Direct Tumor Invasion Research Articles

DNA origami assembled spheroid for evaluating cytotoxicity and infiltration of chimeric antigen receptor macrophage (CAR-M)

Chimeric antigen receptor (CAR) T-cell therapies have shown remarkable results in patients with hematological malignancies. However, their success in treating solid tumors has been limited. As an alternative candidate for the CAR therapy, CAR-macrophages (CAR-M) have demonstrated activation and phagocytosis directed by tumor-associated antigen (TAA), showing promise in the treatment of solid tumors. Nevertheless, the mechanisms by which CARs direct tumor chemotaxis and invasion of CAR-M remain poorly understood. In this study, we aim to investigate the role of CARs in CAR-M attachment and infiltration using 3D tumor spheroids, which were created by utilizing a novel self-assembling nucleic acid nanostructure decorated living cells (NAC). Our results demonstrated that CAR-M exhibited higher invasion and killing capacity in 2D model and 3D tumor spheroids. In summary, the 3D NAC assembled tumor spheroid model provides a suitable platform for target screening and pharmacodynamic evaluation of CAR-M.

Atypical Presentation of Carcinoma Breast as Paraneoplastic Cerebellar Degeneration on [18F]FDG PET/CT

Paraneoplastic neurological syndrome (PNS) represents a rare group of central nervous system disorders that are unrelated to direct tumor invasion or metastasis but may be triggered by an immune system reaction to a neoplasm or malignant tumor. In many patients, PNS is diagnosed before identifying the primary cancer. In such instances, positron emission tomography/computed tomography scan can assess individuals with suspected PNS enabling the detection of hidden malignancies. We share an interesting image of paraneoplastic cerebellar degeneration in a case of invasive ductal carcinoma breast.

Atypical Presentation of Gall Bladder Adenocarcinoma as Paraneoplastic Myeloneuropathy.

Paraneoplastic neurologic syndromes are a rare, heterogeneous group of complications associated with malignancy, unrelated to direct tumor invasion or metastasis. They are the remote effects of a malignancy owing to immune-mediated reaction toward the antigens that are common to both the malignant and normal cells. Few paraneoplastic syndromes are reported with gall bladder cancer. However, neurological symptoms are infrequent. Here we share an interesting case of adenocarcinoma of gall bladder with initial presentation as a paraneoplastic noncompressing myeloneuropathy.

Case Report: A very rare case of a Pleural Effusion revealing Multiple Myeloma

Multiple myeloma is a common malignant bone-based disease. Pleural effusions reported in these patients remain rare. It is commonly due to congestive heart disease, pulmonary embolism, nephrotic syndrome or a second neoplasia. The true myelomatous pleural effusion resulting from a direct tumoral invasion of the pleural are extremely rare. We report here the case of a massive pleural effusion revealing multiple myeloma in a 71-year-old patient. The chest ultrasound showed a massive pleural effusion in the left side with a multinodular thickening of the pleura. The medical thoracoscopy showed a grape-cluster appearance. The diagnosis was made by pleural guided biopsy revealing abnormal plasma cells with an intense positive CD 138 (plasma cell marker) and MUM1 (multiple myeloma oncogene1) staining with a light kappa chain in the protein electrophoresis associated with a myeloma. Unfortunately, our patient died one month after the initial diagnosis. We present also a review of the recent literature in order to highlight the clinical presentations of the myelomatous pleural effusion, the diagnostic tools, the therapeutic strategies as well as the outcomes.

