Sign Of Metastatic Disease Research Articles

Current Evidence and Future Perspectives in the Management of Nonmetastatic Upper Tract Urothelial Carcinoma

This case-based discussion describes the management of a 66-yr-old man who presented to the emergency department with gross hematuria. His urine cytology was benign, and computed tomography (CT) with nephrographic phase revealed a 2.5 cm filling defect within the left renal pelvis and luminal narrowing in the right proximal ureter with hydronephrosis. CT showed no lymphadenopathy and no sign of metastatic disease. Cystoscopy was normal. In a progressive case-based discussion fashion, we will discuss the diagnostic and treatment options with two different perspectives: (1) guidelines-based current standard of care and (2) an outlook on future perspectives using the latest scientific advances that may soon become the standard of care. Patient summaryThis presentation of a real-life clinical scenario will be useful in describing the current standard of care and future perspectives regarding the diagnosis and treatment of upper urinary tract tumors.

LUMPS AND BUMPS: A COMMON COMPLAINT WITH SINISTER IMPLICATIONS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is exceedingly uncommon for malignancy to present as cutaneous metastases. In fact, cutaneous metastases as an initial manifestation of internal neoplasias represent only 0.8% of total cases; and implies, in general, aggressive disease and poor prognosis. We present an atypical manifestation of non-small cell lung cancer (NSCLC) initially presenting as tender cutaneous nodules. CASE PRESENTATION: Patient is a 69 year-old female with pertinent medical history of 70 pack-year tobacco abuse who presented with a complaint of multiple painful, ulcerating skin nodules. 2 months prior to admission, she was seen by her physician for skin lesions and was prescribed a short course of antibiotics without resolution. At admission, patient reported a 1 month history of fatigue, unintentional 15 pound weight loss, and diffuse myalgias. Initial vital signs revealed normal temperature, heart rate of 113 bpm, respiratory rate of 16 breaths per minute, saturating 97% on room air. Labs revealed leukocytosis at 19.8 k/mm3 and lactic acid level of 3 mmol/L. She was suspected to have sepsis secondary to cellulitis. She was given 30 mg/kg fluid bolus and started on broad spectrum antibiotics. On examination, she had multiple ulcerated subcutaneous skin nodules on her chest, abdomen, inguinal area, and scalp. Radiographic imaging revealed a large left upper lobe mass with extensive pulmonary nodules concerning for malignancy. Imaging of her head revealed numerous supra and infratentorial metastatic lesions. Punch biopsy of a skin nodule was taken. Immunohistochemical (IHC) testing was positive for pankeratin and cytokeratin 7, but were negative for any neuroendocrine markers. Biopsy and IHC were consistent with poorly differentiated non-small cell lung adenocarcinoma. DISCUSSION: Cutaneous involvement among patients diagnosed with NSCLC is a rare finding, affecting 2.8%. Even less uncommon as the initial presenting symptom. Patterns of cutaneous metastases vary among women and men. Breast cancer, colorectal cancer, and melanoma frequently metastasize to the skin in women. In men; melanoma, lung cancer, and colorectal cancer are the most common sources of cutaneous metastases. Cutaneous metastases can present asymptomatically or be associated with pain and tenderness. Furthermore, they can often be mistaken for inflammatory dermatosis, infectious cellulitis, bullous or papulosquamous lesions. CONCLUSIONS: While rare, cutaneous manifestation can be the first sign of metastatic disease and often purports a poor prognosis. Therefore, it is important to recognize and evaluate abnormal skin lesions in the correct clinical context with appropriate clinical measures such as history, physical exams, imaging, and biopsy with histochemical staining. Reference #1: Alkhayat H, Hong CH. Cutaneous Metastases from Non-Small Cell Lung Cancer. J Cutan Med Surg. 2006 Nov-Dec;10(6):304-7. Reference #2: Ardavanis A, Orphanos G, Ioannidis G, Rigatos G. Skin Metastases from Primary Lung Cancer. Report of Three Cases and a Brief Review. In vivo. 2001; 20(5):671-3. Reference #3: Baldeo C, Ali R, Seeram V, House J. Lung Cancer Presenting as Soft-Tissue Metastasis. Case Rep Oncol. 2015;8:185-188. DISCLOSURES: No relevant relationships by Brandon Cherry, source=Web Response No relevant relationships by Menalee Hapuarachchi, source=Web Response No relevant relationships by Machaiah Madhrira, source=Web Response No relevant relationships by Harsh Patel, source=Web Response

Leptomeningeal carcinomatosis in patients with breast cancer.

