Left Iliac Lymph Node Research Articles

Discussion article: do we understand the role of local treatments after oligoprogression of ovarian cancer on PARP inhibitors?

The development of poly(ADP‐ribose) polymerase (PARP) inhibitors has been the most significant breakthrough in the treatment of advanced ovarian cancer over recent decades, with olaparib being the first drug of this class. The drug showed its efficacy at many stages of the treatment of various oncological diseases, but its maximum clinical efficacy is demonstrated in the initial treatment of BRCA-associated or HRD-positive ovarian cancer. In the phase III SOLO1 (n = 391) and PAOLA-1 (n = 806) clinical trials, treatment with olaparib reduced the relative risk of disease progression by 67% and 59%, and the risk of death by 45% and 38%, respectively. At the same time, the treatment of patients with disease progression after therapy with PARP inhibitors causes reasonable concerns in clinicians, which is associated with many aspects, primarily with the lack of individually developed approaches to the management of this category of patients. This discussion article through the example of the treatment of a particular patient allows to summarize the current data on the features of the tumour process after disease progression on PARP inhibitors and possible ways to resolve the issue of drug resistance in such patients. In the clinical case under discussion, the maintenance therapy with olaparib after combination treatment in a 50-year-old woman with metachronous multiple primary BRCA-associated malignancies (breast cancer in 2005, ovarian cancer in 2018) allowed to achieve a 2-year cancer remission, after which the oligoprogression of ovarian cancer was observed. PET-CT showed a left iliac lymph node metastasis without other progressive manifestations of the disease, after which a left laparoscopic iliac lymphadenectomy was performed, and the olaparib therapy was continued until progression or intolerable toxicity. The duration of olaparib therapy from the date when the local treatment was performed is 23 months as of this writing. The article states the detailed rationale behind choosing the non-standard management and presents the results of recent studies that support the decisions made.

Heterogeneous uptake of 18F-FDG and 18F-PSMA-1007 PET/CT in lung cancer and lymph node metastasis

BackgroundPSMA PET/CT has shown excellent results in imaging of prostate cancer. However, some nonprostatic malignancies can also demonstrate 18 F-PSMA uptake, including primary lung cancer. 18 F-FDG PET/CT is widely employed in initial staging, response to therapy and follow-up assessment for lung cancer. Here we present an interesting case report on the different patterns of PSMA and FDG uptake between primary lung cancer and metastatic intrathoracic lymph node metastases in a patient with concurrent metastatic prostate cancer.Case presentationA 70-year-old male underwent 18 F-FDG PET/CT and 18 F-PSMA-1007 PET/CT imaging due to suspicion primary lung cancer and prostate cancer. The patient eventually was diagnosed with non-small cell lung cancer (NSCLC) with mediastinal lymph node metastases and prostate cancer with left iliac lymph node and multiple bone metastases. Interestingly, our imaging revealed different patterns of tumor uptake detected on 18 F-FDG and 18 F-PSMA-1007 PET/CT in primary lung cancer and lymph node metastases. The primary lung lesion showed intense FDG uptake, and mild uptake with 18 F-PSMA-1007. Whereas the mediastinal lymph node metastases showed both intense FDG and PSMA uptake. The prostate lesion, left iliac lymph node, and multiple bone lesions showed significant PSMA uptake and negative FDG uptake.ConclusionIn this case, there was a homogeneity of 18 F-FDG intense uptake between LC and metastatic lymph nodes, but a heterogeneity in 18 F-PSMA-1007 uptake. It illustrated that these molecular probes reflect the diversity of tumor microenvironments, which may help us understand the differences of the tumor response to treatment.

Collision nodal metastasis of bladder cancer and melanoma: The first reported case and literature review.

