Bilateral Metastases Research Articles

Abstract #1399687: Precision Oncology in the Management of Medullary Thyroid Cancer in an Adolescent with MEN2B, 1-year Follow-up

Medullary thyroid carcinoma (MTC) is a rare but aggressive thyroid tumor, with 25% of hereditary and 75% of sporadic forms. RET mutations are found in 98% of hereditary MTC and in 55% of sporadic MTC. Targeted therapies are a management option for patients with progressive or symptomatic disease with locoregional or metastatic MTC. We present the case of an adolescent with type 2B multiple endocrine neoplasia (MEN-2B) syndrome with an optimal response to pralsetinib. A 14-year-old adolescent, she was admitted for maxillofacial surgery in September 2019 due to a thyroid nodule and cervical nodes whose FNA reported: MTC; she underwent total thyroidectomy extended to prethyroid muscles + bilateral radical dissection. The pathology reported: multicentric MTC: in LTL tumor of 3.0 x 1.5cm, with invasion of tumor capsule and extraglandular 4mm to the adiposomuscular plane, lymphatic and venous permeation, tumor in isthmus of 1cm and RTL of 0.6cm; Bilateral periglandular and cervical lymph node metastasis (23/58) EC-IVA. Endocrinological evaluation showed a marfanoid phenotype, thick lips, tongue neuromas, diastema, and a history of chronic constipation with segmental colonic dilatation on abdominal radiography. No history of HTA. No similar family history. PET-CT-18FDG: mediastinal lymph nodes suggestive of metastasis. She received cervical-mediastinal radiotherapy: 6000 cGy in April 2020. Follow-up was interrupted due to a pandemic, she was readmitted with mediastinal disease progression according to PET-CT in June 2021. She had access to a genetic NGS tumor study that showed the RET M918T mutation. In December 2021, she started Pralsetinib 200 mg/day, achieving a biochemical and structural response in follow-up sustained to date, without developing major adverse events. The NCCN Guidelines advise performing the RET study at the time of initial diagnosis. Targeted therapies have helped supplant cytotoxic chemotherapy, which has low efficacy against disease progression, but there is still the problem of toxic side effects and frequent development of tumor resistance when using the current treatment regimen. In this case, with the MEN-2B criteria established, the RET M918T mutation detected. and presenting with disease progression (elevated calcitonin and CEA, associated with mediastinal disease progression), she agreed to an expanded program of anti-RET therapy with Pralsetinib, demonstrating safety and efficacy after 1 year of use.

BILATERAL BREAST METASTASES OF RECTAL ADENOCARCINOMA: CASE REPORT AND REVIEW OF THE LITERATURE

Breast metastasis from extramammary neoplasm is rare and with poor prognosis. A 25-year-old patient presented with a lump in her right breastthree months after concurrent chemoradiotherapy for an IIc stage rectal adenocarcinoma (T4bN0M0) and during her neoadjuvant chemotherapy with FOLFOX. The investigationsconfirmeda bilateral breast metastasis of rectal adenocarcinoma.

Bilateral infiltrative kidney metastasis due to non-keratinizing squamous cell carcinoma of the lung: lesson for the clinical nephrologist.

Bilateral infiltrative kidney metastasis due to non-keratinizing squamous cell carcinoma of the lung: lesson for the clinical nephrologist.

Younger Than 55 Years Old and BRAF V600E Mutation are Risk Factors for Lymph Node Metastasis in Papillary Thyroid Carcinomas ≤1.0 cm but Not in >1.0 cm.

Studies on the relationship between BRAF V600E mutation and the clinicopathologic features of papillary thyroid carcinoma (PTC), risk of lymph node metastasis in papillary thyroid microcarcinoma (PTMC) have shown inconsistent results. In this retrospective analysis, clinicopathological data of the patients were collected, and molecular testing was done for BRAF V600E mutation. PTC patients are divided into PTC≤1.0cm (PTMC) and PTC>1.0cm, and the relationship between BRAF V600E mutation and clinicopathologic features was analyzed respectively. Of the 520 PTC patients, 432 (83.1%) were female and 416 (80.0%) were <55 years old. BRAF V600E mutation was detected in 422 (81.2%) tumour samples of PTC. There was no significant difference in the frequency of BRAF V600E mutation between different age groups. There were 250 (48.1%) patients with PTMC and 270 (51.9%) patients with PTC>1.0cm. BRAF V600E mutation was significantly associated with bilateral cancer (23.0% vs 4.9%, P=0.005) and lymph node metastasis (61.7% vs 39.0%, P=0.009) in PTMC patients, while BRAF V600E mutation was significantly associated with bilateral cancer (24.9% vs 12.3%, P=0.048) in PTC>1.0cm patients. Logistic regression analysis showed that, after adjusting for gender, Hashimoto's thyroiditis and calcification, we found that younger age (<55 years old) (OR: 2.384, 95% CI: 1.241-4.579, P=0.009) and BRAF V600E mutation (OR: 2.213, 95% CI: 1.085-4.512, P=0.029) were significantly associated with lymph node metastasis in PTMC, similar results were not obtained in PTC>1.0cm. Younger age (<55 years old) and BRAF V600E mutation was independent risk factor for lymph node metastasis in PTMC.

