Prior History Of Malignancy Research Articles

Solid Tumors in Patients with Chronic Lymphocytic Leukemia Who Received Frontline Lenalidomide Therapy: Distribution and Clinical Outcomes

Introduction: Patients (pts) with Chronic Lymphocytic Leukemia (CLL) are known to have an increased risk of other cancers. Treatment with lenalidomide has been associated with an increased rate of solid tumors (ST) in pts with multiple myeloma (MM). However, the occurrence of ST in patients with CLL receiving therapy with lenalidomide remains unknown.Methods: We evaluated the development of ST in pts with CLL that received front-line treatment with lenalidomide as monotherapy or in combination with rituximab in clinical trials conducted at our institution. We report the characteristics and timing of ST, as well as patient outcome. All pts enrolled had indication for therapy according to the International Workshop on CLL guidelines and no history of malignancy for three years, with the exception of treated malignancy with indolent behavior such as prostate cancer that was treated with surgery or radiation therapy.Results: One-hundred twenty-one pts were enrolled in two consecutive phase II clinical trials of frontline therapy with lenalidomide (N = 61, 51%) or combination of lenalidomide and rituximab (N = 60, 49%). Baseline pts characteristics are shown in Table 1, median age was 66 yrs and 24% of patients were age 70 or older. At a median follow up after lenalidomide therapy of 41 months (range 1-102+), 7 (6%) pts developed a ST: renal cell carcinoma (RCC, 3 pts), localized breast cancer (LCIS and DCIS, 2 pts), pancreatic adenocarcinoma (1 pt) and colon adenocarcinoma (1 pt) (details are shown in Table 2). The median time interval between receiving lenalidomide-based therapy and the development of ST was 1.5 years (range 0-8.5). At the time of this report, 5 out of 7 pts with ST are alive and cancer-free. Two pts died: 12 months and 18 months after developing ST from progression of pancreatic adenocarcinoma and heart failure, respectively.Since pts with CLL have a high rate of non-melanoma skin neoplasms (NMSC), we also monitored patients for new diagnoses of skin cancers. Seven (6%) additional pts developed NMSC, 4 of these pts had prior history of NMSC. All cases of NMSC were superficial and did not require systemic therapy.Additionally, because of the high median age of this population, we reviewed prior history of malignancies. Eleven (9%) pts had history of ST [prostate cancer (N = 9), bladder cancer (N = 1), RCC (N = 1)]. Twenty-two pts (18%) had skin cancers (NMSC, (N = 21) and 1 pt had history of melanoma. None of them had received chemotherapy, two had radiation therapy [prostate cancer = 1, NMSC (basal cell carcinoma of the nose (1 pt)]. All ST were in remission before starting therapy with lenalidomide for more than 3 years as per the inclusion criteria.Conclusions: Seven cases of ST were observed in our population of 121 pts with CLL that received initial therapy with lenalidomide, after a median follow-up of 3.5 years. The most common neoplasm was RCC followed by in-situ breast cancer. In our limited experience the timing, number and type of malignancies do not appear to mirror what was seen in patients with MM. However, this comparison may be limited by the size of our patient population and length of follow-up. Our group reported the incidence of ST in patients treated with FCR. After a similar follow-up the incidence of second malignancies was similar (5.9%), but the type of malignancies was different, although NMSC remained the most common ST in both experiences.Reporting the incidence of other malignancies in patients with CLL enrolled in large studies, including those of novel targeted agents, will help understanding the expected incidence of ST and how novel treatments modulate such risk. [Display omitted] [Display omitted] DisclosuresJain:Pharmacyclics: Consultancy, Honoraria, Research Funding; ADC Therapeutics: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Celgene: Research Funding; Seattle Genetics: Research Funding; Infinity: Research Funding; Abbvie: Research Funding; Genentech: Research Funding; Incyte: Research Funding; Servier: Consultancy, Honoraria; Novimmune: Consultancy, Honoraria; BMS: Research Funding; Novartis: Consultancy, Honoraria. Thompson:Pharmacyclics: Consultancy, Honoraria.

