Multiple Satellite Lesions Research Articles

Neoadjuvant immune-checkpoint blockade therapy combined with TACE for resectable hepatocellular carcinoma with high recurrence risk: A phase II, single-arm clinical trial (MORNING).

e16267 Background: Prognoses of patients with hepatocellular carcinoma (HCC) remain unsatisfactory due to the high recurrence rate after curative hepatectomy. In this study, we investigated the safety and efficacy of neoadjuvant Cadonilimab (PD-1/CTLA-4, a bi-specific antibody) in combination with transarterial chemoembolization(TACE) for patients with high recurrence risk. Methods: For this phase II, single-centre, single-arm trial, resectable HCC (BCLC stage A/B) participants were enrolled, who should meet at least one of the following high-risk criteria: a) Multiple tumors or satellite lesions (≥2); b) tumor diameter>5cm (single tumor); c) AFP ≥ 400 ug/L; d) Predicted to be positive by the Microvascular invasion prediction model of our center according to preoperative imaging. All of the patients received two cycles of Cadonilimab(10mg/kg, Q3W) after TACE treatment. After resection, patients received additional 12 months of Cadonilimab(10mg/kg, Q3W) in the adjuvant setting. The primary end-point was the major pathologic response (MPR, defined as >90% necrosis of the resected tumour), the secondary endpoints are objective response rate (ORR), one-year recurrence rate and safety. Results: Between Apr 26th, 2023, and Jan 5th, 2024, 19 patients were enrolled, 84.2% of whom were male, with the mean age of 55. 9(47.4%) patients had more than one tumor and 13(68.4%) patients had tumors larger than 5cm. All patients received neoadjuvant TACE and at least one cycle of Cadonilimab. Of the 15 patients underwent successful resection, 7(46.7%) had MPR, while 12(80%) of them had 70% or greater tumour necrosis. 11 patients had partial response and the ORR was 73.3% per mRECIST. Additionally, only one patient received a partial response, while twelve patients maintained stable decease as assessed by RECIST1.1. 19(100%) patients had treatment-related adverse events of any grade during the neoadjuvant treatment period. The most common adverse events of any grade were ALT/AST increase (94.7%), abdominal pain (73.7%) and bilirubin increase (57.9%). 4 patients had grade 3 adverse events, including infusion reaction (2 patients), white blood cell decreased (2 patients) and fever (1 patients). The abdominal pain and fever were more relevant to TACE. No grade 4 or 5 events were observed. Conclusions: Cadonilimab combined with TACE as a neoadjuvant therapy seems to demonstrate safety and promising efficacy. Clinical trial information: NCT05578430 . [Table: see text]

A Case of Male Breast Cancer and a Literature Review

Background: Breast cancer in men, similar to that in women, originates in the mammary gland epithelium (ducts), and although less common than in women, its incidence has increased in recent decades, accompanied by significant advances in understanding the disease as a distinct entity. It shares important similarities with its female counterpart, with significant progress in diagnosis and treatment. Case presentation: In this report, we describe the clinical and imagenological characteristics of a 64-year-old man with metastatic adenocarcinoma to the skin. The patient presented with an ulcerative lesion on the right hemithorax, along the mid-clavicular line and anterior axillary line at the fifth intercostal space. The lesion had a soft, necrotic appearance, was prone to bleeding, and was referred by the patient as "resulting from trauma" a year ago, with progressive expansion and deepening, despite antibiotic use and cleansing of the wound. It invaded the surrounding skin, which appeared desquamated, erythematous with neovascularization, friable to the touch prone to bleeding with difficulty to achieve hemostasis, and multiple brownish nodular satellite lesions, with no other associated symptoms. A thoracic CT scan performed in the emergency department revealed a bilateral pleural effusion, predominantly on the right side, occupying 50% of the right lung space, along with an osteolytic lesion at the level of the manubrium of the sternum. A follow-up thoracic CT scan showed a pleural effusion occupying 80% of the right lung space, with a minor pneumothorax. The placement of an endopleural chest tube on the right side resulted in the extraction of 1800 ml of serosanguineous fluid, and pleural fluid culture did not reveal microorganisms or tumor cells, making the diagnosis of pulmonary adenocarcinoma less likely. A biopsy of the surrounding tissue yielded an invasive, poorly differentiated adenocarcinoma. Immunohistochemical staining was positive for estrogen and progesterone receptors, CK19, and negative for CK7, CK20, leading to the primary diagnosis of breast cancer based on clinical presentation and lesion location. Conclusions: Breast cancer in men, while sharing similarities with its female counterpart, presents its own unique characteristics. The identification of these factors and education about the significance of this condition, along with the discovery of specific biomarkers and targeted therapies, have the potential to significantly improve the prognosis of male patients in the future.

