Diffuse Metastases Research Articles

MON-393 Neuroblastoma Masquerading as Pheochromocytoma

Peripheral neuroblastic tumors (PNTs) are a group of tumors arising from sympathetic ganglion cells. It is a malignancy of childhood and rare in adults. The incidence in adulthood is only 0.12-0.2 cases per million per year. A 37 year old male presented with acute exacerbation of low back pain which started months prior to admission. MRI of the lumbar spine revealed a 3.6 x 3.4 cm lobulated heterogeneous mass-like lesion involving his right adrenal gland therefore, endocrinology evaluation was requested but not completed. He was a non-smoker without any significant past medical or surgical history and was not on any medications. On examination, He was normotensive and appeared to be in moderate distress. He had tenderness over the right sacroiliac joint. His renal and liver functions were normal. Serum metanephrines were normal however, normetanephrines were elevated to 501 pg/mL (< or = 148 pg/mL). Urine normetanephrines were 3,192 ug/day (88-444 ug/d), Urine volume of 3 L, total metanephrines of 3,342 ug/d (140-785 ug/d). Chromogranin A was 1,379 ng/mL (0-95 ng/mL). DHEAS, 17- hydroxyprogesterone, androstendione, and ACTH were normal. CT of his abdomen and pelvis with contrast showed a lobular heterogeneous mass involving the right adrenal gland with an increased size of 4.9 x 4.3 cm measuring 55 Hounsfield Units (HU). Right iliac core needle biopsy was done to evaluate his diffuse osseous metastasis which showed crush artifact, with positive chromogranin and synaptophysin staining. Right posterior pelvic crest lesion excision biopsy showed primitive small round cell neoplasm with neuroendocrine features, favoring an adult type neuroblastoma confirmed by immunohistochemical staining. He received chemotherapy and radiation and prior to debulking surgery, we initiated doxazosin. Surgery revealed a 6 cm neuroblastoma with extraadrenal extension. Iodine 123-metaiodobenzylguanidine (I-123 MIBG) showed extensive diffuse osseous metastatic disease. His catecholamines declined after surgery. Bone marrow (BM) involvement was noted and he underwent bone marrow transplantation with clinical improvement six months post-transplant. Although pediatric neurblastoma has a 91% survival rate, rates progressively decline to 40% in adults aged 25-64 years. Metastatic dissemination occurs in up to 40% of adults, mainly in the bone and BM as seen in our case therefore, adults should have a BM assessment upon diagnosis. Main issue is differentiation between PNTs and pheochromocytoma, that might be challenging due to variable imaging characteristics of PNTs and secretion of catecholamines in up to 70% of PNTs. On the other hand, catecholamines can be used as tumor markers for monitoring. Majority of adult PNTs are high-risk tumors with poor prognosis. No guidelines for adult management exists due to the rarity of the disease.

Metastatic Cardiac Tumor from Precursor B Cell Lymphoblastic Lymphoma with a Mediastinal Mass: A Case Report of a 12-Years-Old African Girl

Cardiac involvement in metastatic tumors is not widely investigated. Commonest site of cardiac involvement is the pericardium. However, diffuse metastasis to the myocardium and endocardium is uncommon. Striated cardiac muscle, fast blood flow within the heart and unique lymphatic drainage make malignant metastasis to the heart rare. Cardiac metastasis is a late manifestation of malignancy and most of the cases are diagnosed on Post mortem. We describe a case of metastatic Pre B-Lymphoblastic Lymphoma in a child who presented with heart failure.

Disease characteristics and treatment outcomes of young colorectal cancer patients.