Collision metastasis is a rare phenomenon of concomitant localization of 2 or more different tumors in the same lymph node. In most cases, primary malignancies are synchronous carcinomas arising in the same organ or area of the body. A 82-year-old man presented with hematuria and acute renal failure; he had undergone dermatological consultation ten months ago because of a large deep brown skin lesion in his dorso-lumbar region, which was not excised upon patient’s request. He underwent radical cystectomy with extended pelvic lymphadenectomy due to nonpapillary high-grade urothelial carcinoma, with focal squamous features, infiltrating the bladder wall and prostate gland. In one left iliac lymph node, small foci of metastatic urothelial carcinoma (positive for P63 and CK34betaE12) were close to melanoma cells (positive for HMB45). The patient refused further treatment and died of metastatic disease 12 months after cystectomy. There is no specific clinical feature for nodal collision metastasis. A polymorphic histologic appearance poses the suspect, but immunohistochemical stains are needed to define the primary tumors. Collision metastases are thought to carry a poor prognosis. Their clinical relevance is linked to the fact that the patient faces 2 different metastatic tumors that may require specific multidisciplinary approach once diagnosed as metastatic. We present, to the best of our knowledge, the first case of collision nodal metastasis from bladder cancer and melanoma, and describe its clinical and histopathological characteristics to raise awareness on this rare occurrence, which portends a poorer prognosis than each single tumor.

STUDY OF RECURRENCE AND SITE OF RECURRENCE IN PATIENTS WITH ADVANCED EPITHELIAL OVARIAN CANCER - A SINGLE CENTER EXPERIENCE

OBJECTIVE– Study of recurrence and pattern of recurrence in Stage III epithelial ovarian cancer. METHODOLOGY – A prospective observational, study was conducted at a tertiary hospital in Bangalore, India from April 2017 to April 2019. Informed and written consent was taken before including the patient in the study. All patients diagnosed with stage III epithelial ovarian with no residual disease following cytoreductive surgery (primary, interval and secondary) with or without Hyperthermic Intraperitoneal Chemotherapy (HIPEC) were included in the study. Patients were followed every 3-6 months up to maximum period of 24 months from the date of surgery. Last date of follow up was on 30/04/19. During follow up patient symptoms, physical examination and serum CA-125 were recorded to detect recurrence. If patient symptoms, physical examination and rising serum CA-125 are suggestive of recurrence, imaging in form of CECTabdomen/ PETCT was done for detection of recurrence. Patients were monitored for two types of recurrence. Biochemical recurrence dened as rising CA125 in absence of clinical evidence of recurrence either by physical examination or by imaging. Clinical recurrence dened as recurrence in any part of body noted on physical examination or imaging and then proving it by biopsy with or without rise in serum CA-125.Site of rst recurrence was recorded. RESULTS- A total of 84 patients were included in the study. 45 patients underwent interval, 25 patients underwent primary and 14 patients underwent secondary cytoreductive surgery. Mean duration of follow up was 18.25 months. 4 patients lost follow up. 2 patients died following surgery. Recurrence was noted in 14 patients (16.66%). Clinical recurrence was noted in 13 patients (15.47%) and biochemical recurrence was noted in 1 patient (1.19%). 8 patients had recurrence in peritoneal cavity (57.14%). 1 patient each had recurrence right inguinal lymph node, paraaortic lymph node+ peritoneum, left iliac lymph node, left supraclavicular lymph node and left inguinal lymph node. CONCLUSION – In this study clinical recurrence was more common than biochemical recurrence. Peritoneal cavity was most common site for recurrence. This study shows importance of optimal cytoreductive reductive surgery in preventing recurrence in carcinoma ovary as peritoneal cavity is most common site of recurrence

Ovarian serous eystadenofibroma: Towards a preoperative diagnosis

Background: Ovarian cystadenofibromas are rare benign ovarian neoplasms which contain epithelial and fibrous stromal components which give rise to complex cystic and solid areas which will be visualized sonographically as malignant tumours. The management of cystadenofibroma of ovary is complete surgical removal of the tumour. The prognosis is generally excellent with prompt and appropriate treatment as there is a very low risk of recurrence. Case Presentation: A 45-year-old woman presented to the gynaecology clinic complaining of irregular menstrual bleeding, secondary dysmenorrhea and left sided lower abdominal pain of one month duration. On bimanual examination a cystic, nontender, left adnexal mass was found. Imaging revealed a complex cystic mass in left ovary (10 x 9.6 x 8 cm). There was a thin film of pelvic free fluid adjacent to the inferior margin of the lesion. Few non-specific subcentrimetric para aortic, left iliac lymph nodes were seen. CA-125 level was 179 U/ml. A staging laparotomy was performed and included total abdominal hysterectomy, bilateral salphyngoophorectomy and infracolic omentectomy. Bilateral multilocular ovarian cysts (left cyst – 10 x 8cm and right cyst – 3 x 4cm) were present. Histology revealed bilateral serous cystadenofibromas. No atypical or malignant cells were observed in peritoneal washings. Conclusion: Ovarian cystadenofibromas appear malignant on imaging and macroscopy. Frozen sections does not appear to be reliable indicator and only MRI appears to be dependable in predicting the diagnosis of a cystadenofibroma prior to histological confirmation.

