Metastatic Mass Research Articles

MP37-20 SURGICAL MANAGEMENT OF THE GROWING TERATOMA SYNDROME: A MULTICENTER STUDY

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease I1 Apr 2018MP37-20 SURGICAL MANAGEMENT OF THE GROWING TERATOMA SYNDROME: A MULTICENTER STUDY Pia Paffenholz, David Pfister, and Axel Heidenreich Pia PaffenholzPia Paffenholz More articles by this author , David PfisterDavid Pfister More articles by this author , and Axel HeidenreichAxel Heidenreich More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1226AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The growing teratoma syndrome (GTS) is an infrequent clinical phenomenon constituting only about 2 to 8% of all testis cancer patients. Data in the literature on the therapy of GTS are sparse, reflecting the rarity of the disease. The purpose of this study was to evaluate the diagnostic, surgical and oncological outcome of patients with GTS treated in the 21st century. METHODS We performed a retrospective analysis including 680 patients with advanced non-seminomatous germ cell tumors that underwent a post-chemotherapeutic retroperitoneal lymph node dissection. We analysed the peri- and postoperative outcome of 22 patients (3%) that fulfilled the criteria of a GTS: enlarging metastatic mass in the retroperitoneum or visceral organs during systemic chemotherapy with normalized or decreasing tumor markers. RESULTS Mean patient age was 28 years (22-34). 17 (81%) and 3 (14%) patients were classified as good or intermediate prognosis according to the IGCCCG risk classification, while 1 patient (5%) was in the poor prognosis group. The median tumour diameter at time of surgery was 6 cm (4-12.2). In order to completely resect the residual masses, adjunctive surgery had to be performed in 4 (18%) of all patients: resection of the abdominal aorta, inferior vena cava or renal vain with a graft replacement, nephrectomy and resection of parts of the intestine. 8 postoperative minor or major complications occurred, with 4 complications affecting only 1 patient. After a median follow-up of 25 month (8-47), 2 (9%) patients developed an in-field or out-field recurrence, respectively; all but one patients are alive showing an overall survival of 95.5%. CONCLUSIONS GTS is a rare disease among patients with advanced non-seminomatous germ cell tumors and necessitates complete surgical resection of the masses with curative intention. Due to its complexity, surgery should be performed in tertiary referral centers only. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e499 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Pia Paffenholz More articles by this author David Pfister More articles by this author Axel Heidenreich More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Organ-specific metastasis of breast cancer: molecular and cellular mechanisms underlying lung metastasis.

Breast cancer (BC) is the most common type of cancer in women and the second cause of cancer-related mortality world-wide. The majority of BC-related deaths is due to metastasis. Bone, lung, brain and liver are the primary target sites of BC metastasis. The clinical implications and mechanisms underlying bone metastasis have been reviewed before. Given the fact that BC lung metastasis (BCLM) usually produces symptoms only after the lungs have been vastly occupied with metastatic tumor masses, it is of paramount importance for diagnostic and prognostic, as well as therapeutic purposes to comprehend the molecular and cellular mechanisms underlying BCLM. Here, we review current insights into the organ-specificity of BC metastasis, including the role of cancer stem cells in triggering BC spread, the traveling of tumor cells in the blood stream and their migration across endothelial barriers, their adaptation to the lung microenvironment and the initiation of metastatic colonization within the lung. Detailed understanding of the mechanisms underlying BCLM will shed a new light on the identification of novel molecular targets to impede daunting pulmonary metastases in patients with breast cancer.

3:09 PM Abstract No. 333 Treatment approach for percutaneous ablation of metastatic adrenal masses

The adrenal gland is a common site of metastasis. Palliative ablation can have a role in tumor debulking for symptom management or offer an alternative to adrenalectomy for poor surgical candidates. The position of the adrenal in the retroperitoneum often requires access across the diaphragm or adjacent organs. This report describes our experience with percutaneous image-guided ablation of adrenal masses and approach for tumor access. HiIQ database was reviewed for cases of adrenal ablation performed August 2002 - August 2017. 19 ablations were performed under CT guidance in 12 patients (7 male, median age 61), of which 11/19 (58%) were right-sided. Cases were reviewed for tumor size, etiology, ablation modality, ablation approach, and complications. Etiologies were lung cancer (7), hepatocellular carcinoma (3), renal cell carcinoma (1), and neuroendocrine tumor (1). Mean adrenal size was 4.4 ± 2.5 cm. Ten of 19 cases (53%) used cryoablation (CA), 3/19 (16%) microwave ablation (MW) and 6/19 (32%) radiofrequency ablation (RF). Mean number of ablation sessions per lesion was 1.3 ± 0.5. Median number of probes was 3 for CA and 1 for RF and MW. Half of CA procedures were performed with conscious sedation. Only 3 cases allowed a direct approach. Alternative approaches included transpleural alone (11/19; 58%) or combination transpleural and transhepatic/transplenic (5/19; 26%). One CA procedure was aborted due to patient syncope, resulting in incomplete ablation. There was one minor complication of self-limited asymptomatic right pneumothorax. Percutaneous image-guided adrenal mass ablation is technically feasible with a low rate of complications. The location of the adrenal gland makes direct access often unfeasible; however, alternate approaches can provide safe treatment windows.

