Cm In Largest Dimension Research Articles

Nasal and sinonasal tumors formed by atypical adenomatous lesions arising in respiratory epithelial adenomatoid hamartoma/seromucinous hamartoma.

Two benign adenomatous lesions are commonly recognized within the sinonasal tract, namely respiratory epithelial adenomatoid hamartoma (REAH) and seromucinous hamartoma (SH). We present 10 hitherto unrecognized benign polypoid nasal and sinonasal tumoriform lesions having in average 3.6cm in largest dimension, which are histogenetically related to SH and REAH. In addition to typical structures of REAH and SH, these lesions contained an additional characteristic and slightly atypical adenomatous component, which we termed atypical sinonasal glands arising in SH (ASGSH). ASGSH often produced deep red colored secretion with peripheral clearing similar to that seen in thyroid follicles. In contrast to SH, ASGSH was endowed by both secretory and myoepithelial layers and had mostly angulated shapes with snout-like protrusions into the lumens. Both layers were formed by an irregular, disorganized, and often incomplete cell lining, which had slightly atypical cytological features without mitoses. In 3 cases, ASGSHs revealed sebaceous differentiation, and in 3 cases the stroma produced a well-differentiated cartilage. Neoplastic nature of ASGSH was supported by finding of various mutations as revealed by next generation sequencing in five cases. In two cases each, we found identical mutations in BRAF gene (Val600Glu), and RET gene (Arg912Trp), respectively and in one case FAT1 gene alteration (Pro1665Leu).

Treatment and post-operative follow-up of pulmonary sclerosing pneumocytoma: A case report

Pulmonary sclerosing pneumocytoma (PSP) is a rare tumor thought to originate from respiratory epithelial cells. It is usually benign, but may rarely metastasize to lymph nodes. Surgeons face unique challenges in diagnosis and management of this condition, and ideal surgical management is yet to be established. 48-year-old woman with a 7×7 mm pulmonary lesion discovered incidentally on computerized tomography (CT) imaging, which grew to 9 mm over the following year. Seven years later, follow-up imaging revealed that the mass had grown to 1.3 cm in largest dimension. Surgery was recommended and the mass was resected via a right video-assisted thoracic surgery (VATS) middle lobectomy with mediastinal lymph node dissection. All lymph nodes were negative and the patient's postoperative course was unremarkable. There are few evidence-based guidelines available on the treatment and postoperative surveillance of PSP. Research has shown comparable recurrence-free survival rates for sublobar resection and lobectomy, though recurrence can occur, especially following sublobar resection in larger or more centrally-located tumors. In absence of established guidelines, it was decided to follow this patient according to NCCN guidelines for surveillance of early-stage non-small cell lung cancer due to potential risk of recurrence. This case report adds to the limited literature on PSP and depicts a possible treatment and postoperative follow-up plan. Right VATS middle lobectomy can effectively treat some cases of central PSP. In absence of established guidelines for postoperative follow-up of PSP, NCCN guidelines may outline one possible strategy for postoperative management.

PEG-coated patch parenchymal closure technique and initial outcomes during minimally invasive partial nephrectomy.

The Hemopatch® is a novel polyethylene glycol-coated (PEG-coated) collagen patch that acts as a topical hemostatic agent. It has been applied to a variety of surgical techniques. Here, we present our series and technique using a PEG-coated patch for minimally invasive partial nephrectomy (MIPN). We conducted a retrospective chart review of all patients undergoing MIPN by a single surgeon at a tertiary Canadian medical center between July and December 2018. We included patients if a PEG-coated patch was used to close the renal parenchymal defect. We also describe in detail our technique for laparoscopic patch deployment. A total of 17 patients met inclusion criteria, of whom 12 were male. Mean age was 63 years old. Median size of renal mass was 2.85 cm in largest dimension and median RENAL score was 6. Hilar clamping was carried out in 12 (70.9%) cases, with an average warm ischemic time of 16.1 minutes. The remainder of cases were performed off-clamp. Median estimated blood loss was 238 mL and the mean change in hemoglobin on postoperative day 1 compared to preoperatively was 21.2 g/L. The average length of stay was 1.76 days. No patient required blood transfusion or underwent angioembolization or re-operation for bleeding within 90 days. There were no Clavien-Dindo grade 3 or greater complications. A PEG-coated patch can be used safely and effectively in lieu of traditional two-layer renorrhaphy with acceptable outcomes. Larger, prospective series are required to ascertain its true value and cost-effectiveness.

Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses?

IntroductionThe role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. MethodsWe analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. ResultsA total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 – 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. ConclusionsFor patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.

