Lobe Metastasis Research Articles

High-flow Nasal Oxygen in a Physiologically Difficult Airway for Awake Craniotomy: Optimising the Highs and Lows

Abstract Respiratory failure is a major risk factor for perioperative pulmonary complications, requiring mechanical ventilation following general anaesthesia. Awake craniotomy avoids physiological derangements related to general anaesthesia, while facilitating continuous neurological monitoring of eloquent areas. High-flow nasal oxygen (HFNO) provides effective oxygenation with CPAP of 3–4 cmH2O, along with providing a favourable interface for communication. We present a 53-year-old female with carcinoma breast having brain and lung metastases with malignant pleural effusion and superimposed pulmonary infection, posted for parietal lobe metastasis excision. Due to her pulmonary comorbidities with an oxygen saturation of 88%, she was posted for an awake craniotomy. HFNO was used to maintain her oxygenation intraoperatively. In this patient, HFNO effectively improved the patient’s oxygenation, comfort and compliance without compromising her involvement in neurological testing.

Impressive Response to TANDEM Peptide Receptor Radionuclide Therapy with 177Lu/225AcDOTA-LM3 Somatostatin Receptor Antagonist in a Patient with Therapy-Refractory, Rapidly Progressive Neuroendocrine Neoplasm of the Pancreas.

The present report describes the history of a 58-year-old woman with a rapidly progressing neuroendocrine pancreatic tumor (initially G2) presenting with extensive liver, bone, and lymph node metastases. Previous treatments included chemotherapy, hemithyroidectomy for right lobe metastasis, Peptide Receptor Radionuclide Therapy (PRRT) with [177Lu]Lu-DOTATATE, Lanreotide, Everolimus, and liver embolization. Due to severe disease progression, after a liver biopsy revealing tumor grade G3, PRRT with the somatostatin receptor antagonist LM3 was initiated. [68Ga]GaDOTA-LM3 PET/CT showed intense tracer uptake in the liver, pancreatic tumor, lymph nodes, and bone metastases. Three TANDEM-PRRT cycles using [177Lu]LuDOTA-LM3 and [225Ac]AcDOTA-LM3, administered concurrently, resulted in significant improvement, notably in liver metastases, hepatomegaly reduction, the complete regression of bone and lymph node metastases, and primary tumor improvement. Partial remission was confirmed by positron emission tomography/computed tomography, chest-abdomen-pelvis contrast-enhanced computed tomography, and magnetic resonance of the abdomen, with marked clinical improvement in pain, energy levels, and quality of life, enabling full resumption of physical activity.

The tendency of segmental distribution of hepatic metastasis according to couinaud classification: a comparison of portal versus systemic route of metastatis due to primary colorectal and breast tumors.

The liver is the commonest site of metastatic disease for patients with colorectal cancer (CRC), with at least 25% of patients developing liver metastasis (LM) during their illness. About 50% of patients diagnosed with metastatic breast cancer develop LM, and 5-12% of these patients develop LM as the main site of breast cancer recurrence. This study aims to determine the frequency of segmental distribution of LM seeding from portal versus systemic routes of dissemination due to primary CRC and breast carcinoma, respectively. This retrospective study was conducted in a tertiary care teaching hospital in Pakistan. Ethical approval was taken from the institutional review board. A total of 587 patients were included in the study with 297 CRC patients with LM and 300 breast carcinoma patients with LM. Segment I involvement was excluded from the calculation because of the dual blood supply. Patients' detailed demographics and other information were collected on a predesigned proforma. The authors evaluated axial and multiplanar reformatted computed tomography images for LM and CRC metastasis. Data analysis was done using SPSS version 25. P value less than or equal to 0.05 was considered statistically significant. A study population of 587 patients was employed that comprised 287 CRC and 300 breast carcinoma patients. There were 179 (30.5%) male and 408 (69.5%) female patients. The mean age of patients was 54.9±13.3. The study revealed that 204 (34.8%) CRC patients showed right lobe (V, VI, VII, VIII) and 83 (14.1%) CRC patients showed left lobe involvement of metastasis while 192 (32.7%) breast carcinoma patients showed right lobe involvement and 108 (18.4%) breast carcinoma patients showed left lobe involvement in metastasis (P=0.02). We also found 40 (6.8%) colorectal and 55 (9.4%) breast carcinoma patients showed left lateral segment (II, III) involvement. Medial segment involvement (IV) was seen in 43 (7.3%) CRC patients and 53 (9%) breast carcinoma patients (P=0.03). The right hepatic lobe is the predominant site of metastasis independent of the portal or systemic route of dissemination in primary carcinoma. Moreover, in left lobe metastasis medial segment (IV) is more affected in CRC while the lateral segment (II, III) is more affected in breast carcinoma.

