Thoracic Metastases Research Articles

Electrochemotherapy to Treat a Single Thoracic Metastasis in Patient with Breast Cancer

Electrochemotherapy represents one of the therapeutic breakthroughs in the oncology field. In this case report, we describe a woman diagnosed with breast cancer in 2005. The case was treated surgically with right breast mastectomy, with axillary dissection for estrogen receptor positive ductal carcinoma, followed by a course of chemotherapy. Radiotherapy and hormonal adjuvant therapy with aromatase inhibitor were used for 8 years and the treatment plan was completed in 2014. After 17 years from the surgery, a thoracic Hight Resolution Computed Tomography scan showed a single node localized in right intercostal space, treated with a loco-regional treatment without complications. This allowed us to make the patient disease-free again. This case opens a choice in a loco-regional treatment to offer at a patient a new chance.

Characteristics of lymph node metastasis and short-term outcome of esophageal squamous-cell carcinoma undergoing minimally invasive esophagectomy: a prospective cross-sectional study (with video)

Introduction: Surgery for esophageal squamous-cell carcinoma (ESCC) presents many potential challenges owing to malignant lymph node metastasis, complex procedures and severe postoperative complications. The appropriate lymphadenectomy for ESCC remains controversial. This study aims to evaluate the characteristics of lymph node metastasis and postoperative complications in patients with ESCC undergoing minimally invasive esophagectomy and extended two-field lymph node dissection. Patients and methods: This prospective, single-center, cross-sectional study was conducted from October 2022 to May 2024. All patients with ESCC who underwent minimally invasive esophagectomy and extended two-field lymph node dissection were selected for this study. Postoperative lymph nodes were divided into upper thoracic, middle thoracic, lower thoracic and abdominal lymph node groups. Results: Seventy-four patients with ESCC, including 49 patients who underwent upfront surgery and 25 patients who received preoperative chemoradiotherapy, were selected. The rate of lymph node metastasis in all patients was 39.2%, with 13.6% of patients having upper thoracic metastasis. The factors affecting the rate of lymph node metastasis included preoperative chemoradiotherapy, tumor stage, poor differentiation, lymphovascular/perineural invasion, and tumor size greater than 2 cm, all of which were significantly different (P<0.05). Common postoperative complications included pneumonia (25.7%), recurrent laryngeal nerve (RLN) palsy (10.8%) and anastomotic leak (4.1%). There were no cases required conversion to open surgery, nor any deaths within 90 days postoperatively. Conclusion: Lymph node metastasis in esophageal squamous-cell carcinoma has a high incidence, occurs in the early stages, and is widely distributed in all regions of the mediastinum and abdomen. Minimally invasive esophagectomy and extended two-field lymph node dissection are feasible and safe, with low complication rates.

Discordance of retroperitoneal and thoracic histologic findings in patients with metastatic germ cell tumors at postchemotherapy residual tumor resection

Introduction and objectivesPostchemotherapy residual tumor resection (PC-RTR) is an important part of the multimodal treatment for patients with metastatic germ cell tumors. Simultaneous retroperitoneal and thoracic metastases often require consecutive surgical procedures. This study analyzes the histologic findings after abdominal and thoracic surgery in order to tailor the sequence and intensity of surgery.Patients and methodsFrom a total of 671 PC-RTRs from 2008 to 2021 we analyzed 50 patients with stage III non-seminomatous germ cell tumor (NSGCT) who had undergone both retroperitoneal and thoracic postchemotherapy residual tumor resection after first-line and salvage chemotherapy.ResultsAll patients included had stage III NSGCT. 39 and 11 patients received first-line and salvage chemotherapy, respectively. 45 (90%) patients received retroperitoneal resection first, followed by thoracic surgery. Three patients (6%) underwent thoracic surgery before retroperitoneal surgery and two patients (4%) underwent simultaneous surgery. Overall, the histology of retroperitoneal and thoracic specimens was discordant in 23% of cases. After first-line chemotherapy, of fourteen patients with necrosis in retroperitoneal histology, four patients had vital carcinoma in lung histology. In patients with teratoma in the retroperitoneum, the thoracic findings were concordant in most cases (78%). When teratomatous elements were also present in the orchiectomy specimen, concordance was 100%. After salvage chemotherapy, the discordance rate was 55%.ConclusionThe data presented in this study underline that retroperitoneal residual masses with necrosis cannot reliably predict histologic findings of thoracic specimens. Patients with teratoma in the retroperitoneum have a high likelihood of teratoma in the thoracic specimen.

Opportunistic CT for Prediction of Adverse Postoperative Events in Patients with Spinal Metastases.