“Post-renal acute kidney injury in patients with cancer: Clinical presentation and kidney and patient outcomes”

Background: Post-renal acute kidney injury (PR–AKI) is frequent in patients with cancer requiring emergent intervention. With our study we aimed to describe the clinical features and prognostic factors for kidney and overall survival (OS) in cancer patients with PR–AKI. Methods: This is a single-center retrospective study that included 306 cancer patients with PR–AKI admitted from January 2011 to December 2021. Previous kidney function, AKI episode, and progression to end-stage kidney disease (ESKD) were compared. Kaplan Meier and Cox proportional regression methods were used for survival analyses. Results: The most frequent type of malignancy was the prostate (52, 17%) followed by the uterus (50, 16.3%). The mean baseline eGFR was 62 ml/min/1.73 m2. AKI stage 3 was present in 157 patients (51.3%) and renal replacement therapy (RRT) was performed in 19 patients (6%). At discharge, 197 patients (64.4%) had a quick recovery, and during follow-up 8 (2.6%) patients progressed to ESKD. The risk factors associated with ESKD were previous decreased kidney function (eGFR<30 ml min 1.73m2) (HR 33.275, [95% CI, 3.997–277.002], p = 0.001); glomerular disease, (HR 8.353, [95%CI, 1.022–68.279], p=0.048); concomitant prerenal AKI (HR 5.670, [95% CI, 1.143–28.131], p = 0.034); and need of RRT (HR 19.519, [95% CI, 4.871–78.215], p < 0.001). Median OS was 6 months (IQR 1–24 months). We found differences in the global survival over 60 months, with longtime survivors including patients with Bricker (42.6% vs16.4%) and genito-urinary cancer (27.6% vs 11.7%). Gastric cancer (HR 2.943, [95%CI, 1.837–4.714], p<0.001), metastatic disease (HR 1.913, [95%CI, 1.464–2.499], p < 0.001), and direct tumoral invasion (HR 1.519, [95%CI, 1.115–2.070], p = 0.008) were related with a decreased survival. Conclusions: Gastric cancer, metastatic disease, and direct tumoral invasion were predictors of short survival. The main predictors of evolution to ESKD were previous kidney function, concomitant glomerular disease, and the need for RT.

Efficacy of endoscopic ultrasound-guided pelvic abscess drainage for pelvic abscesses: A case series study

Background and study aimThis is a retrospective study to evaluate the safety and efficacy of endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD) in a single hospital setting. Patients and methodsThe referral criteria for EUS-PAD included patients with a pelvic abscess (PA) that was amenable for the procedure. A total of 14 patients with PA treated with EUS-PAD were included in this study. The mean patient age was 57.4 years, and male-to-female ratio was 7:7. Overall, there were six cases of appendiceal perforation, five of rectal cancer and one case each of the diverticular perforation, perianal abscess, and walled-off necrosis. ResultsOverall, 100% of procedures were successful. Clinical success was achieved in 11 patients and they were discharged after EUS-PAD within 21.4 days on an average and the average duration of stent placement before removal was 27.0 days. Of all, six patients achieved complete improvement status where the cause was appendiceal perforation while two and one of the patients were recovered where the causes were post-curative operation for carcinoma and walled-off necrosis, respectively. Eight out of eleven patients who exhibited appendiceal perforation or underwent radical rectal cancer surgery were discharged after an average of 9.4 days post EUS-PAD. Although two patients showed temporary improvement, with perianal abscess and controlled rectal carcinoma, the PA worsened as the primary disease intensified. The PA drainage was ineffective in three patients where two of them had uncontrolled rectal cancer and one had diverticular perforation. ConclusionConclusively, the EUS-PAD is not only a reliable, safe, and efficient alternative to surgical and percutaneous drainage but also a valuable procedure with a high success rate for patients with acute infections, such as those who have had an appendiceal perforation or curative surgery. Poor indications and contraindications for EUS-PAD include uncontrolled gastrointestinal perforation and direct tumor invasion.

