Liver Venous Deprivation for Rapid Liver Hypertrophy Before Major Hepatectomy: A Case Report

Liver venous deprivation (LVD) is an emerging, minimally invasive strategy to induce rapid liver hypertrophy of the future liver remnant (FLR) before a major hepatectomy. LVD (aka "double vein embolization") entails same-session percutaneous embolization of the portal and hepatic veins of the planned liver resection. This report discusses LVD's utilization and technical challenges in managing a 49-year-old male with recurrent multifocal colorectal liver metastases (CRLM). The patient initially underwent neoadjuvant FOLFOX chemotherapy followed by a simultaneous laparoscopic sigmoid colectomy and liver surgery (microwave ablation of segment V and wedge resections of segment one and IVb), followed by completion of chemotherapy. The patient had an R0 resection with clear colon and liver surgical margins. Nine months after the initial surgery, the patient had a rise in tumor markers, and surveillance imaging demonstrated recurrence of liver metastases in segments I and V. LVD was performed by interventional radiology, which led to a 28% increase in FLR (segments II, III, and IV); initially measuring 464 cm3 before LVD and measuring 594 cm3 on post-procedure day 21. The patient underwent right hemi-hepatectomy and caudate resection on post-procedure day 29. The patient did not have any complications and was discharged on postoperative day 6. The patient remains disease-free with no evidence of recurrence at 12 months follow-up.

Breast mass as the first sign of metastasis from rectal carcinoma: a case report and review of the literature

We present a case report of a 41-year-old woman who developed a left breast mass 18 months after undergoing Dixon rectal cancer surgery. The purpose of this case report is to highlight the possibility of breast metastases in patients with colorectal cancer and emphasize the importance of careful evaluation and follow-up as well as timely and accurate diagnosis and management of the metastatic disease. During the physical examination in 2021, we noted that the lower border of the mass was 9 cm from the anal verge and that it occupied approximately one-third of the intestinal lumen. A pathological biopsy revealed the mass in the patient's intestinal lumen was a rectal adenocarcinoma. The patient underwent Dixon surgery for rectal cancer and received subsequent chemotherapy. The patient had no prior history of breast-related medical conditions or a family history of breast cancer. During the current physical examination, we discovered multiple lymphadenopathies in the patient's left neck, bilateral axillae, and left inguinal region, but none elsewhere. We observed a large erythema of about 15x10 cm on the patient's left breast, with scattered hard nodes of varying sizes. Palpation of the area beyond the upper left breast revealed a mass measuring 3x3 cm. We conducted further examinations of the patient, which revealed the breast mass and lymphadenopathy on imaging. However, we did not find any other imaging that had significant diagnostic value. Based on the patient's conventional pathology and immunohistochemical findings, combined with the patient's past medical history, we strongly suspected that the patient's breast mass was of rectal origin. This was confirmed by the abdominal CT performed afterward. The patient was treated with a chemotherapy regimen consisting of irinotecan 260 mg, fluorouracil 2.25 g, and cetuximab 700 mg IV drip, which resulted in a favorable clinical response. This case illustrates that colorectal cancer can metastasize to unusual sites and underscores the importance of thorough evaluation and follow-up, particularly when symptoms are atypical. It also highlights the importance of timely and accurate diagnosis and management of metastatic disease to improve the patient's prognosis.

Prevalence and Predictors of Physician-Patient Discordance in Prognostic Perceptions in Advanced Cancer

BACKGROUND

Discordance between physicians' and patients' prognostic perceptions in advanced cancer care threatens informed medical decision-making and end-of-life preparation, yet this phenomenon is poorly understood. We sought to: (1) describe the extent and direction of prognostic discordance, patients' prognostic information preferences in cases of prognostic discordance, and physicians' awareness of prognostic discordance; and (2) examine which patient, physician, and caregiver factors predict prognostic discordance.

MATERIALS AND METHODS

Oncologists and advanced cancer patients (median survival ≤12 months; n = 515) from 7 Dutch hospitals completed structured surveys in a cross-sectional study. Prognostic discordance was operationalized by comparing physicians' and patients' perceptions of the likelihood of cure, 2-year mortality risk, and 1-year mortality risk.