The purpose of this study was to assess the value of body composition measures obtained from opportunistic abdominal computed tomography (CT) in order to predict hospital length of stay (LOS), 30-day postoperative complications, and reoperations in patients undergoing surgery for spinal metastases. 196 patients underwent CT of the abdomen within three months of surgery for spinal metastases. Automated body composition segmentation and quantifications of the cross-sectional areas (CSA) of abdominal visceral and subcutaneous adipose tissue and abdominal skeletal muscle was performed. From this, 31% (61) of patients had postoperative complications within 30 days, and 16% (31) of patients underwent reoperation. Lower muscle CSA was associated with increased postoperative complications within 30 days (OR [95% CI] = 0.99 [0.98-0.99], p = 0.03). Through multivariate analysis, it was found that lower muscle CSA was also associated with an increased postoperative complication rate after controlling for the albumin, ASIA score, previous systemic therapy, and thoracic metastases (OR [95% CI] = 0.99 [0.98-0.99], p = 0.047). LOS and reoperations were not associated with any body composition measures. Low muscle mass may serve as a biomarker for the prediction of complications in patients with spinal metastases. The routine assessment of muscle mass on opportunistic CTs may help to predict outcomes in these patients.

The diagnostic yield of preoperative screening for oral cancer in dogs over 15 years, part 2: distant screening.

Determine diagnostic yield of chest, abdomen, and 4-site screening to diagnose metastatic disease and secondary diseases of prognostic significance in dogs with oral cancer. Medical records from 381 dogs with histologically confirmed oral tumors that underwent preoperative screening were retrospectively reviewed. Thoracic metastasis was diagnosed in 4.9% (0.9% odontogenic, 6.5% nonodontogenic) of oral tumors. Oral malignant melanoma and multilobular osteochondrosarcoma were most at risk. Abdominal metastasis was diagnosed in 2% of oral tumors (0% odontogenic, 3.1% nonodontogenic) and cytologically confirmed in 2 cases (0.6% [2/295)] of all abdominal ultrasounds (AUS) 5.5% [2/36] of all AUS that had cytology). Both cases had oral malignant melanoma. Incidental disease was diagnosed in 53.1% and 81.3% of thoracic and abdominal screenings, respectively. Major findings were more common in AUS (7.8%) compared to thoracic screening (1.9%). The prevalence of incidental findings was similar for odontogenic and nonodontogenic tumors. Both metastasis and major findings were diagnosed more commonly with thoracic CT compared to radiographs. Metastasis or a major finding of prognostic significance was diagnosed in at least 1 test in 27.8% of patients that had head CT, lymph node cytology, thoracic screening, and AUS (n = 115). Major incidental findings were more commonly detected with AUS and were diagnosed in 1 in every 12 patients. However, metastatic disease was most commonly detected with thoracic screening. When all 4 screening tests are performed, there is an approximately 1 in 4 chance of diagnosing metastasis or major significant disease regardless of tumor type.

NCMP-06. INTRAMEDULLARY SPINAL CORD METASTASIS OF RENAL CELL CARCINOMA: A COMPARISON OF CASES AND TREATMENT OUTCOMES

Abstract Renal cell carcinoma (RCC) intramedullary spinal cord metastasis (ISCM) is a rare but frequently devastating diagnosis. Due to its rarity, there is currently no clear standard of care for RCC ISCM management. However, with improvements in metastatic RCC management and imaging for early detection of ISCM, we may see a rise in the incidence of RCC patients developing ISCM, for which treatment guidelines are lacking. Here, we aim to add to the growing body of RCC ISCM literature with two cases- one with ISCM managed with surgery, radiation, and immunotherapy, and the other managed with only radiation, immunotherapy, and chemotherapy. Case 1 is a 47 year old male with RCC and lung and bone metastases who underwent nephrectomy, lobectomy, high dose IL-2 therapy, and immunotherapy. He later developed worsening low back pain, and lower extremity paresthesias and weakness. Imaging revealed a thoracic metastasis for which he was started on steroids, underwent surgical resection followed by radiation therapy, and immunotherapy. Serial imaging and clinical exams have not found evidence of ISCM recurrence 5 years after initial resection. Case 2 is a 74 year old female with RCC with cerebellar metastasis who underwent nephrectomy, suboccipital craniotomy with mass resection, radiation therapy, and immunotherapy. 3 years later, she developed neck pain with right arm paresthesias, and imaging revealed cervical spine ISCM. Patient declined surgical intervention, and she was managed with steroids and radiation therapy, followed by chemotherapy. Approximately 5 years after initial ISCM findings, serial imaging and clinical exams have not revealed evidence of disease progression. These cases have several important differences including prior central nervous system metastases, ISCM location, and surgical intervention. However, both have not shown evidence of disease progression at similar time points. We hope these cases add to the small body of cases to move towards developing treatment guidelines.

