Exclusion Of Metastases Research Articles

Exploring the Role of MRI in the Detection of Atypical Liver Hemangiomas and Exclusion of Metastases

Background: In this article, we highlight the importance of utilizing multiple imaging modalities, including CT, MRI, and abdominal Doppler ultrasound, to accurately differentiate between atypical liver hemangiomas (LH) and metastases. Case report: We introduce a 57-year-old male patient who presented with severe abdominal pain. Initial CT scan findings showed hypodense liver lesions and a well-defined hypodense mass in the sub-diaphragmatic region, raising suspicion for metastatic liver lesions, and prompting further evaluation. To differentiate between atypical hemangiomas and metastases, an MRI scan was performed, revealing a hyperintense signal on T2-weighted images and a hypointense signal on T1-weighted images, consistent with the characteristics of LH. These characteristic signal intensities aided in ruling out metastatic liver lesions, which typically present with a more solid and homogeneous appearance. Contrast-enhanced MRI played a crucial role in confirming the diagnosis. The liver lesions demonstrated moderate vascularization during the early phase of contrast enhancement, followed by progressive centripetal filling during the portal venous and delayed phases. This enhancement pattern is consistent with the slow flow within the dilated vascular spaces of liver hemangiomas. The lesion in the right liver lobe is almost completely filled with contrast, further supporting the diagnosis of hemangioma. Abdominal Doppler ultrasound can provide additional information regarding the vascularity of liver lesions. In this case, the Doppler examination likely helped to further confirm the presence of a hemangioma, as these lesions typically demonstrate increased vascularity compared to metastatic lesions. Conclusion: The comprehensive imaging evaluation utilizing CT, MRI, and abdominal Doppler ultrasound allowed for the confident differentiation of atypical liver hemangiomas from metastatic liver lesions in this case. This emphasizes the importance of a multimodal imaging approach in cases of liver lesions with overlapping features, leading to improved patient management and outcomes.

S2047 Is It Anal or Rectal? A Rare Case of Squamous Cell Carcinoma

Introduction: Primary rectal squamous cell carcinomas (SCC) are extremely rare and difficult to distinguish from anal cancers. The majority of rectal SCC are secondary to anal SCC extension and detected at an advanced stage. Although rectal and anal cancers are anatomically close, they are distinct entities with risk factors, different histologic features, patterns of spread, staging systems, and treatment pathways. We present a rare case of a middle-aged man with AIDS who presented with bloody diarrhea, eventually found to have a primary rectal SCC. Case Description/Methods: A 59-year-old-male with a history of AIDS presented with bloody diarrhea and fevers. He denied abdominal or rectal pain. Physical exam only revealed mild tenderness of the abdomen. Labs were unremarkable. Gastrointestinal PCR revealed shigella, enteroaggregative E. Coli, enterotoxigenic E. coli, and enteropathogenic E. coli infection. Computed tomography of the abdomen and pelvis revealed pancolitis and left irregular rectal wall thickening, concerning for rectal carcinoma. He was started on IV ciprofloxacin and metronidazole with improvement in symptoms. Colonoscopy revealed a non-obstructing mass in the rectum. Pathology demonstrated high-grade anal intraepithelial lesion (AIN-3) and focally invasive squamous cell carcinoma, with acute and chronically inflamed rectal mucosa. Given the incongruence between colonoscopy and pathology, it was uncertain whether a primary lesion of the rectum with spread to anus existed or if 2 separate pathologies were present. Repeat colonoscopy to define the anatomic location of the mass revealed a severely ulcerated, friable, rectal lesion, discontinuous from an area of anal inflammation, separated by normal mucosa. Repeat pathology revealed invasive and in situ SCC of the rectum. The patient was referred for chemoradiation with 5-fluorouracil and mitomycin (Figure). Discussion: Primary rectal SCC accounts for 0.01% of all colo-rectal carcinomas. Risk is increased in patients with a history of Human Papilloma virus infection. The diagnosis of primary rectal SCC requires 3 criteria: (i) exclusion of metastasis, (ii) no squamous-lined fistulous tract involving the affected rectum, and (iii) exclusion of anal SCC with proximal extension (absence of continuity between the tumor and the normal anal squamous epithelium). Our patient ultimately fulfilled all these criteria. Primary rectal SCC should be considered a differential diagnosis in patients with HIV/AIDS, presenting with bloody diarrhea and a rectal mass.Figure 1.: CT of the abdomen and pelvis (A) revealing an irregular, asymmetric rectal wall thickening centered laterally on the left, highly concerning for rectal carcinoma, in addition to a focal left-sided outpouching from the rectum, suggesting a thick-walled diverticulum. Colonoscopy showing a rectal mass with ulcerated and friable mucosa (B&D). Area of anal inflammation (yellow circle, C) discontinuous from rectal mass with an adjacent small area of normal epithelium.

