Optic neuritis as isolated manifestation of leptomeningeal carcinomatosis: a case report and systematic review of ocular manifestations of neoplastic meningitis

Introduction. Leptomeningeal carcinomatosis occurs in about 5% of cancer patients. Ocular involvement is a common clinical manifestation and often the presenting clinical feature. Materials and Methods. We report the case of a 52-year old lady with optic neuritis as isolated manifestation of neoplastic meningitis and a review of ocular involvement in neoplastic meningitis. Ocular symptoms were the presenting clinical feature in 34 patients (83%) out of 41 included in our review, the unique manifestation of meningeal carcinomatosis in 3 patients (7%). Visual loss was the presenting clinical manifestation in 17 patients (50%) and was the most common ocular symptom (70%). Other ocular signs were diplopia, ptosis, papilledema, anisocoria, exophthalmos, orbital pain, scotomas, hemianopsia, and nystagmus. Associated clinical symptoms were headache, altered consciousness, meningism, limb weakness, ataxia, dizziness, seizures, and other cranial nerves involvement. All patients except five underwent CSF examination which was normal in 1 patient, pleocytosis was found in 11 patients, increased protein levels were observed in 16 patients, and decreased glucose levels were found in 8 patients. Cytology was positive in 29 patients (76%). Conclusion. Meningeal carcinomatosis should be considered in patients with ocular symptoms even in the absence of other suggestive clinical symptoms.

Appendiceal Carcinoma with Krukenberg's Tumour Mimicking Primary Ovarian Cancer

Appendiceal adenocarcinoma (AACa) is a rare tumour which represents 0.5% of all gastrointestinal malignancies. The prognosis is poor, because it is usually found at an advanced stage, that in turn, is partly due to a low threshold of suspicion and difficulties in diagnosis prior to surgery. It may occasionally demonstrate ovarian metastases that are large and which dominate the clinical and radiological presentations, leading to a misdiagnosis of an ovarian primary malignancy. We are reporting a case of an occult AACa which manifested clinically as a primary ovarian cancer which was at an advanced stage. Staging laparatomy revealed large bilateral ovarian tumours of clinical FIGO Stage III, with presumed appendiceal implants. Histological examination revealed a mucinous adenocarcinoma with a signet ring component, which involved bilateral ovaries and the appendix transmurally. Immunophenotypic analysis revealed a positive expression of CK 20 and CDX 2 and absence of CK 7 staining, which was compatible with appendiceal primary and ovarian metastases. The diagnosis was subsequently revised to AACa with Krukenberg's metastasis, Stage IV. Although AACas are uncommon, they should be considered in the differential diagnosis of intraabdominal masses and the distinction between ovarian and appendiceal primary malignancies is critical, as the treatment modalities vary.

Stereotactic body radiation therapy versus conventional radiation therapy in patients with early stage non-small cell lung cancer: an updated retrospective study on local failure and survival rates

INTRODUCTION

Stereotactic body radiation therapy (SBRT) for early stage non-small cell lung cancer (NSCLC) is now an accepted and patient friendly treatment, but still controversy exists about its comparability to conventional radiation therapy (RT). The purpose of this single-institutional report is to describe survival outcome for medically inoperable patients with early stage NSCLC treated with SBRT compared with high dose conventional RT.

MATERIAL AND METHODS

From August 2005 to June 2012, 100 medically inoperable patients were treated with SBRT at Odense University Hospital. The thoracic RT consisted of 3 fractions (F) of 15-22 Gy delivered in nine days. For comparison a group of 32 medically inoperable patients treated with conventional RT with 80 Gy/35-40 F (5 F/week) in the period of July 1998 to August 2011 were analyzed. All tumors had histological or cytological proven NSCLC T1-2N0M0.

RESULTS

The median overall survival was 36.1 months versus 24.4 months for SBRT and conventional RT, respectively (p = 0.015). Local failure-free survival rates at one year were in SBRT group 93% versus 89% in the conventional RT group and at five years 69% versus 66%, SBRT and conventional RT respectively (p = 0.99). On multivariate analysis, female gender and performance status of 0-1 and SBRT predicted improved prognosis.

CONCLUSION

In a cohort of patients with NSCLC there was a significant difference in overall survival favoring SBRT. Performance status of 0-1, female gender and SBRT predicted improved prognosis. However, staging procedure, confirmation procedure of recurrence and technical improvements of radiation treatment is likely to influence outcomes. However, SBRT seems to be as efficient as conventional RT and is a more convenient treatment for the patients.

Evaluation of the adverse event profile and pharmacodynamics of toceranib phosphate administered to dogs with solid tumors at doses below the maximum tolerated dose

Background

The receptor kinase inhibitor toceranib phosphate (Palladia) was approved for use in dogs in 2009 using a dose of 3.25 mg/kg administered every other day. Preliminary data suggests that lower doses of toeceranib may be associated with a reduced adverse event profile while maintaining sufficient drug exposure to provide biologic activity. The purpose of this study was to determine the Cmax of toceranib in dogs with solid tumors receiving 2.5-2.75 mg/kg every other day and to document the adverse events associated with this dose rate. Secondary objectives included determination of plasma VEGF concentrations in treated dogs and response to therapy.

Results

Dogs with solid tumors were administered toceranib at an intended target dose ranging from 2.5-2.75 mg/kg every other day and plasma samples were obtained for analysis of toceranib and VEGF plasma concentrations on days 0, 7, 14 and 30 of the study at 6 and 8 hours post drug administration. Additionally, plasma samples were obtained at 0, 1, 2, 6, 8, and 12 hours from dogs on day 30 for confirmation of Cmax. Response to therapy was assessed using standard RECIST criteria and adverse events were characterized using the VCOG-CTCAE. Toceranib administered at doses between 2.4-2.9 mg/kg every other day resulted in an average 6–8 hr plasma concentration ranging from 100–120 ng/ml, well above the 40 ng/ml concentration associated with target inhibition. Plasma VEGF concentrations increased significantly over the 30 day treatment period indicating that VEGFR2 inhibition was likely achieved in the majority of dogs. The lower doses of toceranib used in this study were associated with a substantially reduced adverse event profile compared to the established label dose of 3.25 mg/kg EOD.