A phase II trial of hyperthermic intraperitoneal chemotherapy combined with tislelizumab and targeted therapy in high-risk hepatocellular carcinoma after R0 resection.

TPS635 Background: Hepatocellular carcinoma (HCC) is the predominant form of liver cancer, accounting for 75%–85% of cases, for which surgical resection represents the most effective treatment, with curative potential. However, the high incidence of tumor relapse (50%–70% 5 years after surgery) has hindered improved survival. Furthermore, early recurrence within 2 years after surgery accounts for 70% of relapsed HCC cases, is rarely treatable, and has been associated with poor survival. With the development of novel tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors for advanced HCC, the management of patients has been greatly improved. However, no guidelines for novel systematic therapy to treat high risk of relapse HCC have been established. Targeted therapy combined with immunotherapy as systemic treatment has become a new approach in high risk of relapse HCC. Hyperthermic intraperitoneal chemotherapy (HIPEC), as an adjuvant treatment of abdominal malignant tumors, has achieved unique effects in the treatment of many cancers. The aim of this study was to assess the activity and feasibility of a combination of HIPEC with Tislelizumab and TKIs for the treatment of high risk of relapse HCC. Methods: The single-center, open-label, one-armed, Phase 2 study (NCT05546619) will enroll ~30 adults who meet the diagnostic criteria of high risk of relapse HCC (multiple tumors or satellite lesions; tumor diameter > 5cm; HCC rupture and bleeding; combined with vascular invasion; AFP > 32ng/ml). Patients will receive the following treatments as noted in the table. The primary and secondary endpoints are listed in the table. Tumor response will be evaluated once every 6 weeks for the first 48 weeks of treatment, and once every 12 weeks thereafter according to RECIST v1.1; safety will be assessed through monitoring the incidence and severity of adverse events graded according to CTCAE 5.0, vital signs and clinical laboratory results. Clinical trial information: NCT05546619 . [Table: see text]

A Newborn with a Giant Congenital Melanocytic Nevus and Hyperbilirubinemia: What to do Now

Giant congenital melanocytic nevi (GCMN) are rare skin lesions that affect approximately 1 in 20,000 live births. GCMN must be followed up closely because of its association with an increased risk of malignant degeneration. We report a newborn with a giant lession of 14 cm in diameter which was located on the chest and multiple satellite lesions were present on the body. The patient required phototherapy due to hyperbilirubinemia. Some studies suggest that phototherapy can increase the incidence of neonatalnevi, and melanocytic nevi is the most important risk factor for the occurrence of skin melanoma. Considering the risk of developing kernicterus, we concluded that the most appropriate solution for the patient was to cover the lesions and apply phototherapy in the prone position.