Characteristics and oncologic outcomes of patients with Ewing sarcoma of the scapula

Background and objectivesEwing sarcoma is the second most common bone sarcoma of childhood. Ewing sarcomas of the scapula are rare, with little known about their characteristics and outcomes. In this study, we describe the demographic characteristics, tumor characteristics, and oncologic outcomes of patients with Ewing sarcoma of the scapula. MethodsThis is a retrospective case series of thirty-four patients treated at three urban hospitals between 1993 and 2014 for Ewing sarcomas affecting the scapula. Their demographic data, tumor characteristics, and oncologic outcomes are reported and contrasted with data on Ewing sarcoma described in the literature. ResultsPatients in our case series were 59% male. The average age at diagnosis was 16 years. 44% of patients had metastatic disease at presentation. 26% of patients had a tumor size >8 cm in largest dimension at diagnosis. 9 patients in our series had the t (11; 22) translocation present. Patients had a survival rate of 68% at five years. No patients had local recurrence of disease. Compared with findings reported in the literature concerning Ewing sarcoma affecting other locations, patients with Ewing sarcoma of the scapula were slightly older at time of diagnosis, had a lower percentage of tumors with size > 8 cm in largest dimension at presentation, and more commonly had metastatic disease at presentation. Patients in our cohort had a 5-year survival rate of 68%, which is higher than the rate of approximately 55% as reported in the general literature. ConclusionsIn this study, we describe a retrospective case series of thirty-four patients with Ewing sarcomas of the scapula. This is the largest case series to date of Ewing sarcoma affecting this location to our knowledge. These results will contribute to the understanding of the clinical profile and oncologic behavior of Ewing sarcomas affecting the scapula.

Intra-abdominal Follicular Dendritic Cell Sarcoma (FDCS): Series of 18 cases of a rare entity from Pakistan

ObjectivesFollicular Dendritic Cell Sarcoma (FDCS) is a rare neoplastic proliferation of dendritic cells which are immune accessory cells found in both lymphoid and non-lymphoid organs. FDCS can thus occur in lymph nodes as well as non-lymphoid organs. Intraabdominal FDCS is even rarer.Our aim was to describe the clinical and morphological features of intra-abdominal FDCSs diagnosed in our practice and to review published literature on FDCSs including intra-abdominal FDCSs. MethodsAll cases of FDCSs diagnosed between January 1, 2008 and December 31, 2019 were included in the study. Slides of the cases were reviewed and clinical follow up was obtained. ResultsA total of 18 cases of intraabdominal FDCS were diagnosed during the study period. Age range was 17 to 55 years. Mean and median ages were 28 and 29 years respectively. Of the 18 patients, 11 were male and 7 were females. Colon was involved in 9 cases and appendix in 2 cases. 9 cases were received as resection specimens while 9 cases were received as slides and blocks for second opinion. Tumor size ranged from 2.7 to 26 cm. Average tumor size in these 9 cases was 8.2 cm and in 6 of these 9 cases, tumor size was greater than 6 cm in largest dimension. Grossly, tumors were nodular or polypoid and had a fleshy, grey white, homogeneous cut surface. Histologically, all 18 cases showed proliferation of plump to spindle shaped cells arranged in a fascicular or storiform pattern. Tumor cells had mild to moderately pleomorphic spindle to ovoid vesicular nuclei with fine chromatin and inconspicuous to variably conspicuous nucleoli, and moderate amount of pale eosinophilic cytoplasm. Mitotic activity was usually brisk. CD21 and CD23 were positive in all 18 cases. Resection margins were negative in all 9 resection specimens. Lymph nodes positive for metastases were seen in 4 cases. Follow up was available in 13 cases. Recurrence was seen in 6 patients, out of which 3 patients died of disease 15, 17- and 24-months following resection. 1 patient with appendiceal FDCS was free of disease almost 12 years after surgery but recently developed recurrence and is currently undergoing chemotherapy. 6 patients were alive and well at the time of follow-up 5 to 68 months after resection. None of them had developed recurrence or metastases at the time of follow up. 8 of the 13 patients received chemotherapy and/or radiotherapy post-surgical resection. ConclusionColon was involved in 9 of our 18 cases. Lymph nodes were positive for metastases in 4 out of 9 resection specimens. All cases were diagnosed based on morphology supported by positivity for immunohistochemical stains CD21 and CD23. Histological factors associated with aggressive behavior were seen in 14 cases. Majority of patients had an aggressive clinical course.

