Enlarged Para-aortic Lymph Nodes Research Articles

Coexistence of ovarian cancer and peritoneal tuberculosis: a case report.

Peritoneal tuberculosis (TB) is known to mimic advanced ovarian cancer. In this case report, we describe a unique case of ovarian cancer (endometrioid carcinoma grade 3) at the International Federation of Gynecology and Obstetrics (FIGO) stage IC1 with pulmonary and peritoneal TB, which was suspected preoperatively to be a coexistence of advanced ovarian cancer and pulmonary TB. A 68-year-old woman presented with a prominent abdominal mass and fever. Laboratory investigations, imaging, and sputum analysis indicated a probable diagnosis of ovarian cancer at FIGO stage IIIC, characterized by peritoneal dissemination and para-aortic lymph node metastasis, which was further complicated by coexisting pulmonary TB. Surgical management included total abdominal hysterectomy, bilateral salpingo-oophorectomy, and partial omentectomy. Intraoperatively, the tumor was localized to the right ovary with significant peritoneal thickening and adhesions indicative of peritoneal TB. The surgery was completed without apparent complications. Postoperative histopathological evaluation confirmed grade 3 endometrioid carcinoma in the right ovary along with evidence of peritoneal TB. Given the extent of adhesions attributed to TB, lymph node dissection for staging was deemed challenging and was thus not pursued. Initiation of anti-TB treatment on postoperative day 2 resulted in marked regression of the preoperatively identified pulmonary nodules and para-aortic lymph node enlargement, suggesting their inflammatory origin from TB. Although postoperative chemotherapy is typically advocated for patients with stage IC1 endometrioid carcinoma grade 3, the patient opted against it. Consequently, no adjuvant therapy was administered and the patient remained under close observation.

Advanced Ovarian Yolk Sac Tumor in Nine-Year-Old Girl: Case Report and Literature Review, 2023

Background: Yolk sac tumor or primary endodermal tumor is a rare and aggressive malignant tumor, representing 15% to 20% of germ cell tumors of the ovaries, characterized by its high sensitivity to chemotherapy, often-present adolescents from 18 to 30 years old. Case Report: This is a 9 years old female presented with abdominal pain and distention associated with constitutional symptoms and significant weight loss, which she cannot exactly quantify. She had no family history of similar problems and denies any change in bowel habit, vaginal discharge or bleeding. Besides, she had no development of any secondary sex characteristics. On physical examination, she was not in distress with stable vital signs. Chest was clear to auscultation and abdomen was distended with slight deviation to the right side, which is hard, non-tender mobile, with irregular border about 20x18cm size, reaching to the level of umbilicus. There was no sign of fluid collection or inguinal lymph node enlargement. serum tumor markers revealed alpha fetoprotein level >1210 ng/dl, CA 125 of 70.1U/mland CT scan showed right ovarian mass with paraa ortic lymph node enlargement and attachment of the mass to the rectum. Under general anesthesia, midline incision done and about 120mla serous ascetic fluid of was evacuated. Hard, irregular right adnexa mass was identified and a huge retroperitoneal mass fixed to big blood vessels with multiple enlarged para aortic lymph nodes was identified. The omentum was with multiple kicks and the liver surface was irregular with multiple nodules at its lower edges. Peritoneal fluid cytology revealed malignant metastasis and the histopathology analysis was consistent with yolk sac tumor. She was staged surgically as 4B and discharged after clinical improvement to go abroad for chemotherapy treatment. Conclusion: The histopathology, cytology and intraoperative clinical finding were consistent with serum tumor markers that she had advanced stage yolk sac tumor with poor prognosis. Community and health professionals’ awareness for early recognition of the disease for better prognosis and initiation of pediatric chemotherapy in Eritrea is crucial, as these diseases are highly responsive to radio-chemotherapy.

