Evidence Of Metastatic Disease Research Articles

Serum CA-125 as a predictor of radiologic evidence of metastatic disease in type 2 endometrial cancer

Serum CA-125 as a predictor of radiologic evidence of metastatic disease in type 2 endometrial cancer

Salvage low dose rate brachytherapy for prostate cancer recurrence following definitive external beam radiation therapy

PurposeWe sought to describe the safety and efficacy of salvage low dose rate (LDR) brachytherapy for local prostate cancer recurrence following definitive RT. Materials and methodsWe included patients from two prospectively maintained institutional databases who underwent salvage LDR brachytherapy for biopsy confirmed intra-prostatic recurrence following primary RT. All patients were without evidence of metastatic disease. Freedom from biochemical failure (FFbF), prostate cancer specific survival (PCaSS), and overall survival (OS) were determined using the Kaplan–Meier estimates. Cox proportional hazard models were used to identify factors predictive of FFbF. Toxicity was graded by Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Results108 patients were included. Median follow-up was 6.3 years. The 5- and 10-year actuarial survival outcomes were as follows: FFbF, 63.1% and 52.0%; PCaSS, 90.5% and 77.8%; OS, 80.9% and 56.7%. On multivariate modeling, increasing grade group (HR 1.41, 95% CI 1.02–1.95, p = 0.036) and initial PSA at diagnosis (HR 1.02, 95% CI 1.004–1.05, p = 0.022) were associated with worse FFbF. Grade 3 toxicity occurred in 16.7% of patients; including genitourinary events in 15.7% and gastrointestinal events in 2.8% of patients. IPSS scores increased following implant, peaking at 2 months (median IPSS 20, p = 0.002) and thereafter remaining elevated throughout follow-up. ConclusionsSalvage LDR brachytherapy is safe and efficacious, with acceptable grade 3+ toxicity and good biochemical control on long-term follow-up. Patients with higher grade group and higher PSA at initial diagnosis may be at increased risk for biochemical failure.

S3538 Needle Track Seeding in a Patient With Hepatocellular Carcinoma

INTRODUCTION: We present a case of a 56-year-old Caucasian male with a history of CAD, HTN, and HCV who initially presented in 3/2017 with lower extremity edema found to have newly diagnosed systolic heart failure and severe mitral regurgitation. During his workup for CABG and valve repair he was found to have cirrhosis secondary to HCV with hepatocellular carcinoma (HCC) by biopsy. After treatment for HCC the patient later developed recurrence due to needle track seeding. CASE DESCRIPTION/METHODS: After further imaging for his initial presentation of heart failure the patient underwent a CT guided fine needle aspiration and core needle biopsies of newly identified liver lesions in the left hepatic lobe (Figure 1). Pathology was consistent with HCC and the patient had no evidence of metastatic disease at that time. He was not deemed eligible for transplantation and was treated with transarterial chemoembolization (TACE). A surveillance MRI 7 months post-biopsy demonstrated a mass within the right rectus abdominus muscle which was located in the region of a prior biopsy tract (Figure 2). Given concerns for metastatic disease, the lesion was biopsied and histopathology was consistent with HCC. He was treated with cryoablation to the rectus abdominus muscle lesion and selective internal radiation therapy. The lesion was no longer visualized on follow-up imaging obtained four months later (Figure 3). DISCUSSION: Needle track seeding is a known complication with variable rates reported in the literature. More recent studies demonstrate a less than 1% rate of seeding when biopsy is performed alone.1,2 However, the rate is thought to be even lower in cases that use a coaxial biopsy system as was performed in this case. This is an important complication to consider as it may alter treatment; often disqualifying patients from liver transplantation or other curative procedures. For those who are being considered for liver transplantation diagnostic needle biopsies should be avoided if possible.Figure 1.: Axial contrast enhanced CT image in a 56 year old male showing CT guided percutaneous biopsy of a mass in the left hepatic lobe (circle).Figure 2.: Follow-up axial T1 post contrast MR images, 7 months later, showing a hyper-enhancing lesion in the right rectus abdominus muscle.Figure 3.: Axial T1 post contrast MR images of a 56-year-old male showing complete resolution of the soft tissue lesion following cryoablation. Residual tumor is noted in the left hepatic lobe.