RESULTS

Prognostic discordance occurred in 20% (likelihood of cure), 24%, and 35% (2-year and 1-year mortality risk) of physician-patient dyads, most often involving patients with more optimistic perceptions than their physician. Among patients demonstrating prognostic discordance, the proportion who preferred not knowing prognosis varied from 7% (likelihood of cure) to 37% (1-year mortality risk), and 45% (2-year mortality risk). Agreement between physician-perceived and observed prognostic discordance or concordance was poor (kappa = 0.186). Prognostic discordance was associated with several patient factors (stronger fighting spirit, self-reported absence of prognostic discussions, an information source other than the healthcare provider), and greater physician-reported uncertainty about prognosis.

CONCLUSION

Up to one-third of the patients perceive prognosis discordantly from their physician, among whom a substantial proportion prefers not knowing prognosis. Most physicians lack awareness of prognostic discordance, raising the need to explore patients' prognostic information preferences and perceptions, and to tailor prognostic communication.

Association between Temporal Muscle Thickness and Overall Survival in Non-Small Cell Lung Cancer Patients with Brain Metastasis

Temporal muscle thickness (TMT) has recently been suggested as a novel biomarker of sarcopenia in head and neck malignancies. However, few studies have evaluated TMT as a prognostic marker in patients with brain metastasis. This study investigated the association of TMT with overall survival (OS) in non-small cell lung cancer (NSCLC) patients with brain metastasis. The records of all NSCLC patients with brain metastasis between 2009 and 2018 at St. Vincent’s Hospital were reviewed retrospectively. A total of 221 patients met our eligibility criteria. In the group with TMT thicker than the median, OS was longer than the group with TMT thinner than the median (240 days versus 139 days, p = 0.014). In multivariate analysis, the thicker TMT group had longer survival (HR 0.73 CI 0.56−0.96, p = 0.024). Male (HR 1.58 CI 1.19−2.09, p = 0.002) and older age (≥65 years) (HR 2.05 CI 1.53−2.74, p < 0.001) also showed statistical significance. We also performed subgroup analysis in older patients (≥65 years). In this subgroup of 107 patients, the thicker TMT group also showed longer OS than the thinner TMT group (209 days versus 82 days, p = 0.009). Our findings suggest that TMT can be a useful biomarker for OS in NSCLC patients with brain metastasis.

Computerized Tomography (CT) Updates and Challenges in Diagnosis of Bone Metastases During Prostate Cancer

Prostate cancer is one of the most common cancers in men. This cancer is often associated with indolent tumors with little or no lethal potential. Some of the patients with aggressive prostate cancer have increased morbidity and early deaths. A major complication in advanced prostate cancer is bone metastasis that mainly results in pain, pathological fractures, and compression of spinal nerves. These complications in turn cause severe pain radiating to the extremities and possibly sensory as well as motor disturbances. Further, in patients with a high risk of metastases, treatment is limited to palliative therapies. Therefore, accurate methods for the detection of bone metastases are essential. Technical advances such as single-photon emission computed tomography/ computed tomography (SPECT/CT) have emerged after the introduction of bone scans. These advanced methods allow tomographic image acquisition and help in attenuation correction with anatomical co-localization. The use of positron emission tomography/CT (PET/CT) scanners is also on the rise. These PET scanners are mainly utilized with 18F-sodium-fluoride (NaF), in order to visualize the skeleton and possible changes. Moreover, NaF PET/CT is associated with higher tracer uptake, increased target-to-background ratio and has a higher spatial resolution. However, these newer technologies have not been adopted in clinical guidelines due to lack of definite evidence in support of their use in bone metastases cases. The present review article is focused on current perspectives and challenges of computerized tomography (CT) applications in cases of bone metastases during prostate cancer.

Recent Imaging Advancements for Lung Metastases in Children with Sarcoma

In children and adolescents affected by musculoskeletal sarcomas (both soft tissue and bone sarcomas), the presence of lung metastases is a frequent complication, that should be known since the patient's prognosis, as management, and treatment depend on it. During the staging phase, the detection of lung metastases should be sensitive and specific, and it should be carried out by minimizing the radiation exposure. To deal with this problem, imaging has reached important goals in recent years, thanks to the development of cone-beam CT or low-dose computed tomography, with some new iterative reconstruction methods, such as Veo and ASIR. Imaging is also fundamental for the possibility to perform lung biopsies under CT guidance, with less morbidity, less time-consumption, and shorter recovery time, compared to surgical biopsies.Moreover, important results have also been demonstrated in the treatment of lung metastases, due to the improvement of new mini-invasive image-guided percutaneous thermal ablation procedures, which proved to be safe and effective also in young patients.