26. Implementation of a new optimization algorithm in VMAT for the treatment of prostate cancer

Introduction The aim of the current study is to evaluate a new optimization algorithm available since the Eclipse’s version 13.6 (Varian): Photon Optimizer version 13 (PO13). The purpose is to obtain a treatment planning protocol for prostate cancer treatments, reproducible which can be delivered by the treatment machine (patient’s quality assurance QA) and evaluate the dosimetric gain for patients (better organ at risk protection). Methods In our department, the medical prescription for the patients treated for a prostate cancer is a 75 Gy dose (2.5 Gy per fraction) on the prostate (PTVPRO) and a 46 Gy dose (2 Gy per fraction) on the right and left iliac lymph nodes. Treatments planning are made of 2 treatment plans: a first treatment plan in integrated boost, delivering a dose of 57.5 Gy on the PTVPRO and of 46 Gy on the PTVGGs in 23 fractions, and the 2nd treatment plan with a dose of 17.5 Gy on the PTVPRO in 7 fractions. Plans are optimized with PO13 and are calculated in the Eclipse’s Treatment Planning System (AAA algorithm, Varian) version 13.5 in order to be delivered on a Truebeam (Varian) version 2.5 MR2 in VMAT (arcs of 6 MV, dose rate: 600 UM/min). Several adjustable parameters with PO13 are tested on one patient: Normal Tissue Optimization NTO’s influence, calculation resolution during the optimization (1.25 mm, 2.5 mm and 5 mm), one or more arcs, optimization volumes, PTV’s priority compared to OAR priority, PTV’s priority compared to NTO priority, use of the intermediate dose calculation. The methodology used is to obtain the best PTV’s cover, changing a single parameter at each optimization without optimising relatively to the OAR at first. Parameters chosen and fixed, the constraints on the OAR are introduced. These parameters will be tested with several patients (reproducibility). The plan’s dosimetric evaluation is realised with the following Dose Volume Histogram (DVH): - For PTV: D95%, D98%, D2%, Dmin and Confomation Number (CN)1. - For OAR: bladder and rectum (Dmax, V35Gy, V50Gy), femoral heads (Dmax and Dmean). The monitor units number (MU) per arc is also noted. The dosimetric benefit for the patient will be evaluated in comparison with the real treatment plan calculated with the PRO13 algorithm (Progressive Resolution Optimizer algorithm version 13). The validation of the patient QA of these plans will be realised with the portal imager (Gamma index, PDIP Varian). Results The protocol will be based on the plan presenting a sufficient coverage for the PTV with the best CN taking into account the DVH values on the OAR. The 57.5 Gy plan chosen is Plan_1 (Table 1) with 2 arcs, a priority of 200 on the PTV for a priority of 500 on the NTO (automatic), a calculation resolution of 2.5 mm, an intermediate dose calculation. Plan_2 with a single arc has D98% and D95% reduced by 1 Gy compared to the other plans and Plan_4 has a CN too weak on the two PTV. Plan_3 with a calculation resolution of 1.25 mm seems the same as Plan_1 but the optimization time is multiplied by 2, a resolution of 2.5 mm is therefore preferred. The first results including the OAR’s constraints (priority of 100) shows that there is a significant reduction of DVH values V35Gy and V50Gy between the PRO13 and the new protocol in PO13 (Table 1). Download : Download high-res image (261KB) Download : Download full-size image Conclusions This study allowed us to simplify our practices with the use of the NTO as a replacement for optimization volumes (rings). It appears that the treatment plans obtained with PO13 allow a better saving of OAR with an equivalent coverage of PTV.