Surgical Management of Primary Pulmonary Mucoepidermoid Carcinoma of the Proximal Left Mainstem Bronchus

A 29-year-old non-smoking female with a history of recurrent AML presented with worsening dyspnea. A CT scan revealed an 8 X 7 mm polypoid soft tissue nodule 8 mm distal to the carina in the left mainstem bronchus. She was brought to the operating room and a nearly obstructing soft fleshy tumor in the left mainstem bronchus just distal to the carina was removed with bronchoscopy. Pathology revealed a low grade mucoepidermoid carcinoma 0.8 cm in largest dimension with negative margins. The patient returned for a resection and was intubated with a right mainstem double lumen tube and placed in left lateral decubitus. After posterolateral thoracotomy, the azygos vein was divided to mobilize the esophagus and retract it laterally. Level 4 and 7 lymph node dissection were performed to obtain access to the anterior tracheal and subcarinal spaces. There was minimal dissection lateral to the trachea to minimize risk of ischemia. One centimeter of trachea just proximal to the carina was circumferentially isolated with umbilical tape for retraction. We bronchoscopically confirmed the location for transection and advanced a jet ventilator catheter distally. We resected one centimeter of left mainstem bronchus. We inspected the lumen of the airway to confirm no gross residual disease and confirmed negative pathologic margin before performing an end-to-end anastomosis with interrupted absorbable sutures under both jet and cross-table ventilation. Postoperatively, the patient had an uncomplicated course and was discharged without any supplemental oxygen on postoperative day 6. Final pathology was low grade mucoepidermoid carcinoma, T1aN0.

A study on the feasibility of axillary reverse mapping with blue dye only in breast cancer patients

Background: Axillary reverse mapping is (ARM) the concept of visualization of the nodes in axilla that drain the arm and preserving them. Literature describes this procedure being done with blue dye (methylene blue) and 99mTC technetium sulphur colloid. This study was undertaken to look for the feasibility of axillary reverse mapping using blue dye alone as there is lack of availability of the radio colloid in many centres in India.Methods: 30 breast cancer patients who underwent axillary dissection as part of their surgery were included in the study. 2.5–5 ml of methylene blue was injected in the medial upper arm in the intermuscular groove region. The number of blue nodes identified, their location, pathological status and procedure related complications were analysed.Results: The ARM blue node was identified only in 7 out of the 30 patients (sensitivity– 23%) and none had a pathologically positive blue node. In those 7 patients, only 1 blue node was identified. All the nodes were in level 1 and the largest node measured 2cm in largest dimension. The complications associated with the procedure included pain, pigmentation, induration and skin necrosis. 16 (53.3%) had pain, 10 (33.3%) had induration, 6 (20%) had pigmentation and 1 (3.33%) had skin necrosis.Conclusions: The feasibility of ARM being done using blue dye alone needs to be questioned in view of its poor sensitivity. Added to this, the complication rates are higher. However, larger studies are needed to validate the same or otherwise.

Resection of Right Frontal Arteriovenous Malformation: 3-Dimensional Operative Video.

The video demonstrates resection of a Grade II Spetzler-Martin unruptured, medium-sized arteriovenous malformation (AVM). A young woman presented with headaches and seizures. The right frontal lesion measured 4.5 cm in largest dimension and had superficial venous drainage. Partial Onyx embolization, primarily of the anterior cerebral feeding arteries, was performed. Bone removal for exposure allowed identification of indentation from the large superficial draining vein. The video demonstrates careful microsurgical dissection on the AVM/brain interface, with selective interruption of feeding arteries circumferentially. The lesion was removed after ligation of the large superficial draining vein. Postoperative day 1 and 1-yr angiography demonstrated complete resection. The patient's symptoms abated after resection. This case is presented with a waiver of informed consent as per the Institutional Review Board.

Ibrutinib Is Effective in Relapsed or Refractory Transformed Indolent B-Cell Non-Hodgkin Lymphoma: Results from a Prospective Phase II Study