Inter-rater and intra-rater agreement of [99mTc]-labelled NM-01, a single-domain programmed death-ligand 1 (PD-L1) antibody, using quantitative SPECT/CT in non-small cell lung cancer

BackgroundImmune checkpoint inhibitors, including those against programmed cell death protein-1 (PD-1) or its ligand (PD-L1), are routinely used to treat non-small cell lung cancer (NSCLC). PD-L1 is a validated prognostic and predictive immunohistochemical biomarker of anti-PD-1/PD-L1 therapy but displays temporospatial heterogeneity of expression. Non-invasive radiopharmaceutical techniques, including technetium-99m [99mTc]-labelled anti-PD-L1 single-domain antibody (NM-01) SPECT/CT, have the potential to improve the predictive value of PD-L1 assessment. This study aims to determine the inter- and intra-rater agreement of the quantitative measurement of [99mTc]NM-01 SPECT/CT in NSCLC.MethodsParticipants (n = 14) with untreated advanced NSCLC underwent [99mTc]NM-01 SPECT/CT at baseline (n = 3) or at baseline plus 9-week follow-up (n = 11). [99mTc]NM-01 uptake (of primary lung, lymph node, thoracic and distant metastases, and healthy reference tissues) was measured using SUVmax and malignant lesion-to-blood pool ratios with Siemens xSPECT Broad Quantification software by three independent raters. Intraclass correlation coefficients (ICC) were calculated and Bland–Altman plot analysis performed to determine inter- and intra-rater agreement.ResultsThere was excellent inter-rater agreement of manual freehand SUVmax scores of primary lung tumour (T; n = 25; ICC 1.00; 95% CI 0.99–1.00), individual lymph node metastases (LN; n = 56; ICC 0.97; 95% CI 0.95–0.98), thoracic metastases (ThMet; n = 9; ICC 0.94; 95% CI 0.83–0.99) and distant metastases (DisMet; n = 21; ICC 0.91; 95% CI 0.83–0.96). The inter-rater ICCs of tumour-to-blood pool (T:BP), LN:BP, ThMet:BP and DisMet:BP measures of [99mTc]NM-01 uptake also demonstrated good or excellent agreement. Manual freehand scoring of T, LN, ThMet, DisMet and their ratios using [99mTc]NM-01 SPECT/CT following a 28-day interval was consistent for all raters with good or excellent intra-rater agreement demonstrated (ICCs range 0.86–1.00).ConclusionQuantitative assessment of [99mTc]NM-01 SPECT/CT in NSCLC, using SUVmax of malignant primary or metastatic lesions and their ratios with healthy reference tissues, demonstrated good or excellent inter- and intra-rater agreement in this study. Further validation with ongoing and future larger cohort studies is now warranted.Clinical trial registrationClinicalTrials.gov identifier no. NCT04436406 (registered 18th June 2020; available at https://clinicaltrials.gov/ct2/show/NCT04436406) and NCT04992715 (registered 5th August 2021; available at https://clinicaltrials.gov/ct2/show/NCT04992715).

Guideline Compliance Regarding Chest Imaging of Suspicious cT1 Renal Masses in MUSIC-KIDNEY.

Multiple urological societies recommend chest imaging for suspicious renal masses using chest x-ray or CT as clinically indicated. The purpose of chest imaging is to assess for thoracic metastasis at the time of renal mass diagnosis. Ideally, imaging use and type are commensurate with risk related to tumor size and clinical stage. We examined current practice patterns with chest imaging compliance in the state of Michigan and implemented clinician education and value-based reimbursement incentivization on guideline adherence. MUSIC (Michigan Urological Surgery Improvement Collaborative)-KIDNEY (Kidney mass: Identifying and Defining Necessary Evaluation and therapY) is a statewide initiative focusing on quality improvement for patients with cT1 renal masses. Data regarding chest imaging in MUSIC and panel discussion occurred at an in-person MUSIC meeting in October 2019. Adherence to chest imaging guidelines was made a value-based reimbursement metric at the triannual MUSIC meeting in January 2020. Adherence was defined as optional in renal masses <3 cm (CT not indicated), recommended in renal masses 3-5 cm (chest x-ray preferred), and required in renal masses >5 cm (CT preferred). The MUSIC registry was queried for percentage of patients receiving chest imaging by type. Factors associated with adherence were assessed. There was significant practice-level variation in chest imaging rates across the 14 contributing practices, ranging from 11% to 68%. Compliance with MUSIC guidelines for chest imaging during evaluation of T1 renal masses was 81.8% overall, with only 61.8% of patients with masses >5 cm meeting the guideline requiring imaging with preference for CT. Factors associated with increased adherence included larger tumor size (T1b vs T1a) and solid (vs cystic or indeterminate) tumor (P < .05 for each). Prior to value-based reimbursement introduction, 46.7% of patients underwent imaging of either type, compared to 49.0% post-intervention. Imaging rates only slightly increased in masses >5 cm (58.3% before value-based reimbursement vs 61.2% after, P = .56) and 3-5 cm (50.0% before value-based reimbursement vs 56.2% after, P = .0585). Chest imaging guideline adherence during the initial evaluation of cT1 renal masses is acceptable, particularly given that most masses are <3 cm, for which metastatic risk is low. However, despite consensus from major urological societies regarding imaging for masses >4-5 cm, imaging rates were low across MUSIC. After educational and value-based reimbursement incentive initiation, rates of imaging for 3-5-cm and >5-cm masses changed only slightly. There remains significant practice variability and room for improvement.

