Extensive Liver Metastases Research Articles

Evolution of a Meningothelial Meningioma: From WHO Grade 1 to Anaplastic Grade 3 with Extracranial Metastasis Including Extensive Liver Metastasis.

A 61-year-old patient was diagnosed with a left-sided falx meningioma. Histopathological analysis following extirpation showed a meningothelial meningioma ZNS WHO grade 1 with sparse mitoses. Over the course of 12 years, the patient received irradiation (54.0 Gy), peptide radio-receptor therapy (177Lu-DOMITATE) and targeted therapy (mTOR inhibitor). Follow-up imaging revealed an increased size of the residual tumor. Due to increased liver function parameters, imaging of the liver was performed, showing widespread space-occupying lesions with atypical appearance. Biopsy revealed metastasis of the meningioma, now with 2.7 mitoses/mm2, necrosis and homozygous CDKN2A/B deletion, corresponding to an anaplastic CNS meningioma WHO grade 3. A second small meningioma on the left petroclival side has been consistent in size over 12 years. Metastatic meningiomas pose a pertinent clinical challenge due to poor prognosis. The lung, bone, liver and cervical lymph nodes are the most common sites of extracranial metastasis. According to the World Health Organization criteria, the most important predictive factor for recurrence and metastasis is the tumor grade.

Anthracycline-based hepatic arterial infusion chemotherapy achieved 17months of disease regression in a patient with breast cancer liver metastases resistant to multiple systemic chemotherapies.

Hepatic arterial infusion chemotherapy (HAIC) for liver metastases (LMs) from breast cancer is not a standard of care, but its effectiveness in patients with extensive LMs who cannot tolerate systemic therapy has been reported. Herein, we report a case of breast cancer LMs that were controlled by anthracycline-based HAIC. A 46-year-old woman with estrogen receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer who had multiple LMs and bone metastases underwent seven lines of systemic therapy (paclitaxel/bevacizumab for 38months; letrozole, nivolumab/fulvestrant, eribulin, gemcitabine/vinorelbine, high-dose toremifene/abemaciclib, and capecitabine for 21months in total). However, owing to its adverse effects and the continued progression of the LMs, systemic therapy was switched to HAIC (40mg/body epirubicin on day 1, 4mg/body mitomycin C on days 1 and 15, and 500mg/body 5-fluorouracil on days 1, 8, and 15; 28-day courses). In response to HAIC, the LMs remarkably regressed and were controlled for 17months without severe adverse effects. HAIC was stopped when multiple brain metastases arose, and the patient died 2months later. This case suggests that HAIC is a reasonable option for patients with extensive LMs, even in the late stage of treatment. HAIC recipients should be carefully selected through multidisciplinary discussions as the survival benefits of HAIC over systemic treatment remain unclear. Our findings identify a potential window for the use of traditional chemotherapeutic agents such as anthracyclines. Novel strategies to improve drug delivery are warranted in the future.

Intra-arterial peptide-receptor radionuclide therapy for neuro-endocrine tumour liver metastases: an in-patient randomised controlled trial (LUTIA)

PurposePeptide receptor radionuclide therapy (PRRT) using [177Lu]Lu-DOTATATE has been shown to effectively prolong progression free survival in grade 1–2 gastroenteropancreatic neuroendocrine tumours (GEP-NET), but is less efficacious in patients with extensive liver metastases. The aim was to investigate whether tumour uptake in liver metastases can be enhanced by intra-arterial administration of [177Lu]Lu-DOTATATE into the hepatic artery, in order to improve tumour response without increasing toxicity.MethodsTwenty-seven patients with grade 1–2 GEP-NET, and bi-lobar liver metastases were randomized to receive intra-arterial PRRT in the left or right liver lobe for four consecutive cycles. The contralateral liver lobe and extrahepatic disease were treated via a “second-pass” effect and the contralateral lobe was used as the control lobe. Up to three metastases (> 3 cm) per liver lobe were identified as target lesions at baseline on contrast-enhanced CT. The primary endpoint was the tumour-to-non-tumour (T/N) uptake ratio on the 24 h post-treatment [177Lu]Lu-SPECT/CT after the first cycle. This was calculated for each target lesion in both lobes using the mean uptake. T/N ratios in both lobes were compared using paired-samples t-test.FindingsAfter the first cycle, a non-significant difference in T/N uptake ratio was observed: T/NIA = 17·4 vs. T/Ncontrol = 16·2 (p = 0·299). The mean increase in T/N was 17% (1·17; 95% CI [1·00; 1·37]). Of all patients, 67% (18/27) showed any increase in T/N ratio after the first cycle.ConclusionIntra-arterial [177Lu]Lu-DOTATATE is safe, but does not lead to a clinically significant increase in tumour uptake.