Management of growing teratoma syndrome (GTS): Results of the German Testicular Cancer Study Group.

566 Background: Growing teratoma syndrome (GTS) is an infrequent clinical phenomenon constituting only about 2 to 8% of all testis cancer patients. Data in the literature on the therapy of GTS are sparse, reflecting the rarity of the disease. The objective of was to determine the diagnostic, surgical and oncological outcome of patients with GTS treated in the 21st century. Methods: Between 01/2000 and 01/2010 post-chemotherapeutic retroperitoneal lymph node dissections (PCRLND) were performed in 296 patients with advanced NSGCT. We analysed the peri- and postoperative outcome of 16 patients (5.4%) that fulfilled the criteria of a GTS: enlarging metastatic mass in the retroperitoneum or visceral organs during systemic chemotherapy with normalized or decreasing tumour markers. Results: Mean patient age was 31 years (17-57). Initially, all patients had NSGCT with a good or intermediate prognosis according to IGCCCG; one patient had a poor prognosis. In all cases the primary tumour predominantly contained mature teratoma; two patients had a clinical stage IIb, nine and three presented with clinical stage IIc and III respectively. Median tumour diameter at time of surgery was 8.1 cm (1.5-32). Tumour markers were plateauing or normalized in all patients. Tumour masses were localized in the retroperitoneum in 15 patients; one patient demonstrated a pulmonary mass. After a median follow-up of 4.2 years, 2 patients developed outfield recurrences; all but one patients are alive. Conclusions: GTS is a rare disease among patients with advanced NSGCT and necessitates complete surgical resection of the masses with curative intention. Surgery should be considered at time of progression to facilitate complete removal of the growing teratoma and be performed in tertiary referral centers only.

Randomized phase II study to compare docetaxel plus S-1 with cisplatin plus S-1 in advanced gastric cancer without measurable lesions (HERBIS-3).

119 Background: Cisplatin and S-1 (CS) regimen is one of the standard chemotherapy as first-line for advanced gastric cancer. Docetaxel is a well-known agent with high anti-tumor effect for peritoneal metastasis from gastric cancer. A previous phase III study showed docetaxel plus S-1 (DS) regimen was recommended especially for advanced gastric cancer without measurable lesions. However, there was no study comparing the efficacy and safety of these two regimens. Methods: Eligibility criteria included HER2-negative unresectable or recurrent gastric adenocarcinoma, no measurable lesion according to RECIST v1.1, no massive peritoneal metastasis, no prior chemotherapy or radiotherapy, age ≤75, PS 0-2, adequate oral intake, and preserved organ functions. Patients were randomized to receive CS (cisplatin 60 mg/m² on day 8, S-1 40–60 mg twice a day for 3 weeks, every 5 weeks) or DS (docetaxel 40 mg/m² on day 1, S-1 40–60 mg twice a day for 2 weeks, every 3 weeks). Primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival (PFS) and adverse events. Results: Sixty-one patients were randomly allocated the CS group (n = 31) or the DS group (n = 30) between Aug 2011 and Sep 2015. All were unresectable primary cases, and baseline characteristics were well balanced between the two groups. One patient was ineligible due to HER2-positive. There was no treatment-related death. The main grade 3 or worse adverse events were neutropenia (27% in CS vs. 40% in DS), anemia (10% in CS vs. 10% in DS), fatigue (13% in CS vs. 7% in DS), anorexia (10% in CS vs. 3% in DS), and diarrhea (10% in CS vs. 3% in DS). The median OS time were 15.8 months in CS and 20.0 months in DS, respectively (log-rank P = 0.113). Hazard ratio for OS was 0.617 (95%CI, 0.337 – 1.128). The median PFS time were 9.6 months in CS and 11.2 months in DS, respectively (log-rank P = 0.196). Hazard ratio for PFS was 0.698 (95%CI, 0.404 – 1.208). Conclusions: DS showed less toxic and more active profiles than CS for treatment of advanced gastric cancer without measurable lesions. The clinical benefit of DS regimen should be demonstrated in a phase III study. Clinical trial information: UMIN000006179.