PRIMARY PULMONARY ANAPLASTIC LARGE CELL LYMPHOMA IN A YOUNG MALE

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anaplastic large cell lymphoma (ALCL) is a type of non-Hodgkin lymphoma which is subclassified into primary systemic anaplastic lymphoma kinase (ALK)-positive, primary systemic ALK-negative, primary cutaneous ALCL, and breast implant-associated ALCL (1). ALCL is considered an extremely rare type of primary pulmonary lymphomas (2). We report a case of primary pulmonary ALCL in a young immunocompetent male presenting with dyspnea. CASE PRESENTATION: 43 year-old male with no past medical history presented to the emergency department with dyspnea, fatigue and lower extremity swelling which have been worsening over a month. Physical exam showed 3+ pitting edema bilaterally and bilateral decreased breath sound. Laboratory workup showed an elevate d-dimer and an elevated absolute monocytes. Chest X-ray showed numerous nodules throughout the lungs. CT angiogram of the chest, abdomen and pelvis showed a large infiltrative opacity extending from the right hilum to the pleural surface in the right lower lobe, with some extension into the central right middle lobe and innumerable pulmonary and hepatic metastases and lymphadenopathy in the thoracic, abdominal and pelvic lymph node chains. Tumor markers were negative, with mildly elevated CA-125. A right supraclavicular lymph node biopsy showed necrotizing lymphadenitis with no evidence of metastatic disease. Bronchoscopy revealed an extensive obstruction of the bronchial lumen with an endobronchial lesion in the right lower lobe bronchus. Tissue biopsy was consistent with anaplastic large cell lymphoma. Patient was critically ill in the intensive care unit and was intubated due to acute respiratory failure. He had a poor prognosis due to the extensive metastasis of his ALCL. DISCUSSION: ALCL is characterized by large lymphoid cells with pleomorphic nuclei, and uniform CD30/Ki-1 expression (2). The most common form of ALCL presents as primary cutaneous lymphoma and may secondarily involve the lungs. However, primary pulmonary ALCL is extremely rare with 10 published cases between 1990 and 2015 (3). ALK protein expression is an important prognostic indicator for ALCL as ALK-positive lymphomas have a favorable prognosis with a much higher 5-year survival rate (2). The diagnosis of ALCL includes histopathology and immunohistochemistry staining, with strong immunoreactivity for CD30. Our patient had a primary pulmonary ALCL which was ALK-negative, indicating poor overall prognosis, with a strong immunoreactivity for CD30 and Ki-1. The treatment of primary pulmonary ALCL has not been standardized. However, first-line therapy includes anthracycline-based regimen, which is the standard treatment for non-Hodgkin lymphomas. CONCLUSIONS: Our case underlines the importance of maintaining a high index of awareness for the occurrence and impact of the recognition of primary pulmonary ALCL and its implications on the clinical course of critically ill patients. Reference #1: Laurent, Camille; Haioun, Corinne; Brousset, Pierre; Gaulard, Philippe (1 September 2018). “New insights into breast implant-associated anaplastic large cell lymphoma”. Current Opinion in Oncology. 30 (5): 292–300. Reference #2: J.-F. Cordier, E. Chailleux, D. Lauque et al., “Primary pulmonary lymphomas; a clinical study of 70 cases in nonimmunocompromised patients,” CHEST, vol. 103, no. 1, pp. 201–208, 1993. Reference #3: Q. Zhao, Y. Liu, H. Chen et al., “Successful chemo-radiotherapy for primary anaplastic large cell lymphoma of the lung: A case report and literature review,” American Journal of Case Reports, vol. 17, pp. 70–75, 2016. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Raheel Anwar, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Wael Kalaji, source=Web Response No relevant relationships by jad sargi, source=Web Response No relevant relationships by Viswanath Vasudevan, source=Web Response

S2806 A Case of Ileocecal and Distal Sigmoid Carcinoid Tumor With Liver Metastasis

INTRODUCTION: Carcinoid tumors are rare, slow-growing neuroendocrine tumors (NET), often asymptomatic and may not become apparent until there is evidence of metastatic disease or carcinoid syndrome. Digestive involvement is most common in the appendix, mesentery and the ileum. We present a case of carcinoid tumor in the ileocecal valve and distal sigmoid colon, complicated by liver metastasis. CASE DESCRIPTION/METHODS: A 55 year-old African-American with no significant past medical history, presents for eight months of progressive weight loss, subjective fever, chronic watery diarrhea and episodes of flushing. Physical exam was significant for thin habitus. Laboratory tests revealed macrocytic anemia and progressive increase in transaminases (ALT 224 U/L, AST 217 U/L). Right upper quadrant US was showed scattered small indeterminate liver lesions of 1.5 cm. CT abdomen/pelvis revealed a 2.3 × 2.1 cm focal mass and thickening of the terminal ileum and a 2.1 cm mass in the distal sigmoid colon, in addition to multiple liver lesions. Percutaneous liver biopsy consistent with two minute clusters of NET cells at 0.15 mm and 0.10 mm showed positive immunohistochemistry (IHC) positive for synaptophysin an chromogranin. Further laboratory investigation included elevated urine 5-HIAA (60 mg/24 h) and elevated levels of serum chromogranin (167 ng/mL). Colonoscopy with terminal ileum intubation showed a 7 mm pedunculated broad based polyp in the sigmoid colon and a protruding polypoid irregular ileocecal valve. Histopathology from colonic mucosa showed non-specific chronic inflammation and immunoreactivity for CD45, which supports the diagnosis of NET. The patient was treated with Sandostatin injections monthly with significant clinical improvement, and is followed by Oncology and Gastroenterology services. DISCUSSION: Carcinoid tumors although rare, can be found throughout the gastrointestinal tract, generally in the appendix or ileum. Our patient presented with clinical and immunohistochemical characteristics consistent with carcinoid tumor, and apparent unusual localization in the ileocecal valve and distal sigmoid colon. Associated liver metastasis was evident. Recent literature reports that the overall incidence of carcinoid tumors has been steadily increasing likely due to advances in testing, however most cases are being detected after wide-spread disease.CONCLUSION. Further description of the biological and histopathological characteristics of carcinoid tumors is needed for implementation of early detection techniques.

