A Rare Case of Ruptured Tailgut Cyst Leading to Carcinomatosis

Tailgut cysts are congenital cysts arising in the retrorectal space. They are thought to be benign with variable malignancy risks. We report a case with previous surgical intervention decades prior that had undergone a tailgut cyst excision with surgical complications leading to carcinomatosis. An elderly female (70s) presented with tailbone/pelvic pain. She underwent cyst excision that was complicated by an intraoperative rupture. The cyst was pathologically proven to be a tailgut cyst with adenocarcinoma. She presented 13 months postoperatively to the emergency department with worsening abdominal pain. Imaging was concerning for diffuse omental nodules and narrowing of the proximal sigmoid colon. She was not deemed to be a surgical candidate and was transitioned to hospice care, where she passed away shortly afterward. This case report highlights the utility of complete excision of tailgut cysts and possible complications.

The relationship of oncotype Dx Recurrence Score (RS) with Ki 67 in early stage breast cancer patients in a community based cancer center in rural central Nebraska

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Background: Oncotype Dx recurrence score (RS), is a prognostic and predictive test utilized for decision making in adjuvant therapy of 0-3 node/hormone receptor positive(HR+)/ HER-2-negative early breast cancer. Ki-67 is a marker of proliferating cells and is associated with prognosis and response. Immunohistological (IHC) assessment of Ki 67 expression is less expensive and with the approval of CDK inhibitors in the high risk adjuvant setting, it is increasingly being utilized in clinical decision making. A moderate to strong correlation between Ki67 and Oncotype Dx RS has been reported in the literature. We sought to examine the relationship of Ki 67 to Oncotype Dx RS in a community-based cancer center in rural central Nebraska. Methods: Forty-three consecutive postmenopausal breast cancer patients(pts) diagnosed and treated at our community based cancer center between 2020-2021 with T1–2 N0-1 M0, HR+, HER-2-negative disease were evaluated for histological type, tumor size, Nottingham grade, HR levels, Ki 67 expression (low < 10%, intermediate 10 ≥ Ki67 < 25 high ≥ 25), and Oncotype Dx RS(low <16,intermediate 16⩽RS<26), high ⩾26). Ki 67 and Oncotype Dx RS were treated as continuous variables to calculate a Pearson correlation coefficient. Results: Mean age at diagnosis was 59.4 years (range 48-89). Mean tumor diameter was 15.6 mm. 78.9% were intermediate histologic grade and 9.7% patients had lymph node involvement. Median expression of ER and PR were 90% (5-100) and 70% (0-100), respectively. The mean Ki 67 value was 17.5 (range 5-60 %), and mean Oncotype RS was 14.4 (range 4-34). There was a positive linear correlation between Ki 67 expression and Oncotype Dx RS (Pearson Correlation Coefficient=0.49, P-value <0.001). The vast majority of high Ki 67 pts (80%) had high/intermediate Oncotype RS. All pts with low Ki 67 (100%) had low/intermediate RS. Conclusions: Our community based rural cancer center data support a linear, statistically significant, positive correlation between Ki 67 and Oncotype Dx RS in early stage 0-3 node/HR+ positive breast cancer pts. Increasing use of Ki 67 testing in different clinical settings will generate more data to better define this correlation.[Table: see text]

Locally Advanced Gastrointestinal Stromal Tumor in a 33-Year-Old Woman Seeking to Conceive

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract. They commonly present with nonspecific symptoms and thus are often discovered incidentally. They are best identified by CT scan, and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. Several risk stratification classification systems have been developed based on tumor size, mitotic rate, location, and perforation. Traditional chemotherapy and radiation therapy have been very ineffective, making surgery the mainstay of treatment. The discovery of mutations associated with these tumors has revolutionized the treatment approach. Imatinib mesylate, a selective tyrosine kinase receptor inhibitor, used as adjuvant or neoadjuvant therapy, has greatly improved the morbidity and mortality associated with GISTs. As the survival of patients has increased with the long-term use of targeted therapies, quality-of-life issues now have become much more relevant and have come to the forefront of care. We present a young woman who was successfully treated for GIST but now faces associated long-term adverse effects of imatinib, including the challenge of preserving fertility and the potential for childbearing.