Leptomeningeal carcinomatosis (LC) is defined as infiltration of the leptomeninges by metastatic carcinoma, a relatively uncommon but devastating complication of many malignancies. Although only 5% of patients with breast cancer develop leptomeningeal involvement, it remains the most common etiology of LC. It can occur as a late-stage complication of systemic progression or present as the first sign of metastatic disease, with or without parenchymal brain metastases. Lobular carcinomas have a higher propensity to metastasize into the meninges when compared to ductal carcinoma, especially the triple-negative subtype, which usually is associated with a shorter interval between metastatic breast cancer diagnosis and the development of LC. Prognosis remains poor, with median survival of 4 months for patients receiving state-of-the-art treatment. The main factors associated with survival are performance status at diagnosis, CSF protein level and triple-negative subtype. Headache is commonly the first clinical presentation of LC, and the diagnostic workup usually requires CSF-cytological analysis and or/MRI. The current management of LC consists of a combination of intra-CSF chemotherapy, systemic therapy, radiotherapy and/or best-supportive care. The standard intra-CSF chemotherapy regimen is methotrexate. Radiotherapy is used for relieving obstruction points on CSF-outflow channels due to ependymal nodules, tumor deposits or bulky disease. Objective responses have been reported with intrathecal administration of trastuzumab for HER2-positive disease, yet this strategy is still under investigation. Further prospective trials are needed to better address the impact of these treatment modalities on overall survival and quality of life.

Multiple Melanomas of the Right Atrium as a First Sign of a Metastatic Disease

Out of all malignant tumors, metastatic melanoma has the highest propensity of heart metastases. Metastatic heart tumor is often a sign of disseminated malignant disease and poor prognosis. In our 39-year-old female patient, the symptoms of heart failure caused by metastatic melanoma of the right atrium were the first sign of advanced metastatic disease. The tumor masses were completely resected along with the affected wall of the right atrium, which was reconstructed with an autologous pericardial patch. The patient underwent further oncological treatment, and was asymptomatic for four years after surgery. Considering new treatment options in oncology a complete resection of metastatic heart melanoma offers a chance to improve quality of life and prognosis of these patients.

Mo1032 - Clinical Outcomes and Risk of Lymph Node Metastases in Patients with T1B Esophageal Adenocarcinoma

Introduction Oesophageal adenocarcinoma (OAC) carries a poor prognosis compared to other gastrointestinal tract tumours. Advances in minimally invasive endoscopic therapy can provide curative intervention of early OAC arising in Barrett’s oesophagus (BE). Historically, patients with OAC and submucosal involvement (T1b) were offered surgery due to risk of lymph node metastases (LNM). Endoscopic resection (ER) is a viable alternative to surgery in T1b tumours with low risk (LR) histopathological features. Aim: To assess the overall risk of LNM and long-term outcomes of patients with LR and high risk (HR) T1b OAC. Method All patients with T1b OAC on endoscopic resection specimens at a single centre during 2008–2015 were included, with no sign of metastatic disease. All specimens were reviewed by two expert histopathologists. LR tumour was defined as completely resected, well or moderately differentiated, with only superficial submucosal involvement ( 500 µm) or lymphovascular invasion. Disease was considered metastatic if there was lymph node involvement in surgical resection specimens or advanced OAC on follow-up. Results 59 patients with T1b OAC on ER specimens were included: 13 (22%) had LR and 46 (78%) HR tumours. In total 37 patients were treated conservatively (12 LR, 25 hour) and 22 patients (37%) underwent oesophagectomy (1 LR, 21 hour). There was no surgery-related mortality. After a median follow-up of 38 months (range 12–87) no patients with LR OAC developed metastatic disease. Ten of the 46 hour patients (22%) developed metastatic disease at latest follow up; 4 of these had LNM in surgical resection specimens and 6 had metastatic disease detected on follow-up. In the HR group that were treated conservatively compared to those treated with surgery, although a trend was observed towards better survival in the surgery group, there was no statistically significant long-term survival benefit (log rank p=0.22). Conclusion Our results show rate of LNM in T1b OAC with LR histopathological features to be very low and endoscopic treatment in these patients is preferred to surgery. HR T1b cancers in our series carry a significant lymph node metastases risk of 22%. In selected HR patients in whom surgery may not be an option, a conservative approach is a valid alternative but rigorous follow-up is required due to the risk of LNM. Disclosure of Interest None Declared