691 Background: The incidence of colorectal cancer (CRC) in young patients (&lt; 50 years) is increasing but little is known about disease characteristics and treatment outcomes in this patient population. Methods: CRC patients diagnosed at &lt; 50 years of age (UF institutional registry 2000-2017) constituted the IRB approved study cohort. Statistical methods included descriptive statistics, uni-variable cox proportional hazard regression model, Pearson chi-square exact and Wilcoxon rank-sum test. Results: The median age at diagnosis was 45 years (range 17-50, n = 286) with 212 (74%) diagnosed between age 40-50. One third (35.7%) of patients had rectal primary and most common histology was adenocarcinoma (ACa, 84.6%) and 20% of those had poorly differentiated tumor. More than half of patients had an advanced primary (T3/T4, 65%) and 44% had lymph node positive disease. A trend towards increased delivery of perioperative therapy was seen in early staged disease. (See table) Patients who underwent curative resections had better hemoglobin (p = 0.005) and albumin levels (Alb, p &lt; 0.001) and lower CEA level (p &lt; 0.001). Factors associated poor survival were low alb levels ≤ 34 g/l, advanced primary tumor (T3/T4), nodal disease (N1/N2) and presence of diffuse metastasis. For stage 4 disease, the cancer-specific survival (CSS) at 1 year was 77.2%, 3-year CSS was 46.1% and 5-year CSS was 29%; survival was better (HR = 0.4; 95% CI 0.2-0.6, p &lt; 0.001) among patients who underwent metastatectomy. Conclusions: Our data suggests that younger CRC patients were more likely to be managed in an aggressive manner with a higher proportion of early stage patients receiving perioperative therapy. A suggestion of an improved CSS was seen in advanced stage disease even with similar prognostic factors. Review of larger datasets are warranted. [Table: see text]

Metastatic gastric adenocarcinoma in a pregnant woman

Gastric cancers occur in only 0.025% to 0.1% of all pregnancies. We present a pregnant woman with gastric adenocarcinoma associated with bone metastasis. She is 36-year-old (gravida:4, para:0) 16-week pregnancy, complaining of nausea, vomiting, weight loss (~15 kg) and low back pain. Although the patient considered the condition to be related with pregnancy and underestimated its importance. She had high erythrocyte sedimentation rate (107 mm/h) and anemia (hemoglobin = 9.4 gr/dl). Lumbar magnetic resonance imaging showed L4 vertebrae malign compression fracture and diffuse bone metastasis. Because of the patient's melena, esophagogastroduodenoscopy was performed and biopsy result was reported as stomach adenocarcinoma. It is important to evaluate the symptoms of low back pain and pregnancy related symptoms carefully and do not cause delays in diagnosis due to overlapping symptoms.

Metastatic Hepatocellular Carcinoma Presenting as Extensive Bone Metastasis

Hepatocellular carcinoma(HCC) is a primary malignancy of the liver and occurs mainly in patients with underlying chronic liver disease or cirrhosis. It is considered the third leading cause of cancer death worldwide. Here, we present a rare case of HCC with diffuse bone metastasis. 57 y.o. male with past history of Chronic Hepatits B & C presented with diffuse body aches associated with jaundice. Exam did not show any ascites or stigmata of cirrhosis. Relevant labs included: AST 62 ALT 53 Alk Phos 231 T Bili 1.6 INR 1.0 Alb 3.5 CEA 1.46 AFP 5.1. Multiple hepatic lesions seen on imaging were initially concerning for metastatic disease. Bone imaging revealed diffuse lytic lesions, with the largest in the right sacrum. No clear primary malignancy was identified, so patient underwent EGD and colonoscopy, which were negative. A sacral bone biopsy was performed, revealing atypical cells with abundant cytoplasm and abnormal nuclei (Image 1); further reticulin (Image 2), arginase, and heppar (Image 3) staining confirmed malignant hepatic cells. Patient was diagnosed with primary HCC with bone metastasis, Child Pugh score A. Due to the advanced nature of presentation, patient opted for Hospice care. HCC is often seen with early metastasis to lungs, abdominal lymph nodes, central nervous system, and bones—further decreasing median survival. Current treatment options for extra-hepatic HCC generalized to all metastatic types recommends palliative chemotherapy if Child Pugh A/B, and advises only symptomatic treatment if Child Pugh C. HCC with bony metastasis is rare, and is associated with even higher mortality rates and median survival of 3 months without treatment. Chemotherapy with Sorafenib can prolong median survival by on average 2 months, but with significant effect on standard of life due to side effects. Radiation therapy has shown improvement in pain without improved mortality. Other symptomatic treatment includes palliative stents, vitamin D, calcium, and pain control. In deciding care for HCC with bony metastasis, the net clinical benefit of each treatment must be considered by weighing the improvement in survival time versus quality of life. Interventions should focus on maximizing the individual's self-established quality-adjusted life years. Therefore, careful discussion is needed in each case to determine the best option for each patient.2311_A Figure 1. Bone biopsy showing atypical cells with abundant cytoplasm and enlarged round to ovoid nuclei. Together with staining patterns is consistent with HCC.2311_B Figure 2. Reticulin immunohistochemical stain suggestive of hepatic origin.2311_C Figure 3. Heppar immunohistochemical stain positive consistent with cells of hepatic origin.