Clinical efficacy of PD-1 inhibitor combined with radiotherapy in a multi-drug resistant patient with liver metastasis from gastric cancer.

A 54-year-old male was diagnosed with extensive liver metastasis and small nodule metastasis in the lungs from gastric adenocarcinoma [Her-2 (-)]. The patient achieved significant partial response (PR) after chemotherapy combined with anti-angiogenesis therapy but developed progressive disease (PD) after 5 months. Then, the chemotherapeutic and anti-angiogenic drugs were replaced. Meanwhile, the delivery route of some chemotherapeutic drugs was changed, and some chemotherapeutic drugs were given via transcatheter arterial chemoembolization (TACE) to achieve PR, and PD developed after 3 months of remission maintenance. During chemotherapy combined with anti-angiogenesis, the application of programmed cell death-1 (PD-1) inhibitor achieved PR again and maintained for 5 months before disease progression. The progression of the lesions in the left lobe of the liver and the hepatic hilar lymph nodes was significant. Hence, chemotherapy was terminated and gamma stereotactic body radiation therapy (SBRT) was performed on left lobe lesions and hilar lymph nodes. The lesions both inside and outside the radiation field regressed significantly, reaching PR and abscopal effects. The immune-related adverse events (irAEs) occurred, including erythema and black and luster hair. The abscopal effects of lesion reduction in the radiation field and the enhancement of the immune function stimulated by radiation are a highlight of the combination of radiation and immunotherapy. In the end, the patient died of gastrointestinal failure, with overall survival of 18 months.

Pharmacological Monitoring of Capecitabine in a Gastric Cancer Patient with Hyperbilirubinemia

Objective: To examine therapeutic drug monitoring in managing hyperbilirubinemia caused by capecitabine in patients with gastric adenocarcinoma with extensive liver metastases. Results: The initial liver function tests showed an elevation of transaminases (aspartate amino transferase 615 UI/l, alanine aminotransferase 385.9 UI/l), hyperbilirubinemia (total bilirubin at 246.1 μmol/l), and alkaline phosphatase at 694.6 UI/l. We initiated capecitabine based combination chemotherapy, and the clinical pharmacist conducted a full-course medication monitoring of the patient’s treatment including design of individualized dosing regimens and monitoring of bilirubin, infection, cancer pain, parenteral nutrition support and adverse events. After 21 days of supervision by clinical pharmacist and clinicians, the patient’s bilirubin and transaminase decreased progressively, with aspartate aminotransferase, total bilirubin and alkaline phosphatase falling back to 57 UI/l, 69.8 μmol/l, 307.2 UI/l, respectively. The patient’s condition improved significantly at the time of discharge, with the jaundice subsided, and the bloating relieved. Conclusion: Due to adverse reactions, capecitabine requires medication monitoring during use. The relationship between effectiveness and adverse effects is controversial. Adverse reactions should not be the sole criterion for the use of drugs. Clinical pharmacists can improve the safety and effectiveness of patients’ medications and promote rational drug use by monitoring patients, which may be useful to help the doctors identify the high-risk patients for taking efficient treatment strategy decisions.

Clinical characteristics and outcomes in patients with metastatic breast cancer and pseudocirrhosis: a single center retrospective cohort study.