Multidisciplinary Treatment of Liver Metastases from Intracranial SFTs/HPCs: A Report of Three Consecutive Cases.

In the 2016 WHO classification of tumors of the central nervous system, hemangiopericytomas (HPCs) and solitary fibrous tumors (SFTs) were integrated into a new entity (SFT/HPC). Metastases to bone, liver, lung, and abdominal cavity are of concern. Only 37 cases of patients with liver metastases due to intracranial SFTs/HPCs have been reported. Herein, we present our experience in the management of patients with liver metastases from intracranial SFTs/HCPs. All consecutive patients who were treated for liver metastases from intracranial SFTs/HPCs from January 2014 to December 2020 were enrolled. Overall, three patients were treated for liver metastasis from SFTs/HPCs with curative intent. Two patients with bilobar metastases at presentation required surgical resection, transarterial embolization, stereotactic radiofrequency ablation (SRFA) and systemic therapy. One patient with a singular right liver lobe metastasis was treated with SRFA alone. This patient shows no evidence of liver metastases 39 months following diagnosis. Of the two patients with bilobar disease, one died 89 months following diagnosis, while one is still alive 73 months following diagnosis. Long-term survival can be achieved using a multimodal treatment concept, including surgery, loco-regional and systemic therapies. Referral to a specialized tertiary cancer center and comprehensive long-term follow-up examinations are essential.

Metastatic triple negative breast adenocarcinoma presenting as a fungating chest wall mass

A 60-year-old female with no previous medical history presented with progressive left sided weakness. Examination demonstrated a large, fungating chest wall mass with mucopurulent drainage and necrotic odor. The patient stated this lesion was worsening for multiple years and was associated with a 90-pound weight loss; however, she was hesitant to seek medical care until the onset of weakness. Comprehensive imaging, biopsy, and tissue analysis revealed the wound was consistent with fungating triple-negative breast adenocarcinoma with lung and frontal lobe metastasis (Figure 1).

Limb salvage surgery for giant cell tumours around knee joint: a single institute experience

<p class="abstract"><strong>Background:</strong> Giant cell tumours (GCTs) of bone are benign but locally aggressive tumours. The surgical treatment of GCTs in the around knee joint mainly includes curettage and bone grafting, extended curettage and cement filling, segmental resection and modular endo prosthesis reconstruction.</p><p class="abstract"><strong>Methods:</strong> Retrospective analysis of the presentation, the functional outcome following modular endoprosthetic reconstruction, prosthetic survival and the recurrence rate in 17 patients with Campanacci grade 3 GCTs involving distal femur and proximal tibia, who underwent segmental resection and modular endoprosthesis reconstruction in a single centre from 2015 to 2018. The surgery was performed according to the general principles of limb salvage surgery and modular segmental replacement was used. All stems were cemented in place. Isometric exercises and mobilization with crutches were started on 2<sup>nd</sup> postoperative day. Knee joint bending was started for proximal tibia patients after 2 to 3 weeks. Functional outcome was scored by musculoskeletal tumour society scoring (MSTS). Immediate post-operative complication like delayed wound healing, flap necrosis, wound infection, foot drop, leg length discrepancies were evaluated.<strong></strong></p><p class="abstract"><strong>Results:</strong> The average MSTS functional score was 78%.3 year prosthetic survival was 100%. None of the patients had recurrence. One patient had left lower lobe metastasis for which wedge resection was done.</p><p class="abstract"><strong>Conclusions:</strong> Segmental resection and endoprosthetic replacement has good functional outcome in patients with tumours around the knee joint. As GCTs are tumours with less chance of local and distant metastasis after complete excision, endoprosthetic prosthesis is a good treatment option after complete excision.</p>