ODP052 Recurrent Pheochromocytoma Concerning For Surgical Seeding From Prior Partial Adrenalectomy

Abstract Introduction Surgery for a sporadic pheochromocytoma does not always lead to long-term cure, even in patients with a benign tumor, with an estimated recurrence rate of 3% (1). We present a patient with a history of pheochromocytoma s/p partial adrenalectomy 10 years prior found to have recurrence not within the adrenal parenchyma, but in the prior resection bed and diaphragm, concerning for seeding of the surgical bed from prior surgery. Clinical Case A 56-year-old man with a history of pheochromocytoma s/p a laparoscopic left partial adrenalectomy 10 years prior, with no detected rupture of the capsule at time of surgery, presented with symptoms of palpitations and anxiety. The patient had previously tested negative for SDHB, SDHD, MEN2, and VHL. Repeat labs were concerning for recurrence: 24-hour urine normetanephrines 1192 μ g (156-729 μ g) and metanephrines 204 μ g (58-276 μ g), plasma normetanephrine 479.4 pg/mL (0. 0-136.8 pg/mL), metanephrines 38.2 pg/mL (0. 0-88. 0 pg/mL), and chromogranin A 129. 0 ng/mL (0. 0-101.8 ng/mL). MRI with contrast showed a mildly enhancing mass in the left adrenalectomy postsurgical bed with no changes noted in the liver, and an I-123 MIBG scan showed focal uptake in the left adrenal gland corresponding to the mass seen on MRI as well as heterogeneous uptake in the left hepatic lobe. A DOTATE PET scan done prior was negative. The patient underwent laparoscopic left adrenalectomy; the left adrenal gland was dissected and the patient was found to have multiple satellite lesions along the left diaphragm which were excised. On pathology, immunostains were positive for chromogranin and synaptophysin. Multiple nodules of pheochromocytoma/paraganglioma were seen involving the soft tissue of the diaphragm (<0.1-0.6 cm) and the periadrenal soft tissue and prior resection bed (<0.1-2.5 cm), with no tumor seen within the residual adrenal parenchyma. The tumor extended to the cauterized tissue edges and no lymphovascular invasion was seen. No necrosis, no increased mitotic activity, no atypical mitotic figures were noted, and Ki-67 proliferation index was <1%. Testing done six weeks postoperatively showed plasma normetanephrine 49.9 pg/mL, metanephrine <10 pg/mL, and chromogranin A 87.9 ng/mL. Repeat genetic testing was negative for SDHB, SDHD, VHL, and MEN2. One year postoperatively, the patient's blood pressures are well-controlled on a small dose of doxazosin, kept on as a prophylactic measure. Conclusion This case demonstrates a rare presentation of recurrent pheochromocytoma found in the diaphragm, periadrenal tissue, and surgical bed from a prior partial adrenalectomy, concerning for recurrence in setting of surgical seeding from prior surgery. This case highlights the importance of perhaps considering a total adrenalectomy rather than partial when possible. Reference: (1) Holscher I, et al. Recurrence Rate of Sporadic Pheochromocytomas After Curative Adrenalectomy: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab. 2021 Jan 23;106(2): 588-597. Presentation: No date and time listed

Deficient mismatch repair is detected in large-to-giant congenital melanocytic naevi: providing new insight into aetiology and diagnosis.

The aetiologies of large-to-giant congenital melanocytic naevi (LGCMN) remain ambiguous. A previous study discovered signatures associated with deficient mismatch repair (dMMR) in patients with LGCMN. However, a screening diagnostic immunohistochemistry (IHC) panel of dMMR in patients with LGCMN has not been performed to date. To identify the MMR status and aetiologies of LGCMN. A total of 110 patients with CMN, including 30 giant CMN, 30 large CMN, 30 medium CMN and 20 small CMN, underwent diagnostic IHC (for MSH6, MSH2, PMS2 and MLH1) screening of dMMR. The control group comprised normal skin samples from 20 healthy people. MMR proteins with little effect (MSH3 and PMS1) on the MMR system were stained in all samples. The surgical procedures conducted on each patient were noted because they might alter the behaviour of CMN and confound the results. Binary logistic regression analyses were performed between the phenotypic data and MMR status to identify associations. Whole-exome sequencing was performed on the main naevi, satellite naevi and normal skin tissues of four patients to detect variants. Mutational signature analyses were conducted to explore the aetiologies of LGCMN. dMMR was detected in 37% (11 of 30) of giant, 23% (7 of 30) of large and 7% (2 of 30) of medium CMNs, but were not identified in small CMNs or normal skin tissues. Moreover, multiple LGCMNs had a much higher dMMR rate than did single LGCMNs. The regression analyses showed that MMR status was significantly associated with CMN size and the presence of satellites, but was not correlated with age, sex, location, satellite diversity or tissue expansion. Notably, the pattern of protein loss in LGCMN mainly consisted of PMS2 loss. Mutational signature analyses detected dMMR-related signatures in patients with LGCMN. Additionally, rare deleterious germline mutations in DNA repair genes were detected in LGCMN, mainly in MSH6, ATM, RAD50, BRCA1 and ERCC8. These germline mutations were single-patient variants with unknown significance. dMMR is one of the aetiologies underlying LGCMN, particularly in patients with giant main lesions and multiple satellite lesions. Further studies are necessary to investigate the role of the DNA repair system, particularly MMR, in LGCMN.