Conclusions

Doses of toceranib ranging from 2.4-2.9 mg/kg every other day provide drug exposure considered sufficient for target inhibition while resulting in an adverse event profile substantially reduced from that associated with the label dose of toceranib. This lower dose range of toceranib should be considered for future use in dogs with cancer.

Diplopia with a Cavernous Sinus Metastasis of a Remote Endometrial Stromal Tumour

Structural lesions involving the visual pathways often require tissue diagnosis to guide therapy. However, pathology is not always definitive, and a biopsy showing poorly differentiated cells poses significant difficulty in identifying the primary tumour. We report a case of metastatic disease causing cavernous sinus syndrome, in which biopsy revealed poorly differentiated tissue. The patient reported a history of a resected uterine tumour, and it was only after obtaining slides from 7 years prior that the diagnosis was made.

Epithelial-mesenchymal transition: focus on metastatic cascade, alternative splicing, non-coding RNAs and modulating compounds

Epithelial-mesenchymal transition (EMT) is a key process in embryonic development and metastases formation during malignant progression. This review focuses on transcriptional regulation, non-coding RNAs, alternative splicing events and cell adhesion molecules regulation during EMT. Additionally, we summarize the knowledge with regard to the small potentially druggable molecules capable of modulating EMT for cancer therapy.

Perforated gastrointestinal stromal tumor (GIST) in a true jejunal diverticulum in adulthood: report of a case

A 61-year-old man was referred to us for investigation of acute abdominal pain. Computed tomography showed a 5.9 × 5.3 × 5.0 cm lump of food residue in the jejunum, and a large amount of free air and ascites around the liver and right paracolic gutter. He underwent emergency laparotomy for suspected peritonitis from perforation by a foreign body in the small intestine. We identified purulent exudate in the abdominal cavity and perforation of a jejunal cystic mass, attached ~40 cm from Treitz's ligament at the anti-mesenteric side of the jejunum. Based on a diagnosis of jejunal duplication with perforation, we resected that part of the small intestine and performed intra-abdominal drainage. Pathological findings confirmed the diagnosis of a perforated gastrointestinal stromal tumor (GIST) in a true jejunal diverticulum. Histopathological evidence suggests that intestinal pressure and/or hemorrhage can cause perforation in the background of a true jejunal diverticulum. To our knowledge, this is the first case report of a perforated GIST in a true jejunal diverticulum.

Malignant transformation of respiratory papillomatosis in a solid-organ transplant patient: case report and literature review

We report the case of a 77-year-old non-smoker and non-drinker with a solid-organ transplant who had malignant transformation of respiratory papillomatosis 3 years after the initial diagnosis of this benign lesion. This is the first case reported in the literature of malignant transformation of respiratory papillomatosis in a solid-organ transplant patient. Virus-associated cutaneous cancers occur more frequently and aggressively in solid-organ transplant patients. There may be a higher rate of malignant transformation of respiratory papillomatosis in immunosuppressed patients, as this is a virus-associated disease. Closer observation, airway evaluation with laryngoscopy and tracheobronchoscopy, and interval biopsies of immunosuppressed patients with respiratory papillomatosis is recommended.

Primary synovial sarcoma of the kidney

Synovial Sarcoma (SS) is a soft tissue neoplasm that occurs generally in the proximity of large joints. Here, we report a case of a 45-year-old man who was diagnosed with Primary SS of the kidney which is an extremely rare tumor that accounts for less than 2% of malignant renal tumors. We also review the literature on primary synovial sarcomas of the kidney and focus especially on the renal tumors' differential diagnosis.

Biodistribution and dosimetry of (177)Lu-tetulomab, a new radioimmunoconjugate for treatment of non-Hodgkin lymphoma

The biodistribution of the anti-CD37 radioimmunoconjugate ¹⁷⁷Lu-tetraxetan-tetulomab (¹⁷⁷Lu-DOTA-HH1) was evaluated. Biodistribution of ¹⁷⁷Lu-tetraxetan-tetulomab was compared with ¹⁷⁷Lu-tetraxetan-rituximab and free ¹⁷⁷Lu in nude mice implanted with Daudi lymphoma xenografts. The data showed that ¹⁷⁷Lu-tetulomab had a relevant stability and tumor targeting properties in the human lymphoma model. The half-life of ¹⁷⁷Lu allowed significant tumor to normal tissue ratios to be obtained indicating that ¹⁷⁷Lu-tetraxetan-tetulomab could be suitable for clinical testing. The biological and effective half-life in blood was higher for ¹⁷⁷Lu-tetraxetan-tetulomab than for ¹⁷⁷Lu-tetraxetan-rituximab. The biodistribution of ¹⁷⁷Lu-tetraxetan-tetulomab did not change significantly when the protein dose was varied from 0.01 to 1 mg/kg. Dosimetry calculations showed that the absorbed radiation doses to normal tissues and tumor in mice were not significantly different for ¹⁷⁷Lu-tetraxetan-tetuloma b and ¹⁷⁷Lu-tetraxetan-rituximab. The absorbed radiation doses were extrapolated to human absorbed radiation doses. These extrapolated absorbed radiation doses to normal tissues for ¹⁷⁷Lu-tetraxetan-tetulomab at an injection of 40 MBq/kg were significantly lower than the absorbed radiation doses for 15 MBq/kg Zevalin, suggesting that higher tumor radiation dose can be reached with ¹⁷⁷Lu-tetraxetan-tetulomab in the clinic.