A retrospective validation study of three models to estimate the probability of malignancy in patients with small pulmonary nodules from a tertiary oncology follow-up centre

To estimate the probability of malignancy in small pulmonary nodules (PNs) based on clinical and radiological characteristics in a non-screening population that includes patients with a prior history of malignancy using three validated models. Retrospective data on clinical and radiological characteristics was collected from the medical records of 702 patients (379 men, 323 women; range 19-94 years) with PNs ≤12mm in diameter at a single centre. The final diagnosis was compared to the probability of malignancy calculated by one of three models (Mayo, VA, and McWilliams). Model accuracy was assessed by receiver operating characteristics (ROC). The models were calibrated by comparing predicted and observed rates of malignancy. The area under the ROC curve (AUC) was highest for the McWilliams model (0.82; 95% confidence interval [CI]: 0.78-0.91) and lowest for the Mayo model (0.58; 95% CI: 0.55-0.59). The VA model had an AUC of (0.62; 95% CI: 0.47-0.64). Performance of the models was significantly lower than that in the published literature. The accuracy of the three models is lower in a non-screening population with a high prevalence of prior malignancy compared to the papers that describe their development. To the authors' knowledge, this is the largest study to validate predictive models for PNs in a non-screening clinically referred patient population, and has potential implications for the implementation of predictive models.

Chronic myeloid leukemia among patients with a history of prior malignancies: A tale of dual survivorship.

Some patients with chronic myeloid leukemia (CML) have a history of previous malignancies. To the authors' knowledge, outcomes for CML diagnosed in these patients have not been well described. The current study was conducted to determine the outcome of patients with CML and a history of prior malignancies. The current study included patients who were enrolled in clinical trials of tyrosine kinase inhibitors as initial therapy for CML in chronic phase from July 2000 to January 2014. Of the 630 patients with CML who were treated with frontline tyrosine kinase inhibitors, 626 had a known prior malignancy status. Of these, 45 patients (7%) had a prior malignancy other than nonmelanoma skin cancer whereas 17 patients (3%) had a history of nonmelanoma skin cancers alone. Characteristics of CML were similar between the patients with no prior malignancy, those with a prior malignancy, and those with nonmelanoma skin cancer. Patients with a prior malignancy were found to have an older median age compared with the other 2 groups. The most common prior malignancies were nonmelanoma skin cancer in 20 patients, breast cancer in 11 patients, melanoma in 7 patients, prostate cancer in 6 patients, and colorectal cancer in 5 patients. With regard to CML, the event-free survival, transformation-free survival, and failure-free survival rates were found to be similar between the groups. There was a statistically significantly decreased survival in the group with a prior malignancy versus the group with no prior malignancy versus the group with nonmelanoma skin cancer. In a multivariate analysis, advanced age and an elevated creatinine level were found to be associated with worse survival after a diagnosis of CML. Patients with CML with a history of prior malignancies appear to have the same excellent outcome as patients with no prior malignancies. In the few instances in which concomitant therapy for other malignancies was required during therapy with tyrosine kinase inhibitors, this was able to be accomplished without significant toxicity. Cancer 2017;123:609-616. © 2016 American Cancer Society.

Leiomyosarcoma of the Inferior Vena Cava: A Diagnostic Challenge

A 76 year old female with a history of CAD presented to the ER with a chief complaint of two months of progressively worsening sharp lower quadrant abdominal pain radiating to her right upper quadrant. A 10 point review of systems was unremarkable, including no prior history of malignancy, weight loss, melena or hematochezia. She was hemodynamically stable in the ER, and labs revealed a creatinine of 1.2 mg/dl, CEA of 1.3 ng/ml and Ca 19-9 of 30 U/ml. MRI of the abdomen showed a 2.6 cm x 2.6 cm x 2.7 cm solid mass along the posterior head of the pancreas, anterior to the inferior vena cava (IVC) at the origin of renal veins, which seemed to compress the IVC; however no thrombus or invasion was found. A diagnostic endoscopic ultrasound (EUS) showed the peri-duodenal retroperitoneal mass to be hypoechoic, heterogeneous with mixed solid and cystic features and an inconclusive EUS-FNA. A PET scan showed activity in proximal duodenum and pancreatic head, without evidence of regional lymphadenopathy and/or distant spread. Due to the non-diagnostic EUS, an exploratory laparotomy was performed which confirmed that the mass originated from the IVC requiring an en bloc caval resection. Pathology revealed spindle cell proliferation with atypical features positive for vimentin, desmin, actin and myosin, but negative for CD117, S-100 and a Ki67 proliferative index of 40-60% consistent with high grade poorly differentiated Leiomyosarcoma (LMS). Due to the lack of spread, the tumor was staged as Stage 2a (T1bN0M0) and a Grade 3 tumor histologically, for which patient underwent an adjuvant radiotherapy with good outcome. A 36 month follow up scan did not show any evidence of tumor recurrence. LMS of the IVC is a rare tumor that presents a diagnostic challenge. EUS can be helpful to differentiate pancreatic v/s non pancreatic origin. We would like to emphasize that the LMS should always be considered in the differential of retro-peritoneal sarcomas, as survival can improve with early detection. LMS arising from the IVC tend to respond better to surgical resection and neo adjuvant radiotherapy for patients with high grade tumor or positive margins following resection. Studies have not shown any role for adjuvant chemotherapy. Our patient had a unique presentation, and highlights some of the diagnostic challenges associated with retroperitoneal sarcomas. To our knowledge, this is one of the first case of LMS of IVC presenting in this age group with good outcome.Figure 1Figure 2Figure 3