Adjuvant and Neoadjuvant Therapy, Treatment for Advanced Disease, and Genetic Considerations for Adrenocortical Carcinoma: An Update from the SSO Endocrine and Head and Neck Disease Site Working Group.

This is the second of a two-part review on adrenocortical carcinoma (ACC) management. While margin-negative resection provides the only potential cure for ACC, recurrence rates remain high. Furthermore, many patients present with locally advanced, unresectable tumors and/or diffuse metastases. As a result, selecting patients for adjuvant therapy and understanding systemic therapy options for advanced ACC is important. Herein, we detail the current literature supporting the use of adjuvant mitotane therapy, consideration of adjuvant radiation therapy, and utility of cytotoxic chemotherapy in patients with advanced disease. Ongoing investigation into molecular targeted agents, immunotherapy, and inhibitors of steroidogenesis for the treatment of ACC are also highlighted. Lastly, the importance of genetic counseling in patients with ACC is addressed as up to 10% of patients will have an identifiable hereditary syndrome.

Good control of diffuse brain metastasis with lapatinib plus capecitabine in a patient with HER2-positive breast cancer

S&#x0D; We present the case of a patient affected by HER2-positive breast carcinoma, relapsed at supraclavicular and mediastinal lymph nodes level, after three and eight years from initial diagnosis. These relapses were successfully treated by local radiotherapy, hormone therapy and trastuzumab. After 10 years from onset, the patient developed cerebral progression with a number of seizable lesions, overt clinical symptoms. To avoid the short- and long-term side effects of whole brain radiotherapy, the patient is initially treated with lapatinib and capecitabine in light of the favorable data on the efficacy of this combination on brain metastases from HER2-positive breast carcinoma. This therapy results in a considerable lesions reduction, allowing to postpone the panencephalic radiotherapy to a later time with a lower tumor burden. The response to radiotherapy is significant and sustanined for a progression-free interval of about 10 months. This case suggests that lapatinib may represent the treatment of choice in cases of indolent disease, characterized by long progression free intervals with minor symptoms with the aim to postpone the use of more invasive treatments (Oncology).

Lung Resection after Definitive and Neo-Adjuvant Chemoradiation for Stage IIIA/B Locally Advanced Non-Small Cell Lung Cancer: a Retrospective Analysis

The outcomes of so called "salvage" resections after definitive chemoradiation vs. curative resections after neoadjuvant chemoradiation therapy (IT-resection) in patients with stage IIIA/B locally advanced non-small cell lung cancer have rarely been compared. The aim of our study was to compare perioperative results, postoperative and recurrence-free survival and to identify relevant prognostic survival factors for both therapy strategies. Between June 2008 and May 2017, 43 patients underwent pulmonary resection following induction therapy (group 1) and 14 patients underwent salvage resection after definitive chemoradiation (group 2). Retrospective analysis was performed of demographic factors, tumour stage and location, initial therapy, preoperative regression status, perioperative morbidity and mortality, postoperative and recurrence-free survival. In group 2, significantly higher radiation dose was applied (p < 0.001) and the interval between chemoradiation and lung resection was significantly longer (p = 0.02). In addition, significantly higher perioperative blood loss and more frequent blood transfusions were noted (p = 0.003 and 0.005, respectively). Perioperative morbidity and mortality were statistically comparable in the two groups (p = 0.72 and 0.395, respectively). Postoperative 5 year survival in group 1 was 55%, in group 2 48% (log-rank p = 0.353). Five year recurrence-free survival in group 1 was 53%, in group 2 42% (log-rank p = 0.180). Diffuse metastasis occurred mostly in group 2, whereas in group 1 oligometastasis was more frequently noted. Postoperative outcome after salvage resection seems statistically comparable to results following curative resection after induction therapy. Diffuse distant metastasis is frequently noted. Careful patient selection is required.

Surgical treatment of hepatic metastases from gastric cancer.