741 ACUTE PURULENT MYOPERICARDITIS SECONDARY TO ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION CYTOLOGY

Abstract Introduction Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic method to sample peritracheal and peribronchial le- sions under real-time ultrasound guidance. The most important use of TBNA is the diagnosis and staging of lung cancer and the evaluation of sarcoidosis. Although TBNA is considered generally safe, serious or even fatal complication may develop after the procedure. Here we present a case report of acute purulent myopericarditis complicated by cardiac tamponade occurred after EBUS-TBNA procedure. Case Report A 62-year-old man with preexisting hypertension and previous myocardial infarction and coronary angioplasty was admitted to our hospital for persistent, oppressive and worsening chest pain, which started a few days before admission. Of note, the patient underwent EBUS-TBNA 10 days before admission because he was found to have a tumor in the upper lobe of the left lung and enlargement of multiple mediastinal, right hilar, subcarinal and para-aortic lymph nodes. Two days after the procedure, one week before admission, he was treated with amoxicillin clavulanate and levofloxacin because of fever onset. At the ER, his vital signs showed a blood pressure of 80/60 mmHg and a heart rate of 115 bpm; O2 saturation on room-temperature air was 97%. The ECG at presentation showed concave ST segment elevation in anterolateral and inferior leads. The echocardiography revealed moderate circumferential pericardial effusion without clear tamponade signs. Emergency coronary angiography showed patent coronary arteries. The next morning, the patient developed persistent hypotension (BP 75/50 mmHg). A transthoracic echo showed moderate to large circumferential pericardial effusion with tamponade physiology. He therefore underwent subxiphoid pericardiotomy with drainage of 400 ml of frank pus. Cultures from pericardial fluid were negative for common germs. Cytology was negative for malignancy and acid-fast bacilli. Histological examination of the pericardial tissue was diagnostic for acute fibrinous-purulent pericarditis. The patient was started on broad spectrum antibiotics (piperacillin/tazobactam and ciprofloxacin) with subsequent decrease of inflammation markers and clinical improvement. Control contrast enhanced chest CT scan revealed persistency of a mediastinal pluri-concamerate fluid collection. After a collective discussion with cardiac surgeons, infectious disease specialists and oncologists, given the progressive clinical and instrumental improvement, we decided to discharge the patient with long term oral antibiotics plus colchicine and ibuprofen for pericarditis. Infectious disease and oncological follow up was planned before discharge. Conclusion Complications following TBNA are relatively low, typically around 1.2%-1.4%. To date, only few cases of purulent pericarditis secondary to EBUS-TBNA have been reported in literature. Our case report adds to the existing scant literature regarding cardiac infective bronchoscopic complications and emphasizes concern of weather antibiotic prophylaxis may be needed before respiratory tract invasive procedures. Further research is necessary to better understand the existence of risk factors that could increase the probability to develop such rare but potentially lethal complications.

HL-367 ASCT for Treatment-Resistant Mediastinal Gray Zone Lymphoma

Gray zone lymphoma (GZL) is a rare type of blood cancer with intermediate characteristics of diffuse large cell B lymphoma (DLCBL) and classical Hodgkin lymphoma (cHL). There is no universal approach to the management of GZL, and resistant cases often remain challenging. To describe a potential treatment for mediastinal GZL (MGZL) resistant to standard chemotherapy regimens based on a clinical case report. A 40-year-old woman was admitted to the hospital with recent onset of generalized itchiness, weakness, fevers, and night sweats. Upon initial standard workup, a CT scan demonstrated a 7 × 4 cm mediastinal mass with irregular borders and several enlarged paraaortic (2 cm), parasternal (4 cm), and aortic bifurcation (2 cm) lymph nodes. The excision biopsy specimen from the mass showed high expressivity of CD30 and moderate expressivity of CD20, CD3, MUM-1, Fascin, and CD79a, with Ki67 detected in 75%-80%. CD15, AE1/3, ALK, PAX-5, CD45, CD19, CD 23, CD68, BOB 1, and PD-1 were negative. The patient was diagnosed with stage IIB MGZL with intermediate features of DLCBL and cHL. Interventions and Main Outcomes: Initial treatment with the R-BEACOPP regimen resulted in some shrinkage in lymph node sizes; however, after the fourth cycle of chemotherapy, a PET-CT scan demonstrated disease progression with Ds5 metabolic activities in the left axillary, mediastinal, and bronchopulmonary nodes, along with left lung consolidation. Salvage therapy with 2 courses of R-DHAP regimen was administered without significant success, as the consequent CT scan demonstrated a tumor size of 9.4 × 5.9 × 7.6 cm with extension to the left lung. This was followed by 3 cycles of BV, resulting in 3-4 months of disease remission. Due to subsequent disease progression, 2 cycles of BvB and 2 cycles of BV-ICE were initiated, followed by autologous stem cell transplantation (ASCT). The procedure resulted in pancytopenia and oral mucositis, both of which were resolved with appropriate treatment. The patient is currently in the third week of follow-up for further management. ASCT may ultimately be a candidate for treatment-resistant MGZL. These findings should be validated in larger studies.

