Left Inguinal Node Dissection Research Articles

6983 Pembrolizimab Induced Hypophysitis: Uncommon Side Effect Leading To Late Diagnosis

Abstract Disclosure: T. Chaudhary: None. O. Syed: None. A. Shridar: None. R. Kaur: None. O. Chaudhary: None. M.S. Zubair: None. Background: Pembrolizumab, an immune checkpoint inhibitor, has shown efficacy inducing remission in various malignancies. Associated immune-related adverse effects (irAEs) have been recorded but cases of concomitant hypophysitis and thyroiditis are rare. Clinical case: The patient is a 41-year-old male with a past medical history significant for metastatic melanoma of the left calf, status post sentinel lymph node biopsy and left inguinal lymph node dissection, treated with pembrolizumab for one year. He initially presented with a severe headache that was preceded by two months of fatigue and impaired concentration. CT and MRI head were both unremarkable while lab work was significant for cortisol 0.2 ug/dL and adrenocorticotropic hormone (ACTH) 1.1 pmol/L. A full hormone panel was ordered which showed normal insulin-like growth factor-1 (IGF-1), luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Free testosterone was at the lower end of normal. Prolactin was elevated at 27.3 ng/mL. The thyroid function tests showed primary hypothyroidism with elevated thyroid stimulating hormone (TSH) at 109 uIU/mL, low T4 at 1.5 ug/dL, and low free T4 at 0.4 ng/dL. There were no signs or symptoms of posterior pituitary dysfunction. The patient was diagnosed with hypophysitis and started on hydrocortisone 20 mg once daily along with levothyroxine 175 mcg once daily. DEXA scan showed normal bone mineral density. Subsequently, the patient presented to our care and reported symptom improvement after taking the prescribed medication however he continued to develop fatigue by the end of the day. Therefore, hydrocortisone prescription was switched to 15 mg in the morning and 10 mg at noon. A repeat thyroid function panel, sex hormone binding globulin, and LH were ordered, to be followed up at the patient's next visit. The patient was also advised to wear a medical alert bracelet at all times moving forward. Conclusion: Due to non-specific symptoms at onset, hypophysitis can be undiagnosed or misdiagnosed therefore it is important to have a high clinical suspicion with patients on PD-1 inhibitors presenting with such symptoms. It is also imperative to order a full set of hormones as this patient had concomitant primary hypothyroidism. Presentation: 6/1/2024

A Secondary Urothelial Carcinoma of the Penis Diagnosed

Aim: Penile cancer is one of the rarest urogenital cancers. Penile metastases after cystectomy are possible and seem to be associated with the existence of an extensive tumor on the surgical specimen. Case Presentation: We report here the case of old man 78 years old, with a history of Radical Cysto-Prostatectomy with Bricker type urinary diversion, indicated for a pT3N0M0R0 infiltrating urothelial carcinoma of the bladder. He had consulted 7 years post surgery for an indurated lesion of the penis with urethrorrhagia. On examination, he presented an ulcerative-necrotic lesion under the left lateral coronal area of the penis, a diffuse induration of corporal bodies from the glans to the bulb, bilateral inguinal macro lymphadenopathies. Magnetic Resonance Imaging of the penis suggested a tumor extending over the entire penis, infiltrating the corpora cavernosa and spongiosa, with invasion of the albuginea, adjacent fat and skin. In view of this picture, a total penectomy with emasculation was performed. The histology of the surgical specimen showed a poorly differentiated urothelial carcinoma with an immunohistochemical study in favor of a primary urothelial origin (GATA3+). The tumor infiltrated both corpora cavernosa and the urethra with positive margins of resection. The right inguinal lymph node dissection showed one metastatic node out of two. The left inguinal lymph node dissection showed one metastatic lymph node out of six with capsular rupture. Thoracic-abdominopelvic CT Scan showed a right inguinal adenopathy with no other lesions suggestive of secondary localization. The diagnosis of secondary urothelial carcinoma of the penis classified as pT4N2M0R1 was made and the patient underwent chemotherapy on tumor board meeting. Conclusion: Secondary cancers of the penis, although rare, can occur years after radical treatment of the primary tumor. Immuno-histochemestry was esential to differentiate from primary squamous cell carcinoma in our case.

Primary signet ring cell adenocarcinoma arising in exstrophy of the urinary bladder (epispadias-exstrophy complex).