PATTERN OF NECK LYMPH NODE METASTASIS AND FACTORS AFFECTING THE LYMPH NODE METASTASIS IN SQUAMOUS CELL CARCINOMAS OF HEAD AND NECK

Background: Head and neck cancer exhibits metastases to cervical lymph nodes through certain lymphatic drainage routes. The 5-year survival rate for patients with neck metastases reduces depending on the number and level of nodes involved. To assess the patterns of lymph Objective: node metastasis for squamous cell carcinoma of head and neck and analyse the prognostic factors of cervical node status and highlight their effect on treatment and prognosis. The study entailed a cross sectional analysis of Method: 66 patients with squamous cell carcinoma of head and neck radiologically or pathologically proven. Data collected and was analysed by a chi square test using SPSS (version 20). Of the 66 clinically Results: node-positive patients, 18 had bilateral lymph node metastasis and 48 had ipsilateral LNM. In all primary sites pattern of lymph drainage was followed except for in 1 case of carcinoma larynx where metastasis was to level II and IV without involvement of level III. We Conclusion: concluded majority of the HNSCC cases followed normal pattern of drainage and in individuals with oral cavity and oropharynx SCC, the incidence of bilateral neck LNMs are high particularly to level II of contralateral side. With higher stage of the disease and long duration of symptoms chances of lymph node metastasis is high thus worsening the prognosis. Bilateral neck dissection is recommended for primary surgical treatment, with the exception of early stages, when ipsilateral neck dissection may be performed

Pattern of Neck Node Metastases In Laryngeal Carcinoma

Background: Cancer continues to be a major health problem despite advances in medical technology for its diagnosis and treatment. Cancer of the larynx is the eleventh most common cancer in the world. Carcinoma larynx is a multifactorial disease. Smoking, betel-nut, betel-leaf chewing habit and drinking alcohol are the most important factors associated with carcinoma larynx. Objective: To find out the patterns of neck node metastases in laryngeal carcinoma. Methods: Observational cross-sectional study was carried out in the Department of ENT and Head Neck Surgery, Dhaka Medical College Hospital (DMCH) from January’ 2018 to December’ 2019. Total 100 patients diagnosed as laryngeal carcinoma with neck metastases were included in this study. Statistical analyses were carried out by using the Statistical Package for Social Sciences version 23.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Results: The mean age was found 57.8±12.7 years with range from 37 to 79 years. Males were predominant (76.0%) and females were (24.0%). Male: female ratio was 3.17:1. More than two third (68.0%) patients had supraglottis, 26.0% had glottis and 6.0% had subglottis. Supraglottic was found in 68 patients among them 27(39.7%) were T3, 18(26.5%) were T3. Glottic was found in 26 patients among them 16(61.5%) were T3, 6(23.1%) were T2, 4(15.4%) were T4a. Subglottic was found in 6 patients among them 4(66.7%) were T3 and 2(33.3%) was T2. Supraglottic was found in 68 patients among them 34(50.0%) were N1, 28(41.1%) were N2 and 6(8.8%) were N3. Glottic was found in 26 patients among them 20(76.9%) were N1 and 6(23.1%) were N2. Subglottic was found in 6 patients among them 4(66.7%) were N1 and 2(33.3%) was N2. supraglottic was found in 68 patients, among them majority 17(50.0%) patients were found in level II of neck nodes. Glottis was found in 26 patients, among them 16(61.5%) patients were found in level III of neck nodes. Subglottic found in 6 patients, among them 4(66.7%) patient was found in level IV of neck nodes. Unilateral neck node metastasis was more common 9(96.0%) than bilateral neck node metastasis 4(4.0%), out of them single neck node metastasis 84(84.0%) is more than multiple neck node metastasis 16(16.0%). Majority 46(46.0%) patients had stage III, 38(38.0%) had stage II, 10(10.0%) had stage I and 6(6.0%) had stage IV. Conclusion: Laryngeal carcinoma is a common clinical entity in otolaryngology practice. Male were more predominant and the highest age group was 51-60 years. Common clinical presentation was difficulty in swallowing and hoarseness of voice. In this study most common Laryngeal carcinoma was supraglottic in nature and majority of them were in level II. N1 was the most common pattern of neck node metastasis. Most of the neck nodes are unilateral and single. Stage III was the commonest stage of involvement. J Dhaka Med Coll. 2021; 29(1): 52-60

