention was required. Hyperchloremic metabolic acidosis which was seen on biochemical parameter but clinically patient have no manifestation and was treated with sodium bicarbonate. A postoperative PET scan was done at 6 months after the completion of adjuvant therapy in lymph node-positive patients and 6 months after surgery in node-negative patients. Exenteration has a definitive role in the treatment of advanced cervical cancer. Results have demonstrated the feasibility of this procedure [1-4].

Radical surgical approach for synchronous ovarian and uterine cervix tumor with uterine cervix liver metastasis

Synchronous ovarian and uterine cervix malignancies are extremely rare gynecologic neoplasia. In the meantime the presence of hepatic metastases originating from cervical cancer is another rare situation, the liver being more often a common site of metastases for ovarian malignancies. We present the case of a 63-year-old patient who was diagnosed with a moderately differentiated squamous cell cervical tumor with urinary bladder invasion associated with an ovarian tumorand liver metastases. An anterior exenteration and atypical liver resection were performed; the histopathological studies revealed the presence of a moderately differentiated squamous cell uterine cervix carcinoma and a well differentiated serous epithelial ovarian adenocarcinoma; the histopathological examination of the liver lesions confirmed the presence of a squamous cell type originating from the uterine cervix neoplasm.

Clear cell adenocarcinoma of the urethra: review of the literature.

Background. Clear cell adenocarcinoma of the urethra (CCAU) is extremely rare and a number of clinicians may be unfamiliar with its diagnosis and biological behaviour. Aims. To review the literature on CCAU. Methods. Various internet databases were used. Results/Literature Review. (i) CCAU occurs in adults and in women in the great majority of cases. (ii) It has a particular association with urethral diverticulum, which has been present in 56% of the patients; is indistinguishable from clear cell adenocarcinoma of the female genital tract but is not associated with endometriosis; and probably does not arise by malignant transformation of nephrogenic adenoma. (iii) It is usually, readily distinguished from nephrogenic adenoma because of greater cytological a-typicality and mitotic activity and does not stain for prostate-specific antigen or prostatic acid phosphatase. (iv) It has been treated by anterior exenteration in women and cystoprostatectomy in men and at times by radiotherapy; chemotherapy has rarely been given. (v) CCAU is aggressive with low 5-year survival rates. (vi) There is no consensus opinion of treatment options that would improve the prognosis. Conclusions. Few cases of CCAU have been reported. Urologists, gynaecologists, pathologists, and oncologists should report cases of CCAU they encounter and enter them into a multicentric trial to determine the best treatment options that would improve the prognosis.

Reoperative Pelvic Surgery

Reoperative pelvic surgery is technically challenging and carries with it significant potential risk. Pelvic pathology that requires reoperative surgery typically involves recurrent malignancies, complications from ileal pouch-anal anastomoses (IPAA) for inflammatory bowel disease, complications from low pelvic anastomoses, and palliative situations. The goals of reoperative pelvic surgery are resection/repair of the primary indication and reconstruction whenever possible. This review describes pelvic anatomy and operative management for recurrent rectal cancer. Complications following IPAA, low anastomotic complications, and palliative reoperative pelvic surgery are also detailed. Tables outline prognostic factors negatively impacting outcomes following surgery for recurrent rectal cancer, absolute and relative contraindications for exenterative surgery, survival following exenteration for recurrent rectal cancer, intraoperative radiotherapy doses related to resection margin, indications for reoperative pouch surgery, and mobilization techniques for difficult reconstructions. Figures show anterior and posterior exenteration; the anatomy of presacral space after rectal mobilization; vascular exposure and dissection; unicortical transverse osteotomy; placement of Silastic mesh; division of the sacrospinous and sacrotuberous ligaments and piriformis muscle; posterior sacral osteotomy; transperineal delivery of pedicled myocutaneous rectus flap; vertical rectus abdominis myocutaneous flap; gracilis flap; total thigh fillet flap; sacropelvic resection classification; and increasing colon length with primary, secondary, and tertiary maneuvers. This review contains 18 figures, 6 tables, and 89 references.

Periocular Sebaceous Cell Carcinoma Following Chemical Burn

This study reports a unique case of a Marjolin ulcer in a patient who presented with periocular sebaceous cell carcinoma 16 years after a lye chemical burn. A 68-year-old woman presented with a long history of irregular and tender right upper and lower eyelid margins, periocular erythema, madarosis, trichiasis, ptosis, and chemosis, occurring many years after chemical burn to the area. After eyelid biopsy established the diagnosis of sebaceous cell carcinoma, subsequent map biopsies of the conjunctival surface revealed extensive sebaceous cell carcinoma with pagetoid spread, necessitating anterior exenteration for definitive treatment. This report describes the first case in which a sebaceous cell carcinoma has arisen in the area of a chemical burn. Sebaceous cell carcinomas should be included in the spectrum of Marjolin ulcers, and ophthalmologists should be aware of this entity when evaluating patients with a history of a burn to the eyelids.