Multidisciplinary approach in the treatment of malignant paraganglioma of the glomus vagale: a case report

Malignant paraganglioma of the glomus vagale is a rare tumor entity originating from paraganglia or glomus cells. It typically affects middle age. It differs from benign paraganglioma because of its rapid growth and more aggressive clinical behavior. We report the case of a 40-year-old man presenting with a 5 cm lesion in the upper right cervical region detected by computed tomography (CT) and magnetic resonance imaging (MRI), which also showed enlargement of ipsilateral spinal and jugulodigastric lymph nodes with contrast enhancement. Clinical manifestations at diagnosis included a partial neurological deficit involving the right cranial nerves X, XI and XII. Tumor vascularization was assessed by digital angiography. The tumor mass was entirely removed by a right cervical approach with en-bloc resection with the regional lymph nodes. Histopathological examination showed a paraganglioma with cellular pleomorphism, necrotic microfoci, perineural infiltration and angiogenesis. Massive metastases in two of three jugulodigastric and one spinal lymph nodes on the right side were also detected. Postoperative workup included MRI, positron emission tomography (PET)/CT, meta-iodine-benzyl-guanidine (MIBG) scan, liver ultrasound and chest radiography. Subsequently, the patient underwent conformal radiotherapy with concomitant cisplatin administration. At the last clinical and radiological follow-up examination 5 years after completion of treatment, the patient was free of tumor recurrence. The integrated treatment by surgery and chemoradiation was feasible and effective in the management of this rare case of malignant paraganglioma of the glomus vagale. Multicenter studies should be done to increase the knowledge of tumor presentation and natural history and to analyze the possible treatment options.

WITHDRAWN: Distinguishing Metastases from Benign Adrenal Masses: What can CT Texture Analysis Do?

// Bing Shi 1,2,* , Gu-Mu-Yang Zhang 1,* , Hao Sun 1 , Min Xu 3 and Zheng-Yu Jin 1 1 Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, China 2 Department of Radiology, Shenzhen Sun Yat-Sen Cardiovascular Hospital, uohu District, Shenzhen, China 3 CT Scientific Collaboration, Siemens Healthcare Limited, Shanghai, China * These authors have contributed equally to this work Correspondence to: Hao Sun, email: sunhao_robert@126.com Zheng-Yu Jin, email: zhengyu_jin@126.com Keywords : adrenal; metastasis; CT; texture analysis Received: July 22, 2017     Accepted: November 17, 2017     Epub: January 05, 2018 Abstract Objective: To determine whether quantitative CT Texture Analysis(CTTA) can be used to differentiate metastases from benign adrenal masses on CT images. Materials and methods: 225 patients with 265 adrenal masses (101 metastatic and 165 benign masses) were included in this retrospective study. CTTA was performed and texture parameters were recorded on both unenhanced and contrast-enhanced CT images. Receiver operating characteristic (ROC) analysis was performed and the area under the ROC curve (AUC) was calculated using the significant texture parameters for the objective. Diagnostic performance was evaluated using the cutoff values of texture parameters by ROC analysis. Results: Compared to benign adrenal masses, metastases had significantly lower mean gray-level intensity (Mean), entropy, mean of positive pixels (MPP) and kurtosis on unenhanced images ( P < 0.05). On contrast-enhanced CT images, these texture-quantifiers were lower in the metastatic compared to the other group. Standard deviation (SD) and skewness were also significantly lower in metastases ( P < 0.05). A model incorporating Mean, SD, Entropy and MPP produced an AUC of 0.85±0.03 with an SVM accuracy of 77% to identify metastases from benign adrenal masses. Conclusion: Differentiation of metastatic and benign adrenal masses can be achieved accurately with CTTA on contrast-enhanced CT images.

Electrosurgical Excision and Differential Pathological Diagnosis of External Genital Tumors in Bitch