Bladder exstrophy is a rare congenital anomaly in which the urinary bladder develops outside the body. It may be part of the bladder epispadias-exstrophy-cloacal complex, which is a serious embryological defect where a spectrum of abnormalities involving the urinary tract, genital tract, musculoskeletal system, and intestinal tract is seen. Primary signet ring cell adenocarcinoma (PSRCA) arising in exstrophy of the urinary bladder is extremely rare with only a few cases reported in the literature. A 32-year-old man with congenital, untreated bladder exstrophy presented with a large fungating mass on the lower abdominal wall. Physical examination revealed a 15 × 12 cm exophytic mass with a penile epispadias. Ultrasonography showed a replacement of the urinary bladder by a mass of size 9 × 8 × 7 cm with a defect in the abdominal wall. On Contrast-enhanced computed tomography (CECT), a mass protruding from a large, inferior abdominal wall defect of 5.3 cm was seen. Widened pubic symphysis with divarication of recti and an absent urinary bladder, consistent with bladder exstrophy, was also noted. The biopsy showed a signet ring cell adenocarcinoma. A radical cystectomy with ileal conduit and left inguinal lymph node dissection was done. Histopathology examination revealed a PSRCA with metastasis to the left inguinal lymph nodes. Immunohistochemistry (IHC) showed strong positivity with CDX2 and CK20 while CK7 was negative. PSRCA shows an aggressive behavior, as was seen in our case, which had metastatic inguinal lymph nodes at the time of presentation. Metastatic signet ring cell adenocarcinomas from other sites need to be ruled out. Bladder exstrophy can develop high-grade malignancies at any stage of life. Hence, surgical treatment early in life with lifelong follow-up is recommended.

Neoadjuvant concurrent chemoradiation for curative treatment of penile squamous cell carcinoma.

Introduction. Penile cancer is a rare malignancy often treated with neoadjuvant chemotherapy followed by surgery. However, the utility of neoadjuvant chemoradiation, particularly when the tumor is resistant to chemotherapy alone, has not been established. In this study, we report a case of pT3cN3M0 penile squamous cell carcinoma with progression of nodal disease on chemotherapy, which was cured with use of neoadjuvant concurrent chemoradiation. Case Report. A 65-year-old male presented with a fixed left inguinal lymph node with associated firmness of the penile glans. Biopsies of both sites revealed evidence of squamous cell carcinoma. The patient underwent partial penectomy for the primary lesion and began neoadjuvant chemotherapy to reduce the size of the unresectable left inguinal node. However, he displayed disease progression in the left inguinal node. As such, we attempted concurrent chemoradiation therapy with regression of his nodal disease. The patient was able to undergo left inguinal node dissection and has no evidence of disease 18 months since his initial surgery. Conclusion. The use of neoadjuvant chemoradiation for bulky cN2-3 disease seems appropriate in the setting of progressive disease. Further studies are necessary to assess the utility of concurrent chemoradiation both in the neoadjuvant and salvage setting.

Primary adenoid cystic carcinoma of sweat glands in vulva: Report of an unusual case and review of the literature

Adenoid cystic carcinoma arising from the vulvar sweat glands is a rare malignancy of the female genital tract. We report a case of adenoid cystic carcinoma of sweat glands occurring in the left labia majora of a 52-year-old female patient. The patient underwent radical hemivulvectomy and left inguinal lymph node dissection with negative surgical margins and negative inguinal lymph node metastasis. Then, four episodes of combined chemotherapy without further radiotherapy were given. However, the tumor recurred after 3 months. Currently, the patient has been followed up for 2 years with no distant metastasis. According to our experience, although the tumor has a high tendency of local recurrence after resection, an acceptable survival time of the patient can be achieved with primary surgery.

メルケル細胞癌の1例

自然消退傾向を示したメルケル細胞癌の1例を報告した。症例68歳女。2003年12月頃, 右頬部に米粒大の自覚症状を欠く常色調の小結節が出現。2004年3月当科初診。初診時, 光沢を有し, 紅色調でドーム状に隆起する小指頭大結節が認められた。生検組織では表皮直下から脂肪織にかけて, 繊細な核網を有し円形の核を持つ異型細胞の増殖が認められた。異型細胞はS100蛋白, Synaptophysin, Chromogranin A, Keratin陽性, 電顕検査にて細胞質に有芯顆粒が認められ, Merkel細胞癌と診断した。生検から1ヵ月後の拡大切除時には, 臨床的に生検時の癩痕を認めるのみであった。組織HE染色像でも真皮内にリンパ球の密な浸潤を認めその中に変性した腫瘍細胞塊が散見された。生検時には組織学的に腫瘍は残存しており, 腫瘍細胞が自然消退したものと考えられた。

Primary epithelioid sarcoma of the vulva in pregnancy

Primary epithelioid sarcoma (ES) of the vulva is an extremely rare tumor, and to date, only 20 cases have been reported. We report the second case of vulvar ES presenting in pregnancy. A 25-year-old woman, at 6 weeks of gestation, was diagnosed as having vulvar sarcoma and was referred to our hospital. Immunohistochemical studies revealed that the tumor cells were positive for cytokeratin, epithelial membrane antigen (EMA), and wimentin. The tumor cells did not stain for S-100, SMA, HMB-45, desmin, LCA, CD-34, or estrogen and progesterone receptors. The tumor showed diffuse and strong staining for CD-117 (c-kit). After the curettage, she underwent local wide excision and left inguinal lymph node dissection and received external-beam radiation therapy. At 16 months of follow-up the patient was well without any disease recurrence. The appropriate treatment of vulvar ES is not clear, and the role of chemotherapy is disappointing; however, it might be worth investigating the role of Imatinib in c-kit overexpressing vulvar ES.