Mixed chimerism induction influences cytokine release from chimeric mice cells

Interest in mixed chimerism has evolved from its role in the induction of alloantigen tolerance. However, its precise impact on the host organism remains to be elucidated. In the present work, we analyzed cytokine secretion from chimeric mice cells to assess the influence of different mixed chimerism induction protocols on immune system function in recipient mice. To our knowledge, there have been no reports on using this parameter for the optimization of the mixed chimerism induction method. B6.SJL-PtprcaPep3b or C57BL/6J mice were used as recipients and Balb/c as donors. We utilized four protocols which consisted of: 3Gy total body irradiation (day -1), the injection of 20-30×10(6) bone marrow cells (day 0), and a combination of CD40L (days 0 and 4), CD8 (day -2), and NK1.1 (day -3) blocking antibodies and cyclophosphamide (175mg/kg - day 2). The concentrations of cytokines (IFN-γ, IL-2, IL-4, IL-6, IL-10, IL-17A, and TNF) were evaluated in the supernatants of unstimulated or phytohemagglutinin-stimulated chimeric spleen, bone marrow and peripheral blood cells in the 8th week of experiment. The induction of tolerance to Balb/c mouse antigens was initially tested in chimeric mice by assessing the presence of Vβ5 and Vβ11 TCR-expressing lymphocytes. The cytokine production was considerably increased, especially in chimeric mice treated by cyclophosphamide. Also the mixed chimerism itself seems to affect IFN-γ, IL-2, IL-4, IL-6, IL-17A, and TNF secretion. Using the optimized induction protocol, we established that chimeric mice cells secreted lower IFN-γ, IL-2, IL-4 and higher IL-6, IL-17A, and TNF levels as compared to control animals. We found that both donor and recipient cells markedly participated in the cytokine production. In conclusion, our optimization study based on cytokine assessment contributes to establishing an effective protocol of mixed chimerism induction with no cyclophosphamide use and better understanding of the influence of this phenomenon on the recipient organism.

Bortezomib-induced painful peripheral neuropathy: an electrophysiological, behavioral, morphological and mechanistic study in the mouse

Bortezomib is the first proteasome inhibitor with significant antineoplastic activity for the treatment of relapsed/refractory multiple myeloma as well as other hematological and solid neoplasms. Peripheral neurological complications manifesting with paresthesias, burning sensations, dysesthesias, numbness, sensory loss, reduced proprioception and vibratory sensitivity are among the major limiting side effects associated with bortezomib therapy. Although bortezomib-induced painful peripheral neuropathy is clinically easy to diagnose and reliable models are available, its pathophysiology remains partly unclear.

In this study we used well-characterized immune-competent and immune-compromised mouse models of bortezomib-induced painful peripheral neuropathy. To characterize the drug-induced pathological changes in the peripheral nervous system, we examined the involvement of spinal cord neuronal function in the development of neuropathic pain and investigated the relevance of the immune response in painful peripheral neuropathy induced by bortezomib.

We found that bortezomib treatment induced morphological changes in the spinal cord, dorsal roots, dorsal root ganglia (DRG) and peripheral nerves. Neurophysiological abnormalities and specific functional alterations in Aδ and C fibers were also observed in peripheral nerve fibers. Mice developed mechanical allodynia and functional abnormalities of wide dynamic range neurons in the dorsal horn of spinal cord. Bortezomib induced increased expression of the neuronal stress marker activating transcription factor-3 in most DRG. Moreover, the immunodeficient animals treated with bortezomib developed a painful peripheral neuropathy with the same features observed in the immunocompetent mice.

In conclusion, this study extends the knowledge of the sites of damage induced in the nervous system by bortezomib administration. Moreover, a selective functional vulnerability of peripheral nerve fiber subpopulations was found as well as a change in the electrical activity of wide dynamic range neurons of dorsal horn of spinal cord. Finally, the immune response is not a key factor in the development of morphological and functional damage induced by bortezomib in the peripheral nervous system.

The role of VEGFR-2 expression in outcomes and survival of patients with peritoneal carcinomatosis from appendiceal cancer

BACKGROUND

Vascular endothelial growth factor (VEGF) is a prognostic factor and target treatment for metastatic colorectal and ovarian cancer. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival on peritoneal carcinomatosis (PC) from appendiceal cancer. We hypothesize that tumoral high expression of VEGF receptor 2 (VEGFR-2) is a negative prognostic factor for survival in patients with PC from appendiceal cancer.

METHODS

A retrospective study of a prospective database revealed 89 patients with PC from appendiceal cancer who underwent 127 CRS/HIPECs. Surgical specimens from 59 patients were tested to identify high vs. low VEGFR-2 expression. Patient outcomes and survival were analyzed.

RESULTS

There were 26 males and 33 females. Mean age was 51 years. Forty-seven VEGFR-2 high expressers and 15 low expressers were identified. Mean follow-up of high and low expressers was 25.1 and 26.6 months, respectively (p = 0.806). At follow-up, 33 (70%) high expressers were alive and 14 (30%) deceased, while 11 (92%) low expressers were alive and 1 (8%) deceased. Recurrence, use of bevacizumab, CC score, PCI, and LN status showed no differences between high and low expressers. OS for high expressers was 90.5%, 59.8%, and 47.1% at 1-, 3-, and 5-years, respectively, while OS for low expressers remained stable at 91.7% at 1-, 3-, and 5-years (p = 0.133).

CONCLUSION

There is a trend towards better outcomes and survival in patients with PC from appendiceal cancer who have low expression of VEGFR-2 compared to high expression. More studies are encouraged to confirm this trend.