ABSTRACT: Forty-five necropsies from mixed breeds dogs were examined at animal reproduction research institute, agriculture research center, Egypt over 18-month period., Dogs’ age ranged from 2 to 5 years. The mean weight was 25.6 kg. The necropsies were diagnosed as vaginal mass, and bleeding, accompanied with ultrasonography imaging to find out any metastatic mass in abdomen region. Following general anesthesia with xylazin-ketamine, the tumor was excised by the electrosurgical technique (high frequency radio waves) which eliminates nerve and muscle stimulation; the cutting wave forms vaporize the cellular fluid causing cellular explosions. The tumor mass was preserved in formalin solution and submitted for histopathological and immunohistochemical evaluation using multi-cytokeratin, vimentin, S-100, CD79, p53, Ki 67, PCNA, estrogen receptor and progesterone receptors as well as actin and desmine. Thirty cases of Transmissible venereal tumors (TVT), six cases of Fibroma and three cases of Fibrosarcoma as well as three cases defined as Lipoleiomyoma or atypical leiomyoma (leiomyoma with bizarre nuclei) (ALM), and finally three cases leiomyosarcoma (LMS) of the vagina were distinguished. Moreover, we find that, malignant tumors (TVT, Fibrosarcoma and Leiomyosarcoma) were more frequent in older age while the benign were more in younger (fibroma and Leiomyoma). As German Shepard and Golden Retriever are more susceptible to TVT at average age 3 -4 years and 2-3 years whereas Pitbull and Rottweiler more affected with fibroma and fibrosarcoma at age 2-3 years while Leiomyoma (LM) and Leiomyosarcoma (LMS) were more frequent in Golden Retriever at age 2-3 and, 3-4 years respectively on the other hand Fibrosarcoma more frequently at 3-4 years age followed by Leiomyoma (LM) at 2-3 years age and finally Leiomyosarcoma (LMS) 3-4 years age. Finally, all the cases were subjected to a checkup monthly for six months after surgery and take special procedures and precautions if need in cases of malignancy. We concluded that, electrosurgery provides atraumatic, scalpel-like cutting precision and hemostasis, that resulting in reduced bleeding and tissue injury. Adding to, the important role of histopathology and immunohistopathological as well as hormonal receptors picture for diagnosis and differential diagnosis of vaginal tumors for the follow up of cases after surgery and take special percussions if need in cases of malignancy.

Bowel perforation secondary to metastatic lung cancer: Report of two cases with literature review

IntroductionGastrointestinal metastases from pulmonary neoplasm represent a rare but potentially fatal pathology that can complicate the disease in most advanced stages; this is a rare but well-known phenomenon in Literature and small intestine is the most common metastatic site. Generally these are patients with a known or surgically treated pulmonary neoplasm; the onset of pulmonary neoplastic disease with a symptomatic intestinal metastasis is to be considered extremely rare. Presentation of casesWe report two cases of small intestine perforation from pulmonary metastasis; diagnosis was made at the time of exploratory laparotomy and the operation was in one patient the resection of the perforated bowel and in the second a resection and an intestinal bypass to overcome the stenosis caused by the metastatic masses. In the postoperative period, a patient died of pulmonary complications, the second was dismissed, but survival was only three months. DiscussionIntestinal metastasis of a pulmonary tumor is a rare occurrence but must be suspected in acute abdominal syndrome in a patient with a diagnosed pulmonary neoplasia. ConclusionEmergency surgical treatment of abdominal metastases of a lung cancer is mandatory but prognosis is extremely unfavorable.

Traditional Chinese Medicine Integrated with Chemotherapy for Stage II-IIIA Patients with Non-Small-Cell Lung Cancer after Radical Surgery: A Retrospective Clinical Analysis with Small Sample Size.

Objective This study was designed to evaluate the clinical efficacy of combined traditional Chinese medicine (TCM) and conventional chemotherapy versus conventional chemotherapy in patients with stage II-IIIA non-small-cell lung cancer (NSCLC) after radical surgery. Methods A retrospective cohort study was conducted in patients with stage II-IIIA NSCLC from Subei People's Hospital and Yangzhou Traditional Chinese Medicine Hospital in Yangzhou City of Jiangsu Province from 2012 to 2016. Patients were divided into two groups: the TCM user group (patients receiving treatment with integrated TCM and conventional chemotherapy) and the non-TCM user group (patients receiving conventional chemotherapy only). The two groups were compared for their median disease-free survival (DFS) and median overall survival (OS). Results A total of 67 patients with stage II-IIIA NSCLC were enrolled between January 2012 and December 2016. The median DFS for the non-TCM user group was 601 days (95% confidence interval [CI], 375.7-826.3). The median DFS for TCM user group could not be calculated. However, log-rank analysis showed that the median survival time in the TCM user group was significantly longer than that of the non-TCM user group (P < 0.05). In addition, several significant risk factors were detected for predicting disease prognosis in patients with NSCLC, such as age, ECOG, lymphatic metastasis, and body mass index (BMI). For patients harboring these independent risk factors, the DFS of TCM user group was much longer than that of non-TCM user group (P < 0.05). Conclusion Adjuvant therapy with TCM may reduce the rate of tumor recurrence and metastasis and prolong DFS of patients with stage II-IIIA NSCLC.