The purpose of the study was to investigate the clinical factors influencing the prognosis of patients submitted to hepatectomy for metastases from gastric cancer and their clinical role. We conducted a retrospective multicentre review. We evaluated how survival from surgery was influenced by patient-related, tumour-related and treatment-related prognostic factors. We analysed data on 144 patients submitted to hepatectomy for metastases from gastric cancer, in the synchronous and metachronous setting. In 117 cases, an R0 resection was achieved, while in 27 an R + hepatic resection was performed. Chemotherapy was administered to 55 patients. Surgical mortality was 2.1% and morbidity 21.5%. One-, 3-, and 5-year OS rates after surgery were 49.9, 19.4 and 11.6%, respectively, with a median OS of 12.0months. T4 gastric cancer, H3 hepatic involvement, non-curative resection, recurrence after surgery, and abstention from chemotherapy were associated with a worse prognosis. Factor T and H displayed a clear (p < 0.001) cumulative effect. Our data show that R0 resection must be pursued whenever possible. The treatment of T4 gastric cancer with hepatic bilateral and diffuse metastasis (H3) should be considered carefully or it should be probably avoided. Finally, a multimodal treatment associating surgery and chemotherapy offers the best survival results.

Living-Donor Liver Transplant for Fibrolamellar Hepatocellular Carcinoma With Hilar Lymph Node Metastasis: A Case Report.

Fibrolamellar hepatocellular carcinoma is a rare primary malignant liver neoplasm. Benefits from liver transplant for patients with fibrolamellar hepatocellular carcinoma have not yet been reported. Here, we report a 19-year-old female patient who presented with abdominal pain. A computed tomography scan revealed bilobar and multiple solid lesions with the largest measuring 15 cm in diameter on the right lobe of her liver. Her blood alpha-fetoprotein level and viral hepatitis markers were normal. A fine-needle biopsy of the largest lesion detected fibrolamellar heptocellular carcinoma. Because no distant metastasis was evident and the carcinoma was unresectable, a right lobe living-donor liver transplant with hilar lymph node dissection was performed. A pathology report revealed poorly differentiated fibrolamellar hepatocellular carcinoma, and further testing indicated microvascular invasion and hilar lymph node metastasis. The largest tumor measured 12 cm. She was discharged on postoperative day 14. During postoperative month 22, multiple vertebral metastases were detected, and she died with diffuse metastasis during postoperative month 26. Our patient, with poor prognostic criteria such as hilar lymph node metastasis, microvascular invasion, and poor differentiation, had 22 months of tumor-free survival and 26 months of overall survival after having undergone living-donor liver transplant.

Reduction Of Metastasis With Plasma-Treated Liquid In Mice: The Role Of Myleoid Cells In The Tumor Microenvironment

Plasma-treated liquids have been proposed to be effective against tumor growth in vitro and in vivo. Recently, we have shown antitumor effects of DMEM exposed to the plasma of the kINPen MED in a murine, orthotopic pancreatic cancer model of diffuse peritoneal tumor metastasis [1]. Mice in the treatment group showed less metastasis formation, slower metastasis growth, increased apoptosis in tumor nodes, and better overall survival. At the same time, treatment was safe and did not affect other organs. In this study, we followed up on cellular and molecular events in the tumor microenvironment of peritoneal cancer lesions of treated compared to control mice. Special emphasize was given to myeloid cells. Tumor nodes were sectioned onto microscopy slides and stained with fluorescently labeled antibodies targeting subsets of myeloid cells. Congruent to the zone of apoptotic cell death, we identified a strong and significant influx of murine macrophages. As apoptosis was only on the tumor side exposed to the peritoneal cavity, macrophages likely influxed from this site. We next sought to identify their subtype with regard to the polarization paradigm. Almost all macrophages stained positive for CD206, a marker associated with M2 macrophages. Macrophages positive for inducible nitric oxide synthase (iNOS), a prominent marker for M1 macrophages, were nearly absent. Staining was confirmed with mouse tissues containing the respective population. This finding suggested that tumor growth was halted despite presence of M2 macrophages, which are thought to support tumor growth in general when becoming tumor-associated macrophages. Next, we stained for granulocytes influx. While we detected fewer granulocytes in tissues, we found indices for extracellular trap formation within tumor nodes, which are here linked to improved anticancer responses. Finally, we co-cultured murine PDA6606 pancreatic cancer cells with murine RAW-macrophages in vitro. Cancer cells strongly polarized macrophages to M2 but plasma treatment halted this to some extent. Plasma also increased migratory activity of macrophages but only when co-cultured with pancreatic cancer cells. Together with a rather inflammatory cytokine profile and cell surface marker expression with properties of M2 as well as M1, we propose a mixed response of murine RAW-macrophages in the tumor microenvironment upon plasma treatment. Download : Download high-res image (365KB) Download : Download full-size image Fig. 1: Tumor nodes were collected after 21 days with daily injection of NTP or medium (control), respectively and stained for F4/80 (A). The number of macrophages was significantly enhanced in treated tumors (B).