Ileal Neuroendocrine Tumour Causing Carcinoid Syndrome in Absence of Hepatic Metastasis

Carcinoid syndrome consists of the classic symptom triad of flushing, diarrhoea, and valvular heart disease. It occurs in the majority of patients with liver metastases. This report presents a 68-year-old female who suffered from chronic diarrhoea with a history of multiple admissions for the same. On evaluation, a Computed Tomography (CT) scan showed a terminal ileal lesion and bulky ovaries. Suspecting Neuroendocrine Tumour (NET) with carcinoid syndrome, a Gallium 68 DOTANOC (DOTA-1-Nal3- octreotide) scan was done which revealed somatostatin receptor expression in enhancing soft tissue lesion in terminal ileum as well as in bilateral adnexa. This confirmed the diagnosis of NET of the ileum and bilateral ovarian metastases. The patient underwent laparoscopic curative resection of the primary tumour along with bilateral oophorectomy. The patient was diagnosed with ileal NET and presented with clinical symptoms of carcinoid syndrome, yet did not have evidence of hepatic metastasis, but instead had bilateral ovarian metastasis which itself is a rare entity.

Unusual and extremely rare sites of metastases in gallbladder carcinoma

Gallbladder carcinoma is an aggressive neoplasm that is often diagnosed only in the later stages of the disease progression. Common sites of distant metastases of primary carcinoma gallbladder include lymph nodes, peritoneum and lung. Only a few cases of metastases to adrenal glands and kidneys have been reported in literature. Cutaneous and muscular metastases from gallbladder cancer are also unusual, and an extensive literature search revealed only a few cases to date. We present two such cases of gallbladder carcinoma which presented with metastases to these rare sites at the time of diagnosis which were detected by 18 fluorodeoxyglucose positron emission tomography/ computed tomography (18F FDG PET/CT). The first case is of a 45-year-old lady who presented to the general surgery department with complaints of abdominal pain, loss of appetite and nausea for 2 months. Conventional imaging with ultrasound and contrast-enhanced computed tomography (CECT) of the abdomen showed asymmetric gallbladder wall thickening occupying the fundus and body with extensive regional lymphadenopathy. 18F FDG PET/CT revealed a metabolically active gallbladder mass with bilateral adrenal gland lesions with cutaneous, muscular and skeletal metastases. The second case is of a 35-year-old lady who complained of left upper quadrant abdominal pain and nausea for one month. Successive CECT and Magnetic Resonance Cholangiopancreatography (MRCP) studies made the radiological diagnosis of gallbladder neoplasm. Pre-operative 18F FDG PET/CT showed a metabolically active gallbladder mass with bilateral adrenal gland lesions, lymph node involvement and bilateral renal metastasis. The Third case was 75 years old male who had incidental carcinoma gall bladder on cholecystectomy and PETCT was done for staging, and it showed metabolically active liver SOL, Bilateral adrenal deposits with mediastinal abdominal, retroperitoneal and lymph nodes. The fourth case is a 55 year old female who was diagnosed as neck gall bladder wall thickening on ultrasonography on further evaluation PETCT was done which showed hypermetabolic gall bladder neck wall thickening along with bilateral adrenal lesion and abdominal, retroperitoneal and retro-crural and right supraclavicular lymph nodes. Adrenal and other metastasis detection on 18F FDG PET/CT led to a change in the management from curative surgery to palliative chemotherapy in all patients. Thus,18F FDG PET/CT is a valuable modality in such type of cases that aids decision making regarding staging, appropriate management and monitoring response to therapy.

Immunohistochemical Algorithm for the Classification of Muscle-Invasive Urinary Bladder Carcinoma with Lymph Node Metastasis: An Institutional Study.

