Iliac Lymph Nodes Research Articles

Comparison of therapeutic features and oncologic outcome in patients with pN1 prostate cancer among robot-assisted, laparoscopic, or open radical prostatectomy.

To compare the therapeutic features and oncological outcomes of robot-assisted radical prostatectomy (RARP) with those of open radical prostatectomy (ORP) or laparoscopic radical prostatectomy (LRP) in lymph node (LN) positive prostate cancer patients in a retrospective observational multi-institutional study. We evaluated the clinical results of 561 patients across 33 institutions who underwent RARP, LRP, or ORP and who were diagnosed with LN-positive prostate cancer during RP with pelvic LN dissection (PLND). We determined the following survival outcomes: metastasis-free survival, overall survival, cancer-specific survival, and biochemical recurrence-free survival. The Kaplan-Meier method, log-rank test, and Cox proportional hazards regression model were used to evaluate the effect of treatment on oncological outcomes. Statistical significance was set atP < 0.05. There was no significant difference for any of the survival outcomes between the three surgical groups. However, RARP achieved a greater LN yield compared to that of ORP or LRP. When the extent of PLND was limited to the obturator LNs, the number of removed LNs (RLNs) was comparable between the three surgical groups. However, higher numbers of RLNs were achieved with RARP compared to the number of RLNs with ORP (P < 0.001) when PLND was extended to the external and/or internal iliac LNs. RARP, LRP, and ORP provided equal surgical outcomes for pN1 prostate cancer, and the prognosis was relatively good for all procedures. Increased numbers of RLNs may not necessarily affect the oncological outcome.

Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery

PurposeTo assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery. Material and MethodsLymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome. ResultsLG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling. ConclusionsLE was effective for treating pelvic surgery-related lymphatic leaks. Reintervention may be required. Drainage of >1,500 mL/d was associated with clinical failure and a post-LE catheter dwell time of longer than 1 week.

Abdominal Lymphadenopathy: Hypothesize Cat-Scratch Disease and Avoid Abdominal Excisional Biopsy

The finding of lymphadenopathy is usually the consequence of a benign infection, although a neoplastic origin must always be excluded. Through a careful anamnesis, physical examination, and serological tests several differential diagnoses are frequently possible. Nevertheless, sometimes an excisional biopsy of superficial lymph nodes is required, which is the best means to reach a definitive diagnosis. More concerns arise when lymphadenopathy is only abdominal/retroperitoneal: percutaneous biopsy is often inconclusive and the excisional node biopsy becomes a surgical procedure, certainly indicated in case of malignancy but avoidable in case of inflammatory diseases. We present the case of a 30-year-old man with a deep iliac lymphadenopathy who was evaluated at the Hematological Unit of Sapienza University of Rome. The enlargement of an iliac lymph node is quite unusual for an infectious disease. Although symptoms such as pain, fever, and chills suggested it was the case, cat-scratch disease was not hypothesized. Radiological investigations did not exclude a malignant disease and a laparoscopic excisional biopsy was scheduled, but the slight improvement of his spontaneous symptoms suggested a careful follow-up. Given the lack of disappearance of lymphadenopathy, the lack of diagnosis, and an ipsilateral superficial (inguinal) lymph node with similar ultrasonographic and radiological features, the patient underwent biopsy, which disclosed a diagnosis of cat-scratch disease, avoiding more invasive surgical procedures.

Lymphoma of the urinary bladder with concomitant septic peritonitis in a dog

AbstractA 6‐year‐old, female, neutered German shepherd dog presented with an acute history of stranguria and pollakiuria. The dog was depressed but the remainder of the examination was unremarkable. Urine cytology revealed severe bacteriuria and pyuria, suggesting urinary tract infection, and a low number of large atypical lymphoid cells. Abdominal ultrasound revealed the presence of diffuse thickening of the urinary bladder wall in the area of the trigone, enlargement of the left medial iliac lymph node and a large volume of peritoneal effusion. Cytology of the lymph node confirmed large cell lymphoma, and cytology of the abdominal effusion revealed septic neutrophilic inflammation. Urinary bladder lymphoma and septic peritonitis were diagnosed, and euthanasia was elected. Full gross and histopathological postmortem examination concluded the presence of a primary urinary bladder B‐cell lymphoma. No definitive cause of the septic peritonitis could be established, but bacterial translocation from the urinary bladder was suspected.