Background Relapsed or refractory (R/R) transformed indolent B-cell non-Hodgkin lymphoma (iB-NHL) is associated with a poor prognosis. Unfortunately, there is little prospective data using novel agents, including kinase inhibitors, since trials tend to specifically exclude transformed disease. To address this question we evaluated single agent ibrutinib in patients with R/R transformed iB-NHL.Methods This was a single-arm, open-label phase II trial for patients with R/R transformed iB-NHL (NCT02207062). Eligibility included no prior treatment with ibrutinib, ECOG 0-2, measurable biopsy-proven transformed iB-NHL, and prior receipt of at least one line of therapy for the transformed disease. Treatment consisted of oral ibrutinib 560 mg daily until disease progression or unacceptable toxicity. The primary endpoint was investigator-assessed overall response rate (ORR, per Lugano criteria), with a predefined threshold of success ≥ 30%. Secondary endpoints included clinical benefit rate (CBR, defined as ORR and/or stable disease of ≥ 6 months), progression-free survival (PFS), and safety.Results As of July 1, 2018, 17 patients were treated. The median age was 68 years (range, 36 to 89) and 53% were women. Median number of treatment regimens prior to enrollment was 4 (range 2-9) and 41% had no response to their last prior treatment. Prior therapies included rituximab (100%), anthracycline (100%), platinum (76%), and a novel agent on protocol (36%). Prior autologous hematopoietic stem cell transplantation (HSCT) had been performed in 47% and prior CAR-T in 12%. The most common histologies of the indolent B-NHL included follicular lymphoma (65%), small lymphocytic lymphoma (12%), and lymphoplasmacytic lymphoma (12%). Histology of the transformed disease was diffuse large B cell lymphoma in all cases, and included germinal center B-cell (GCB) subtype by immunohistochemistry in 71% and MYC rearrangement in 12%. Five patients had bulky disease (at least one tumor mass > 5 cm in largest dimension) at the start of treatment.Fifteen patients were evaluable for response at the time of this data cut (Figure 1). The ORR was 40% and CBR was 47% with complete response (CR) seen in 2 patients (13%). Median PFS was 4.1 months and median duration of response was 6.8 months; estimated 12-month PFS was 23%. The 2 patients that achieved CR continue on study in remission at 37 and 15 months, respectively. ORR was associated with disease bulk, with 60% ORR in non-bulky vs 0% ORR in cases of bulky disease (p = 0.04). ORR was not associated with cell of origin (42% in GCB subtype vs 33%) or MYC rearrangement (50% in MYC rearrangement vs 35%). After treatment with ibrutinib, 2 patients proceeded to CAR-T and 1 of these subsequently underwent allogeneic HSCT. No deaths or unexpected toxicities occurred with these therapies.The side effect profile was consistent with other trials with most common adverse events (AEs) for all pts being grade 1-2 and including fatigue (59%), bruising (53%), and diarrhea (24%). Grade ≥ 3 AEs occurred in 8 patients (47%) including neutropenia (6%), lymphopenia (6%), esophagitis (6%), nausea (6%), pneumonia (6%), sepsis (6%), and atrial flutter (6%). Treatment was discontinued due to AE (grade 3 mucositis) in 1 patient after 3 weeks on therapy. One patient died while on treatment due to unknown cause.Conclusions Ibrutinib appears active in patients with R/R transformed iB-NHL that had previously received multiple agents, including rituximab and anthracycline therapy in all cases. Prolonged PFS was observed in some patients, with an estimated 12-month PFS of 23%, with higher efficacy seen in those with lower disease burden. These pilot data indicate that trials in patients with R/R transformed lymphoma can be accomplished and that ibrutinib may be clinically beneficial to a subset of such patients. The final outcome data for full accrual (n = 20) will be reported in December.Figure 1 Waterfall (a) and swimmers (b) plots. In 1a, the best response is noted: CR = complete response; PR = partial response; SD = stable disease; PD = progressive disease. In 1b, the antecedent indolent histology is noted: FL = follicular lymphoma; LPL = lymphoplasmacytic lymphoma; SLL = small lymphocytic lymphoma. Arrowhead = continues on treatment. [Display omitted] DisclosuresGraf:Beigene: Research Funding; TG Therapeutics: Research Funding; Acerta: Research Funding. Cassaday:Amgen: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Seattle Genetics: Other: Spouse Employment, Research Funding; Kite Pharma: Research Funding; Incyte: Research Funding; Jazz Pharmaceuticals: Consultancy; Merck: Research Funding; Adaptive Biotechnologies: Consultancy. Becker:GlycoMimetics: Research Funding. Smith:Incyte Corporation: Research Funding; Portola Pharmaceuticals: Research Funding; Pharmacyclics: Research Funding; Merck Sharp and Dohme Corp.: Consultancy, Research Funding; Acerta Pharma BV: Research Funding; Genentech: Research Funding; Seattle Genetics: Research Funding. Gopal:Incyte: Consultancy; Teva: Research Funding; Spectrum: Research Funding; Brim: Consultancy; Pfizer: Research Funding; Merck: Research Funding; Aptevo: Consultancy; Asana: Consultancy; Takeda: Research Funding; Seattle Genetics: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Gilead: Consultancy, Research Funding; BMS: Research Funding.

Postoperative Stereotactic Radiosurgery for Resected Brain Metastases: A Comparison of Outcomes for Large Resection Cavities.

Although historical trials have established the role of surgical resection followed by whole brain irradiation (WBRT), WBRT has recently been shown to cause significant neurocognitive decline. Many practitioners have employed post-operative stereotactic radiosurgery (SRS) to tumor resection cavities to increase local control without significant neurocognitive sequelae. However, there have been no significant series detailing outcomes of large brain metastases treated with resection and post-operative SRS. Here, we compare outcomes in patients with large brain metastases > 4 cm to those with smaller metastases ≤ 4 cm treated with surgical resection followed by SRS to the resection cavity. Consecutive patients with brain metastases treated at our institution with surgical resection and post-operative SRS were retrospectively reviewed. Patients were stratified into ≤ 4 cm and > 4 cm cohorts based on pre-operative maximal tumor dimension. Cumulative incidence of local failure, radiation necrosis, and death were analyzed for the two cohorts. A total of 117 consecutive cases were identified. Of these patients, 90 (77%) had pre-operative tumors were ≤ 4 cm, and 27 (23%) were > 4 cm in greatest dimension. The only significant baseline difference between the two groups was a higher proportion of patients with gross total resection of their tumors in the ≤ 4 cm compared to the > 4 cm cohort, 76% vs. 48%, (p<0.01). The 1-year rates of local failure, radiation necrosis, and overall survival for the ≤ 4 cm and > 4 cm cohorts were 12.3% and 16.0%, 26.9% and 28.4%, and 80.6% and 67.6%, respectively (all p>0.05). The rates of local failure and radiation necrosis were not statistically different on multivariable analysis based on tumor size. Brain metastases > 4 cm in largest dimension managed by resection and radiosurgery to the tumor cavity have promising local control rates without a significant increase in radiation necrosis on our retrospective review.