MILIARY METASTATIC ADENOCARCINOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Miliary opacities are defined as innumerable 1- 4mm pulmonary nodules scattered throughout the lung fields. Differential for miliary pattern is wide including tuberculosis, fungal infection and distinct organ metastasis. We present a case of a 37 year old male with miliary pattern seen on the chest radiograph and CT scan with ostial lesion in his L2 vertebrae, who was initially thought to have miliary TB with Pott's disease later diagnosed with primary adenocarcinoma of the lung with spinal, brain and calvarium metastasis. CASE PRESENTATION: A 37-year-old male with no significant medical history presented to the ED with 2 months of lower back pain. He endorsed shortness of breath and 40 pound unintentional weight loss over 3 months. He was incarcerated 5 years ago at which time his PPD was negative.Chest x-ray showed diffuse bilateral infiltrates with micronodular pattern. Following this, CT scan was obtained to evaluate for lower back pain which showed pathological compression deformity in L2 and innumerable pulmonary nodules consistent with miliary pattern and also showed left upper lobe lung mass.Given his history of incarceration, weight loss, shortness of breath and deformity in his lumbar vertebra, miliary tuberculosis and Potts disease was considered. QuantiFERON gold and AFB sputum were obtained. After AFB x3 negative on sputum studies it was decided to proceed with bronchoscopy with bronchoalveolar lavage (BAL).Lymph node biopsies and BAL pathology reports came back positive for adenocarcinoma. Upon further investigation with MRI of the brain and the spine it was also noted that the patient had Cavalier metastasis, left frontal lobe metastasis and numerous enhancing bone lesions in lumbar and sacral spine with osseous metastasis.Oncology and radiation oncology were consulted and he was started on stereotactic radiation therapy to the left frontal lobe metastasis as well as a right calvarial metastasis and systemic chemotherapy and immunotherapy. DISCUSSION: Miliary opacities are seen in a wide array of conditions including infectious etiologies like miliary TB, histoplasmosis, other fungal infections and noninfectious etiologies including miliary metastasis from thyroid, renal, breast carcinomas, metastatic melanoma. There has also been documentation of miliary patterns seen in Langerhans' cell histiocytosis, hypersensitivity pneumonitis and a few cases of primary pulmonary lung cancers.History is a key component in diagnosis especially for patients coming from areas and populations where TB and other infectious disease are prevalent. Once infectious etiologies have been ruled out approach to rule out malignancies and metastasis should be perused. CONCLUSIONS: It is impossible to distinguish between infectious etiologies and malignancies solely based on CT scan in patient with miliary pattern, hence when definitive diagnosis is uncertain, tissue diagnosis should be perused. REFERENCE #1: Khan D, Danjuma M, Saddique M, U, Murshed K, A, H, Yassin M, A: Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis. Case Rep Oncol 2020;13:139-144. doi: 10.1159/000505685 DISCLOSURES: No relevant relationships by Sarasi Jayaratne, source=Web Response No relevant relationships by Gaurang Prabhu, source=Web Response No relevant relationships by Gaurav Prabhu, source=Web Response

Brain metastatic breast cancer: Epidemiology, survival and prognosis: Single center experience

IntroductionBreast carcinoma is the most common malignancy in women worldwide. It is also one of the most frequent causes of brain metastasis (BM). Studies have identified BM as one of the worst prognostic signs. MethodsWe retrospectively analyzed data from 71 patients with BM from BC with the aim of clarifying the epidemiological criteria and management in our setting. We also aimed to identify predictors of survival and factors affecting the length of the BM-free interval in our group of patients. ResultsAll the patients were female with a mean age at diagnosis of primary cancer of 41.6 years. The most common site of BM was the parietal lobe. The BM-free interval was longer with N1 disease (in comparison to N2 and 3) and in luminal B breast cancer subtype. Survival was shorter in older patients, those with hormone receptor negative and/or HER2-neu positive disease, synchronous BM, primary tumour not removed, soft tissue/non-regional nodes concomitant metastasis, and those who did not receive palliative chemotherapy. Survival tended to be longer in patients with temporal lobe metastasis, but this result was not statistically significant. ConclusionBM is a bad prognostic sign. Large scale prospective studies are needed to further delineate its nature.