Merkel Cell Carcinoma of the Upper Eye Lid with Atypical Clinical Appearance.

Merkel cell carcinoma (MCC) is a rare aggressive neuroendocrine skin tumor that occurs mainly in the sun-exposed head and neck region, but rarely in the eyelid region. Early lymphogenic spread often leads to locoregional metastases, which is why early diagnosis is crucial. Classically, periocular MCC presents as a reddish-livid nodule in elderly patients, a visual diagnosis. However, given its low incidence and variable appearance, diagnosis can also be challenging. In both cases presented here, the MCC presented as a skin-colored swelling. In patient 1, the tumor showed a partially deep subaponeurotic localization and mimicked a B-cell lymphoma histopathologically, whereas in patient 2 it imitated a diffuse chalazion clinically. After immunohistochemical characterization and exclusion of metastases, the initial clinically benign appearing lesions in both patients were classified as CK20 negative MCC. The extensive upper eyelid defects were reconstructed by Cutler-Beard plastic surgery, a particular challenge in patient 1 given the oculus unicus situation. Our two cases demonstrate that Merkel cell carcinomas not only manifest as deep red cherry-shaped tumors, but can be skin-colored and mimic benign changes when atypical in location or infiltration pattern.

Primary hepatic neuroendocrine carcinoma with colon adenoma: A case report with literature review.

Introduction and importancePrimary hepatic neuroendocrine tumors (PHNETs) are extremely rare, and the clinical symptoms, test results, and imaging characteristics are nonspecific in most patients; thus, it is difficult to differentiate from other liver masses before surgery. Histopathology and immunohistochemistry are the main basis for the diagnosis. PHNETs and colon tumors co-occur in a patient and are non-homologous, as reported in the English-language literature for the first time.Case presentationWe present a case of a 60-year-old woman with right hepatic lobe mass accidentally discovered on abdominal ultrasonography during a routine examination. Preoperative liver contrast-enhanced computed tomography suggested hepatocellular carcinoma; then, surgery were performed. Pathological results revealed a Grade 2 neuroendocrine tumor of the liver. In search of the primary tumor, upper and lower endoscopy of the GI tract was performed and revealed a mass in the ascending colon. Ascending colon cancer was considered; then, laparoscopic right hemicolectomy was performed. Pathological results suggested tubular villous adenoma of the ascending colon. The final diagnosis was not colon cancer with liver metastases but was PHNETs with colon adenoma.Clinical discussionPHNETs are rare cancers that are difficult to diagnose, requiring not only differentiation from other liver masses but also exclusion of metastases from extrahepatic sources. The pathological results play an important in making an accurate diagnosis.ConclusionPathology, postoperative follow-up, and comprehensive imaging examinations are powerful tools in the diagnosis of PHNETs. Currently, surgery is the best treatment to achieve a potential cure and prolong the patient's survival.