Study of cutaneous melanoma recurrences after sentinel node biopsy: Patterns of dissemination and use of complementary test in follow-up

OBJECTIVES

To investigate the patterns of melanoma recurrence in the local population, including factors that may influence in this event and timing of relapse, and to determine the mode of detection of them.

METHODS

This is a retrospective cohort study of patients with melanoma who underwent sentinel lymph node biopsy at the Complejo Hospitalario de Navarra (Spain) from 2002 to 2012. The following data were collected of each patient: age, gender, date of diagnosis, location of melanoma, histological subtype, Breslow thickness, ulceration, mitosis, sentinel node status, AJCC 8th edition stage, site of first diagnosed metastasis, mode of relapse, date of first relapse and time of death.

RESULTS

Of 308 patients, 30% people suffered metastasis. The mean follow-up time was 68.63 months. 51.1% of relapses were locoregional and 48.9% haemato-visceral. Sentinel node status was the only variable associated with higher risk of haemato-visceral metastasis (p < 0.001). The mean time between diagnosis of melanoma and recurrence was 2.7 years. Most recurrences were detected by the patient himself or had any type of symptoms and were consequently selected for a complementary test.

CONCLUSION

It is important to follow-up all patients with diagnosis of cutaneous melanoma, essentially during the first 5 years after diagnosis.

Unique Skin Metastasis from Recurrent Cancer. Case Report

Introduction

Cutaneous metastasis is defined as the dissemination of malignant cells from a primary tumor to the skin. Skin may be affected by tumors, either through direct invasion from an adjacent organ or by cutaneous metastasis from an internal organ malignancy. We report a case of a 75-year-old female patient with skin metastasis 8 years after the initial treatment of primary breast cancer.

Patient Concern

The patient presented only with papules and nodular skin lesions in the left lateral abdominal area, without any other clinical manifestations.

Diagnosis

All laboratory tests were normal. Histological examinati revealed the infiltration of the dermis by tumor cells.

Interventions/Outcome

After the diagnosis of skin metastasis, she was treated with chemotherapy with complete remission of skin lesions.

Conclusion

Skin metastasis from internal organs is rarely the first sign. In this case, skin metastasis was the only clinical sign and the only diagnostic tool to drive to the correct diagnosis of a recurrent cancer after 8 years. Dermatologists might be the first doctors to facilitate the diagnosis of skin metastasis.

Predictors of long-term survival in patients with hepatic resection of colorectal metastases: Analysis of a Brazilian Cancer Center Cohort

BACKGROUND

Hepatic metastases are a major cause of death in patients with colorectal cancer. A comprehensive assessment of the prognostic factors associated with long-term survival could improve patient selection for surgical approaches and decrease morbidity and futile locoregional treatments.

METHODS

We performed a retrospective analysis of patients who underwent hepatectomy for colorectal liver metastases at a single center from 2000 to 2012.

RESULTS

To identify factors associated with 5- and 10-year overall (OS) and disease-free survival (DFS), we analyzed 280 patients and 150 patients in the 5- and 10-year cohorts, respectively. Only seven relapses occurred after 5 years of follow-up, and no relapses occurred after 10 years. Multivariable analysis indicated that bilobar disease and extra-hepatic disease before hepatectomy were independent 5- and 10-year predictors of OS, and major postoperative complications predicted OS in the 5-year survival cohort only. Our analysis indicated that prognostic factors associated with DFS included some confounders and was therefore inconclusive.

CONCLUSIONS

Taken together, our results suggest that the predictors of 5- and 10-year OS rates of colorectal cancer patients with hepatic metastases are similar, differing only by postoperative complications that influenced exclusively 5-year survival. Since no relapse occurred 10 years after hepatic resection, oncological remission is likely.

Temporal subtraction of low-dose and relatively thick-slice CT images with large deformation diffeomorphic metric mapping and adaptive voxel matching for detection of bone metastases: A STARD-compliant article