MON-093 Pleuropulmonary Blastoma and Multinodular Goiter in a 22 Yr Old Male with DICER1 Syndrome

Background DICER1 syndrome is an autosomal dominant condition due to mutations in the DICER1 gene, located on chromosome 14q32.13. Patients are at increased risk for malignant and benign tumors, including pleuropulmonary blastoma (PPB), cystic nephroma, ovarian Sertoli-Leydig cell tumors, multinodular goiter (MNG) and differentiated thyroid cancer (DTC). MNG is very common in patients with DICER1 Syndrome but data on incidence is lacking. MNG is more common in females than males.Case presentation:22 year old man who originally presented with pleuropulmonary blastoma, Type 3 at 3 years of age. His treatment included pulmonectomy, radiation of 46.6 Gy to thorax, and alkylating agents including Cisplatin, Ifosphamide and Cytoxan. He developed frontal lobe metastasis over the course of 3 years and was treated with focal cranial radiation. His father and maternal uncle had history of lung cancer.He was evaluated at the Endocrine clinic at 12 years 10 months for short stature. His height was 132.5 cm (SDS -2.96), weight 29.7 kg (SDS -2.40), and BMI 16.99kg/m² (SDS -0.61). On examination he had normal thyroid exam and Tanner 2 bilateral 4 cc testicles. He was treated with Levothyroxine for subclinical hypothyroidism (TSH: 5.96 uIU/ml (0.35–5.5) and Free T 4: 0.99 ng/dl (0.8–1.80) and growth hormone (GH) for growth hormone deficiency (peak GH was 7.7 ng/ml after Arginine and Clonidine GH stimulation test).At 14 years 10 month he developed respiratory distress. CT scan of chest showed right lower pole nodule 1.6 x 1.5 x 1.4 cm. Ultrasound of thyroid showed right thyroid solid mid pole isoechoic nodule 1.4 x 1.7 x 1.3 cm with multiple enlarged bilateral cervical nodes, largest left supraclavicular region > 1 cm. Biopsy of the right nodule was negative for malignancy. Over the course of 2 years he developed new right thyroid isoechoic nodule in the lower pole 2.1 x 2.5 x 1.9 cm and new left thyroid isoechoic nodule in the upper pole 1.0 x 0.5 x 0.5 cm. Biopsy was negative for malignancy.Due to his PPB, MNG and family history of lung cancer he was evaluated at our genetic cancer clinic and tested positive for germline DICER1 pathogenic variant c.4605_4606del (p.Cys1535Trpfs*3)Conclusion:Our 22 year old male presented with pleuropulmonary blastoma and over the course of few years developed MNG. Genetic testing was positive for germline DICER1 pathogenic variant c.4605_4606del (p.Cys1535Trpfs*3). Our case illustrates the importance of consideration of: 1) Testing children with PPB for DICER1 Syndrome as there are screening recommendations including regular thyroid ultrasound and examinations to look for MNG or other features concerning for thyroid gland neoplasia. 2) MNG is uncommon in children and detection of this should raise suspicion for consideration of testing for DICER1 Syndrome.

Fregoli Delusion: A disorder of Misidentification with Temporal Lobe Metastasis Secondary to Lung Carcinoma (4822)

Fregoli Delusion: A disorder of Misidentification with Temporal Lobe Metastasis Secondary to Lung Carcinoma (4822)