Radiotherapy for Oligometastatic Lung Cancer.

Non-small cell lung cancer (NSCLC) typically presents at an advanced stage, which is often felt to be incurable, and such patients are usually treated with a palliative approach. Accumulating retrospective and prospective clinical evidence, including a recently completed randomized trial, support the existence of an oligometastatic disease state wherein select individuals with advanced NSCLC may experience historically unprecedented prolonged survival with aggressive local treatments, consisting of radiotherapy and/or surgery, to limited sites of metastatic disease. This is reflected in the most recent AJCC staging subcategorizing metastatic disease into intra-thoracic (M1a), a single extra thoracic site (M1b), and more diffuse metastases (M1c). In the field of radiation oncology, recent technological advances have allowed for the delivery of very high, potentially ablative, doses of radiotherapy to both intra- and extra-cranial disease sites, referred to as stereotactic radiosurgery and stereotactic body radiotherapy (or SABR), in much shorter time periods compared to conventional radiation and with minimal associated toxicity. At the same time, significant improvements in systemic therapy, including platinum-based doublet chemotherapy, molecular agents targeting oncogene-addicted NSCLC, and immunotherapy in the form of checkpoint inhibitors, have led to improved control of micro-metastatic disease and extended survival sparking newfound interest in combining these agents with ablative local therapies to provide additive, and in the case of radiation and immunotherapy, potentially synergistic, effects in order to further improve progression-free and overall survival. Currently, despite the tantalizing potential associated with aggressive local therapy in the setting of oligometastatic NSCLC, well-designed prospective randomized controlled trials sufficiently powered to detect and measure the possible added benefit afforded by this approach are desperately needed.

Case report: An HIV + patient presenting with pancytopenia, hepatic failure, and coagulopathy; a rare small cell liver carcinoma with diffuse splenic and bone marrow metastasis diagnosed at autopsy

A 34-year old male with a giant condyloma acuminatum of the anus secondary to HIV infection presented to the emergency department with a persistent nose bleed lasting 2–3days, acute anemia, thrombocytopenia, and coagulopathy. The patient also had significant hepatosplenomegaly and elevated liver enzymes which were a new finding since the patient's last hospitalization 1–2month prior to the current admission. A bone marrow biopsy showed diffuse infiltration by carcinoma with neuroendocrine features. The patient quickly developed multi-organ injury, decompensated, and died. An autopsy was obtained which established the diagnosis of small cell carcinoma of the liver.

The treatment options of pancreatic neuroendocrine neoplasm with liver metastasis

Liver metastasis is the one of the main prognostic factors of pancreatic neuroendocrine neoplasm (PNEN). With the development of multidisciplinary collaboration among surgical oncology, medical oncology, and intervention treatment, the treatment of PNEN with liver metastasis gradually tends to become diversification. Surgery is still the only way for curing the patients with pancreatic neuroendocrine tumor with liver metastasis when the histological types are G1 and G2. Medical oncology and intervention treatment could be selected for those having PNEN with diffuse liver metastasis or those cannot tolerate surgery. Liver transplantation only suits for a small number of selected patients. The present article explored the relationship between histological classifications and the treatment options of PNEN with liver metastasis, and discussed the specific treatments from perspectives of surgical treatment, medical treatment and intervention treatment.