Castleman lymphadenopathy: case review

Background. While examining regional lymph nodes removed with the tumor, the pathomorphologist is often limited to the exclusion of metastases, omitting changes in lymphoid tissue. The aim of the work is to describe a rare variant of Castleman-like lymphadenopathy in the surgical material obtained during the removal of colon cancer with regional lymph nodes. Methods. Pathomorphological examination of removed lymph nodes using histological and immunohistochemical methods (CD23). Results. A 73-year-old patient underwent surgery for rectal cancer. Pathomorphological analysis diagnosed adenocarcinoma of high degree of differentiation (G1) and revealed Castleman-like changes in some of the enlarged regional mesenteric lymph nodes: signs of different stages of development of lymphoid follicles, including their hyperplasia, atresia and fragmentation with preservation of activated CD23+ follicular dendritic cells and reaction of microvasculature, including vascular proliferation in the interfollicular areas with uneven narrowing of the sinuses. The discussion analyzes the probable genesis of changes in lymphoid tissue, which may be a reflection of the early stage of Castleman's disease, complication of radiation therapy performed in the preoperative stage, or a consequence of impaired immune status due to tumor growth, in particular with antigenic overloading of draining lymphoid tissue, effects of cytokines produced by inflammatory infiltrate cells that accumulate directly near the tumor, and the formation of a state of genetic instability, which progresses under the influence of radiation. Conclusion. Despite the rarity of Castleman-like lymphadenopathy, in each case of examination of lymph nodes in the surgical material it is necessary to conduct a thorough analysis of lymphoid tissue, as this may be important both to assess the prognosis and to select adequate therapy.

Primary high-grade myoepithelial carcinoma of the lung: A study of three cases illustrating frequent SMARCB1-deficiency and review of the literature

Primary myoepithelial carcinoma of the lung is exceptionally rare and, hence, remained poorly characterized. We present 3 tumors affecting 2 males and 1 female aged 60 to 84 years. Tumor size ranged from 4 to 10 cm. All presented as well circumscribed non-encapsulated peripheral solitary masses. One patient died postoperatively. The other two were lost to follow-up. Histologically, all tumors were high-grade with predominance of myxoid/chordoid (2) and rhabdoid (1) pattern. Immunohistochemistry (IHC) showed reactivity with vimentin, pankeratin, EMA and smooth muscle actin. Two tumors were SMARCB1-deficient (one with additional loss of SMARCA2 and PBRM1). RNA sequencing revealed no gene fusions. Review of reported cases (total: 16) showed that pulmonary myoepithelial carcinoma affects both sexes equally at a median age of 60 years (24–84), presents predominantly as peripheral masses (69%) in the lower lobes (66%) of smokers (70%) with a median size of 6 cm (1.5–13), and originates as high-grade de novo carcinoma. Forty percent of patients died of disease at a median of 12.5 months (0 to 62). Only 40% of patients were disease free at last follow-up (median, 9.5 months). Prominent lobulation and myxoid stroma were frequent histological features. Most tumors displayed variable combinations of epithelioid, spindle, plasmacytoid, clear, ovoid or round cells. Three of 6 tumors subjected to different RNA panels showed EWSR1 rearrangements (fused to PBX1, ZNF444 or to unknown partner). Two of 3 tumors lacking gene fusions were SMARCB1-deficient (both showed secondary EWSR1 FISH abnormalities due to 22q deletion). Primary pulmonary myoepithelial carcinoma is a rare aggressive malignancy that recapitulates its soft tissue and salivary counterpart. Exclusion of metastasis from other primaries is mandatory and can only be achieved by detailed clinical history and imaging.

Pheochromocytoma and paraganglioma-an update on diagnosis, evaluation, and management.

Pheochromocytomas and paragangliomas (PPGLs) generally grouped together are rare catecholamine-secreting endocrine tumors. Symptoms of catecholamine excess are non-specific and therefore a high index of suspicion in children with sustained hypertension, family history of endocrine tumors, or features of syndromes associated with PPGLs leads to a timely diagnosis and treatment. Freemetanephrines in theplasma or 24-h urine are the preferred tests to establish catecholamine excess. Considerations for false-positive conditions improve diagnostic yield and accuracy. Functional imaging, targeting either specific cell membrane transporters or vesicular catecholamine transport systems, is indicated for incidental lesions suspicious for PPGLs with inconclusive biochemical testing, assessment of regional extension or multifocality, and exclusion of metastases. Surgery is the mainstay of treatment for PPGLs. Preoperatively, sequential use of alpha adrenergic receptor blockade and volume expansion followed by beta blockade is mandatory to reduce intraoperative intravascular instability and blood pressure fluctuation due to tumor manipulation. Since genetic mutations have been reported in tumor susceptibility genes in nearly 50% of patients with PPGLs, genetic counselling and testing should be considered in all patients with a confirmed tumor.