Is Routine Nodal Dissection in Early Epithelial Ovarian Cancers Required?

The staging of ovarian cancer is unique because it is done surgically, wherein, along with hysterectomy and bilateral oophorectomy, pelvic and para-aortic nodes are routinely removed to find evidence of metastatic disease, which is not detected clinically. With advances in imaging modalities, it is now possible to predict, with reasonable accuracy, whether a regional lymph node is metastatic or not. Hence, in this study we compared the nodal staging in early ovarian cancers (FIGO I) as determined by CT scan (clinical nodal staging) with that of the nodal staging after a staging laparotomy (pathological nodal staging), to determine whether routine lymphadenectomy is justified in all patients with early epithelial ovarian cancer. Apparently early ovarian epithelial tumors were evaluated with contrast-enhanced computed tomography. Patients (n = 39) in whom the ovarian neoplasm appeared malignant and with pelvic and para-aortic nodes less than 10 mm in short-axis diameter and normal morphology were enrolled in the study. All women were subjected to a laparotomy and frozen section of the ovarian mass, followed by a routine staging laparotomy with pelvic and para-aortic nodal dissection, if the frozen section was reported as a malignant ovarian neoplasm. Clinical and pathological nodal staging was compared statistically. Pathological T stage, pathological subtype, grade, and CA-125 levels were also studied to determine whether these variables had an impact on the pathological nodal staging. The difference between clinical nodal staging (as determined by CT scan) and pathological nodal staging is insignificant (p 0.07). Factors, such as pathological T staging, pathological subtype, grade, and CA-125 levels, do not have a significant correlation with pathological nodal staging. Clinical staging of regional nodes, as determined by CT scan, correlates well with the pathological nodal staging in early epithelial ovarian cancer (FIGO I), and hence, a routine lymphadenectomy may not be warranted in all patients.

Abstract 1109: Integrative analysis of clinical and genomic information identifies predictive markers of metastatic risk

Abstract Despite the fact that the majority of cancer related deaths are due to metastatic disease, existing large-scale cancer sequencing projects such as The Cancer Genome Atlas have so far focused mainly on primary tumors. Moreover, most publicly available datasets in cancer genomics lack information about spatiotemporal patterns of metastatic spread. We have developed new clinical data extraction methods and performed an integrative analysis of clinical and genomic features from 34,836 patients treated at Memorial Sloan Kettering Cancer Center (MSK), stratified into 45 cancer subtypes. Tumors were sequenced with MSK-IMPACT, a targeted next-generation sequencing assay that identifies genomic alterations in 468 genes. Indications of metastatic events, including affected organs and detailed timeline annotations, were extracted from the electronic medical records. This allowed us to distinguish not only sequenced primaries (58%) from sequenced metastases (42%), but also primaries in patients with evidence of metastatic disease (33%) from patients without evidence of metastatic disease (25%) at the time of sequencing. Tumors from patients with evidence of metastatic disease exhibited increased copy-number alterations, measured as fraction of genome altered (FGA) in multiple cancer types, including prostate adenocarcinoma, endometrial endometrioid, HR+/HER2- breast invasive carcinoma and lung adenocarcinoma (all p < 0.001). This supports the existence of a positive correlation between disease burden and chromosomal instability, although this effect is weaker or non-existent in some cancer types, including hepatocellular carcinoma, ovarian serous, and cholangiocarcinoma. We investigated associations between somatic alterations and metastatic organotropisms. For example, among patients with microsatellite stable colorectal cancer, tumors that metastasized exclusively to the peritoneum were enriched in BRAF alterations when compared to patients that never metastasized to that site (21% vs. 6%; p=0.003), while tumors that metastasized exclusively to the lung were enriched in KRAS alterations (69% vs. 41%; p=0.002). By analyzing primary tumors in patients with no evidence of metastatic disease at the time of sequencing, and comparing those that would eventually metastasize with those that would not, we identified predictive markers of metastatic risk. For example, in bladder cancer, tumors with altered TP53 were twice as likely to metastasize (54% vs. 27%; p<0.001), while tumors with FGFR3 alterations exhibited the opposite trend (24% vs. 43%; p<0.001). We present a comprehensive, spatiotemporal map of metastasis that integrates clinical and molecular information and can be used to build personalized risk models of metastatic spread at target-organ resolution based on individual molecular profiles, which can enhance precision medical care and optimize clinical outcomes. Citation Format: Christopher J. Fong, Francisco Sanchez-Vega, Bastien Ngyuen, Anisha Luthra, Subhiksha Nandakumar, Henry Walch, Walid Chatila, Arjun Rajanna, Ahmet Zehir, Michael Berger, Jianjiong Gao, Nikolaus Schultz. Integrative analysis of clinical and genomic information identifies predictive markers of metastatic risk [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1109.