Bathing trunk naevus

Giant congenital melanocytic naevus is a naevus measuring more than 20 cm in adulthood. Its incidence is 1:20,000 and is more common in girls. Bathing trunk naevus, a specific form of giant congenital melanocytic naevus is even rarer with incidence of 1:500,000. Giant congenital melanocytic naevus usually presents as a brown lesion, with flat or mamillated surface, well-defined borders and hypertrichosis. Dermoscopic examination of melanocytic naevi shows brown-blackish background, globules, reticular network and vascular structures. Although giant congenital melanocytic naevus is often diagnosed clinically, dermoscopy aids in detecting early changes of complications such as malignant melanoma. We report a case of bathing trunk naevus with multiple satellite lesions in a brown child with dermoscopic findings.

Congenital Melanocytic Hairy Nevi in a Child from North-Western Nigeria

Aim: To present the first report of a large congenital melanocytic nevus with satellite nevi in an apparently healthy child from Sokoto, North-Western Nigeria.
 Presentation of Case: A three year old girl was brought to the paediatric out-patient clinic of Paediatrics department of Usmanu Danfodiyo University Teaching Hospital (UDUTH) Sokoto with complaints of darkened skin colour on the left side of the face and scalp, the left arm, lower back, buttocks, and thighs, and excessive hair growth over the same side of the face since birth. There were no neurological symptoms Physical examination findings revealed a well-nourished, not ill looking child. She had a hyper pigmented patch on the left side of the face extending from the lower jaw to the scalp, measuring 21 cm in its longest length, with hypertrichosis on the same site, and two distinct, firm, painless nodular lesions on the left temporal region measuring 3 mm and 4mm respectively. On the lower one-third of the left arm was a hairy, velvety area of hyperpigmentation measuring 2X3 cm in diameter. Other affected sites were the lower back, the gluteal region and the thighs. Her neurologic and other systemic examinations were normal. A diagnosis of large congenital facial melanocytic hairy nevus with multiple satellite nevi was made.
 Discussion: Congenital melanocytic nevi are benign proliferations of melanocytic cells said to be present at birth or in the first two years of life. Large lesions are rare, they measure 20 cm or more and are said to occur more commonly on the trunk and thighs. The exact pathogenesis of congenital melanocytic nevi is yet, unknown. It is thought to occur as a result of a morphological error in the neuroectoderm during embryogenesis. Treatment of patients with large congenital melanocytic nevus may include surgical or non-surgical procedures as well as psychological interventions. Large lesions, multiple satellite lesions or paravertebral and axial locations are sometimes associated with the risk of neurological complications and malignant transformation.
 Conclusion: Large congenital melanocytic nevi are uncommon skin lesions that can occur in apparently healthy children. Individualization of the patients with regards to treatment options and long term monitoring are imperative.