2371 Non-Cirrhotic Portal Hypertension Presenting With Variceal Bleeding in a Patient With Breast Cancer on Capecitabine

INTRODUCTION: We describe a case of variceal bleeding in a cancer patient with improving liver metastases without radiographic evidence of cirrhosis. CASE DESCRIPTION/METHODS: A 66 year-old woman with stage IV bilateral breast cancer presented to the hospital with hematemesis. Platelet count was 98,000/mcL and INR 1.2 with normal albumin and liver enzymes. Upper endoscopy showed large varices with stigmata of recent bleeding and portal hypertensive gastropathy. Varices were banded without further bleeding. CT abdomen/pelvis with contrast showed left hepatic lobe atrophy, normal spleen, normal liver contour and no portal venous thrombosis (PVT). She was diagnosed with breast cancer 26 years prior and underwent lumpectomy and radiation. Eight years ago, she had recurrence, underwent mastectomy and then was diagnosed with contralateral breast cancer followed by mastectomy. Six years ago, she had recurrence requiring axillary dissection with chemotherapy and radiation. Four years ago, imaging showed new metastases with heavy left liver tumor burden with left portal vein cut off, ascites and bony metastases. Liver lesion biopsy showed breast cancer. She started doxorubicin with resolution of ascites and marked left lobe atrophy by imaging. For two years, she was remained on doxorubicin without evidence of disease. Three months prior to admission, PET CT showed two small right hepatic lobe metastasis, and she was started on capecitabine. DISCUSSION: Non-cirrhotic portal hypertension in the setting of liver metastases occurs for various reasons. One etiology is PVT, which imaging ruled out. Pseudocirrhosis describes a radiographic appearance of cirrhosis without histopathologic cirrhosis due to capsular retraction from metastases shrinkage after therapy, nodular regenerative hyperplasia (NRH) due to chemotherapy and fibrotic changes around metastases. While this is reported with capecitabine, our patient did not appear cirrhotic on imaging. Portal hypertension due to micronodular metastases is reported, but this is unlikely with improved liver lesions on imaging. Hepatic steatosis with elevated transaminases is reported with capecitabine. Several chemotherapies cause NRH, including doxorubicin. We suspect underlying NRH from previous doxorubicin and left hepatic lobe atrophy from shrinkage of metastases combined with new capecitabine caused an increased in liver stiffness. This case demonstrates the complex effects on the liver from both metastases and cancer treatments in a patient without known liver disease.

MON-320 Lost in the Rugae: High Grade Gastric Neuroendocrine Tumor in an MEN1 Patient with Zollinger-Ellison Syndrome

BACKGROUND: Gastric neuroendocrine tumors (carcinoid) associated with Zollinger Ellison Syndrome (ZES) induced hypergastrinemia in Multiple Endocrine Neoplasia type 1 (MEN1) occur in 15-50% of patients and are generally thought to be benign. Here we present a case of metastatic grade 3 gastric neuroendocrine tumor in MEN1. CASE: A 41-year male with history of MEN1 syndrome manifested by hyperparathyroidism, pancreatic neuroendocrine tumors, and Zollinger-Ellison Syndrome had been followed for 10 years. The patient had undergone yearly surveillance including CT, MRI, upper GI endoscopy (EGD) and 68Ga-DOTATATE, which had identified multiple small foci in the pancreas and duodenum. However, only MRI revealed a T2 hypointense 2.6 cm mildly enhancing mass along the lesser curvature of the stomach that was not visible on CT, MRI, EGD or 68Ga-DOTATATE within the 2 years prior. Gastrin levels remained <500 pg/mL during this time. EGD within 3 months prior to diagnosis demonstrated near complete suppression of acid (on omeprazole 120mg BID) confirmed with an acid output of 0 mEq/hr and no visible masses within the enlarged gastric folds. A follow-up 68Ga-DOTATATE scan identified an intraluminal mass on the medial aspect of the gastric wall (17.55 SUV). On review, the tumor was not able to be visualized on prior scans due to the diffuse ZES-induced hypertrophic gastric mucosa and poorly distended stomach. In addition, 18F-FDG-PET/CT scan demonstrated a faint but discrete photopenic defect associated with known mass in the gastric wall. The patient underwent surgical resection of a 3.5cm mass. Pathology demonstrated strong and diffusely positive synaptophysin and chromogranin A with Ki-67 labelling index (MIB-1) >20% and mitotic count >20 per 10 high powered fields. At the time of diagnosis, this lesion was histologically classified as well to moderately differentiated, high grade neuroendocrine carcinoma (Grade 3), large cell type. Loss of heterozygosity for the MEN1 gene at 11q13 was confirmed in the tumor. Monitoring with serial scans demonstrated right hepatic lobe metastasis by 1-year post-surgery. CONCLUSION: Previous reports of MEN1/ZES gastric carcinoid are associated with high gastrin levels, long disease duration, and are typically grade 1 or 2[i]. Special attention to identification of gastric mucosal nodules with well-controlled ZES is required as these lesions may rarely become malignant. Endnotes i Berna MJ, et al. A prospective study of gastric carcinoids and enterochromaffin-like cell changes in multiple endocrine neoplasia type 1 and Zollinger-Ellison syndrome: identification of risk factors. JCEM. 2008; 93(5):1582-91.

