Solitary Metastatic Lesion Research Articles

802 Preservation of a Reconstructed Breast Whilst Undertaking Total Sternal Resection for Metastatic Breast Cancer with a Pedicled Latissimus Dorsi Flap and a Methyl Methacrylate Mesh Sandwich

Abstract Background Sternal resection and reconstruction are a complex and challenging procedure that requires a multidisciplinary approach and input from both thoracic and plastic surgeons. Limited data exist on sternal resection and reconstruction for secondary breast malignancies. The goals of sternal and anterior chest wall reconstruction are to maintain chest wall integrity, rigidity, and the negative pressure necessary for respiratory and cardiac functions, protect intrathoracic contents, and restore the chest wall contour. Case Presentation A 40-year-old lady developed a solitary sternal metastatic lesion three years after her initial diagnosis with BRCA2 positive breast cancer. She had previously undergone left mastectomy, axillary clearance and implant reconstruction followed by right prophylactic mastectomy and implant reconstruction. She also had neoadjuvant chemotherapy and adjuvant chest wall radiotherapy. Her solitary sternal metastasis was managed with curative intent by complete sternal resection and a combined alloplastic and autologous sternal reconstruction with methyl methacrylate sandwiched between a polypropylene mesh and covered with a pedicled latissimus dorsi flap. The flap was successfully tunnelled under the previous implant-based breast reconstruction capsule. The surgical margins were clear, there were no post-operative complications and no further disease. The patient achieved good cosmetic outcomes. Conclusions We describe the first case of breast implant preservation whilst undertaking total sternal resection for an isolated sternal metastasise and reconstruction with a pedicle latissimus dorsi flap and methyl methacrylate mesh sandwich. We advocate combined approach with thoracic and plastic surgery, which allows a safe single stage procedure.

The Potential Role of Peritumoral Apparent Diffusion Coefficient Evaluation in Differentiating Glioblastoma and Solitary Metastatic Lesions of the Brain.

Differentiating glioblastoma (GBM) and solitary metastasis is not always possible using conventional magnetic resonance imaging (MRI) techniques. In conventional brain MRI, GBM and brain metastases are lesions with mostly similar imaging findings. In this study, we investigated whether apparent diffusion coefficient (ADC) ratios, ADC gradients, and minimum ADC values in the peritumoral edema tissue can be used to discriminate between these two tumors. This retrospective study was approved by the local institutional review board with a waiver of written informed consent. Prior to surgical and medical treatment, conventional brain MRI and diffusion-weighted MRI (b = 0 and b = 1000) images were taken from 43 patients (12 GBM and 31 solitary metastasis cases). Quantitative ADC measurements were performed on the peritumoral tissue from the nearest segment to the tumor (ADC1), the middle segment (ADC2), and the most distant segment (ADC3). The ratios of these three values were determined proportionally to calculate the peritumoral ADC ratios. In addition, these three values were subtracted from each other to obtain the peritumoral ADC gradients. Lastly, the minimum peritumoral and tumoral ADC values, and the quantitative ADC values from the normal-appearing ipsilateral white matter, contralateral white matter, and ADC values from cerebrospinal fluid (CSF) were recorded. For the differentiation of GBM and solitary metastasis, ADC3 / ADC1 was the most powerful parameter with a sensitivity of 91.7% and specificity of 87.1% at the cut-off value of 1.105 (p < 0.001), followed by ADC3 / ADC2 with a cut-off value of 1.025 (p = 0.001), sensitivity of 91.7%, and specificity of 74.2%. The cut-off, sensitivity and specificity of ADC2 / ADC1 were 1.055 (p = 0.002), 83.3%, and 67.7%, respectively. For ADC3 - ADC1, the cut-off value, sensitivity, and specificity were calculated as 150 (p < 0.001), 91.7%, and 83.9%, respectively. ADC3 - ADC2 had a cutoff value of 55 (p = 0.001), sensitivity of 91.7%, and specificity of 77.4, whereas ADC2 - ADC1 had a cut-off value of 75 (p = 0.003), sensitivity of 91.7%, and specificity of 61.3%. Among the remaining parameters, only the ADC3 value successfully differentiated between GBM and metastasis (GBM 1802.50 ± 189.74 vs. metastasis 1634.52 ± 212.65, p = 0.022). The integration of the evaluation of peritumoral ADC ratio and ADC gradient into conventional MR imaging may provide valuable information for differentiating GBM from solitary metastatic lesions.