Treatment outcomes of radiotherapy for malignant psoas syndrome: A single-center retrospective study

IntroductionThe efficacy of radiotherapy for symptomatic relief of malignant psoas syndrome (MPS) remains unknown because there are limited publications with high level evidence, including analyses with sufficient number of cases, clinical trials, and systematic reviews about radiotherapy for MPS. We aimed to investigate the characteristics of and symptom relief rates in patients treated with radiotherapy for MPS in palliative intent. MethodsIn this single-center retrospective study, we analyzed data of 22 consecutive patients treated with radiotherapy for MPS at our institution in Japan between 2012 and 2022. We recorded patient characteristics, including primary site, invasion pattern, recognition of MPS by the attending physician, radiation regimen, biological effective dose with α/β = 10 Gy (BED10), and adverse events. Since no objective evaluation index for palliative radiotherapy for non-bone metastases has been established, we modified and used an International Consensus on Palliative Radiotherapy Endpoint, which was originally used for bone metastases, to evaluate symptom relief in the present retrospective study. “Response” was defined as symptom relief described in medical records or the use of analgesic medications reduced by ≥25% within 3 months post-initiation of radiotherapy. ResultsGenitourinary organs (41%) were the most common primary-tumor sites. MPS was caused by metastasis in the iliopsoas muscle in 14 patients (64%) and by direct invasion of the primary tumor in eight patients (36%). Since the optimal radiation dose for MPS has not been established, the radiation dose varied from low dose, which are used in palliative radiotherapy for painful bone metastases, to high dose with conventional fraction using 1.8 to 2 Gy per fraction, with a median BED10 of 48 Gy (range, 10.6–79.2 Gy). Fifteen patients (68%) achieved a response. No acute nor late adverse events of grade 2 or higher, according to Common Terminology Criteria for Adverse Events version 5.0, were reported during the observation period. ConclusionRadiotherapy for symptomatic MPS might be an effective treatment option with a high response rate (68%) and minimal adverse events. Since the present study is a retrospective study with small number of cases, a prospective study with a larger sample size is required.

Cardiac Metastatic Tumors: Current Knowledge.

Cardiac tumors are a heterogeneous group of pathologic masses of the heart that contain primary tumors-benign or malignant, and secondary tumors. Metastases are significantly more frequent, mostly originating from lung, breast, gastrointestinal tract, or ovary carcinomas. Secondary cardiac tumors may be asymptomatic or may cause cardiovascular, systemic, or embolic symptoms. The study is a summary of the available knowledge on cancerous metastatic lesions of the heart. Pleural mesothelioma (48.4%), adenocarcinoma (19.5%), or squamous cell carcinoma (18.2%) of lung, breast carcinoma (15.5%), ovarian carcinoma (10.3%), and bronchoalveolar carcinomas (9.8%) are cited as the most common origin of secondary heart tumors. Masses can spread by direct tumor invasion, by lymphatic vessels, veins, or arteries. Patients with cancer and nonspecific cardiovascular symptoms should be particularly vigilant, and the possibility of metastasis in an unusual location such as the myocardium should be considered in the diagnosis. Diagnostic methods include echocardiography, cardiac magnetic resonance, computed tomography, positron emission tomography, and histologic evaluation. Treatment of choice is managing primary carcinoma, due to the poor outcomes of surgical methods.

Case Report: A very rare case of a pleural effusion revealing multiple myeloma

Multiple myeloma is a common malignant bone-based disease. Pleural effusions reported in these patients remain rare. It is commonly due to congestive heart disease, pulmonary embolism, nephrotic syndrome or a second neoplasia. The true myelomatous pleural effusion resulting from a direct tumoral invasion of the pleural are extremely rare. We report here the case of a massive pleural effusion revealing multiple myeloma in a 71-year-old patient. The chest ultrasound showed a massive pleural effusion in the left side with a multinodular thickening of the pleura. The medical thoracoscopy showed a grape-cluster appearance. The diagnosis was made by pleural guided biopsy revealing abnormal plasma cells with an intense positive CD 138 (plasma cell marker) and MUM1 (multiple myeloma oncogene1) staining with a light kappa chain in the protein electrophoresis associated with a myeloma. Unfortunately, our patient died one month after the initial diagnosis. We present also a review of the recent literature in order to highlight the clinical presentations of the myelomatous pleural effusion, the diagnostic tools, the therapeutic strategies as well as the outcomes.