Indications for selective lymphadenectomy and systematic axillary, inguinal and iliac lymph node dissection

Lymphadenectomy is asurgical procedure in which lymph nodes are surgically resected. It is usually carried out for oncological surgical treatment of various malignant diseases. These include carcinomas of the breast, penis, vulva and anus as well as malignant melanomas and the broad field of sarcomas. Adistinction is made between the removal of regional lymph nodes, the sentinel lymph node and the radical removal of lymph nodes in abody region. Cervical, axillary, inguinal and iliac lymph nodes are clinically relevant. The strategy of sentinel lymph node dissection, in which the first lymph node in the drainage system is resected and histopathologically examined for malignant tissue, has brought decisive advantages for the patients, as radical lymphadenectomy with its severe morbidities is utilized in fewer cases. This can improve the patient's quality of life by sparing the lymphatic drainage pathways and reducing lymphedema, inflammation and wound healing disorders. In addition, alymphadenectomy may be indicated as part of palliative interventions. Another form of lymph node removal is the vascularized lymph node transplantation, which is used for reconstructive purposes in lymphedema. Therefore lymph node grafts are transferred to the site where lymph nodes were previously removed. This review presents the current status of lymphadenectomy in accordance with the German guidelines, anatomical knowledge and specific indications for axillary, inguinal and iliac lymphadenectomy. In addition, an overview of vascularized lymph node transfer is given.

Relationship between metastasis in the para-aortic lymph nodes of cervical cancer and pathological features

Objective: To investigate the incidence and the related risk factors of para-aortic lymph node metastasis in cervical cancer. Methods: The pathological data of 727 patients with cervical cancer who underwent radical hysterectomy and pelvic and para-aortic lymph node dissection were retrospectively analyzed. The relative postoperative pathological parameters of para-aortic lymph node metastasis were statistically analyzed. Results: Among the 727 patients with cervical cancer, 123(16.9%) had para-aortic lymph node metastasis. Univariate analysis showed that the tumor size, the depth of muscular invasion, the vessel invasion, the uterine body invasion, the vaginal invasion, the parametrial invasion, positive surgical margin, the ovary metastasis, the fallopian tubes metastasis, the pelvic lymph node metastasis, and the common iliac lymph node metastasis were associated with para-aortic lymph node metastasis. While the multivariate logistic regression analysis showed that the diameter of primary tumor >4.2 cm, the parametrial invasion, the pelvic lymph node metastasis, and the common iliac lymph node metastasis were the independent risk factors of para-aortic lymph node metastasis. Conclusions: The diameter of primary tumor >4.2 cm, the parametrial invasion, the pelvic lymph node metastasis, and the common iliac lymph node metastasis are the independent risk factors of para-aortic lymph node metastasis in cervical cancer. The tumor size and the common iliac lymph node status should be fully evaluated before the initial operation. Additionally, assessment of the postoperative pelvic lymph node status and the parametrial status will help reduce the rate of misdiagnosis and missed diagnosis, providing a basis for individualized treatment and prognostic judgment.

Radiation Therapy for Stage IIA/B Seminoma: Modeling Secondary Cancer Risk for Protons and VMAT vs. 3D Photons

<h3>Purpose/Objective(s)</h3> Radiation therapy to the para-aortic and iliac lymph nodes is an effective treatment for stage IIA and appropriately selected stage IIB seminoma patients. However, there are concerns for serious late complications, particularly an increased risk of secondary cancers due to the large areas of normal tissue irradiated. The purpose of this study was to quantify the expected differences in secondary cancer risk for stage II seminomas when evaluating proton pencil-beam scanning (PBS) and volumetric modulated arc therapy (VMAT) compared to conventional AP-PA photon (3D) treatment plans. <h3>Materials/Methods</h3> Five seminoma patients (four stage IIA receiving 30 Gy and one stage IIB receiving 36 Gy) ranging in age from 38 to 48 (mean 41.2) treated at our institution with PBS had two additional plans generated for comparison— one photon VMAT and one photon 3D. Dose differences to critical organs were examined and the risks of second primary cancers in those organs were calculated as the Excess Absolute Risk (EAR), reported in cancers per 10,000 person years, and Lifetime Attributable Risk (LAR), reported in percentage increase in risk, both projected to age 70. <h3>Results</h3> PBS reduced the mean organ dose compared to photons, on average by 60% but ranging from 30%-95% for different organs, except for the spinal cord which received the lowest mean dose with VMAT. PBS also reduced the EAR for all organs, with the greatest reduction for large and small bowel, liver, and stomach. Table 1 shows the average ratio of LAR between PBS, 3D, and VMAT for critical organs in five patients, and this ratio is greater than 1 for all organs for 3D compared to PBS. VMAT plans provide a mean dose reduction to some critical organs compared to 3D, particularly the spinal cord and pancreas, where VMAT also reduces the LAR compared to PBS. However, VMAT increases the low dose bath through other organs, leading to slightly increased LAR for the bladder, liver, and rectum compared to 3D. <h3>Conclusion</h3> The use of protons in stage IIA/B seminoma provides a favorable dose distribution with an expectation that this will transfer into decreased toxicity and reduced secondary cancer risk compared to conventional 3D photons. VMAT is another alternative to conventional 3D photons that provides a reduction in dose to some critical organs and comparable or reduced secondary cancer risk predictions for most organs.