Role of preoperative x-ray endovascular interventions for improvement of resectability of colorectal liver metastases

The objective was of the study to evaluate the role of preoperative x-ray endovascular interventions – transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) – for improvement of resectability of colorectal liver metastases.Material and methods. Between 1997 and 2017, we treated 11 patients who simultaneously had large-volume (60–70 %) of right liver lobe colorectal metastases and small future remnant liver. The treatment was started from 1–4 cycles of TACE to reduce or stabilize the rapid growth of the tumor. In case of good effect, we performed PVE and then we performed liver resection.Results. There were no major complications of TACE or PVE. After 1–4 cycles of TACE, the volume of metastases showed partial decrease or stabilization. The following PVE allowed to increase the future remnant volume of the left liver lobe up to a safe 40–45 %. Right – sided hemihepatectomy was performed in 6 patients and extended right-sided hemihepatectomy in 5 patients. There were no postoperative mortality or severe complications. At present, 4 patients are alive without recurrence during 1.5–8 years, and 4 other patients received endovascular treatment for local recurrence are alive during 1.5–5 years. The 3 patients died from tumor progression during 13–30 months. CONCLUSION. In patients with simultaneously extensive for resection volume of right liver lobe metastases and small left liver lobe, the primary treatment with TACE is reasonable. Only after the documentation of tumor decrease or stabilization, it is necessary to determine the timing of PVE and following major liver resection. This order of treatment procedures allows to improve resectability in cases with extensive, large-volume, rapidly grown malignant liver lesions.

A rare case of primary breast angiosarcoma in a male: a case report

BackgroundSarcomas account for less than 1% of primary breast cancers, and breast angiosarcomas are responsible for only 0.05% of all breast malignancies. The male breast has the same potential for malignant transformation as the female breast. However, due to anatomical differences in the breast and the low incidence of angiosarcoma, it is difficult to determine how male breasts can be affected by this type of tumor.Case presentationA 36-year-old male patient was admitted to the hospital with a palpable lump in his right breast. Lymphadenopathy was negative. Ultrasonography showed a hypoechoic mass with partially defined contours, measuring 4.0 × 3.0 cm, with muscle infiltration. Histological examination revealed a malignant tumor. Radical mastectomy was then performed with clear surgical margins. The patient began chemotherapy with paclitaxel. Following the second cycle of chemotherapy, he presented with headache and seizures due to a frontal lobe metastasis. Twenty days after the onset of neurological symptoms, the patient died.ConclusionsPrimary angiosarcomas of the male breast are extremely rare. This is the sixth case published in the literature. It is in agreement with other studies in the literature concerning clinical presentation and poor prognosis. Treatment consists in surgical removal of the tumor with clear margins and without axillary lymphadenectomy.

MANAGEMENT OF SEVERE PERIOPERATIVE BLEEDING IN PATIENTS DURING EXTENSIVE LIVER RESECTIONS FOR COLORECTAL METASTASES

Aim of the study. To estimate an influence of the Cavitron ultrasonic surgical aspirator (CUSA) on intraoperative blood loss. Material and methods. An analysis of 185 cases of extensive liver resections in patients for colorectal liver metastases has been performed. All patients were assigned to CUSA group (n = 56) or clamp crashing group (n = 129). Patients from the first group received regional FOLFOX6 or FOLFOX6 + bevacizumab chemotherapy. Preoperative chemotherapy did not performed for second group of patients. Results. Liver transection with CUSA did not lead to the decline in intraoperative blood loss (p = 0.35). Conclusion. Median intraoperative blood loss was 1065 and 1180 ml respectively. Method for liver transection did not lead to the decline in intraoperative blood loss (p = 0.35). Intraoperative blood loss increases from standard to extensive liver resection (p = 0.0007). Resection of contralateral blood lobe metastases did not lead to statistically significant increase in blood loss as compared with standard mode of the operation (p = 0.005).

Occipital Lobe Metastasis of Hepatocellular Carcinoma Presenting as Homonymous Hemianopia

Occipital Lobe Metastasis of Hepatocellular Carcinoma Presenting as Homonymous Hemianopia

THE LARGEST WESTERN EXPERIENCE WITH HEPATOPANCREATODUODENECTOMY: LESSONS LEARNED WITH 35 CASES.