Síndromes paraneoplásicos del sistema nervioso

Paraneoplastic syndromes are clinical manifestations of a tumor that are not related to the direct invasion of the primary tumor or its metastases. Therefore, cerebrovascular, infectious, nutritional metabolic, or toxic complications associated with neoplasms and also treatment-derived complications (surgery, radiotherapy, chemotherapy, or biologic therapies) are excluded. They comprise a heterogeneous group of syndromes that can affect any part of the central nervous system (CNS) or peripheral nervous system (PNS), neuromuscular junction, and muscle and occasionally affect multiple areas in the same patient. They are uncommon, with a general incidence in patients with cancer of less than 1%. Incidence varies according to the type of tumor, with small cell lung cancer (SCLC) being the most commonly involved, with an incidence of 3%. The presence of onconeural antibodies supports the diagnosis of a compatible clinical syndrome. However, they are only present in approximately 50% of cases and therefore its absence does not rule out a diagnosis. As previously stated, paraneoplastic syndrome can occur in patients with an already-diagnosed neoplasm, but it is not apparent in many cases. Therefore, the search for the occult neoplasm is necessary when the syndrome is present. If possible, treatment must be started as soon as possible, given that paraneoplastic syndromes progress in weeks and can cause irreversible damage or even the patient's death.

Paraneoplastic Syndromes from Head to Toe: Pathophysiology, Imaging Features, and Workup

Patients often have symptoms due to the mass effect of a neoplasm on surrounding tissues or the development of distant metastases. However, some patients may present with clinical symptoms that are not attributable to direct tumor invasion. In particular, certain tumors may release substances such as hormones or cytokines or trigger an immune cross-reactivity between malignant and normal body cells, resulting in characteristic clinical features that are broadly referred to as paraneoplastic syndromes (PNSs). Recent advances in medicine have improved the understanding of the pathogenesis of PNSs and enhanced their diagnosis and treatment. It is estimated that 8% of patients with cancer develop a PNS. Diverse organ systems may be involved, most notably the neurologic, musculoskeletal, endocrinologic, dermatologic, gastrointestinal, and cardiovascular systems. Knowledge of various PNSs is necessary, as these syndromes may precede tumor development, complicate the patient's clinical presentation, indicate tumor prognosis, or be mistaken for metastatic spread. Radiologists should be familiar with the clinical presentations of common PNSs and the selection of appropriate imaging examinations. Many of these PNSs have imaging features that can assist with arriving at the correct diagnosis. Therefore, the key radiographic findings associated with these PNSs and the diagnostic pitfalls that can be encountered during imaging are important, as their detection can facilitate early identification of the underlying tumor, reveal early recurrence, and enable monitoring of the patient's response to therapy. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy.

Since stroke is often associated with cancer, acute stroke patients with cancer undergoing endovascular therapy (EVT) are not uncommon. Reportedly, the proportion of such cases is approximately 6%-7% of all stroke EVT cases. Ischemic stroke in patients with active cancer (cancer-associated stroke) includes not only strokes caused by cancer-related hypercoagulability but also coincident strokes due to common etiologies, strokes associated with tumor emboli, direct tumor invasion of blood vessels, and strokes associated with cancer therapy. Stroke caused by cancer-related hypercoagulability itself encompasses various entities, including paradoxical embolism, stroke due to nonbacterial thrombotic endocarditis, and in situ arterial occlusion due to disseminated intravascular coagulation or thrombotic microangiopathy. Thus, diverse mechanisms contribute to cancer-associated stroke, emphasizing the need to consider individualized treatment strategies for acute cases involving large vessel occlusion. Observational studies have shown that EVT for cancer-associated stroke results in poorer clinical outcomes, but with comparable rates of successful reperfusion and symptomatic intracranial hemorrhage when compared with stroke patients without cancer. This suggests that denying patients EVT solely on the basis of comorbid active cancer is inappropriate, and decision-making should be shared with the patients and their families, preferably through a multidisciplinary team approach. Thrombi retrieved from patients with stroke caused by cancer-related hypercoagulability have unique characteristics, being predominantly platelet rich and difficult to retrieve. Preprocedural imaging and serum biomarkers, including the hyperdense vessel sign on non-contrast CT, susceptibility vessel sign on T2* or susceptibility-weighted MRI, three-territory sign on MRI, and D-dimer levels, are valuable in evaluating the stroke subtype and thrombus features. Thrombectomy techniques, such as contact aspiration and stent retriever monotherapy, have shown varying degrees of effectiveness for stroke caused by cancer-related hypercoagulability, warranting further study. After reperfusion therapy, appropriate treatment for the prevention of stroke recurrence should be initiated, considering the specific stroke subtypes. In conclusion, cancer-associated stroke encompasses diverse subtypes, and thrombi associated with stroke caused by cancer-related hypercoagulability present various challenges for thrombectomy. Individualized treatment approaches based on underlying mechanisms are essential for improving outcomes in acute stroke patients with active cancer. Optimization of preprocedural diagnosis, EVT techniques, and secondary prevention of stroke caused by cancer-related hypercoagulability will lead to better management of these patients and enhance their quality of life.