Risk-Adjusted Chemoradiation according to Human Papilloma Virus Status for Anal Cancer: A Pilot Registry Study

<h3>Purpose/Objective(s)</h3> Radiation with concurrent chemotherapy (CRT) represents standard definitive therapy for anal cancer. CRT protocols result in good local control, but are associated with significant acute and late morbidity. Whether radiation dose escalation beyond 55-60 Gy improves local control remains unknown. Most anal cancers are associated with HPV infection. Patients with HPV positive (+) cancers have better outcomes compared to those with HPV negative (-) disease. HPV+ anal cancer patients may not benefit from standard CRT. <h3>Materials/Methods</h3> Since 2019, we have instituted a REB-approved prospective registry study that tailored CRT for anal cancer according to HPV status in addition to disease stages. Patients with HPV+ T1, T2 and T3/T4 disease received a total dose of 45, 50.4 and 55.8 Gy respectively. Elective nodal radiation dose was 30.6 Gy. For HPV- disease, total doses for T1, T2 and T3/T4 disease were 50.4, 55.8 and 63 Gy respectively, and 36 Gy was given for N0 disease. Concurrent chemotherapy consisted of a single dose of mitomycin C (12 mg/m²) and daily oral capecitabine (825 mg/m² bid) on days of radiation only. Patients were planned following CT, PET/CT and MR simulation. Treatment was delivered using volumetric modulated arc radiotherapy (VMAT) with daily cone beam CT. We report results of an interim analysis, which was planned after the first consecutive cohort of patients had a minimum 18 months of follow-up from CRT. <h3>Results</h3> There were 20 patients with HPV+ (HPV16, 15; HPV18, 1; other HPV types, 3) tumor and 4 were HPV-. All HPV+ tumors demonstrated p16 immunoreactivity. In the HPV+ cohort, there were one T1 (1.6 cm), eleven T2 (2.1-4.8 cm), five T3 (5.1-5.8 cm) and three T4 (4-8.5 cm) lesions. Eight patients (N1a, 4; N1b, 1; N1c, 3) presented with nodal metastases. All HPV+ patients completed protocol RT without RT interruption. Two refused chemotherapy. Grade 2 acute toxicities were observed in all 20 patients and five had grade 3 acute toxicities (skin reactions, pain and anemia). Restaging MRI was done at a median of 170 days (103-204 days) from date of RT. There were two local failures. Both (T4N1c and T2N0) had persistent local disease. Of four patients with HPV- cancer, one (T2N1b) had persistent local disease and one (T2N1c) failed in the iliac nodes; one (T4N0) developed a perforated ischemic sigmoid at 14 months requiring surgery. The local failure rate of 4/24 (16.7%) in this registry study was similar to our historic local failure rate of 28/180 (15.6%) in a retrospective cohort of patients managed by CRT from 2001-2009. These patients were managed using the current RT protocol for HPV- disease but with two cycles of mitomycin C and 5-Fluorouracil. <h3>Conclusion</h3> Treatment de-escalation for HPV+ anal cancer appears safe and may result in similar local control rates compared to standard CRT protocols.