Radiotherapy for Large Single Brain Metastasis of Non-Small Cell Lung Cancer: A Case Report

Background: Lung cancer is the most common primary site of brain metastases. Patients with a single brain metastasis from non-small cell lung cancer (NSCLC) have the potential for long term survival. Case report: A 39-year-old man presented stage IIIB (cT2N3M0) NSCLC. He underwent concurrent chemoradiotherapy. Follow-up chest CT and PET-CT showed complete tumor remission. The patient had headache and visual symptom 18 months after completion of treatment. The brain MRI showed metastatic brain mass. The size of single mass was 6.6 cm. He refused surgical procedure for brain lesion. He received radiation therapy. Total dose to PTV was 30 Gy in 5 fractions. The radiation therapy was well tolerated. Partial response of brain lesion was achieved and remained stable for 10 months until bone metastasis was found. Conclusions: Fractionated stereotactic radiotherapy (FSRT) in the current study could achieve good local tumor control and prevent neurological symptoms from worsening.

Accuracy of Diagnostic Methods for Detection of Head and Neck Primary Origin in Metastatic Neck Mass

Background and Objectives It is important to localize the primary site when cervical lymph node metastasis is detected. The purpose of this study was to evaluate the accuracy of diagnostic methods to detect the head and neck primary site in patients with metastatic neck mass. Subjects and Method Sixty-six patients who had presented with neck mass and were confirmed to have metastatic carcinoma by fine needle aspiration cytology from January 1998 to June 2016 were enrolled. We analyzed the accuracy of diagnostic modalities that inluded physical and endoscopic examination, CT, MRI, PET/CT, and guided biopsy. Results The mean age of patients was 58.7±12.6 years with the male to female ratio of 55:11. The metastatic lymph nodes were most common at level II (60/66, 90.9%) followed by levels III, IV, I and V. The most common primary site was tonsil (45.5%), followed by the nasopharynx, base of tongue and hypopharynx, and eight patients (12.1%) were diagnosed as metastatic carcinoma of unknown origin. The primary sites were detected by: physical and endoscopic examination in 36/66 (54.5%), CT in 41/66 (62.1%), MRI in 39/52 (75%) and PET/CT in 46/63 (73.1%). The primary sites were additionally detected using PET/CT for nine cases of the 20 cases, where primary sites were not found using physical and endoscopic examination, CT or MRI. Guided biopsy was done in 11 cases, where primary sites were not detected by all of the methods; hence, primary sites for 3 cases were additionally revealed. Conclusion PET/CT is a useful method when physical examination, CT and MRI cannot reveal the primary site of metastatic neck mass. Guided biopsy can be performed when primary site is not founded by any of the physical and imaging examinations. Key words: Diagnosis ㆍ Guided biopsy ㆍ Head and neck cancer ㆍ Metastatic neck mass ㆍ Unknown primary tumor

Description of a Feline Injection-Site Fibrosarcoma with Metastasis in the Cerebellum

Abstract Feline injection-site sarcomas were initially described by Hendrick and Goldschmidt (1991). The link between vaccination site and sarcoma occurrence suggested the term of vaccine-associated sarcomas. Our paper describes an unusual feline injection-site fibrosarcoma with cerebellar metastasis. A 7-year-old female domestic short-hair cat was submitted to the Pathology Department (Faculty of Veterinary Medicine Cluj- Napoca, Romania) for necropsy. A subcutaneous tumor (relapse) in the interscapular region and multiple metastatic masses in the lungs, kidneys, subcutaneous tissue (scapular and thigh regions) and cerebellum were observed. Cytological, histological and immunohistochemical (for vimentin, desmin, multi-cytokeratin, α-smooth muscle actin, S100 and CD45) analyses from all tumors were performed. Cytological examination identifi ed highly pleomorphic spindle-shaped cells admixed with neoplastic multinucleated giant cells. Histologically, all neoplastic masses were composed of numerous spindle cells arranged into interlacing bundles. Extensive intratumoral areas of necrosis along with a neutrophilic infiltrate were also detected. A fibrillary material was present among neoplastic cells (green stained by Masson’s trichrome method), suggesting a collagenous structure. In all tumors assessed, immunohistochemistry showed an intense reaction only for vimentin in numerous neoplastic cells. Based on the history, gross, cytological, histological and immunohistochemical data, the final diagnosis was recurrent feline injection-site fibrosarcoma, with multiple metastases (including in the cerebellum). Overall, an uncommon case of feline injection-site fibrosarcoma has been reported. This is the first consistent record of an injection site sarcoma in a cat with cerebellar metastasis.

Overexpression of periostin and distinct mesothelin forms predict malignant progression in a rat cholangiocarcinoma model.