A 64-Year-Old Man With Germline BRCA2-Mutated Breast Cancer: Known and Unknown Aspects of Male Breast Cancer

Male breast cancer is a rather uncommon and understudied disease. It accounts for less than 1% of all breast cancers, but in recent decades its frequency has been on the rise. Clinical trials of breast cancer have traditionally excluded men. Due to the lack of large-scale prospective studies, most published data come from single-institution, small-cohort studies, and treatment recommendations are based on the extrapolation of data from clinical trials enrolling only women. Although to some extent etiology, diagnosis, and treatment characteristics can be similar, male breast cancer exhibits some distinct features. Men tend to be diagnosed with breast cancer at an older age and at a more advanced stage. A better understanding of the biologic features, clinically relevant differences, effective treatments, and outcomes of male breast cancer is crucial to appropriately manage these patients. We present a male breast cancer case with a germline BRCA2 mutation and discuss the epidemiologic, pathologic, and clinical characteristics along with treatment and follow-up recommendations in view of our recent understanding of this disease.

Diagnostic discrepancies in second opinion pathology reviews in a community-based cancer center

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Background: Tracking diagnostic discrepancies is a common quality indicator in anatomic pathology. Many cases are re-reviewed as care is transferred from one facility to another. Most published data on these discrepancies is from the perspective of the tertiary receiving facility. Disparities in patient access to pathology expertise and technologies in small community hospitals can affect the accuracy of cancer diagnosis and the quality of care. Mary Lanning Healthcare (MLH) is a regional community hospital with a well-established referral pattern to several neighboring health systems. As part of a quality assurance process, we evaluated the diagnostic concordance rate of our cancer related pathology diagnoses with the referred institutions. Methods: Between 2017 and 2020, a cohort of cancer related cases was identified where the initial diagnosis was at MLH, then as part of coordinated care, a second pathologic interpretation was rendered at another instution. Data regarding specimen type, discrepancy in original diagnosis, nature and severity of discrepancy, disagreement in histologic grade, concordance or lack thereof with third party reviewers, and distribution among reviewing pathologists were collected. Results: A total of 521 cancer related cases (890 specimens) were sent to 16 facilities for second opinion. There were 46 (5%) discrepancies. Majority of them 45 (98%) were minor. Third party review of one major discrepancy came back in agreement with our original diagnosis. The most common discrepancy was interobserver variability in findings without strictly defined criteria. A change in histologic grade was the second most frequent deviation with prostate and breast being the most common sites. Upgrades and downgrades to the original diagnoses were nearly evenly split (19 to 21). A total of 33 pathologists were involved. While one reviewing pathologist generated 30% of all discrepancies, 3 other pathologists accounted for 67%. Conclusions: Accurate pathologic diagnoses significantly impact clinical outcomes. Our data which represents a rural community-based cancer program identified an overall discrepancy rate in the range of 0.1 to 1.1% for second opinion review. The vast majority of differences were minor in nature with no change in patient care and could be attributed to expected interobserver variability.[Table: see text]

Pancreatic Neuroendocrine Tumor With Humoral Hypercalcemia and High Tumor PD-L1 Score

Pancreatic neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms. They can be functioning tumors with secretion of a variety of peptide hormones, or nonfunctioning tumors with metastases to the liver at the time of diagnosis. Well-differentiated tumors tend to be slow-growing and characterized by low tumor mutational burden (TMB) and lower propensity to express PD-L1. Hypercalcemia due to malignancy can occur in about 20% to 30% of patients with cancer. The secretion of parathyroid hormone-related protein (PTH-rP) is among the causes of malignant hypercalcemia and has seldom been associated with hypercalcemia of NETs. Although the therapeutic landscape for neuroendocrine neoplasms has evolved substantially over the past decade, the role of immunotherapy has not yet been completely explored in this group of patients. We present a rare case of a metastatic pancreatic NET with high TMB, high PD-L1 tumor proportion score, and high PTH-rP related hypercalcemia.

Hereditary vs Familial Pancreatic Cancer: Associated Genetic Syndromes and Clinical Perspective

Pancreatic ductal adenocarcinoma (PDAC) is a disease marked by high rates of mortality; it is mostly incurable at the time of diagnosis. Only about 7% of patients survive 5 years after diagnosis. Diagnosis at a late stage and rapid progression with minimal response to available treatments are the main reasons for this poor outcome. It is crucial to identify individuals at high risk of developing PDAC so preventive and early detection measures can be employed. Approximately 10% to 15% of PDAC cases have a hereditary or familial basis. In the majority of PDAC cases, no main causative gene has been identified, but several known germline pathogenic mutations have been shown to be related to an increased risk of this cancer. The presence of 2 or more patients with pancreatic cancer within the circle of first-degree relatives, without the presence of a causative germline mutation, is defined as familial pancreatic cancer; this accounts for 4% to 10% of PDAC. Based on the growing evidence supporting the benefit of germline genetic testing in patients with PDAC, both the American Society of Clinical Oncology and the National Comprehensive Cancer Network recently updated their guidelines to include recommendations around genetic testing for patients with pancreatic cancer. However, there is no general consensus on the group of patients and individuals who should be studied and screened. We present a demonstrative case and review the available data on hereditary and familial PDAC.