Background: Hepatopancreatoduodenectomy is one of the most complex abdominal operations mainly indicated in advanced biliary carcinoma. Aim: To present 10-year experience performing this operation in advanced malignant tumors. Methods: This is a retrospective descriptive study. From 2004 to 2014, 35 hepatopancreatoduodenectomies were performed in three different institutions. The most common indication was advanced biliary carcinoma in 24 patients (68.5%). Results: Eighteen patients had gallbladder cancer, eight Klatskin tumors, five neuroendocrine tumors with liver metastasis, one colorectal metastasis invading the pancreatic head, one intraductal papillary mucinous neoplasm with liver metastasis, one gastric cancer recurrence with liver involvement and one ocular melanoma with pancreatic head and right liver lobe metastasis. All patients were submitted to pancreatoduodenectomy with a liver resection as follows: eight right trisectionectomies, five right lobectomies, four left lobectomies, 18 central lobectomies (IVb, V and VIII). The overall mortality was 34.2% (12/35) and the overall morbidity rate was 97.4%. Conclusion: Very high mortality is seen when major liver resection is performed with pancreatoduodenectomy, including right lobectomy and trisectionectomy. Liver failure in combination with a pancreatic leak is invariably lethal. Efforts to ensure a remnant liver over 40-50% of the total liver volume are the key to obtain patient survival.

Isolated brain metastasis – A rare site of recurrence in a recurrent epithelial carcinoma ovary

A 40-year-old lady presented with 15 months after completion of adjuvant chemotherapy with headache and impaired memory. MRI brain revealed isolated frontal lobe metastasis. She underwent surgical excision, whole brain RT followed by six cycles of chemotherapy.

DEBIRI and capecitabine in refractory prevalently liver metastases of colorectal cancer: A phase II study.

724 Background: Treatment options for metastatic colorectal cancer (mCRC) patients refractory to chemotherapy are limited and clinical outcome is poor. In mCRC patients with liver-dominant disease hepatic locoregional therapy might be a treatment option. In this pilot study we evaluated the safety, tolerance, and efficacy of drug-eluting beads irinotecan (DEBIRI) in combination with capecitabine in the treatment of patients with mCRC with predominally liver disease. Methods: Twenty patients affected by liver metastasis of colorectal cancer were included in this study. All patients had progression of disease after two or more lines of chemotherapy and liver was the major or the predominant site of disease. DEBIRI, beads loaded with 100 mg irinotecan, was administered biweekly via hepatic artery. All patients assumed capecitabine 1,000 mg/m2 twice daily on days 1 to 14 every 3 weeks, until disease progression. Primary endpoints were safety, tolerance and overall responce rate (ORR); secondary endpoints were progression free servival (PFS) and overall survival (OS). Results: Twenty patients underwent a total of 54 DEBIRI treatments of the 66 planned; the median number was 3 (range 2-4) administrated for patients. Grade 1-2 toxic effects included fatigue (70%), diarrhea (45 %), anemia (45%), elevated liver enzymes (45%), nausea (40%), neutropenia (35%) and thrombocytopenia (25%). One grade 3 diarrhea and a case of acute vasospastic angina were observed and required patient hospitalization, but no deaths at 30 days post occurred. Two partial responses were reported (10%) with ORR of 60%. PFS and OS were 4 and 7, 3 months respectively. Univariate analysis showed that patients with KRAS wild-type, good ECOG performance status and single lobe metastases have a better prognosis. Multivariate analysis confirmed that only the good clinical conditions represent an important positive prognostic factor (p=0.03). Conclusions: DEBIRI with capecitabine seem to be a safe, technically feasible and well-tolerated treatment in chemotherapy refractory mCRC with prevalently liver metastases. It has a moderate but not negligible activity in this heavily treated group of patients and deserves further studies in a larger series.

Isolated caudate lobe metastasis from carcinoma breast with locoregional recurrence: Documentation by fluorodeoxyglucose-positron emission tomography/computed tomography

Isolated caudate lobe metastasis from carcinoma breast with locoregional recurrence: Documentation by fluorodeoxyglucose-positron emission tomography/computed tomography