Appendiceal Mucinous Tumor Presenting as Recurrent Bowel Obstruction.

Appendiceal mucinous tumors are rare, with variable malignant potential, and they are usually found incidentally. Clinical symptoms are nonspecific. Rarely, appendiceal mucinous neoplasm causes bowel obstruction and makes diagnosis more difficult. We present a case of an 84-year-old female who came to our emergency department having had abdominal fullness and constipation for 5 days. Ileus, due to an affected adhesion band, was diagnosed initially, and symptoms improved gradually under conservative treatment. However, 3 months later she presented to the emergency department again with abdominal pain and distension; small bowel obstruction due to adhesion was again diagnosed. Recurrent bowel obstruction prompted emergent surgery. Operative findings showed a whitish appendiceal tumor adhering to and directly invading the adjacent ileum, with a segment of herniated small bowel wedged in between, causing the obstruction. Upon reviewing the initial computed tomography scan, the dilated tubular structure of appendiceal tumor was misrecognized as small bowel loop; there was no surrounding inflammatory sign, leading to diagnosis difficulty. Instead of a common cause of bowel obstruction, such as adhesion band, this case revealed bowel obstruction can be caused by the direct invasion of an appendiceal tumor. Awareness of this condition with careful image evaluation of small bowel obstruction is essential for diagnosis.

Treatment efficacy and prognosis analysis in locally advanced or metastatic colorectal cancer patients with hydronephrosis.

The effect of hydronephrosis, a common complication of metastatic colorectal cancer (CRC), on the treatment outcome and prognosis of locally advanced or metastatic CRC remains to be elucidated. The present study investigated the clinical characteristics, outcomes, and prognoses of patients with locally advanced or metastatic colorectal cancer (CRC) with hydronephrosis. Clinical data of patients with locally advanced or metastatic CRC who were attending Peking University Shenzhen Hospital and Shenzhen Cancer Hospital between January 2016 and December 2020 were retrospectively collected. A total of 52 patients with hydronephrosis based on CT or MRI findings were selected, and their clinical characteristics, treatment outcomes, and survival times were analyzed. Of the 52 patients, 33 were male (63.5%), and the median age was 49 years (range, 31-76 years). A total of 15 (28.8%) patients with CRC had synchronous hydronephrosis and the remaining 37 patients had metachronous hydronephrosis. Ureters were either compressed by peritoneal or abdominal cavity metastatic lymph nodes in 34 cases (65.4%) or by direct tumor invasion in 18 cases (34.6%). However, objective response rate (ORR) was higher in the group in which ureters were compressed by peritoneal or abdominal cavity metastatic lymph nodes; ORR, disease control rate and median progression-free survival (PFS) between the two groups were not statistically different. (P>0.05). The median survival period was only 27.0 months (95% CI, 20.549-33.451) in patients complicated with malignant hydronephrosis. Univariate and multivariate analyses showed that CA19-9 might be a prognostic factor for locally advanced and metastatic CRC patients with hydronephrosis. Metachronous metastatic CRC has a high incidence rate of complicated hydronephrosis. Targeted drugs in combination with chemotherapy improve the treatment efficacy and prognosis of patients. Notably, the present study found that CA19-9 level might be a prognostic factor in CRC patients with hydronephrosis.