Risk‐stratifying clinicopathologic criteria for ovarian preservation in premenopausal women with early stage low‐risk endometrial cancer

To establish the rate of occult ovarian micro-metastases in early stage disease and to provide an eligibility framework for providers to consider ovarian preservation in a patient population with presumed early stage disease. A retrospective review from January 2005 to December 2010 identified women with presumed early stage endometrial cancer from a single institutional database. Inclusion criteria included: (1) FIGO grade 1 endometrioid endometrial cancer on endometrial biopsy; or (2) the same pathology as (1) on frozen section specimen with less than 50% myometrial biopsy; and (3) no evidence of metastatic disease on preoperative imaging or visible metastatic disease in the peritoneal cavity. Of the 52 patients, 86.5% were diagnosed with stage IA and 11.5% were diagnosed with stage II disease. One patient (1.9%) had microscopic adnexal involvement in a fallopian tube, which upstaged her to stage IIA disease. None of the patients had ovarian involvement. Preservation of the ovaries appears to be a safe and viable option for premenopausal women who are diagnosed with presumed early stage endometrioid endometrial cancer. It is believed that ovarian preservation in this select population will provide them with significant health benefits and improve their quality of life.

POF (paclitaxel/oxaliplatin/5-FU/leucovorin) versus SOX/CAPOX/FOLFOX as a postoperative adjuvant chemotherapy for curatively resected stage III gastric cancer: Study protocol for a randomized controlled trial, FNF-014 trial.

TPS4647 Background: Postoperative chemotherapy (S-1, CAPOX, or Docetaxel/S-1) is a standard treatment for stage II/III gastric cancer in Asia. With regard to single agent or doublet, the need for improvement has consistently been pointed out because of the relatively poor outcome for patients with stage III gastric cancer. Triplet (FLOT) has shown significant survival benefits in perioperative setting. POF, our regiment similar to FLOT, demonstrated priority to doublet (FOLFOX) in advanced setting (2019 ASCO-GI). We conducted a randomized, multicenter, phase III study to compare triplet to doublet regimens for patients with stage III gastric cancer. Methods: This is currently enrolling patients (n = 544) with pathologic stage III gastric cancer after D2 lymph node dissection. Patients are randomized 1:1 and stratified by tumor stage (IIIA, IIIB, or IIIC, AJCC 8th) into POF or SOX/CAPOX/FOLFOX (chosen by the clinicians). SOX: oxaliplatin 130 mg/m2 on day 1, oral S-1 80mg/m2 divided by two on days 1 to 14 every 21 days for 8 cycles. CAPOX: oxaliplatin 130 mg/m2 on day 1, oral capecitabine 1000 mg/m2 twice daily on days 1 to 14 every 21 days for 8 cycles. FOLFOX: oxaliplatin 85 mg/m2, levo-leucovorin 200 mg/m2, and 5-FU 400 mg/m2 bolus on day 1, then 5-FU 2400 mg/m2 continuous infusion over 46 hours, every 14 days for 12 cycles. Three doublets were chosen by the clinicians. POF: paclitaxel 135 mg/m2, followed by FOLFOX omitted 5-FU bolus, every 14 days for 12 cycles. Eligibility criteria: patients aged 18-70 years, primary histologically proven gastric adenocarcinoma (including adenocarcinoma of the gastroesophageal junction) of stage III with no evidence of metastatic disease, R0 resection with D2 lymph node dissection, good performance status (ECOG PS ≤1). Subjects must be able to take orally, and without other concomitant medical conditions that required treatment, initially treated with curative surgery followed by chemotherapy within 42 days. Life expectancy estimated more than 6 months. Adequate organ function. All patients provided written informed consent prior to treatment. Key exclusion criteria: patients with other primary malignancies, gastrointestinal bleeding. The primary end point is 3-year disease-free survival. Secondary end points are 3-year overall survival, 5-year overall survival, 5-year disease-free survival, and adverse events. Clinical trial information: NCT03788226 .

Adjuvant crizotinib in high-risk uveal melanoma following definitive therapy.