Pirfenidone as salvage treatment for refractory bleomycin-induced lung injury: a case report of seminoma

BackgroundBleomycin-induced lung injury, a major complication of chemotherapy for germ cell tumors, occasionally fails to respond to the standard treatment with corticosteroids and develops into severe respiratory insufficiency. Little is known about salvage treatment for refractory cases.Case presentationA 63-year-old man who had been diagnosed with stage I seminoma and undergone a high orchiectomy 1 year previously developed swelling of his left iliac lymph node and was diagnosed with a recurrence of the seminoma. He was administered a standard chemotherapy regimen of cisplatin, etoposide, and bleomycin. At the end of second cycle, he developed a dry cough and fever that was accompanied by newly-identified bilateral infiltrates on chest X-ray. Despite initiation of oral prednisolone, his exertional dyspnea and decline in pulmonary functions continued to be aggravated. High-dose pulse treatment with methylprednisolone was introduced and improved his symptoms and radiologic findings. However, the maintenance dose of oral prednisolone allowed reactivation of the disease with evidence of newly-developed bilateral lung opacities on high-resolution CT scans. Considering his glucose intolerance and cataracts as complications of corticosteroid treatment, administration of pirfenidone was initiated with the patient’s consent. Pirfenidone at 1800 mg/day was well tolerated, and resolved his symptoms and abnormal opacities on a chest CT scan. Subsequently, the dose of prednisolone was gradually tapered without worsening of the disease. At the most recent follow-up, he was still in complete remission of seminoma with a successfully tapered combination dose of prednisolone and pirfenidone.ConclusionsPirfenidone, a novel oral agent with anti-inflammatory and -fibrotic properties, should be considered as a salvage drug for refractory cases of bleomycin-induced lung injury.

Secondary Müllerian System: An Atypical Case of Tumor Originating From Vestigial Müllerian Cells Embedded in the Peritoneum

Clinical Practice Points Tumors originating from vestigial Mullerian cells embedded in the peritoneum could give rise to a primitive, peritoneal, mixed neoplasia with a predominant myoid differentiative trait and a double mesenchymal component. When possible, the most adequate treatment involves the en bloc resection of the mass together with the pelvic, parietal, and diaphragmatic peritoneum, and omentum, uterus, and annexes. The surgical treatment should be completed with the removal of the bulky right and left iliac lymph nodes. The components of the Mullerian ducts that do not undergo processes of differentiation and organogenesis constitute the secondary Mullerian system, from which various proliferative disorders might originate, such as endometriosis, endosalpingiosis, and endocervicosis. Epithelial-like cancers can also originate from the secondary Mullerian system, such a serous, mucinous, and endometrioid hystotypes.

Metastatic basosquamous carcinoma detected by sentinel lymph node biopsy

We describe a rare case of basosquamous carcinoma (BSC) in a 69-year-old man. He had noticed a pigmented nodule on his left thigh. Dermoscopic examination showed ulceration at the center and non-typical leaf-like areas at the periphery. Linear-irregular vessels were also seen. He underwent tumor excision in addition to sentinel lymph node biopsy (SLNB). Histopathological examination revealed both features of basal cell carcinoma (BCC) and squamous cell carcinoma. The sentinel lymph node was positive for tumor cells. Immunostaining for Ber-EP4 was focally positive for invasive tumor cells. Although complete inguinal lymphadenectomy had been performed, multiple in-transit metastases around the primary lesion and left iliac lymph node metastasis developed after the operation. It is considered that BSC has a worse prognosis than BCC with a potential for metastasis. Based on the findings of previously reported cases and our case, SLNB may be applied for certain high-risk cases including BSC larger than 3cm in size and careful follow up is recommended for patients with BSC.

