Benign and malignant prolapsed uterine tumors : 4 case reports of an extremely rare entities

Prolapsed uterine tumors within the cervix or vagina, are attached to the uterine cavity by a soft tissue stalk. Malignant tumors and leiomyoma are the first diagnostic considerations for a prolapsed uterine mass with a visible stalk at MRI. This article describes 4 cases of patients who presented with large, necrotic prolapsed uterine tumors that were surgically confirmed and were diagnosed prospectively on the basis of MRI findings. Imaging, particularly MRI, plays a crucial role in the management of patients with prolapsed pedunculated uterine tumors, especially for pre-operative localization and surgical treatment. The 4 patients underwent a total hysterectomy with a complete resection of the mass. The histopathological report confirmed in the first case the diagnosis of a uterine leiomyoma with aseptic necrobiosis, in the second and third cases a sarcoma, and in the fourth case a serous adenocarcinoma.

Rare case of enteric type of urachal adenocarcinoma: A case report

Urachal adenocarcinomas, constituting 10 % of bladder adenocarcinomas, pose a significant challenge with limited literature. A 43-year-old male presented with haematuria and abdominal pain, leading to surgical intervention for a 13 cm pelvic tumor. Histopathology identified an intestinal-type primary urachal adenocarcinoma, staged as IIIA, no recurrence on follow-up. Early detection is crucial for improved outcomes in these rare malignancies. While surgery remains the primary treatment, outcomes vary, emphasizing the need for research on standardized protocols. Enhanced awareness and interdisciplinary collaboration are vital for effective management. Comprehensive guidelines are essential for optimizing patient prognoses in urachal adenocarcinomas.

Antacids and reflux esophagitis as a risk factor for gastric neoplasm of fundic-gland type: A retrospective, matched case-control study

BACKGROUND AND AIM

Since the first report of gastric adenocarcinoma of the fundic-gland type in 2010, the clinicopathological characteristics of gastric neoplasm of the fundic-gland type (GNFG) have become clearer; however, their risk factors remain unclear. This exploratory study aimed to identify the risk factors for GNFG.

METHODS

We conducted a single-center, retrospective, matched case-control study using medical information recorded at our health management center from January 2014 to July 2023. During this period, 39 240 people underwent upper gastrointestinal endoscopy. GNFG were extracted as cases and matched to controls, according to age and sex, in a 1:8 ratio, excluding those with a history of gastrointestinal surgery and those with a history or comorbidity of cancer. Univariate analysis was used to compare patient background and endoscopic findings. Multivariable analysis was performed, adjusting for factors with P values < 0.1 and antacid use.

RESULTS

A total of 20 GNFG cases and 160 matched healthy controls were included. In the univariate analysis, only reflux esophagitis was significantly more common in GNFG (40.0% vs 18.1%; P = 0.036). Factors antacids and duodenitis had P values < 0.1. Logistic regression analysis was performed, adjusting for antacids, reflux esophagitis, and duodenitis. Antacids and reflux esophagitis were the independent risk factors for GNFG (odds ratio = 3.68 [95% confidence interval: 1.04-11.91] and 3.25 [95% confidence interval: 1.11-9.35]).

CONCLUSIONS

Although the sample of patients with GNFG was small, antacids and reflux esophagitis were identified as a risk factor. The pathogenesis of antacids and reflux esophagitis may be involved in the development of GNFG.

Cadherin-17 as a target for the immunoPET of adenocarcinoma

PURPOSE

Cadherin-17 (CDH17) is a calcium-dependent cell adhesion protein that is overexpressed in several adenocarcinomas, including gastric, colorectal, and pancreatic adenocarcinoma. High levels of CDH17 have been linked to metastatic disease and poor prognoses in patients with these malignancies, fueling interest in the protein as a target for diagnostics and therapeutics. Herein, we report the synthesis, in vitro validation, and in vivo evaluation of a CDH17-targeted 89Zr-labeled immunoPET probe.

METHODS

The CDH17-targeting mAb D2101 was modified with an isothiocyanate-bearing derivative of desferrioxamine (DFO) to produce a chelator-bearing immunoconjugate - DFO-D2101 - and flow cytometry and surface plasmon resonance (SPR) were used to interrogate its antigen-binding properties. The immunoconjugate was then radiolabeled with zirconium-89 (t1/2 ~ 3.3 days), and the serum stability and immunoreactive fraction of [89Zr]Zr-DFO-D2101 were determined. Finally, [89Zr]Zr-DFO-D2101's performance was evaluated in a trio of murine models of pancreatic ductal adenocarcinoma (PDAC): subcutaneous, orthotopic, and patient-derived xenografts (PDX). PET images were acquired over the course of 5 days, and terminal biodistribution data were collected after the final imaging time point.

RESULTS

DFO-D2101 was produced with a degree of labeling of ~ 1.1 DFO/mAb. Flow cytometry with CDH17-expressing AsPC-1 cells demonstrated that the immunoconjugate binds to its target in a manner similar to its parent mAb, while SPR with recombinant CDH17 revealed that D2101 and DFO-D2101 exhibit nearly identical KD values: 8.2 × 10-9 and 6.7 × 10-9 M, respectively. [89Zr]Zr-DFO-D2101 was produced with a specific activity of 185 MBq/mg (5.0 mCi/mg), remained >80% stable in human serum over the course of 5 days, and boasted an immunoreactive fraction of >0.85. In all three murine models of PDAC, the radioimmunoconjugate yielded high contrast images, with high activity concentrations in tumor tissue and low uptake in non-target organs. Tumoral activity concentrations reached as high as >60 %ID/g in two of the cohorts bearing PDXs.

CONCLUSION

Taken together, these data underscore that [89Zr]Zr-DFO-D2101 is a highly promising probe for the non-invasive visualization of CDH17 expression in PDAC. We contend that this radioimmunoconjugate could have a significant impact on the clinical management of patients with both PDAC and gastrointestinal adenocarcinoma, most likely as a theranostic imaging tool in support of CDH17-targeted therapies.

Risk stratification for synchronous/metachronous recurrence after endoscopic submucosal dissection for Barrett's esophageal adenocarcinoma using the length of Barrett's esophagus

BACKGROUND

In Japan, the standard management of Barrett's esophageal adenocarcinoma after endoscopic submucosal dissection involves follow-up; however, multifocal synchronous/metachronous lesions are sometimes observed after endoscopic submucosal dissection. Risk stratification of multifocal cancer facilitates appropriate treatment, including eradication of Barrett's esophagus in high-risk cases; however, no effective risk stratification methods have been established. Thus, we identified the risk factors for multifocal cancer and explored risk-stratified treatment strategies for residual Barrett's esophagus.

METHODS

We retrospectively reviewed the data of 97 consecutive patients with superficial Barrett's esophageal adenocarcinomas who underwent curative resection with endoscopic submucosal dissection. Multifocal cancer was defined by the presence of synchronous/metachronous lesions during follow-up. We used Cox regression analysis to identify the risk factors for multifocal cancer and subsequently analyzed differences in cumulative incidences.

RESULTS

The cumulative incidences of multifocal cancer at 1, 3, and 5 years were 4.4%, 8.6%, and 10.7%, respectively. Significant risk factors for multifocal cancer were increased circumferential and maximal lengths of Barrett's esophagus. The cumulative incidences of multifocal cancer at 3 years were lower for patients with circumferential length < 4 cm and maximal length < 5 cm (2.9% and 1.2%, respectively) than for patients with circumferential length ≥ 4 cm and maximal length ≥ 5 cm (51.5% and 49.1%, respectively).

CONCLUSIONS

Risk stratification of multifocal cancer using length of Barrett's esophagus was effective. Further multicenter prospective studies are needed to substantiate our findings.

Extent of Resection and Long-Term Outcomes for Appendiceal Adenocarcinoma: a SEER Database Analysis of Mucinous and non-Mucinous Histologies

BACKGROUND

Mucinous appendiceal adenocarcinomas (MAA) and non-mucinous appendiceal adenocarcinomas (NMAA) demonstrate differences in rates and patterns of recurrence, which may inform the appropriate extent of surgical resection (i.e., appendectomy versus colectomy). The impact of extent of resection on disease-specific survival (DSS) for each histologic subtype was assessed.

PATIENTS AND METHODS

Patients with resected, non-metastatic MAA and NMAA were identified in the Surveillance, Epidemiology, and End Results database (2000-2020). Multivariable models were created to examine predictors of colectomy for each histologic subtype. DSS was calculated using Kaplan-Meier estimates and examined using Cox proportional hazards modeling.

RESULTS

Among 4674 patients (MAA: n = 1990, 42.6%; NMAA: n = 2684, 57.4%), the majority (67.8%) underwent colectomy. Among colectomy patients, the rate of nodal positivity increased with higher T-stage (MAA: T1: 4.6%, T2: 4.0%, T3: 17.1%, T4: 21.6%, p < 0.001; NMAA: T1: 6.8%, T2: 11.4%, T3: 25.6%, T4: 43.8%, p < 0.001) and higher tumor grade (MAA: well differentiated: 7.7%, moderately differentiated: 19.2%, and poorly differentiated: 31.3%; NMAA: well differentiated: 9.0%, moderately differentiated: 20.5%, and 44.4%; p < 0.001). Nodal positivity was more frequently observed in NMAA (27.6% versus 16.4%, p < 0.001). Utilization of colectomy was associated with improved DSS for NMAA patients with T2 (log rank p = 0.095) and T3 (log rank p = 0.018) tumors as well as moderately differentiated histology (log rank p = 0.006). Utilization of colectomy was not associated with improved DSS for MAA patients, which was confirmed in a multivariable model for T-stage, grade, and use of adjuvant chemotherapy [hazard ratio (HR) 1.00, 95% confidence interval (CI) 0.81-1.22].