10075 Background: Uveal melanomas (UM) measuring at least 12mm in base diameter with a class 2 signature as defined by gene expression profiling (DecisionDx-UM) are characterized by high metastatic risk, with a median time to recurrence of 32 months. No therapy has been shown to reduce this risk. The growth factor receptor Met is highly expressed in UM. We have previously shown that crizotinib, an inhibitor of Met, is an effective adjuvant therapy in preclinical models (Surriga et al, Mol Cancer Ther 2013). We therefore conducted a phase II study of adjuvant crizotinib in high-risk UM. Methods: Eligibility included: primary lesion ≥12mm in base diameter; class 2 by DecisionDx-UM testing; definitive therapy within 120 days before starting crizotinib; and, no evidence of metastatic disease. Patients (pts) received 12 four-week cycles of crizotinib (250 mg twice daily). Surveillance imaging (chest CT and MRI abdomen/pelvis) were performed q3 months. The primary endpoint was distant relapse-free survival (RFS). Secondary endpoints were overall survival (OS) and toxicity. We hypothesized that the addition of crizotinib would increase the 32 month RFS from 50% to 75% (α = 0.05; β = 0.11). Results: As of 1/31/2020, 34 pts had enrolled and received at least one dose of study drug with median age of 60 (range, 26-86); 41% female; and median ECOG PS 0 (range, 0-1). 2 pts could not be evaluated for the primary endpoint due to early withdrawal and loss to follow-up. The median time from primary treatment to crizotinib initiation was 60 days (range, 0-106). All pts experienced a treatment-related adverse event (AE) of any grade. 11/34 (32%) experienced a grade 3 or 4 AE, the most common being transaminase elevation (n = 8/11). 9 pts (28%) did not complete the full 48-week treatment course due to disease recurrence (n = 5) or toxicity (n = 4). An additional 5 pts required dose reduction due to hepatic toxicity or diarrhea. 15/32 evaluable pts developed distant disease relapse, with 14 developing relapse within 32 months. With a median duration of follow up of 28.7 months, the median RFS was 30.6 months (95% CI: 27.8-58.5%). The median OS was not reached. Conclusions: The use of adjuvant crizotinib in patients with high-risk UM did not reduce rates of relapse in this multicenter, single arm trial. 9/32 (28%) pts required dose modification or discontinuation due to AE which may have limited efficacy. Further investigations of adjuvant treatment options are warranted. Clinical trial information: NCT02223819.

SAT-201 Adrenal Myelolipoma in a Patient with Sickle Cell Disease

Background: Adrenal myelolipoma is a rare benign tumor of the adrenal gland, consisting of adipose tissue and hematopoetic elements. It has been reported to be associated with many chronic diseases such as haematological disorders. The majority of the adrenal myelolipomas are diagnosed in the fourth-sixth decades of life, usually as incidental findings. Despite its benign behavior, it may cause difficulties in the differential diagnosis. Clinical Case: A 33-year-old woman was found to have a right adrenal incidentaloma in a kidney ultrasonography, during work-up for suspected kidney pathology ultimately not confirmed. Her past medical history was significant for sickle cell disease. There was no history of hypertension nor personal or family history of endocrine diseases. The physical examination was unremarkable.The ultrasonography revealed a mass above the right kidney, measuring 5.5 cm in diameter, markedly heterogeneous and hypoechoic in the center. On CT imaging, one month later, this mass measured 6.2x4.3cm. The absolute contrast washout of 52% was indeterminate for adrenal adenoma. The MRI, twelve months later, showed a well-demarcated and heterogeneous tumor with 8x4.7x4cm, with fat areas, suggesting adrenal myelolipoma, but not excluding the possibility of a malignant lesion, such as liposarcoma. The mass was in contact with the liver although not invading it nor the kidney or inferior vena cava. There was no evidence of metastatic disease. Basal biochemical work-up did not disclose hormonal hypersecretion. The ACTH level was 19.6 pg/ml (N7.2-63.3); free urinary cortisol (24 hours) was 101 μg/24h (N36-137) and the overnight 1 mg dexamethasone suppression test was also normal (0.5 μg/dL). Serum metanephrines were within the normal range: metanephrine 7,8 pg/mL (N <65) and normetanephrine 52,3 pg/mL (N<196). Her remaining laboratory values were within normal values including potassium and sodium values.Due to the size, rate of growth and atypical features of the mass, right laparoscopic adrenalectomy was performed. The resected adrenal weighed 66.6g and within it there was an intraparenchymal nodule, measuring 7.5 x 3 x 3.5 cm, which on histologic examination proved to be an adrenal myelolipoma. Conclusion: Adrenal myelolipomas are usually clinically silent. However, their incidental diagnosis should warrant careful diagnostic study. Although the pathogenesis of these tumors remains unclear, theories include retention of embryonic rests, adrenocortical metaplasia and extramedullary hematopoiesis. In this patient with sickle cell disease, bone marrow elements within the myelolipoma may have grown as a result of the persistent anemia. Particular to this case is the patient’s young age, since most cases reported have occurred during the fourth-sixth decades of life. In addition, the association with sickle cell anemia has only been reported in a few cases.