Pneumonectomy - permanent injury or still effective method of treatment? Early and long-term results and quality of life after pneumonectomy due to non-small cell lung cancer.

IntroductionDespite the constant decrease of performed pneumonectomies (PN) in recent years, it is still necessary for 15–20% of patients with non-small cell lung cancer (NSCLC) to undergo total lung resection due to the local progression of the disease.AimTo assess the frequency and type of postoperative complications, quality of life, and the early and long-term results after PN performed due to NSCLC.Material and methodsIn the total group of 1160 patients, operated on in 2008–2011 due to NSCLC, 192 of them underwent PN (16.6%). The quality of life was analysed using EORTC-QLQ-C30 questionnaire.ResultsPerioperative mortality after PN was 4%. Five-year survival reached 45%. The factors that significantly affected the 5-year survival in multivariate analysis were: pTNM stage, pN stage, intrapericardial resection, and additional extrapulmonary structures resection. The mean Global Quality of Life was 50.8. The Symptom Scale ranged from 7 to 54.3, the Functional Scale from 58.2 to 76.3 and the rate for NSCLC symptoms ranged from 2.2 to 48.1.ConclusionsPneumonectomies in patients with NSCLC is associated with higher risk of postoperative complications but it does not significantly increase the perioperative mortality. Long-term results in this group of patients are encouraging. According to the questionnaire, the quality of life is favourable. Low intensity of typical NSCLC symptoms was observed. The appropriate qualification for right-sided PN and exclusion of metastasis in N2 nodes are crucial.

Completion pneumonectomy and chemoradiotherapy as treatment options in local recurrence of non-small-cell lung cancer.

IntroductionThe selection of treatment for local recurrence in patients with non-small-cell lung cancer (NSCLC) depends on the possibility of performing a radical tumor resection, the patient's performance status, and cardiopulmonary efficiency. Compared with chemoradiotherapy, surgical treatment offers a greater chance of long-term survival, but results in completion pneumonectomy and is associated with a relatively high rate of complications.Aim of the studyAim of the study was to evaluate early and long-term results of surgery and conservative treatment (chemoradiotherapy) in patients with local NSCLC recurrence.Material and methodsBetween 1998 and 2011, 1697 NSCLC patients underwent lobectomy or bilobectomy at the Department of Thoracic Surgery in Poznań. Among them, 137 patients (8.1%) were diagnosed with cancer recurrence; chemotherapy or chemoradiotherapy was provided to 116 patients; 21 patients (15.3%) were treated with completion pneumonectomy. The median time from primary surgery to recurrence was 13.4 months. No metastases to N2 lymph nodes were observed among the patients undergoing surgery; in 7 patients N1 lymph node metastases were confirmed.ResultsThe rate of complications after surgery was significantly higher in comparison with conservative therapy (80.9% vs. 48.3%). Patients treated with surgery were most likely to suffer from complications associated with the circulatory system (80.9%), while hematologic complications were dominant in the group undergoing oncological treatment (41.4%). There were no perioperative deaths after completion pneumonectomy. The age of the patients was the only factor which significantly influenced the incidence of complications in both groups of patients. Analysis of the survival curves demonstrated statistically significant differences in survival between the groups treated with surgery, chemoradiotherapy, and chemotherapy (p = 0.00001). Five-year survival probability was significantly higher among patients treated surgically as compared to patients undergoing systemic therapy.ConclusionsDespite the significant rate of postoperative complications (mostly circulatory), the long-term results of the surgical treatment of local NSCLC recurrence are more favorable than those achieved with chemoradiotherapy. The success of surgical treatment is conditioned on the exclusion of metastasis in N2 lymph nodes.

Cutaneous metastasis as an initial presentation of an unknown primary

Cutaneous metastasis from underlying visceral malignancies is a rare phenomenon. Rarely, cutaneous metastasis can be the first manifestation of an underlying malignancy. Cutaneous metastases, in most patients, usually reveal a terminal stage of illness. Hence, in such cases, it is crucial to use a minimally invasive technique for either the diagnosis or exclusion of metastasis. Fine needle aspiration cytology can be used as an alternative to biopsies, as this is a minimally-invasive, relatively simple, rapid and inexpensive procedure. The site of primary may remain unknown in some cases, as was seen in our case.