Chondrosarcoma Associated With the Appendicular Skeleton of 2 Domestic Ferrets

A 5-year-old male neutered ferret (Mustela putorius) and a 2-year-old male neutered ferret were evaluated for fast growing immobile swellings involving the left hock and the right scapula, respectively. In both cases, serum chemistry was unremarkable and a complete blood count demonstrated mild anemia. In case 1, radiographic evaluation demonstrated increased soft tissue density in the region of the distal tibia and fibular tarsal bone. A fine-needle aspirate demonstrated atypical mesenchymal cells, and an incisional biopsy revealed irregular partly mineralized proliferations of cartilage consistent with chondrosarcoma. Computed tomography was performed, demonstrating attachment of the mass to the distolateral tibial epiphysis. A limb-sparing surgery was performed; however, 5 months following resection local reoccurrence was noted. At 18 months, the ferret underwent a left hind limb amputation. No sign of metastatic disease was reported at 27 months. In case 2, radiographic evaluation demonstrated a poorly organized mineralized soft tissue mass extending from the right acromion to the area surrounding the neck of the scapula. Microscopic evaluation of an incisional biopsy revealed a chondrosarcoma. A forequarter amputation was performed. The ferret died 4 years later with no evidence of local recurrence or the development of metastatic disease. These 2 cases represent the first reports of chondrosarcoma in the appendicular skeleton of 2 ferrets. Based on these 2 cases, local recurrence may be expected unless adequate surgical margins are achieved. The metastatic potential of chondrosarcoma in this species appears to be low.

Aneurysmal bone cyst-like areas as a sign of metastatic disease in the spinal column

Aneurysmal bone cysts (ABCs) are vascular lesions with well-defined radiological signs. A fairly common MRI finding in both ABC and other primary bone tumors with high vascularity is the presence of cysts with fluid-fluid levels. Metastatic lesions with fluid-fluid leveling have not previously been defined in the literature. We report three cases of fluid-fluid leveling of the axial skeleton in metastatic lesions. Two patients had single-level and one multi-level neoplastic disease with distinctive cysts showing fluid-fluid levels on MRI evaluation. Diagnosis of gastric carcinoma in two patients and breast carcinoma in the third was achieved with trocar biopsies. At the time of this report all patients had completed initial oncologic treatments and were disease free.

Case Report of Long Term Complete Remission of Metastatic Renal Squamous Cell Carcinoma after Palliative Radiotherapy and Adjuvant Dichloroacetate

Renal squamous cell carcinoma is a rare form of renal cancer which is considered incurable once metastases develop. Prognosis is poor and average survival of advanced stage disease is typically in the range of several months, despite all available conventional therapies. We describe the case of a 72 year old female with metastatic renal squamous cell carcinoma who had a radical nephrectomy with positive surgical margins, renal vein invasion and metastases to multiple abdominal lymph nodes. She received a course of palliative radiotherapy to the abdomen with 4500cGy in 25 fractions over 5 weeks. Following radiotherapy, she was treated with a cyclic regimen of oral sodium dichloroacetate (“DCA”). Treatment was discontinued after 3 months due to development of peripheral neuropathy. Follow-up imaging upon completion of DCA treatment revealed no sign of metastatic disease. The neuropathy gradually improved and computed tomography imaging four years later demonstrated no cancer recurrence. The patient continues to feel well with no clinical evidence of recurrence five years after completion of therapy, and is living a normal and active life.

Prenatal management of diaphragmatic rhabdomyosarcoma presenting with fetal hydrops

Fetal malignant tumors are rare. We present a case of intrauterine diagnosis of a diaphragmatic tumor presenting with fetal hydrops at 32 weeks' gestation. The sonographic findings were bilateral pleural effusion, ascites and skin edema. A large right-sided diaphragmatic tumor was identified. Owing to the findings on ultrasound and magnetic resonance imaging a solid malignant tumor was suspected. The pleural effusions were drained and malignant cells identified. Because of rapid tumor progression Cesarean section was performed and a hydropic female newborn was delivered at 34 + 0 weeks' gestation. There was no sign of metastatic disease. Postnatally tumor biopsy revealed an alveolar rhabdomyosarcoma. Therapy included chemotherapy and secondary surgical intervention. After a good primary response with complete remission after 6 months, the rhabdomyosarcoma relapsed at 12 months with cerebral metastasis. The prognosis was poor.