Giant congenital melanocytic nevus with neurotized lesions mimicking neurofibromas – A rare presentation

Giant congenital melanocytic nevus (GCMN) is a deeply pigmented lesion, often associated with hypertrichosis and multiple scattered satellite lesions. During infancy apart from textural changes, rapidly growing “proliferative nodules” mimicking melanoma can occur in the nevus. Areas of the nevus may be infiltrated by an overgrowth of fat or nerve tissue, so-called lipomatous or neurotized areas, respectively, common in larger nevi. We report a case of GCMN associated with multiple neurotized areas mimicking large neurofibromas, a rare phenomenon.

2454 Hepatocellular Carcinoma After Fontan Surgery

INTRODUCTION: Tricuspid atresia is a congenital cyanotic heart disease characterized by inability of the blood to flow from the right atrium to the right ventricle. The Fontan operation was first described for tricuspid atresia in 1971. The surgery creates an extra cardiac conduit to maintain circulation in the pulmonary artery without the pump function of the ventricle. This leads to low cardiac output and an increased central venous pressure mostly due to the resistance in the pulmonary circulation. Post- surgery, patients are at risk for liver cirrhosis and possibly hepatocellular carcinoma (HCC), due to venous congestion. Official guidelines do not exist for the screening of patient's for hepatocellular carcinoma after Fontan surgery. We present a case report of a woman with HCC and a history of Fontan surgery. CASE DESCRIPTION/METHODS: A 46-year-old woman with a past medical history of Fontan surgery for tricuspid atresia at age nine presented to the hospital with right upper quadrant discomfort. The patient had a negative history for alcohol abuse, hepatitis or family history for liver disease. Physical examination revealed jaundice and a palpable mass in the right upper quadrant. Laboratory data demonstrated elevated liver enzymes, bilirubin of 1.8 (mg/dl) and an alpha fetoprotein of 1386 (ng/ml). Computed tomographic (CT) scan of the abdomen demonstrated a subcapsular mass with multiple satellite lesions, in the liver. Liver biopsy confirmed moderately differentiated hepatocellular carcinoma. CT scan of lung was compatible with multiple metastatic lesions. She was started on chemotherapy with sorafenib and underwent radio-embolization. She had a poor clinical response to this initial treatment and was subsequently started on nivolumab. The patient was later admitted to the medical intensive care unit with decompensated liver disease and unfortunately, died soon after. DISCUSSION: Her only identifiable risk factor for hepatocellular carcinoma was her history of Fontan surgery. Current opinion is to screen patients for liver disease after Fontan procedure with magnetic resonance imaging (MRI) or CT scan of the liver every 3-5 years, starting at five years after surgery. We aim to increase awareness about the association between Fontan surgery and HCC with the help of our case report.

Neurocutaneous Melanosis in Association With Large Congenital Melanocytic Nevi in Children: A Report of 2 Cases With Clinical, Radiological, and Pathogenetic Evaluation.

Background: Melanocytic nevi present at birth, or within the first few months of life, are defined as congenital melanocytic nevi (CMN). Neurocutaneous melanosis (NCM) is a rare disorder, represents pigment cell tumors of the leptomeninges, and occurs in association with large or multiple CMN. NCM carries an extremely poor prognosis. NRAS and BRAFV600E genetic mutations were reported in CMN. Our aim was to report 2 rare cases of NCM associated with large-sized CMN.Materials and Methods: Two cases were enrolled, a 19-month-old boy with multiple satellite and giant CMN (GCMN); and a 57-month-old girl with large CMN (LCMN). Both patients had central nervous system (CNS) symptoms, and therefore, were studied from clinical, radiological, and immunohistopathological aspects. Cytogenetic study was done for one of them.Results: Both patients had CMN located in the head/neck, with no cutaneous melanoma. MRI was the most reliable method for early detection of NCM. NCM was proved in the 2 studied cases by immunohistopathology performed after surgery. The boy with GCMN carried NRAS mutation at codon 61, in addition to the characteristic facial features relevant to RASopathies. Both patients died despite surgical intervention.Conclusion: Our report highlights the need for pediatricians to be alert to the risk of NCM in association with CMN, especially when a CMN lesion is large, or there are multiple satellite lesions, or the nevus location is at the head or neck. Moreover, in the setting of CMN, the absence of skin melanoma does not exclude the presence of NCM.