MP39-16 COST-EFFECTIVENESS ANALYSIS OF UNIVERSAL CT STAGING VERSUS SELECTIVE CT STAGING STRATEGIES FOR PATIENTS WITH cT1a RENAL MASSES

You have accessJournal of UrologyCME1 Apr 2023MP39-16 COST-EFFECTIVENESS ANALYSIS OF UNIVERSAL CT STAGING VERSUS SELECTIVE CT STAGING STRATEGIES FOR PATIENTS WITH cT1a RENAL MASSES Diana Magee, Kevin Ginsburg, Jared Schober, Laura Bukavina, Spencer Bell, Elizabeth Handorf, Alexander Kutikov, Robert Uzzo, and Andres Correa Diana MageeDiana Magee More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Jared SchoberJared Schober More articles by this author , Laura BukavinaLaura Bukavina More articles by this author , Spencer BellSpencer Bell More articles by this author , Elizabeth HandorfElizabeth Handorf More articles by this author , Alexander KutikovAlexander Kutikov More articles by this author , Robert UzzoRobert Uzzo More articles by this author , and Andres CorreaAndres Correa More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The incidence of metastasis in patients with cT1a masses is an exceedingly rare event. However, guidelines recommend some form of thoracic imaging for patients with newly diagnosed renal masses. Screening for thoracic metastasis can be accomplished with either a chest x-ray (CXR) or CT of the thorax (CTT) and guidelines are agnostic to type of imaging modality utilized. Therefore, we designed a study evaluating the cost-effectiveness of CXR followed by selective CTT compared with that of universal CTT staging. METHODS: Using TreeAgePro 2019 software, we developed a clinical decision tree to estimate the thoracic metastasis detection rate and cost of a selective CTT strategy compared to universal CTT at the time of initial staging in patients with cT1a renal masses. Patients who had a positive CXR subsequently had a CTT to confirm the positive result. In the universal CTT arm all patients were staged with a CTT. Model probabilities were derived from published literature. Direct costs were obtained from the Medicare procedure database. Our primary outcomes were proportion of true cancers detected, accuracy of and the incremental cost effectiveness ratio (ICER) which evaluates the incremental cost per additional true positive (TP) metastasis identified. RESULTS: The universal CTT strategy resulted in a greater proportion of true cancers detected (TP/baseline prevalence of pulmonary metastases) (93.9%) when compared to CXR (66.7%). However, when the imaging tests were assessed by accuracy (true positive + true negative), the selective CTT staging strategy was found to be more accurate at 93.2% compared to 76.7% for the universal CTT staging strategy. This is balanced by a proportion of false positive (23.2%) in the universal CTT arm compared with 6.6% in the CXR based screening arm. To identify an additional metastasis diagnosed by a universal CTT that would be missed by a CXR based screening strategy would cost $59,931 . Our results are robust to sensitivity analyses evaluating the baseline prevalence of metastasis, but the ICER does vary considerably when the sensitivity of CT imaging was varied. CONCLUSIONS: Our study demonstrates that while a greater proportion of true positive tests are obtained using a universal CT staging strategy this is at the expense of a greater false positive rate. Given the low pretest probability of chest metastasis in patients with cT1a renal masses, there is considerable additional cost associated with screening this population with CTT to identify the few masses that would be missed with CXR based screening protocols. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e542 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Diana Magee More articles by this author Kevin Ginsburg More articles by this author Jared Schober More articles by this author Laura Bukavina More articles by this author Spencer Bell More articles by this author Elizabeth Handorf More articles by this author Alexander Kutikov More articles by this author Robert Uzzo More articles by this author Andres Correa More articles by this author Expand All Advertisement PDF downloadLoading ...

Can We Use Artificial Intelligence Cluster Analysis to Identify Patients with Metastatic Breast Cancer to the Spine at Highest Risk of Postoperative Adverse Events?