CONCLUSIONS

Colectomy was associated with improved DSS for patients with NMAA but not MAA. Colectomy for MAA may not be required.

Primary mucinous adenocarcinoma of the urethra: A contemporary clinicopathologic analysis of 17 patients

Mucinous adenocarcinoma of the urethra is rare. Here we performed a contemporary clinicopathologic analysis of this entity in both male and female patients. All cases with secondary tumors involving the urethra were excluded. Clinicopathologic parameters and follow up was obtained. Seventeen patients were included in the study, 9/17 (53 %) male and 8/17 (47 %) female. The mean patient age was 68 years (range: 53-88 years). The majority (11/17, 65 %) of patients were African American, with an even greater incidence (7/8, 87 %) in female patients. In male patients, prostatic urethra was the most common part of the urethra (6/9, 67 %) where the tumor arose from. Immunohistochemical stains were performed in 11/17 (65 %) tumors and were positive for CK20 (11/11, 100 %), CDX2 (11/12, 92 %), CK7 (8/9, 88 %), GATA3 (3/8, 37 %) and negative for NKX3.1, PSA, p63, PAX8, and Beta-Catenin. In resection specimens, tumors were categorized as pT2 (3/11, 27 %), pT3 (1/11, 9 %), and pT4 (7/11, 64 %). Lymph node status was categorized as pN0 (6/9, 67 %), pN1 (1/9, 11 %), and pN2 (2/9, 22 %). Available follow up data showed 7/13 (54 %) patients developed recurrence after surgical resection and chemotherapy, of which 3/7 (43 %) died of widespread metastatic disease. It is critical for pathologists and urologic oncologists to be aware of this entity in both male and female patients in view of potential diagnostic pitfalls, prognosis, and therapeutic implications.

Docetaxel-Based Neoadjuvant Chemotherapy Followed by En Bloc Resection for Esophageal Adenocarcinoma: A 15-Year Retrospective Analysis from a Regional Upper Gastrointestinal Cancer Network

BACKROUND

Real-world, long-term survival outcomes of neoadjuvant, docetaxel-based therapy for esophageal and junctional adenocarcinoma are lacking. This study describes the long-term survival outcomes of patients with esophageal and junctional adenocarcinoma treated with neoadjuvant docetaxel-based chemotherapy and en bloc transthoracic esophagectomy.

METHODS

A retrospective cohort analysis of a prospectively maintained database from a regional upper gastrointestinal cancer network in Quebec, Canada, was performed. From January 2007 to December 2021, all patients with locally advanced (cT3 and/or N1) esophageal/Siewert I/II adenocarcinoma treated with neoadjuvant DCFx3 (Docetaxel/Cisplatin/5FU) or FLOTx4 (5FU/Leucovorin/Oxaliplatin/Docetaxel) and transthoracic en bloc esophagectomy were identified. Postoperative, pathological, and survival outcomes were compared.

RESULTS

Overall, 236 of 420 patients met the inclusion criteria. Tumor location was esophageal/Siewert I/Siewert II (118/33/85), most were cT3-4 (93.6%) and cN+ (61.0%). DCF and FLOT were used in 127 of 236 (53.8%) and 109 of 236 (46.2%). All neoadjuvant cycles were completed in 87.3% with no difference between the regimens. Operative procedures included Ivor Lewis (81.8%), left thoraco-abdominal esophagectomy (10.6%) and McKeown (7.6%) with an R0 resection in 95.3% and pathological complete response in 9.7% (DCF 12.6%/FLOT 6.4%, p = 0.111). The median lymph node yield was 32 (range 4-79), and 60.6% were ypN+. Median follow-up was longer for the DCF group (74.8 months 95% confidence interval [CI] 4-173 vs. 37.8 months 95% CI 2-119, p <0.001. Overall survival was similar between the groups (FLOT 97.3 months, 78.6-115.8 vs. DCF 92.9, 9.2-106.5, p = 0.420).

CONCLUSIONS

Neoadjuvant DCF and FLOT followed by transthoracic en bloc resection are both highly effective regimens for locally advanced esophageal adenocarcinoma with equivalent survival outcomes despite high disease load.

Prognosis of spread through air spaces in invasive mucinous lung adenocarcinoma after curative surgery

INTRODUCTION

The purpose of this study is to investigate the prognostic impact of spread through air spaces (STAS) in invasive mucinous adenocarcinoma (IMA).

MATERIALS AND METHODS

From 2015 to 2019, patients who underwent complete resection of IMA were extracted from the prospective database. Multivariable Cox-regression analysis and inverse probability of treatment weight (IPTW) - adjusted log-rank test for 5-year recurrence-free survival (RFS) were performed.

RESULTS

STAS was observed in 39.1% (53 out of 133). The STAS (+) group shows larger tumor size (2.9 ± 2.4 cm vs 3.8 ± 2.4 cm, p = 0.031) and higher incidence of lympho-vascular invasion (6 [7.5%] vs 18 [34.0%], p < 00.001) compared to the STAS (-) group. The 5-year RFS was 66.1% in the STAS (+) group and 91.8% in the STAS (-) group (p < 00.001), and the incidence of locoregional recurrence was significantly higher in the STAS (+) group than the STAS (-) group (1 [1.2%] vs 12 [22.6%], p < 00.001). Multivariable analysis revealed that STAS was associated with poor prognosis for all-recurrence (hazard ratio 2.81, 95% confidence interval 1.01-7.81, p = 0.048). After IPTW adjustment, 5-year RFS was 66.3% in the STAS (+) group and 92.9% in the STAS (-) group (p = 0.007), and risk for locoregional recurrence was greater in the STAS (+) group than the STAS (-) group (1.1 [0.9%] vs 20.8 [16.6%], p < 00.001).

CONCLUSIONS

STAS showed negative prognostic impact on all-recurrence, especially due to locoregional recurrence, after curative resection of IMA.

Primary Mucinous Eccrine Carcinoma in Nasomaxillary Region: a Rare Case Report and Management Insights

Primary Mucinous eccrine carcinoma (MEC) is a rare malignant neoplasm of skin believed to arise from eccrine sweat gland commonly with periocular involvement. Here we report a case of 60-year male with a recurrence of unilateral nasomaxillary mass and epiphora. Imaging suggested nasolacrimal duct as probable site of origin. Histopathology and immunochemistry confirmed the diagnosis and managed surgically. This case report emphasizes the significance of including primary MEC in the differential diagnosis of nasomaxillary mass for its recurrence nature and histological similarity with metastasis from other viscera.

Fish: A Promising Screening Tool for Malignancy After Augmentation Cystoplasty?

INTRODUCTION

Malignancy after augmentation cystoplasty (AC) is reported up to 5.5 %. We assessed the use of urine fluorescence in situ hybridization (FISH) screening for bladder malignancy after AC.

PATIENTS AND METHODS

In this study, 36/98 patients under follow-up who have completed tenth year after ileal AC were included prospectively. Twenty-four (66.7 %) patients were tested with FISH initially and overall 28 (77.8 %) patients with conventional cytology (CC). Twenty-four (66.7 %) patients with FISH analysis also had cytology analysis. Blinded from the cytology results, 32 (88.9 %) patients who were consented underwent cystoscopy with random biopsy (native bladder, ileal segment, ileovesical junction). Two patients those were tested with FISH did not consented cystoscopy. This study was registred to the government registry (No: 71146310).

RESULTS

Mean follow-up time after AC was 15.4 ± 4.8 years. 2/32 (5.6 %) patients were diagnosed with adenocarcinoma in cyctoscopic biopsy. FISH analysis of 3/24 (12.5 %) patients demonstrated abnormal findings consistent with malignancy. Two FISH malignant patients were patients who had adenocarcinoma. The third patient's biopsy was benign and the third year control cystoscopy was normal. 2/4 patients with malignant CC had adenocarcinoma and 2/4 patients had benign biopsy. The sensitivity and specificity of FISH in our series were 100 % and 95 % respectively. Whereas the sensitivity and specificity of CC was 100 % and 91.6 % respectively.

CONCLUSION

Despite limited number of patients in this study, FISH showed higher specificity than CC in this series. FISH is a promising tool for malignancy screening after AC.

TYPE OF STUDY

Diagnostic Studies.

LEVEL OF EVIDENCE

II.