Mixed adeno(neuro)endocrine carcinoma arising from the ectopic gastric mucosa of the upper thoracic esophagus

We report a case of mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. A 64-year-old man who had been diagnosed with an esophageal tumor on the basis of esophagoscopy was referred to our hospital. Upper gastrointestinal endoscopy revealed the presence of ectopic gastric mucosa and an adjacent pedunculated lesion located on the posterior wall of the upper thoracic esophagus. Subtotal esophagectomy with three-field lymph node dissection was performed. A microscopic examination revealed that there was a partially intermingling component of neuroendocrine carcinoma adjacent to a tubular adenocarcinoma which was conterminous with the area of the ectopic gastric mucosa. Although the tubular adenocarcinoma was confined to the mucosa and submucosa, the neuroendocrine carcinoma had invaded the submucosaand there was vascular permeation. Each component accounted for 30% or more of the tumor, so the final histopathological diagnosis was mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. Adjuvant chemotherapy was not performed, because the postoperative tumor stage was IA. The patient was well and had no evidence of recurrence 16 months after surgery.

Lethal outcomes in Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is an uncommon congenital angiodysplasia that manifests in infancy and is characterized by venous and lymphatic malformations of the skin, soft tissue, and bone causing limb hypertrophy. We report 2 patients with long-term KTS who developed lethal complications from uncommon and unusual manifestations. The 1st patient was a female with KTS who at 2 years of age underwent a below-the-knee amputation for a massively hypertrophied and malformed left foot. Two years later she required additional surgical removal of vascular malformations involving her left calf with extension to the groin, pubis, and ipsilateral abdomen. Fifteen years later she underwent splenectomy (400 g) revealing multifocal, cystically dilated vascular channels distorting the splenic architecture and died suddenly of massive intra-abdominal hemorrhage on the 2nd postoperative day. The 2nd patient was a 72-year-old male with long-standing KTS who presented with debilitating chronic penile and scrotal edema. Surgical excision of his lymphedematous scrotal and penile skin revealed a low-grade angiosarcoma arising in the setting of chronic lymphedema. The patient died shortly after surgery from massive hemorrhage due to traumatic rupture of malformed leg vessels. KTS may lead to significant morbidity and mortality, and pathologic consequences from long-term KTS have been rarely reported. These cases illustrate the risk of lethal hemorrhage, organomegaly from protracted vascular malformation, and development of vascular neoplasia associated with chronic lymphedema in KTS.

Biochemical and objective response to abiraterone acetate withdrawal: incidence and clinical relevance of a new scenario for castration-resistant prostate cancer

OBJECTIVE

To describe the incidence and clinical relevance of biochemical and objective responses to abiraterone acetate (AA) withdrawal (AAWD) in patients with castration-resistant prostate cancer (CRPC).

MATERIALS AND METHODS

Twenty-six patients with progressive CRPC treated with first-line docetaxel-based chemotherapy were administered with AA at the standard dose of 1000 mg/day in combination with prednisone until progression. The patients were regularly followed up during treatment and after AAWD.

RESULTS

Nineteen of the 26 patients discontinued AA because of progression. Three of the patients undergoing AAWD experienced a biochemical response, which was accompanied by a metabolic and radiological response as revealed by choline positron emission tomography in 2 cases.

CONCLUSION

Regardless of the underlying molecular bases, AAWD response does not occur rarely. It is sometimes long-lasting and accompanied by a metabolic and radiographic improvement. AAWD response should be taken into account when further therapeutic strategies are planned in patients with CRPC with progressive disease during abiraterone therapy.

Facts and fiction: premalignant lesions of lung tissues

Lung cancer is now the leading cause of death from cancer in Australia. Most patients are diagnosed with late-stage disease. Although diagnosis at pre-invasive stages could theoretically improve outcomes, mooted precursor lesions are often asymptomatic and often undetectable by non-invasive investigations. Nonetheless, they merit study to identify early and essential molecular steps involved in lung carcinoma pathogenesis, with the aim of developing therapies targeted against one or more such steps. Some lung cancers appear to develop via a series of progressive morphological changes with correlating molecular alterations, but others seem to arise in histologically normal epithelium, and these differences may reflect anatomically and functionally distinct epithelial compartments of the respiratory tract. Pre-invasive precursor lesions recognised by the World Health Organization (WHO) include squamous metaplasia with dysplasia and carcinoma in situ, atypical adenomatous hyperplasia, and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. Other lesions that likely represent pre-invasive lesions, but which are not currently WHO-listed, include human papillomavirus (HPV)-related respiratory papillomatosis and mesothelioma in situ. No single cancer stem cell marker has been identified. Field cancerisation plays an important role in lung cancer development, and includes the spread of pre-invasive clones along the respiratory epithelium or the occurrence of multiple separate foci of pre-invasive abnormalities such as squamous dysplasia and carcinoma in situ.In addition to well-characterised step-wise progression in squamous cell carcinomas and some adenocarcinomas, alternative pathways exist, and are currently being investigated. In addition, molecular techniques, including miRNA screening on blood samples or cytology samples--such as sputum samples--may become clinically relevant and more accurate in predicting lung cancer progression.

Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections

OBJECTIVE

To review our 34-year experience with 574 consecutive resections for perihilar cholangiocarcinoma and to evaluate the progress made in surgical treatment of this disease.

BACKGROUND

Few studies have reported improved surgical outcomes for perihilar cholangiocarcinoma; therefore, it is still unclear whether surgical treatment of this intractable disease has progressed.

METHODS

Between April 1977 and December 2010, a total of 754 consecutive patients with perihilar cholangiocarcinoma were treated, of whom 574 (76.1%) underwent resection. The medical records of these resected patients were retrospectively reviewed.