Warthin's Tumor Masquerading as Metastatic Tumor in Patients with Prior History of Malignancy: Utility of Fine Needle Aspiration (FNA) Cytology

Warthin's Tumor Masquerading as Metastatic Tumor in Patients with Prior History of Malignancy: Utility of Fine Needle Aspiration (FNA) Cytology

Deep vein thrombosis, an unreported first manifestation of polyglandular autoimmune syndrome type III.

SummaryA 71-year-old woman with severe right lower leg pain, edema and erythema was presented to the Emergency Department and was found to have an extensive deep vein thrombosis (DVT) confirmed by ultrasound. She underwent an extensive evaluation due to her prior history of malignancy and new hypercoagulable state, but no evidence of recurrent disease was detected. Further investigation revealed pernicious anemia (PA), confirmed by the presence of a macrocytic anemia (MCV=115.8fL/red cell, Hgb=9.0g/dL), decreased serum B12 levels (56pg/mL), with resultant increased methylmalonic acid (5303nmol/L) and hyperhomocysteinemia (131μmol/L), the presumed etiology of the DVT. The patient also suffered from autoimmune thyroid disease (AITD), and both antithyroglobulin and anti-intrinsic factor antibodies were detected. She responded briskly to anticoagulation with heparin and coumadin and treatment of PA with intramuscular vitamin B12 injections. Our case suggests that a DVT secondary to hyperhomocystenemia may represent the first sign of polyglandular autoimmune syndrome III-B (PAS III-B), defined as the coexistent autoimmune conditions AITD and PA. It is important to recognize this clinical entity, as patients may not only require acute treatment with vitamin B12 supplementation and prolonged anticoagulation, as in this patient, but may also harbor other autoimmune diseases.Learning pointsA DVT can be the first physical manifestation of a polyglandular autoimmune syndrome.Hyperhomocysteinemia secondary to pernicious anemia should be considered as an etiology of an unprovoked DVT in a euthyroid patient with autoimmune thyroid disease.Patients with DVT secondary to hyperhomocysteinemia should undergo screening for the presence of co-existent autoimmune diseases in addition to treatment with B12 supplementation and anticoagulation to prevent recurrent thromboembolism.

Incidental Suspicious Regional Lymph Nodes on Breast Sonography: Is Sampling Necessary?

Suspicious regional lymph nodes may be incidentally identified on breast ultrasound examinations in patients who present for sonographic evaluation without a known or a suspected breast malignancy, and there is a paucity of data on whether biopsy should be performed. This study aims to characterize incidental sonographically detected suspicious regional lymph nodes and determine whether tissue sampling or follow-up imaging is required. A total of 40,773 consecutive breast ultrasounds were reviewed. Overall, 7 women with nonpalpable, incidental, suspicious axillary or supraclavicular lymph nodes in an otherwise unremarkable breast and without history of malignancy or systemic disease were identified. In all, 5 women with 6 nodes underwent ultrasound-guided fine needle aspiration and 2 women with 3 nodes were recommended follow-up ultrasound. Follow-up imaging, cytology, and all-cause clinical data were reviewed to evaluate outcomes. All 6 biopsied lymph nodes (mean = 1.5cm) were benign on cytology. Follow-up imaging was available for 3 nodes (mean = 2.6 years), with all-cause follow-up for all nodes of 2.2 years. In the follow-up group, 3 lymph nodes (mean = 1.6cm) were monitored (mean = 4.3 years) with all-cause follow-up of 4.7 years. No new cancers, growth, or suspicious features were found in these nodes during follow-up for either group of women. In conclusion, women without history of prior malignancy or systemic disease with incidentally detected, nonpalpable, suspicious regional lymph nodes with an otherwise normal breast ultrasound examination underwent fine needle aspiration or were recommended short-term follow-up ultrasound. No indeterminate features or malignancies were observed at the time of tissue sampling or developed over several years of follow-up. Avoiding sampling of these nodes would reduce patient morbidity and health care costs.