Endoscopic metallic stent followed by elective laparoscopic surgery for malignant colorectal obstruction

To investigate the feasibility of endoscopic metallic stent as a bridge to elective laparoscopic surgery in patients with malignant colorectal obstruction. Clinical data of 63 patients with obstructive colorectal cancer who underwent endoscopic metallic stent insertion under radiologic monitoring at the Longyan First Hospital between June 2012 and August 2016 were analyzed retrospectively. After complete remission of the obstruction, all the patients received multi-disciplinary team (MDT) evaluation to make the further treatment strategy. The subsequent surgery included open and laparoscopic procedures, and the short-term efficacy of these two procedures was compared. There were 30 male and 33 female patients with age of 30 to 90 (mean 67) years, including 3 cases of ascending colon cancer, 4 cases of transverse colon cancer, 12 cases of descending colon cancer, 26 cases of sigmoid cancer, and 19 cases of rectal cancer. Only one patient (1.6%) developed sigmoid perforation at 3 hours after stent placement, and underwent emergency laparotomy with Hartmann procedure. The remaining 62 patients had bowel movements. After MDT evaluation, 10 patients (16.1%) were treated with palliative chemotherapy because they were unfit for surgery or for diffuse distant metastases. A total of 52 patients underwent radical surgery after a mean interval from stent insertion of 10 days (7-20 days), including open (n=18, including two cases with conversion to open surgery) and laparoscopy (n=34). The baseline data between open and laparoscopy groups were similar (all P>0.05). Primary anastomosis was successfully performed in all the patients without preventive stoma. Compared to open group, laparoscopy group had faster bowel movement [(2.88±1.06) d vs. (4.05±2.43) d, P=0.022] and shorter postoperative hospital stay [(7.85±0.96) d vs. (9.82±4.41) d, P=0.002]. There were no statistically significant differences in operative time, intraoperative blood loss, number of harvested lymph node, and postoperative complication rate between two groups (all P>0.05). Endoscopic metallic stent placement can effectively remove malignant colorectal obstruction, and thus enables surgeons to perform an elective radical surgery, avoiding emergency surgery with stoma and unnecessary surgery for patients with distant metastasis. In the era of enhanced recovery after surgery, the endoscopic metallic stent placement combined with laparoscopic procedures, as a less invasive alternative, is effective and safe.

Successful use of docetaxel for emergency treatment of disseminated intravascular coagulation due to hormone-refractory metastatic prostate cancer

Abstract Disseminated intravascular coagulation (DIC) is a fatal presentation of metastatic adenocarcinoma of the prostate. A 59-year old male presented with a 2-week history of fatigue, red urine, and bruises on his body. Physical examination and ultrasonography showed that the patient had an enlarged prostate. Laboratory analysis was consistent with DIC. The patient's PSA level was 90 ng mL−1. Bone scintigraphy showed diffuse metastasis. Histopathological analysis of a biopsy specimen showed prostate adenocarcinoma. Acute DIC improved rapidly following initiation of leuprolide and bicalutamide hormone therapy. The patient's PSA dropped from 90 to 0.01 ng mL−1 after 1 month of treatment. The patient had recurrence of the initial complaints and elevated PSA while receiving leuprolide treatment in first year. As the patient's clinical condition deteriorated, we initiated docetaxel-containing chemotherapy. The patient's symptoms became less severe and his abnormal laboratory findings began to normalize after 2 weeks of the chemotherapy, and they completely resolved returned to normal after 2 months. In conclusion, docetaxel-containing chemotherapy in a patient with metastatic prostatic carcinoma and DIC was effective, despite a low platelet count and bleeding.

Multivisceral Transplantation for Portomesenteric Thrombosis and Unresectable Neuroendocrine Tumor