Lower Extremity Cutaneous Lesions as the Initial Presentation of Metastatic Adenocarcinoma of the Colon

Cutaneous metastases from colorectal cancers are rare and are usually present on the abdominal wall or previous surgical incision sites. Remote cutaneous lesions have been reported, however, often occur in the setting of widespread metastatic disease including other visceral secondaries. We present a case of lower extremity cutaneous metastases as the first sign of metastatic disease in a patient with adenocarcinoma of the colon. This case illustrates that new skin lesions may be the initial presentation of metastatic disease in a patient with a history of cancer.

Metástasis cutáneas de un carcinoma transicional vesical productor de β-HCG

In spite of the high incidence of transitional cell carcinoma, cutaneous metastases are infrequent, especially when they are the first sign of metastatic spread, with a low survival rate.Thirty five per cent of transitional cell carcinoma of the bladder have ectopic beta- human chorionic gonadotropin (β-HCG) production. It has been related with high grade tumors, advanced stage, metastatic disease, radioresistent tumors and low survival rate because of its effect as a growth modulator with a probably antagonist action in the apoptotic cascade. We present a thirty six years old woman affected by a transitional cell carcinoma of the bladder producing β-HCG that showed two cutaneous metastases as first sign of metastatic disease. The exceptional coincidence of these two circumstances announced a very aggressive tumor behaviour and bad prognostic, with a quickly multiple metastatic dissemination including a pericardic metastases.

Ocular abnormality as the first sign of metastatic breast cancer: the presentation of two cases

Breast cancer patients occasionally present with ocular symptoms which may be the first sign of metastatic disease. One patient presents with choroidal metastasis and resulting retinal ablation and the other patient with orbital manifestation and resulting exophthalmos. In both cases, metastatic involvement of multiple organs was detected. Oncological therapies resulted in tumour regression and reduced ocular symptoms. Since specific treatment may control intraocular or intraorbital manifestations, thorough ophthalmological examination is mandatory in cancer patients with ocular symptoms.

CUTANEOUS MALIGNANT MELANOMA METASTATIC TO THE VITREOUS

We describe a patient with dysplastic nevus syndrome and cutaneous melanoma in whom vitreous involvement was the first sign of metastatic disease. Cytologic examination of vitreous aspirate can usually confirm the diagnosis. Enucleation may be a treatment option if the vitreous is the sole metastatic site.

Incidence and clinical characteristics of symptomatic choroidal metastasis from breast cancer

To determine the clinical incidence and characteristics of symptomatic choroidal metastasis (CM) in breast cancer. Forty-six consecutive patients with CM from breast cancer were retrospectively reviewed in respect of ocular findings, medical history and systemic disease. Clinical incidence of CM was determined and compared with the incidence predicted from prevalence data obtained in ocular screening studies. Choroidal metastasis occurred with a median interval of 42.4 months after diagnosis of breast cancer and was predominantly unilateral (63% patients) and solitary (57% affected eyes). A total of 32% of patients had no history of metastatic tumour disease, but systemic screening with CT and scintigraphy revealed metastatic disease in 100% of patients. A median number of three other organs were affected by metastasis. Median survival from diagnosis of CM was 13.1 months. The mean number of local patients diagnosed with CM was 2.9 per year, which was one order of magnitude less than predicted from clinical screening studies. Choroidal metastasis occurs in advanced metastatic breast cancer, indicating a grave vital prognosis. In a minority of patients (32%) it is the first sign of metastatic disease. The clinical incidence of CM is far smaller than predicted from prevalence data obtained from ocular screening studies.