To evaluate the improvement of radiologist performance in detecting bone metastases at follow up low-dose computed tomography (CT) by using a temporal subtraction (TS) technique based on an advanced nonrigid image registration algorithm.Twelve patients with bone metastases (males, 5; females, 7; mean age, 64.8 ± 7.6 years; range 51-81 years) and 12 control patients without bone metastases (males, 5; females, 7; mean age, 64.8 ± 7.6 years; 51-81 years) were included, who underwent initial and follow-up CT examinations between December 2005 and July 2016. Initial CT images were registered to follow-up CT images by the algorithm, and TS images were created. Three radiologists independently assessed the bone metastases with and without the TS images. The reader averaged jackknife alternative free-response receiver operating characteristics figure of merit was used to compare the diagnostic accuracy.The reader-averaged values of the jackknife alternative free-response receiver operating characteristics figures of merit (θ) significantly improved from 0.687 for the readout without TS and 0.803 for the readout with TS (P value = .031. F statistic = 5.24). The changes in the absolute value of CT attenuations in true-positive lesions were significantly larger than those in false-negative lesions (P < .001). Using TS, segment-based sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the readout with TS were 66.7%, 98.9%, 94.4%, 90.9%, and 94.8%, respectively.The TS images can significantly improve the radiologist's performance in the detection of bone metastases on low-dose and relatively thick-slice CT.

Single community-based institutional series of stereotactic body radiation therapy (SBRT) for treatment of liver metastases

Background

Stereotactic body radiation therapy (SBRT) is a safe and effective option for treatment of liver metastases. However, existing data are mostly reported by high-volume centers. There have been reports that advanced radiotherapy techniques performed at low-volume centers result in inferior outcomes. Our goal was to assess the implementation of SBRT for the treatment of liver metastases at a low-volume center by studying the efficacy and toxicity of this technology through retrospective database review at a single, community-based institution.

Methods

We performed an IRB approved patient registry study. Patients had a median age of 65, KPS of at least 70 (median 90) and primary tumor controlled. All patients underwent fiducial marker placement under CT-guidance 1-2 weeks prior to planning scans. Gross tumor volume (GTV) was delineated using contrast enhanced CT scans, as well as fusion with PET and/or MRI scans. GTV was expanded by 5 mm to create the planning target volume (PTV). Treatment was delivered by image guided stereotactic robotic radiosurgery with respiratory motion tracking. Lesions were treated with 3 fractions to a median total dose of 54 Gy. Overall survival, progression-free survival (PFS) and local failure-free survival were estimated using the Kaplan-Meier method. Log-rank statistic was used to compare local control based on GTV volume.

Results

Between 2006 and 2016, 42 consecutively treated patients with 81 metastatic liver lesions were treated with SBRT. Median follow-up was 25 months. Major primary tumor sites were colon (n=18) and lung (n=7). Synchronous extrahepatic disease was present in 15% of the treated lesions and 46% had prior local treatment of liver metastases. The number of lesions treated concurrently ranged from 1 to 4. Lesions had a median maximum diameter of 2.5 cm (range, 0.5-9.5 cm), and a mean volume of 53 cc (range, 0.5-363.0 cc). Kaplan-Meier estimated 1- and 2-year overall survival was 72% and 62%. Estimated 1- and 2-year progression free survival was 32% and 23%. Estimated 1- and 2-year local control was 86% and 80%. Two-year local control was worse for lesions >50 cc compared to lesions ≤50 cc (62% vs. 84%, P=0.04). Toxicity occurred in 26% of treatment courses and included grade 1 (n=12) and grade 2 toxicity (n=3).

Conclusions

These results are comparable to available published data regarding the safety and efficacy of liver metastasis SBRT on trial at high volume institutions. Our findings, therefore, demonstrate the successful implementation of a liver metastasis SBRT program in the low-volume, community-hospital setting. These findings suggest that low-volume and high-volume centers are both options for liver metastasis SBRT.

Tumor enhancement of colorectal liver metastases on preoperative gadobutrol-enhanced MRI at 5 minutes post-contrast injection is associated with overall survival post-hepatectomy

Previous studies have demonstrated that target tumor enhancement (TTE) of colorectal cancer liver metastases (CRCLM) on 10-minute delayed phase gadobutrol-enhanced MRI is associated with overall survival post-hepatectomy. The purpose of this study was to determine whether TTE of CRCLM on preoperative gadobutrol-enhanced MRI measured at 5-minute delayed phase is also associated with overall survival. We performed a single-institution, REB-approved, retrospective study of 121 patients with CRCLM who had received a clinical gadobutrol-enhanced MRI after treatment with chemotherapy and prior to liver surgery between January 1, 2006 and December 31, 2012. The TTE of the colorectal liver metastases (CRLM) on 5-minute delayed phase was determined. Kaplan-Meier and Cox-regression survival analyses were used in order to determine the association between TTE on 5-minute delayed phase and overall survival, after adjusting for known prognostic variables. TTE of chemotherapy-treated CRLM on gadobutrol-enhanced MRI at 5-minute post-contrast injection is associated with overall survival post-hepatectomy. On Kaplan-Meier survival analysis, there was a significant difference in overall survival between strong and weak TTE groups (log-rank P=0.009) with 74.4% survival at 36 months in the strong TTE group compared to only 44.6% in the weak TTE group. On Cox-regression analysis, the adjusted hazard ratio of death for patients with low TTE was 0.40 (95% CI: 0.18-0.90, P=0.026), after adjusting for known prognostic variables. This study provides preliminary evidence that tumor enhancement of CRLM at 5 minutes post-contrast injection on gadobutrol-enhanced MRI may provide preoperative prognostic information. This may be helpful for risk stratification of patients for surgery.