Murine Typhus-Related Acute Febrile Hepatitis: A Case Series

Murine typhus is a flea-borne zoonosis caused by Rickettsia typhi (R. typhi). Acute hepatitis accompanying this infection has not been well emphasized in the literature. We describe two patients with febrile hepatitis due to rickettsial infection. Case 1 A 62 year old (y.o.) male with an unremarkable past medical history presented with high grade fever. A thorough review of systems was unremarkable for rash, arthralgias, headache, abdominal pain, back pain or cough. Physical examination was notable for a temperature of 102.2 degrees Fahrenheit (F). Laboratory findings are noted in the attached table. Computed tomography of the abdomen revealed no intra-abdominal pathology. Serological assays for hepatitis A, B,C, Cytomegalovirus, Epstein Barr virus and Chikungunya virus were negative. An indirect fluorescent antibody (IFA) assay showed immunoglobulin M (IgM) antibodies against R. typhi with a titer of 1:64. A liver biopsy demonstrated mild hepatitis with portal and lobular infiltration by mixed inflammatory cells, apoptotic hepatocytes, edematous portal tracts, and Kupffer cell hyperplasia. He was treated with Doxycycline for 2 weeks and is due for follow-up.Figure: Case 1.Figure: Case 2.Figure: Laboratory values of patients on admission to our institution. WBC= White Blood Cells; AST= Aspartate Transaminase; ALT=Alanine Transaminase; ALP= Alkaline Phosphatase; T.BR= Total Bilirubin; PT=Prothrombin time.Case 2: A 50 y.o. male state trooper with no prior history of liver disease presented with high grade fever, headache, myalgias and polyarthralgias. On admission, he was febrile with a temperature of 104 F. Scleral icterus and a diffuse faint erythematous macular rash on the upper torso were present. Abdominal examination was remarkable for splenomegaly. Laboratory data are provided in the attached table. Ultrasound of the abdomen was notable for splenomegaly measuring 14 cm in largest dimension. An extensive infectious workup was negative except for a positive IgM antibody titer against R.typhi of 1:512. A liver biopsy showed acute mild hepatitis with an inflammatory infiltrate comprised of histiocytes, lymphocytes, plasma cells, and eosinophils. He was treated with Doxycyline for 2 weeks and lost to follow-up. Discussion: Rickettsial infections may have liver involvement and should be considered in the differential diagnosis of acute hepatitis. These cases highlight the role of a liver biopsy in the evaluation of acute febrile hepatitis. To our knowledge, this is the first case series reported in the United States with serologic diagnosis of murine typhus and accompanying acute hepatitis confirmed on liver biopsy.

Postoperative stereotactic radiosurgery for resected brain metastases: A comparison of outcomes for large resection cavities

PurposeAlthough historical trials have established the role of surgical resection followed by whole brain irradiation (WBRT) for brain metastases, WBRT has recently been shown to cause significant neurocognitive decline. Many practitioners have employed postoperative stereotactic radiosurgery (SRS) to tumor resection cavities to increase local control without causing significant neurocognitive sequelae. However, studies analyzing outcomes of large brain metastases treated with resection and postoperative SRS are lacking. Here we compare outcomes in patients with large brain metastases >4 cm to those with smaller metastases ≤4 cm treated with surgical resection followed by SRS to the resection cavity. Methods and materialsConsecutive patients with brain metastases treated at our institution with surgical resection and postoperative SRS were retrospectively reviewed. Patients were stratified into ≤4 cm and >4 cm cohorts based on preoperative maximal tumor dimension. Cumulative incidence of local failure, radiation necrosis, and death were analyzed for the 2 cohorts using a competing-risk model, defined as the time from SRS treatment date to the measured event, death, or last follow-up. ResultsA total of 117 consecutive cases were identified. Of these patients, 90 (77%) had preoperative tumors ≤4 cm, and 27 (23%) >4 cm in greatest dimension. The only significant baseline difference between the 2 groups was a higher proportion of patients who underwent gross total resection in the ≤4 cm compared with the >4 cm cohort, 76% versus 48%, respectively (P <.01). The 1-year rates of local failure, radiation necrosis, and overall survival for the ≤4 cm and >4 cm cohorts were 12.3% and 16.0%, 26.9% and 28.4%, and 80.6% and 67.6%, respectively (all P >.05). The rates of local failure and radiation necrosis were not statistically different on multivariable analysis based on tumor size. ConclusionsBrain metastases >4 cm in largest dimension managed by resection and radiosurgery to the tumor cavity have promising local control rates without a significant increase in radiation necrosis on our retrospective review.