Optimal endocrine therapy for breast cancer patients 45-50 years of age at diagnosis.

551Background: Aromatase inhibitors (AI) are superior to tamoxifen (TAM) in postmenopausal estrogen receptor positive (ER+) breast cancer patients. TAM is standard of care for premenopausal ER+ patients. The SOFT/TEXT trials showed, however, that ovarian function suppression combined with the AI exemestane significantly improves disease-free survival compared to TAM in premenopausal patients. Evidence on perimenopausal women at breast cancer diagnosis is scarce as they are usually excluded from studies. We therefore aim to provide evidence for the optimal treatment of ER+ breast cancer patients 45-50 years of age, using data from the population-based Netherlands Cancer Registry (NCR). Methods: All pre-menopausal Dutch women, without prior history of malignancy, diagnosed between 2004-2007 at age 45-50 years with an ER+, non-metastatic, primary invasive breast cancer for which they received chemotherapy and endocrine treatment, were identified through the NCR. Cox proportional hazards regression was used t...

Diagnostic Ability of Percutaneous Needle Biopsy Immediately After Radiofrequency Ablation for Malignant Lung Tumors: An Initial Experience.

To evaluate the safety and diagnostic ability of percutaneous needle biopsy performed immediately after lung radiofrequency ablation (RFA). From May 2013 to April 2014, percutaneous needle biopsy was performed immediately after RFA for 3 patients (2 men and 1 woman, aged 57-76years) who had lung tumors measuring 1.3-2.6cm in diameter. All patients had prior history of malignancy, and all tumors were radiologically diagnosed as malignant. Obtained specimens were pathologically classified using standard hematoxylin and eosin staining. We completed three planned sessions of RFA followed by percutaneous needle biopsy, all of which obtained tumor tissue that could be pathologically diagnosed. Two tumors were metastatic from renal clear cell carcinoma and rectal adenocarcinoma, respectively; one tumor was primary lung adenocarcinoma. There was no death or major complication related to the procedures. Although pneumothorax occurred in two patients, these resolved without the need for aspiration or chest tube placement. Tumor seeding was not observed, but 21months after the procedure, one case developed local tumor progression that was treated by additional RFA. Pathologic diagnosis was possible by needle biopsy immediately after RFA for lung tumors. This technique may reduce the risks and efforts of performing biopsy and RFA on separate occasions.

Diffuse malignant mesothelioma and synchronous lung cancer: A clinicopathological study of 18 cases

ObjectivesTo examine the clinicopathologic characteristics of individuals with diffuse malignant mesothelioma (DMM) occurring concurrently with lung cancer (LC). Materials and methodsA database of approximately 3800 patients with DMM was reviewed, from which 18 patients (0.5%) who had synchronous LC were identified. The clinicopathologic features, as well as the occupational exposure history and fiber burden analysis data were examined. ResultsThe patient median age was 68 years (range 58–84 years). Of the 18 patients (14 male, 4 female), 11 (61%) had epithelial, 5 (28%) had biphasic, and 2 (11%) had sarcomatoid DMM, with the majority (16 cases; 89%) originating in the pleura and only 2 were peritoneal. Among the histologic types of LC, adenocarcinoma was most frequent (12 cases; 67%), while 5 cases of squamous cell carcinoma, and 1 case of small cell carcinoma were observed. Three patients also had a history of prior malignancy (1 with testicular seminoma and bladder carcinoma and 2 with prostate carcinoma). Fifteen patients had a positive smoking history. All but 3 had documented asbestos exposure. Three had histologic features of asbestosis. Mineral analysis performed in 8 showed an elevated asbestos fiber burden in 4 (22%). Amosite was detected in 4 patients, crocidolite in 3, and non-commercial amphiboles in 5. ConclusionThe finding of simultaneous carcinoma of the lung and DMM is distinctly unusual. The majority of patients are male smokers with pleural epithelial DMM and lung adenocarcinoma. This study represents the largest cohort of patients reported to date with synchronous malignant mesothelioma and lung cancer, and we propose guidelines for making a diagnosis of synchronous malignant mesothelioma and primary lung cancer.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of secondary tumors involving the pancreas: An institution's experience.