Periostin and mesothelin have each been suggested to be predictors of poor survival for patients with intrahepatic cholangiocarcinoma, although the clinical prognostic value of both of these biomarkers remains uncertain. The aim of the current study was to investigate these biomarkers for their potential to act as tumor progression factors when assessed in orthotopic tumor and three‐dimensional culture models of rat cholangiocarcinoma progression. Using our orthotopic model, we demonstrated a strong positive correlation between tumor and serum periostin and mesothelin and increasing liver tumor mass and associated peritoneal metastases that also reflected differences in cholangiocarcinoma cell aggressiveness and malignant grade. Periostin immunostaining was most prominent in the desmoplastic stroma of larger sized more aggressive liver tumors and peritoneal metastases. In comparison, mesothelin was more highly expressed in the cholangiocarcinoma cells; the slower growing more highly differentiated liver tumors exhibited a luminal cancer cell surface immunostaining for this biomarker, and the rapidly growing less differentiated liver and metastatic tumor masses largely showed cytoplasmic mesothelin immunoreactivity. Two molecular weight forms of mesothelin were identified, one at ∼40 kDa and the other, a more heavily glycosylated form, at ∼50 kDa. Increased expression of the 40‐kDa mesothelin over that of the 50 kDa form predicted increased malignant progression in both the orthotopic liver tumors and in cholangiocarcinoma cells of different malignant potential in three‐dimensional culture. Moreover, coculturing of cancer‐associated myofibroblasts with cholangiocarcinoma cells promoted overexpression of the 40‐kDa mesothelin, which correlated with enhanced malignant progression in vitro. Conclusion: Periostin and mesothelin are useful predictors of tumor progression in our rat desmoplastic cholangiocarcinoma models. This supports their relevance to human intrahepatic cholangiocarcinoma. (Hepatology Communications 2018;2:155–172)

Employing 18F-FDG PET/CT for distinguishing benign from metastatic adrenal masses

BackgroundMetastatic adrenal disease can occur in a wide diversity of malignancies. Distinguishing benign from metastatic adrenal masses in oncologic patients is vital. ObjectiveTo appraise the 18F-FDG PET/CT performance for distinguishing benign from metastatic adrenal masses. Material and methodsIn the current prospective study, 21 patients with proven extra-adrenal primary malignancy, having adrenal masses ≥10 mm on the axial CT images of their PET/CT examinations, were enrolled. Positive PET findings for malignancy were considered if the mass showed FDG uptake equivalent to or more prominent than the FDG liver uptake. Alternatively, negative PET findings for malignancy were considered if the mass showed FDG uptake not as much of the FDG liver uptake. Afterward, the obtained results were correlated with serial imaging follow-up or histopathological diagnosis by surgery or percutaneous biopsy as the diagnostic standard of reference. ResultsAn overall number of 24 adrenal masses was diagnosed. Positive PET/CT results were found in 14 adrenal masses. All were finally considered to be metastases by serial imaging follow-up (n = 8) and histopathological analysis by surgery (n = 1) and percutaneous biopsy (n = 5). Accordingly, no false positive result was obtained. Negative PET/CT results were observed in 10 adrenal masses, 9 of them were finally confirmed to be benign by serial imaging follow-up. The remaining mass was finally confirmed to be metastasis by percutaneous biopsy and hence, it represented the false negative result. 93% sensitivity, 100% specificity and 96% accuracy for identifying adrenal metastases were obtained. Conclusion18F-FDG PET/CT is a precise, non invasive modality for distinguishing benign from metastatic adrenal masses in oncologic patients.

Post Traumatic Chronic Encapsulated Intracerebral Hematoma in a Child: Case Report and Brief Review of Literature

Chronic encapsulated intracerebral hematoma (CE-ICH) is an uncommon pathology that presents with headache, seizure, focal neurological deficits, or as a tumor. Trauma as a cause for CE-ICH is even rare and we believe this is the first case report as “trauma causing chronic encapsulated intracerebral hematoma “search in PubMed did not reveal any results. Repeated micro-hemorrhages in the CM or AVM are supposed to cause this lesion which progress from an earlier encapsulated phase to a thick capsulated stage with edema and clinical symptoms. CT or MRI is the diagnostic modality and it mimics, tumor, AVM, CM, angiomableed, cerebral abscess, metastatic mass or neurocysticercosis. Burr hole, mini-craniotomy, craniotomy, CT guided stereotactic aspiration or endoscopic excision are some options with equally good results. The present case with history of trauma was managed successfully with craniotomy with no recurrence for past one year. Nepal Journal of Neuroscience, Volume 14, Number 3, 2017, page: 46-48

Unique Obstructive Intestinal Manifestations of Metastatic Melanoma: A Case Series