Pseudocirrhosis is a term used to describe changes in hepatic contour that mimic cirrhosis radiographically, but lack the classic pathologic features of cirrhosis. This radiographic finding is frequently found in patients with metastatic breast cancer (MBC), but the risk factors and clinical consequences are poorly understood. In this retrospective study, we identified patients with MBC and pseudocirrhosis who were treated at a single center from 2002 to 2021. We used chart extraction and radiology review to determine demographic characteristics, treatment history, imaging features, and complications of pseudocirrhosis. 120 patients with MBC and pseudocirrhosis were identified with the following BC subtypes: hormone receptor (HR) positive, HER2 negative (n = 99, 82.5%), HR+/HER2+ (n = 14, 11.7%), HR- /HER2+ (n = 3, 2.5%), and triple negative (TNBC; n = 4, 3.3%). All patients had liver metastases and 82.5% (n = 99) had > 15 liver lesions. Thirty-six patients (30%) presented with de novo metastatic disease. Median time from MBC diagnosis to pseudocirrhosis was 29.2months. 50% of patients had stable or responding disease at the time of pseudocirrhosis diagnosis. Sequelae of pseudocirrhosis included radiographic ascites (n = 97, 80.8%), gastric/esophageal varices (n = 68, 56.7%), splenomegaly (n = 26, 21.7%), GI bleeding (n = 12, 10.0%), and hepatic encephalopathy (n = 11, 9.2%). Median survival was 7.9months after pseudocirrhosis diagnosis. Radiographic ascites was associated with shorter survival compared to no radiographic ascites (42.8 vs. 76.2months, p = < 0.001). This is the largest case series of patients with MBC and pseudocirrhosis. Nearly all patients had HR+ MBC and extensive liver metastases. Survival was short after pseudocirrhosis and prognosis worse with radiographic ascites.

PSAT387 An Unusual Case of Sporadic Metastatic Medullary Thyroid Cancer Without a Primary Tumor Presenting with Paraneoplastic Cushing's Syndrome

Abstract Introduction Medullary thyroid carcinoma (MTC) accounts for 5-10% of all thyroid cancers and up to 30% of MTCs are hereditary. Only 0.6% of MTCs are associated with a paraneoplastic ACTH-dependent Cushing's syndrome (CS) (PMID: 16029131). Even rarer are MTCs without a primary intra-thyroidal tumor. Here we describe a patient with metastatic MTC without a known primary intrathyroidal tumor presenting with paraneoplastic ACTH-dependent CS. Clinical Case A 47-year-old Ukrainian man was referred to our center for management of metastatic MTC. During evaluation of refractory diarrhea two years earlier, an elevated serum calcitonin (1758 pg/mL, normal: &amp;lt;11.5) led to the diagnosis. Thyroid ultrasound revealed a normal thyroid with bulky cervical lymphadenopathy. Cervical lymph node biopsy revealed metastatic MTC with positive calcitonin, synaptophysin, and chromogranin-A on immunohistochemistry (IHC) and RET protooncogene M918T pathogenic variant on molecular testing. Germline testing for RET pathogenic variants was negative. Prior to referral, the patient was on octreotide to control diarrhea and vandetanib for a few months, but they were discontinued due to financial stress. At our center, patient complained of 4-6 watery bowel movements daily. Physical examination revealed facial plethora, dorsocervical fat pad, central adiposity, wide purple striae, and pustular acne on the chest wall and proximal muscle weakness. Biochemical testing revealed elevated serum calcitonin (158,535 pg/mL, normal: &amp;lt;14.3), carcinoembryonic antigen (3,634 ng/mL, normal: 0.8–6.2), and chromogranin-A (5504 ng/mL, normal&amp;lt;93) levels. Morning serum cortisol (40.4 mcg/dL, normal: 3.7–19.4), and plasma ACTH (116.0 pg/mL, normal: 5.0-46.0) levels were elevated, along with markedly elevated 24-hour urine free cortisol levels (12,460.8 mcg/24-hour, normal: 35-45.0), consistent with ACTH-dependent Cushing's syndrome. Further IHC testing of the tumor biopsy sample revealed mild ACTH positivity. A pituitary MRI was normal. Stool osmolality studies showed a secretory diarrhea pattern. Computed tomography (CT) of neck and torso demonstrated bulky cervical, retroperitoneal, and inguinal lymphadenopathy, and extensive liver metastasis, all of which were strongly avid on an 18-fluorodeoxyglucose positron emission tomography CT scan, but poorly avid on a gallium-68 DOTATATE scan. Sodium fluoride bone scan revealed multiple osseous metastases in the spine, ribs, pelvis, and in the right femoral shaft. An adrenal CT scan revealed bilateral adrenal hyperplasia. The patient was unfortunately not eligible for any ongoing local clinical trials on RET-mutated cancer therapies. After extensive discussion with the patient, a palliative approach was pursued. The cervical lymphadenopathy and right femoral shaft metastasis were treated with external beam radiation. Diarrhea was controlled with loperamide. Cushing's syndrome was initially managed with metyrapone and ketoconazole, followed by bilateral adrenalectomy and hydrocortisone and fludrocortisone replacement. Conclusion Sporadic metastatic MTC can rarely present without an intrathyroidal primary tumor and may originate from ectopic C-cells. Paraneoplastic syndromes such as Cushing's syndrome can be observed in MTC due to ectopic-ACTH production. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Zinc Finger Proteins: Functions and Mechanisms in Colon Cancer.