Imaging features of mucinous carcinoma arising from mature teratoma showing cytokeratin 7+ and cytokeratin 20+ expression profile: A case report

Ovarian mature teratomas are benign, but malignant transformation can occur infrequently, especially in women of advanced age. The tissue that undergoes malignant change is mostly squamous cell carcinoma, although adenocarcinoma has been reported in a small number of cases. The immunostaining results of adenocarcinoma usually show a cytokeratin (CK)7-/CK20+ expression profile, corresponding to lower gastrointestinal tract origin. In this report, we describe a case of mucinous carcinoma arising from an ovarian mature teratoma showing a CK7+/CK20+ profile and discuss its imaging features. A 40-year-old woman presented to her primary care physician with abdominal distension and poor oral intake, and she was referred to our hospital. She had been diagnosed with an ovarian mature teratoma at our institution 3 years earlier. At the current presentation, pelvic magnetic resonance imaging showed a large multilocular cystic mass with adipose tissue extending into the upper abdomen. Densely packed cysts were observed inside the mass, which showed weak contrast enhancement on contrast-enhanced imaging and a mildly high signal on diffusion-weighted imaging. A portion of the cysts also showed abnormal 18F-fluorodeoxyglucose uptake (maximum standardized uptake value, 13.2) on positron emission tomography/computed tomography. The patient was subsequently diagnosed with mucinous carcinoma showing a CK7+/CK20+ profile arising from a mature teratoma by pathologic examination. This mucinous carcinoma arising from a mature teratoma showed a CK7+/CK20+ profile and took the form of densely packed multilocular cysts. In this respect, it was similar to primary ovarian epithelial mucinous carcinoma on both magnetic resonance imaging and pathologic examination despite showing a much higher maximum standardized uptake value than that of primary ovarian mucinous carcinoma. When a large ovarian teratoma contains a large multilocular cyst, the presence of densely packed multilocular cysts should not be missed even in a mass without solid components. Clinicians should consider the possibility of mucinous carcinoma showing a CK7+/CK20+ profile arising from a mature teratoma in such cases.

Development and validation of a deep learning signature for predicting lymphovascular invasion and survival outcomes in clinical stage IA lung adenocarcinoma: A multicenter retrospective cohort study

PURPOSE

The presence of lymphovascular invasion (LVI) influences the management and outcomes of patients with clinical stage IA lung adenocarcinoma. The objective was the development of a deep learning (DL) signature for the prediction of LVI and stratification of prognosis.

METHODS

A total of 2077 patients from three centers were retrospectively enrolled and divided into a training set (n = 1515), an internal validation set (n = 381), and an external set (n = 181). A -three-dimensional residual neural network was used to extract the DL signature and three models, namely, the clinical, DL, and combined models, were developed. Diagnostic efficiency was assessed by ROC curves and AUC values. Kaplan-Meier curves and Cox proportional hazards regression analyses were conducted to evaluate links between various factors and disease-free survival.

RESULTS

The DL model could effectively predict LVI, shown by AUC values of 0.72 (95 %CI: 0.68-0.76) and 0.63 (0.54-0.73) in the internal and external validation sets, respectively. The incorporation of DL signature and clinical-radiological factors increased the AUC to 0.74 (0.71-0.78) and 0.77 (0.70-0.84) in comparison with the DL and clinical models (AUC of 0.71 [0.68-0.75], 0.71 [0.61-0.81]) in the internal and external validation sets, respectively. Pathologic LVI, LVI predicted by both DL and combined models were associated with unfavorable prognosis (all p < 0.05).

CONCLUSION

The effectiveness of the DL signature in the diagnosis of LVI and prognosis prediction in patients with clinical stage IA lung adenocarcinoma was demonstrated. These findings suggest the potential of the model in clinical decision-making.

Impact of central nervous system metastasis after complete resection of lung adenocarcinomas harboring common EGFR mutation - A real-world database study in Japan: The CReGYT-01 EGFR study

OBJECTIVES

To clarify the impact of central nervous system (CNS) metastasis on performance status (PS) at relapse, on subsequent treatment(s), and on survival of patients with lung adenocarcinoma harboring common epidermal growth factor receptor (EGFR) mutation.

METHODS

We conducted the multicenter real-world database study for patients with radical resections for lung adenocarcinomas between 2015 and 2018 at 21 centers in Japan. EGFR mutational status was examined at each center.

RESULTS

Of 4181 patients enrolled, 1431 underwent complete anatomical resection for lung adenocarcinoma harboring common EGFR mutations. Three-hundred-and-twenty patients experienced disease relapse, and 78 (24%) had CNS metastasis. CNS metastasis was significantly more frequent in patients with conventional adjuvant chemotherapy than those without (30% vs. 20%, P = 0.036). Adjuvant chemotherapy did not significantly improve relapse-free survival at any pathological stage (adjusted hazard ratio for stage IA2-3, IB, and II-III was 1.363, 1.287, and 1.004, respectively). CNS metastasis did not affect PS at relapse. Subsequent treatment, mainly consisting of EGFR-tyrosine kinase inhibitors (TKIs), could be equally given in patients with or without CNS metastasis (96% vs. 94%). Overall survival after relapse was equivalent between patients with and without CNS metastasis.

CONCLUSION

The efficacy of conventional adjuvant chemotherapy may be limited in patients with lung adenocarcinoma harboring EGFR mutations. CNS metastasis is likely to be found in practice before deterioration in PS, and may have little negative impact on compliance with subsequent EGFR-TKIs and survival after relapse. In this era of adjuvant TKI therapy, further prospective observational studies are desirable to elucidate the optimal management of CNS metastasis.

Enteroblastic adenocarcinoma of the ampulla of Vater

Adenocarcinoma with enteroblastic differentiation is a rare histologic subtype of adenocarcinoma of the gastrointestinal tract that shows unique histologic and immunohistochemical features that resemble fetal intestinal epithelium. This histological subtype has been widely described in the stomach, where it most frequently appears, but, in other locations, it is misdiagnosed because of the poor experience in routine diagnostic setting. Here we present a case of an 87-year-old male with an adenocarcinoma of the ampulla of Vater with enteroblastic differentiation with a literature review of the cases described of this subtype in this location to date. The anatomical peculiarity of the ampulla, joined with the infrequent nature of this histological subtype, makes this case of great interest to aid to better characterize the biological behavior of these tumors.

Usefulness of the preoperative inflammation-based prognostic score and the ratio of visceral fat area to psoas muscle area on predicting survival for surgically resected adenocarcinoma of the esophagogastric junction

BACKGROUND

Sarcopenic obesity is associated with gastrointestinal cancer prognosis through systemic inflammation. However, in patients with adenocarcinoma of the esophagogastric junction (AEG), the relationship between the inflammation-based prognostic score (IBPS), muscle loss, visceral fat mass, and prognosis has not been sufficiently evaluated. We investigated the prognostic value of the preoperative IBPS and the visceral fat area ratio to the psoas muscle area (V/P ratio) in patients with AEG undergoing surgery.

METHODS

We retrospectively analyzed 92 patients with AEG who underwent surgery. The prognostic value of the preoperative neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio, systemic inflammation response index, C-reactive protein-to-albumin ratio, prognostic nutritional index, modified Glasgow Prognostic Score, and V/P ratio at the third lumbar vertebra was investigated using univariate and multivariate survival analyses.

RESULTS

Multivariate analysis revealed that a high pathological stage (p = 0.0065), high PLR (p = 0.0421), and low V/P ratio (p = 0.0053) were independent prognostic factors for poor overall survival (OS). When restricted to patients with body mass index (BMI) ≥ 25 kg/m2, a high V/P ratio was a poor prognostic factor (p = 0.0463) for OS. Conversely, when restricted to patients with BMI < 25 kg/m2, a low V/P ratio was a poor prognostic factor (p = 0.0021) for OS.

CONCLUSIONS

Both PLR and V/P ratios may be useful prognostic biomarkers in surgical cases of AEG. V/P ratio and BMI may provide an accurate understanding of the muscle and fat mass's precise nature and may help predict AEG prognosis.

Utilization of texture features of volumetric ADC maps in differentiating between serous cystadenoma and intraductal papillary neoplasms

INTRODUCTION

The rising incidence of incidental detection of pancreatic cystic neoplasms has compelled radiologists to determine new diagnostic methods for the differentiation of various kinds of lesions. We aim to demonstrate the utility of texture features extracted from ADC maps in differentiating intraductal papillary mucinous neoplasms (IPMN) from serous cystadenomas (SCA).

METHODS

This retrospective study was performed on 136 patients (IPMN = 87, SCA = 49) split into testing and training datasets. A total of 851 radiomics features were extracted from volumetric contours drawn by an expert radiologist on ADC maps of the lesions. LASSO regression analysis was used to determine the most predictive set of features and a radiomics score was developed based on their respective coefficients. A hyper-optimized support vector machine was then utilized to classify the lesions based on their radiomics score.

RESULTS

A total of four Wavelet features (LHL/GLCM/LCM2, HLL/GLCM/LCM2, /LLL/First Order/90percent, /LLL/GLCM/MCC) were selected from all of the features to be included in our classifier. The classifier was optimized by altering hyperparameters and the trained model was applied to the validation dataset. The model achieved a sensitivity of 92.8, specificity of 90%, and an AUC of 0.97 in the training data set, and a sensitivity of 83.3%, specificity of 66.7%, and AUC of 0.90 in the testing dataset.

CONCLUSION

A support vector machine model trained and validated on volumetric texture features extracted from ADC maps showed the possible beneficence of these features in differentiating IPMNs from SCAs. These results are in line with previous regarding the role of ADC maps in classifying cystic lesions and offers new evidence regarding the role of texture features in differentiation of potentially neoplastic and benign lesions.

Mucinous neoplasm of the appendix: A case report and review of literature

BACKGROUND

Appendiceal mucinous neoplasms (AMNs), although not classified as rare, are relatively uncommon tumors most often discovered incidentally during colorectal surgery. Accurate identification of AMNs is difficult due to non-specific symptoms, overlapping tumor markers with other conditions, and the potential for misdiagnosis. This underscores the urgent need for precision in diagnosis to prevent severe complications.