Introduction: Though rare in adults, intussusception can occur anywhere in the gastrointestinal (GI) tract causing variable symptoms. 90% of cases may be due to disorders like neoplasm or postoperative status and may cause 1% of small bowel obstructions (SBO). Metastatic melanoma (MM) may involve the GI tract, and its various manifestations accentuate the need for astute awareness when treating patients with MM for GI symptoms.We report the cases of 3 women with MM diagnosed with partial SBO (pSBO) of varying types due to metastases.Figure: A) Axial fused PET/CT of the pelvis reveals a hypermetabolic focus in the ileum. B) Axial contrast-enhanced CT of the pelvis reveals ileal bowel wall thickening and associated intussusception caused by melanoma metastatic mass functioning as a lead-point (orange arrow). Oral contrast reveals distended small bowel proximal to intussusception indicating secondary partial SBO (yellow arrows).Figure: C) Enhancing partially obstructing mass (orange arrow) within the bowel lumen which expands the small bowel at that level. There is an adjacent distended loop of proximal small bowel which is partially filled with gas.Figure: D) Axial contrast CT with right lower quadrant intussusception, likely ileocolonic. E) Axial contrast CT with small bowel intussusception of the left mid-abdomen.Case Presentations: Case 1: A 55-year-old woman with MM (right inguinal primary lesion) to right axillary lymph nodes post excision and radiation underwent positron emission tomography/computed tomography (PET/CT) to address mild abdominal pain and for surveillance. PET/CT detected hypermetabolic activity in the small bowel (A) concerning for a soft tissue mass acting as a lead-point for intussusception and pSBO (B). Surgical excision of the mass confirmed MM. She received chemotherapy, but CT showed new mesenteric and hepatic masses. Case 2: A 75-year-old woman with MM (right heel primary lesion) throughout her abdomen was admitted for SBO causing left lower quadrant pain and constipation. She underwent prior excisions (several intra-abdominal surgeries) and several courses of chemotherapy. CT showed a left lower quadrant intraluminal enteric mass with proximal bowel distention consistent with a metastatic mass causing intermittent or pSBO (C). She improved with nonsurgical therapy. She was too ill for a novel chemotherapy trial and pursued hospice. Case 3: A 58-year-old woman with MM (periumbilical primary lesion) to the shoulder, lung, kidney, spleen, mesentery and brain presented with bilateral upper quadrant pain, postprandial emesis and decreased stool output. 2 months prior, a SBO resolved with conservative therapy. She had no prior abdominal surgery. In addition to intra-abdominal metastases, CT showed 2 areas of small bowel intussusception (D-E) with likely MM lead points causing pSBO. She improved without surgery and resumed chemotherapy. Discussion: These cases highlight the importance of maintaining high clinical suspicion of metastatic GI masses as culprits for SBO. When GI symptoms exist in patients with known malignancy such as MM, attempting to identify a soft tissue mass on imaging as a lead-point in intussusception or transition point in SBO for timely and accurate diagnosis is imperative to optimize management.

Unusual Cause of Bradycardia: Cardiac Metastasis From Pancreatic NK/T Cell Lymphoma

Extranodal NK/T cell lymphoma (NKTL) is a rare malignancy, accounting for 5-10% of all NHL. A majority of patients with NKTL present with nasal/sinus involvement. About 30% present with extranasal disease involving the upper airway, gastrointestinal tract, lungs, or soft tissues. Cardiac metastasis, in particular, is rare and difficult to diagnose given the lack of symptoms in most cases. Here we present a case of primary pancreatic NKTL with a metastatic right atrial mass. A 34 year-old previously healthy male presented with epigastric pain, jaundice, clay-colored stool, and dark urine for 1 week. He also complained of increasing dyspnea on minimal exertion without chest pain. On exam, he was jaundiced, bradycardic, with epigastric tenderness. Labs showed ALP 907, total bilirubin 10.2, AST 250, ALT 452, and lipase 381. Hepatitis and HIV serologies were negative. EKG showed junctional bradycardia at 42 bpm. CT showed a dilated common bile duct (CBD), pancreatic head and tail masses, and a filling defect in the right atrium. TTE showed a 2x4 cm mass in the right intra-atrial septum. CT guided biopsy of the pancreatic tail mass revealed EBV positive, nasal type NKTL. PET scan revealed hyper-metabolic foci consistent with lymphoma involving the right atrium, pancreas, spleen, and left adrenal gland. ERCP showed a high grade stricture in the distal CBD requiring a sphincterotomy with 2 stents placed in the CBD. The patient was then treated with chemotherapy. Repeat TTE after one cycle showed decrease in the right atrial mass size. Despite that, the patient developed atrial flutter with variable block, which was ultimately controlled with metoprolol. He was subsequently discharged with appropriate follow-up. We presented a rare case of primary pancreatic NKTL with cardiac metastasis. NKTL is a highly aggressive malignancy which rarely involves the heart. Our case emphasizes the point that clinicians should have a high index of suspicion for cardiac metastasis in a patient who presents with a pancreatic mass and cardiac symptoms such as arrhythmias, chest pain or dyspnea. Following the first round of chemotherapy, our patient's arrhythmia evolved to atrial flutter with variable block. This suggests that myocardium infiltrated with lymphoma cells may be susceptible to the development of potentially life-threatening arrhythmias. Thus, particular attention should be made to patients with NKTL and cardiac involvement to avoid arrhythmias post-chemotherapy.