Recurrent Carotid artery blow out in a head & neck patient

Introduction and importanceCarotid artery blowout syndrome is a rare complication of head and neck cancer treatment. It defines a rupture of the carotid artery wall through vessel wall necrosis. This is typically precipitated by radiotherapy, direct tumour invasion, or a combination of these factors. We describe a rare case of three consecutive carotid artery blowouts in a head and neck cancer patient.Case presentationA 58-year-old man with a history of T3NO hypopharyngeal squamous cell carcinoma (SCC) treated with chemotherapy and radiation presented with a four-month history of progressive dysphagia and right sided neck pain. Flexible nasendoscopy revealed laryngeal oedema and slough. A panendoscopy and biopsy showed no evidence of tumour recurrence. The patient was discharged and represented with worsening dyspnoea. He subsequently experienced a large volume hemorrhage necessitating ligation of his right external carotid artery. He underwent pharyngolaryngectomy indicated due to the extent of laryngeal radiation necrosis. Thereafter he suffered two additional acute carotid bleeds from his right common carotid necessitating ligation in theatre.Clinical discussion and conclusionThis case report illustrates the key issues to be considered in patients with locally advanced hypopharyngeal squamous cell carcinoma and subsequent management of acute carotid blowout syndrome, which without prompt management, can be fatal.

High-Dose-Rate Interstitial Brachytherapy for Deeply Situated Gynecologic Tumors Guided by Combination of Transrectal and Transabdominal Ultrasonography: A Technical Note.

Background and PurposeHigh-dose-rate interstitial brachytherapy (HDR-ISBT) is recommended to obtain a better local tumor control for uterine cancer patients in specific situations such as bulky lesions, an extension to the lateral parametrium, or tumors with irregular shapes. Our group uses real-time transrectal ultrasonography (TRUS) to guide freehand interstitial needle insertion. Occasionally, target tumors locate deeper beyond the rectum and cannot be visualized by TRUS. CT can guide needles to deeply located tumors, but in such cases, repeated image obtainment is required to achieve ideal needle localization. In this report, we present nine cases of patients who underwent HDR-ISBT for deeply situated tumors guided by a combination of transrectal and transabdominal ultrasonography (TR/TA-US).Material and MethodsNine uterine cancer patients whose tumors were located deeper than the reach of TRUS and underwent HDR-ISBT guided by TR/TA-US were presented. All nine cases had no distal organ metastasis and underwent external beam radiation therapy (EBRT) to the pelvic region for 45–50.4 Gy in 25–28 fractions followed by boost HDR-ISBT for deeply situated tumors guided by TR/TA-US.ResultsThere were seven cervical cancer and two endometrial cancer patients: six with extensive uterine corpus invasion, one cervical cancer with massive pelvic lymph node metastasis, one cervical cancer with postoperative pelvic recurrence, and one with left ovarian direct tumor invasion. The median follow-up period was 15 months (range 3–28 months). The average clinical target volume at the time of first HDR-ISBT was 131 ml (range 44–335 ml). The linear distance from the vaginal entrance to the deepest part of the tumor at first time brachytherapy of nine cases was 14.0 (9.0–17.0) cm. HDR-ISBT dose fractionation was 24–30 Gy in four or five fractions. Seven out of nine cases had no local recurrence in the follow-up period. One had local in-field recurrence 25 months after HDR-ISBT. Another case with carcinosarcoma could not obtain local control and underwent salvage hysterectomy for a residual uterine tumor 11 months after HDR-ISBT. Four cases had extra-field recurrence in lymph nodes or distant organs.ConclusionsIn brachytherapy for gynecologic malignancies, deeply situated tumors located out of reach of TRUS may obtain favorable local control by HDR-ISBT guided with TR/TA-US.