CASE SUMMARY

This case report describes the unexpected discovery and treatment of a low-grade AMN (LAMN) in a 74-year-old man undergoing laparoscopic hemicolectomy for transverse colon adenocarcinoma (AC). Preoperatively, non-specific gastrointestinal symptoms and elevated tumor markers masked the presence of AMN. The tumor, presumed to be an AMN peritoneal cyst intraoperatively, was confirmed as LAMN through histopathological examination. The neoplasm exhibited mucin accumulation and a distinct immunohistochemical profile: Positive for Homeobox protein CDX-2, Cytokeratin 20, special AT-rich sequence-binding protein 2, and Mucin 2 but negative for cytokeratin 7 and Paired box gene 8. This profile aids in distinguishing appendiceal and ovarian mucinous tumors. Postoperative recovery was uncomplicated, and the patient initiated adjuvant chemotherapy for the colon AC.

CONCLUSION

This case highlights the diagnostic complexity of AMNs, emphasizing the need for vigilant identification to avert potential complications, such as pseudomyxoma peritonei.

Multicentre validation of CT grey-level co-occurrence matrix features for overall survival in primary oesophageal adenocarcinoma

BACKGROUND

Personalising management of primary oesophageal adenocarcinoma requires better risk stratification. Lack of independent validation of proposed imaging biomarkers has hampered clinical translation. We aimed to prospectively validate previously identified prognostic grey-level co-occurrence matrix (GLCM) CT features for 3-year overall survival.

METHODS

Following ethical approval, clinical and contrast-enhanced CT data were acquired from participants from five institutions. Data from three institutions were used for training and two for testing. Survival classifiers were modelled on prespecified variables ('Clinical' model: age, clinical T-stage, clinical N-stage; 'ClinVol' model: clinical features + CT tumour volume; 'ClinRad' model: ClinVol features + GLCM_Correlation and GLCM_Contrast). To reflect current clinical practice, baseline stage was also modelled as a univariate predictor ('Stage'). Discrimination was assessed by area under the receiver operating curve (AUC) analysis; calibration by Brier scores; and clinical relevance by thresholding risk scores to achieve 90% sensitivity for 3-year mortality.

RESULTS

A total of 162 participants were included (144 male; median 67 years [IQR 59, 72]; training, 95 participants; testing, 67 participants). Median survival was 998 days [IQR 486, 1594]. The ClinRad model yielded the greatest test discrimination (AUC, 0.68 [95% CI 0.54, 0.81]) that outperformed Stage (ΔAUC, 0.12 [95% CI 0.01, 0.23]; p = .04). The Clinical and ClinVol models yielded comparable test discrimination (AUC, 0.66 [95% CI 0.51, 0.80] vs. 0.65 [95% CI 0.50, 0.79]; p > .05). Test sensitivity of 90% was achieved by ClinRad and Stage models only.

CONCLUSIONS

Compared to Stage, multivariable models of prespecified clinical and radiomic variables yielded improved prediction of 3-year overall survival.

CLINICAL RELEVANCE STATEMENT

Previously identified radiomic features are prognostic but may not substantially improve risk stratification on their own.

KEY POINTS

• Better risk stratification is needed in primary oesophageal cancer to personalise management. • Previously identified CT features-GLCM_Correlation and GLCM_Contrast-contain incremental prognostic information to age and clinical stage. • Compared to staging, multivariable clinicoradiomic models improve discrimination of 3-year overall survival.

Primary urethral carcinoma: Recommendations of the oncology committee of the French Urology Association

Primary urethral carcinoma (PUC) is defined as a tumor process arising within the urethra, with no history of other urinary tract localization or synchronous tumor of the urinary tract. The most common histological types are urothelial carcinoma (UC), squamous cell carcinoma (SCC) and adenocarcinoma (AC). In men, UC predominates, while AC is rare. In women, AC affects around one in two patients, while EC and UC are equally divided between the remaining cases. Diagnosis is often delayed, and requires endoscopic examination with biopsies. MRI is the gold standard for local staging. FDG-PET scan can help in cases of doubt about regional or distant extension. The prognosis remains unfavorable despite aggressive surgical treatment. Multimodal management combining surgery, radiotherapy and chemotherapy appears to improve prognosis in severe forms.

Computed tomography-based 3D convolutional neural network deep learning model for predicting micropapillary or solid growth pattern of invasive lung adenocarcinoma

PURPOSE

To investigate the value of a computed tomography (CT)-based deep learning (DL) model to predict the presence of micropapillary or solid (M/S) growth pattern in invasive lung adenocarcinoma (ILADC).

MATERIALS AND METHODS

From June 2019 to October 2022, 617 patients with ILADC who underwent preoperative chest CT scans in our institution were randomly placed into training and internal validation sets in a 4:1 ratio, and 353 patients with ILADC from another institution were included as an external validation set. Then, a self-paced learning (SPL) 3D Net was used to establish two DL models: model 1 was used to predict the M/S growth pattern in ILADC, and model 2 was used to predict that pattern in ≤ 2-cm-diameter ILADC.

RESULTS

For model 1, the training cohort's area under the curve (AUC), accuracy, recall, precision, and F1-score were 0.924, 0.845, 0.851, 0.842, and 0.843; the internal validation cohort's were 0.807, 0.744, 0.756, 0.750, and 0.743; and the external validation cohort's were 0.857, 0.805, 0.804, 0.806, and 0.804, respectively. For model 2, the training cohort's AUC, accuracy, recall, precision, and F1-score were 0.946, 0.858, 0.881,0.844, and 0.851; the internal validation cohort's were 0.869, 0.809, 0.786, 0.794, and 0.790; and the external validation cohort's were 0.831, 0.792, 0.789, 0.790, and 0.790, respectively. The SPL 3D Net model performed better than the ResNet34, ResNet50, ResNeXt50, and DenseNet121 models.

CONCLUSION

The CT-based DL model performed well as a noninvasive screening tool capable of reliably detecting and distinguishing the subtypes of ILADC, even in small-sized tumors.

Effects of neoadjuvant chemotherapy vs chemoradiotherapy in the treatment of esophageal adenocarcinoma: A systematic review and meta-analysis

BACKGROUND

Neoadjuvant therapy is an essential modality for reducing the clinical stage of esophageal cancer; however, the superiority of neoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT) is unclear. Therefore, a discussion of these two modalities is necessary.

AIM

To investigate the benefits and complications of neoadjuvant modalities.

METHODS

To address this concern, predefined criteria were established using the PICO protocol. Two independent authors performed comprehensive searches using predetermined keywords. Statistical analyses were performed to identify significant differences between groups. Potential publication bias was visualized using funnel plots. The quality of the data was evaluated using the Risk of Bias Tool 2 (RoB2) and the GRADE approach.

RESULTS

Ten articles, including 1928 patients, were included for the analysis. Significant difference was detected in pathological complete response (pCR) [P < 0.001; odds ratio (OR): 0.27; 95%CI: 0.16-0.46], 30-d mortality (P = 0.015; OR: 0.4; 95%CI: 0.22-0.71) favoring the nCRT, and renal failure (P = 0.039; OR: 1.04; 95%CI: 0.66-1.64) favoring the nCT. No significant differences were observed in terms of survival, local or distal recurrence, or other clinical or surgical complications. The result of RoB2 was moderate, and that of the GRADE approach was low or very low in almost all cases.

CONCLUSION

Although nCRT may have a higher pCR rate, it does not translate to greater long-term survival. Moreover, nCRT is associated with higher 30-d mortality, although the specific cause for postoperative complications could not be identified. In the case of nCT, toxic side effects are suspected, which can reduce the quality of life. Given the quality of available studies, further randomized trials are required.

Analysis of atypical glandular cells in ThinPrep Pap smear and follow-up histopathology

Background

Diagnosing atypical glandular cells (AGC) is a significant challenge in cytomorphology.

Methods

A retrospective study was undertaken to assess the prevalence of AGC and the subsequent histological outcomes over 5 years at a single institution.

Results

A total of 159,649 ThinPrep Pap tests, including 395 cases of AGC, were retrieved, of which 330 AGC cases had follow-up histopathology. Among these 330 cases, 43.9% were classified as AGC not otherwise specified, followed by AGC-endocervical cells at 33.3%. The most frequently observed histological findings at follow-up included CIN1 and benign mucosa with reactive changes, followed by high-grade squamous intraepithelial lesion and cervical squamous cell carcinoma. The overall 5-year insignificant AGC rate was 0.12%, and the overall 5-year significant AGC rate was 0.08%. Notably, 36.7% of AGC cases tested positive for high-risk human papillomavirus. Interestingly, the level of experience did not significantly impact the rates for significant or insignificant AGC diagnosis. However, senior cytopathologists had a higher AGC report rate compared to their junior peers.

Conclusion

The AGC diagnostic rate at our institution falls within the range given by the College of American Pathologists. A significant number of cases had follow-up histologic results available, and the overall 5-year insignificant AGC rate was 0.12%.

Tobacco use, self-reported professional dental cleaning habits, and lung adenocarcinoma diagnosis are associated with bronchial and lung microbiome alpha diversity

RATIONALE

The lung microbiome is an inflammatory stimulus whose role in the development of lung malignancies is incompletely understood. We hypothesized that the lung microbiome associates with multiple clinical factors, including the presence of a lung malignancy.

OBJECTIVES

To assess associations between the upper and lower airway microbiome and multiple clinical factors including lung malignancy.