RESULTS

The incidence of major hepatectomies has increased, and limited resections, including central hepatectomies and bile duct resections, were rarely performed. Combined vascular resection was being used more often. Operative time has become shorter, and intraoperative blood loss has also decreased significantly. Because of refinements in surgical techniques and perioperative management, morbidity decreased significantly but was still high, with a rate of 43.1% in the last 5 years. Mortality rate has also decreased significantly (P < 0.001) from 11.1% (8/72) before 1990 to 1.4% (3/218) in the last 5 years. The ratio of advanced disease defined as pStage IVA and IVB has increased significantly from 49.4% before 2000 to 61.4% after 2001. The disease-specific survival for the 574 study patients (including all deaths) was 44.3% at year 3, 32.5% at year 5, and 19.9% at year 10. The survival was significantly better in the later period of 2001 to 2010 than in the earlier period of 1977 to 2000 (38.1% vs 23.1% at year 5, P < 0.001). For pM0, R0, and pN0 patients (n = 243), the survival in the later period was good with 67.1% at year 5, which was significantly better than that of the earlier period (P < 0.001). For pM0, R0, and pN1 patients (n = 142), however, the survival in the later period was similar to that of the earlier period (22.1% vs 14.6% at year 5, P = 0.647). Multivariate analysis revealed that lymph node metastasis was the strongest prognostic indicator.

CONCLUSIONS

Surgical treatment of perihilar cholangiocarcinoma has been evolving steadily, with expanded surgical indication, decreased mortality, and increased survival. Survival for R0 and pN0 patients was satisfactory, whereas survival for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.

A phase I study of an agonist CD40 monoclonal antibody (CP-870,893) in combination with gemcitabine in patients with advanced pancreatic ductal adenocarcinoma

PURPOSE

This phase I study investigated the maximum-tolerated dose (MTD), safety, pharmacodynamics, immunologic correlatives, and antitumor activity of CP-870,893, an agonist CD40 antibody, when administered in combination with gemcitabine in patients with advanced pancreatic ductal adenocarcinoma (PDA).

EXPERIMENTAL DESIGN

Twenty-two patients with chemotherapy-naïve advanced PDA were treated with 1,000 mg/m(2) gemcitabine once weekly for three weeks with infusion of CP-870,893 at 0.1 or 0.2 mg/kg on day three of each 28-day cycle.

RESULTS

CP-870,893 was well-tolerated; one dose-limiting toxicity (grade 4, cerebrovascular accident) occurred at the 0.2 mg/kg dose level, which was estimated as the MTD. The most common adverse event was cytokine release syndrome (grade 1 to 2). CP-870,893 infusion triggered immune activation marked by an increase in inflammatory cytokines, an increase in B-cell expression of costimulatory molecules, and a transient depletion of B cells. Four patients achieved a partial response (PR). 2-[(18)F]fluoro-2-deoxy-d-glucose-positron emission tomography/computed tomography (FDG-PET/CT) showed more than 25% decrease in FDG uptake within primary pancreatic lesions in six of eight patients; however, responses observed in metastatic lesions were heterogeneous, with some lesions responding with complete loss of FDG uptake, whereas other lesions in the same patient failed to respond. Improved overall survival correlated with a decrease in FDG uptake in hepatic lesions (R = -0.929; P = 0.007).

CONCLUSIONS

CP-870,893 in combination with gemcitabine was well-tolerated and associated with antitumor activity in patients with PDA. Changes in FDG uptake detected on PET/CT imaging provide insight into therapeutic benefit. Phase II studies are warranted.

[Lymph node pathology - an update]

Immune suppression is a risk factor for malignant lymphoma development. Progress in medical science has increased the numbers of immunosuppressed patients due to organ transplantations or successful treatment of autoimmune diseases. Different forms of immune suppression and the respective lymphoma entities are discussed in this article. Another issue treated are gray zone lymphomas between Hodgkin's lymphoma and diffuse large B cell lymphoma. This category not only represents a diagnostic challenge but also represents more a true biological continuum.

Bilateral renal artery thrombosis secondary to acute necrotizing pancreatitis

Renal artery thrombosis is a rare, but serious and often under-diagnosed condition. We report a case of bilateral renal artery thrombosis secondary to acute necrotizing pancreatitis. A 66-year-old female presented with abdominal pain and acute kidney injury (AKI). A renal biopsy showed organized intraluminal thrombi and a computer tomography scan of the abdomen showed bilateral renal artery thrombosis. Emergent laprotomy showed necrosed pancreas. Doppler studies showed deep vein thrombosis of the lower extremities and internal jugular vein thrombosis. Workup for hypercoagulability was unremarkable. The final diagnosis was AKI secondary to bilateral renal artery thrombosis probably due to hypercoagulability of acute necrotizing pancreatitis.

Advances of lab-on-a-chip in isolation, detection and post-processing of circulating tumour cells

Circulating tumour cells (CTCs) are shed by primary tumours and are found in the peripheral blood of patients with metastatic cancers. Recent studies have shown that the number of CTCs corresponds with disease severity and prognosis. Therefore, detection and further functional analysis of CTCs are important for biomedical science, early diagnosis of cancer metastasis and tracking treatment efficacy in cancer patients, especially in point-of-care applications. Over the last few years, there has been an increasing shift towards not only capturing and detecting these rare cells, but also ensuring their viability for post-processing, such as cell culture and genetic analysis. High throughput lab-on-a-chip (LOC) has been fuelled up to process and analyse heterogeneous real patient samples while gaining profound insights for cancer biology. In this review, we highlight how miniaturisation strategies together with nanotechnologies have been used to advance LOC for capturing, separating, enriching and detecting different CTCs efficiently, while meeting the challenges of cell viability, high throughput multiplex or single-cell detection and post-processing. We begin this survey with an introduction to CTC biology, followed by description of the use of various materials, microstructures and nanostructures for design of LOC to achieve miniaturisation, as well as how various CTC capture or separation strategies can enhance cell capture and enrichment efficiencies, purity and viability. The significant progress of various nanotechnologies-based detection techniques to achieve high sensitivities and low detection limits for viable CTCs and/or to enable CTC post-processing are presented and the fundamental insights are also discussed. Finally, the challenges and perspectives of the technologies are enumerated.