Evaluation of the Prognostic Stage in the 8th Edition of the American Joint Committee on Cancer in Patients with Breast Cancer and Internal Mammary Lymph Node Metastasis

BACKGROUND/AIM

This study evaluated the prognostic value of the 8th edition of American Joint Committee on Cancer (AJCC) cancer staging system for patients with internal mammary lymph node (IMN) metastases.

MATERIALS AND METHODS

Of the patients with breast cancer who were treated between 2009 and 2013, 66 were diagnosed as cN3b. We restaged the patients and analyzed the prognostic value of the prognostically staged groups.

RESULTS

With a median follow-up of 53.9 months, the 5-year overall survival rates of patients with IIIA, IIIB, and IIIC stages were 100%, 95%, and 50% (p=0.001), while the progression-free survival rates were 100%, 83%, and 50% (p=0.005).

CONCLUSION

Despite the small number of patients, the prognostic stage provided accurate information for IMN metastasized breast cancer, which will lead to more accurate prognosis predictions and optimal treatment selection.

Inverse Perfusion Requirements of Supra- and Infratentorial Brain Metastases Formation

Background and Aims: Vascular border zones and the gray-white matter junction are preferred sites for the development of brain metastases (BM), whereas microvascular lesions are known to be a protective factor. In this proof of concept study, we aim to study the relationship of blood perfusion and the spatial distribution of BM.

Materials and Methods: An average CT perfusion atlas of 107 healthy patients was created. Voxel-wise reference perfusion values were extracted from BM-negative and BM-positive regions in a second cohort of 100 untreated patients harboring 809 BM confirmed by MRI. A comparison of regional perfusion values was performed using the independent t-test.

Results: In contrast to supratentorial BM that develop preferably in areas with lower CBV/CBF and longer MTT/TTP compared to the average regional perfusion (p < 0.001), infratentorial BM showed a higher CBV/CBF and shorter MTT/TTP (p < 0.001).

Conclusion: Our results imply differing pathophysiological mechanisms underlying supra- and infratentorial BM spreading. The inverse perfusion patterns may result from differences in vascular supply, hemodynamic requirements, and/or production of pro-angiogenic factors.

Treatment strategies in recurrent esophageal or junctional cancer

Little evidence is available about survival rates in patients with recurrent disease after potentially curative surgery for esophageal or junctional cancer. Only in limited occasions, potentially curative salvage strategies are available. The aim of this study is to analyze survival rates and patterns of dissemination, and to identify independent prognostic factors in a consecutive series of patients who develop recurrent esophageal or junctional cancer. Between 1994 and 2015, patients who developed disease recurrence after neoadjuvant chemo(radio)therapy followed by radical esophagectomy for esophageal or junctional cancer were retrospectively analyzed. The Kaplan-Meier estimates were performed to calculate and compare overall survival between patients with different patterns of dissemination and to compare between different treatment strategies. Furthermore, univariate and multivariate Cox-regression analyses were performed to identify independent prognostic factors for post recurrence survival. In this study, we included 219 patients. The median overall survival of all included patients was 3.2 months (range: 0.0-101.1 months). The median overall survival in patients with exclusively locoregional recurrence (n = 23, 10.8%) was 4.9 months (range: 0.1- 55.6) and 2.9 months (range: 0.0-101.1) in patients who had distant metastases (n = 189, 89.2%), P = 0.003. Patients who received treatment aimed at complete tumor eradication (n = 28, 13.7%) had a median overall survival of 13.6 months (range: 1.1-101.1) and palliative treated patients (n = 94, 46.1%) of 4.7 months (range: 0.3-25.6), P < 0.001. In a selected group of patients survival of more than 20 months was achieved. Univariate and multivariate Cox-regression analysis showed that a higher age at the diagnosis of recurrent disease (hazard ratio: 1.087, P ≤ 0.001), an irradical resection of the primary tumor (hazard ratio: 3.355, P = < 0.001), the number of positive lymph nodes after neoadjuvant therapy (hazard ratios: ypN2 = 1.724 (P = 0.024) and ypN3 = 2.082 (P = 0.028) and the presence of a single hematogenous distant metastases (hazard ratio: 2.281, P = 0.003) or more than one hematogenous distant metastasis (hazard ratio: 2.385, P = 0.005) were associated with a shorter postrecurrence survival. The prognosis of patients who develop recurrent esophageal or junctional cancer is poor. In a selected group of patients however relatively long survival can be achieved. This offers new perspectives to improve treatment strategies and survival rates.