METHODS

We conducted a prospective cohort study of upper and lower airway microbiome samples from 44 subjects undergoing lung lobectomy for suspected or confirmed lung cancer. Subjects provided oral (2), induced sputum, nasopharyngeal, bronchial, and lung tissue (3) samples. Pathologic diagnosis, age, tobacco use, dental care history, lung function, and inhaled corticosteroid use were associated with upper and lower airway microbiome findings.

MEASUREMENTS AND MAIN RESULTS

Older age was associated with greater Simpson diversity in the oral and nasopharyngeal sites (p = 0.022 and p = 0.019, respectively). Current tobacco use was associated with greater lung and bronchus Simpson diversity (p < 0.0001). Self-reported last profession dental cleaning more than 6 months prior (vs. 6 or fewer months prior) was associated with lower lung and bronchus Simpson diversity (p < 0.0001). Diagnosis of a lung adenocarcinoma (vs. other pathologic findings) was associated with lower bronchus and lung Simpson diversity (p = 0.024). Last professional dental cleaning, dichotomized as ≤ 6 months vs. >6 months prior, was associated with clustering among lung samples (p = 0.027, R2 = 0.016). Current tobacco use was associated with greater abundance of pulmonary pathogens Mycoplasmoides and Haemophilus in lower airway samples. Self-reported professional dental cleaning ≤ 6 months prior (vs. >6 months prior) was associated with greater bronchial Actinomyces and lung Streptococcus abundance. Lung adenocarcinoma (vs. no lung adenocarcinoma) was associated with lower Lawsonella abundance in lung samples. Inhaled corticosteroid use was associated with greater abundance of Haemophilus among oral samples and greater Staphylococcus among lung samples.

CONCLUSIONS

Current tobacco use, recent dental cleaning, and a diagnosis of adenocarcinoma are associated with lung and bronchial microbiome α-diversity, composition (β-diversity), and the abundance of several respiratory pathogens. These findings suggest that modifiable habits (tobacco use and dental care) may influence the lower airway microbiome. Larger controlled studies to investigate these potential associations are warranted.

Comparison of mismatch repair and immune checkpoint protein profile with histopathological parameters in pancreatic, periampullary/ampullary, and choledochal adenocarcinomas

BACKGROUND

Pancreatic, periampullary/ampullary, and choledochal adenocarcinomas are aggressive malignancies with a poor prognosis. Immune checkpoint blockade is a promising treatment option for several tumor types. H long terminal repeat-associating 2 (HHLA2), which is analogous to programmed death-ligand 1 (PD-L1), is a recently discovered member of the B7/cluster of differentiation 28 family and is expressed in many malignancies.

AIM

To analyze the expression of HHLA2 and its association with the pathologic biomarkers that predict sensitivity to immunotherapy.

METHODS

Ninety-two adenocarcinoma cases located in the pancreas, ampulla, and distal common bile duct were identified. This study assessed 106 pancreaticoduodenectomy and distal/total pancreatectomy samples that were delivered to Ankara City Hospital between 2019 and 2021. Immunohistochemistry was conducted to examine the expression of DNA mismatch repair (MMR), PD-L1, and HHLA2 proteins.

RESULTS

Patients with high HHLA2 expression had a higher mean age than those with low expression. Low HHLA2 expression was associated with high perineural invasion. HHLA2 expression was low in pathological stage T3 (pT) 3 cases and high in pathological stage T1, T2, and T4 cases. There was no correlation between HHLA2 expression and the expression of MMR proteins and PD-L1.

CONCLUSION

Evaluation of HHLA2 expression in microsatellite stable and PD-L1-negative tumors may be useful for predicting the response of individuals to immunotherapy and may serve as a novel therapeutic target for immunotherapy in advanced-stage disease.

Identification of breath volatile organic compounds to distinguish pancreatic adenocarcinoma, pancreatic cystic neoplasm, and patients without pancreatic lesions

BACKGROUND

Volatile organic compounds (VOCs) are a promising potential biomarker that may be able to identify the presence of cancers.

AIM

To identify exhaled breath VOCs that distinguish pancreatic ductal adenocarcinoma (PDAC) from intraductal papillary mucinous neoplasm (IPMN) and healthy volunteers.

METHODS

We collected exhaled breath from histologically proven PDAC patients, radiological diagnosis IPMN, and healthy volunteers using the ReCIVA® device between 10/2021-11/2022. VOCs were identified by thermal desorption-gas chromatography/field-asymmetric ion mobility spectrometry and compared between groups.

RESULTS

A total of 156 participants (44% male, mean age 62.6 ± 10.6) were enrolled (54 PDAC, 42 IPMN, and 60 controls). Among the nine VOCs identified, two VOCs that showed differences between groups were dimethyl sulfide [0.73 vs 0.74 vs 0.94 arbitrary units (AU), respectively; P = 0.008] and acetone dimers (3.95 vs 4.49 vs 5.19 AU, respectively; P < 0.001). After adjusting for the imbalance parameters, PDAC showed higher dimethyl sulfide levels than the control and IPMN groups, with adjusted odds ratio (aOR) of 6.98 (95%CI: 1.15-42.17) and 4.56 (1.03-20.20), respectively (P < 0.05 both). Acetone dimer levels were also higher in PDAC compared to controls and IPMN (aOR: 5.12 (1.80-14.57) and aOR: 3.35 (1.47-7.63), respectively (P < 0.05 both). Acetone dimer, but not dimethyl sulfide, performed better than CA19-9 in PDAC diagnosis (AUROC 0.910 vs 0.796). The AUROC of acetone dimer increased to 0.936 when combined with CA19-9, which was better than CA19-9 alone (P < 0.05).

CONCLUSION

Dimethyl sulfide and acetone dimer are VOCs that potentially distinguish PDAC from IPMN and healthy participants. Additional prospective studies are required to validate these findings.

Simultaneous gastric, pancreatic, and renal metastasis from poorly differentiated hepatocellular carcinoma

Common extrahepatic metastasis sites of hepatocellular carcinoma (HCC) are the lungs, adrenal glands, and bones. Herein, we report a rare case of metastatic gastric, pancreatic, and renal tumors from HCC simultaneously, and review the relevant literature. A 75-year-old woman presented with right hypochondralgia, appetite loss, and weight loss. Computed tomography revealed suspected metastatic liver, lung, and renal tumors. A blood test revealed a leukocyte count of 26,210/μL and a high inflammatory reaction. As sepsis was suspected, the patient was referred to our hospital. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging revealed a hypovascular liver tumor that was suspected to be metastatic. Upper gastrointestinal endoscopy revealed two suspected metastatic gastric tumors. Liver and gastric tumor biopsies revealed poor carcinoma in both. The patient's condition gradually worsened and she died on day 8 of the illness. Based on autopsy findings, the patient was finally diagnosed with metastatic gastric and renal tumors originating from HCC. Additionally, a metastatic pancreatic tumor originating from the HCC was identified during autopsy. The pathological diagnosis of the pulmonary lesion was primary lung adenocarcinoma. In conclusion, HCC should be suspected in cases with multiple metastases of unknown primary lesions.

Sinonasal adenocarcinoma presented as a giant anterior cranial fossa mass: a case report and review of the literature

BACKGROUND

Intestinal adenocarcinoma accounts for less than 0.1-4% of all malignancies in the region. It is common among woodworkers and leather workers. Sinonasal adenocarcinoma usually arises from the ethmoid sinus (40%) or nasal cavity (25%). Extension to nearby structures is common, but intracranial spread is very rare. These tumors are usually treated with surgery, with a reported 5-year survival rate of 59% to 80%.

CASE PRESENTATION

This is a 60-year-old Black African male patient who presented with globalized headache, nasal obstruction with snoring during sleep, anosmia, change in mentation, sometimes agitation and left-side visual loss of one-year duration with worsening his above symptoms over the last one month. He couldn't smell soap bilaterally; in his left eye he could see only hand movement at nearly 30 cm. On brain magnetic resonance imaging, there was a T1 hypo- and T2 hyper-intense anterior cranial fossa mass arising from the left ethmoid sinuses and sphenoid sinuses and compressing the left optic structures, and brain computed tomography demonstrated heterogeneous hypo- to isodense mass. Complete tumor excision achieved and discharged with significant improvement and linked to oncology unit for radiotherapy.

CONCLUSION

The management of these patients is multidisciplinary, involving neurosurgeons, otolaryngologists, oncologists, and maxillofacial surgeons. Surgical resection is the main treatment strategy, followed by radiotherapy, particularly intensity-modulated therapy. Chemotherapy is used in highly advanced, metastatic, and unresectable tumors.

Clinical significance of initial symptoms in endometriosis-associated ovarian cancer

Objective

Endometriosis is associated with various symptoms, but their severity varies from case to case. In this study, we investigated the reality of symptoms presented by patients with clinically early-stage endometriosis-associated ovarian cancer (EAOC) and explored the relationship between symptoms and laboratory/imaging findings, pathological findings, and prognosis.

Materials and Methods

This was a retrospective case-control study of patients who received initial surgical treatment and were diagnosed with clinically early-stage EAOC, including ovarian endometrioid carcinoma (OEC), ovarian clear cell carcinoma (OCCC), and seromucinous borderline tumor (SMBT). Patients with OEC/OCCC diagnosed between 2006 and 2016 and those with SMBT diagnosed between 2006 and 2020 were included. Chi-square and Kaplan-Meier estimates were used for statistical analyses.