Macular Colobomata: Comparison of Clinical and Optical Coherence Tomography Features With Serologic Results

To assess the correlation between the morphologic features and serology in eyes with macular colobomata (MC). Retrospective comparative case series. Setting: Institutional. Patients presenting with MC to the retina clinic over a period of 2 years (January 2016 to December 2017). Interventional/Observational Procedure: Color fundus and swept-source optical coherence tomography (SSOCT) features were reviewed and assessed in 3 groups based on the serum IgG results: positive for Toxoplasma, positive for cytomegalovirus (CMV), and serology negative. Morphologic features on clinical and OCT-based examination. A total of 49 eyes of 27 patients were recruited. The mean age was 24.8 ± 14.9 years (range 7-60 years). While the lesion size, the presence of satellite lesions, choroidal excavation, and choroidal lacunae (large choroidal vessels) on SSOCT differed significantly among the groups, pigmentation, retinal fibrosis, shape, retinal vessel pattern, and choroidal vessel visibility did not vary significantly. The lesions in CMV serology-positive cases were mostly solitary (n= 8/8), large (n= 5/8) and deeply excavated (n= 8/8). The lesions in Toxoplasma serology-positive cases were mostly flat to shallow (n= 18/26), medium-sized (n= 19/26), and either a solitary lesion (n= 17/26) or multiple satellite lesions (n= 9/26). The lesions in serology-negative cases were mostly small to medium (n= 13/15), solitary (n= 15/15), deeply excavated lesions (n= 11/15) with choroidal lacunae (n= 8/15). The clinical and SSOCT features such as the lesion size, the presence of satellite lesions, choroidal excavation, and choroidal lacunae can provide a clue toward the etiology of macular colobomata.

Melena as a first sign of metastatic hepatic angiosarcoma: A case report

Introduction. Angiosarcomas are malignant tumors of vascular endothelium that may arise from different locations. Although primary hepatic angiosarcoma accounts for only 1.8% of primary liver tumors, it is the most common malignant mesenchymal tumor of the liver. We report a case of primary hepatic angiosarcoma with melena as an unusual initial manifestation of this extremely rare tumor. Case report. Forty-four-years old patient with melena was referred to our Clinic because melena was not resolved after repeated argon plasma coagulation of bleeding lesions during esophagogastroduodenoscopy in the regional hospital. Abdominal ultrasound and multislice computed tomography (MSCT) revealed enlarged liver, with focal lesion 6 cm in diameter localized in the left lobe with multiple satellite lesions in both liver lobes, enlarged spleen and extremely dilated and long umbilical vein. Double-balloon enteroscopy and video capsule endoscopy detected the multiple bleeding vascular lesions in the small bowel. Histopathological examination and immunohistochemistry of the small bowel lesions revealed malignant mesenchymal proliferation with vascular/endothelium differentiation of neoplastic cells. The patient was diagnosed with metastatic angiosarcoma probably of hepatic origin with metastasis in the small bowel, that caused melena, and in the lumbar spine, causing back pain. Conclusion. Rare causes of melena include bleeding from primary or metastatic hemangiosarcoma localized in the gastrointestinal tract, especially small bowel.