Group patients who required open surgery for metastatic breast cancer to the spine by functional level and metastatic disease characteristics to identify factors that predispose to poor outcomes. A retrospective analysis included patients managed at 2 tertiary referral centers from 2008 to 2020. The primary outcome was a 90-day adverse event. A 2-step unsupervised cluster analysis stratified patients into cohorts using function at presentation, preoperative spine radiation, structural instability, epidural spinal cord compression (ESCC), neural deficits, and tumor location/hormone status. Comparisons were performed using χ2 test and one-way analysis of variance. Five patient "clusters" were identified. High function (HIGH) had thoracic metastases and an Eastern Cooperative Oncology Group (ECOG) score of 1.0±0.8. Low function/irradiated (LOW+RADS) had preoperative radiation and the lowest Karnofsky scores (56.0±10.6). Estrogen receptor or progesterone receptor (ER/PR) positive patients had >90% estrogen/progesterone positivity and moderate Karnofsky scores (74.0±11.5). Lumbar/noncompressive (NON-COMP) had the fewest patients with ESCC grade 2 or 3 epidural disease (42.1%, P < 0.001). Low function/neurologic deficits (LOW+NEURO) had ESCC grade 2 or 3 disease and neurologic deficits. Adverse event rates were 25.0% in the HIGH group, 73.3% in LOW+RADS, 24.0% in ER/PR, 31.6% in NON-COMP, and 60.0% in LOW+NEURO (P=0.003). Function at presentation, tumor hormone signature, radiation history, and epidural compression delineated postoperative trajectory. We believe our results can aid in expectation management and the identification of at-risk patients who may merit closer surveillance following surgical intervention.

1271: MUCINOUS ADENOCARCINOMA MIMICKING INTERSTITIAL LUNG DISEASE DISCOVERED POST-TRANSPLANT

Introduction: Mucinous adenocarcinomas typically present with cough, dyspnea and pleuritic chest pain. They have a wide range of radiographic appearances including a single nodule, lobar consolidation, or diffuse nodules. These tumors can mimic infectious and non-infectious pulmonary pathologies both clinically and radiographically. We report a rare case of invasive mucinous adenocarcinoma, mimicking interstitial lung disease discovered post bilateral lung transplant. Unfortunately, the diagnosis was made after lung transplantation posing a challenge in the management of immunosuppression in the setting of malignancy. Description: A 47-year old male with no prior medical history initially presented with progressive dyspnea on exertion for several months. Family history was significant for pulmonary fibrosis in his mother. High resolution CT chest showed extensive ground-glass opacification, upper lobe honeycombing, and consolidative changes with air bronchograms in bilateral lower lobes. Autoimmune workup and hypersensitivity pneumonitis panel were negative. Bronchoscopy and multiple sputum cultures were unrevealing. Genetic testing identified a mutation in the SFTPA2 gene, associated with familial pulmonary fibrosis. Patient’s respiratory status improved with intravenous steroids and he was discharged with oxygen supplementation, prednisone and nintedanib. However, patient was admitted two months later with clinical deterioration and acute hypoxemic respiratory failure requiring venovenous extracorporeal membrane oxygenation as a bridge to successful bilateral lung transplantation. A lung biopsy prior to transplant could not be obtained given the rapid progression of patient’s respiratory failure. Subsequently, pathology of the explanted lungs showed invasive mucinous adenocarcinoma with metastatic disease to a perihilar lymph node. PET CT scan was negative for extra thoracic metastasis. Discussion: After a multidisciplinary discussion, it was decided to continue immunosuppression with tacrolimus and a decreased dose of mycophenolate. Additionally, active surveillance with PET CT scans every three months was recommended. This case highlights the difficulties faced in the diagnosis of pulmonary adenocarcinoma due to its clinical and radiographic overlap with interstitial lung disease.

WITHDRAWN: Thoracic spinal metastasis as recurrence of borderline Brenner tumor without local recurrence: A case report

Brenner tumor is a rare epithelial ovarian neoplasm that accounts for 2-3% of all ovarian neoplasms. Herein, we report the first case of thoracic spinal metastasis of recurrent Brenner tumor without local recurrence.Case Description.A 70-year-old female presented with a feeling of abdominal distension. Computed tomography revealed cystic lesions in her bilateral ovaries. Blood examination revealed high CA-125 [74.9 U/ml]. We excised bilateral ovaries, uterus, and omentum. Borderline Brenner tumor was diagnosed [Ki-67 labeling index: 10%]. Follow-up abdominal echo and CA-125 examination revealed no local recurrence. 26months later she developed paraplegia. Magnetic resonance imaging revealed tumor in the 5th-9th thoracic vertebra and compression of spinal cord at the 6th thoracic vertebra level. Her paraplegia was progressive. We performed semi-urgent partial resection of tumor and release of spinal cord compression. Spinal metastasis from Brenner tumor was diagnosed [Ki-67 labeling index: 50-60%]. She received adjuvant radiation of 30Gy in 10 fractions to the 4th-10th thoracic vertebra. After radiation and rehabilitation, she was discharged home on foot. She received adjuvant radiation and chemotherapy but died 11months after spinal surgery. An autopsy has not been performed on her, and the cause of death is unknown. We report the first case of thoracic metastasis of recurrent Brenner tumor without local recurrence.