Cost Effectiveness of Routine Laparoscopic Ultrasound for Assessment of Resectability of Gallbladder Cancer

In addition to a diagnostic laparoscopy (DL), a routine laparoscopic ultrasound (LUS) has been proposed to identify undetected hepatic metastases and/or anatomically advanced disease in patients with T2 or higher gall bladder cancer (GBC) patients planned for surgical resection. It was hypothesized that a routine LUS is not a cost-effective strategy for these patients. Decision tree modeling was undertaken to compare DL-LUS vs. DL at the time of definitive resection of GBC (with no prior cholecystectomy). Costs in US dollars (payer's perspective), quality-adjusted life weeks (QALWs), and incremental cost-effectiveness ratios (ICER) were calculated (horizon: 6 weeks, willingness-to-pay: $1,000/QALW or $50,000/QALY). DL-LUS was cost effective at the base case scenario (costs: $30,838 for DL vs. $30,791 for DL-LUS and effectiveness 3.81 QALWs DL vs. 3.82 QALW DL-LUS), resulting in a cost reduction of $9,220 per quality-adjusted life week gained (or $479,469 per QALY). DL-LUS became less cost effective as the cost of ultrasound increased or the probability of exclusion from resection decreased. Routine LUS with DL for the assessment of resectability and exclusion of metastases is cost effective for patients with GBC. Until improvements in preoperative imaging occur to decrease the probability of exclusion, this appears to be a feasible strategy.

Cost-effectiveness of routine laparoscopic ultrasound for the assessment of resectability of gallbladder cancer.

272 Background: In addition to a diagnostic laparoscopy (DL), aroutine laparoscopic ultrasound (LUS) has been proposed to identify undetected hepatic metastases and/or anatomically advanced disease in patients with T2 or higher gall bladder cancer (GBC) planned for surgical resection. It was hypothesized that a routine LUS is not a cost-effective strategy for these patients. Methods: Decision tree modeling was undertaken to compare DL-LUS vs. DL at the time of definitive resection of GBC (with no prior cholecystectomy). Costs in US dollars (payers’ perspective), quality-adjusted-life-weeks (QALWs) and incremental-cost-effectiveness-ratios (ICER) were calculated (horizon: 6 weeks, willingness-to-pay: $1,000/QALW or $50,000/ QALY). Results: DL-LUS was cost effective at the base case scenario (costs: $30,838 for DL vs. $30,791 for DL-LUS and effectiveness 3.81 QALWs DL vs. 3.82 QALW DL-LUS, resulting in a cost reduction of $9,220 per quality adjusted life week gained (or $479,469 per QALY). DL-LUS became less cost effective as the cost of ultrasound increased (threshold: $163.18) or the probability of exclusion from resection decreased (threshold 0.29) (Table represents the results of univariate analyses). Conclusions: Routine LUS with diagnostic laparoscopy for the assessment of resectability and exclusion of metastases is cost effective for patients with GBC. Until improvements in pre-operative imaging occur to decrease the probability of exclusion, this appears to be a feasible strategy. [Table: see text]

Primary testicular mucinous neoplasms: case report and literature review

Testicular epithelial mucinous tumours are an extremely rare, but interesting form of testicular neoplasm. We reviewed the medical literature using PubMed search terms: testis, mucinous cystadenoma, mucinous cystadenocarcinoma, neoplasms and testicular neoplasms. We describe a case from our institution and provide a review of the literature. Only 11 previously reported cases of mucinous testicular tumours have been reported in the English literature. The natural history of these tumours is poorly understood, due to their rarity, but it appears that, like their ovarian counterparts, they have an excellent prognosis. Exclusion of metastasis is an important point for the urologist when encountering a mucinous testicular tumour, as metastatic cystic lesions may mimic a primary mucinous tumour. We describe a case of ossified testicular mucinous tumour of low malignant potential. Such tumours are common in the ovary, but arise very rarely in the testicle. The clinical and histological features of this tumour are presented, and previously reported cases are reviewed to highlight important clinical features.