According to the global cancer burden data for 2020 issued by the World Health Organization (WHO), colorectal cancer has risen to be the third-most frequent cancer globally after breast and lung cancer. Despite advances in surgical treatment and chemoradiotherapy for colon cancer, individuals with extensive liver metastases still have depressing prognoses. Numerous studies suggest ZFPs are crucial to the development of colon cancer. The ZFP family is encoded by more than 2% of the human genome sequence and is the largest transcriptional family, all with finger-like structural domains that could combine with Zn2+. In this review, we summarize the functions, molecular mechanisms and recent advances of ZFPs in colon cancer. We also discuss how these proteins control the development and progression of colon cancer by regulating cell proliferation, EMT, invasion and metastasis, inflammation, apoptosis, the cell cycle, drug resistance, cancer stem cells and DNA methylation. Additionally, several investigations have demonstrated that Myeloid zinc finger 1 (MZF1) has dual functions in colon cancer, which may both promote cancer proliferation and inhibit cancer progression through apoptosis. Generally, a comprehensive understanding of the action mechanisms of ZFPs in colon cancer will not only shed light on the discovery of new diagnostic and prognosis indicators but will also facilitate the design of novel targeted therapies.

Clinical and radiographic characteristics of patients with metastatic breast cancer and pseudocirrhosis: A single-center retrospective cohort study.

1101 Background: Pseudocirrhosis is a term used to describe changes in hepatic contour that mimic cirrhosis radiographically, but lack the classic pathologic features of cirrhosis. This radiographic finding is frequently found in patients with metastatic breast cancer (MBC); the pathophysiology and clinical consequences are poorly understood. The objective of this study is to describe the patient, tumor, and treatment characteristics associated with pseudocirrhosis, and to assess associated clinical outcomes. Methods: In this retrospective study, we identified patients with MBC and imaging findings consistent with pseudocirrhosis (diffuse liver contour abnormalities) who were treated at the University of California San Francisco from 2002-2021. We used chart extraction and radiology review to determine demographic characteristics, treatment history, response to treatment, imaging features, and complications of pseudocirrhosis. Comparisons between groups were made using the unpaired t-test or two-sided Fisher’s exact test. Results: 120 patients with MBC and radiographic evidence of pseudocirrhosis were identified with the following BC subtypes: Hormone receptor (HR) positive, HER2 negative (n = 99, 82.5%), HR+/HER2+ (n = 14, 11.7%), HR-/HER2+ (n = 3, 2.5%), and triple negative (TNBC; n = 4, 3.3%). All patients with pseudocirrhosis had liver metastases (n = 120, 100.0%) and 82.5% (n = 99) had &gt; 15 lesions. Median time from diagnosis of MBC to radiographic evidence of pseudocirrhosis was 29.2 months. Most patients received chemotherapy for MBC prior to the finding of pseudocirrhosis (n = 111, 92.5%) with median 2.0 lines. Pseudocirrhosis was observed in the setting of stable or responding disease in 50% of patients (n = 60). Patients received a median of 1.0 line of additional therapy after pseudocirrhosis diagnosis, with a median overall survival of 7.9 months from pseudocirrhosis to death. Sequelae of pseudocirrhosis included the radiographic finding of ascites (n = 97, 80.8%), gastric/esophageal varices (n = 68, 56.7%), splenomegaly (n = 26, 21.7%), GI bleeding (n = 12, 10.0%), or hepatic encephalopathy (n = 11, 9.2%). Radiographic evidence of ascites was associated with a shorter survival from MBC diagnosis compared to no ascites (42.8 vs. 76.2 months, p = &lt; 0.001). GI/Hepatology consultation was uncommon (n = 9, 7.5%). Conclusions: To our knowledge, this is the largest reported case series of patients with MBC and pseudocirrhosis. Nearly all patients had HR+ disease and extensive liver metastases. Pseudocirrhosis was frequently observed in the setting of responding or stable disease, creating complexity in management. Survival was short in all patients, particularly patients with radiographic evidence of ascites. Further understanding of the pathogenesis of and risk factors for pseudocirrhosis could help improve outcomes for this condition.