Excluding the External Iliac Nodes Irradiation during Neoadjuvant Radiotherapy Decreases Lower Intestinal Toxicity without Compromising Efficacy in T4b Rectal Cancer Patients with Tumor Involving Anterior Structures

<h3>Purpose/Objective(s)</h3> The aim of this study was to evaluate whether neoadjuvant radiotherapy (NRT) with reduced clinical target volume (CTV) due to the exclusion of the external iliac nodes (EIN) is a feasible strategy for T4b rectal cancer patients with tumor involving anterior structures. <h3>Materials/Methods</h3> We retrospectively analyzed the data of 132 patients with T4b rectal cancer involving anterior structures who treated with NRT followed by surgery between May 2010 and June 2019. The CTV was delineated according to the international consensus guidelines except for the delineation of the external iliac nodes. 29 (22.0%) patients received EIN irradiation (EIN group) while 103 (78.0%) patients did not (NEIN group). We compared the overall survival (OS), locoregional recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) by treatment group using Kaplan-Meier analysis. Patterns of recurrence and treatment toxicities were also compared between the two groups. Multivariate Cox proportional hazard regression was used to analyze the major factors affecting survival. <h3>Results</h3> A total of 132 patients with a median age of 55 years (range, 24-81 years) were included in the analysis. 95.5% patients were diagnosed as clinical stage III rectal cancer. The median follow-up was 49 months (range, 5-104 months). Concurrent chemotherapy was administrated for 100% and 96.1% patients in the EIN group and the NEIN group, respectively (<i>P</i> = 0.293). Patient treatment variables were well balanced between the two groups. No patients developed locoregional recurrence in the EIN group while 4 patients (3.9%) in the NEIN group developed locoregional recurrence (<i>P</i> = 0.576). No relapse occurred in the external iliac lymph nodes. The 4-year OS, LRRFS and DMFS were 82.4% vs. 84.7% (<i>P</i> = 0.886), 100% vs. 96.7% (<i>P</i> = 0.141), 81.8% vs. 76.7% (<i>P</i> = 0.312) for the EIN group and NEIN group, respectively. For patients with clinical N stage positive, NEIN irradiation consistently did not decrease the OS, DMFS and LRRFS compared to the EIN group. The incidence of grade 3-4 toxicity of lower intestinal during radiotherapy was significantly higher in the EIN group than in the NEIN group (13.8% vs. 1.9%, <i>P</i> = 0.021). Multivariate analyses demonstrated that the pT stage (hazard ration [HR] 2.966, <i>P</i> < 0.001) and pathological complete response (HR 13.801, <i>P</i> = 0.031) were significantly related to OS; meanwhile, pT stage (HR 3.040, <i>P</i> < 0.001) was also an independent risk factor for DMFS. None was associated with LRRFS. EIN irradiation was not a significant predictor for OS, LRRFS or DMFS. <h3>Conclusion</h3> Exclusion of the EIN from the CTV during NRT in T4b rectal cancer patients with tumor involving anterior structures could reduce lower intestinal side effects without compromising oncological outcomes. These results need further evaluation in future randomized trials.

Necessity of External Iliac Lymph Nodes and Inguinal Nodes Radiation in Rectal Cancer with Anal Canal Involvement

<h3>Purpose/Objective(s)</h3> Considerable controversy still exists in regard to the elective irradiation of the external iliac lymph nodes (EIN) and inguinal nodes (IN) in rectal cancer with anal canal involvement (ACI) without convincing evidence. This study aimed to explore the necessity of the EIN and IN region in clinical target volume (CTV) for rectal carcinomas covering the anal canal region. <h3>Materials/Methods</h3> Between January 2006 and April 2017, a total of 399 consecutive patients with primary low rectal cancer located below the peritoneal reflection identified with magnetic resonance imaging (MRI) and received neoadjuvant chemoradiotherapy (NCRT), without elective EIN and IN irradiation, followed by surgery were reviewed in this study. Patients were divided into two groups according to whether the lower edge of the tumor came in contact with the anal canal (P group, n=109) or not (Rb group, n=290). Overall survival (OS), disease-free survival (DFS), locoregional recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) were compared using inverse probability of treatment weighting (IPTW) and multivariable analyses. The EIN and IN failure rates were compared between the two groups using the Fisher's exact tests and Gray's test. <h3>Results</h3> After a median follow-up of 77 months, P group showed a similar adjusted proportion and 5-year cumulative rate of EIN failure as Rb group. The adjusted proportion (6.3% versus 0.7%; P=0.008) and 5-year cumulative rate (7.4% versus 0.8%; P<0.001) of IN failure in P group was higher compared with Rb group. However, there were no significant differences in the adjusted 5-year OS (HR 1.48, 95% CI 0.95-2.25, p=0.0810), DFS (HR 1.40; 95% CI 0.95-2.08, p=0.0910), DMFS (HR 1.23, 95% CI 0.78-1.96, p=0.374) and LRFS (HR 1.29, 95% CI 0.76-2.19, p=0.346) between the two groups. The station of the anal canal involvement also showed no effect on OS (HR 1.30, 95% CI 0.76-2.22, P=0.336), DFS (HR1.31, 95% CI 0.82-2.08, P=0.260), DMFS (HR 1.23, 95% CI 0.78-1.96, p=0.374) or LRFS (HR 1.29, 95% CI 0.76-2.19, p=0.346), respectively. <h3>Conclusion</h3> It may be feasible to exclude the EIN and IN from the CTV during NCRT for rectal cancer with ACI, further studies are needed to clarify whether the cranial border of the CTV can be limited.