The great masquerader of pancreatic tuberculosis

BackgroundPancreatic tuberculosis is a rare clinical entity. It represents a diagnostic challenge as the clinical presentation may mimic pancreatic malignancy.Case presentationA 66-year-old gentleman presented with an incidental finding of a pancreatic tail mass on routine ultrasonography of the abdomen whilst working up on chronic kidney disease. He denied abdominal pain, fever, night sweats, constitutional symptoms or tuberculosis contact. On examination, there was no palpable mass per abdomen. The tumour marker of Ca 19-9 was normal. Ultrasonography revealed a lobulated heterogeneous hypovascular and hypoechoic mass at the tail of the pancreas. Contrast-enhanced computed tomography (CT) of the thorax and abdomen revealed a thickened right pleura, right pleural effusion with right lung collapsed consolidation and multiple mediastinal lymph nodes. There is an ill-defined hypodense mass seen in the tail and body of the pancreas measuring 3 × 7 × 3 cm with the presences of calcification within. The constellation of CT findings suggests a pancreatic malignancy with metastasis to the lungs. Endoscopic ultrasonography (EUS) assessment showed an irregular hypoechoic mass measuring 3.0 × 2.7 cm at the tail of the pancreas. Multiple rounded hypoechoic lesions were also seen scattered within the body of the pancreas with multiple enlarged para-aortic lymph nodes. A fine-needle aspiration biopsy of the lesion was consistent with granulomatous inflammation. The diagnosis of disseminated tuberculosis was made. The patient was subsequently started on antitubercular medication and recovered well.ConclusionA high index of suspicion is needed to diagnose pancreatic tuberculosis, especially in patients whose radiological imaging shows a pancreatic mass with necrotic peripancreatic lymphadenopathy in endemic countries. EUS-guided fine-needle aspiration is the diagnostic modality of choice, and vigorous attempts should be made at obtaining a preoperative histological or bacteriological diagnosis to avoid unnecessary surgery.

Sarcomatoid Chromophobe Renal Cell Carcinoma

Dear Editor, We read with great interest and attention the recent paper by De La Parra and co-authors on the sarcomatoid transformation of chromophobe renal cell carcinoma.[1] In the review of the literature, these authors incorporate 10 cases of this uncommon condition including two own cases (their Table 1). However, the article of Akhtar et al.[2] and the work of our group[3] on this kind of tumor are missing. The first case of sarcomatoid chromophobe renal cell carcinoma was published by Akhtar et al. in 1996.[2] The patient, a 64-year-old woman, was admitted because of a six-month history of right upper quadrant pain and a mass in the right flank. Ultrasound and CT scan of the abdomen showed a large mass invading the anterior portion of the kidney. A chest radiograph revealed a questionable metastatic lesion in the right lung. A radical nephrectomy was performed. The nephrectomy specimen weighed 1050 g. The kidney was extensively replaced by a multinodular, firm, well delimited, 7x5x4 cm mass. Pathologic diagnosis was sarcomatoid chromophobe renal cell carcinoma showing presence of equal proportions of carcinoma and sarcomatoid component. The carcinoma component was positive for colloidal iron acid stain, cytokeratins (CKs) 8,18,19, and epithelial membrane antigen (EMA). One year later, she was readmitted. Ultrasound examination of the abdomen revealed enlargement of para-aortic and mesenteric lymph nodes and massive recurrence of the tumor in the right renal bed. Besides, a metastatic nodule in the right lung and a supraclavicular mass were also present. She was given palliative radiotherapy to the renal bed and then discharged. She did not return for her follow-up visit and was considered dead. In 1997, we described one case of this aforementioned neoplasm.[3] A 61-year-old man presented with a sixmonth history of hematuria. A CT scan revealed an 11 cm hypodense mass with a central scar in the lower pole of the right kidney, suggesting the diagnosis of renal oncocytoma. The patient underwent a right radical nephrectomy. The right nephrectomy specimen weighed 667 g and measured 17x11x7.5 cm. The kidney presented an 11.2 cm light brown mass in the lower pole with hemorrhagic and necrotic foci that infiltrated the renal capsule and the perinephric adipose tissue (pT3aN0M0, stage III UICC). The microscopic study revealed a neoplasm composed of sheets of voluminous polygonal epithelial cells, with a narrow zone of condensation along the cell boundaries and translucent finely reticulated cytoplasm. The nuclei were central and vesicular with some areas where small nucleoli could be identified. 40% of the tumor displayed spindle-shaped and pleomorphic cells with large nuclei and prominent nucleoli and a significant number of mitotic figures (5/10 HPF; where 1HPF = 0.1924 mm2 ). Epithelial cells showed an intense diffuse reaction of the cytoplasm with Hale´s

Clinical relevance of addition of conventional treatment to concurrent chemoradiotherapy in patients with FIGO stage III-IV cervical cancer: a retrospective analysis of a Japanese cohort.