Muscle-invasive urothelial carcinoma represents 20% of newly diagnosed cases of bladder cancer, and most cases show aggressive biological behavior with a poor prognosis. It is necessary to identify biomarkers that can be used as prognostic and predictive factors in daily clinical practice. In our study, we analyzed different antibodies in selected cases of muscle-invasive urinary bladder carcinoma and lymph node metastasis to identify immunohistochemical types and their value as possible prognostic factors. A total of 38 patients were included, 87% men and 13% women, with a mean age of 67.8 years. The most frequent histopathological type was urothelial carcinoma. In the primary lesion, the mixed type was the most common. In unilateral metastasis, the mixed type was the most frequently found. In cases of primary lesions and bilateral metastasis, the luminal and mixed types were observed. The luminal subtype was the most stable in immunohistochemical expression across primary tumors and metastases. The basal type showed a better prognosis in terms of disease-free survival. In conclusion, immunohistochemical studies are useful in assessing primary and metastatic lesions in patients with urothelial carcinoma. Immunohistochemical classification can typify muscle-invasive urothelial carcinoma, and the immunophenotype seems to have prognostic implications.

CLEAR CELL VARIANT OF SQUAMOUS CELL CARCINOMA PENIS – A CASE REPORT

Carcinoma penis is a rare malignancy in males. The World Health Organization Classification of Tumors of the Urinary System and Male Genital Organs classifies squamous cell carcinoma of the penis into human papillomavirus (HPV) and non HPV related. Among the HPV-related Squamous cell carcinomas of the penis, clear cell variant is a rare. Here we report a case of clear cell variant of squamous cell carcinoma of penis with bilateral inguinal lymph node metastasis. We have treated this patient with radical surgery, wide excision and bilateral inguinal lymph node dissection followed by post operative chemo radiation. But during radiation itself the disease progressed, with rapid recurrence of inguinal lymph node metastasis, finally end up with palliative chemotherapy. Clear cell carcinoma is an aggressive form of cancer, with frequent metastasis to the inguinal lymph nodes, as seen in this case. Immunohistochemistry examination P16 was absent. So it is considered as clear cell variant of squamous cell carcinoma. Clinical experience with penile carcinoma is limited because of their rarity.

NCMP-02. RENAL CELL CARCINOMA WITH METASTASIS TO THE CHOROID PLEXUS

Abstract BACKGROUND Intraventricular brain tumors make up only 0.9–4.5% of all cases of metastatic brain cancer.1 Involvement of the choroid plexus (CP) is even rarer with only a handful of documented cases. 2,3 Here we describe a case of bilateral multifocal metastasis to the choroid plexus appearing 10 years after nephrectomy in a male with stage IV renal cell carcinoma (RCC). CASE PRESENTATION: Our patient is a 74-year-old male with stage IV RCC diagnosed in 2006 and treated with radical nephrectomy and immunotherapy in 2011. In 2020, he presented to the emergency department with altered mental status. Brain magnetic resonance imaging (MRI) revealed an enhancing hemorrhagic lesion in the trigone of the right lateral ventricle (LV) and nodular thickening in the center of the right LV and trigone of the left LV, suggestive of metastatic disease. In 2021, the patient developed refractory seizures, and serial MRIs showed disease progression. He underwent several craniotomies with pathology confirming metastatic clear cell carcinoma, consistent with a renal primary. In 2022, the patient again presented with altered mental status. MRI revealed new avidly enhancing subcentimeter solid nodules in the CP of both LVs consistent with metastatic disease. Per the wishes of the family, palliative measures were pursued, and the patient was discharged home. CONCLUSION RCC can reappear several years after nephrectomy. 4 Metastatic RCC appears to have a unique propensity to spread to the ventricular system and the CP, which indicates late progression of disease. 1,5,6 While surgery may be viable if tumor burden is low, therapeutic options are limited in the advanced disease stages, as in our patient. Palliative care should be offered early to maximize remaining quality of life.