Postoperative outcomes among patients undergoing thoracostomy tube placement at time of diaphragm peritonectomy or resection during primary cytoreductive surgery for ovarian cancer

ObjectivePrimary cytoreductive surgery in patients with stage IIIC–IV epithelial ovarian cancer frequently includes diaphragm peritonectomy or resection, which can lead to symptomatic pleural effusions when the resection specimen is ≥10cm. Our objective was to evaluate whether the placement of an intraoperative thoracostomy tube decreased the incidence of symptomatic pleural effusions in these cases. MethodsWe identified 156 patients who underwent primary debulking surgery involving diaphragm peritonectomy or resection for stage III–IV ovarian cancer from 1/01–12/09. Using standard statistical tests, the incidence of symptomatic pleural effusions and other variables were compared between patients who did and did not have intraoperative chest tubes placed. ResultsForty-nine patients had a resected diaphragm specimen ≥10cm in largest dimension; 28 (57%) did not undergo chest tube placement (NCT group) while 21 (43%) did (CT group).Mediastinal lymph node dissection (0% vs 19%, P=0.028) and liver resections (11% vs 38%, P=0.037) were higher in the CT group.Postoperatively, 57% of the NCT group developed a moderate or large pleural effusion compared to 19% of the CT group (P=0.007). Thirteen patients (46%) in the NCT group developed respiratory symptoms requiring either placement of a postoperative chest tube or thoracentesis compared to 3 patients (14%) in the CT group (P=0.018). ConclusionsDiaphragm peritonectomy or resection can often lead to moderate or large pleural effusions that may become symptomatic. In these patients, intraoperative chest tube placement may be considered to decrease the incidence of symptomatic effusions and the need for postoperative chest tube placement or thoracentesis.

Subcutaneous mass as the primary manifestation of gestational choriocarcinoma: A case report

1. IntroductionChoriocarcinoma is a highly malignant trophoblastic tumor com-posed of two types of cells, syncytiotrophoblasts and cytotrophoblasts(Seckl et al., 2010). Its incidence is reported variously from 1 in 13,000 to 50,000 pregnancies (Alveyn and Loehry, 1988). Metastasis ismost often associated with choriocarcinomas in contrast to other vari-ants of the GTT (Berkowitz and Goldstein, 1996). Choriocarcinomacommonly metastasizes to the lungs and vagina, and less commonly,to the liver, brain, kidneys and gastrointestinal tract (Bagshawe,1992). Vaginal bleeding, abdominal swelling, amenorrhea, chest andneurologicalsymptomsarethemostcommonpresentationsdependingontheextentofthedisease,butbyfarthecommonestsymptomisvag-inal bleeding, a consequence of the tumor invading the uterus (Chamaet al., 2002).To the best of our knowledge, there was no choriocarcinoma withclinical presentation of subcutaneous metastasis reported in the liter-ature. An abdominal subcutaneous mass as the primary manifestationof choriocarcinoma is extremely rare and difficult for diagnosis. Herewe reported a case of gestational choriocarcinoma with the primarymanifestationof subcutaneousmetastasis10 yearsafterher lastpreg-nancy. No uterine or ovarian tumors were noted except subcutaneoustumor over anterior abdominal wall with bilateral multiple pulmo-nary nodules by image studies. Wide excision of the abdominal tumorrevealed that the tumor cells were positive for cytokeratin and humanchorionic gonadotropin by immunohistochemical stainings. DNA poly-morphism analysis revealed that the tumor cells possessed both geno-mic DNA alleles from the patient and her husband. Gestationalchoriocarcinoma was finally diagnosed. The serum level of β-hCG inthepatientwas 382 mIu/ml after surgery. So the EMA-COchemothera-peutic regimens (etoposide, methotrexate, and actinomycin, followedbycyclophosphamideandvincristine)weregiven.Thepatientachievedclinicalremissionfor7 monthsafterchemotherapy.Subcutaneousmasscan be the first manifestation of choriocarcinoma. Choriocarcinomashould be the differential diagnosis for special manifestation ofwomen in reproductive ages.2. Case reportA49-year-oldwomanpalpatedarapidgrowingmassoverlowerab-domen for three months. Her menstrual cycles became irregular since2 months ago. The patient had conceived 7 times with 4 miscarriagesand her three children were all delivered through cesarean section.Her last cesarean section was 20 years ago and her last pregnancy wasartificial abortion 10years ago.Pelvicexaminationrevealedasmoothcervix,andnormalsizeofuter-usandbilateraladnexae.Amultilo culatedmasswhichwasaroundbase-ball size within the abdominal wall was noted. The subcutaneous masslocated nearby the wound of the cesarean section with intact abdominalskin. Transabdominal ultrasonography revealed a multilocular tumormeasuring 8×6×5 cm located behind the cesarean scar and within thelower anterior subcutaneous layer. No abnormal finding was identifiedin the endometrial cavity, uterus and bilateral ovaries. Magnetic reso-nance imaging (MRI) study showed a large in filtrative and heteroge-neous mass, measured around 14 cm in largest dimension, and locatedwithin the anterior pelvis wall ( Fig. 1). Computed tomography (CT)study showed bilateral multiple pulmonary nodules. Subcutaneous ma-lignancy with pulmonary metastases was suspected. Biopsies of the ab-dominal wall tumor were undergone and the pathologic reportrevealed a poorly-differentiated squamous cell carcinoma. Immunohis-tochemically, the tumor cells were po sitive for cytokeratin (AE1/AE3)andp63butnegativeforvimentin,CD31,CD34,S-100 protein,calretinin