Growth Pattern of Hepatic Metastasis as a Prognostic Index Reflecting Liver Metastasis-Associated Survival in Breast Cancer Liver Metastasis.

Breast cancer with liver metastasis (BCLM) frequently cause hepatic failure owing to extensive liver metastasis compared to other cancers; however, there are no clinicopathologic or radiologic parameters for estimating BCLM prognosis. We analyzed the relationship between radiologic and clinicopathologic characteristics with survival outcomes in BCLM. During 2009–2019, baseline and final abdomen computed tomography or liver magnetic resonance imaging of BCLM patients were reviewed. Liver metastasis patterns were classified as oligometastasis (≤3 metastatic lesions), non-confluent or confluent mass formation, infiltration, and pseudocirrhosis. Thirty-one surgical or biopsy specimens for liver metastasis were immunostained for L1 adhesion molecule (L1CAM), Yes-associated protein 1/Transcriptional co-activator with PDZ-binding motif (YAP/TAZ), and β1-integrin. Out of 156 patients, 77 initially had oligometastasis, 58 had nonconfluent mass formation, 14 had confluent mass formation, and 7 had infiltrative liver metastasis. Confluent or infiltrative liver metastasis showed inferior liver metastasis-associated survival (LMOS) compared to others (p = 0.001). Positive staining for L1CAM and YAP/TAZ was associated with inferior survival, and YAP/TAZ was related to final liver metastasis. Initial hepatic metastasis was associated with LMOS, especially confluent mass formation, and infiltrative liver metastasis pattern was associated with poor survival. Positive staining for YAP/TAZ and L1CAM was associated with inferior LMOS, and YAP/TAZ was related to final liver metastasis.

What Gastroenterologists Should Know about Carcinoid Syndrome

Carcinoid syndrome (CS) is the most common functional syndrome associated with neuroendocrine neoplasia (NEN), particularly in intestinal NEN with extensive liver metastases. Owing to the heterogenous symptomatic scenario present in CS, recognition of these patients may be challenging. In this review, we explore some key clinical factors used to identify patients affected by CS, with particular focus on differential diagnoses of diarrhea, which is the main symptom of CS. Moreover, we highlight the importance of nutritional screening as a clinical indication to prevent malnutrition and to manage the most common nutrient deficiencies present in these patients.

Triple Unified-Modality for Parenchymal Hypertrophy (TRIUMPH): Combination of Transarterial Radioembolization, Portal Vein Embolization and Hepatic Venous Embolization for Liver Surgery

Introduction: The purpose of this abstract is to report on the application of a triple unified-modality for parenchymal hypertrophy (TRIUMPH) for patients with extensive liver colorectal metastasis. This includes transarterial radioembolization (TARE), portal vein embolization (PVE) and hepatic vein embolization (HVE). Methods: Four patients underwent TRIUMPH between March and August 2020. Results: Patients had a median age of 59 years (45-66) and received 7.5 cycles of chemotherapy (7-16). Time between diagnosis and TARE was of 140.5 days (87.5-199.75), between TARE and PVE of 30.5 days (26.25-91), between PVE and HVE of 1 day (1-74.25, figure 1). The functional liver remnant underwent a relative growth of 100.9 ± 28.4%, with a kinetic rate of 3.3 ± 1.7% per week and an increase in the FLR to 971.5 ± 457ml. All patients underwent successful open extended right hepatectomies with length of stay of 4 days (3-5), and no severe complications (Clavien-Dindo of 0-2). Pathological response was partial in two patients and near complete and complete in the other two. Discussion: This is a promising minimally invasive approach to induce maximal parenchymal hypertrophy and ultimately provide patients with a chance for surgical cure. Even though multiple series have reported ALPPS to be successful in causing liver remnant hypertrophy, it is known to have high morbidity. TRIUMPH holds the advantage of providing local tumor control and contralateral liver hypertrophy in a minimally invasive fashion. Conclusion: The review of these four cases shows the feasibility of what the authors call TRIUMPH in rescuing patients with extensive liver metastasis.