11C-Choline Positron Emission Tomography-Detected Prostate Cancer Thoracic Metastases

<h3>Purpose/Objective(s)</h3> Prostate cancer metastasis to the chest is considered a poor prognostic indicator but is not well-described in the era of molecular imaging. We evaluate the radiographic features, management, and outcomes associated with prostate cancer thoracic metastases detected by ¹¹C-choline positron emission tomography/computed tomography (PET/CT). <h3>Materials/Methods</h3> A prospectively maintained database of 6,118 prostate cancer patients with ¹¹C-choline PET/CT findings was used to identify thoracic metastases detected from 2011 to 2021. Biopsy confirmation was not required, but patients with a negative biopsy were excluded from analysis. Patient, disease, and treatment characteristics were identified and analyzed for their association with outcomes. <h3>Results</h3> Sixty-seven patients (1.1% of those in the database) were included with a median follow-up of 45 months (IQR: 17-57.5) from metastasis detection. Primary local treatment was radical prostatectomy in 36 (55.2%) patients and radiotherapy in 21 (31.3%). Thirty-seven patients (55.2%) had histologic confirmation. Median interval from initial diagnosis to thoracic metastasis detection was 66 months (IQR: 38-107). Thirty-nine patients (58.2%) were oligometastatic (≤5 lesions) and 23 (34.3%) had previously diagnosed extrapulmonary metastases. Lesions were more often in the lung parenchyma (80.5%) than mediastinum (9.8%), hila (8.5%), or pleura (1.2%). Median greatest dimension was 1.0 cm (IQR: 0.8-1.3). Eight patients (11.9%) had lesions detectable on CT without PET avidity, five of whom had histologic confirmation. Median SUV_max was 3.3 (IQR: 2.5-4.4) for all ¹¹C-choline PET/CT-avid lesions and 3.9 (IQR: 2.5-4.6) in histologically confirmed lesions. Fifty-seven patients (85.1%) were managed with systemic therapy. Eighteen lesions in 17 patients were managed with local therapy, 15 surgically and 3 with radiotherapy. Among the 39 patients with oligometastatic disease, median time to subsequent radiographic progression was 28 months compared to 14 months in those with widely disseminated disease. Median time to progression in the 17 men receiving metastasis-directed therapy was 33 months, despite a lower rate (52.9%) of systemic therapy use in this group. Forty-nine (73.1%) patients were alive at last follow-up. <h3>Conclusion</h3> We provide the largest single institution report to date of patients with ¹¹C-choline PET/CT-detected prostate cancer thoracic metastases. In well-selected men, metastasis-directed therapy may delay time to radiographic progression and initiation of systemic therapy. At the time of detection, a third of patients have diffuse pulmonary involvement. Despite this finding, survival outcomes remain encouraging with nearly three-quarters of patients alive at a median follow-up of 45 months. Efforts are ongoing to identify clinicopathologic and molecular characteristics which may guide management in this population.

S3613 Gastric Spindle Cell Leiomyosarcoma Is Associated With Chronic Helicobacter pylori Infection

Introduction: Chronic Helicobacter pylori (HP) infection has been shown to be strongly associated with development of gastric malignancies, mostly gastric adenocarcinomas and lymphomas. We present a case of primary gastric leiomyosarcoma in a patient with persistent epigastric pain and HP infection. Case Description/Methods: A 59-year-old female presented to clinic with persistent, postprandial epigastric pain. Cardiopulmonary workup was negative. She had a history of esophageal leiomyoma resected endoscopically with negative margins 10 years ago. She was treated in the past for HP infection but never had repeat testing to confirm eradication. Abdominal computed tomography showed focal hepatic infiltration. She was advised to have a repeat upper endoscopy for surveillance but was lost to follow-up due to psychiatric comorbidities. She presented 6 years later with epigastric pain. Repeat CT abdomen showed a new 2.8 cm hypoattenuating lesion in the lesser curvature of the stomach. Patient did not follow up due to psychosocial issues. Two years later, she returned to clinic for epigastric pain and underwent repeat upper endoscopy and endoscopic ultrasound (EUS) with fine needle aspiration (FNA). EGD showed sub-gastric nodule attached gastric wall, about 30 mm in maximal dimension and gastric biopsy confirmed active HP infection. The EUS showed a 31.7x23.5 mm hypoechoic homogeneous gastric mass along the lesser gastric curvature. Cytology showed cellular spindle cell neoplasia with myogenic differentiation concerning for possible leiomyoma or leiomyosarcoma. Abdominal magnetic resonance imaging and chest computed tomography revealed no evidence of abdominal or thoracic metastasis. Subsequently, partial underwent sleeve gastrectomy. Pathology revealed Grade 1 myxoid leiomyosarcoma with negative margins. (Figure) Discussion: Prior studies demonstrated associations between HP infection and gastric malignancies - typically gastric adenocarcinoma or lymphomas. Few studies investigated the relationship between HP infection and gastric leiomyosarcomas.4,5 Importantly, this patient never had clearance of HP infection and may have allowed a leiomyosarcoma to develop. It is imperative that clinicians confirm eradication of HP infection given risk of leiomyosarcoma development in addition to other malignancies HP infections are known to cause.Figure 1.: Endoscopic and histologic examination of gastric leiomyosarcoma. (A) Endoscopic ultrasound visualization demonstrating tumor within lesser curvature of stomach. (B) Upper endoscopy revealing tumor approximately 4 cm from gastroesophageal junction. (C) Hematoxylin and eosin (H&E) stain of gastric tumor biopsy demonstrating spindle cell proliferation in a myxoid background with significant nuclear atypia and pleomorphism consistent with myxoid leiomyosarcoma. Magnification x400. (D) Immunohistochemical staining of gastric lesion biopsy demonstrating strong immunoreactivity to desmin. Not shown are positive stains for smooth muscle actin (SMA) as well as negative stains for Cytokeratin AE1/AE3, Myogenin, MyoD1, DOG-1, CD117, S100, SOX10, CD34, ALK-1 and ER. Positive and negative controls stained appropriately but are not included.