The Role of Transanal Endoscopic Microsurgery for Rectal Tumors

The management of rectal tumors is complex, because of the balance between preserving rectoanal function and curing the patient. Transanal endoscopic microsurgery (TEM) is both an effective treatment for benign rectal tumors and early cancers, and a diagnostic tool for determining tumor depth, or for residual tumors of post endoscopic mucosal resection. In the present study, we evaluated the role of TEM in the management of rectal tumors. Twenty-six patients with rectal tumors underwent TEM from December 2000 through March 2005 in our department. The operations were performed by a single surgeon, and the indications were mainly limited to a) benign tumors for which endoscopic resection was difficult, b) early cancers that had invaded the submucosa within 500 microm of the muscularis mucosae, c) submucosal tumors, i.e., gastrointestinal stromal tumor, carcinoid tumors, d) local excision for diagnosis, and e) palliative resection for high-risk cases. Anesthesia, operation time, sizes of the tumor and of resected specimens, postoperative complications, length of hospitalization, pathological results, and postoperative recurrence rate were reviewed. The mean age of patients was 61.9 years, and the cases included 14 rectal cancers, 7 adenomas, 1 gastrointestinal stromal tumor, and 3 rectal carcinoid tumors. The mean operation time was 96 min (range, 40 approximately 235 min.). The average postoperative hospital stay was 4.8 days. All tumors were resected with horizontal and vertical safety margin. The mean size of the resected specimens was 9.0 cm(2). In one case, the tumor had infiltrated the proper muscle layer, as shown by intraoperative frozen sectioning, which necessitated abdominoperineal resection. In 3 cases, pathological examination revealed massive infiltration into the submucosal layer. 2 patients underwent low anterior resection, and the remaining patient refused additional surgery despite our recommendation. No deaths occurred. No major postoperative complications were noted. The mean follow-up period was 27.2 months. Only one case of lymph node metastasis was observed, in the left iliac lymph node 3 years after TEM. TEM is a minimally invasive surgical procedure for rectal tumors, which allows the whole depth of the rectal wall to be resected with a safety surgical margin. Although TEM requires technical skill and accurate preoperative diagnosis, the procedure is safe, facilitates accurate diagnosis of tumor depth, and limits the need for additional surgery.

顕著な結合組織の増生を伴う牛の腎細胞癌の1例

A four-year-old Holstein-Friesian cow, in which rectal palpation demonstrated a large massat the left kidney, was examined pathologically. Macroscopically, the left kidney was markedly enlarged, hard, and pale in color. The lobular structure was preserved. On its cut surface, hard whitish tissue had displaced the renal parenchyma. Numerous hard, whitish masses (1 to 10cm in diameter) were detected between the left renal lymph node and the left iliac lymph node. In histopathological terms, irregular tubules lined with atypical neoplastic epithelial cells were diffused through the left kidney, remarkably proliferated connective tissue, replacing the renal parenchyma. Similar tumor tissues were observed in other hard, whitish masses. The tumor cells stained positive for the anti-uromodulin antibody. Ultrastructural examination revealed the tumorous cells to have microvilli and desmosome structures. On the basis of these findings, the tumor was diagnosed as renal cell carcinoma with marked connective-tissue proliferation.

Posters. P15 The presentation of papillary serous carcinoma of the endometrium in a cervical thinprep sample

Papillary serous carcinoma of the endometrium (PSCE) is a distinct but rare type of endometrial carcinoma. It has an aggressive nature and tumours with lympho‐vascular involvement are more likely to have extra‐uterine disease and poor prognosis.1 Post menopausal bleeding (PMB) is the most common presenting symptom. A liquid‐based cervical sample was received from a 77‐year‐old female with PMB. The sample was prepared using the ThinPrep technique. The specimen was heavily blood‐stained and the initial slide showed scattered, highly abnormal cell groups, which were difficult to assess. A glacial acetic acid wash was performed to optimize the preparation. The resultant slide showed numerous highly abnormal cell groups, with enlargement, pleomorphism and abnormal chromatin pattern and were frequently arranged in papillary clusters, many with prominent nucleoli and numerous bare nuclei with background necrosis. These characteristics are consistent with previous descriptions of the cytomorphology of PSCE in conventional cervical smears.2 The cervical biopsy and endometrial currettings showed the presence of high‐grade PSCE. Follow‐up peritoneal washings showed a few clusters of suspicious cell groups and the hysterectomy confirmed high‐grade PSCE with cervical involvement and positive left iliac lymph nodes, which is consistent with the aggressive pattern of the disease.