Liver transplantation for advanced liver-only colorectal metastases.

Liver transplantation provided a 5-year overall survival rate of 100 per cent in patients with colorectal cancer who had undergone liver resection previously. Patients with extensive liver metastases (over 20 lesions) and a left-sided primary tumour had long survival, whereas those with an ascending colonic primary tumour had inferior survival after liver transplantation.

CHEK2 mutation in a patient with pancreatic adenocarcinoma—a rare case report

Pancreatic cancer (PaCa) is very aggressive malignancy with poor prognosis. Individuals with a family history of PaCa have a higher risk of developing cancer which points to a hereditary component. Here, we report a unique case of CHEK2 mutant PaCa in a patient with no medical but significant family history. A 59-year old female presented with 3-month history of worsening epigastric pain and jaundice. CT abdomen/pelvis with contrast showed pancreatic head mass which was confirmed by endoscopic ultrasound guided biopsy. She was diagnosed with pancreatic adenocarcinoma harboring CHEK2 mutation. She had extensive surgery followed by adjuvant chemotherapy. Follow up imaging in 3 months obtained after surgery and adjuvant chemotherapy showed extensive liver metastasis and patient decided to pursue hospice. Germline testing in all PaCa patients has become essential as mutations in CHEK2 and other DNA repair genes constitute a unique subset of PaCas. Not only does it help in assessment of cancer risk in the individual and family members but also guide anticancer therapy selection. PaCa patients harboring CHEK2 mutations do not usually respond to chemotherapeutic agents such as gemcitabine. However, new treatment strategies such as PARP inhibitors targeting defective DNA repair mechanism are currently being investigated and showed some promise in treating CHEK2 mutant PaCa patients.

Solitary extrapleural fibrous tumor with hepatic bilobar metastases: multimodal approach treatment

BackgroundSolitary fibrous tumor is an unusual fibroblastic mesenchymal neoplasm typically described in the pleura. It may appear anywhere with a varied anatomic distribution and essentially it can develop from any soft tissue or visceral location. Its course is usually indolent and it rarely causes distant metastases, so it has a prolonged survival rate. It sometimes presents itself as a disseminate disease being the liver the most frequently involved location. In these occasions, the management should be discussed in a multidisciplinary tumor committee formed by surgeons, oncologists and radiologists. Surgery remains the gold standard for treatment.Case representationWe present the case of a woman with a tumor in the left abdominal wall and bilobar massive liver metastases, both locations histologically diagnosed as solitary fibrous tumor. She receives biological treatment for a severe case of Crohn´s disease. Evaluated in a multidisciplinary committee, surgery was recommended for both the primary lesion and the liver metastases. The hepatobiliary surgeons considered a two-stage hepatectomy with portal vein embolization (PVE) as the best strategy. After the first procedure consisting in cleaning the left hepatic lobe followed by PVE the future liver remnant volume (FLRV) was considered inadequate, so the patient was also treated with right transarterial radioembolizacion with yttrium 90 (TARE-Y90) intending a double goal: to treat the tumor and to increased the FLRV. Furthermore, a severe flare of Crohn´s disease forced us to intensify the patient’s treatment with the addition of biological agents (infliximab and adalimumab) until complete remission of the symptoms. The second stage of the liver surgery had to be postponed for more than 6 months and could finally be carried out without complications, achieving an R0 resection. The postoperative course was uneventful and the follow up has showed no recurrence to date.ConclusionSolitary fibrous tumours with extensive liver metastases are infrequent but when they appear modern surgical strategies like two stage hepatectomy are the treatment of choice and must be carried out by specialised units. The therapeutic decisions should be guided by a multidisciplinary committee.