Background:Pancreatic masses may seldom represent a metastasis or secondary involvement by lymphoproliferative disorders. Recognition of this uncommon occurrence may help render an accurate diagnosis and avoid diagnostic pitfalls during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). In this study, we review our experience in diagnosing secondary tumors involving the pancreas.Materials and Methods:The electronic database of cytopathology archives was searched for cases of secondary tumors involving the pancreas at our institution and a total of 31 cases were identified. The corresponding clinical presentations, imaging study findings, cytological diagnoses, the results of ancillary studies, and surgical follow-up, if available, were reviewed.Results:Nineteen of the patients were male and 12 female, with a mean age of 66 years. Twenty-three patients (74%) had a prior history of malignancy, with the latency ranging from 6 months to 19 years. The secondary tumors involving the pancreas included metastatic carcinoma (24 cases), metastatic sarcoma (3 cases), diffuse large B-cell lymphoma (2 cases), and plasma cell neoplasm (2 cases). The most common metastatic tumors were renal cell carcinoma (8 cases) and lung carcinoma (7 cases). Correct diagnoses were rendered in 29 cases (94%). The remaining two cases were misclassified as primary pancreatic carcinoma. In both cases, the patients had no known history of malignancy, and no ancillary studies were performed.Conclusions:Secondary tumors involving the pancreas can be accurately diagnosed by EUS-FNA. Recognizing uncommon cytomorphologic features, knowing prior history of malignancy, and performing ancillary studies are the keys to improve diagnostic performance and avoid diagnostic pitfalls.

Metastases to the Pancreas Encountered on Endoscopic Ultrasound-Guided, Fine-Needle Aspiration.

Metastatic lesions in the pancreas are very uncommon and may be difficult to differentiate from the more commonly encountered primary neoplasms derived from the exocrine and endocrine pancreas because of the significant overlap in clinical presentation, imaging, and cytologic features. Metastasis to the pancreas may occur years after treatment of the primary neoplasm and is often not considered on initial evaluation because of the rarity of such events. The possibility of a metastasis to the pancreas should be entertained in patients with any prior history of malignancy because a proper diagnosis is essential in identifying surgical candidates, or avoiding potentially unnecessary surgery and facilitating triage to more appropriate nonoperative therapy. Herein, we describe intrapancreatic metastases secondary to renal cell carcinoma, melanoma, and lung carcinoma, as documented by cytologic examination of endoscopic ultrasound-guided fine-needle aspiration of the pancreatic masses.

Secondary tumors involving the thyroid gland: A multi-institutional analysis of 28 cases diagnosed on fine-needle aspiration.

Fine-needle aspiration (FNA) is routinely used to evaluate primary thyroid lesions (PTLs), however, its role in diagnosing secondary thyroid neoplasms (STNs) has not been extensively studied. The goal was to examine the clinical and cytopathologic features of STNs diagnosed on FNA. The clinico-pathologic features of 28 STNs were analyzed. All PTLs, lymphomas, and locally invasive tumors were excluded. There were 28 STNs (0.18% incidence) out of 15,800 thyroid FNAs (12 males, 16 females, 32 - 85 years), all occurring metachronously (3 weeks-20 years, average 78.3 months) comprising 24 (85.7%) metastatic carcinomas (14 [50%] renal; 4 [14.3%] head and neck squamous cell carcinomas, 3 [10.7%] breast, and 1 [3.6%] colorectal, uterine serous carcinoma, and lung adenosquamous carcinoma, respectively), 3 sarcomas (10.7%) and 1 melanoma (3.6%). STNs are rare and diverse tumors which may occur decades after primary malignancy. Renal carcinomas are the most common. Prior history of malignancy, high index of suspicion, and attention to key distinguishing cytologic clues are critical for accurate diagnosis.