PSUN24 Adrenal Metastases Treated with Radiotherapy: Development of Adrenal Insufficiency

Abstract Introduction Adrenal metastases are the second most common neoplasms of the adrenal cortex. Adrenal insufficiency (AI) develops when more than 90% of the cortex is destroyed. In patients with adrenal metastases requiring local treatment, stereotactic ablative radiation therapy (SAbR) has been shown to be well tolerated. Yet, data on the development of AI following adrenal SAbR are scarce. Therefore, we aimed to assess the incidence, timing, and factors associated with the development of AI in patients undergoing SAbR for the treatment of adrenal metastases. Utilizing an IRB approved registry protocol, we conducted a retrospective longitudinal follow-up study to characterize 66 patients (73% men; median age 61 years) with adrenal metastases who underwent SabR, followed for median 3.8 years from the initial cancer diagnosis and 11.5 months from SAbR. The diagnosis of primary AI was based on low morning serum cortisol levels (&amp;lt;5 μg/dL) with &amp;gt;2-fold elevated plasma ACTH, or peak cortisol &amp;lt;18 μg/dL post cosyntropin. Primary carcinomas included renal cell (41%), lung (38%), colorectal (9%), melanoma (5%), and others (7%). Twenty-four (38%) patients had bilateral adrenal metastases. At the time of SAbR, 41 (62.1%) patients had uninvolved contralateral adrenal glands, 16 (24.2%) had bilateral adrenal metastases, and 9 (13.6%) had contralateral adrenalectomy prior to SAbR. Nine patients had bilateral SAbR and 9 had SAbR to one adrenal gland in the setting of contralateral adrenalectomy. Most patients (66.7%) underwent 5 SAbR fractions, with a median dose of 800 cGy/fraction. In our cohort, 39/66 (59%) patients underwent comprehensive assessment of adrenal function. Overall, 7 (10.6%) patients developed post-SAbR AI at median time of 4.3 months (range, 0.7-20.2). The incidence of post-SAbR AI was 22.2% (2/9) in patients with prior contralateral adrenalectomy, 18.8% (3/16) with bilateral adrenal metastases, and 0% (0/41) with normal contralateral adrenal gland. A 6-month-AI-free survival rate was 72.7% (95% CI, 37.0-90.3) in patients with bilateral metastases and 64.8% (1.6-73.7) in patients with contralateral adrenalectomy. Post-SAbR median progression-free survival (local disease) was 3.0 years, with 6-month and 1-year survival rates of 82.4% and 75.0%, respectively. Conclusions Our study shows thatpatients with a normal contralateral adrenal gland are unlikely to develop post-SAbR AI. In contrast, AI occurred in ∼ 20% of patients with prior contralateral adrenalectomy or bilateral adrenal metastases. In this high-risk cohort, only 60% of patients underwent assessment of adrenal function. It is crucial to monitor adrenal function in patients undergoing SAbR for adrenal metastasis, especially in those with affected or surgically absent contralateral gland. This study reinforces the importance of a team-based approach to the management of patients with adrenal metastasis to improve patient outcomes. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP446 Where's the Nodule?: Atypical Presentation of an Occult Metastatic Papillary Thryoid Carcinoma

Abstract Papillary thyroid Carcinoma (PTC) with apparent distant metastasis but lacking a primary thyroid cancer on pre-operative ultrasonographic examination, is referred by some as occult PTC. In most cases, primary carcinomas are identified after careful pathologic examination of the specimen but in some rare cases the primary tumors were not detected. Hereby, we describe the rare case of a patient with metastatic PTC without initial visualization on imaging of primary tumor location along with inconsistent pathology results between fine needle aspiration (FNA) biopsy and gross specimen pathology results. A 60-year-old female with past medical history of Diabetes Mellitus type 2 and Hypothyroidism presenting for follow-up visit after being found with neck nodules on head and neck CT scan. Thyroid and neck Ultrasound (US) were performed finding three right irregularly shaped hypoechoic lymph nodes (LN's) measuring &amp;gt; 1 cm, concerning for metastatic disease, but no thyroid nodules were noted. Patient denies family history of thyroid cancer, and no head and neck radiation exposure. Physical examination did not reveal goiter or palpable nodules. Laboratory results: TSH: 2.95 and Total T4: 9.32, both within normal range. Cervical LN's FNA biopsy was performed, yielding results consistent with PTC tall cell variant. Chest CT scan showed suspicious lesions for pulmonary micrometastasis. Total thyroidectomy was performed and gross pathology findings showed an infiltrating, follicular variant PTC with multifocal tiny primary tumors of the thyroid, with lesions measuring up to 0.2 cm, dimension which explains why nodules could not be identified on imaging studies. LN's FNA biopsy results and thyroid pathology did not correlate. Thyroid gross pathology was clearly PTC with follicular variant, infiltrating a small area away from greatest dimension tumor, with cells with apparent dedifferentiation to tall cell cytologic features. Due to high risk of recurrence, radioactive iodine therapy was recommended as adjunctive therapy for metastatic disease and eradication of residual neck disease to be started with levels of TSH&amp;gt;30 mU/ml. Postopertative Thyroglobulin level (Tg) was adequate &amp;lt; 0. 01 ng/ml but unreliable based on above normal range antithyroglobulin antibody &amp;gt; 1000 IU/ml, which increases risk of recurrence. Whole body scan also done showing bilateral lung metastasis and small neck metastatic disease. Repeated postoperative thyroid US also demonstrated a suspicious cystic lymph node in right central neck for which FNA with saline washout of aspirate for Tg measurement was ordered. Metastatic thyroid carcinoma without primary tumor after extensive thyroid sampling is a rare but existent phenomenon that can be encountered in daily practice. Genotyping or immunostaining mestastatic lesions could help direct the Pathologist to the source of the metastasis. Patients with a higher risk of recurrence are monitored more aggressively as it is believed that early detection of recurrent disease offers the best opportunity for effective treatment. Presentation: No date and time listed