Laparoscopic Anterior Exenteration with Intra-Corporeal Uretero-Sigmoidostomy

In advanced pelvic cancers laparoscopy has been established a one of the modalities for doing anterior exenteration. The problem is not only the advanced procedure, but urinary diversion. There are various diversions available. Continent neo-bladder is not possible in post radiotherapy and post chemotherapy cases in female. the rest of the urinary diversions have an abdominal stoma. In our country stomas are not well accepted. Thus ureterosigmoidostomy is the best option. If this can be done laparoscopically,then the morbidity would be less. In the last 10 years we have done 40 anterior exenterations with uretero-sigmoidostomy. Though hyerchloremic acidosis is a known complication, the biochemical alterations are not so much to require hospitalisation. We present our technique of Laparoscopic anterior exenteration with intra-corporeal ureterosigmoid.

The role of palliative surgery in castration-resistant prostate cancer.

Androgen deprivation therapy with luteinising hormone releasing hormone (LHRH) analogues or antagonists represents the treatment of choice in men metastatic prostate cancer (PCA). Depending on the serum concentration of the prostate-specific antigen (PSA) nadir, the survival might vary between 11 and 78 months. About one-third of all patients without local treatment of the primary will develop significant complications of the lower and upper urinary tract because of local progression of PCA. It is the purpose of the review to inform the treating physician about palliative surgical options in men with castration-resistant prostate cancer (CRPC). In men with CRPC and lower urinary tract symptoms, palliative transurethral resection of the prostate (TUR-P) can be performed with a 60-70% success rate. Infiltration of the pelvic floor, the bladder neck and trigone and the external urethral sphincter can make palliative radical surgery necessary. Bladder neck closure with continent vesicostomy, radical cystoprostatectomy with an incontinent urinary diversion, and anterior and posterior exenteration are individual therapeutic options in men with a good performance status and a considerable life expectancy. Symptomatic involvement of the upper urinary tract can be managed by placement of endoluminal stents or a percutaneous nephrostomy in men with a poor performance. In men with a good response to androgen deprivation therapy (ADT) and a good performance status reconstructive ureteral surgery might be considered and the options of ureteral reimplantation, ureter ileal replacement and a subcutaneous pyelovesical bypass have to be discussed. There are various palliative surgical treatment options in the management of men with CRPC and symptomatic deterioration of the lower or the upper urinary tract, which should be considered in well selected patients. The indication to perform one of the above-mentioned surgical approaches needs to be discussed in a multidisciplinary tumour board.

DUBENS EKSENTERACINĖS OPERACIJOS – ULTRARADIKALIOS OPERACIJOS KLAIPĖDOS UNIVERSITETINĖJE LIGONINĖJE

Tyrimo tikslas: apžvelgti ir išanalizuoti Klaipėdos universitetinės ligoninės patirtį atliekant dubens eksenteracines operacijas bei palyginti su literatūros duomenimis. Tyrimo metodai: retrospektyvinė apžvalga moterų, kurioms nuo 2011 m. gegužės mėn. iki 2013 m. gruodžio mėn. buvo atliktos dubens eksenteracinės operacijos. Įvertintos jų komplikacijos bei baigtys. Rezultatai: išanalizuota 8 ligonių duomenys. Vidutinis amžius – 56,6 (36 – 72) m. Vidutinis atkryčio laikas nuo pirminio naviko gydymo buvo apie 3,5 (0,5 – 8) m. 7 moterims iš 8 dubens eksenteracinė operacija atlikta kaip radikalus, o 1 – paliatyvus gydymo metodas. Dažniausia indikacija operacijai buvo gimdos kaklelio vėžio recidyvas (62,5%). Iš 8 į studiją įtrauktų moterų 3 atliktos pilnos, 3 – priekinės ir 2 – užpakalinės dubens eksenteracinės operacijos. 1 atlikta infralevatorinė rezekcija, likusioms 7 – supralevatorinės rezekcijos. Vidutinė operacijos trukmė – 306,25 (210 – 370) min. Radikaliai operaciją pavyko atlikti 75% moterų (n=6). Nebuvo nei vieno mirties atvejo po operacijos hospitalizacijos metu. Vidutinis hospitalizacijos laikas - 23,375 (14- 51) dienos. Komplikacijos ankstyvuoju pooperaciniu periodu išryškėjo 37,5% (n =3) pacienčių. Vėlyvų komplikacijų pasitaikė 50% moterų (n=4). Per mūsų studijos stebėjimo laikotarpį buvo vienas mirties atvejis dėl ligos progresavimo ir vienas mirties atvejis dėl miokardo infarkto. Ligos progresavimas diagnozuotas 37,5% pacienčių (n=3). Dviem iš jų dubens eksenteracinė operacija atlikta neradikaliai. Po dubens eksenteracinės operacijos 3 moterims taikyta chemoterapija. Išvados: 1. Dubens eksenteracinė operacija išlie- DUBENS EKSENTERACINĖS OPERACIJOS – ULTRARADIKALIOS OPERACIJOS KLAIPĖDOS UNIVERSITETINĖJE LIGONINĖJE Raimondas Šiaulys1, Justina Domarkaitė1,2, Michail Tarachovskij1,2 1Klaipėdos universitetinė ligoninė, 2Vilniaus universiteto Medicinos fakultetas ka paskutinis radikalus gydymo metodas moterims su recidyvuojančia onkoginekologine patologija. 2. Pacientės turi būti maksimaliai ištirtos, kad sumažėtų neradikalių operacijų skaičius. Nepaisant to, visada bus dalis ligonių, kurioms galimybę atlikti radikalią operaciją pavyks įvertinti tik pačios operacijos metu. 3. Pooperacinės komplikacijos yra dažnos ir gali būti mirtinos.