Results

One hundred-seven patients (OEC, n=31; OCCC, n=39; SMBT, n=37) were included. Fifty-nine (55.1%) patients presented with symptoms, and the proportion of patients with OEC who presented with symptoms was significantly higher than that of others (OEC, 77.4%; OCCC, 43.6%; SMBT, 48.6%). The details of symptoms differed significantly among the pathological types (lower abdominal pain/abdominal discomfort/abnormal bleeding, OEC: 11/8/9; OCCC: 6/12/1; SMBT: 15/5/3). Only in the OEC group did symptomatic patients show significantly higher white blood cell (WBC) count and neutrophil/lymphocyte (N/L) ratio (symptomatic vs. asymptomatic, median: WBC count: 7250 vs. 5000, p=0.008; N/L ratio: 4.6 vs. 1.7, p=0.013). None of the asymptomatic patients showed recurrence during follow-up.

Conclusion

Patients with EAOC show varying symptoms depending on the histological type of the tumor. Laboratory findings underlying symptoms also vary by histopathological type, which may reflect differences in the carcinogenesis process.

Multicenter analysis on the value of standard (chemo)radiotherapy in elderly patients with locally advanced adenocarcinoma of the esophagus or gastroesophageal junction

BACKGROUND

To assess the tolerability and oncological results of chemoradiation in elderly patients with locally advanced adenocarcinoma of the esophagus or gastroesophageal junction.

METHODS

This multi-center retrospective analysis included 86 elderly patients (≥ 65 years) with esophageal or gastroesophageal junction adenocarcinoma (median age 73 years; range 65-92 years) treated with definitive or neoadjuvant (chemo)radiotherapy. The treatment was performed at 3 large comprehensive cancer centers in Germany from 2006 to 2020. Locoregional control (LRC), progression-free survival (PFS), distant metastasis-free survival (DMFS), overall survival (OS), and treatment-associated toxicities according to CTCAE criteria v5.0 were analyzed, and parameters potentially relevant to patient outcomes were evaluated.

RESULTS

Thirty-three patients (38%) were treated with neoadjuvant chemoradiation followed by surgery, while the remaining patients received definitive (chemo)radiation. The delivery of radiotherapy without dose reduction was possible in 80 patients (93%). In 66 patients (77%), concomitant chemotherapy was initially prescribed; however, during the course of therapy, 48% of patients (n = 32) required chemotherapy de-escalation due to treatment-related toxicities and comorbidities. Twenty-nine patients (34%) experienced higher-grade acute toxicities and 14 patients (16%) higher-grade late toxicities. The 2-year LRC, DMFS, PFS, and OS amounted to 72%, 49%, 46%, and 52%, respectively. In multivariate analysis, neoadjuvant chemoradiation followed by surgery was shown to be associated with significantly better PFS (p = 0.006), DMFS (p = 0.006), and OS (p = 0.004) compared with all non-surgical treatments (pooled definitive radiotherapy and chemoradiation). No such advantage was seen over definitive chemoradiation. The majority of patients with neoadjuvant therapy received standard chemoradiotherapy without dose reduction (n = 24/33, 73%). In contrast, concurrent chemotherapy was only possible in 62% of patients undergoing definitive radiotherapy (n = 33/53), and most of these patients required dose-reduction or modification of chemotherapy (n = 23/33, 70%).

CONCLUSIONS

In our analysis, omission of chemotherapy or adjustment of chemotherapy dose during definitive radiotherapy was necessary for the overwhelming majority of elderly esophageal cancer patients not eligible for surgery, and hence resulted in reduced PFS and OS. Therefore, optimization of non-surgical approaches and the identification of potential predictive factors for safe administration of concurrent chemotherapy in elderly patients with (gastro)esophageal adenocarcinoma is required.

Ileocecal colonic intussusception with adenocarcinoma: A rare case report and management strategy

INTRODUCTION AND IMPORTANCE

Intussusception, a condition primarily seen in pediatric populations, involves the telescoping of one segment of the bowel into an adjacent section. In adults, intussusception is rare and presents unique diagnostic and management challenges. This case report highlights a 73-year-old female with ileocecal colonic intussusception complicated by an underlying adenocarcinoma, emphasizing the need for early diagnosis and a multidisciplinary approach.

CASE PRESENTATION

A 73-year-old female with a history of hypertension and type 2 diabetes presented with right-sided abdominal pain, nausea, and vomiting. Physical examination revealed tenderness in the right upper quadrant, and no palpable mass or rectal bleeding. Lab results, including tumour markers, were normal. Multi-detector computed tomography (MDCT) identified ileocecal colonic intussusception with the "target sign" and low colonic wall enhancement. An emergency laparoscopic right colectomy was performed due to compromised blood supply. Postoperatively, an anastomotic leak was managed with antibiotics, bowel rest, and wound care. Pathological examination revealed cecal adenocarcinoma with one positive lymph node, staged as T3N1aM0, necessitating adjuvant chemotherapy.

CLINICAL DISCUSSION

Adult intussusception, a rare condition, often has an identifiable organic cause, with clinical symptoms ranging from acute to chronic or asymptomatic. Diagnostic imaging, such as MDCT, plays a crucial role in diagnosis and evaluation. Surgical management varies based on the nature and location of the lead point. In this case, the chronic symptoms, lymph node as the lead point, and low colonic wall enhancement warranted an urgent laparoscopic right colectomy with complete mesocolic excision.

CONCLUSION

This case underscores the complexity of adult ileocecal colonic intussusception, especially when associated with adenocarcinoma. Timely diagnosis, multidisciplinary collaboration, and meticulous surgical intervention are essential. Effective management of postoperative complications, like the anastomotic leak, is crucial.

IL-33 immunohistochemical pattern of expression in neoplastic and nonneoplastic peripheral lung tissues of stage 1 o 2 lung adenocarcinoma

IL-33 is a multifaceted cytokine, plays a pivotal role in various biological processes, making it a subject of extensive research and intrigue in the field of immunology. This cytokine acts as a key regulator, effectively putting the brakes on proinflammatory nuclear factor-kappa B (NF-κB), thereby modulating chromatin compaction by promoting nucleosome-to-nucleosome interactions. IL-33's influence extends to the realm of innate and acquired immunity through its binding to the membrane-bound ST2 molecule (ST2L) of the IL-33R complex, which is expressed on various immune cells, such as Th2 cells, mast cells, natural killer cells, myeloid cells, and dendritic cells. IL-33's role in inflammation is far from one-dimensional, as it has been found to have a dual role in inflammatory disorders. In the quest to understand the origins of IL-33, immunohistochemical examination of lung tissue samples from patients with adenocarcinoma could shed light on its presence in bronchial epithelial and vascular endothelial cells, in lung tissue cancerous lesions. For this reason, we conducted a pilot study about the immunohistochemical expression of IL-33 in surgical specimens of stage 1 o 2 lung adenocarcinoma received after lung resection surgery.Our results demonstrated that patients had nuclear IL-33 immunopositivity in the alveolar pneumocytes of the normal lung tissue at the periphery of lung adenocarcinoma specimen. Note the evident negativity of the neoplastic adenocarcinoma cells. Other data showed IL-33 nuclear immunoexpression in endothelial cells of intratumoral vascular structures.This finding could indicate that IL-33 might be involved in regulating blood vessel formation and maintenance within the tumor, which is a critical factor in tumor growth and progression.The presence of IL-33 in normal lung tissue and intratumoral vascular structures may be related to its physiological functions in these contexts, while its absence in neoplastic adenocarcinoma cells could indicate a potential loss of regulatory control, which might have implications for the development and progression of the tumor.

Global Cervical Cancer Incidence by Histological Subtype and Implications for Screening Methods

BACKGROUND

Cervical cancer is a major global health concern, disproportionately affecting women in developing countries. Cervical cancer has two primary subtypes, squamous cell carcinoma (SCC) and adenocarcinoma (AC), each with distinct characteristics and screening effectiveness. In this study, we aimed to estimate the global incidence of cervical cancer according to histological subtype to inform prevention strategies.

METHODS

Using data from population-based cancer registries, we computed the rates of SCC, AC, and other specified histology among all cervical cancer cases by country and by 5-year age group. Proportions were subsequently applied to the estimated number of cervical cancer cases from the Global Cancer Observatory 2020. Age-standardized incidence rates were calculated.

RESULTS

SCC accounted for 82.72% of global cervical cancer cases, with AC contributing 12.18%. The highest SCC incidence was in Sub-Saharan Africa (29.79 per 100,000 population). The AC incidence was highest in South-Eastern Asia (3.67 per 100,000 population). Age-specific trends showed SCC peaking at approximately age 55 years and AC plateauing after age 45 years.

CONCLUSIONS

This study provided a comprehensive estimate of cervical cancer incidence by histological subtype. SCC remained the dominant subtype globally, whereas the incidence of AC varied across regions. These findings highlighted the need for tailored prevention strategies, especially testing for human papillomavirus to detect AC in high burden areas.

ALK Rearrangement Positive Lung Adenocarcinoma in Pregnancy Treated With Alectinib: A Case Report

There are few reported cases of ALK gene rearranged (ALK+) non-small cell lung cancer (NSCLC) during pregnancy. There is a lack of information on the safety of ALK inhibitors in pregnant patients. We present a 25-year-old African American woman who was diagnosed with metastatic ALK+ lung adenocarcinoma at 15 weeks of gestation. Treatment with alectinib was initiated at 18 weeks' gestation with resultant radiological treatment response. The patient did not experience any adverse effects from alectinib during her pregnancy. An elective induction of labor at 39 weeks resulted in an uncomplicated vaginal delivery. This case adds to available data and provides insight on the safety of using alectinib in a pregnant, ALK+ NSCLC patient, allowing the patient to continue her pregnancy to term while treating advanced lung adenocarcinoma.