Concurrent chemoradiotherapy has limited therapeutic efficacy for stage III-IV cervical cancer. We aimed to identify a subgroup of patients with stage III-IV cervical cancer who benefit from concurrent chemoradiotherapy with additional treatment. We retrospectively reviewed 120 patients with stage III-IV cervical cancer who were treated with concurrent chemoradiotherapy from 2002 to 2018. We compared overall survival between patients treated with concurrent chemoradiotherapy alone and those who received concurrent chemoradiotherapy with additional conventional treatments (systemic chemotherapy before and/or after concurrent chemoradiotherapy and/or extended-field radiation). Prognostic factors were statistically analysed. Overall, 44 (36.7%) and 21 (17.5%) patients were radiologically diagnosed with pelvic and para-aortic lymph node enlargement, respectively. The median tumour diameter was 5.7cm. A total of 69 (57.5%) patients received no additional treatment, and 51 (42.5%) received additional treatment. Cox regression analysis identified the following prognostic factors: histological non-squamous cell carcinoma (hazard ratio, 3.9; 95% confidence interval, 1.8-8.2), tumour diameter of ≥6cm (hazard ratio, 2.1; 95% confidence interval, 1.2-3.7), radiological pelvic lymph node enlargement (hazard ratio, 2.1; 95% confidence interval, 1.1-4.0) and radiological para-aortic lymph node enlargement (hazard ratio, 2.1; 95% confidence interval, 1.1-4.1). Even in the lowest risk group (no risk factors), the 5-year overall survival rate was lower in the additional treatment group than in the concurrent chemoradiotherapy alone group (78.7% vs. 80.9%, respectively; log-rank test, P=0.79). Addition of conventional treatments to concurrent chemoradiotherapy might not improve survival in patients with advanced cervical cancer. Novel treatment strategies including immune checkpoint inhibitors should be considered for such patients.

Clinical Impact of Unexpected Para-Aortic Lymph Node Metastasis in Surgery for Resectable Pancreatic Cancer.

Simple SummaryPara-aortic lymph node (PALN) metastasis in pancreatic cancer (PC) is regarded as a contraindication to surgical resection. Nevertheless, the prognostic impact of unexpected intraoperative PALN metastasis is not firmly established. This retrospective study aims to analyze the prognostic impact of unexpected PALN metastasis and give insight on what surgeons should consider for patients with unexpected intraoperative PALN metastasis.Radiologically identified para-aortic lymph node (PALN) metastasis is contraindicated for pancreatic cancer (PC) surgery. There is no clinical consensus for unexpected intraoperative PALN enlargement. To analyze the prognostic role of unexpected PALN enlargement in resectable PC, we retrospectively reviewed data of 1953 PC patients in a single tertiary center. Patients with unexpected intraoperative PALN enlargement (group A1, negative pathology, n = 59; group A2, positive pathology, n = 13) showed median overall survival (OS) of 24.6 (95% CI: 15.2–33.2) and 13.0 (95% CI: 4.9–19.7) months, respectively. Patients with radiological PALN metastasis without other metastases (group B, n = 91) showed median OS of 8.6 months (95% CI: 7.4–11.6). Compared with group A1, groups A2 and B had hazard ratios (HRs) of 2.79 (95% CI, 1.4–5.7) and 2.67 (95% CI: 1.8–4.0), respectively. Compared with group A2, group B had HR of 0.96 (95% CI: 0.5–1.9). Multivariable analysis also showed positive PALN as a negative prognostic factor (HR 2.57, 95% CI: 1.2–5.3), whereas positive regional lymph node did not (HR 1.32 95% CI: 0.8–2.3). Thus, unexpected malignant PALN has a negative prognostic impact comparable to radiological PALN metastasis. This results suggests prompt pathologic evaluation for unexpected PALN enlargements is needed and on-site modification of surgical strategy would be considered.

Long-Term Outcomes and Sites of Failure in Locally Advanced, Cervical Cancer Patients Treated by Concurrent Chemoradiation with or without Adjuvant Chemotherapy: ACTLACC Trial.

Objectives:To evaluate sites of failure and long-term survival outcomes of locally advanced stage cervical cancer patients who had standard concurrent chemo-radiation (CCRT) versus those along with adjuvant chemotherapy (ACT) after CCRT. Methods:Patients aged 18–70 years who had FIGO stage IIB-IVA without para-aortic lymph node enlargement (excluding by International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIIC2r), The Eastern Cooperative Oncology Group (ECOG) scores 0–2, and non-aggressive histopathology were randomized to have CCRT with weekly cisplatin followed by observation (arm A) or ACT with paclitaxel plus carboplatin every 4 weeks for 3 cycles (arm B). Results:From 2015-2017, 259 patients were evaluated. The majority of patients were in stage II and had squamous cell carcinoma with a median tumor size of 5 cm. After the median follow-up of 40.87 months, 17.1% of the patients in arm A and 12.3% of the patients in arm B experienced recurrences (p=0.280). Adding all events of failure (persistence/progression/recurrence), treatment failures tended to be lower in arm A than in arm B: 13.2 versus 21.5 % for loco-regional failure (p = 0.076) and 3.9 versus 6.9% for loco-regional failure and systemic failure (p = 0.278). On the other hand, systemic failure tended to be higher in arm A than in arm B: 13.2% versus 6.9% (p =0.094). The 5-year progression-free survival and 5-year overall survival of patients in both arms were not significantly different. Conclusions:ACT with paclitaxel plus carboplatin after CCRT did not improve response or survival of patients compared to CCRT alone. Although systemic failure tended to be lower in patients who had ACT after CCRT than those who had only CCRT, loco-regional failure with or without systemic failure tended to be higher. However, all of these differences were not statistically significant.