Inflammatory myofibroblastic tumor with extensive involvement of the bladder in an adolescent: a case report

Inflammatory myofibroblastic tumor (IMT) is a rare lesion of unclear pathogenesis that shows a wide, highly variable spectrum of clinical behavior. We describe the case of a 17-year-old boy with a large IMT that infiltrated the bladder, ileocecal junction, peritoneum and pelvic retroperitoneal space. The tumor was associated with extensive toughening and thickening of the bladder, and, although it showed a tendency for invasive growth, it affected mainly the bladder and adjacent tissue. To the best of our knowledge, this case report is the first to describe an IMT involving the entire bladder and several adjacent pelviabdominal organs. The bladder wall was tough and could hardly be cut by scalpel. Levels of inflammatory response markers such as C-reactive protein fell after surgery.

Disease flare after discontinuation of crizotinib in anaplastic lymphoma kinase-positive lung cancer

We report the case of a 50-year-old male former smoker. He was diagnosed as having lung adenocarcinoma and treated with induction chemoradiation therapy followed by surgery and adjuvant chemotherapy. Molecular testing revealed that his tumor had an echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) rearrangement. Therefore, he was treated with crizotinib when his disease recurred. He achieved a partial response, which persisted for 10 months until progressive disease was confirmed. Crizotinib was continued for 1 month and the tumor size increased slightly. At that time, crizotinib was discontinued and he participated in a clinical trial of erlotinib ± Met inhibitor; however, his disease progressed rapidly after discontinuation of crizotinib, and the diagnosis of disease flare was made. Readministration of crizotinib was started immediately; however, his disease progressed rapidly, and he died 2 days after starting crizotinib retreatment. Currently, the incidence of disease flare is unknown and it is impossible to predict who will experience it. Therefore, continuing crizotinib after disease progression may be a reasonable option to avoid disease flare.

Contrast enhanced ultrasound of a gallbladder lesion in a patient with a history of renal cell and rectal cancer

The gallbladder is an uncommon site of metastatic cancer. Although ultrasound can be regarded as a first line investigation for the detection of gallbladder lesions, differentiation between benign and malignant tumors usually requires resection. Real-time contrast enhanced ultrasound (CEUS) is a well-established technique for the classification of liver, pancreatic, and renal diseases (Weskott, 2008). The application of CEUS in the diagnosis of gallbladder tumors has rarely been described. We report the application of contrast enhanced ultrasound for the characterization of a gallbladder lesion in a 63-year-old patient with a history of renal cell and rectal cancer.

Diseases associated with human papillomavirus infection

Human papillomaviruses (HPVs) are ubiquitous, well adapted to their host and cleverly sequestered away from immune responses. HPV infections can be productive, subclinical or latent in both skin and mucosa. The causal association of HPV with cervical cancer, and increasingly with rising numbers of squamous cell carcinomas at other sites in both men and women, is increasingly recognised, while the morbidity of cutaneous HPV lesions, particularly in the immunosuppressed population is also significant. This chapter sets out the range of infections and clinical manifestations of the consequences of infection and its persistence and describes why HPVs are both highly effective pathogens and carcinogens, challenging to eliminate.

Bilateral optic disc oedema and associated optic neuropathy in the setting of FOLFOX chemotherapy

Background

To report a case of bilateral optic disc oedema and associated optic neuropathy in the setting of FOLFOX chemotherapy.

Case presentation

A case of a 57-year-old male being treated with FOLFOX chemotherapy for stage 3B colorectal cancer, who developed bilateral optic disc oedema and associated left sided optic neuropathy is described. The patient presented following cycles 7, 8 and 9 of chemotherapy with a history of bilateral simultaneous intermittent inferior altitudinal field defects. These episodes progressed to bilateral optic nerve oedema and a subsequent left sided optic neuropathy. The patient’s symptoms and oedema regressed with discontinuation of chemotherapy.

Conclusion

This is the first report suggesting a vasospastic role of 5-fluoruracil in 5-FU associated optic neuropathy. It highlights that 5-FU may have the potential to cause arterial vasospasm outside the cardiac vasculature, resulting in end-organ optic nerve ischaemia.

Sunitinib-induced reversible purpuric rash in a patient with gastrointestinal stromal tumor

Sunitinib which is used in the treatment of kidney cancer, gastrointestinal stromal tumor, and advanced pancreatic neuroendocrine tumor is a multi-targeted tyrosine kinase inhibitor. Although sunitinib is associated with some side effects, it is generally well tolerated. In the present case, the diagnosis of gastrointestinal stromal tumor was four years ago. The patient had multiple liver metastases at the time of diagnosis. Sunitinib was initiated with a dose of 50 mg daily for four weeks and two weeks off, because of resistance of imatinib. The patient was admitted to the hospital with purpuric rash on her arms and body in the eighth week of treatment. No other disorders or drugs which may cause purpuric rash were detected in the patient. Purpuric rash disappeared two weeks after sunitinib discontinuation without any further intervention.