A CONFOUNDING CASE OF SUPERIOR VENA CAVA SYNDROME

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Superior Vena Cava Syndrome (SVCS) results from obstruction of blood flow through the superior vena cava (SVC). It can either be due to malignant obstruction caused by direct invasion of tumor into the SVC, or by external compression of the SVC by thoracic or mediastinal structures. Face or neck swelling is one of the commonest findings in SVCS and might be mistaken for an allergic reaction.Here, we present a case of a patient who presented with SVCS due to malignancy which was initially misdiagnosed as angioedema. CASE PRESENTATION: A 72-year-old Caucasian female with a medical history of hyperlipidemia presented to the emergency department (ED) with facial & neck swelling and dyspnea for 6 weeks. The swelling was more prominent in the morning and decreased as the day progressed. Before the presentation, she went to urgent care and was treated with antibiotics for 2-3 weeks. Despite that, her symptoms persisted, and she went to an otolaryngologist, an allergist & an immunologist who treated her with antihistamines and steroids for possible angioedema. Since it was not getting better, she came to the ED. She did not report fever, night sweats, cough, weight loss, or fatigue. She had a 30 pack-year smoking and 10-year vaping history. On presentation, vitals and laboratory investigations were normal. Physical examination was significant for facial edema and erythema in the malar area. There was no swelling in the upper extremities. The chest radiograph was normal. Computed tomography revealed confluent right paratracheal lymphadenopathy measuring 3 x 4 cm in aggregate extending to the right hilum. She underwent endobronchial ultrasound with a transthoracic needle aspiration biopsy. Pathology results were diagnostic for squamous cell carcinoma (SqCC) of the lung positive for P63 and CK5/6. She underwent radiation therapy and chemotherapy with paclitaxel and carboplatin that provided relief to the symptoms. DISCUSSION: SVCS can be challenging to diagnose and can be mistaken as inflammatory, infectious, or allergic conditions (1). Our patient did not have any constitutional symptoms suggestive of malignancy. On physical examination, she had facial swelling but did not have upper extremity swelling. The absence of upper extremity swelling; one of the commonest symptoms, seen in one-third of SVCS patients (2), made the diagnosis difficult. Significant smoking and vaping history prompted us to get further imaging and biopsy which ultimately lead to diagnosis. Evidence suggests that amongst lung cancers, small cell lung cancer is most likely to cause SVCS (3), however, our patient was diagnosed with SqCC which was also unique in our case. CONCLUSIONS: SVCS can be a life-threatening condition and warrants a timely diagnosis. Our case demonstrates that suspicion for SVCS should be high in patients with a significant smoking history presenting with facial swelling unresolved with angioedema treatment. REFERENCE #1: Rochelle Tonkin, Christopher Sladden. What lies downstream? A case of superior vena cava syndrome presenting in the dermatology clinic: A case report. SAGE Open Medical Case Reports. https://doi.org/10.1177/2050313X20919618 REFERENCE #2: Armstrong BA, Perez CA, Simpson JR, Hederman MA. Role of irradiation in the management of superior vena cava syndrome. Int J Radiat Oncol Biol Phys. 1987;13(4):531-539. doi:10.1016/0360-3016(87)90068-x REFERENCE #3: Wei S, Liu J, Li X, et al. A retrospective stenting study on superior vena cava syndrome caused by lung cancer. Thorac Cancer. 2020;11(7):1835-1839. doi:10.1111/1759-7714.13461 DISCLOSURES: No relevant relationships by Ghulam Aftab, source=Web Response No relevant relationships by Sidharth Bhasin, source=Web Response No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Monarch Shah, source=Web Response No relevant relationships by Abi Watts, source=Web Response

Endocrine paraneoplastic syndromes in lung cancer: a respiratory physician's perspective.

Lung malignancy is known to be one of the leading causes of cancer-related mortality. Endocrine paraneoplastic syndromes in lung cancer are common. These are due to secretion of various substances and not because of direct tumour invasion or me-tastasis. These syndromes have also been associated with lung cancer prognosis. This review describes the many endocrine paraneoplastic syndromes seen in lung cancer and narrates their incidence, biology, clinical features, diagnosis, and management.