Membranous nephropathy in a patient with pulmonary tuberculosis infection and lung adenocarcinoma: a case report

We report a case of membranous nephropathy (MN) in a patient with tuberculosis infection and lung adenocarcinoma. A 50-year-old Filipino woman underwent a renal biopsy for the evaluation of proteinuria and hematuria. Immunofluorescence analysis revealed positive staining of IgG in the glomerular basement membrane and mesangial matrices, while electron microscopy demonstrated the presence of sub-epithelial deposits, suggesting MN. To screen for secondary causes of MN, we conducted a computed tomography (CT) scan of the chest and abdomen, which revealed a ground-glass opacity in the middle lobe of the right lung and an enlarged paraaortic lymph node. A T-SPOT test was positive, suggesting the possibility of a latent tuberculosis infection, as she was asymptomatic. A follow-up chest CT scan showed persistent presence of the ground-glass opacities, suggesting a non-infectious cause. Video-assisted thoracoscopic resection of the middle right lobe and partial resection of the lower right lobe were performed because the possibility of lung cancer could not be excluded. Notably, pathological analysis of the lung revealed adenocarcinoma in the middle lobe and epithelioid granuloma in the lower lobe, suggesting an active tuberculosis infection. One month after surgery, anti-tuberculosis treatment was initiated. Thereafter, her proteinuria, which had increased to 6g/gCre preoperatively, began to decrease. Five months after surgery, the patient achieved complete remission. The speed of remission suggests that tuberculosis likely played a primary role in the etiology of MN. Our case underscores the importance of screening tests for infections and malignancies in patients with MN, even if suggestive symptoms are absent.

Ultrasound-guided fine needle aspiration cytology of Para-aortic lymph node metastasis in uterine cervical cancer: diagnostic accuracy and impact on clinical decision making

ObjectiveThe main aim of this study was to ascertain the effectiveness of ultrasound-guided fine needle aspiration cytology (US-FNAC) in the diagnosis of para-aortic lymph node (PALN) metastasis in uterine cervical cancer and to establish its potential impact on clinical therapeutic decision making.MethodsWe retrospectively reviewed clinical data from 92 patients diagnosed with cervical cancer with PALN enlargement between 2010 and 2018. Cytological results obtained with US-FNAC were classified by the same experienced cellular pathologists. Diagnostic indicators were determined on the basis of biopsy, imaging and clinical follow-up results. Univariate and multivariate analyses were used to assess the differences of influencing factors. The effect of US-FNAC on clinical decision making was evaluated.ResultsCytological results of US-FNAC were categorized as malignancy (n = 62; 67.4%), suspicious malignancy (n = 11; 12.0%), undetermined (n = 5; 5.4%), benign (n = 10; 10.9%), and inadequate (n = 4; 4.3%). Satisfactory biopsy samples were obtained from 95.7% of PALNs sampled (88/92). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FNAC in distinguishing benign from malignant cases were 90.1% (95% CI: 0.809–0.953), 100% (95% CI: 0.561–1), 100% (95% CI: 0.938–1), 46.7% (95% CI: 0.223–0.726) and 90.9% (95% CI: 0.848–0.970), respectively. Univariate analysis indicated significant differences in experience of puncture physicians (radiologists) between the correct and wrong diagnosis groups (P < 0.05), which was further confirmed as an independent predictor of diagnostic accuracy in multivariate analysis (p = 0.031, OR = 0.077, 95% CI: 0.354–0.919). All patients tolerated the US-FNAC procedure well and only nine presented slight abdominal discomfort. The therapeutic strategies for 74 patients (80.4%) were influenced by US-FNAC findings.ConclusionsUS-FNAC was a relatively safe and effective technique for examination of enlarged para-aortic lymph nodes and may therefore serve as a routine diagnostic tool to guide clinical decision making for management of cervical cancer.

The Case Report of Malignant Pericardial Effusion in Recurrent Endometrial Cancer: An Emergency Treatable Condition

Malignant-related pericardial effusion from endometrial cancer is a considerably rare condition. Massive fluid accumulation can cause a cardiac tamponade, which could lead to a life threatening condition. Here, the author presented a case of 45-year-old woman diagnosed of stage IIIC2 endometrial cancer, with para-aortic lymph nodes metastases. Fourteen months after completion of systemic chemotherapy and adjuvant sequential radiotherapy, she had been suffering from acute shortness of breath, tachypnea, tachycardia, and hemodynamic instability. Massive pericardial effusion was confirmed by echocardiogram. Malignant tumor cells were found on the cytological analysis. Beside pericardial effusion, computed tomography scan also demonstrated pleural effusion and multiple enlarged para-aortic lymph nodes. Pericardial window was done on the second day of admission after the diagnosis was confirmed by pericardiocentesis. Six courses of systemic chemotherapy, carboplatin and paclitaxel, were administered, followed by hormonal therapy. The patient was scheduled for follow up, every month, for 10 consecutive times. Her physical performance was in good condition without any clinical potential recurrence. Pericardial window is a palliative surgical treatment in emergency circumstance and systemic chemotherapy should be considered with clinical response result. Keywords: Malignant pericardial effusion, Endometrial cancer, Treatment