Choroidal melanoma overlying scleral buckle evading detection treated with proton beam radiotherapy

Purposeto present a case of a choroidal melanoma located along a scleral buckle contour and was successfully treated with proton beam radiotherapy, without disturbing the scleral buckle. ObservationsA 60-year-old woman presented with photopsias and history of retinal detachment repair with scleral buckle 36 years prior. She had annual dilated exams with her ophthalmologist over the last several years. While initially diagnosis of choroidal detachment, hemorrhage and intraocular buckle intrusion were suspected, the patient was referred to an ophthalmic oncology center and choroidal melanoma was confirmed. The patient underwent tantalum marker placement, trans-retinal biopsy and proton beam radiotherapy. Despite no evidence of metastatic disease on systemic imaging, prognostic genetic testing of the tumor revealed high-risk alterations for future metastasis, and the patient enrolled in an adjuvant clinical trial. ConclusionsThe location of this choroidal melanoma along a scleral buckle contour presented a unique therapeutic challenge. We successfuly treated the tumor with proton beam radiotherapy without disturbing the scleral buckle. Importancechorioretinal elevations adjacent a scleral buckle may be presumed to be due to the buckle element; ultrasound can be helpful in distinguishing an intraocular tumor. Proton beam radiotherapy has the advantage over plaque brachytherapy in this setting as removing the scleral buckle is not needed and placing a plaque over the scleral buckle risks altering the effective radiotherapy dose.

Ewing’s sarcoma of proximal humerus: A rare case report

Ewing’s sarcoma is a highly malignant small round cell tumor from bone or soft tissue. The clinical manifestation is non-specific, with local pain being the most common symptom by far. It affects prevalently among children younger than ten years. The chromosomal translocation t(11;22)(q24:q12) is one of the causes of Ewing’s sarcoma. The gold standard diagnostic is incisional biopsy, additionally with cytogenic immunohistochemical. The current standard treatment for resectable Ewing’s sarcoma begins with neoadjuvant chemotherapy, followed by limb salvage procedure and postoperative adjuvant chemotherapy. After resection of Ewing’s sarcoma, the large bone defects should be reconstructed to restore the function of the affected limbs. The main options for reconstruction include autogenous bone grafts and endoprosthesis. Prognosis of Ewing’s sarcoma is highly dependent on clinically evident metastatic disease, which may be preventable with early detection and treatment with aggressive local disease control and systemic multidrug chemotherapy. This article presents a rare case of an 8-year-old elementary schoolboy, diagnosed with Ewing’s sarcoma of the proximal left humerus that was confirmed by plain radiograph and immunohistochemical biopsy. Patient’s family discontinued the chemotherapy schedule and ignored the surgical reconstruction procedure.

Occult Breast Cancer Presented with Axillary Lymph Node Metastases: A Small Case Series to a Frustrating Medical Issue

Occult breast carcinoma (OBC) presenting with axillary metastases and no identifiable breast tumor is a rare entity that can be a diagnostic and therapeutic challenge. Retrospectively, we gathered data from five female patients who presented to us with enlarged axillary nodes. Data collected included age at diagnosis, presenting complaints, imaging studies, surgical findings, histology, treatment, and progress. All patients underwent mammographic examination as well as breast ultrasound with no evidence of disease. In all five cases, there was a positive preoperative biopsy of the affected lymph node for breast adenocarcinoma. All patients were treated with modified radical mastectomy (MRM) except for one case, in which ALND was performed. The histology reports of three patients that underwent MRM revealed no sign of intramammary adenocarcinoma. In two cases, there was history of contralateral breast cancer. Only one patient did not receive perioperative chemotherapy. The disease-free survival ranges between 6 months and 2 years. OBC presenting with axillary metastases is an unusual presentation, and there is not enough evidence to support recommendations regarding the management. For patients with no evidence of metastatic disease, the management can be individualized. There is vast heterogeneity in studies concerning the treatment of OBC.

18F]Fluciclovine-PET/MRI use in monitoring response to androgen deprivation therapy in men with prostate cancer following initial staging.