Primary intestinal-type adenocarcinoma: Report of a rare case involving a young patient

The aim of this report was to describe a rare example of sporadic intestinal-type adenocarcinoma of the major salivary glands and oral cavity. A 23-year-old female patient presented an asymptomatic, progressive-growing mass involving the floor of mouth and the left submandibular gland. Fine-needle aspiration cytology, imaging exams, and surgical specimen findings were consisted with the diagnosis of primary intestinal-type adenocarcinoma, despite its similar immunohistochemical results with colorectal adenocarcinoma. Adjuvant chemotherapy and radiotherapy were performed, but the patient developed multiple metastatic lesions after one year of initial the intervention and deceased following 13 months of follow-up, despite several therapeutic efforts. We verified that sporadic cases of primary intestinal-type adenocarcinoma still lack information regarding etiology and tumorigenesis, especially in young and females. A complete diagnostic workflow is indispensable to rule out the presence of primary colorectal adenocarcinoma.

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells, a two cases report

INTRODUCTION AND IMPORTANCE

Fine needle aspiration is the standard method for the pathological evaluation of pancreatic masses. In the following context, rare variants of such masses might present a challenge. Our goal is to describe the clinical, cytological, and histological findings of two cases of undifferentiated carcinoma with osteoclast-like giant cells (UCOCGC) a rare variant of pancreatic ductal adenocarcinoma (PDAC).

CASE PRESENTATION

Two cases were identified. Cytological findings exhibit similarities between the two cases. One patient received multiple chemotherapy regimens and a surgery and recurred within three years of diagnosis, while the other succumbed to cholangitis resulting from hepatic metastases a year after their initial surgery.

DISCUSSION

UCOCGC is a rare variant of pancreatic cancer, characterized by a unique cytological aspect. Recognizing this variant is essential considering its distinct prognosis compared to usual pancreatic adenocarcinoma.

CONCLUSION

We presented two cases of UCOCGC a rare pancreatic cancer variant, exposing diagnostic particularities and clinical evolution.

Does dose reduction of afatinib affect treatment outcomes of patients with EGFR-mutant metastatic non-small cell lung cancer in real-world clinical practice?

Background

Afatinib can be started at a dose lower than the recommended starting dose of 40 mg/day for the treatment of epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC), however treatment outcomes in real-world clinical practice remains unclear.

Methods

This retrospective study of patients with NSCLC from 18 major hospitals (public, private or university teaching hospitals) enrolled in Malaysia's National Cardiovascular and Thoracic Surgical Database (NCTSD) assessed the efficacy of lower doses of afatinib on treatment outcomes in a real-world clinical practice. Data on clinical characteristics, afatinib dosing, and treatment outcomes for patients included in NCTSD from 1st January 2015 to 31st December 2020 were analyzed.

Results

Of the 133 patients studied, 94.7% had adenocarcinoma. Majority of the patients (60.9%) had EGFR exon 19 deletion and 23.3% had EGFR exon 21 L858R point mutation. The mean age of patients was 64.1 years and majority (83.5%) had Eastern Cooperative Oncology Group performance status of 2-4 at diagnosis. The most common afatinib starting doses were 40 mg (37.6%), 30 mg (29.3%), and 20 mg (26.3%) once daily (OD), respectively. A quarter of patients had dose reduction (23.3%) due to side effects or cost constraints. Majority of the patients had partial response to afatinib (63.2%) whilst 2.3% had complete response. Interestingly, the objective response rate was significantly higher (72.3%) with afatinib OD doses of less than 40 mg compared to 40 mg (54.0%) (P=0.032). Patients on lower doses of afatinib were two times more likely to achieve an objective response [odds ratio =2.64; 95% confidence interval (CI): 1.20-5.83; P=0.016]. These patients had a numerically but not statistically longer median time to treatment failure (TTF). Median TTF (95% CI) for the overall cohort was 12.4 (10.02-14.78) months. Median overall survival (95% CI) was 21.30 (15.86-26.75) months.

Conclusions

Lower afatinib doses (<40 mg OD) could be equally effective as standard dose in patients with EGFR-mutant advanced NSCLC and may be more suited to Asian patients, minimizing side effects that may occur at higher dosages of afatinib leading to dose interruptions and affecting treatment outcomes.

Lymph node ratio is a more robust predictor of overall survival than N stage in stage III colorectal adenocarcinoma

BACKGROUND

Lymph node ratio (LNR) may offer superior prognostic stratification in colorectal adenocarcinoma compared with N stage. However, candidate cutoff ratios require validation. We aimed to study the prognostic significance of LNR and its optimal cutoff ratio.

METHODS

We reviewed the pathology records of all patients with stage III colorectal adenocarcinoma who were managed at the King Hussein Cancer Center between January 2014 and December 2019. We then studied the clinical characteristics of the patients, correlates of lymph node count, prognostic significance of positive lymph nodes, and value of sampling additional lymph nodes.

RESULTS

Among 226 included patients, 94.2% had ≥ 12 lymph nodes sampled, while 5.8% had < 12 sampled lymph nodes. The median number of lymph nodes sampled varied according to tumor site, neoadjuvant therapy, and the grossing pathologist's level of training. According to the TNM system, 142 cases were N1 (62.8%) and 84 were N2 (37.2%). Survival distributions differed according to LNR at 10% (p = 0.022), and 16% (p < 0.001), but not the N stage (p = 0.065). Adjusted Cox-regression analyses demonstrated that both N stage and LNR at 10% and 16% predicted overall survival (p = 0.044, p = 0.010, and p = 0.001, respectively).

CONCLUSIONS

LNR is a robust predictor of overall survival in patients with stage III colorectal adenocarcinoma. At a cutoff ratio of 0.10 and 0.16, LNR offers better prognostic stratification in comparison with N stage and is less susceptible to variation introduced by the number of lymph nodes sampled, which is influenced both by clinical variables and grossing technique.

Adult sigmoid intussusception resembling rectal prolapse: A case report

BACKGROUND

Rectal prolapse arises from benign etiology. When symptoms of internal intussusception mirror those of rectal prolapse, a misdiagnosis is possible, especially under limited clinical presentation. It is crucial to recognize and differentiate rectal prolapse from internal intussusception because the two diagnoses have different prognoses. Here, we describe a case of adult sigmoid intussusception presenting as rectal prolapse.

CASE SUMMARY

A 64-year-old woman with no known medical history visited a gastrointestinal outpatient department due to hard bloody stool defecation for 1 wk followed by constipation for 3 d. Colonoscopy revealed a huge polypoid ulcerated tumor at the sigmoid colon with lumen stenosis. The patient was admitted due to post-procedural dull abdominal pain. Due to failed colonoscopy reduction and stent insertion, the patient underwent sigmoid colon resection with primary end-to-end anastomosis, with the transverse colostomy pathological report showing adenocarcinoma, pT3N0M0. She recovered well from the operation and was discharged with regular outpatient clinic follow-up.

CONCLUSION

Presentation and manifestation of sigmoid intussusception may resemble that of rectal prolapse, necessitating careful observation due to distinct prognostic implications.

Early adenocarcinoma mixed with a neuroendocrine carcinoma component arising in the gastroesophageal junction: A case report

BACKGROUND

Early adenocarcinoma mixed with a neuroendocrine carcinoma (NEC) component arising in the gastroesophageal junctional (GEJ) region is rare and even rarer in young patients. Here, we report such a case in a 29-year-old Chinese man.

CASE SUMMARY

This patient presented to our hospital with a 3-mo history of dysphagia and regurgitation. Upper endoscopy revealed an elevated nodule in the distal esophagus 1.6 cm above the GEJ line, without Barrett's esophagus or involvement of the gastric cardia. The nodule was completely resected by endoscopic submucosal dissection (ESD). Pathological examination confirmed diagnosis of intramucosal adenocarcinoma mixed with an NEC component, measuring 1.5 cm. Immunohistochemically, both adenocarcinoma and NEC components were positive for P53 with a Ki67 index of 90%; NEC was positive for synaptophysin and chromogranin. Next-generation sequencing of 196 genes demonstrated a novel germline mutation of the ERCC3 gene in the DNA repair pathway and a germline mutation of the RNF43 gene, a common gastric cancer driver gene, in addition to pathogenic somatic mutations in P53 and CHEK2 genes. The patient was alive without evidence of the disease 36 mo after ESD.

CONCLUSION

Early adenocarcinoma with an NEC component arising in the distal esophageal side of the GEJ region showed evidence of gastric origin.

PET-scan in diagnosis of non-bacterial thrombotic endocarditis: a case report

BACKGROUND

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis or Libman-Sacks endocarditis, is a rare non-infectious condition affecting mostly the left-sided heart valves of patients who, most often, suffer from malignancies and connective tissue disorders. Herein, we present a case of a male patient with marantic endocarditis due to occult lung adenocarcinoma.