Multilevel radical resection in treatment of patients with spine tumors

Introduction. Radical surgical resections in the treatment of malignant tumors of the spine have proven effective in improving both overall and disease-free survival of patients. Indications for such interventions are primary malignant tumors of the spine, primary benign tumors with aggressive growth, and solitary metastatic lesions in patients with a favorable oncological prognosis. Due to the anatomical features of the vertebral column, it is very difficult to perform radical resections. An even more difficult task is to perform such interventions for multilevel spinal lesions.The study objective is to evaluate the results of radical surgical treatment for multilevel tumor lesions of the spine.Materials and methods. From 2004 to 2019, in the department of spine surgery of the N.N. Blokhin National Medical Research Center of Oncology treated 36 patients with spinal tumors, who underwent multilevel radical resections. The analysis of this surgical treatment of patients with multilevel neoplastic lesions of the spine was carried out.Results. Performing radical surgical interventions on the spine makes it possible to reduce the frequency of local relapses, improve functional results and overall survival of patients. After performing multilevel resections, complications often occur.

Performance of Conventional and Machine-Learning Approaches for the Diagnosis of Tumor Recurrence on MRI after Radiation Therapy of Brain Metastases

Objective: To compare the performance of conventional and machinelearning approaches for the diagnosis of tumor recurrence after radiation therapy of brain metastases. Methods: 184 symptomatic patients with solitary metastatic brain lesions treated with radiation therapy were enrolled in a monocentric retrospective study from June 2013 to May 2018. The diagnosis was tumor recurrence (n=71) and radiation necrosis (n=113) using as reference standard expert-consensus derived from pathology and long-term follow-up. 37 potential predictors were recorded at the time of radiological progression (7-15 months after therapy): 6 clinical features and 31 imaging features including 20 radiomics features derived from standard of care 3D T1-gadolinium sequences. We compared four approaches (A, B, C, D): expert report using MRI sequences without (A) and with delayedcontrast MRI (TRAM) sequences (B), 11 non-Radiomics imaging features alone (C) and a signature combining variables selected using unsupervised machinelearning algorithms (D), training:validation sets: n=144:40 pts). Results: Overall (n=184), approaches B and C (using TRAM sequence alone) reached comparable performances with respective AUCs [95% CI] of 78.7% [72.3%-85.1%] and 76.8% [70.3%-83.3%]. Both significantly outperformed approach A with AUC [95% CI] of 57.4% [50.7%-64.1%] (DeLong’s test, p-value=10-7). In the validation set (n=40), the signature reached an AUC [95% CI] of 92% [87%-97%]. Conclusion: A quantitative analysis of TRAM sequence seems the best approach for the diagnosis of recurrent tumor after radiation therapy. It is parsimonious, objective and less time-consuming than interpreting all sequences. A signature derived from the analysis of standard of care 3D T1- gadolinium sequence showed promising results that warrant prospective validation.

Outcomes with definitive local treatment to the primary site in non-nasopharyngeal head and neck squamous cell carcinoma patients with synchronous distant metastasis.