Discrimination of ascitic fluid infection in malignant ascites by polymorphonuclear neutrophil ratio and count: Investigating the validity of count ≥250/mm3 as the one-size-fits-all criterion.

Neutrocytic ascites, traditionally defined as a polymorphonuclear neutrophil count ≥250/mm3 , is infrequently reported during paracenteses to relieve malignant ascites (MA). This study aims to explore new potential diagnostic criteria to discriminate ascitic fluid infection associated with MA and to examine the clinical and laboratory characteristics of neutrocytic ascites. The investigators retrospectively collected data on paracenteses to relieve MA at the Emergency Department of National Cancer Center, Korea, from January 2014 to February 2017. We analyzed the patients whose ascites fulfilled the traditional criteria for classification as neutrocytic ascites; polymorphonuclear neutrophils ≥250/mm3 with no history of either hepatocellular carcinoma or liver cirrhosis. In total, 1467 patients underwent paracentesis to relieve MA. Excluding 98 follow-up paracenteses cases, 112 cases (8.2%) showed neutrocytic ascites. Of these 112 patients, 27 (24.1%) had positive culture results. Receiver-operating characteristic analysis indicated that the area under the curve (AUC) values were 0.90 (95% CI 0.82-0.95) and 0.86 (95% CI 0.78-0.92) for polymorphonuclear neutrophil ratio and count, respectively. The difference between the two AUCs was not statistically significant (P=.29). Moreover, the best cutoff points were 70% and 1500/mm3 for polymorphonuclear neutrophil ratio and count, respectively. In addition, extensive liver metastasis was a significant independent risk factor of MA associated with ascitic fluid infection. Both polymorphonuclear neutrophil ratio and count had good discriminative abilities for culture results in MA. Polymorphonuclear neutrophil ratio was somewhat better despite lacking statistical significance compared to polymorphonuclear neutrophil count, with 70% as best cutoff.

Hepatic Arterial Infusion Combined with Systemic Chemotherapy for Patients with Extensive Liver Metastases from Gastric Cancer.

PurposeLiver metastases in patients with gastric cancer often indicate poor prognosis. Once liver metastases are extensive, it is difficult to achieve disease control by using systemic chemotherapy alone. The purpose of this study was to evaluate the effect and safety of hepatic arterial infusion (HAI) combined with systemic chemotherapy on extensive liver metastases from gastric cancer.Patients and MethodsBetween 2012 and 2019, 21 patients with extensive liver metastases from gastric cancer (LMGC) were enrolled in our study. Liver metastases were identified as unresectable and a major factor affecting prognosis mainly based on size and number of intrahepatic lesions. All patients received systemic chemotherapy with S-1 and HAI oxaliplatin plus floxuridine (FUDR).ResultsLiver metastases in 16 patients (76.2%) were evaluated as H3. The overall response rate was 76.2% (9.5% complete response). Intrahepatic and extrahepatic median progression-free survival times were 9.5 and 5.2 months, respectively. Median survival time (MST) was 12.3 months. All patients did not have the toxicity of grade 4. Grade 3 toxic effects included bone marrow suppression (14.3%) and diarrhea (9.5%). The other treatment-related toxicities were mild and reversible.ConclusionHAI combined with systemic chemotherapy for extensive LMGC seems to be safe and effective, which achieves a high-local response and may contribute to long survival time for patients.

Hepatic Arterial Infusion Chemotherapy for Metastatic Breast Cancer Patients With Resistance to Standard Systemic Chemotherapies.

Hepatic arterial infusion chemotherapy (HAIC) is a treatment option for metastatic breast cancer (MBC) patients with extensive liver metastasis (LM); however, the appropriate regimen and the treatment effects have not been discussed. The aim of this study is to evaluate the efficacy and safety of HAIC with the 5-FU, epirubicin, and mitomycin-C (FEM) regimen. We reviewed MBC patients with critical LM who were resistant to standard systemic chemotherapies and had received HAIC with an FEM regimen. We identified 57 patients who received HAIC between 2003 and 2017. The patient characteristics were as follows: i) median age=56 (30-80), and ii) Eastern Cooperative Oncology Group Performance Status, 0/1/2=43/11/3. The median number of LMs was 8 (range 1 to ≥20), the median diameter of LM was 5.2 cm (range=1.6 to 20.1). The median overall survival from the initiation of HAIC was 11.3 months (95% confidence interval=8.5-15.6). The objective response rate of LM was 63%. HAIC with an FEM regimen is an effective salvage treatment for MBC patients with advanced LM.