Enhancing Radiation Therapy Plan Quality in a Multi-Site Randomized Clinical Trial with a Benchmark Credentialing Exercise: The VA STARPORT Experience

<h3>Purpose/Objective(s)</h3> VA STARPORT is a phase 2/3 trial comparing systemic therapy +/- PET-directed, metastasis directed radiation therapy (RT) for oligo recurrent prostate cancer enrolling at 16 sites. RT options include SBRT to metastases only or elective nodal RT with a simultaneous integrated boost (ENRT+SIB). We hypothesized that benchmark credentialing exercise results that were shared across study sites would enhance protocol understanding, increase compliance, and identify opportunities to improve the study protocol. <h3>Materials/Methods</h3> A hypothetical benchmark patient scenario was created including prior definitive prostate RT with recurrences in a right obturator node, right external iliac node, and right iliac bone. OARs, target structures, and prior RT dosimetry were created on an open-source CT dataset. The benchmark exercise included: Phase 1: Each site described their preferred protocol treatment approach (SBRT or ENRT+SIB) and RT details (dose, fractions, PTV margins, and method to address prior RT). Phase 2: Each site performed 2 standardized treatment planning exercises on the dataset (SBRT vs. ENRT+SIB). Compliance worksheets summarized and assessed dose metrics, target coverage, and conformality. Plan DICOM files, worksheets, and IMRT QA were submitted for central RT quality assurance (RTQA). Phase 3: SBRT and ENRT + SIB plans were scored by the study RTQA team using a numerical plan scoring system. Scorecards and lessons learned were discussed with local investigators and further communicated to all study sites. <h3>Results</h3> Site survey results (n=16) revealed 8 preferred ENRT+SIB. Only 4 ENRT+SIB prescriptions were per-protocol, and there was PTV margin non-compliance in an intended SBRT plan. Benchmark lessons learned are summarized in the Table. <h3>Conclusion</h3> A practical and useful benchmark exercise successfully assessed protocol compliance, revealed key lessons, and identified ways to improve the protocol's RT section and RTQA process. Teaching points and learned planning strategies were shared across study sites and have a potential to improve metastasis-directed RT planning for both trial and non-trial patients at each facility.

Online MR guided dose escalated radiotherapy for organ preservation in distal rectal cancer

IntroductionNon-surgical management of rectal cancer aiming for organ-preservation is an important development to improve rectal cancer treatment. Dose escalated radiotherapy represents one approach to increase clinical complete response (cCR) rates. In the present study we present feasibility and outcome data on rectal cancer patients who were treated with dose escalated radiotherapy using an MR guided online response-adaptive workflow. Material and methodsA total of five patients were treated with 45 Gy in 25 fractions to the mesorectum and the internal iliac lymph nodes and a simultaneous integrated boost to the primary tumor with 50 Gy in 25 fractions on a conventional linac. In addition, weekly response-adaptive boost fractions with 3 Gy per fraction were scheduled on a 1.5 T MR-Linac. Concomitant chemotherapy with 5-fluorouracil was given as continuous venous infusion during the first and last week of treatment. Response was evaluated approximately-three months after the end of treatment and surgery was omitted in case of a clinical complete response (cCR) or a near cCR. Toxicity was graded by using PRO-CTCAE, Quality of life by the EORTC-QLQ-C30 questionnaire and continence according to the Wexner scale. ResultsResponse-adaptive dose escalated radiotherapy was feasible and well tolerated by all patients. Four reached a clinical complete response, one had a local excision confirming pathological complete response (pCR). All PRO-CTCAE grade 3 toxicities resolved within six months after the end of treatment. Quality of life and continence scores during follow-up were comparable to baseline levels. ConclusionDose-escalated online response-adaptive MR-guided radiotherapy appears to be a very promising treatment with the goal of organ preservation in rectal cancer leading to high response rates, excellent organ function and limited side effects. Further prospective evaluation is needed.