216 Background: [18F]Fluciclovine PET is clinically approved for detection of biochemically recurrent prostate cancer (PCa). However, its use for initial staging and treatment monitoring remains uncertain. No published data exists evaluating the use of fluciclovine-PET for monitoring response to androgen deprivation therapy. Thus, the purpose of this study is to evaluate the potential use of fluciclovine-PET in monitoring response to androgen deprivation therapy (ADT) during initial treatment of patients with newly diagnosed high risk PCa. Methods: A prospective study enrolled patients with high-risk PCa who had no imaging evidence of metastatic disease. All patients underwent a pretreatment fluciclovine-PET/MRI for primary staging, 6 weeks of ADT, and had a follow-up PET/MRI. All exams were interpreted by 3 nuclear medicine physicians. Identification of the primary intraprostatic lesion and nodal metastatic disease was performed with mean and maximum SUV of the MRI-defined primary prostatic lesions and lymph node metastases measured before and after ADT. Results: A total of 10 patients were enrolled. Gleason scores of their primary tumor were 3+4 (n = 2), 4+3 (n=2), 8 (n = 3), and 9 (n = 3). The average pretreatment serum PSA value was 33.04 ng/mL (range 2.83–76.5). The average serum PSA 6 weeks following initiation of ADT was 2.13 ng/mL (range 0.29–5.66). The primary intraprostatic lesion was accurately identified in all 10 patients and 7/10 patients demonstrated suspicious lymph nodes on the pretreatment PET/MRI. Following ADT, all 10 patients demonstrated a decrease in tracer activity both within the primary intraprostatic lesion and suspicious lymph nodes. The primary lesion mean SUV prior to treatment was 4.46±1.14 and 2.37±1.07 following initiation of ADT (p=0.0007). The primary lesion maximum SUV prior to treatment was 7.13±1.70 and 3.54±2.04 following initiation of ADT (p=0.0006). Conclusions: Fluciclovine-PET tracer activity in patients with PCa undergoing ADT appears to correlate with decrease in serum PSA. Fluciclovine-PET imaging may be useful in monitoring response to ADT, particularly if there is a failure of appropriate PSA response. Clinical trial information: NCT03264456.

Surgical removal of a thyroglossal duct cyst in a geriatric dog

A 12-year-old, body condition score (BCS) 9, female, Poodle mix dog was presented for coughing, gasping sounds and exercise intolerance. The symptoms started 2 months prior to the presentation. Clinical...

Imaging of Pancreatic Carcinoma on Multidetector Computed Tomography, A Tertiary Care Experience at Liaquat National Hospital, Karachi

Introduction: Pancreatic cancer is a lethal disease. The mortality rate for pancreatic tumor has changed over the last 20 years. Early diagnosis of pancreatic carcinoma is very important for therapeutic decisions and surgical planning. Contrast enhance CT facilitated the detection of primary tumor and staging. Objective: This study is to evaluate various presentations of pancreatic carcinomas on their initial MDCT (Multidetector Computed Tomography) and to evaluate its resectability and to compare CT features among resectable and non-resectable tumors. Methodology: All the patients underwent multi-phasic CT scan on a 16-slice MDCT. CT findings were analyzed included tumor location, size, enhancement pattern, nodal disease, duct dilatations, vascular involvement and evidence of metastatic disease. Results: Total 63 records of patients examined during 2017 and 2019 meeting the inclusion criteria were reviewed. The average age at time of MDCT examination was 62.51 ± 13.17 years. The disease was more common in males (n=36, 57.1%). Out of 63 pancreatic tumors, 14 (22.22%) tumors were identified as resectable tumors on MDCT examination. Tumor size (p&lt;0.001), peripancreatic nodes (p=0.006), contrast enhancement (p=0.018), vessel involvement (p&lt;0.001), ascites (p=0.006), hepatic metastases (p=0.001) and peripheral organ involvement (p&lt;0.001) were significantly different among resectable and non-resectable tumors. Conclusion: MDCT is an excellent and most commonly used modality for diagnosis and staging of pancreatic carcinoma particularly with a high sensitivity for detection of vascular invasion and metastatic disease.

Adjuvant MUC vaccination with tecemotide after resection of colorectal liver metastases: a randomized, double-blind, placebo-controlled, multicenter AIO phase II trial (LICC)