Xanthogranulomatous orchitis in an adult Nigerian

Xanthogranulomatous orchitis (XGO) is a rare benign disease of the testis which has not been previously documented in tropical Africa. We report a case of a 24-year-old Nigerian man who presented with a painless left hemiscrotal swelling. Our clinical diagnosis was left testicular cancer. Testicular tumor markers were normal. At surgical exploration, we found a left testicular tumor. Histopathological examination of the specimen showed XGO of the left testis. He had left radical orchiectomy and left inguinal node dissection. He has remained stable 8 months after the treatment. Xanthogranulomatous orchitis cannot be distinguished clinically from testicular cancer unless by histopathological examination. Orchiectomy is the treatment of choice. However, in all patients and particularly young patients and those with a single testis, histopathological confirmation is suggested to avoid unnecessary radical orchiectomy, useless irradiation and ill-timed chemotherapy.

陰嚢に生じた有きょく細胞癌の３例

(Case 1) A 62-year-old man suffered from psoriasis for several decades and was treated with ultraviolet A. He noticed a tumor on the right side of his scrotum 10 months ago. A biopsy specimen of the tumor led us to the diagnosis of squamous cell carcinoma (SCC) . Wide excision and right inguinal lymph node dissection were performed. Inspite of the treatment, paraaortic lymph node and lung metastases developed 18 months later. Combination chemotherapy (carboplatin, 5-FU, and peplomycin) could not inhibit the tumor progression and he died 3 years after the first visit.(Case 2) A 42-year-old man presented with a tumor on the left side of his scrotum. He had worked at an ironworks and used machine oil. After wide excision and left inguinal lymph node dissection, he was treated with 3 courses of peplomycin chemotherapy. The tumor recurred locally 4 years later and was surgically removed again. He has been tumor-free for more than 6 years.(Case 3) A 77-year-old man, who also worked at an ironworks before, had a tumor on the left side of his scrotum and had it resected at another hospital 4 years ago. Local recurrence occurred and was widely excised. He has been tumor-free for more than 4 years.During the past 11 years, we experience 251 cases of SCC in our institutions. Among them, 3 cases developed on the scrotum. It is often indicated that SCC occurs on the scrotum soaked with machine oil or exposed to ultraviolet rays. [Skin Cancer (Japan) 2004; 19: 181-185]

メルケル細胞癌の１例

A 63 year-old man with Merkel cell carcinoma is reported. He noticed an asymptomatic reddish macule on his left lower leg about 8 years previously. The lesion gradually enlarged to a nodule. As the nodule expanded rapidly during past 3 months, he visited our hospital. At his first visit, the lesion was seen as a 70×70mm, indurated reddish plaque accompanied with a dark reddish nodule of 47×45×18mm in size. Biopsy specimen revealed aggregation of atypical small tumor cells, that were immunohistochemically positive for CK20, chromogranine A, and NSE, supporting the diagnosis of Merkel cell carcinoma. We performed wide resection of the primary lesion along with left inguinal lymph node dissection. Inguinal lymph node metastases were confirmed histopathologically. Postoperatively, radiotherapy (50.4Gy XRT) was perfoemed. However, multiple metastases to the liver, pancreas, and distant lymph nodes and local reccurence developed. He was treated with CAV/PE alternating chemotheapy. The metast tic and recurrent lesions reduced, indicating effectiveness of this regimen. After 4 months from the introduction of chemotherapy, the lesions enlarged again. Other regimens of chemotherapy were performed, but he was died due to complication of DIC. [Skin Cancer (Japan) 2001; 16: 51-55]

Ｃｌｅａｒ ｃｅｌｌ ｓａｒｃｏｍａの１例

We report a case of clear cell sarcoma. A 42-year-old Japanese man noticed a solitary subcutaneous nodule on the left side of his foot 5 years previously. After incomplete removal of the nodule by an orthopedician, he was referred to our clinic.At his first visit, metastases to the left inguinal lymph nodes were already observed together with the residual nodule on the foot. Histological examination of the nodule on the foot revealed nests of round cells with clear cytoplasm separated by fibrous septa. Immunohistochemically, turnor cells were positive for S-100 protein and HMB-45. Translocation t (12; 22) (q13; q13) and other chromosomal abnormalities were detected by chromosomal analysis. We performed the amputation of his left leg and left inguinal lymph node dissection followed by adjuvant chemotherapy. However, multiple bone metastases developed a month after the surgery and he died of the disseminated disease. [Skin Cancer (Japan) 2001; 16: 345-348]

A CASE OF FISTULA-CANCER

Fistula-cancer is a carcinoma arised from a chronic anal fistula. We report here a case of fistula-cancer with a review of the literature. The patient was a 62-year-old male who had undergone an operation for an anal fistula 18 years before. Sometimes he has felt anal discomfort postoperatively. Mucous discharge from the operation scar appeared 1 year before and did not improve despite of several re-operations. Recently a painful tumor appeared on the same portion. Histopathologically, the tumor was adenocarcinoma. Under the diagnosis of an anal cancer arised from the anal fistula, abdominoperineal excision of the rectum and left inguinal lymph node dissection were performed. The tumor was 2cm in diameter, Borrmann 5 type and was located in the direction from 2 to 5 O'clock of the anus. Histopathologically, the tumor was well-differentiated adenocarcinoma.