Ovarian mass, pleural effusion, and ascites: revisiting Meigs syndrome

The triad of pleural effusion, ascites, and benign ovarian fibroma is rare. Often, the ovarian mass is accompanied by elevated cancer antigen-125, both in serum and in pleural and peritoneal fluid. When benign ovarian fibroma is associated with ascites and/or pleural effusion it is termed Meigs syndrome. Meigs syndrome, however, is a diagnosis of exclusion only after ovarian carcinoma is ruled out. The presentation of symptoms and radiographic findings mimics that of metastatic ovarian cancer, creating a significant clinical challenge. We report a case of a patient with recurrent pleural effusions and an ovarian mass, with the outside hospital pleural fluid cytology report describing ovarian cancer. Although initially suspected to have metastatic ovarian cancer, subsequent workup of the patient's pleural and peritoneal fluid revealed no carcinoma. Surgical biopsy of the ovarian mass showed the presence of a benign tumor (fibroma). Postovarian mass resection, the patient showed resolution of pleural and peritoneal effusions. We describe our case in detail and review the literature on Meigs syndrome.

Late relapse of progressive multifocal leucoencephalopathy postallogenic transplant in a young patient with CLL

We describe a case of progressive multifocal leucoencephalopathy (PML) in a 39-year-old patient diagnosed with chronic lymphocytic leukaemia (CLL) who underwent two allogenic matched-sibling stem cell transplantations. PML was confirmed just after the first transplantation with cerebral MRI and by PCR in the cerebrospinal fluid. After immunosuppression withdrawal and cidofovir treatment, he achieved a reversal of clinical symptoms, John Cunningham (JC) virus positivity and MRI lesions regression. He remained asymptomatic for 5 years with no signs of infection activity, even though he received three new chemotherapy regimens due to a CLL relapse. However, after the second stem cell transplantation, new neurological symptoms began and a reactivation of the JC virus infection was detected. This time, treatment with mefloquine was started, but he experienced a progressive neurological deterioration and died 1 month after the symptoms began.

A phase II study of sunitinib in advanced hepatocellular carcinoma

BACKGROUND

In 2007, sorafenib was the first drug able to improve overall survival in patients with advanced hepatocellular carcinoma.

AIM

In 2005 we designed a phase II study to assess safety and efficacy of sunitinib.

METHODS

This is a single arm, open-label, single-centre phase II trial. Eligibility criteria were advanced hepatocellular carcinoma; no prior chemotherapy, performance status 0-1; and Child≤B8. The treatment schedule was 50mg each day orally, 4 weeks on, 2 weeks off.

RESULTS

Between 10/2007 and 10/2010, 34 patients were enrolled. A significant worsening of liver functional reserve after sunitinib was observed. Grade 3/4 adverse effects occurred in 80% of patients and included fatigue (47%), nausea (15%), liver failure (15%), encephalopathy (12%) and upper gastrointestinal bleeding (12%). Six patients (18%) died within 60 days of enrolment. A partial response was observed in 4 patients (12%). Median time to tumour progression was 2.8 months and median overall survival was 5.8 months.

CONCLUSION

A dose of 50mg/d induces a high rate of severe adverse events. Toxicity remains a key concern also at the dose of 37.5mg/d. However, sunitinib is able to induce a prolonged response in some patients. Positron Emission Tomography/Computed Tomography scans may select good responders.

The ‘Trojan horse’ oncogenic strategy of HPVs in childhood

HPVs are considered to be the principal cause of cervical cancer worldwide. During the last decade, their possible oncogenic involvement has also been proposed in a substantial proportion of nongenital cancers, such as breast and lung cancer. The presence of high-risk HPVs in the neonatal oral mucosa supports the transmission of HPVs from the mother to her newborn. This review presents current evidence that supports the perinatal transmission of high-risk HPVs and suggests that this may be the initial step of the oncogenic strategy of high-risk HPVs in humans. The hypothesis that children are a unique reservoir of silent high-risk HPVs, analogously to the Trojan horse, should be investigated further.

Novel des-γ-carboxy prothrombin in serum for the diagnosis of hepatocellular carcinoma

BACKGROUND AND AIM

Serum des-γ-carboxy prothrombin (DCP) levels using a newly developed electrochemiluminescence immunoassay (ECLIA, novel DCP [NX-DCP]) were measured, and the utility of NX-DCP and DCP/NX-DCP ratio for the diagnosis of hepatocellular carcinoma (HCC) was investigated. Antigenic differences in DCP between HCC and non-HCC patients were elucidated.

METHODS

The subjects included 170 patients with HCC, 61 with benign liver disease, 12 with obstructive jaundice, and 10 warfarin users. NX-DCP was quantitated by sandwich ECLIA employing novel anti-DCP monoclonal antibodies, P11 and P16. Conventional DCP was quantitated by standard ECLIA. DCP extracted from serum by affinity-chromatography was analyzed by Western blotting.

RESULTS

Conventional serum DCP levels were high in patients with HCC and obstructive jaundice, and in warfarin users, consistent with previous reports. Serum NX-DCP levels were high only in warfarin users and obstructive jaundice patients (vitamin K-deficient patients) but not in HCC patients. The DCP/NX-DCP ratio was significantly higher in the HCC group than in the benign liver disease, obstructive jaundice, and warfarin groups (P < 0.001). Receiver operating characteristic analysis showed significant superiority of the DCP/NX-DCP ratio over conventional DCP as a marker for HCC diagnosis (P < 0.05). Western blot analysis showed that P11 and P16 reacted strongly with DCP from a warfarin user and an obstructive jaundice patient but very faintly with DCP from an HCC patient. Immunohistochemistry on HCC samples and autopsied normal liver tissues from warfarin users showed similar results.

CONCLUSIONS

The DCP/NX-DCP ratio is very useful for diagnosing HCC. DCP in HCC patients is distinct from that in vitamin K-deficient patients.

