Primary peritoneal clear cell carcinoma treated with IMRT and interstitial HDR brachytherapy: a case report

Primary Peritoneal Clear Cell Carcinoma Presenting with Nonspecific Gastrointestinal Symptoms in a 39-Year-Old Woman: A Case Report

Introduction

Primary peritoneal clear cell carcinoma (PPCCC) is a rare abdominal tumor, affecting 7 out of every million people. Its vague presenting signs and symptoms often lead to delayed diagnosis and poor prognosis. We present a case involving a young woman with anemia and abdominal discomfort who on further investigation had a 26-cm abdominal tumor identified to be PPCCC. Multimodal therapy with tumor debulking and chemotherapy was pursued. Given the aggressive nature of PPCCC, any clinical suspicion of peritoneal carcinoma should prompt thorough diagnostic evaluation.

Case Presentation

A 39-year-old woman with menorrhagia and peptic ulcer disease presented with abdominal discomfort of 2 days duration. She initially had headaches managed with ibuprofen. Following this, she had generalized abdominal pain with bloating that worsened with food and had no relief with use of stool softeners. She had associated dizziness with palpitations, chest pressure, and exertional dyspnea. In the emergency department, the patient was mildly tachycardic but otherwise stable. On exam, she had a distended abdomen with generalized tenderness and normoactive bowel sounds. Labs showed normocytic anemia with a hemoglobin of 5.2 mg/dL. Electrocardiogram and abdominal and chest X-rays were normal. A non-contrast computed tomography of the abdomen and pelvis showed a fibroid uterus and posterior displacement of multiple bowel loops by a large septate cystic mass (13.5 × 26.0 × 26.7 cm) occupying the entire abdominal cavity. Elevated CA 125 and CA 19-9 were also noted. She underwent exploratory laparotomy with mass resection, partial omentectomy, left colectomy (given extension into transverse colon), appendectomy, and total abdominal hysterectomy with bilateral salpingectomy. Biopsy and immunohistochemical staining (positive for PAX-8, ER, P53, P16, Napsin A and negative for PR and WT-1) confirmed mass as stage IIIB PPCCC. There was no evidence of malignancy in other tissue samples. The patient was discharged with a plan for outpatient chemotherapy and genetic counseling.

Conclusion

Given the rarity of PPCCC, our case highlights how increased clinical vigilance and prompt multidisciplinary efforts are essential for an accurate diagnosis, especially in younger patients to not delay management. Currently, there are no established management guidelines; however, initial treatment with surgical debulking followed by chemotherapy is often practiced.

Malignancies Associated with Extraovarian Endometriosis: A Literature Review

Endometriosis-associated ovarian malignancies have been well documented. Although these malignancies also occur as extraovarian lesions, little is known about them. Thus, this literature review aimed to further explore these rarely experienced tumors. A total of 257 published cases between April 1990 and April 2020 were found using PubMed, and 212 cases were included in the analysis considering Sampson’s criteria and the history of endometriosis. We classified these cases as follows: intestine, abdominal scar, vagina and vulva, peritoneum and deep endometriosis, urinary tract, uterine cervix, and others. Age of patients, history of endometriosis, types of past hormonal therapy, symptoms, histological types, and treatment were identified. The most common tumor site was the intestine. Endometrioid carcinoma was the dominant histological type. Contrary to the ovary, clear cell carcinoma was rare in extraovarian sites. On the other hand, clear cell carcinoma represented the largest number of abdominal scars. This difference may help us to understand the development of endometriosis-related malignancies. Hormonal treatment was mentioned in 67 cases and estrogen replacement therapy in 33 cases. Although risks of estrogen therapy are still controversial, the highly differentiated histological types and hormone-dependent characteristics of endometriosis-associated malignancy should be considered. Physicians should be careful about estrogen monotherapy after hysterectomy and long-term hormone replacement therapy in patients with a history of endometriosis.

Interstitial High-Dose-Rate Gynecologic Brachytherapy: Clinical Workflow Experience From Three Academic Institutions

An interstitial brachytherapy approach for gynecologic cancers is typically considered for patients with lesions exceeding 5 mm within tissue or that are not easily accessible for intracavitary applications. Recommendations for treating gynecologic malignancies with this approach are available through the American Brachytherapy Society, but vary based on available resources, staffing, and logistics. The intent of this manuscript is to share the collective experience of 3 academic centers that routinely perform interstitial gynecologic brachytherapy. Discussion points include indications for interstitial implants, procedural preparations, applicator selection, anesthetic options, imaging, treatment planning objectives, clinical workflows, timelines, safety, and potential challenges. Interstitial brachytherapy is a complex, high-skill procedure requiring routine practice to optimize patient safety and treatment efficacy. Clinics planning to implement this approach into their brachytherapy practice may benefit from considering the discussion points shared in this manuscript.

Dosimetric impact of interfractional organs at risk variation during high-dose rate interstitial brachytherapy for gynecologic malignancies

We sought to develop a framework for the identification and management of patients at risk for organs at risk (OARs) overdosing due to interfractional anatomic variation during high-dose rate interstitial brachytherapy for gynecologic malignancies. We analyzed 40 high-dose rate interstitial brachytherapy fractions from 10 patients. Planned OAR doses were compared to delivered doses, which were calculated from computed tomography scans obtained prior to each treatment fraction. Doses were converted to equivalent doses in 2 Gy fractions (EQD2) and doses to the most exposed 2 cm³ (D_2cc) were reviewed. Patients were risk-stratified by identifying dose thresholds corresponding to a 10% or lower risk of receiving an OAR dose exceeding the corresponding planning constraint. For each OAR, 30% to 62.5% of patients received total doses greater than planned, although the magnitude of these differences was <4 Gy in over 75% of cases. Using EMBRACE II guidelines, one patient who had met the planning constraint for bladder and one for small bowel were found to have received doses exceeding the recommended limits. We next calculated thresholds for estimating the risk of OAR overdosing in individual patients and developed a framework based on these thresholds to direct time- and resource-intensive imaging and replanning efforts toward patients who are most likely to derive benefit. In summary, differential OAR dosing due to interfractional anatomic variation is common but likely rarely clinically meaningful. The proposed framework could decrease toxicity and maximize clinical efficiency.

Primary peritoneal clear cell carcinoma versus ovarian carcinoma versus malignant transformation of endometriosis: a vexing issue

Peritoneum is a site for both primary and secondary tumors. Primary peritoneal tumors are fairly rare. The most common primary tumors of the peritoneum are malignant mesothelioma and serous papillary adenocarcinoma. Clear cell carcinoma of the peritoneum is extremely rare and often misdiagnosed as mesothelioma, serous carcinoma, or metastatic adenocarcinoma, so it represents a diagnostic challenge for both clinicians and pathologists. Up to date, to the best of our knowledge, only 11 cases of primary peritoneal clear cell carcinoma have been reported in the English literature. Distinguishing this tumor of the peritoneum versus ovarian carcinoma can be problematic. Herein, we report a rare case of primary peritoneal clear cell carcinoma occurring in a 49-year-old woman, along with a review of the literature.

Clear cell adenocarcinoma of the peritoneum: a case report and literature review

Clear cell adenocarcinoma (CCC) is generally thought to originate from ovarian, endometrial, or renal tissue. A CCC of the peritoneum (CCAP) is an extremely rare medical condition and is associated with a poor prognosis. To date, only 10 cases of CCAP have been reported, of which half resulted in death or recurrence within 6 months after initial treatment because CCAP is commonly resistant to multiple drugs. In this report, we present a case of CCAP of the pouch of Douglas coexisting with an endometriosis and we offer a review of the related literature.