HER-2/neu over-expressing DCIS phenotypes and the transition from in situ to invasive breast cancer: implications for breast cancer prevention.

Abstract Abstract #1161 Background: Prognostically significant invasive breast cancer subtypes, distinguishable through immunohistochemistry for ER, PR and HER-2/neu expression, have recently been identified. The implication of similar phenotypic patterns in ductal carcinoma in situ (DCIS) lesions remains uncertain. The objective of this study was to determine whether DCIS phenotypes are associated with different rates of progression to invasive cancer.&amp;#x2028; Methods: Immunohistochemical staining for ER, PR and HER-2/neu was performed on biopsy and resection specimens from consecutive patients evaluated with DCIS between March 2003 and May 2008. DCIS lesions were characterized as luminal A (ER+ or PR+, HER-2/neu-), luminal B (ER+ or PR+, HER-2/neu+), HER-2/neu positive (ER- and PR-, HER-2/neu+) or basal-like (ER-, PR- and HER-2/neu-). All patients underwent breast MRI and those patients with evidence of invasive disease greater than 1cm in largest dimension were excluded from the analysis. Rates of invasive disease associated with DCIS lesions with different phenotypes were compared using a chi square test. Multivariate logistic regression was used to evaluate the relationship between phenotype and invasion adjusting for patient age, lesion size, nuclear grade, and the presence of comedo necrosis.&amp;#x2028; Results: One hundred and seven patients were included in the analysis. Luminal A was the most common phenotype and accounted for 59% of lesions (63/107). Associated invasive disease was identified in 6 patients with such lesions (10%). The HER-2/neu positive phenotype accounted for 21% of lesions (23/107). Invasive disease was identified in 8 patients with such lesions (35%). Seventeen patients had luminal B DCIS (16%) and 8 of these patients had associated invasive disease (47%). Basal-like lesions were uncommon; only four patients with such lesions were identified. The rates of invasion differed significantly between groups (overall rxc chi square p=0.002). By univariate analysis, the rates of invasion associated with luminal B and HER-2/neu positive phenotypes were significantly higher than the rate of invasion associated with the luminal A phenotype (p&amp;lt;0.001 and p=0.005, respectively). Luminal B DCIS was significantly associated with invasive disease after multivariate adjustment (OR=11.1 p &amp;lt;0.001).&amp;#x2028; Discussion: Invasive foci are more commonly associated with HER-2/neu over-expressing DCIS phenotypes. Moreover, co-expression of HER-2/neu and ER in DCIS lesions is an independent predictor for the presence of associated invasive disease. Novel therapies targeting HER-2/neu in addition to anti-estrogen therapies may, therefore, play a role in breast cancer prevention. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1161.

Giant Cystic Hygroma of the Thymus in a Child

Abstract: A 4-year-old asymptomatic boy was found to have a large multicystic mass occupying the anterior mediastinum and approximately 80% of the left chest cavity. The lesion was resected and consisted of a large cystic hygroma measuring 18.0 cm in largest dimension, involving the thymus and the adjacent mediastinal soft tissues. The multicystic spaces were filled with straw-colored fluid, consistent with old hemorrhage, and were lined by endothelial-lined vascular spaces showing smooth muscle bundles and patchy lymphoid aggregates in their walls. Focal areas of stromal calcification were present. No teratomatous elements were identified within the mass. The patient recovered fully from the surgical procedure. Cystic hygromas (cystic lymphangiomas) are unusual tumors in children that usually develop in the neck but have been described in the thorax, abdomen, extremities, and other locations. Approximately 10% of cervical cystic hygromas extend to the mediastinum, but primary mediastinal lymphangiomas are extremely rare neoplasms that have been described mostly in fetuses and a few children and adult patients. The clinicopathologic findings of this unusual case and the differential diagnosis of mediastinal cysts in young children are discussed.