Does the anatomical region predict blood loss or neurological deficits in embolized renal cancer spine metastases? A single-center experience with 31 patients

BackgroundNo comparison of a single hypervascular tumor entity in terms of major complications in different spinal regions has been performed. We aimed to evaluate post-embolic and post-operative outcomes in anatomic regions with renal cell carcinoma (RCC) metastases to the spine.MethodsWe retrospectively evaluated data from patients with confirmed, embolized, and surgically treated RCC spine metastases at a single-spine center between 2010 and 2020. Patients were divided into thoracic (TSM) and lumbar (LSM) spine metastasis groups.ResultsSeventeen patients had TSM and 14 had LSM. In all cases, embolization was performed preoperatively. The ΔHb value did not differ between the two groups pre- and postoperatively (p=0.3934). There was no significant difference in intraoperative blood loss between both groups either within 1 day or 2 days after embolization. Neurological deficits occurred in eight patients after embolization or surgery, with no significant difference between TSM (n=5) and LSM (n=3).ConclusionsEmbolization is the standard procedure for the preoperative treatment of hypervascular spinal metastases, possible up to 48 h before surgery, without the risk of higher intraoperative blood loss. Regardless of intraoperative complications, major complications can occur up to several hours after embolization. We recommend surgery the day after embolization to reliably detect neurologic complications from this procedure.

Abstract No. 578 Bone and soft tissue ablation of painful thoracic metastasis: single center review of palliative ablation of metastatic rib and intercostal lesions

Abstract No. 578 Bone and soft tissue ablation of painful thoracic metastasis: single center review of palliative ablation of metastatic rib and intercostal lesions

Malignant pleural effusion in patients with ovarian cancer

Introduction. Ovarian cancer is the most lethal gynecological cancer. The most common manifestation of thoracic metastasis is pleural effusion. Pleural effusion with positive cytology is regarded as stage IVa of the International Federation of Gynecology and Obstetrics classification, and the overall five-year survival in these patients is less than 20%. We analyzed the data of patients with ovarian cancer who were treated at the Oncology Institue of Vojvodina, in order to establish the incidence of malignant pleural effusions, laterality of pleural effusions, and clinical manifestations. Material and Methods. The study included 731 patients with ovarian cancer who were treated at the Oncology Institue of Vojvodina from January 2012 to May 2020. The obtained data were compared with data found in the literature in the same period. Results. The incidence of malignant pleural effusion in our study was 5.75%; right-sided pleural effusion was found in 57.15% of patients, 33.33% of patients had effusion on the left side, and 9.52% had bilateral effusions. Thus, unilateral effusion was found in 90.48% of cases, and bilateral in only 9.52%. The most common symptom was dyspnea, reported in 33 patients (78.6%). Conclusion. The incidence of malignant pleural effusion in our study was most similar to data found by Zamboni et al. published in 2015; the right side was the dominant side of pleural effusions. The most common symptoms were dyspnea, shortnes of breath and chest pain.

Thoracic metastasis of malignant melanoma of unknown primary: A case report and literature review.