S2233 Anorectal Melanoma

Introduction: Mucosal melanoma is rare and accounts for approximately 1% of all melanomas. Mucosal melanomas occur primarily in the head and neck (55%), anorectal, and vulvovaginal regions (18%). Anorectal mucosal melanoma accounts for 0.05% of all colorectal malignancies and 1% of all anal canal cancers. Case Description/Methods: A 61 year-old-male patient with no significant past medical history presented to the hospital with anal pain for one month with subsequent rectal bleeding. On examination, his heart rate and blood pressure were within normal limits. His digital rectal exam was remarkable for a palpable anorectal mass. His blood tests showed no anemia. Colonoscopy revealed a large non-obstructing cauliflower mass occupying the anorectum with overlying friable mucosa that easily bleeds on touch (Figure A, B). Histopathology showed undifferentiated spindle and round cell malignancy consistent with nodular type of malignant melanoma. Immunohistochemical staining revealed strong positivity for S100, Melan A, and HMB45 markers confirming the diagnosis of malignant melanoma. Magnetic resonance imaging (MRI) of the abdomen and pelvis redemonstrated a large anorectal endoluminal mass lesion with multiple enlarged presacral and bilateral internal iliac lymph nodes. Positron emission tomography-computed tomography scan (PET-CT) showed a fluorodeoxyglucose (FDG)-avid anorectal wall thickening and internal iliac lymph nodes. After a multidisciplinary team discussion, the patient underwent abdominoperineal resection with bilateral iliac lymph nodes dissection (Figure C). Discussion: Malignant melanoma of the anorectum is a rare mucosal neoplasm that typically presents in the fifth or sixth decade. Mucosal melanoma occurs in the anorectum due to abundance of the melanocytes in the mucosa of the anal canal. It usually presents with nonspecific complaints such as anal pain or rectal bleeding that can be misdiagnosed as hemorrhoids or rectal polyps and lead to delayed diagnosis. Surgical resection is the mainstay of treatment, while the benefit of radiotherapy and chemotherapy remains uncertain. This tumor is an aggressive tumor that carries a poor prognosis; and even with surgical intervention, the reported 5-year overall survival rate is 6%–15%.Figure 1.: Endoscopic image of the anorectal mass lesion on retroflection (A) and with the i-Scan (B). (C) Abdominoperineal resection with bilateral iliac lymph nodes dissection.

S2191 A Case Report of Syphilitic Proctitis Mimicking Rectal Cancer

Introduction: Syphilis rarely affects the gastrointestinal tract, and even more rarely manifests with lower gastrointestinal signs and symptoms. We report a rare case of syphilitic proctitis that presented with inguinal lymphadenopathy and pain with defecation mimicking anorectal malignancy. Case Description/Methods: A 31-year-old male with a history of multiple, recent male sexual partners, sexually transmitted infections (STIs), anxiety, depression, and migraines presented to the emergency department with a 2-month history of left inguinal pain, perianal pain, and pain with defecation. His initial exam was notable for a palpable rectal mass and tender left inguinal lymphadenopathy. CT abdomen/pelvis demonstrated a markedly enlarged left inguinal lymph node measuring 3.9 x 2.7 x 3.1 cm with multiple enlarged perirectal and left internal iliac lymph nodes, radiographically concerning for metastatic disease. Colonoscopy revealed congested mucosa in the rectum and a palpable external rectal mass on digital rectal exam. He was tested for sexually transmitted diseases and was found to have a reactive RPR with a titer of 1:128 and positive T. pallidum antibodies. His biopsy resulted with findings of syphilitic proctitis and spirochetosis confirmed by treponema pallidum immunostain, consistent with secondary syphilis. He was treated with a 14-day course of doxycycline (due to penicillin allergy) with initial improvement in symptoms. Discussion: Syphilis is an important public health issue with increasing cases in the United States over the last 20 years. Syphilis uncommonly affects the gastrointestinal tract, and even less commonly the lower GI tract. Syphilitic proctitis most often presents with pain on defecation, rectal bleeding, tenesmus, and diarrhea and is often difficult to distinguish from inflammatory bowel disease or malignancy. Given the rise in sexually transmitted infections, it is important for providers to be aware of this presentation, which requires a thorough sexual history and prompt testing if exposure is suspected, to prevent ongoing transmission and development of complications. Our case highlights the rare presentation of syphilis and the importance of screening for STIs in high-risk patients.