Low local recurrence rate without postmastectomy radiation in node-negative breast cancer patients with tumors 5 cm and larger

To assess the need for adjuvant radiotherapy following mastectomy for patients with node-negative breast tumors 5 cm or larger. Between 1981 and 2002, a total of 70 patients with node-negative breast cancer and tumors 5 cm or larger were treated with mastectomy and adjuvant systemic therapies but without radiotherapy at three institutions. We retrospectively assessed rates and risk factors for locoregional failure (LRF), overall survival (OS), and disease-free survival (DFS) in these patients. With a median follow-up of 85 months, the 5-year actuarial LRF rate was 7.6% (95% confidence interval, 3%-16%). LRF was primarily in the chest wall (4/5 local failures), and lymphatic-vascular invasion (LVI) was statistically significantly associated with LRF risk by the log-rank test (p=0.017) and in Cox proportional hazards analysis (p=0.038). The 5-year OS and DFS rates were 83% and 86% respectively. LVI was also significantly associated with OS and DFS in both univariate and multivariate analysis. This series demonstrates a low LRF rate of 7.6% among breast cancer patients with node-negative tumors 5 cm and larger after mastectomy and adjuvant systemic therapy. Our data indicate that further adjuvant radiation therapy to increase local control may not be indicated by tumor size alone in the absence of positive lymph nodes. LVI was significantly associated with LRF in our series, indicating that patients with this risk factor require careful consideration with regard to further local therapy.

Androgen Receptor Remains Critical for Cell-Cycle Progression in Androgen-Independent CWR22 Prostate Cancer Cells

The majority of prostate cancers (PCa) that relapse after androgen deprivation therapy (androgen-independent PCa) continue to express androgen receptor (AR). To study the functional importance of AR in these tumors, we derived androgen-independent CWR22 PCa xenografts in castrated mice and generated a cell line from one of these xenografts (CWR22R3). Similarly to androgen-independent PCa in patients, the relapsed xenografts and cell line expressed AR and were resistant to treatment with bicalutamide. However, expression of the AR-regulated PSA gene in the CWR22R3 cell line was markedly decreased compared to the relapsed xenografts in vivo. Transfections with androgen-regulated reporter genes further indicated that the cells lacked androgen-independent AR transcriptional activity and were not hypersensitive to low androgen concentrations despite constitutive activation of the Erk/MAP kinases. Nonetheless, AR remained essential for androgen-independent growth because retroviral shRNA-mediated AR down-regulation resulted in marked long-term growth suppression. This was associated with increased levels of p27(kip1) and hypophosphorylation of retinoblastoma protein but not with decreases in D-type cyclin levels or MAP kinase activation. These results reveal a potentially critical function of AR in androgen-independent PCa that is distinct from its previously described transcriptional or nontranscriptional functions.

Clear Cell Trichoblastoma

Clear cell change in basal cell carcinomas is a well-recognized phenomenon, but is obviously rare in trichoblastomas. We present two cases of clear cell trichoblastoma in which clear cell change was very much prominent, and the results of an ultrastructural study intended to explore the basis of that feature. Both our patients were women, aged 56 and 77 years, who presented with solitary, slowly growing nodules that measured 3 to 5 cm in largest dimension and were located on the scalp and the flexor aspect of the lower arm. Microscopically, the tumors in both cases were symmetric, non-ulcerated, and composed of variably sized and shaped (cribriform, racemiform, strands, cords, nodules) aggregations of monomorphous basaloid epithelial cells that were associated with a specific trichogenic stroma. Common to both tumors was clear cell cytoplasm evident in the majority of the epithelial cells in one case and almost in the entire epithelial cell population in the other. In most epithelial aggregations the epithelial cells with clear cytoplasm often appeared columnar and were arranged in a palisade along a recognizable basal membrane, thus indicative of outer sheath differentiation at the bulb. There were other signs of follicular differentiation. Ultrastructurally, variably sized clusters of uniform small basaloid epithelial cells were separated from the stroma by a thin discontinuous basement membrane. In addition to the usual organelles, the cytoplasm contained fairly conspicuous tonofilaments and variably sized vacuoles devoid of a limiting membrane, located between the palisaded nuclei and the outer cell membrane. The majority of vacuoles were empty, although clumps of a finely granular substance were occasionally evident. No distinct lipid droplets or glycogen particles were identified. The basaloid cells were joined by scattered small desmosomes. These findings were consistent with trichilemmal differentiation at the bulb.