Malignes Melanom imitiert ein neurotrophes Ulkus

A 77-year-old female patient with an ulceration of the heel is described, which was treated over a period of 2 years as a neurotrophic ulcer related to diabetes mellitus. After the initial examination in the outpatient wound healing clinic, a malignant melanoma already showing invasive growth with a penetration depth of 4.6 mm was detected in a biopsy. After diagnosis and exclusion of metastases, a phase-adapted complete excision was carried out. Furthermore, an adjuvant immunotherapy was introduced. Malignant melanoma is a primary cutaneous malignant tumor. Its thickness at the time of the initial diagnosis is crucial to the prognosis. Ulcerated and amelanotic melanomas still present a considerable clinical challenge due to the likelihood of being mistaken for benign diseases and the occurrence of filiae when diagnosis is made too late. This case report demonstrates the importance of differential diagnostic consideration of neoplasias, for example malignant melanoma, in cases of unclear, therapy-refractory wounds and discusses the relevant aspects in avoiding an unnecessary prolongation of diagnostics.

Rezidivierendes hochdifferenziertes ekkrines Karzinom des Daumens - Fallbericht

The eccrine carcinoma is a rare tumour originating from the sweat glands. They are mainly located in the palm of the hand and the sole of the foot, the digits, the head and the trunk. We report on a now 68-year-old male, who underwent partial amputation of the thumb at the level of the proximal phalanx due to an eccrine carcinoma in 1990. In the following years, three local recurrences were excised. After the exclusion of metastases an amputation at the MP I level was performed at our institution. To restore grip function, we performed a distraction of the first metacarpal bone followed by deepening of the first web space. So far, there are no defined treatment recommendations due to the rarity of the tumor. In some cases, metastatic disease has been reported, and in most cases, a high rate of local recurrence. After diagnostic biopsy, we recommend staging to exclude metastatic spread of the tumor followed by aggressive local surgical treatment.

Primary intraosseous odontogenic carcinoma arising in an odontogenic cyst or de novo: a clinicopathologic study of five new cases

The term primary intraosseous odontogenic carcinoma (PIOC) has been primarily used to describe a squamous cell carcinoma within the jaws arising either from a previous odontogenic cyst or, more rarely, de novo. Diagnostic criteria of PIOC require absence of initial connection with the overlying mucosa or skin and exclusion of metastasis from a distant primary tumor by physical and radiographic examination during at least a 6-month follow-up. We report 5 patients with PIOC treated at the University of Maryland, Baltimore, during the period from 1997 to 2004. Three of the patients were female and 2 were male. Their age ranged from 18 to 84 years with a mean age of 52.8 years. One case involved the anterior maxilla, and 4 cases occurred in the mandible, 3 of them being located posteriorly. One patient complained of pain and paresthesia, and the remaining patients were asymptomatic. The typical radiographic presentation of our cases was that of a radiolucent lesion with well defined or irregular margins. Histopathologically, 4 cases were diagnosed as PIOC arising from previous odontogenic cysts (including 2 odontogenic keratocysts and 2 periapical cysts); all 4 were well differentiated keratinizing carcinomas. The remaining case, a poorly differentiated nonkeratinizing squamous cell carcinoma, was not associated with a cystic component and appeared to have arisen de novo. Four patients underwent surgical removal with postoperative radiotherapy, and 1 patient was treated with surgery only. Lymph node involvement and distance metastasis were not present in any of our patients at the time of diagnosis and did not develop during a follow-up period ranging from 15 to 77 months. To date, all patients are alive and free of disease. Knowledge of the clinical, radiographic, and histopathologic features of PIOC will allow accurate diagnosis and appropriate treatment of this rare malignancy. The term primary intraosseous odontogenic carcinoma (PIOC) has been primarily used to describe a squamous cell carcinoma within the jaws arising either from a previous odontogenic cyst or, more rarely, de novo. Diagnostic criteria of PIOC require absence of initial connection with the overlying mucosa or skin and exclusion of metastasis from a distant primary tumor by physical and radiographic examination during at least a 6-month follow-up. We report 5 patients with PIOC treated at the University of Maryland, Baltimore, during the period from 1997 to 2004. Three of the patients were female and 2 were male. Their age ranged from 18 to 84 years with a mean age of 52.8 years. One case involved the anterior maxilla, and 4 cases occurred in the mandible, 3 of them being located posteriorly. One patient complained of pain and paresthesia, and the remaining patients were asymptomatic. The typical radiographic presentation of our cases was that of a radiolucent lesion with well defined or irregular margins. Histopathologically, 4 cases were diagnosed as PIOC arising from previous odontogenic cysts (including 2 odontogenic keratocysts and 2 periapical cysts); all 4 were well differentiated keratinizing carcinomas. The remaining case, a poorly differentiated nonkeratinizing squamous cell carcinoma, was not associated with a cystic component and appeared to have arisen de novo. Four patients underwent surgical removal with postoperative radiotherapy, and 1 patient was treated with surgery only. Lymph node involvement and distance metastasis were not present in any of our patients at the time of diagnosis and did not develop during a follow-up period ranging from 15 to 77 months. To date, all patients are alive and free of disease. Knowledge of the clinical, radiographic, and histopathologic features of PIOC will allow accurate diagnosis and appropriate treatment of this rare malignancy.