IntroductionMetastatic melanoma of unknown primary (MUP) is an unusual entity found in distant sites without evident skin lesion. We report a case of 45-year-old woman who underwent monobloc resection of a metastatic thoracic malignant melanoma of unknown primary, and who is currently under immunotherapy without local or distant recurrence during a follow-up of 18 months. We demonstrate through this case that R0 resection of an MUP associated with immunotherapy improves the prognosis and survival in these patients.Case reportThis is a 45-year-old woman who underwent monobloc resection of a mass carrying the anterior arch of the second left rib associated with a wedge resection of a nodule at the left upper lobe. Histology confirmed that it was a malignant melanoma. Her history was negative for melanocytic lesions, physical examination and imaging had failed to identify a primary lesion. The patient is currently under nivolumab for Stage IV melanoma and does not present any complications or recurrence during the long term follow up.DiscussionMetastatic melanoma of unknown primary (MUP) is a melanocytic lesion in distant sites in the absence of apparent skin involvement and is rare, accounting for 3, 2% of all incident melanomas as well as being yet poorly understood in terms of pathogenesis (Bae et al., 2015) [1]. MUP is clinically understudied, investigators to date have reported largely on the use of localized treatment for MUP (surgery or radiotherapy), while the efficacy of systemic therapy in MUP patients remains unexplored. Clinical trials of immunotherapy and targeted therapy in patients with advanced cutaneous melanoma have not explicitly reported response rates specific to MUP patient subgroups due to its low incidence and lack of annotation. MUP's response to these now FDA-approved therapies could add to the discussion of MUP's elusive biological characteristics, as well as aid in making clinical recommendations (Utter et al., 2017).ConclusionMetastatic MUP is an extremely rare entity which is still poorly understood, few cases are described in the literature, its treatment remains controversial and there are no specific treatment recommendations for patients with MUP. Several authors recommend local treatment when possible and tend to apply similar strategies for patients with paired stage primary known melanoma (PKM).

Non-fusion palliative spine surgery without reconstruction is safe and effective in spinal metastasis patients: retrospective study

Considering the shorter life expectancy and poorer prognosis of metastatic epidural spinal cord compression patients, anterior reconstruction and fusion may be unnecessary. This study aimed to investigate the outcomes of palliative surgery for metastatic epidural spinal cord compression with neurological deficit among patients who underwent posterior decompression and instrumentation without fusion or anterior reconstruction. This single-center retrospective review included all patients aged > 18 years with thoracic or lumbar spinal metastasis who were surgically treated for metastatic spinal cord compression without fusion or anterior reconstruction at the Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during July 2015 to December 2017. Data from preoperation to the 1-year follow-up, including demographic and clinical data, Frankel classification, pain scores, complication, revision surgery, health-related quality-of-life scores, and survival data, were collected and analyzed. A total of 30 patients were included. The mean age was 59.83 ± 11.73 years, and 20 (66.7%) patients were female. The mean operative time was 208.17 ± 58.41 min. At least one Frankel grade improvement was reported in 53.33% of patients. The pain visual analog scale, the EuroQOL five-dimension five-level utility score, and the Oswestry Disability Index were all significantly improved at a minimum of 3 months after surgery. No intraoperative mortality or instrument-related complication was reported. The mean survival duration was 11.4 ± 8.97 months. Palliative non-fusion surgery without anterior reconstruction may be considered as a preferable choice for treating spinal metastasis patients with spinal cord compression with neurological deficits.

Submicron particle docetaxel intratumoral injection in combination with anti-mCTLA-4 into 4T1-Luc orthotopic implants reduces primary tumor and metastatic pulmonary lesions

We describe here characterization of the response of local and metastatic disease and immunomodulation following intratumoral (IT) injection of submicron particle docetaxel (SPD) administered alone or in combination with systemic antibody anti-mCTLA-4 (anti-mCTLA-4) in the metastatic 4T1-Luc2-1A4 (4T1) murine breast cancer model. In-life assessments of treatment tolerance, tumor volume (TV), and metastasis were performed (n = 10 animals/group). At study end, immune cell populations in tumor-site tissues and peripheral blood were analyzed using flow cytometry. Signs of distress typical of this aggressive tumor model occurred across all animals except for the combination treated which were asymptomatic and gained weight. TV at study end was significantly reduced in the combination group versus untreated [43% reduced (p < 0.05)] and vehicle controls [54% reduced (p < 0.0001)]. No evidence of thoracic metastasis was found in 40% of combination group animals and thoracic bioluminescence imaging (BLI) was reduced vs. untreated controls (p < 0.01). Significant elevations (p < 0.05) in CD4 + T, CD4 + helper T, Treg, and NKT cells were found in tumor and blood in SPD or combination treatment compared to controls or anti-mCTLA-4. Combination treatment increased tumor-associated CD8 + T cells (p < 0.01), peripheral B cells (p < 0.01), and tumor associated and circulating dendritic cells (DC) (p < 0.05). Tumor-associated NK cells were significantly increased in SPD ± anti-mCTLA-4 treatments (p < 0.01). Myeloid-derived suppressor cells (MDSC) were reduced in bloods in SPD ± anti-mCTLA-4 groups (p < 0.05). These data demonstrate that both SPD and anti-mCTLA-4 produce local anti-tumor effects as well as reductions in metastasis which are significantly enhanced when administered in combination.