Introduction: Multivisceral transplantation (MVTx) -defined as the en bloc transplantation of the abdominal viscera (stomach, duodenum, pancreas, liver and small bowel) is mostly performed for complicated diffuse and complete portomesenteric thrombosis. Experience is limited and the procedure still in its relative infancy, but the number of cases is likely to rise with the advent of new indications. Case description: In August 2011, a 20 year-old male was referred to our department with complete portomesenteric thrombosis. Imaging showed extensive hepatosplenomegaly with diffuse perfusion defects and degenerative changes in the pancreas. In December 2013, despite medical treatment, the patient’s condition severely deteriorated with cholestasis, ascites requiring regular percutaneous drainage, variceal bleeding and intestinal failure. The only therapeutic option left was MVTx. In March 2014, MVTx was performed. First, the celiac trunk and the superior mesenteric artery were embolized to reduce perioperative bleeding, followed by resection of the native organs, and finally en bloc transplantation of the corresponding organs. The patient recovered well and was discharged at day 66 post-transplant. He became nutritionally independent 2 months’ post-transplant. Unexpectedly, the resection specimen showed an underlying grade III (Ki67 of 20.3%) pancreatic tail neuro-endocrine carcinoma with direct invasion of the spleen and diffuse liver metastasis with diffuse portomesenteric tumor thrombosis. The resection margins were negative. There was no nodal involvement and further imaging showed no residual tumor activity. Everolimus –by virtue of its anti-tumoral properties- was associated to classical tacrolimus and steroids-based immunosuppression. No adjuvant therapy was given. 2.5 years post-transplant, regular MRI scan and serum chromogranin levels have remained normal and the patient is leading a normal life. Conclusion: This case confirms that MVTx is an effective treatment for portomesenteric thrombosis. In addition, it demonstrates that MVTx could be considered in selected cases of extensive and otherwise unresectable intra-abdominal tumors. In the latter, MVTx – complete splanchnic exenteration and replacement- allows the greatest chance for complete tumoral clearance. In addition, arterial embolization immediately pre-transplant could induce tumor necrosis and prevent perioperative vascular seeding.

Prognostic Markers and Histologic Subtypes in Patients with Meningeal Carcinomatosis in Breast Cancer

Objective: Meningeal carcinomatosis (MC) is a rare complication in breast cancer patients. It is defined as a diffuse or multifocal leptomeningeal metastasis. Study Design: From our institution database, we retrospectively studied 19 patients diagnosed with MC in the cerebrospinal fluid (CSF) in 1997-2015, in order to evaluate tumor prognostic markers, histologic subtypes, and clinical outcome. Results: All patients were female, with a mean age of 53 years (range 36-75 years). The mean interval between diagnosis of breast carcinoma and MC was 28 months (range 6-62 months). The median survival from the time of diagnosis was 2 months (1-51 months). Sixteen cases (84%) were the ductal phenotype, 62% of which were of a high grade (grade 3), and 3 cases (16%) were lobular. Estrogen and progesterone receptors were positive on immunohistochemistry (IHC) in 53 and 33% of patients, respectively. HER2 IHC was positive (3+) in 20% of the cases; all were amplified by fluorescence in situ hybridization. The incidence of MC in triple-negative tumors was 40%. Twelve patients (63%) already had known metastasis at the time of diagnosis. Conclusions: Most cases of MC are high-grade ductal. MC is more common in triple-negative breast cancers. The outcome of these breast cancer patients with MC was poor. There was no survival difference according to age, histologic subtype, grade, or hormonal or HER2 status.

Liver transplantation as a potentially lifesaving measure in neuroblastoma stage 4S

ABSTRACTNeuroblastoma (NBL) stage 4s is an incompletely understood phenomenon with variable clinical course. While the majority of patients may undergo spontaneous regression and achieve complete resolution without intensive therapy, a small proportion is at increased risk of developing secondary complications. One such situation is liver insufficiency due to diffuse metastases. We report a patient suffering from NBL 4S who required double lifesaving liver transplantation. Abdominal and respiratory complications due to hepatomegaly are crucial determinants for treatment intensity and duration in 4S NBL [1,2]. We provide an algorithm in order to facilitate the clinical decision when dealing with similar potentially life-threatening events.

Myometrium and Sigmoid Colon Metastatic Melanoma Simulating a Ewing Tumor: A Case Report

Malignant melanomas or lymphoma of the skin are malignant tumors of the skin and/or the mucous membranes whose uterine metastases are rare. The secondary uterine localizations, although rare, must be evoked in front of a pelvic tumoral syndrome, or diffuse metastases and a personal past history of melanoma, even after a long time of remission. In our observation, the evolution of the tumor in the pelvis extended to the muscular structures of the uterus and the sigmoid colon of a 72 year old patient, what made it an exceptional case. The diagnosis of these secondary localizations is a diagnosis of elimination, almost always post-operative, made on the histopathological and immunocytochemical study of the surgical specimen, supported by cytogenetics, even molecular biology. The treatment is based on chemotherapy.