Umbilical metastasis from prostate carcinoma (Sister Mary Joseph’s nodule): a case report and review of literature

Sister Mary Joseph's nodule is referred to as metastatic lesion of the umbilicus. Most of the tumors are adenocarcinomas originating from gastroenteric and genital tracts. Only rarely were metastases from other locations reported. We describe here an unusual case of a Sister Mary Joseph's nodule that was metastasized from prostate carcinoma 3 years after radiation therapy. The lesion was the first sign of metastatic disease, and the diagnosis was made on skin biopsy. The patient died of extensive metastases of prostate carcinoma 4 months later. We report this case to extend the list of differential diagnosis for Sister Mary Joseph's nodule in male patients and emphasize the importance of Sister Mary Joseph's nodule as an ominous diagnostic sign.

Adrenocortical carcinoma producing 11-deoxycorticosterone: A rare cause of mineralocorticoid hypertension

A 37-yr-old man presented with the classic signs of mineralocorticoid excess hypertension and hypokalemia. The cause was not aldosterone excess, but elevation of plasma 11-deoxycorticosterone (DOC). Computed tomography (CT) scans showed a large right adrenal mass without signs of metastatic disease. The tumor was removed by open laparotomy, and histology revealed an adrenocortical carcinoma. Two yr after diagnosis, the patient is in good general condition and there is no sign of recurrence or metastatic disease, despite the large tumor size. DOC producing adrenocortical carcinomas causing mineralocorticoid hypertension are very rare, so far only 10 cases have been described in the literature.

Muscle Metastasis as Initial Manifestation of Epidermoid Carcinoma of the Lung

ABSTRACT: Typical sites of squamous cell carcinoma of lung metastases include liver, brain, bones, pulmonary and adrenal glands. In advanced dissemination it can rarely involve the skeletal muscle. The patient in this case report was a 46-year-old man, with no significant medical history. He was admitted to hospital because of a large swelling on his left thigh. Investigations resulted in a diagnosis of primary squamous cell carcinoma of the lung. Biopsy of the left great adductor muscle produced similar pathology to that of the lung primary. This case report describes a skeletal muscle metastasis as the first sign of metastatic disease.

Melanoma metastatic to stomach, small bowel, or colon

Approximately 60% of patients who die from melanoma have gastrointestinal (GI) metastases at autopsy, yet antemortem diagnosis is uncommon. A retrospective review was completed on 32 patients who underwent an operation at Memorial Sloan-Kettering Cancer Center between 1977 and 1987 for complications of melanoma metastatic to the stomach, small bowel, or colon. Operations were most often performed on an emergent basis, and indications included bleeding or anemia in 12, obstruction in 10, abdominal pain in 8, intestinal perforation in 1, and acute GI bleeding with obstruction in 1. GI involvement was the first sign of metastatic disease in 10 patients. Median survival after operation was 6.2 months (range: 1 to 42 months). Five patients were alive 2 years after operation, although only one remains free of disease 39 months after complete resection of a single site. Operative mortality was 3%, and 94% of patients were discharged from the hospital. Due to the low operative mortality, surgical palliation should be considered for those in whom the quality of life may be improved.

The Pattern of Vertebral Involvement in Metastatic Vertebral Breast Cancer

The spine is a common site of bony metastasis. To date, studies have not identified the initial site and pattern of vertebral metastasis in a homogeneous group of patients. Twenty-seven magnetic resonance imaging studies performed on 25 patients with metastatic vertebral breast cancer were reviewed retrospectively. The location and extent of metastatic vertebral involvement were determined. The vertebral body is the most frequent initial site of metastatic seeding. Although radiographically an absent pedicle is often the first sign of metastatic disease, involvement of the pedicle is by direct extension from either the vertebral body or the posterior elements and is therefore a late occurrence in the disease process.

Metastatic Renal Cell Carcinoma to the Eye and Adnexae: A Report of Three Cases and Review of the Literature

Three cases of metastatic renal cell carcinoma to the ocular structures are presented. Each of these tumors clinically simulated a more common ocular entity, thus causing diagnostic difficulty. The first patient had a metastatic tumor to the eyelid that clinically simulated a large chalazion. The second patient had a choroidal tumor with clinical features and ancillary studies strongly suggestive of a primary choroidal melanoma. The third patient presented with unilateral proptosis secondary to an orbital mass that was clinically believed to be a cavernous hemangioma of the orbit. In each case, there was a long interval between the initial diagnosis (15 months, 9 years, and 15 years respectively), and the ocular metastasis, which represented the first sign of metastatic disease.