PSAT281 Crico-tracheal Resection with End-to-End Anastomosis for Locally Advanced Thyroid Cancer: A Case Series of Early Postoperative Outcomes of a Low-Income Country from Latin America

Abstract Introduction Tracheal invasion is a poor prognostic factor in patients with aggressive thyroid cancer. Crico-tracheal resection and primary anastomosis (CTRA) is the preferred surgical technique. Appropriate resection can improve early postoperative outcomes and long-term oncological outcomes. A recent systematic review of eastern literature showed a moderate rate of postoperative complications. However, there is a paucity of data regarding early postoperative complications in Latin America. Therefore, the aim of this report is to describe the early postoperative outcomes of three patients with thyroid cancer invading the trachea who underwent CTRA in two tertiary referral centers (1 public and 1 private) in a low-income country. Clinical Cases There were 2 females (F1: 53 y, F2: 55 y) and 1 male (M1: 53 y) patients from Ecuador. Patient F1 had follicular variant of papillary thyroid cancer (PTC) and was operated on in the public center and patients F2 and M1 had classic variant of PTC. Neck CT and perioperative flexible endoscopy were performed for airway invasion assessment. All patients underwent total thyroidectomy with circumferential CTRA. Patient F1 had a right lobe thyroid tumor with intraluminal invasion of the 5th tracheal ring up to the cricoid cartilage, the recurrent laryngeal nerve (RLN) and common carotid artery, and bilateral central neck lymph node metastasis. She underwent bilateral central neck dissection, carotid shaving, and RLN resection. Patient F2 showed an enlarged, multinodular thyroid invading the 4th up to the 1st tracheal ring, without luminal compromise. There was no invasion to other structures. Patient M1 had a right lobe thyroid tumor, with intraluminal invasion of the 4th tracheal ring up to the cricoid cartilage and invasion of the RLN. He underwent RLN resection. Patient F1 and M1 were classified as Shin IV and patient F2, Shin III. Regarding the 30-day postoperative complications, patient F1 had tracheostomy infection on day 5, tracheal dehiscence and anastomotic dehiscence that caused massive bleeding, cardiorespiratory failure and death on day 8. Patient M1 only presented mild bleeding through the traqueostomy tube on day 1, non-compressive cervical hematoma on day 2, and was discharged on day 5. Patient F2 had no complications and was discharged on day 3. The last 2 patients were decanulated successfully at the 2-week follow-up and received adjuvant radioactive iodine. Conclusions CTRA seems to be a safe procedure with moderate postoperative complications, low mortality, and zero tracheotomy-dependency rates in patients operated in Ecuador. Our results are similar to those described in the international literature. Further studies are needed to confirm these results and draw robust conclusions. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

S1676 Things Are Not Always What They Seem: A Rare Case of Pancreatic Carcinoma Manifesting Through Cutaneous Metastasis