Contrast-Enhanced Ultrasonography in Evaluation of the Therapeutic Effect of Chemotherapy for Patients with Liver Metastases

BACKGROUND

The therapeutic effect of chemotherapy for liver metastases is currently determined by changes in tumor diameter depicted on computed tomography (CT) and magnetic resonance imaging, but it cannot accurately determine if there is central necrosis. Furthermore, due to the risk of radiation exposure and high cost, frequent examination using these methods places a heavy burden on patients. Meanwhile, real-time observation of blood flow and vessel morphology within tumors has become possible by contrast-enhanced ultrasonography (CEUS). However, use of CEUS in evaluating the therapeutic effect of anticancer chemotherapy has rarely been investigated. This study investigated whether changes in the time-intensity curve (TIC) of CEUS are useful indicators of the therapeutic effect of chemotherapy.

METHODS

Five patients with liver metastases who had undergone CEUS before and after chemotherapy were included in this study. The TIC of each time point was prepared to examine whether the following five TIC parameters serve as indicators of the therapeutic effect of chemotherapy: peak intensity, time to wash-in, time to peak intensity, slope of wash-in, and area under the curve. In each parameter, rate of change (ROC) was calculated by the expression [(values before chemotherapy minus those after chemotherapy)/those before chemotherapy × 100(%)].

RESULTS

(i) Among the five TIC parameters tested, ROC of the slope of wash-in and the area under the curve reflected the therapeutic effect of chemotherapy better than the remaining three parameters. (ii) TIC parameters after one cycle of chemotherapy were examined in two of five patients, and changes in the slope of wash-in and the area under the curve were in good agreement with the computed tomography findings indicative of the therapeutic effect after the fourth chemotherapy cycle.

CONCLUSION

The findings of this study suggest that ROC of the slope of wash-in and the area under the curve of the TIC are useful in evaluating the therapeutic effect of chemotherapy. Furthermore, there is a possibility that TIC analysis may enable early prediction of the therapeutic effect.

Synthetic treatment of intracranial peripheral primitive neuroectodermal tumor with multiple metastasis: a case report

Ewing sarcomas (ES) and peripheral primitive neuroectodermal tumors (pPNET) are now thought to belong to the same tumor family. Ewing sarcoma family tumor (ESFT) members commonly originate in bones and soft tissues. However, a few published articles describe ESFT arising from cranial cavities. Pathologically, ES/pPNET are composed of small round cells. Unambiguous distinction between pPNET and other small round cell tumors, in particular central PNET, is of clinical significance. Definitive diagnoses of pPNET can be obtained through CD99 (MIC2 gene product) membrane positivities and molecular identifications of chromosomal rearrangements between EWS and ETS family genes. Multimodal approaches comprising surgical resections, radiotherapies, and chemotherapies are required for the treatment of ESFT. Decompressive medical measures are preferentially performed when epidural masses are compressing spinal cords. In cases of ES-induced brain herniations, emergent radiotherapies may serve as effective tools. We report a case of multiple disseminated intracranial ES/pPNET for which synthetic treatments were used.

Hepatic resection of non-colorectal non-endocrine liver metastases

BACKGROUND

Hepatic resection is standard treatment for liver metastases from colorectal and neuroendocrine cancers as well as primary biliary and hepatic carcinomas. The role of hepatic resection in patients with non-colorectal non-endocrine liver metastases (NCNELM) is less defined. Overall survival in this group of patients is poor with few patients surviving beyond two years, even with modern chemotherapy.

METHODS

A prospective database of all liver resections performed by a single surgeon (KSH) from January 2007 to December 2014 was maintained. Patient demographics, surgical and pathological data were collected prospectively; survival data were updated retrospectively. Patients were grouped according to pathology and analysis was performed using SPSS (version 21).