Primary proximal urethral adenocarcinoma: Case report and brief review

Primary urethral cancer in females is rare. It has a poor prognosis. The published data on this topic are limited, composed mostly of small case series. This paper presents a case of an advanced adenocarcinoma of the urethra, intestinal type, treated with anterior exenteration.

Characteristics of Gynecologic Oncology Patients in King Chulalongkorn Memorial Hospital - Complications and Outcome of Pelvic Exenteration

Pelvic exenteration is a procedure which includes enbloc resection of pelvic organs followed by surgical reconstruction. Aims include both cure and palliation but data for pelvic exenteration in Thailand are very limited. This study was conducted to evaluate characteristics of patients, operative procedure outcomes and complications. This retrospective review covered all of the charts of exenteration patients during January 2002 to December 2011. Baseline characteristic of the patients were collected as well as details of clinical results. A total of 13 cases of pelvic exenteration were included. Most underwent total pelvic exenteration (9 cases) and the remainder posterior and anterior exenteration. Their primary cancers were ovarian, cervical and vulva. Mean operative time was 532 minutes (SD 160.2, range 270- 750) and estimated blood loss was 2830 ml (1850, 1000-8000). Mean tumor size was 7.33 cm (3.75, 4-15). Mean hospital stay was 35.2 days (29.8, 13-109). The most common post operative complication was urinary tract infection. Overall disease free survival with a negative surgical margin was significantly better than in positive surgical margin patients (p=0.014). Surgical margin was the most significant prognostic factor for disease free survival, in line with earlier studies.

Primary Clear Cell Adenocarcinoma of a Urethral Diverticulum Treated with Multidisciplinary Robotic Anterior Pelvic Exenteration

Primary urethral carcinoma is extremely rare and is marked by a variety of clinical symptoms. Primary carcinoma of a urethral diverticulum is still rarer and clear cell adenocarcinoma of the urethra is particularly uncommon (Swartz et al., 2006). Such infrequency has led to inadequate management guidance in the literature for a disease that is often late in presentation and carries substantial morbidity and mortality. This treatable but grave disease deserves definitive curative treatment. We present the first published instance in which it was treated with robotic anterior exenteration. In our case, a 47-year-old female was referred to the urology service for investigation of recurring urinary tract infections. During the workup, the patient was found to have an advanced clear cell urethral adenocarcinoma originating in a urethral diverticulum. We discuss the natural history of this condition, its consequences, and the first instance of its treatment using robotic anterior pelvic exenteration.

Primary Clear Cell Adenocarcinoma in a Female Urethral Diverticulum: A Case Report and Review

Clear Cell Adenocarcinoma is a very rare variant of lower urinary tract malignancy. We present a 54 years old lady who presented with haematuria and a urethral mass on ultrasound. MRI subsequently demonstrated a heterogeneous mass within a urethral diverticulum. Biopsies of the mass demonstrated clear cell adenocarcinoma with clearing of the cytoplasm, moderate nuclear pleomorphism. Immunohistochemically cells were positive for: cytokeratin 7 and p16, p53, CA125, CAM5.2, AE1/AE3. They were negative for: thrombomodulin, oestrogen, progesterone, cytokeratin 20, p63, CD10, CEAP, WT1, AFP, s100. She underwent anterior exenteration with pelvic lymphadenectomy, and ileal conduit formation. Histology of which demonstrated surgically clear margins but 3/6 positive lymph nodes. She underwent 50.4Gy for consolidative radiotherapy given the lack of known benefit for chemotherapy. Subsequent PET scans have demonstrated lymphatic disease progression, but remains alive one year after diagnosis. doi: http://dx.doi.org/10.4021/wjnu67w