Introduction: Pancreatic cancer is an aggressive disease that commonly metastasizes to the liver, lung, and peritoneum. Cutaneous metastasis is a rare occurrence with an incidence of only 2.0%. We present a case of metastatic pancreatic adenocarcinoma primarily presenting as a cutaneous nodule. Case Description/Methods: A 50-year-old male was undergoing outpatient evaluation for a raised, left scalp lesion along with neck nodules. Associated symptoms included an unintentional 30lb weight loss. Outpatient CT soft tissue neck revealed numerous necrotic lateral neck lymph nodes, lytic lesion with epidural soft tissue extension at C2-4, and occlusion/thrombosis of the left subclavian, brachiocephalic, and left internal jugular veins (Figure). Given these findings, the patient was referred to the Emergency Department (ED). At time of ED arrival, vital signs were stable along with initial laboratory values. CTA PE study showed no pulmonary embolism but revealed numerous pulmonary and bilateral adrenal nodules, multifocal liver and osseous lesions, and widespread lymphadenopathy. Additionally, CT head demonstrated a left scalp soft tissue lesion. Follow up CT abdomen/pelvis revealed a 2.8 x 2.2 x 1.8 cm ill-defined pancreatic lesion and confirmed widespread metastasis including to the muscles. Additional testing revealed elevated cancer markers with Cancer antigen 19-9 (CA 19-9) of 5418 U/mL and carcinoembryonic antigen (CEA) of 63.8 ng/mL. Pathology from initial scalp lesion biopsy showed fragments of necrotic dermis with small foci of poorly differentiated carcinoma. Biopsies of the right and left neck masses revealed poorly differentiated adenocarcinoma of uncertain primary. Therefore, liver biopsy was performed and confirmed non-small cell carcinoma of pancreatobiliary origin. Further imaging to determine treatment course discovered intracranial metastasis and cervical spine disease resulting in cord compression. Ultimately, the patient underwent 4 out of 10 fractions of palliative radiation to the cervical spine but passed away after transitioning to comfort care one month after diagnosis. Discussion: There are less than 25 documented cases of pancreatic cancer with cutaneous involvement; however, it is even more rare that cutaneous involvement prompts initial diagnosis. The umbilicus is the most common site of cutaneous involvement and is referred to as the Sister Mary Joseph Nodule. Involvement of the soft tissue of the scalp and neck is much less common and poorly documented making this case extremely unique.Figure 1.: Axial contrast enhanced CT of the abdomen shows a 2.8 cm ill-defined hypoattenuating mass in the pancreatic tail (A) with multifocal metastatic liver lesions and bilateral adrenal metastasis (B). Axial CT image of the pelvis shows a metastatic lesion in the right rectus femoris muscle (C). On liver biopsy, H&E, 40X,(S21-41666) revealed high grade carcinoma with vesiculated nuclei, prominent nucleoli (D), CA 19-9 IHC 20X diffuse positivity in tumor cells (E) and CK AE1/3 IHC, 20X, diffusely positivee for pancytokeratin in tumor cells confirming carcinoma (F). Axial CT of the head shows a 2.4 cm nodular left parietal scalp soft tissue lesion (G) which was also seen on clinical examination (H). Biopsy of the scalp lesion (H&E, 40X) demonstrated high grade carcinoma with vesiculated nuclei, prominent nucleoli and mitoses (I), histologically similar to liver biopsy findings.

S3566 Birthing a Baby or Surfacing a Hidden Tumor?

Introduction: Malignancy is a rare finding during pregnancy and if present, often carries poor prognosis. We present to you a case of Krukenberg tumor- a metastatic malignancy of the ovary- in a 29 year old female. Case Description/Methods: A 29-year-old female with no past medical history, presented to the hospital with preterm labor at 30 weeks gestation which lead to low transverse caesarian delivery secondary to recurrent prolonged decelerations and preterm contractions. Patient had an uneventful pregnancy course until this hospitalization. Intraoperatively, a large right sided ovarian mass was discovered. Tissue pathology revealed metastatic poorly differentiated adenocarcinoma. CT scan of the abdomen pelvis was suggestive of right adnexal mass measuring 10 × 14 × 13 cm with increased vascularity, large degree of abdominal pelvic ascites, with few lymph nodes in the upper mesenteric arcade, along with moderate thickening of the gastric wall. Esophagogastroduodenoscopy (EGD) revealed a gastric mass at cardia (Figure a), and tissue pathology was consistent with adenocarcinoma with presence of signet ring cells (Figure b). Additional work up was positive for elevated CA 125 and AFP tumor marker measuring 355 U/ml and 10.8 U/ml, respectively. Subsequent follow up with CT abdomen revealed bilateral ovarian metastasis with large volume ascites. Diagnostic paracentesis was negative for malignant ascites. Clinical course was complicated by recurrent ascites and progressive clinical deterioration. Due to poor performance status, the patient did not undergo any surgical intervention. Patient is currently being managed with palliative chemotherapy and paracentesis for symptomatic relief. Discussion: Krukenberg tumor is a metastatic malignancy of the ovary which is characterized by mucin-rich signet-ring adenocarcinoma that arises primarily from a gastrointestinal site. It accounts for almost 1%–2% of all ovarian tumors. The incidence of gastric cancer in the women of reproductive age group is 0.4%–0.5%, making these tumors extremely rare during pregnancy. Pregnancy symptoms masks the presence of the disease leading to diagnosis at a later stage. Unfortunately, no optimal treatment strategy for these tumors have been identified so far. Chemotherapy as well as radiation therapy does not seem to have any significant role in the prognosis of these patients. Due to metastatic nature and lower rate of resectability, surgery is deferred as it does not offer any increased survival time. The overall prognosis remains poor.Figure 1.: (a) EGD revealing gastric mass at cardia (b) Tissue pathology showing adenocarcinoma with presence of signet ring cells.