4528 Endoscopic ultrasound versus spiral computed tomography in staging locoregional lymphadenopathy in esophageal cancer.

After exclusion of metastases, malignant locoregional lymphadenopathy is the most important predictor of survival and the need for adjuvant therapy in esophageal cancer (EsoCa). Endoscopic ultrasound (EUS) has been shown to be superior to dynamic computed tomography (CT) in predicting metastases to lymph nodes but has not been compared to spiral CT. We prospectively compared the ability of EUS and spiral CT to detect malignant lymph nodes in patients with EsoCa. Methods: Patients with metastatic disease, those who received neoadjuvant therapy, and those who were unable to undergo spiral CT, EUS, or esophagectomy were excluded from the protocol. Thirty-three consecutive patients to date with biopsy proven EsoCa have undergone spiral CT, EUS, and esophageal resection with lymph node dissection. CT criteria for malignant lymph nodes was size greater 1 cm and EUS criteria were based on size, shape, border demarcation, and internal echo pattern. The ability of spiral CT and EUS to detect malignant lymphadenopathy was compared to histology at surgery. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of spiral CT and EUS to determine cancerous nodes were calculated. Accuracy, sensitivity, and specificity of the two tests were compared using the McNemar test. Results: EUS was significantly more sensitive than spiral CT in detecting malignant lymph nodes (88% vs. 54%, p=.02). EUS was more accurate than spiral CT, but the difference did not achieve significance (78% vs. 58%, p=. 15). Spiral CT was more specific than EUS, but the difference did not reach significance (71 % vs. 43%, p=.50). Conclusions: 1) EUS is superior to spiral CT in determining the presence of metastatic regional lymph nodes in EsoCa. 2) The use of EUS and spiral CT in conjunction improves the ability to detect malignant lymph nodes preoperatively in EsoCa with accuracy, sensitivity, and positive predictive value all greater than 80%. 3) The combination of EUS and spiral CT should be used in the staging of all patients with esophageal carcinoma.

INFILTRATING CARCINOMA OF THE BLADDER

An inquiry into the reasons for the existing low survival rate in cases of infiltrating carcinoma of the bladder has disclosed four cardinal causes of failure with any method of treatment: (1) preexisting metastases; (2) preexisting extravesical extension; (3) intercurrent complications, and (4) incomplete destruction or extirpation of the primary growth. It therefore seems obvious that accurate evaluation of the efficacy of any treatment in the total eradication of primary infiltrating tumors will depend first on the exclusion of metastasis and extravesical extension. The clinical application of our recent pathologic observations1to each individual patient now permits the exclusion or recognition of metastasis and extravesical extension in a fairly high percentage of cases and indicates the prognosis in most instances. In 1944 the late Dr. Hugh H. Young proposed to me an analysis of the 1,400 cases of carcinoma of the bladder in the files of the Brady Urological