Metastatic Melanoma (Secondary Malignancy) after Recovery from Acute Lymphoblastic Leukemia in a 10-year-old Girl: a case report

Acute lymphoblastic leukemia is the most common malignancy in children with a 5-year survival rate, accounting for 80% of cases. Melanoma is rare in children and has been reported as a sporadically occurring secondary malignant neoplasm in children with acute lymphoblastic leukemia. This study presented a 10-year-old Iranian child with pre-B-cell acute lymphoblastic leukemia that was diagnosed at age 6. She was fully recovered after 2 years of treatment. One year and six months after cessation of treatment, she was referred with a 1×2 cm mass in her right parietal region of scalp. Biopsy of the lesion confirmed the diagnosis of malignant melanoma. Computed tomography scan of the chest and abdomen also confirmed extensive liver metastasis which was corroborated by liver biopsy. Bone scan also revealed bone metastases. Early diagnosis and treatment of these tumors is extremely important and these patients should be closely monitored and undergo regular physical examination.

SUN-LB086 Hypercalcemia in Metastatic Cholangiocarcinoma Due to Coexisting Elevated Parathyroid Hormone Related Protein (PTHrP) and 1,25-Dihydroxy Vitamin D (Calcitriol): A Case Report

Background: Hypercalcemia due to cholangiocarcinoma is not common. However, it is rarer to have both calcitriol and PTHrp mediated humoral hypercalcemia of malignancy Clinical Case: A 68 year old woman presented to a tertiary care cancer center after a CT scan for abdominal pain showed a large mass involving the right lobe of the liver extending into the porta hepatis with multiple low attenuation lesions scattered in the right and left lobe. Pancreas and gallbladder were normal. A liver biopsy was consistent with intrahepatic cholangiocarcinoma that was positive for CK7 and negative for CK 20, CD-X2, HepPar-1,TTF-1, Napsin-A, GATA-3, WT-1 and ER. Prior colonoscopy did not show evidence of adenocarcinoma. At baseline carbohydrate antigen (CA) 19-9 was mildly elevated (75 U/mL). Her initial biochemical abnormality was hypercalcemia (12.2 mg/dL, normal 8.4-10.2) along with elevated alkaline phosphatase (288 IU/L, normal 38-126). Parathyroid hormone (PTH) was low [6.6 pg/ml, normal 8.7-77.1] suggesting non-PTH mediated hypercalcemia. Parathyroid hormone related peptide (PTHrP) was normal [<1.1 pmol/L, normal <2] and early in treatment 1, 25- dihydroxyvitamin D (calcitriol) was high normal [75.7 pg/mL, normal 19.9-79.3]. She was started with gemcitabine and cisplatin for 3 cycles but changed to 2nd line oxaliplatin because of progression of disease with appearance of multiple pulmonary nodules and increased in size and number of multifocal cholangiocarcinoma masses and marginally increased abdominal/retroperitoneal adenopathy on CT scan about 3 months after initial chemotherapy. Her 2nd line treatment was stopped after 4 cycles because of further progression of disease on imaging. As her primary malignancy progressed, the levels of 1, 25 dihydroxyvitamin D (123 pg/mL) and PTHrP (3.8 pmol/L) became elevated. She was treated multiple times with IV fluids, zoledronic acid and denosumab. She was evaluated for a clinical trial but was unable to enroll because of persistent hypercalcemia. With options running out, she was started on PD-1 inhibitor pembrolizumab for 3 cycles. Unfortunately, her disease continued to progress with extensive liver metastasis and peritoneal carcinomatosis and increases in CA-19.9 (838 U/mL) and referred for hospice care. Her hypercalcemia continued to progress and at the time of hospice referral, her serum calcium was 13.6 mg/dL. Conclusion: Health care providers especially oncologists should be aware of humoral hypercalcemia of malignancy mediated by both calcitriol and PTHrp in cholangicarcinoma. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.