e18014 Background: Data on the efficacy of including definitive local therapy to the primary head and neck disease (PHN) for non-nasopharyngeal head and neck squamous cell carcinoma (HNSCC) patients with synchronous distant metastasis are lacking. Methods: In this single institution retrospective study, we evaluated the outcomes of patients treated from 2000-2020 at UPMC for non-nasopharyngeal HNSCC with synchronous distant metastasis whose therapy included definitive therapy to the PHN. We evaluated overall survival (OS), calculated as date of diagnosis to date of death and progression free survival (PFS), calculated as date of diagnosis to date of death or progression. Based on an initial univariate analysis, the potential significant predictors were evaluated further in the multiple covariates Cox model via stepwise procedures. The relative mortality rates were summarized with hazard ratio (HR), with HR &gt; 1.0 corresponding to increased mortality. Results: A total of 40 patients met inclusion criteria. The median age was 61, primary sites included 52.5% oropharynx (48% HPV +), 40% larynx/hypopharynx, 7.5% oral cavity, and 85% had a solitary metastatic lesion, most commonly in the lung. Definitive treatment of the PHN was with surgery (55%) or chemoradiation (45%), and 45% also underwent local treatment for all distant disease. The median PFS was 8.6 months (95% CI, 6.4-11.6), and OS was 14.2 months (95% CI, 10.9-27.5). In the 28% of patients that received induction therapy, there was a two-fold increase in median OS to 27.5 vs. 13.7 months, p = 0.06. In the 33% of patients that received anti-PD-1 mAb immunotherapy (IO), the median OS was significantly increased to 41.7 months (95% CI, 8.7-NR) vs. 12.1 months (95% CI, 8.4-14.4), p = 0.01, with a numeric increase in PFS as well (11.3 vs. 8.2 months respectively, p = 0.07). Notably no difference in PFS or OS was seen with type of local therapy to the PHN, receipt of local treatment to all distant disease, by HPV status, or year of diagnosis. In multivariate analysis including induction and other variables significant in univariate analysis (age, number of metastatic sites), IO was independently associated with improved OS (HR 3.123 (No IO vs. IO) (95% CI, 1.198-8.137), p = 0.02), as was age and number of metastatic sites. In the patients that received IO started as part of induction the median PFS and OS were 19.5 and 45.5 months respectively. Conclusions: We observed impressive survival in select non-nasopharyngeal HNSCC patients with synchronous distant metastasis treated with definitive local therapy to the primary head and neck disease in addition to induction and/or IO, with IO independently associated with improved OS. To our knowledge this is the first evaluation of the efficacy of definitive local therapy and IO in this population. Prospective evaluation is warranted.

Structural Iliac Crest Autograft for Segmental Reconstruction After Metastatic Renal Cell Tumor Resection of the Radial Shaft

Introduction: Metastatic bone lesions are sometimes managed with en bloc resection that creates defects often requiring reconstruction. Reconstructive options for intercalary segmental bone defects are dependent on defect site and size. The radius is a rare site of metastatic disease and even rarer to require resection. While vascularized or nonvascularized fibular autografts have been used in this setting, there is no prior report detailing the use of a large autogenous iliac crest bone graft. We report structural iliac crest autograft reconstruction in a surgically resected radial diaphyseal solitary renal cell carcinoma metastasis. Case Report: A 62-year-old man presented with a solitary osseous metastatic bone lesion to the radial shaft. After nephrectomy, resection of the bone lesion followed by reconstruction with autogenous iliac crest bone graft was accomplished. Postoperative plain radiographs a year later showed integration at both graft-host junctions without hardware failure. The Musculoskeletal Tumor Society (MSTS)/Enneking score at 1 year was 22/30 points. Discussion: This article presents a case illustrating unique use of structural iliac crest autograft in segmental diaphyseal reconstruction of the radial shaft following metastatic renal cell carcinoma bone resection. This technique has the advantage of potentially increasing rate and decreasing time of healing when compared with allograft techniques and avoids increased operative time and potential donor site morbidity of vascularized fibular grafts.

Oligo metastatic renal cell carcinoma: stereotactic body radiation therapy, if, when and how?