ABSTRACT Resection of colorectal liver metastases (CRLM) is a potential curative treatment for patients with metastatic colorectal cancer (mCRC) with liver-limited disease (LLD). Although long-term survival improved considerably within the last decades, high recurrence rates of 50-75% after resection remain a major challenge.Tecemotide (L-BLP25) is an antigen-specific cancer vaccine inducing immunity against mucin-1 (MUC1). The LICC trial aimed to improve survival in patients with mCRC after R0/R1 resection of CRLM. LICC was a binational, randomized, double-blind, placebo-controlled, multicenter phase 2 study including patients with R0/R1 resected CRLM without evidence of metastatic disease outside the liver. Co-primary endpoints were recurrence-free survival (RFS) and 3-year overall survival (OS) rate, secondary endpoints were RFS and OS in subgroups with different MUC1 expression and safety. In total, 121 patients were 2:1 randomized between Oct 2011 and Dec 2014to receive tecemotide (N=79) or placebo (N=42). Baseline characteristics were well balanced. Median RFS was 6.1 months (95% CI 4.5-8.9) and 11.4 months (95% CI 3.7-21.2) (P = .1754), 3-year OS rate 69.1% and 79.1%, median OS 62.8 months and not reached in the tecemotide vs. placebo arm (P = .2141), respectively. Cox regression models revealed no dependence of RFS or OS on MUC1 expression. The most common tecemotide-related grade 3/4 adverse events were diarrhea, injection site reaction, intestinal perforation, peritonitis and tinnitus (1.3% each). The LICC trial failed to meet its primary endpoints of significantly improving RFS and OS with tecemotide. However, both arms showed unexpectedly long OS. MUC1 expression was not associated with outcome. EudraCT No: 2011–000218-20 Clinical Trial Information: NCT01462513 Financial Support: Merck KGaA, Darmstadt, Germany Abbreviations: AE: adverse event; CP: cyclophosphamide; CRC: colorectal cancer; CT: computed tomography; ECOG: Eastern Cooperative Oncology Group; FU: follow-up; HR: hazard ratio; IHC: immunohistochemical staining; ITT: intention-to-treat; DSMB: Data Safety Monitoring Board; LLD: liver-limited disease; mCRC: metastatic colorectal cancer; MPLA: monophosphoryl lipid; AMRI: magnetic resonance imaging; MUC1: mucin 1; NA: not applicable; NCI-CTCAE: National Cancer Institute Common Terminology Criteria for Adverse Events; NS: normal saline; NSCLC: non-small-cell lung carcinoma; OS: overall surviva; lPP: per protocol; RAS: Rat sarcoma; RFS: recurrence-free survival; TEAE: treatment-emergent adverse event; UICC: Union for International Cancer Control; US: ultrasound; vs.: versus.

Gastric leiomyosarcoma: A common tumor in an uncommon location

A previously healthy 51-year-old female presented with gradually worsening, 10/10 non-radiating epigastric abdominal pain associated with nausea, bilious vomiting, and weight loss. Computed tomography (CT) of the abdomen with intravenous contrast showed a large 10.7 × 9.5 cm exophytic mass in the antrum/body of the stomach (Figure 1A). An upper endoscopic evaluation revealed a large fungating, infiltrative, and ulcerated mass in the gastric body (Figure 1B). Histopathology of the biopsied mass was notable for spindle cells with a fascicular pattern, moderate nuclear atypia, abundant eosinophilic cytoplasm, and numerous mitotic figures. Immunohistochemistry analysis revealed that the tumor was diffusely positive for smooth muscle actin (SMA) (Figure 2A), desmin (Figure 2B), and calponin (Figure 2C). Ki-67 stain (Figure 2D) showed a high labeling index of 60% indicating a high-grade leiomyosarcoma. There was a complete lack of reactivity with DOG-1 and CD-117 (c-KIT) which excluded the diagnosis of a gastrointestinal stromal tumor (GIST). No evidence of metastatic disease and no lymph node involvement were noted in the head, abdomen, or thorax on the respective CT scans which were done for staging. Due to the large size of the tumor, the patient was started on a neoadjuvant chemotherapy regimen consisting of doxorubicin, ifosfamide, and mesna to reduce tumor burden with a future plan for surgical excision.

084 Bad Pumps and Incidental Lumps: An Illustrative Case Series of Phaeochromocytoma-Induced Cardiomyopathy

Phaeochromocytomas are rare tumours with the majority of diagnoses incidental in nature. Some cases are suspected due to symptoms and presentations secondary to crises are extremely rare. We present two cases of phaeochromocytoma-induced cardiomyopathy presenting with phaeochromocytoma crisis precipitated by infection. A 65 year old female and 40 year old male similarly presented with cardiogenic shock requiring ventilatory and inotropic support following upper respiratory viral infections. Both cases had Picornavirus detectable by PCR on nasopharyngeal swabs. The female patient was also found to have gram negative sepsis secondary to Enterobacter hormaechei. Cardiac investigations for both patients were similar including significant troponin elevation and severe left ventricular dysfunction with mid to basal akinesis and apical hyperkinesis on transthoracic echocardiography. Recovery of cardiac function was similarly rapid. Subsequent diagnoses of phaeochromocytoma were made following further evaluation of hypertension and systemic symptoms, coupled with identification of abdominal masses and elevated serum metanephrines. Neither patient had evidence of metastatic disease on DOTATATE-PET imaging. The female patient had normal coronary arteries and underwent myocardial biopsy which demonstrated lymphocytic infiltrate consistent with mild viral myocarditis. A concurrent diagnosis of viral myocarditis could not be excluded. The male patient did not undergo angiography due to concerns of precipitating further phaeochromocytoma crisis secondary to iodine contrast. These cases highlight the need to consider phaeochromocytoma in the setting of unexplained cardiogenic shock, and further as a potential causes of stress cardiomyopathy.