RESULTS

A total of 48 patients underwent hepatic resection for NCNELM, of which 18 were major resections. Pathologies encountered included sarcoma in 8/48, both breast and ovarian in 6/48 each and renal cell carcinoma and melanoma, each representing 5/48. A result of 38/48 patients undertook chemotherapy prior to surgery. R0 margin was achieved in 96%. Seven patients suffered complications from surgery and one peri-operative mortality. Overall survival at 1, 3 and 5 years was 93%, 83% and 61%, respectively. Forty-four percent of patients developed disease recurrence, 29% at distant sites.

CONCLUSION

Hepatic resection can be achieved safely for NCNELM. Patient selection is key, along with a standardized surgical and anaesthetic technique. Patients should be rigorously investigated to exclude disseminated disease and multidisciplinary discussion must take place prior to surgery. Patients with NCNELM should not routinely be excluded from liver resection and selected patients may benefit from resection.

National treatment patterns in patients presenting with Stage IVC head and neck cancer: analysis of the National Cancer Database

Head and neck cancer patients presenting with distant metastases are generally considered incurable. Treatment patterns and survival by primary disease site and therapy have not been described. Retrospective cohort analysis of 2525 patients in the National Cancer Database (2003–2006). Kaplan–Meier and Cox proportional hazards analyses were performed. Combined locoregional and systemic therapy was the most common treatment regimen (39.2%), followed by no treatment (23.9%), locoregional (19.0%), and systemic treatment (17.8%). Multivariate analysis demonstrated decreased survival was associated with age 65–79 years hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.14–1.80), Medicaid/uninsured status (HR 1.27, 95% CI 1.13–1.42), Medicare/other government insurance (HR 1.21, 95% 1.07–1.38), treatment at a nonacademic/research program (HR 1.17, 95% CI 1.07–1.27), and Charlson comorbidity score of 1 (HR 1.33, 95% 1.19–1.48). Compared to systemic therapy alone, receiving locoregional and systemic therapy was associated with decreased risk of death (HR 0.73, 95% CI 0.65–0.83). Only 14.6% and 0.6% of patients were recorded as receiving palliative therapy or being enrolled in a clinical trial, respectively. Significant treatment diversity exists in distantly metastatic head and neck cancer. Those who received combination locoregional and systemic therapy were more likely to have improved overall survival, but important factors in treatment selection are unknown. A small proportion of patients was found to receive either palliative therapy or was enrolled in a clinical trial, although these data likely underestimate the true proportions.

Perioperative chemotherapy for resectable colorectal hepatic metastases-What does the EORTC 40983 trial update mean?

The liver is the most common site of colorectal cancer metastasis. Although successful resection leads to durable overall survival (OS), local and distant recurrence is common. As a result, multidisciplinary strategies have been developed to decrease recurrence rates as well as increase the number of candidates for resection. A recent update to the European Organisation for Research and Treatment of Cancer (EORTC) Intergroup trial 40983 has been published comparing perioperative chemotherapy to surgery alone. This randomized trial initially demonstrated a benefit in progression free survival (PFS) with the administration of perioperative FOLFOX chemotherapy, albeit with an increased rate of complications. Although this led many investigators and clinicians to adopt the perioperative approach, the recent update failed to report any advantage in OS and therefore results in further controversy as to the role of perioperative systemic chemotherapy in the treatment of resectable colorectal hepatic metastases.

Gamma Knife surgery for treating brain metastases arising from hepatocellular carcinomas

OBJECT

Brain metastases from hepatocellular carcinoma (HCC) are rare, and the evidence of the effectiveness of Gamma Knife surgery (GKS) in this disease is lacking. The authors report their institutional experience with GKS in patients with brain metastases from HCCs.

METHODS

The authors retrospectively reviewed the medical records of 73 consecutive patients who had a combined total of 141 brain metastases arising from HCCs and were treated with GKS. Sixty-four (87.7%) patients were male, and the mean age of the patients was 52.5 years (range 30-79 years). The mean tumor volume was 7.35 cm(3) (range 0.19-33.7 cm(3)). The median margin dose prescribed was 23 Gy (range 15-32 Gy). Univariate and multivariate survival analyses were performed to identify possible prognostic factors of outcomes.