Renal cell carcinoma (RCC) has traditionally been considered radioresistant with a limited role for conventional fractionation as a local approach. Nevertheless, since the appearance of stereotactic body radiation therapy (SBRT), radiotherapy (RT) has been increasingly employed in the management of metastatic RCC (mRCC). The aim of this study was to evaluate the role of SBRT for synchronous and metachronous oligo metastatic RCC patients in terms of local control, delay of systemic treatment, overall survival and toxicity. A Monocentric single institution retrospective data collection was performed. Inclusion criteria were: (1) oligo-recurrent or oligo-progressive disease (less than 5 metastases) in mRCC patients after radical/partial nephrectomy or during systemic therapy, (2) metastasectomy or other metastasis-directed, rather than SBRT not feasible, (3) any contraindication to receive systemic therapy (such as comorbidities), (4) all the histologies were included, (5) available signed informed consent form for treatment. Tumor response and toxicity were evaluated using the response evaluation criteria in solid tumors and the Common Terminology Criteria for Adverse Events version 4.03, respectively. Progression-free survival in-field and out-field (in-field and out-field PFS) and overall survival (OS) were calculated via the Kaplan-Meier method. The drug treatment-free interval was calculated from the start of SBRT to the beginning of any systemic therapy. From 2010 to December 2018, 61 patients with extracranial and intracranial metastatic RCC underwent SBRT on 83 lesions. Intracranial and extracranial lesions were included. Forty-five (74%) patients were treated for a solitary metastatic lesion. Median RT dose was 25Gy (range 10-52) in 5-10 fractions. With a median follow-up of 2.3years (range 0-7.15), 1-year in-field PFS was 70%, 2-year in-field PFS was 55%. One year out-field PFS was 39% and 1-year OS was 78%. Concomitant systemic therapy was employed for only 11 (18%) patients, for the others 50 (82%) the drug treatment-free rate was 70% and 50% at 1 and 2 years, respectively. No > G1 acute and late toxicities were reported. The pattern of failure was pre-dominantly out-of-field, even if the population was negatively selected and the used RT dose could be considered palliative. Therefore, SBRT appears to be a well-tolerated, feasible and safe approach in oligo metastatic RCC patients with an excellent in-field PFS. SBRT might play a role in the management of selected RCC patients allowing for a delay systemic therapy begin (one out of two patients were free from new systemic therapy at 2years after SBRT). Further research on SBRT dose escalation is warranted.

A solitary brain metastasis as the only site of recurrence of HR positive, HER2 negative breast cancer: a case report and review of the literature

BackgroundBreast cancer is one of the most common causes of brain metastases. However, the presence of isolated central nervous system (CNS) metastatic disease early in the course of disease relapse is a rare event in cases of hormone receptor positive, human epidermal growth factor receptor 2 (HER2) negative breast cancer.Case presentationWe summarize the clinical course of a pre-menopausal, 39-year old Caucasian female with history of operable, hormone receptor positive, HER2 negative breast cancer who was initially treated with curative-intend therapy but who unfortunately developed solitary metastatic lesion in the left thalamus. A biopsy of the lesion confirmed the presence of hormone receptor positive, HER2 negative metastatic breast cancer. Patient’s CNS metastases continued to progress without any evidence of metastatic disease outside of the central nervous system and she eventually passed away about 5 years after the date of her initial diagnosis and 18 months following the diagnosis with brain metastasis.ConclusionBased on our case, although rare, patients with treated, operable, hormone receptor positive, HER2 negative breast cancer can present with solitary brain metastasis as the only sign of disease recurrence.

Heterotopic ossification in lymph node metastasis after rectal cancer resection: a case report and literature review

BackgroundHeterotopic ossification (HO) is the formation of osseous tissue outside the skeleton. HO in malignant tumors of the digestive tract is extremely rare, as is ossification in metastatic lesions from HO-negative digestive tract tumors. Regarding the pathogenesis of HO, two theories have been proposed. The first is that the osteoblastic metaplasia of tumor cells (driven by the epithelial-mesenchymal transition, EMT) results in HO, and the second is that factors secreted by cancer cells lead to the metaplasia of stromal pluripotent cells into osteoblasts. However, the osteogenic mechanisms remain unclear.Case presentationAn 83-year-old Japanese woman underwent low anterior rectal resection for rectal cancer before presentation at our institution, in June 2018. The final diagnosis was stage IIB rectal adenocarcinoma (T4aN0M0). Histological examination did not reveal HO in the primary tumor. Thirteen months after the operation, a solitary metastatic lesion in the brain 20 mm in size and a solitary metastatic lesion in a right axillary lymph node 20 mm in size were diagnosed. The patient was treated with gamma-knife therapy for the brain metastasis. One month later, she was referred to our institution. She underwent lymph node resection. Histological examination revealed that most portions of the affected lymph node were occupied by metastatic tumor cells and that central necrosis and four small ossified lesions without an osteoblast-like cell rim were present in the peripheral region. Immunohistochemical analysis showed tumor cells positive for BMP-2, osteonectin, osteocalcin, AE1/AE3, TGF-β1, Gli2, Smad2/3, and CDX2 and negative for nestin, CD56, and CK7.ConclusionThis is the first English case report of HO in a metachronous metastatic lymph node after the curative resection of HO-negative rectal cancer. Unlike HO lesions in past reports, the HO lesion did not show peripheral osteoblast-like cells, and the immunohistochemical findings indicated that the present case resulted from the EMT.