Ovarian metastases from ALK-positive lung adenocarcinoma: a case report and review of the literature

BackgroundOvarian metastasis is an extremely rare condition in patients with lung adenocarcinoma. Lung adenocarcinoma patients with ovarian metastases were difficult to distinguish from primary ovarian cancer. Anaplastic lymphoma kinase (ALK) gene rearrangement is only found in 3–7% of patients with lung cancer. It is worth noting that the incidence of lung cancer with ovarian metastasis is extremely low, however, ALK rearrangement is often reported in these cases. Here we reported a young woman, aged 23 years, with ALK-positive lung adenocarcinoma and ovarian metastasis.Case DescriptionThe patient underwent laparoscopic bilateral ovarian tumor resection after discovering an abdominal mass accidentally. A series of lung adenocarcinoma-specific immunohistochemical features were detected postoperatively by immunohistochemistry (IHC) analysis. Then extensive-stage metastatic masses of different sizes were identified by 2-deoxy-2-[18F]fluoro-d-glucose (18F-FDG) positron emission tomography combined with low-dose computed tomography (PET/CT), among which the largest nodule was 1.7 cm × 1.4 cm located in the middle lobe of the right lung. Genetic testing of the paraffin tissue DNA revealed the fusion mutation of EML4_ALK (E14:A20) gene. The patient was pathologically diagnosed with lung adenocarcinoma with bilateral ovarian metastasis, administered with oral alectinib [600 mg twice daily (bid)] and followed-up quarterly. Currently, the patient responded to alectinib stably, with a progression-free survival (PFS) of more than 12 months, and experienced no significant adverse events. In addition, we reviewed the publications associated with the characteristics of ALK-positive lung cancer with ovarian metastases and the identification of primary and secondary ovarian tumors.ConclusionsThis case provides a meaningful reference for the possibility of adnexal metastases from lung cancer, particularly for ALK-rearranged young female patients. In addition, this case highlights the advantages of IHC together with genetic testing for identifying origin sites of ovarian metastases and provides a promising treatment option.

An unusual large metastasis

This is a concise letter on the observation of a patient with large bilateral asymmetric ulcerative cutaneous metastasis from rectal carcinoma.

Resection of Colorectal Liver Metastases: Prognostic Impact of Tumor Burden Score Varies with Unilateral Versus Bilateral Metastatic Spread

Resection of Colorectal Liver Metastases: Prognostic Impact of Tumor Burden Score Varies with Unilateral Versus Bilateral Metastatic Spread

The Eyelid Angiosarcoma: A Systematic Review of Characteristics and Clinical Course.

A systematic search for eyelid angiosarcoma was performed from inception to December 2020 in Medline, EMBASE, and the Cochrane databases. Forty two eyelid angiosarcoma cases in 32 articles were analyzed. Eyelid angiosarcomas showed an incidence peak in the eighth decade of life, and was reported more frequently in Caucasian males. Eyelid angiosarcomas were associated with a mortality rate of 26.2%, a recurrence rate of 14.3%, and a cure rate of 45.2%. Four years event-free survival (EFS) rate was 36.0%, with median EFS of 36 months. Eyelid angiosarcomas with bilateral involvement or metastasis showed higher mortality and recurrence rates than unilateral eyelid invasion cases. In the prognosis analysis according to treatment modalities, the mortality and recurrence rates were the lowest in patients who underwent surgical excision. The 4-year EFS probability in a group with surgical excision was 60.6%, but in a group without surgical excision it was 30.3%. A total of 45.2% of the cases was misdiagnosed and 21.4% of the cases could not be correctly diagnosed with the first biopsy trial. The prognosis for eyelid angiosarcomas was better than that of angiosarcomas invading the face and scalp. Surgical excision was the most important treatment modality; thus, should be considered as the first treatment of choice.