RESULTS

The estimated rate of local tumor control was 79.6% at 3 months after GKS. The median overall survival time after GKS was 16 weeks. The actuarial survival rates were 76.7%, 58.9%, and 26.0% at 4, 12, and 24 weeks after GKS, respectively. In the univariate analysis, an age of ≤ 65 years, Child-Pugh Class A (pertaining to liver function), high Karnofsky Performance Scale score (≥ 70), and low Radiation Therapy Oncology Group recursive partitioning analysis class (I or II) were positively associated with the survival times of patients. No statistically significant variable was identified in the multivariate analysis.

CONCLUSIONS

Although survival was extremely poor in patients with brain metastases from HCCs, GKS showed acceptable local tumor control at 3 months after the treatment. The authors suggest that GKS represents a noninvasive approach that may provide a valuable option for treating patients with brain metastases from HCCs.

Co-existent Paget's Disease of the Bone, Prostate Carcinoma Skeletal Metastases and Fracture on Skeletal Scintigraphy-Lessons to be Learned

Bone scintigraphy, despite being non-specific, is a very sensitive and simple investigation for patients with active Paget's disease of the bone. Skeletal metastases and Paget's disease may co-exist in the elderly patients as both conditions are commonly seen in this age group. Clinical and radiological correlation may help to improve the diagnostic specificity of a bone scintigram. We report a patient in whom concurrent Paget's disease and a rib fracture became evident only on repeat scintigraphy following successful treatment of prostate carcinoma skeletal metastases.

CONFLICT OF INTEREST

None declared.

Bone matters in lung cancer

BACKGROUND

Bone metastases are a significant and undertreated clinical problem in patients with advanced lung cancer.

DESIGN

We reviewed the incidence of bone metastases and skeletal-related events (SREs) in patients with lung cancer and examined the burden on patients' lives and on health care systems. Available therapies to improve survival and lessen the impact of SREs on quality of life (QoL) were also investigated.

RESULTS

Bone metastases are common in lung cancer; however, owing to short survival times, data on the incidences of SREs are limited. As with other cancers, the costs associated with treating SREs in lung cancer are substantial. Bisphosphonates reduce the frequency of SREs and improve measures of pain and QoL in patients with lung cancer; however, nephrotoxicity is a common complication of therapy. Denosumab, a recently approved bone-targeted therapy, is superior to zoledronic acid in increasing the time to first on-study SRE in patients with solid tumours, including lung cancer. Additional roles of bone-targeted therapies beyond the prevention of SREs are under investigation.

CONCLUSIONS

With increasing awareness of the consequences of SREs, bone-targeted therapies may play a greater role in the management of patients with lung cancer, with the aim of delaying disease progression and preserving QoL.

Positive predictive values of the coding for bisphosphonate therapy among cancer patients in the Danish National Patient Registry

BACKGROUND

The purpose of this study was to estimate the positive predictive value (PPV) of the coding for bisphosphonate treatment in selected cancer patients from the Danish National Patient Registry (DNPR).

METHODS

Through the DNPR, we identified all patients with recorded cancer of the breast, prostate, lung, kidney, and with multiple myeloma. We restricted the study sample to patients with bisphosphonate treatment recorded during an admission to Aalborg Hospital, Denmark, from 2005 through 2009. We retrieved and reviewed medical records of these patients from the initial cancer diagnosis onwards to confirm or rule out bisphosphonate therapy. We calculated the PPV of the treatment coding as the proportion of patients with confirmed bisphosphonate treatment.

RESULTS

We retrieved and reviewed the medical records of 60 cancer patients with treatment codes corresponding to bisphosphonate therapy. Recorded code corresponded to treatment administered intravenously for 59 of 60 patients, corresponding to a PPV of 98.3% (95% confidence interval 92.5-99.8). In the remaining patient, bisphosphonate treatment was also confirmed but was an orally administered bisphosphonate; thus, the treatment for any bisphosphonate regardless of administration was confirmed for all 60 patients (PPV of 100%, 95% confidence interval 95.9-100.0).

CONCLUSION

The PPV of bisphosphonate treatment coding among cancer patients in the DNPR is very high and the recorded treatment nearly always corresponds to intravenous administration.

Multiple metastatic deposits in the head and neck region from a renal cell carcinoma

Metastatic renal cell carcinoma (RCC) presenting with multiple deposits in the head and neck region is unusual. It is not uncommon for a RCC to metastasise to a distant site after years of a tumour-free period, but most of it would be expected to have a single site of deposit. We report a rare case of a patient who had a nephrectomy 10 years earlier for RCC and presented with tumours in the frontal sinus and posterior pharyngeal wall. Radiological imaging and histology confirmed metastatic RCC at both sites.