Metastasis in Sinonasal Region Revealing a Silent Primary: A Series of 2 Cases with Review of Literature.

Metastasis to thenasalcavity and paranasal sinuses are very rare and only few cases have been reported so far. Metastatic nasal mass with silent primary renal cell carcinoma (RCC) is even rarer. So are giant cell tumors which rarely affects soft tissues whether superficial or deep. These rarely occur in nasal cavity. We would like to discuss 2 cases-one being a 74year old female with a solitary asymptomatic extensive metastatic lesion in sinonasal area of silent primary renal cell carcinoma and other being a 38year old female multiple lytic expansile lesions in facial and skull bones who was previously treated for giant cell tumor of long bone-tibia. We aim to bring their occurrence to notice as they are rare, to highlight importance of these tumors in differential diagnosis of sinonasal masses and treatment options for the same.

Renal Cell Cancer with Solitary Contralateral Adrenal Gland Metastasis: Feasibility of Simultaneous Metastatectomy with Preservation of Ipsilateral Adrenal Gland

Renal cell cancer (RCC) metastasizes predominantly by haematogenous route. Metastasis may occur synchronously with the primary tumour or in various organs many years after the treatment of the primary RCC. Involvement of ipsilateral adrenal gland is now considered T4 disease, and contralateral adrenal gland involvement suggests metastatic disease according to latest TNM classification. However, isolated synchronous adrenal metastasis in case of RCC is rare. Solitary metastatic lesion should be considered for metastatectomy whenever feasible as it prolongs survival. We discuss a unique case of solitary synchronous contralateral adrenal metastasis in a case of RCC and discuss the feasibility of metastatectomy and preservation of ipsilateral adrenal gland to prevent adrenal insufficiency.

Role of metastases-directed therapy (MDT) in the management of solitary metastatic prostate cancer.

143 Background: Systemic treatment in the management of metastatic prostate cancer is inevitable. However, there is a growing interest in metastases-directed therapy (MDT). We sought to investigate the efficacy of MDT in treating patients with solitary metastatic prostate cancer and hence, delaying initiation of systemic treatment (i.e., Androgen deprivation therapy or chemotherapy). Methods: We retrospectively identified 61 patients treated with targeted therapy in the form of surgery (n = 30), stereotactic body radiation therapy (SBRT) (n = 25), or cryotherapy (n = 7) for their solitary metastases prostate cancer. Complete response was defined by achieving a PSA value of ≤0.2 ng/ml plus resolution of the solitary metastatic lesion on C-11 choline PET choline scan, while incomplete response was defined by a residual PSA of &gt; 0.2 ng/ml and/or radiographic evidence of disease following metastases-targeted therapy. Results: Mean (±SD) age was 68.4 (±7.8) yrs., median (IQR) primary Gleason Score was 7 (7-9) and median (IQR) pre-MDT PSA was 2 (1.3-3.8) ng/ml. Median (IQR) time from primary treatment of the prostate to MDT was 5.1 (2.7-10.1) years. None of the patients were on hormone therapy at the time of presentation with solitary metastases prostate cancer. 30 patients had bone metastases, 29 patients had lymph node metastases, 1 patient had soft tissue metastasis (pelvic metastatic mass), and another patient had visceral metastasis (to the lung). 42% of the patients (n = 26) achieved complete response to targeted therapy. Median time to initiation of 2nd line systemic treatment following MDT was 17.8 months for the complete responders versus 9.3 months for incomplete responders. 11% of the patients (n = 7) did not require 2nd line therapy after their MDT for a mean (±SD) time of 56.9 (±22.5) months. Conclusions: The use of targeted therapy in the management of patients with solitary metastatic disease or low-volume metastatic disease can provide comparable outcomes to those of systemic treatment. Further studies are warranted.