Imaging features of rosette-forming glioneuronal tumours

To describe the imaging features of rosette-forming glioneuronal tumours (RGNTs) to enable accurate diagnosis. Image data and clinical findings for seven patients with histopathologically confirmed RGNTs were studied comprehensively. Six neoplasms were located near the midline and all were relatively well circumscribed. Most lesions were hypointense on T1-weighted images and hyperintense on T2-weighted images. Furthermore, five tumours were hypointense on diffusion-weighted imaging (DWI). On computed tomography (CT), the solid tumour portions showed hypo-attenuation compared with brain parenchyma. Obvious calcification was found in two cases, and hydrocephalus was seen in five. Cerebrospinal fluid (CSF) dissemination and multiple satellite lesions were not observed in these cases. Haemorrhage was found in one case. The "green bell pepper sign" was present in five cases on gadolinium-enhanced magnetic resonance imaging (MRI). Each of the patients accepted surgical treatment, and no recurrences occurred during follow-up. RGNTs are very rare mixed glioneuronal tumours and mostly affect young people. They are usually hypointense on T1-weighted images and DWI, hyperintense on T2-weighted images, and hypo-attenuated on CT images. The "green bell pepper sign" after gadolinium enhancement, intratumoural haemorrhage, CSF dissemination, and multiple satellite lesions provide additional clues to the correct diagnosis. A relatively well-demarcated tumour with these features and a midline location should raise suspicion of an RGNT.

Giant Congenital Melanocytic Nevus with Limb Hypoplasia and Lipomatosis: A Rare Association

The congenital melanocytic nevi (CMN) are very rare, hyper pigmented macular lesions formed by overgrowth of the melanocytes and melanoblasts. This exists since birth and also named as bathing trunk, coat sleeve or stocking nevi. They occur in less than 1% of the neonates in any site of the body but commonly occur over the trunk and thigh areas. The giant congenital nevus is greater than 20 cm in size, pigmented and often hairy. Here, we are discussing a classical case of large congenital melanocytic nevus presented over right part of torso, lower limb, lower back and buttocks, with multiple satellite lesions all over body with right lower limb hypotrophy. The diagnosis was confirmed by histopathology. Apart from the rarity of the disease, this case report highlights the rare association of CMN with hypotrophy of limb.

Warner and Wilson-Jones syndrome

Recurrent pyogenic granuloma with satellite lesions is also known as Warner and Wilson-Jones syndrome. Local recurrences do occur but presenting with multiple satellite lesions is very rare. We provide a characteristic clinical image and microphotographs of a case of pyogenic granuloma with satellitoses in an 18-year-old male who presented with a painful erythematous nodule on his back in interscapular region. A punch biopsy was taken from the lesion and it showed features of pyogenic granuloma. Combining clinical and microscopic features, a final diagnosis of pyogenic granuloma with satellite lesions was made. Surgeons excised the lesion and skin grafting was done which healed well. Three years follow-up of the patient was uneventful

Giant malignant melanoma of the anterior chest wall with widespread metastasis

Introduction: Giant melanomas are defined as lesions greater than 10 cm; independent of their depth of invasion; these entities are rarely encountered in clinical practice and they represent a real treatment challenge as many patients are diagnosed with advanced disease. Herein, we document our experience with the first reported giant melanoma of the anterior chest wall and the 5th largest melanoma of any anatomic site. case report: A 63-year-old caucasian male presented with an irregular, pigmented, non-healing ulcer, measuring 1.5x1.5 cm on his chest. He was referred for a skin biopsy but was lost to follow-up. He returned one year later complaining of fatigue, night sweats, and unintentional weight loss in addition to further growth of the skin lesion. His skin lesion was now a large, fungating mass, fixed to the chest wall and measuring 15x13x2.5 cm. there were multiple satellite lesions on the chest wall and palpable left axillary lymphadenopathy. skin biopsy confirmed the diagnosis of malignant melanoma. computed tomography scan demonstrated innumerable pulmonary nodules, retroperitoneal and peri

Independent predictors of overall survival and recurrence in biphenotypic hepatocellular cancer.