76-Year-Old Woman With a Bluish-Purple Lump in her Left Upper Medial Leg

A woman, aged 76 years, presented with a bluish-purple lump in her mid- to upper medial left thigh. It started initially as a flat rash, and over a 2-month period, it turned into a mass measuring 2.5 cm by 3.1 cm. Work-up, including a PET-CT scan, showed the soft tissue mass on the inner thigh to have a Standardized Uptake Value of 4; there were no other sites of disease. A biopsy of the lesion was performed.

Synchronous Bilateral Lung Cancer With Discordant Histology

Synchronous multiple primary lung cancer (SMPLC) is a rare occurrence affecting 0.5% to 2% of patients with lung cancer. Synchronous discordant histology with small cell and non-small cell lung carcinoma is an even less common entity. There have been several presentations of synchronous or metachronous multiple primary lung cancers in the literature. However, reports discussing treatment options and prognosis in patients with SMPLC of discordant histology with small cell and non-small cell carcinoma in the same patient are scarce. We report a case of SMPLC presenting with a limited stage left upper lobe small cell lung cancer and an operable right upper lobe non-small cell lung adenocarcinoma. Diagnostic, surgical, and medical treatment options for the patient along with a review of SMPLC topics are presented.

Locally Advanced Rectal Cancer, What is the Standard of Care?

Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one-third of newly diagnosed cases. A comprehensive trimodality approach involving neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy has been the standard of care for medically operable patients with nonmetastatic, locally advanced rectal cancer. Despite a marked reduction in local recurrence rates with good local control, systemic recurrence rates of as high as 35% constitute the leading cause of death in this population. This has led to increasing interest in neoadjuvant systemic therapy before or after neoadjuvant chemoradiation a new approach called total neoadjuvant therapy. This case study will review the current status of clinical stage II or III locally advanced rectal cancer (T3/4, N0, or node-positive) treatment regarding neoadjuvant therapy.

Transiently Pink-Tinged Serum in a Patient With Multiple Myeloma and Anemia Undergoing Lenalidomide Treatment

OBJECTIVES

While in vitro hemolysis is a preanalytical interferent, in vivo hemolysis is a pathologic process requiring investigation. We present a case of an anemic patient with multiple myeloma undergoing chemotherapy with lenalidomide who had multiple serum samples drawn before and after chemotherapy treatment. Some of these samples showed hemolysis. This triggered further investigations to differentiate the cause of the hemolysis.

METHODS

Various laboratory tests and additional investigations were necessary to establish the root of the hemolytic process.

RESULTS

Multiple laboratory tests and a rigorous review of the samples, time of collection, and laboratory results revealed that only samples collected shortly after lenalidomide administration showed hemolysis. This indicates that the chemotherapeutic agent itself was most likely the proximate cause of the in vivo hemolysis in a non-immune-mediated manner.

CONCLUSIONS

Upon administration, chemotherapeutic agents, such as lenalidomide, can immediately induce transient hemolysis, which can be visualized as transiently pink-tinged serum samples.

How well do we communicate?: a comparison of intraoperative diagnoses listed in pathology reports and operative notes

OBJECTIVES

To compare surgeons' interpretations of intraoperative diagnoses with those rendered by the pathologist.

METHODS

Consecutive intraoperative diagnoses over a nine-month period were retrospectively reviewed. For each case, operative notes were obtained from the hospital information system. The intraoperative diagnoses listed in the final pathology reports were compared with those dictated by the surgeon. Discrepancies were stratified by potential clinical impact: category A, overall correct diagnosis with minor unimportant differences; category B, discrepant diagnosis with both either benign or malignant; and category C, intraoperative diagnoses differing between benign and malignant. The method of communication of each discrepant intraoperative diagnoses (in person vs telephone) was also examined.

RESULTS

There was no record of the intraoperative diagnoses in 20% of operative notes. Comparison of intraoperative diagnoses was possible in 1,131 cases. Category A errors were noted in 94 (8.3%) cases, B in 11 (1%), and C in 4 (0.3%). The most frequent means of communication in A and B cases was the telephone, with more C cases being relayed in person.

CONCLUSIONS

A subset of verbally reported intraoperative diagnoses is misinterpreted by surgeons. While rare events, miscommunication can lead to inappropriate intraoperative management. Communicating diagnoses by phone may increase the risk of perception errors.