Abstract CT227: MC1273: Phase II evaluation of aggressive dose de-escalation for adjuvant chemoradiation in HPV associated oropharynx cancer

Abstract Background: Traditional adjuvant therapy for oropharyngeal squamous cell carcinoma (OPSCC) consists of 60-66 Gy of radiation therapy (XRT) given in 2 Gy daily fractions along with high dose cisplatin if the patient has high risk factors. Despite the excellent cure rates for HPV+ OPSCC, one in three patients treated with conventional treatment will develop grade >3 long-term sequelae from therapy. There is intense interest in de-intensifying adjuvant therapy for this patient population in order to maximize quality of life while maintaining excellent historical rates of disease control. Methods: MC1273 is a phase II non-randomized trial open at Mayo Clinic Rochester testing a novel course of aggressive therapy de-escalation following surgery for HPV+ OPSCC. The primary endpoint is local/regional control at 2 years while secondary endpoints include toxicity and quality of life (QOL). The eligibility criteria include all patients with p16-positive OPSCC with less than a ten pack-year smoking history who have had a complete surgical resection. Exclusion criteria include positive surgical margins, prior history of malignancy, and history of connective tissue disorders. Patients are divided into two prospective cohorts depending upon risk factors found at surgery. Patients with intermediate risk disease (≥T3, ≥N2, lymphovascular invasion, or perineural invasion) are enrolled in MC1273A while patients with extracapsular extension (ECE) are enrolled in MC1273B. Patients on MC1273A receive 30 Gy of radiation delivered in 1.5 Gy twice-daily fractions over the course of two weeks along with weekly docetaxel (15 mg/m2) given on day 1 and day 8. Patients on MC1273B receive a similar treatment regimen but also have the nodal level with positive ECE concurrently boosted to 36 Gy in 1.8 Gy twice-daily fractions. In addition to standard of care follow-up, patients receive a swallowing assessment with speech therapy immediately before XRT, one month post-XRT, and one year post-XRT. Patients also have QOL assessment consisting of the XeQOLS, Eq-5D, FACT H&N (Vers 4) and Dermatology Life Quality Index assessed at pre-XRT and 3, 12, and 24 months post-XRT. Results: Each cohort of MC1273 is powered to detect a 10% local/regional failure rate with 85% confidence. Each cohort will accrue 35 evaluable patients and 5 additional patients to account for ineligibilities and violations (40 patients total per cohort.) MC1273A began accrual in September 2013. The first five patients were monitored for grade ≥4 acute toxicities before proceeding to open accrual. MC1273B began accrual in May 2014 and has also proceeded to open accrual. Accrual will also begin in Mayo Clinic Scottsdale in the first quarter of 2015. Conclusions: MC1273 is meeting its accrual targets and should finish accrual by 2016. We anticipate that preliminary results for toxicity will be available by 2017 and local/regional data will be available by 2018. Citation Format: Daniel J. Ma, Katharine A. Price, Eric J. Moore, Joaquin J. Garcia, Scott H. Okuno, Daniel L. Price, Jeff A. Sloan, Nathan R. Foster, Robert L. Foote. MC1273: Phase II evaluation of aggressive dose de-escalation for adjuvant chemoradiation in HPV associated oropharynx cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT227. doi:10.1158/1538-7445.AM2015-CT227

Case report: Non-small-cell lung carcinoma presenting as a foot swelling.