Prognostic significance of enlarged paraaortic lymph nodes detected during left-sided colorectal cancer surgery: a single-center retrospective cohort study

BackgroundVery few studies have been conducted on the treatment strategy for enlarged paraaortic lymph nodes (PALNs) incidentally detected during surgery. The purpose of this study was to investigate the benefit of lymph node dissection in patients with incidentally detected enlarged PALNs.MethodsWe retrospectively reviewed patients with left colon and rectal cancer who underwent surgical resection with PALN dissection between January 2010 and December 2018. The predictive factors for pathologic PALN metastasis (PALNM) were analyzed, and survival analyses were conducted to identify prognostic factors.ResultsAmong 263 patients included, 19 (7.2%) showed pathologic PALNM and 5 (26.33%) had enlarged PALNs incidentally detected during surgery. These 5 patients accounted for 2.2% of 227 patients who had no evidence of PALNM on preoperative radiologic examination. Radiologic PALNM (odds ratio [OR] 12.737, 95% confidence interval [CI] 3.472–46.723) and radiologic distant metastasis other than PALNM (OR = 4.090, 95% CI 1.011–16.539) were independent predictive factors for pathologic PALNM. Pathologic T4 stage (hazard ratio [HR] 2.196, 95% CI 1.063–4.538) and R2 resection (HR 4.643, 95% CI 2.046–10.534) were independent prognostic factors for overall survival (OS). In patients undergoing R0 resection, pathologic PALNM was not associated with 5-year OS (90% vs. 82.2%, p = 0.896).ConclusionDissection of enlarged PALNs incidentally detected during colorectal surgery may benefit patients with favorable survival outcomes.

Prevalence of Para-Aortic Lymphadenopathy in Locally Advanced Cervical Cancer using Computed Tomography: A Retrospective Study

Introduction: Determination of status of Para-Aortic Lymph Node (PALN) in patients with cervical cancer is one of the most important factors guiding the treatment. It is essential in determining individualised therapy and prognosis. Aim: To assess the prevalence of para-aortic lymphadenopathy among patients with advanced cervical carcinoma referred for radiotherapy. Materials and Methods: A retrospective study of patients referred to Radiotherapy and Oncology Department of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria was carried out. Patient demographics, history of co-morbid conditions, histology, stage at diagnosis, and Computed Tomographic (CT) scan findings of enlarged PALN greater or equal to 10 mm in short axis diameter were retrieved. Data was analysed using IBM SPSS statistics version 23. Results: A total of 220 patients, age range 27-84 years with mean age 49.95±11.96 years were studied. The histological diagnosis were squamous cell carcinoma in 182 (87.2%), adenocarcinoma in 22 (10%), clear cell carcinoma in 9 (4.1%) while 7 (3.2%) patients had other histological variants. Co-morbities found were chronic cervicitis and HIV in 27 (12.3%) and 19 (8.6%) of the patients, respectively. CT prevalence of PALN was 23 (10.5%). The prevalence of PALN according to International Federation of Gynaecology and Obstetrics (FIGO) stage were 4.3%, 17.4%, 34.8%, 30.4% and 13.0% in stages IIB, IIIA, IIIB, IVA and IVB, respectively. Clinical stage determined based on physical examination and imaging findings, was shown to be related to PALN by univariate analysis (χ2=29.162, p=0.0001). Conclusion: This study found a 10.5% prevalence of para-aortic lymphadenopathy and a significant relationship between clinical stage and PALN. This should be taken into consideration during treatment planning for patients with advanced cervical carcinoma.

A case of protein-losing gastroenteropathy caused by systemic AA amyloidosis secondary to undifferentiated carcinoma of unknown primary origin.

We report the case of a 61-year-old woman with Kartagener syndrome who presented with a 3-month history of chronic watery diarrhoea and severe hypoalbuminaemia. Histopathological examination of duodenum and large intestine biopsies showed amyloid A (AA) amyloid deposition. Scintigraphy and alpha-1 anti-trypsin clearance evaluations revealed protein-losing gastroenteropathy. Computed tomography with contrast and positron emission tomography showed a pelvic mass with multiple para-aortic lymph node enlargement. We suspected protein-losing gastroenteropathy secondary to AA amyloid produced related to malignant tumours. Following tumour resection, histopathological examination of the lesion revealed undifferentiated carcinoma of unknown origin. Postoperatively, the patient’s nutritional condition improved. There has been no recurrence of protein-losing gastroenteropathy 6 months postoperatively. This is the first report of protein-losing gastroenteropathy and AA amyloidosis secondary to undifferentiated carcinoma. Early recognition and intervention could increase the likelihood of amyloidosis remission.