Clinical analysis of prophylactic para-aortic intensity-modulated radiation in cervical cancer

This study aimed to compare the survival and toxicity of patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIIC cervical cancer without common iliac node metastasis treated with extended-field intensity-modulated radiotherapy (EF-IMRT) or pelvic IMRT (P-IMRT). Thirty-one patients treated with EF-IMRT and 37 patients who underwent P-IMRT were analysed retrospectively. Both groups were treated with high-dose-rate 192Ir two-dimensional brachytherapy and concurrent chemotherapy. The chi-square test and Kaplan-Meier method were used to compare toxicity and survival between the two groups. The median follow-up time of EF-IMRT group and P-IMRT group was 22 and 30 months, respectively. The 3-year overall survival (OS), progression-free survival (PFS), and para-aortic lymph node metastasis-free survival (PAMFS) in the EF-IMRT group and P-IMRT group were 87% versus 74.6%, 83.6% versus 61.7%, and 96% versus 80.5%, respectively. Treatment regimens, tumour size, and radiation time were independent prognostic factors of OS and PFS. Treatment regimens, tumour size, and total equivalent dose in 2 Gy/f (EQD2) of point A were independent prognostic factors of PAMFS. Five patients in the EF-IMRT group and 14 patients in P-IMET group experienced treatment failure. The cumulative incidence of grade 3 and 4 acute leukopenia in the EF-IMRT group was 51.6%, in comparison with 27.03% in the pelvic group. No difference was found in thrombocytopenia between two groups. Patients with FIGO 2009 stage IB1-IIIC cervical cancer without common iliac node metastases may be benefit from EF-IMRT. Notably, EF-IMRT exhibits increased toxicity incidence; however, this remains within an acceptable range.

Combined treatment with radiotherapy, chemotherapy and avelumab results in regression of metastatic Merkel cell carcinoma and improvement of associated Lambert-Eaton myasthenic syndrome: A case report.

Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine malignancy arising from mechanoreceptors in the basal epidermis. Due to a pronounced risk of spread and a high propensity for recurrence after treatment, immediate treatment is of utmost importance. Lambert-Eaton myasthenic syndrome (LEMS) is a paraneoplastic phenomenon affecting the muscles with autoimmune pathophysiology, and >50% of known cases are associated with an underlying malignancy. In the present report, the case of a 67-year-old man presenting with progressive proximal muscle weakness, autonomic dysfunction and involuntary weight loss is described. Symptoms and detection of voltage-gated calcium channel antibodies were consistent with LEMS. Distant metastases were found in the inguinal and iliac lymph nodes, and these were immunohistochemically confirmed to be of epithelial and neuroendocrine origin, consistent with MCC. Local radiotherapy and chemotherapy improved the symptoms; however, a change of treatment was required due to the side effects of the chemotherapy. Avelumab, an immune checkpoint inhibitor, was therefore introduced, and within a year the patient did not only experience tumor remission but also exhibited marked improvements in muscle strength and mobility. At present, 2 years later, the MCC is still in remission. To the best of our knowledge, the present report is the first to describe MCC with associated LEMS, which was successfully treated with avelumab after previous radiotherapy and chemotherapy, with both improved functional motor recovery and tumor reduction. In conclusion, the present case report demonstrated that the present treatment strategy is a potential treatment option and could thus be considered in similar cases.