Sir, Acrometastases are defined as malignant secondary lesions of the bones located in the hands and/or feet. Acrometastases are very rare and are generally late manifestations of occult cancer and associated with a poor prognosis. In literature, only few cases of acrometastases due to occult lung cancer have been reported.[1] We report a case of acrometastasis to the left foot from an occult lung cancer. A 55-year-old female patient presented with complains of pain and swelling in the left foot of two-month duration. Magnetic Resonance Imaging (MRI) of the left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortex [Figure 1]. Biopsy from the second metatarsal bone was suggestive of metastatic deposit and tumor cells were positive for cytokeratin 7 (CK-7), Epithelial membrane antigen (EMA), Thyroid transcription factor-1 (TTF-1), and NAPSIN, suggestive of Non-Small Cell Lung Cancer, Adenocarcinoma (NSCLC) [Figure 2].Figure 1: MRI of left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortexFigure 2: (a) H & E section showing tumor cells arranged in nests and glandular pattern. Tumor cells were positive for, (b) CK-7, (c) TTF-1, and (d) NAPSINOn careful history taking, she was a 15-pack-a-year smoker. The whole body positron emission tomography (PET) computed tomography (CT) showed a left lung lower lobe, hypermetabolic, soft tissue mass and subcarinal and left hilar lymphnodes [Figure 3a]. A hypermetabolic soft-tissue mass in the left base of the second metatarsal, with enlarged lymphnodes, was seen in the proximal left external iliac, left obturator, left inguinofemoral, and popliteal regions [Figure 3b]. The epidermal growth factor receptor (EGFR) mutation was not detected in the biopsy specimen.Figure 3: (a) PET CT showed a hypermetabolic soft tissue mass seen in the left foot with destruction of the underlying base of the second metatarsal, (b) Left lung lower lobe showed a peripheral lobulated hypermetabolic soft tissue massThe patient was started on external beam radiation therapy (EBRT) to the left foot, followed by systemic chemotherapy with Pemetrexed- and Cisplatin-based palliative chemotherapy. Post two courses of chemotherapy she had a dramatic response to the treatment with a decrease in pain in the left foot. Bone metastasis is a common occurrence in patients with advanced carcinomas, particularly in those with lung, breast, and prostate cancer. However, metastases distal to the knee are very rare and metastases to the bones of the foot are even rarer. Metastases to bone develop in 30% of all patients with cancer, with only 0.007 to 0.3% having acrometastasis.[1] The most common sources of acrometastasis are colorectal, renal, and lung carcinomas (50%), with the bladder, uterus, and breast responsible for 25% of the metastases to the foot.[2] Acrometastases are rarely the initial presentation of metastatic carcinoma. In a series by Healey et al., they were seen as the initial manifestation of an occult malignancy in four (14%) of the 29 patients.[3] Acrometastasis are often initially mistaken for more benign processes, such as infection, trauma, inflammatory arthritis, osteomyelitis or gout. Persistent symptoms, unresponsiveness to conservative therapy or prior history of malignancy should prompt the physician to consider metastases, when evaluating a patient. Given the bleak prognosis of digital acrometastatic lung cancer, treatment is largely palliative. Amputation and chemotherapy have been used, but recent literature suggests that localized radiotherapy can successfully relieve the pain and return the function to the affected foot.[4] There may also be a targeted role for bone-remodeling and pharmacotherapies, such as, bisphosfonates or denosumab, which have demonstrated utility in treating other bony metastases.[5] Treatment is directed toward the relief of symptoms and restoration of functional capacity.

Spinal Burkitt's Lymphoma Mimicking Dumbbell Shape Neurogenic Tumor: A Case Report and Review of the Literature.

Non-Hodgkin's lymphoma (NHL), a disease which may involve the spine, is frequently associated with advanced disease. Radiculopathy caused by spinal root compression as the initial presentation in patients with NHL is very rare and thought to occur in less than 5% of cases. A 69-year-old woman complained of a history of low back pain with right sciatica for 1 month prior to admission. Computed tomography and magnetic resonance imaging of the lumbar spine showed a dumbbell-shape epidural mass lesion extending from L2 to L3, which was suggestive of a neurogenic tumor. After paraspinal approach and L2 lower half partial hemilaminectomy, total excision of the tumor was achieved, followed by rapid improvement of back pain and radiating pain. The lesion was confirmed to be Burkitt's lymphoma by histopathological examination. We then checked whole-body PET-CT, which showed multifocal malignant lesions in the intestine, liver, bone and left supraclavicular lymph node. Although a rare situation, Burkitt's lymphoma should be considered in the differential diagnosis for patients presenting with back and lumbar radicular pain without a prior history of malignancy. Burkitt's lymphoma could be the cause of dumbbell-shape spinal tumor.

Lobular Carcinoma of the Breast with Gastrointestinal Metastasis

We present the case of a 74-year-old woman with metastatic lobular carcinoma with an occult breast primary presenting as a suspected ampullary tumor due to its ampullary metastasis. The patient's clinical presentation is of interest in two aspects. First, lobular carcinoma of the breast metastatic to the ampulla is extremely rare. Second, in the absence of a detectable primary lesion, prior history of malignancy, or distinguishing clinical, radiological, and endoscopic features, histopathological assessments are pivotal for arriving at the appropriate diagnosis and for optimizing treatment.

Value of routine staging imaging studies (RSIS) for patients with stage III breast cancer (BC).