The Role of Metastasectomy in Urothelial Carcinoma: Where Are We in 2020?

Systemic therapy is the mainstay of treatment for metastatic urothelial carcinoma (UC). Responses to first-line platinum-based therapy tend to be short-lived with potential toxicity. Despite the approval of checkpoint inhibitors, the long-term prognosis for patients with metastatic UC remains dismal. Herein we report the case of a patient with a solitary pulmonary metastatic lesion of urothelial origin as the only site of metastatic disease who remained free of disease for more than 2 years without systemic therapy after metastasectomy. We review the literature discussing the role of combined surgical and medical management of oligometastatic UC. As our case illustrates, a growing body of evidence suggests a potential role for a multimodal approach in patients with oligometastatic UC.

Adrenal gland as a target of synchronous and metacronous metastasis from renal cell carcinoma: results of surgical treatment in a single institution

Background. Surgical treatment of solitary and oligometastatic metastases in renal cell carcinoma (RCC) is one of the treatment options for modern oncology.The objective of study to compare surgical outcomes in treatment of synchronous and metachronous solitary metastatic adrenal tumors in RCC.Materials and methods. The study included 93 patients with kidney cancer, from 1997 till 2018, who underwent surgical treatment in the urological oncology department of the P.A. Hertzen Moscow Oncology Research Institute. The 1st group is represented by 58 patients with RCC and synchronous secondary adrenal gland lesion, who underwent simultaneous surgery, consist of radical nephrectomy and adrenalectomy without subsequent adjuvant therapy. The 2nd group included 35 patients with metachronous solitary metastatic adrenal gland lesion who underwent surgical treatment.Results. The progression of disease to left adrenal gland was observed in 40 (43.0 %) cases, to the right – in 39 (41.9 %), both adrenal glands — 14 (15.1 %) cases. The median diameter of the adrenal tumors was 44 (4—170) mm, the most common in both groups were tumors less than 5 cm (58.1 %). The sensitivity of ultrasound in the diagnosis of adrenal tumors was 80.6 %, computed tomography – 93.5 %, adrenal biopsy – 73.9 %. The median of the observation time was 42 months (1st group — 24 months, 2nd group – the median was not achieved). The one-year survival of patients with a metachronous lesion of adrenal was 82.3 ± 76.6 % versus 52.8 ± 7.1 % in the synchronous lesion group, three-year survival was 79.2 ± 7.0 % versus 32.3 ± 7.6 % and five-year – 57.0 ± 10.0 % versus 16.2 ± 12.0 %, respectively. In multivariate analysis, only a metachronous lesion is a factor of favorable prognosis (p = 0.002).Conclusion. Surgical treatment for metachronous adrenal gland metastatic lesions is appropriate intervention and provides better patient survival rates compared to synchronous lesions.

Avascular necrosis of head of femur mimicking skeletal metastasis on 99mTc MDP bone scintigraphy - a rare case report

Background: 99mTc-Methylene diphosphonate (MDP) bone scan of a patient with known breast carcinoma showed a solitary osteoblastic lesion in the femoral head. Solitary bone metastatic lesion and a benign cause-like remodeling phase of avascular necrosis (AVN) were the top most differential diagnoses and therefore can easily be misinterpreted for each other. Magnetic resonance imaging (MRI) is considered as the gold standard for diagnosis of AVN and can help in differentiation between AVN and skeletal metastasis. Case Presentation: A 40-year-old female patient of right breast carcinoma, treated with mastectomy, chemotherapy, and radiotherapy underwent 99mTc-MDP bone scintigraphy for pain in left hip with restricted movements. The bone scan showed focal uptake in the head of left femur with suspicion of AVN, which turned out to be a metastatic lesion on MRI. Later on, longitudinal follow-up of bone scan after 1 year showed a lesion in the left femoral head extending up to the trochanteric region with additional new lesions confirming skeletal metastasis. Conclusion: Solitary skeletal metastatic lesion in the head of femur is a rare finding, although in the presence of local symptoms AVN always remains at the top of the list for differential diagnosis of solitary osteoblastic focus in the femoral head. Bone scan is a primary tool for skeletal metastatic survey due to high sensitivity but due to low pathognomonic specificity, additional imaging with MRI must be considered as a safe, non-invasive, and easily available option for further characterization of solitary lesions.