Triple Primary Malignancy

The occurrence of more than two primary malignant neoplasms in the same person has long been recognized as rare. Drooker (1), on analyzing the figures reported in the excellent review by Warren and Gates (2), states that multiple cancer constitutes 1.84 per cent of autopsied cases of malignancy, of which triple carcinomas comprise 2.9 per cent. In round figures, approximately one in two thousand cancer autopsies, or in twenty thousand routine autopsies, reveals more than two primary malignant lesions. In 1879 Billroth, reporting the earliest recognized cases of true multiple malignancy, postulated that each tumor must have a different histologic appearance, must arise in a different location, and must produce its own metastases. Mercanton, in 1893, added that there must be no reappearance on removal. In the numerous case reports and several general reviews that have appeared since, notably the contribution of Seecoff (19), these criteria have been discarded as too strict in that they would exclude early cancer of such characteristically non-metastasizing or late metastasizing types as basal-cell carcinomata or adenocarcinomata of the uterine fundus. Warren and Gates (2) emphasized that each tumor must afford a picture of malignancy, each must be distinct, and the probability of one being a metastasis of the other must be ruled out. They criticize many records of supposedly multiple malignant tumors, especially on this last score. For example, it is at present conceded that in bilateral breast cancers, the probability of metastasis to one breast from the other is very strong. Similarly we now recognize that many cases of coincident gastric and ovarian or multiple ovarian tumors may very well come under the category of metastases. In view of the newer concepts of the range of cellular anaplasia and metaplasia, numerous so-called carcinosarcomas, especially when of the same organ, may also be open to question. Moreover, lesions which ordinarily are either multiple or multicentric, as myelomas or certain hepatic carcinomas, are not usually to be included as multiple malignancies. Reasonably practical rules for establishing true multiplicity of new growths were formulated by Goetze (3). He suggested that the macroscopic and microscopic appearance of the tumors must be that of the usual carcinomas of the organs involved. To this he added that exclusion of metastasis must be certain, constituting the very crux of the problem, and that diagnosis might be confirmed by the character of metastasis in each case.

Multiple Heteromorphologic Malignant Tumors of the Uterus

IN spite of the fact that mortality statistics rank malignancy as one of the leading causes of death, the incidence of multiple malignant tumors in the same individual is comparatively rare. Cases in which three morphologically dissimilar tumors occur are regarded as curiosities. The case herewith presented illustrates the occurrence of three such malignant tumors of the uterus. Billroth (1) is credited with the first report on multiple primary malignant growths in the same individual. He emphasized the importance of certain basic criteria before the diagnosis of such a condition could be established. His postulates are as follows: (1) each tumor must have an independent histologic appearance; (2) the tumors must arise in different situations, and (3) each tumor must produce its own metastasis. Mercanton added a fourth prerequisite—that there be no recurrence of the tumors following their removal. The demand for the fulfillment of the third postulate of Billroth, as well as that of Mercanton, is quite as unreasonable in the diagnosis of multiple primary malignancy as in that of a single carcinoma. In the latter case, to diagnose malignancy only in the presence of metastasis would create a deplorable situation. Hurt and Broders (9) and Hanlon (8) felt that the criteria advocated by Goetze are reasonable, and were fulfilled in their cases. They are: (1) the tumors must have the macroscopic and microscopic appearance of the usual tumors of the organs involved; (2) exclusion of metastases must be certain, and (3) diagnosis may be confirmed by the character of the individual metastasis. Burke (2) believed that the reasonable criteria for the diagnosis of multiple primary cancers are: (1) each tumor must be distinct in morphology ; (2) must present a definite histologic picture of malignancy, and (3) must not represent a metastasis. There is considerable difference of opinion as to the incidence of multiple primary malignant tumors in the general cancer population. The work of Warren and Gates (14) is particularly noteworthy in this respect. They collected 1,259 such cases, including 40 of their own. Based on statistics of all the reviewed cases, they found that the frequency of multiple malignancy in cancer patients was 1.84 per cent; on the basis of American statistics it was 3.9 per cent, and in a series of 1,078 autopsies at their clinic the incidence was 3.7 per cent. Counseller and Butsch (4) reviewed the incidence of multiple primary malignant tumors in various series of cases reported and found that the percentage varied from 0.5 to 5.2. Burke (2) reported a series of 46 cases of multiple malignancy, with an incidence of 7.8 per cent—the highest reported in the literature. If we are to place much reliance on the socalled “general cancer-producing factors,” we might consider that an individual affected with one malignant tumor would be fertile soil for the development of other dissimilar tumors.