A randomized controlled trial comparing concurrent chemoradiation versus concurrent chemoradiation followed by adjuvant chemotherapy in locally advanced cervical cancer patients: ACTLACC trial.

ObjectiveTo compare response rate and survivals of locally advanced stage cervical cancer patients who had standard concurrent chemoradiation therapy (CCRT) alone to those who had adjuvant chemotherapy (ACT) after CCRT.MethodsPatients aged 18–70 years who had International Federation of Gynecology and Obstetrics stage IIB–IVA without para-aortic lymph node enlargement, Eastern Cooperative Oncology Group scores 0–2, and non-aggressive histopathology were randomized to have CCRT with weekly cisplatin followed by observation (arm A) or by ACT with paclitaxel plus carboplatin every 4 weeks for 3 cycles (arm B).ResultsData analysis of 259 patients showed no significant difference in complete responses at 4 months after treatment between arm A (n=129) and arm B (n=130): 94.1% vs. 87.0% (p=0.154) respectively. With the median follow-up of 27.4 months, 15.5% of patients in arm A and 10.8% in arm B experienced recurrences (p=0.123). There were no significant differences of overall or loco-regional failure. However, systemic recurrences were significantly lower in arm B than arm A: 5.4% vs. 10.1% (p=0.029). The 3-year progression-free survival (PFS) and 3-year overall survival (OS) of the patients in both arms were not significantly different. The hazard ratio of PFS and OS of arm B compared to arm A were 1.26 (95% CI=0.82–1.96; p=0.293) and 1.42 (95% CI=0.81–2.49; p=0.221) respectively.ConclusionsACT with paclitaxel plus carboplatin after CCRT did not improve response rate and survival compared to CCRT alone. Only significant decrease of systemic recurrences with ACT was observed, but not overall or loco-regional failure.Trial RegistrationClinicalTrials.gov Identifier: NCT02036164Thai Clinical Trials Registry Identifier: TCTR 20140106001

Systemic Laparoscopic Para-Aortic Lymphadenectomy to the Left Renal Vein.

Background:No large-scale clinical study has been done to show the standard surgical boundary and efficacy of laparoscopic para-aortic lymphadenectomy (LPAL).Objectives:Therfore, this study aimed to evaluate the feasibility, efficacy, and standard surgical boundary of LPAL performed up to the left renal vein level in gynecological malignancies.Methods:Medical records of 333 patients were retrospectively reviewed. All cases had gynecologic malignancies and had an operation including LPAL by a single surgical team between November 2003 and May 2018.Results:Three hundred twenty-six patients underwent LPAL as part of their staging, restaging, or debulking surgery. Seven patients with isolated para-aortic lymph node recurrence underwent a repeat LPAL. The median age and body mass index were 54 years (range, 28–81 years) and 26.0 kg/m2 (range, 20.3–37.2 kg/m2), respectively. The median operating time was 60 minutes (range, 24–135 minutes), and the median number of harvested para-aortic lymph nodes was 12 (range, 6–49). There were 11 cases of complications: 5 of major vessel injuries (3 inferior vena cava, 1 aorta, and 1 common iliac vein), 2 lymphocysts, 2 cases of chylous ascites, a cisterna chyli rupture, and 1 case of ureteric injury. There were 2 conversions to laparotomy: 1 left common iliac vein laceration that needed to be repaired and removal of an enlarged para-aortic lymph node completely.Conclusion:It is feasible and efficient to perform LPAL to the left renal vein level for women with gynecologic malignancies by well-trained gynecologic oncology surgeons according to our suggested standard surgical boundary.