Immunotherapy-Induced Rectovaginal Fistula After Prior Reirradiation for Recurrent Cervical Cancer in a Pelvic Lymph Node

A 48-year-old woman received a diagnosis of American Joint Committee on Cancer stage IIIB (cT1b2N1M0), International Federation of Gynecology and Obstetrics stage IB2 cervical squamous cell carcinoma. She received concurrent weekly cisplatin and 3-dimensional conformal radiation therapy (4-field box) to the whole pelvis (including the common iliac nodes) to a dose of 45 Gy in 25 fractions, followed by a sequential boost of 9 Gy in 5 fractions to the involved 3- × 2-cm left external iliac lymph node (total dose 54 Gy), and intracavitary brachytherapy using tandem and ovoids to a total dose of 28 Gy in 4 fractions prescribed to the cervical high-risk clinical target volume (defined on computed tomography [CT] and magnetic resonance imaging [MRI]).

Cutaneous Metastsis of An Endometrioid Adenocarcinoma to The Face

Background: Cutaneous metastasis is uncommon in endometrial cancer. Recurrence to the skin has been demonstrated to occur in the abdomen, pelvis and scalp. This is the first case presented of a cutaneous metastasis to the face. Case: A 60-year-old Nepalese woman stage 1A grade 1 endometrial adenocarcinoma experienced metastasis to her external iliac lymph node 15 months after her initial presentation. After the recurrence was treated with chemotherapy, she experienced cutaneous metastasis of her endometrial carcinoma to her face 34 months after her initial surgery. The patient passed away 3 months after. Conclusion: Endometrial adenocarcinoma can metastasize to the face and is associated with a poor prognosis

A Rare Case of Sarcoidosis With Urologic Symptoms As the Presenting Feature

Sarcoidosis is a multisystem idiopathic disease that can affect virtually any organ of the human body. However, genitourinary tract involvement is rare. We describe the case of a 33-year-old man with post-coital right scrotal pain. Scrotal ultrasound showed two vascularized nodular lesions in the right testicle and one in the left. A thoracic and abdominopelvic computed tomography scan showed micronodular infiltrate in the liver, spleen, lungs, and millimetric retroperitoneal and iliac lymph nodes. Levels of alpha-fetoprotein and human chorionic gonadotropin beta were normal. On positron emission tomography, the previously documented micronodular infiltrate exhibited features suggestive of an inflammatory etiology. The aspiration cytology of an iliac ganglion was described as normal, with no malignant cells. A liver biopsy revealed non-caseating epithelioid granulomas characteristic of granulomatous hepatitis. After exclusion of other causes of granulomatous inflammation, conjugation of clinical and histological features led us to the diagnosis of sarcoidosis with pulmonary, hepatic, splenic, and genitourinary involvement. This clinical report describes one of the rare occasions when the reproductive tract is affected by sarcoidosis and is the first organ to present signs of involvement by the disease, which reinforces the importance of considering sarcoidosis in the differential diagnosis of urologic conditions. The diagnosis of testicular sarcoidosis is challenging and the issue of its impact on fertility is particularly important.

Anatomic, computed tomographic, and ultrasonographic assessment of the lymph nodes in presumed healthy adult cats: the abdomen, pelvis, and hindlimb

BackgroundThe computed tomography (CT) and ultrasonography (US) features of lymph nodes of the abdomen, pelvis, and hindlimb in healthy cats are poorly described in the current literature. A prospective anatomic and reference interval study was therefore performed. The lymph nodes of six feline cadavers were identified, and dimensions were measured (length, width, and height). The lymph nodes from 30 healthy adult cats were identified and measured using CT (pre- and postcontrast) and US. The identification and dimensions of the separate lymph nodes were compared between imaging techniques and the anatomic study.ResultsThe identification of lymph nodes was most frequent in CT, and the dimensions were overall larger than those identified and measured in US and the anatomic study. The caudal epigastric and sacral lymph nodes were not identified in the anatomic study. The ischiatic, lumbar aortic, internal iliac, and caudal epigastric lymph nodes were not visualized in US. The height presented the main statistical differences among techniques. The lymph nodes were mainly homogeneous in pre- and postcontrast CT and US images. Some lymph nodes showed a hyperattenuating periphery with a hypoattenuating center (on pre- and postcontrast images) and a hypo-/isoechoic periphery with a hyperechoic center, representing the hilar fat. The lymph nodes were commonly elongated and rounded except for the jejunal lymph nodes, which had an irregular shape.ConclusionsThe assessment of most of the abdominal, pelvic, and hindlimb lymph nodes in the cat is feasible using CT and US, with CT performing best. Factors like the amount of adipose tissue and contrast administration subjectively improved the lymph node visualization and assessment. The measurements and features reported are proposed as reference values.