122 Background: RSIS (CT, bone and PET scan) in pts with stage I or II BC is not recommended by NCCN and is considered optional in stage III BC. 10-15% of pts with stage III BC have occult metastases by RSIS, but it is unclear if this finding affects pt management or outcome. The addition of PET scans to conventional imaging (CT and bone scans) is of little added value (Niikura, et al. Oncologist 2011; 16: 772-82). We hypothesized that the use of RSIS in pts with stage III BC does not lead to changes in treatment or pt outcomes. Methods: After IRB approval, we retrospectively identified 875 women with stage III or stage IV BC from 2000-2010 through the Los Angeles County-University of Southern California and Norris Comprehensive Cancer Center cancer registries. Pts with clinically apparent stage IV disease, pregnancy at time of diagnosis, a history of prior malignancy, or incomplete medical records were excluded. Pts who underwent RSIS prior to planned treatment (before surgery, neoadjuvant or adjuvant therapy) were identified. RSIS results and the treatment plan in response to the results were recorded. Results: 424 pts were identified with clinical or pathologic stage III BC: 197 pts (46%) were < 50 years old, 224 (53%) had ER+ or PR+/HER2- tumors, 111 (26%) had ER-/PR-/HER2+ tumors, 74 (17%) had triple negative tumors, 15 (4%) had missing biomarker data, and 61 (14%) had inflammatory BC. 365 pts (86%) underwent RSIS. RSIS were negative for metastatic disease in 266 (73%), indeterminate in 75 (21%), and positive in 24 (7%). Treatment was altered in 21 pts (6%) based on RSIS (20 with metastatic disease, 1 with indeterminate disease). Median follow-up was 3.8 years (range: 0.1 to 13.3). When controlled for age, stage, or biomarker status, no differences in progression-free survival (PFS) were observed between the pts who underwent RSIS compared to those that did not. Conclusions: Most pts with stage III BC undergo RSIS. However, the results of RSIS infrequently affect treatment decisions. We did not observe a difference in PFS between pts who underwent RSIS and those who did not. Our findings suggest RSIS in stage III BC has limited value. A prospective study of this research question is warranted.

Lung cancer in never-smokers from the Princess Margaret Cancer Centre.

8099 Background: Lung cancer in never smokers accounts for ~15-20% of cases, and globally is a growing clinical problem. Methods: We identified 570 never-smokers with lung cancer diagnosed from 1988-2013 at the Princess Margaret Cancer Centre. Clinical and demographic data were retrieved from the electronic patient record with the aim of characterizing the epidemiology, demographics, pathology, molecular profile, treatment, and survival in these patients. Results: There were 409 females (72%) and 161 males (28%), median age 62.1 years (18– 94), 46% Caucasian, 34% Asian, 6% Black, 4% South Asian, 4 % Filipino, 6% Other/Unknown. Environmental tobacco exposure was identified in only 17%. A history of prior malignancy was present in 89 (14.2%) patients (1 cancer 81; multiple cancers 8 patients). Most patients (87.3%) had adenocarcinoma and most presented in stage IV - 54.9%, followed by I - 26%, III - 12.8% and II - 6.3%. In stage IV patients, 88% were ECOG PS 0-1. Among 310 patients with molecular results to...

Risk of Radiation-Induced Malignancy With Heterotopic Ossification Prophylaxis: A Case–Control Analysis

To determine the risk of radiation-induced malignancy after prophylactic treatment for heterotopic ossification (HO). A matched case-control study was conducted within a population-based cohort of 3489 patients treated either for acetabular fractures with acetabular open reduction internal fixation or who underwent total hip arthroplasty from 1990 to 2009. Record-linkage techniques identified patients who were diagnosed with a malignancy from our state health registry. Patients with a prior history of malignancy were excluded from the cohort. For each documented case of cancer, 2 controls were selected by stratified random sampling from the cohort that did not develop a malignancy. Matching factors were sex, age at time of hip treatment, and duration of follow-up. A total of 243 patients were diagnosed with a malignancy after hip treatment. Five patients were excluded owing to inadequate follow-up time in the corresponding control cohort. A cohort of 238 cases (control, 476 patients) was included. Mean follow-up was 10 years, 12 years in the control group. In the cancer cohort, 4% of patients had radiation therapy (RT), compared with 7% in the control group. Of the 9 patients diagnosed with cancer after RT, none occurred within the field. The mean latency period was 5.9 years in the patients who received RT and 6.6 years in the patients who did not. Median (range) age at time of cancer diagnosis in patients who received RT was 62 (43-75) years, compared with 70 (32-92) years in the non-RT patients. An ad hoc analysis was subsequently performed in all 2749 patients who were not matched and found neither an increased incidence of malignancy nor a difference in distribution of type of malignancy. We were unable to demonstrate an increased risk of malignancy in patients who were treated with RT for HO prophylaxis compared with those who were not.