Treatment Outcomes after Pulmonary Stereotactic Body Radiotherapy for Oligometastatic or Oligorecurrent Lung Lesions

Abstract Objective Using ablative techniques like stereotactic body radiation therapy (SBRT) in patients with limited metastases may improve survival outcomes in select groups of patients. We review the outcomes of patients treated with oligometastatic/recurrent lung lesions in our centre and analyse variables that might have affected them. Methods A retrospective review of patients treated from Jan 2010 to Dec 2016 was conducted. The data was analysed using SPSS ver23. Results A total of 46 patients with 51 lung lesions were treated with SBRT. Majority of lesions were of lung and colorectal cancers. Histological confirmation was obtained in 50%. Median SBRT biological effective dose (BED) was 105.6Gy and median follow-up was 26.9 months. There were 12 (22.6%) local failures at last follow-up. Median progression free survival (PFS) was 13.7 months (95% CI: 3.9 -23.5 months). Median overall survival (OS) was 42.2 months (95% CI: 30.8 - 53.5 months). The 2 year PFS and OS was 32.6% and 81.9% respectively. There were 3 (6.5%) likely radiotherapy related grade 3-4 pulmonary toxicities. On univariate analysis, local control rates were better with a higher BED and in squamous cell histology. Progression free survival was better for patients with metachronous lesions, higher BED, controlled primary lesions and when treatment to all visible lesions was given. Only patients with solitary metastatic lesions had better OS (44.7 months) and PFS (21.9 months) on univariate analysis. Local failure and progression predicted for worst OS. Conclusion The patients in this study are heterogeneous. Survival outcomes were better in patients with solitary metastatic lesions. This may be due to selection of patients with indolent disease biology. Better PFS were seen with higher BED and when all visible lesions were ablated. Further studies are needed.

Unusual Early Cerebral Metastasis of Ovarian Carcinoma as Initial Presentation

Background: Although systemic malignancies are frequently metastasizing to the central nervous system (CNS), ovarian carcinoma, which is a common malignancy in females, is rarely affecting brain. In general, the outcome for ovarian carcinoma with brain metastases is dismal as most of these patients usually present late with metastases elsewhere.Materials and methods: A retrospective review of four cases with cerebral metastases as the initial presentation of ovarian carcinoma in patients ages 25 to 45 years. Three patients received hormonal therapy for infertility. All cases presented initially with symptoms and signs suggestive of increased intracranial pressure with unknown primary pathology. CT and MRI scans showed intracranial enhancing lesions in different locations. Full malignancy work up showed a primary lesion arising from the pelvis with no other lesions detected.Results: Three patients underwent laparotomy for ovarian carcinoma resection once their neurological condition optimized, one case died early before she had laparotomy. All cases underwent Craniotomy for excision of the solitary metastatic lesion. In all cases, the histopathology demonstrated metastatic ovarian carcinoma. Subsequently, patients received chemo-radiotherpy. Although treatment all cases died within two years.Conclusion: It is unusual for ovarian carcinoma to present initially with CNS involvement. Unlike other primary tumours, ovarian carcinoma does not have a predilection for the central nervous system. However, CNS involvement occurs at late stage of the disease. Although multimodal treatment the outcome still poor. Hormonal therapy for infertility may be a risk factor for ovarian carcinoma and its aggressive behavior with cerebral metastasis.

The impact of pulmonary metastasectomy from gastric cancer.