CASE PRESENTATION

The patient fulfilled the modified Duke's criteria of possible bacterial endocarditis of the aortic valve; however, multiple blood cultures and serological tests were negative. In addition, the patient's clinical course was constantly deteriorating. Thus, a fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was conducted. This examination revealed multiple positive thoracic lymph node groups, as well as a positive lung lesion. The patient underwent aortic valve replacement and lymph biopsies during the operation established the diagnosis of solid/micropapillary lung adenocarcinoma and consequently of the non-bacterial thrombotic endocarditis.

CONCLUSIONS

Advanced imaging techniques may be needed to diagnose NBTE and should be kept in mind when the Duke criteria are not definite. Clinical suspicion is key to implement these premises. However, the exact role of the PET-scan has yet to be specified.

Development and validation of a clinic-radiological model to predict tumor spread through air spaces in stage I lung adenocarcinoma

OBJECTIVES

Tumor spread through air spaces (STAS) is associated with poor prognosis and impacts surgical options. We aimed to develop a user-friendly model based on 2-[18F] FDG PET/CT to predict STAS in stage I lung adenocarcinoma (LAC).

MATERIALS AND METHODS

A total of 466 stage I LAC patients who underwent 2-[18F] FDG PET/CT examination and resection surgery were retrospectively enrolled. They were split into a training cohort (n = 232, 20.3% STAS-positive), a validation cohort (n = 122, 27.0% STAS-positive), and a test cohort (n = 112, 29.5% STAS-positive) according to chronological order. Some commonly used clinical data, visualized CT features, and SUVmax were analyzed to identify independent predictors of STAS. A prediction model was built using the independent predictors and validated using the three chronologically separated cohorts. Model performance was assessed using ROC curves and calculations of AUC.

RESULTS

The differences in age (P = 0.009), lesion density subtype (P < 0.001), spiculation sign (P < 0.001), bronchus truncation sign (P = 0.001), and SUVmax (P < 0.001) between the positive and negative groups were statistically significant. Age ≥ 56 years [OR(95%CI):3.310(1.150-9.530), P = 0.027], lesion density subtype (P = 0.004) and SUVmax ≥ 2.5 g/ml [OR(95%CI):3.268(1.021-1.356), P = 0.005] were the independent factors predicting STAS. Logistic regression was used to build the A-D-S (Age-Density-SUVmax) prediction model, and the AUCs were 0.808, 0.786 and 0.806 in the training, validation, and test cohorts, respectively.

CONCLUSIONS

STAS was more likely to occur in older patients, in solid lesions and higher SUVmax in stage I LAC. The PET/CT-based A-D-S prediction model is easy to use and has a high level of reliability in diagnosing.

Diagnostic analysis of pleural fluid cell blocks using relevant immunohistochemical markers in clinically suspicious cases of malignancy

Objective

Thoracocentesis is a less invasive and expensive procedure than pleural biopsy, enabling sample collection for cytological evaluation. Cell blocks prepared from these samples provide histopathological diagnoses; further, immunohistochemistry (IHC) can be performed for subtyping malignancies, guiding the clinician in choosing the appropriate treatment modality for the patient. We aimed to determine the various histological subtypes of malignancies using cell block IHC and compare the cell block and conventional cytology methods for diagnosing malignant pleural effusion.

Material and Methods

All pleural fluid samples from the clinically suspicious cases of malignancy collected at the Department of Pathology, Government Medical College Kottayam, India, during 18 months, except duplicate and inadequate samples, were included in this prospective observational study. IHC was performed on cell blocks that were positive for malignancy.

Results

This study analyzed 630 samples, of which 121 cell blocks demonstrated the presence of malignancy. Overall, 80%, 13%, and 7% of cases were negative, suspicious, and positive for malignancy based on conventional cytology, and 81%, 0%, and 19% were negative, suspicious, and positive for malignancy based on cell blocks, respectively. Among all malignancies, adenocarcinomas from the lung (56%) were the most common, followed by adenocarcinomas from the breast (6%), squamous cell carcinomas (5%), and adenocarcinomas from the ovary (3%). Cell blocks helped detect more malignancies (19%) than conventional cytology (7%), despite a moderate agreement between both methods.

Conclusion

Adenocarcinomas were the most common cause of malignant pleural effusions, and the most frequent site of origin was the lungs. Cell blocks helped diagnose more malignancies than conventional cytology.

Survival disparities in non-Hispanic Black and White cervical cancer patients vary by histology and are largely explained by modifiable factors

PURPOSE

We investigated racial disparities in survival by histology in cervical cancer and examined the factors contributing to these disparities.

METHODS

Non-Hispanic Black and non-Hispanic White (hereafter known as Black and White) patients with stage I-IV cervical carcinoma diagnosed between 2004 and 2017 in the National Cancer Database were studied. Survival differences were compared using Cox modeling to estimate hazard ratio (HR) or adjusted HR (AHR) and 95% confidence interval (CI). The contribution of demographic, socioeconomic and clinical factors to the Black vs White differences in survival was estimated after applying propensity score weighting in patients with squamous cell carcinoma (SCC) or adenocarcinoma (AC).

RESULTS

This study included 10,111 Black and 43,252 White patients with cervical cancer. Black patients had worse survival than White cervical cancer patients (HR = 1.40, 95% CI = 1.35-1.45). Survival disparities between Black and White patients varied significantly by histology (HR = 1.20, 95% CI = 1.15-1.24 for SCC; HR = 2.32, 95% CI = 2.12-2.54 for AC, interaction p < 0.0001). After balancing the selected demographic, socioeconomic and clinical factors, survival in Black vs. White patients was no longer different in those with SCC (AHR = 1.01, 95% CI 0.97-1.06) or AC (AHR = 1.09, 95% CI = 0.96-1.24). In SCC, the largest contributors to survival disparities were neighborhood income and insurance. In AC, age was the most significant contributor followed by neighborhood income, insurance, and stage. Diagnosis of AC (but not SCC) at ≥65 years old was more common in Black vs. White patients (26% vs. 13%, respectively).

CONCLUSIONS

Histology matters in survival disparities and diagnosis at ≥65 years old between Black and White cervical cancer patients. These disparities were largely explained by modifiable factors.

Enhancing treatment strategies for small bowel cancer: a clinical review of targeted therapy and immunotherapy approaches

Small bowel cancer (SBC) is a rare and aggressive disease with a poor prognosis, necessitating the exploration of novel treatment approaches. This narrative review examines the current evidence on targeted therapy and immunotherapy for SBC, focusing on the two most common subtypes: adenocarcinoma and neuroendocrine tumor. A comprehensive search of PubMed, Scopus, and Google Scholar databases was conducted to identify relevant clinical trials and case reports published in English up to September 2023. The review includes 17 clinical trials and 10 case reports, indicating that targeted therapy and immunotherapy can have the potential to improve survival rates in patients with SBC. Notably, promising targeted medicines include bevacizumab, cetuximab, and trastuzumab, while pembrolizumab and nivolumab show potential as immunotherapies. However, it should be noted that the magnitude of the increase in survival rates with these interventions was small. Further research is needed to determine the optimal combination of targeted therapy and immunotherapy for individual patients with SBC.

IL-32 production from lung adenocarcinoma cells is potentially involved in immunosuppressive microenvironment

Interleukin 32 (IL-32) is a proinflammatory cytokine secreted from several kinds of cancer cells. In the present study, we investigated the significance of IL-32 in lung adenocarcinoma by immunohistochemistry and bioinformatics analysis. IL-32 was positive in cancer cells of 21 cases (9.2%) of total 228 cases. Increased IL-32 gene expression was linked to worse clinical course in TCGA analysis, however, IL-32 expression in immunohistochemistry was not associated to clinical course in our cohort. It was also found that high IL-32 expression was seen in cases with increased lymphocyte infiltration. In vitro studies indicated that IFN-γ induced gene expression of IL-32 and PD1-ligands in lung adenocarcinoma cell lines. IL-32, especially IL-32β, also induced overexpression of PD1-ligands in human monocyte-derived macrophages. Additionally, Cancer-cell-derived IL-32 was elevated by stimulation with anticancer agents. In conclusion, IL-32 potentially induced by inflammatory conditions and anticancer therapy and contribute to immune escape of cancer cells via development the immunosuppressive microenvironment. IL-32 might be a target molecule for anti-cancer therapy.

Adenocarcinoma of sigmoid colon with metastasis to an ovarian mature teratoma: A case report

BACKGROUND

Colorectal cancer ranks third in global cancer-related mortality, often due to metastases to liver and lungs. Ovarian metastases are less common, accounting for 3.6% to 7.4% of cases. In contrast, mature ovarian teratomas are frequently benign. Tumor-to-tumor metastasis is a rare phenomenon, with a limited number of documented cases. Three cases of mature ovarian teratomas metastasizing from different cancers have been reported. This report focuses on a case of tumor-to-tumor metastasis from sigmoid colon adenocarcinoma to a mature ovarian teratoma.

CASE SUMMARY

A 41-year-old Taiwanese woman with no known systemic diseases presented with lower back pain, which led to imaging revealing malignant lesions in the spine, pelvis, liver, and multiple lung metastases. She was diagnosed with sigmoid colon adenocarcinoma with metastases to the liver, lung, bone, and a left ovarian teratoma. Treatment involved radiotherapy and chemotherapy, resulting in regression of the primary tumor and stable lung and liver lesions. Due to abdominal symptoms, she underwent exploratory surgery, unveiling a mature teratoma in the left ovary with signs of metastatic adenocarcinoma.

CONCLUSION

Consider resecting mature ovarian teratomas with concurrent colorectal adenocarcinoma to prevent tumor-to-tumor metastasis.