Metastatic Breast Cancer Presenting as a Hilar Mass

A 62-year-old woman with history of lobular cancer of the left breast, status post mastectomy was referred for evaluation of elevated liver function tests. She had complaints of worsening abdominal pain, 15-pound weight loss, itching and decreased appetite. Laboratory studies revealed total bilirubin 0.8 mg/dl, AST of 138 IU/L, ALT of 146 IU/L and alkaline phosphatase 828 IU/L. Ca 19-9 was slightly elevated at 78 U/ml and CEA was normal. Abdominal MRI was performed which revealed 33 mm x 27 mm hilar soft tissue mass, suspicious for cholangiocarcinoma, encasing the proximal common bile duct with porta hepatis and left para-aortic lymph node enlargement. Endoscopic ultrasound confirmed the presence a 24 mm x 20 mm irregular hypoechoic mass lesion seen in the hilum region of the liver. Dilatation of the biliary tree was seen upstream from the mass lesion. A single lymph node was visualized in the perihilar area adjacent to the hilar mass. The ultrasound image of node appeared with hypoechoic center and hyperechoic outer area. The node measured 26mm on the long axis and 17mm on the short axis, suspicious for malignant involvement. Fine needle aspiration was performed from the perihilar node and pathology revealed ER/PR positive, Her-2 neu negative, metastatic breast lobular carcinoma. The patient was referred to oncology and started on chemotherapy. Breast cancer is the most common malignancy and the leading cause of death in women. It metastasizes via hematogenous spread preferentially to bone, lungs, and the brain. Metastatic breast cancer can involve the extrahepatic ducts via direct extension of liver metastasis into the intrahepatic ducts and into the extrahepatic ducts. However, very few cases demonstrate hematogenous spread targeting the extrahepatic biliary tree without hepatic involvement. The largest case series published by Popp et al in the 1970s followed 7 women who underwent surgery for biliary obstruction from metastatic breast cancer. 6 of the 7 cases were due to bile duct compression from lymph node metastases; only one patient had direct metastasis to the biliary duct. This case illustrates, a rare case of metastatic breast cancer presenting as a hilar mass. In patients with breast cancer history who develop worsening abdominal pain and signs of biliary outflow tract obstruction, it is important to consider the biliary tree as a location for possible recurrence of metastatic disease.Figure: Diffuse mild intrahepatic biliary duct dilation is noted to the level of hepatic hilum. There is a 3.3 x 2.7 cm mass in the hepatic hilum.Figure: Histological appearance of biopsied perihilar node revealing ER positive, PR positive, HER2 Neu negative metastatic breast lobular cancer.

Merkel Cell Carcinoma.

Merkel cell carcinoma is a primary neuroendocrine tumour of the skin arising from the dermis and extending into the subcutis, occurring commonly in sun-exposed areas of the head and neck of the elderly. Clinically, non-specific erythematous or violaceous firm nodules or small plaques which may be surrounded by small adjacent satellite tumours are seen. Diagnosis of Merkel cell carcinoma is difficult by light microscopy alone and need of ancillary techniques like electron microscopy and immunohistochemistry may be necessary. Treatment modalities are dependent on the stage of the disease. We report a 73-year-old male who presented with multiple nodular swellings on the right buttock, right side of the lower abdomen, and right upper thigh since 2months. Biopsy revealed Merkel cell carcinoma and immunohistochemistry confirmed it. In order to stage the disease, an ultrasound abdomen was done which showed multiple enlarged para-aortic lymph nodes and retroperitoneal lymph nodes with necrotic centres and right-sided hydroureteronephrosis and computed tomography is advised for further co-relation. Computed tomography of the abdomen showed extensive lymphadenopathy with perinodal fat forming conglomerate masses in the para-aortic, aortocaval, retrocaval, bilateral iliac, and inguinal region encasing the aorta, vena cava, and bilateral iliac arteries; extensive soft tissue density nodules in the skin extending into the subcutaneous plane and superficial muscular plane of the gluteal region and lower abdomen; and mild hydronephrosis of the right kidney due to encasement of lower ureter by lymphadenopathy. We report a case of Merkel cell carcinoma with distant metastases with the same relevant discussion.

Impact of EUS-FNA for preoperative para-aortic lymph node staging in patients with pancreatobiliary cancer

In patients with pancreatobiliary cancer, para-aortic lymph node (PALN) metastasis is considered to be the involvement beyond the regional lymph nodes, namely, distant metastasis. Effective methods for preoperative PALN staging, however, are not established. This study aimed to compare the diagnostic capability for PALN metastasis between EUS-FNA and (18)F-fluorodeoxyglucose positron emission tomography with CT (PET/CT). We performed a prospective, nonrandomized, single-center trial. Between December 2010 and March 2014, 208 patients with pancreatobiliary cancer without apparent distant metastasis except for PALNs were assessed for study eligibility before surgery. Among them, 52 consecutive patients with PALN enlargement were enrolled in the study. (18)F-Fluorodeoxyglucose PET/CT and EUS-FNA were performed sequentially as a single combined procedure to evaluate PALN metastases. The primary outcome was to compare the diagnostic capability of EUS-FNA and PET/CT for PALN metastasis. Of 71 enlarged PALNs in the 52 patients, 30 (42.3%) were finally diagnosed as metastases in 21 patients (40.4%). Of the 21 patients with PALN metastases, preoperative EUS-FNA or PET/CT made a correct diagnosis in 20 (95.2%) or 12 (57.1%), respectively. EUS-FNA had higher sensitivity and specificity for the diagnosis of PALN metastasis (sensitivity, 96.7% [29/30]; 95% confidence interval, 82.2%-99.9%; specificity, 100% [39/39]; 95% confidence interval, 91.0%-100%) than PET/CT. EUS-FNA is superior to PET/CT for preoperative PALN staging in patients with pancreatobiliary cancer. Because of the clinical benefit of EUS-FNA to reduce unnecessary surgery, it should be part of the standard preoperative examination for patients with pancreatobiliary cancer. (UMIN clinical trials registry number: 000006408.).