Gastric cancer remains the most commonly-occurring cancer and the third most frequent cause of cancer-associated mortality in Japan. Solitary pulmonary metastasis of gastric cancer is rare and the outcome of pulmonary metastasectomy is still unclear. Herein we report the impact of pulmonary resection in patients with metastasis from gastric cancer. The present study retrospectively reviewed the preoperative data and clinical courses of 10 patients who underwent pulmonary resection for metastasis from gastric cancer at our institution between July 1986 and December 2017. The data on the outcomes, including morbidity, mortality and survival, were obtained from the patient records. All patients were followed-up from the time of pulmonary resection until mortality or referral to another hospital. The statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for the R software program (The R Foundation for Statistical Computing, Vienna, Austria). The study population included 7 male patients and 3 female patients. A total of 5 patients underwent total gastrectomy, and 5 underwent distal gastrectomy. The median disease-free interval after initial gastric resection was 34.5 months. Five patients received adjuvant chemotherapy, of the 10 thoracotomies, 5 were lobectomy, 3 were wedge resection and 2 were segmentectomy. The median overall survival following pulmonary metastasectomy was 59 months and the 5-year survival rate was 40.5%. Taken together, the results of the present study suggest that pulmonary resection may be an effective therapeutic option for metastatic gastric cancer when a patient has a solitary metastatic lesion.

Elective neurosurgical humanitarian care in a deployed setting.

OBJECTIVEActive-duty neurosurgical coverage has been provided at Bagram Air Force Base in Afghanistan since 2007. Early operative logs were reflective of a large number of surgical procedures performed to treat battlefield injuries. However, with maturation of the war effort, the number of operations for battlefield injuries has decreased with time. Consequently, procedures performed for elective neurosurgical humanitarian care (NHC) increased in number and complexity prior to closure of the Korean Hospital in 2015, which resulted in effective termination of NHC at Bagram. Monthly neurosurgical caseloads for deployed personnel have dropped precipitously since this time, renewing a debate as to whether the benefits of providing elective NHC in Afghanistan outweigh the costs of such a strategy. To date, there is a paucity of information in the literature discussing the overall context of such a determination.METHODSThe author retrospectively reviewed his personal database of all patients who underwent neurosurgical procedures at Bagram during his deployment there from April 17 to October 29, 2014. Standardized clinical parameters had been recorded in the ABNS NeuroLog system. All cases of nonelective surgical care for battlefield injuries were identified and excluded. Records of all other procedures, which represented elective NHC delivered during this period, were accessed to extract salient clinical and radiological data.RESULTSDuring the 6-month deployment, 49 patients (29 male and 20 female, age range 18 months to 63 years) were treated by the author in elective NHC. Procedures were performed for spinal degenerative disease (n = 28), cranial tumors (n = 11), pediatric conditions (n = 6), Pott's disease (n = 2), peripheral nerve impingement (n = 1), and adult hydrocephalus (n = 1). The duration of follow-up ranged from 3 to 23 weeks. Complications referable to surgery included asymptomatic, unilateral lumbar screw fracture detected 3 months postoperatively and treated with revision of hardware (n = 1); wound infection requiring cranial flap explantation and staged cranioplasty (n = 1); and unanticipated return to the operating room for resection of residual tumor in a patient with a solitary metastatic lesion involving the mesial temporal lobe/ambient cistern (n = 1). There were no instances of postoperative neurological decline.CONCLUSIONSElective NHC can be safely and effectively implemented in the deployed setting. Benefits of a military strategy that supports humanitarian care include strengthening of the bond between the US/Afghan military communities and the local civilian population as well as maintenance of skills of the neurosurgical team during the sometimes-lengthy intervals between cases in which emergent neurosurgical care is provided for treatment of battlefield injuries.

Intermediate results of combination therapy in patients with oligometastatic non-small cell lung cancer

At the present time, a small group of patients with oligometastases (who have a solitary metastatic lesion in another organ along with the primary tumour of the lung) is differentiated among the patients with metastatic lung cancer. A total of 14 patients of the study citied in this article underwent a comprehensive treatment of oligometastatic non-small cell lung cancer (ONSCLC), which included systemic therapy and local influence on solitary metastasis. The median overall survival for this group was 20 months (16.0–32.6, CI 95%). The 1-year and 2-year overall survival rates accounted for 84.5 and 65.7%, respectively. The findings of the study demonstrate the possibilities of an aggressive approach to the treatment of patients with ONLDLC.