Gastric Xanthoma (GX) as an Incidental Endoscopic Finding: A Report of 2 Cases

Gastric xanthomas (GXs) are yellow mucosal lesions characterized by the accumulation of lipid-laden histiocytes in the lamina propria. It is usually an incidental endoscopic finding of unclear clinical significance. It has a quite variable incidence that increases with age. GX was reported to be associated with chronic gastritis, hyperplastic polyps, gastric cancer and H.pylori infection. It has been hypothesized that GX could be related to gastric injury, which was supported by the higher prevalence of gastric atrophy among reported cases. Surprisingly, no correlation between GX and hyperlipidemia was found. Case 1: A 54 year-old Caucasian female with a history of primary pulmonary hypertension and ESRD post renal and bilateral lung transplant, admitted to the hospital with epigastric pain. Vital signs were normal, physical examination was significant for mild epigastric tenderness. Laboratory work and Imaging studies were inconclusive. EGD was remarkable for a single 5 mm sessile in the gastric fundus, complete resection was accomplished. (Figure 1) Pathology results revealed GX with focal active inflammation and erosion, No Helicobacter pylori organisms identified. There was no evidence of malignancy.FigureCase 2: This is an 82 year-old male with a significant history of DM II and renal cell carcinoma, who presented to our hospital with melena. On physical examination, he looked pale and tired. Vital signs were stable, his labs were remarkable only for normocytic anemia (HB: 7.9 g/dL, MCV: 92 fL). EGD was performed next day and it revealed a mass in the gastric body and a small gastric antral polyp (Figure 2), both biopsied. Subsequently, pathology results showed clear cell carcinoma consistent with metastatic renal cell carcinoma (the mass). Gastric antral polyp biopsy was suggestive of gastric xanthoma, confirmed by immunohistochemical staining for CD68. Eventually, laparoscopic partial gastrectomy was performed successfully. GX is a rare condition of unknown etiology, there is increasing evidence on the association between GX and gastric injury. GX should be considered as a warning sign, to look for other concomitant serious conditions, most importantly gastric cancer. In our reported cases, there was no evidence of H. pylori infection or primary gastric cancer, lipid profile was normal. However, the second patient endoscopy revealed a metastatic gastric mass. We think it is prudent to look for GX gastric partners and always send for histologic confirmation.Figure

A Novel Approach to the Differentiation of Intrabulbar Tumors in Color Doppler Imaging

ABSTRACTAim of the study: The similarity of many benign intrabulbar lesions to a malignant tumor requires detailed differential diagnostics. However, none of the known methods can be used as the only one to determine the type of lesions. The aim of this study was to determine color Doppler imaging (CDI) markers characteristic of choroidal melanoma and metastatic intrabulbar tumors, increasing the diagnostic value and giving a new insight into the use of this method.Materials and methods: CDI was performed in 44 patients with malignant tumors and in 49 patients with benign tumors. Patients with malignant tumors were divided into melanomas (n = 28) and metastatic tumors (n = 16). Univariate analysis with the logistic regression method and multivariate stepwise logistic regression analysis to create models testing tumor malignancy and differentiating melanoma from metastatic lesions were used. Model sensitivity and specificity were evaluated by the receiver–operating characteristic curve. A K-fold validation was performed.Results: Arterial blood flow, regular tumor surface, and tumor location in peripheral choroid were found significant for tumor malignancy. Mixed blood flow increased the accuracy of the test (p > 0.05). Model sensitivity and specificity were 83.7% and 75.7%. A regular tumor surface and hypoechoic or isoechoic tumor mass differentiated melanoma and metastatic masses in the regression model, with a sensitivity of 85.2% and a specificity of 75.0%. The area under curve (AUC) for both the models was 0.851 SE (standard error) 0.041 and 0.853 SE 0.063, respectively. AUC in five-fold cross-validation was 0.80 SE 0.0477 and 0.743 SE 0.094, respectively.Conclusions: Arterial or mixed blood flow, regular tumor surface, and tumor location in peripheral choroid may be characteristic of malignant tumors. Regular tumor surface and echogenicity of tumor mass could differentiate melanoma from metastatic tumor.