The Role of Extracorporeal Membrane Oxygenation in the Anesthetic Management of Superior Vena Cava Syndrome: Is it Time to Use a Scoring System?

SUPERIOR VENA cava (SVC) syndrome is characterized by a mechanical obstruction to the SVC, decreasing preload to the heart and causing the constellation of neck vein distention, facial, and upper extremity edema, and sometimes cerebral edema. 1 Kishi K Sonomura T Mitsuzane K et al. Self-expandable metallic stent therapy for superior vena cava syndrome: Clinical observations. Radiology. 1993; 189: 531-535 Crossref PubMed Scopus (109) Google Scholar ,2 Qanadli S El Hajjam M Bruckert F et al. Helical CT phlebography of the superior vena cava: Diagnosis and evaluation of venous obstruction. Am J Roentgenol. 1999; 172: 1327-1333 Crossref PubMed Scopus (53) Google Scholar Malignancy has been the historic cause of SVC syndrome, although there has been a shift toward nonmalignant etiologies accounting for up to half of cases. 3 Nossair F Schoettler P Starr J et al. Pediatric superior vena cava syndrome: An evidence-based systematic review of the literature. Pediatri Blood Cancer. 2018; 65: e27225 Crossref PubMed Scopus (12) Google Scholar ,4 Siegel Y Kuker R. Superior vena cava obstruction in hemodialysis patients: Symptoms, clinical presentation and outcomes compared to other etiologies. Ther Apher Dial. 2016; 20: 390-393 Crossref PubMed Scopus (5) Google Scholar Malignancies arising in the anterior mediastinum are well-known to cause SVC syndrome by direct tumor invasion or SVC compression. These typically advanced tumors also may cause external compression of the respiratory tract, complicating mechanical ventilation and the provider's options for securing an airway sufficient for ventilation and oxygenation. 5 Straka C Ying J Kong F et al. Review of evolving etiologies, implications and treatment strategies for the superior vena cava syndrome. Springerplus. 2016; 5: 229 Crossref PubMed Scopus (43) Google Scholar Although general anesthesia generally is considered high risk, it routinely is required for surgical biopsy, before resection, or for palliative treatments. The imminent risks of cardiovascular and respiratory collapse during induction of general anesthesia pose a real challenge for the anesthesiologist, and may require extracorporeal membrane oxygenation (ECMO) perioperativelt to safely manage patients with SVC syndrome.

Relationship between clinicopathological features and prognosis of pancreatic ductal adenocarcinoma

Objective: To investigate the relationship between clinicopathologic features and prognosis of pancreatic ductal adenocarcinoma located in the head of pancreas. Methods: A retrospective study was performed on 169 patients undergoing radical resection for pancreatic head cancer collected in the First Affiliated Hospital with Nanjing Medical University from January 2018 to April 2019. Univariate analysis and multivariate analysis were performed. Results: Patient's age, tumor differentiation, tumor maximum diameter, resection margin (several resection margins including portal vein groove resection margin, posterior resection margin, and uncinate resection margin), number of positive lymph nodes, number of regional lymph node dissected, and some preoperative and postoperative indicators were associated with prognosis (P<0.05). Direct tumor invasion of organs and surrounding tissues, perineural and vascular invasion, pathologic variants etc. had no statistical significance for survival time. Patient's age, maximum tumor diameter, degree of differentiation, uncinate incision margin, number of regional lymph nodes dissected, and preoperative CA19-9 were independent factors affecting prognosis. Patients older than 74 years of age, with tumors larger than 3 cm in diameter, poorly differentiated, less than 7 regional lymph node dissected, positive uncinate margin, and preoperative CA19-9 higher than 1.5×105 U/L were independent risk factors in patients with pancreatic head cancer. Conclusions: Old age, tumor lager than 3 cm, poor differentiation, low examined lymph nodes, direct uncinate margin involvement and (or) with preoperative CA19-9 higher than 1.5×105 U/L are related to poor prognosis of head pancreatic cancer.