291 Background: Biphenotypic hepatocellular cancer (BPHCC), which is a combined hepatocellular cancer (HCC) and cholangiocarcinoma (CC), is a rare form of primary liver cancer, whose long term prognosis is extremely poor as compared to either HCC or CC alone. Little is known about the recurrence rates and predictors of recurrence in BPHCC. Our objective was to 1) identify both overall survival and recurrence rates after primary resection or systemic and liver directed therapies and 2) to evaluate the independent predictors of survival and recurrence. Methods: Our Hepatobiliary Registry identified 65 patients with BPHCC from February 1999 till April 2013 at Siteman Cancer Center, Washington University, St. Louis MO. We conducted univariate Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression to identify factors independently associated with overall survival. We also conducted multivariable logistic regression analysis to identify factors independently associated with recurrence. Results: Of the 65 patients in our study, 18 (28 %) with prior resection, 2 (3 %) after OLT, 45 (69 %) ineligible for surgery, 40 (62 %) were treated with chemotherapy, 17 (26%) with liver directed therapies. Overall survival was 39.2 % at 1 year. Independent factors associated with survival were: smoking (HR 2.84, 95% CI 1.29-6.23, p = 0.0089), tumor thrombus (HR 5.45, 95% CI 2.05-14.50, p = 0.0007), any liver directed treatment (HR 3.01, 95% CI 1.21-7.48, p = 0.0175), multiple satellite lesions (HR 3.17, 95% CI 1.71-8.58, p = 0.025) and prior tumor resection (HR 2.65, 95% CI 1.16-6.03, p = 0.020). Risk of recurrence was independently predicted by male sex (OR 3.98, 95% CI 1.30-12.15, p = 0.015) and multiple satellite lesions (OR 15.42, 95% CI 2.68-88.62, p = 0.0076). Conclusions: Patients with biphenotypic cancers have a devastating overall survival. Tumor thrombus and satellite lesions were the strongest predictors of poor survival; satellite lesions also strongly predicted recurrence. In this rare form of cancer, this is the largest study to identify factors associated with overall survival and recurrence. These factors should help guide clinical care of patients with BPHCC.

Malignant granular cell tumor of the back: a case report and review of the literature.

Malignant granular cell tumors are rare, intensely aggressive entities. This paper presents a case of a large rapidly recurrent malignant granular cell tumor with regional and distal metastases on the back of a 54-year-old Cuban man. The primary tumor recurred within six months of the original wide local excision and with satellite lesions apparent at twelve months, and the mass was diagnosed using the histological criteria established by Fanburg-Smith et al. for malignant granular cell tumors. By fifteen months, right axillary lymphadenopathy, multiple satellite lesions, pulmonary nodules, and distant metastasis in the right thigh were present. At sixteen months, wide local excision of recurrent mass and local satellite masses along with right axillary dissection and placement of Integra with subsequent split-thickness skin graft were performed by surgical oncology and plastic surgery teams. The surgical specimen measured 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses with the largest mass 22.0 × 9.0 × 4.6 cm. Following surgery, patient was started on Pazopanib 800 mg/day based on phase III randomized trial data in the treatment of soft tissue sarcomas showing this as a potential novel therapy for malignant granular cell tumors.

Oral floor and gingival metastasis of cholangiocarcinoma: a case report and review of the literature.

The oral cavity is very unusual site of metastases even though wide spread metastatic disease may be present. The most common primary sites that metastasize to the oral cavity are lung, kidney, breast, and hepatocellular carcinoma. We present a rare case of a 77-year-old Caucasian female with metastasis from a cholangiocarcinoma to the oral floor contiguous with lingual gingival mucosa. The patient presented with left sided rib pain. A CT scan of the chest, abdomen, and pelvis showed multiple pulmonary nodules and a single dominant mass in the right lobe of the liver. This tumor was 6.5 cm with multiple satellite lesions surrounding it. The liver biopsy was diagnostic of a moderately to poorly differentiated adenocarcinoma, consistent with a primary cholangiocarcinoma. After undergoing one cycle of gemcitabine chemotherapy, the patient noticed an extremely rapidly growing mass involving her right lower gingiva and the entire right floor of her mouth. The biopsy of that mass also showed a moderately to poorly differentiated adenocarcinoma. The gingival tumor had a similar cytomorphology and immunophenotype as her cholangiocarcinoma. Therefore, an unusual site for metastatic cholangiocarcinoma was confirmed.