Primary bone metastasis as initial presentation of endometrial cancer (stage IVb)

INTRODUCTION

Endometrial cancer is the most common malignancy among females in developed countries. Abnormal uterine bleeding is the leading symptom in approximately 90 % of cases. The incidence of stage IV disease is approximately 5-10 % with a 5-year overall survival of less than 10 %.

MATERIALS AND METHODS

A rare case presented with femoral pathological fracture and underlying endometrial cancer. We discuss the diagnosis, management and literature review for this extremely rare entity which can be present even in the absence of vaginal bleeding.

RESULTS

Literature search revealed 28 cases with primary bone metastasis and all were symptomatic at the time of diagnosis. Eighty percent of them had tumour on the lower limb and the majority did not have vaginal bleeding. The predominant histopathological type was endometrioid (72.4 %) and grade 1-2 (59 %). Treatment had been individualised and 57 % of the cases underwent surgery with removal of uterus and adnexa and only three patients (10.7 %) received pelvic radiotherapy. Bone tumour was treated with radiotherapy in 80 % of the cases, alone (28 %), or combined with primary surgery (12 %) or chemotherapy (40 %). Overall, 54 % of patients received chemotherapy and 46 % received hormone therapy. The mean survival of patients who presented with single-bone metastasis was significantly better than those with multiple extrauterine metastatic sites: mean 85.7 months (SE: 9.2) versus 22.9 months (SE: 5.2), p < 0.003, CI 95 %. These two different survival patterns are more likely to reflect two different biological disease behaviours. Those with advanced local and widespread disease progress quicker, in contrast to those with a single-bone extrauterine metastatic site and local disease limited to the uterus, which continues to behave as early stage endometrial cancer.

CONCLUSIONS

Although extremely rare, endometrial cancer can present as initial bone pathology. Endometrial biopsy should be included in the patient's workup when investigating for metastatic bone adenocarcinoma of unknown origin, even when gynaecological symptoms are lacking, as this rare presentation of stage IVb endometrial cancer appears to have good survival outcomes.

Herbal-drug interaction induced rhabdomyolysis in a liposarcoma patient receiving trabectedin

BACKGROUND

Rhabdomyolysis is an uncommon side effect of trabectedin which is used for the second line therapy of metastatic sarcoma after anthracycline and ifosfamide failure. This side effect may be due to pharmacokinetic interactions caused by shared mechanisms of metabolism involving the cytochrome P450 (CYP) system in the liver. Here, for the first time in literature, we describe the unexpected onset of heavy toxicity, including rhabdomyolysis, after the fourth course of trabectedin in a patient with retroperitoneal liposarcoma who at the same time was taking an alternative herbal medicine suspected of triggering this adverse event.

CASE PRESENTATION

This is the case of a 56 year old Caucasian man affected by a relapsed de-differentiated liposarcoma who, after the fourth cycle of second-line chemotherapy with trabectedin, complained of sudden weakness, difficulty walking and diffuse muscle pain necessitating complete bed rest. Upon admission to our ward the patient showed grade (G) 4 pancytopenia and a marked increase in liver lytic enzymes, serum levels of myoglobin, creatine phosphokinase (CPK) and lactate dehydrogenase. No cardiac or kidney function injuries were present. Based on these clinical and laboratory features, our conclusive diagnosis was of rhabdomyolysis induced by trabectedin.The patient did not report any trauma or muscular overexertion and no co-morbidities were present. He had not received any drugs during treatment with trabectedin, but upon further questioning the patient informed us he had been taking a folk medicine preparation of chokeberry (Aronia melanocarpa) daily during the last course of trabectedin and in the 2 subsequent weeks.One week after hospitalization and cessation of intake of chokeberry extract, CPK and other markers of myolysis slowly returned to standard range, and the patient noted a progressive recovery of muscle strength.The patient was discharged on day 14 when a blood transfusion and parenteral hydration gradually lowered general toxicity. Progressive mobilization of the patient was obtained as well as a complete normalization of the laboratory findings.

CONCLUSIONS

The level of evidence of drug interaction leading to the adverse event observed in our patient was 2 (probable). Thus our case underlines the importance of understanding rare treatment-related toxicities such as trabectedin-induced rhabdomyolysis and the possible role of the drug-drug interactions in the pathogenesis of this rare side effect. Furthermore, this report draws attention to a potential problem of particular concern, that of nutritional supplements and complementary and alternative drug interactions. These are not widely recognized and can cause treatment failure.

Laparoscopic approach for isolated splenic metastasis: comprehensive literature review and report of 6 cases

BACKGROUND

Splenic metastases are extremely unusual. The aim of this paper is to review the world experience to date concerning to laparoscopic approach for splenic metastasis, and to report ours at the Hospital de Sant Pau.

METHODS

Literature review was carried out and relevant reports on laparoscopic approach to splenic metastasis were obtained. In addition, we reviewed our patient's database and retrieved the data of those who underwent laparoscopic splenectomy due to splenic involvement.

RESULTS

Electronic search yielded 8 relevant articles on open splenectomy and 7 articles on laparoscopic splenectomy for splenic metastasis. During the study period, 6 patients were operated on laparoscopically. Primary neoplasms were 3 melanomas, 2 colon carcinomas, and 1 malignant fibrous histiocytoma. None of the patients had surgical complications. Outcome ranged from 2-month to 11-year survival.

CONCLUSIONS

The laparoscopic approach for splenic metastasis is feasible. Of course, it must be individualized in each case.

Case of childhood laryngeal papillomatosis with metastatic carcinoma esophagus in adulthood

A young male patient was diagnosed to have laryngeal papillomas at the age of 3 years for which he underwent permanent tracheostomy and also multiple surgical and laser excision procedures. Then, later in life, the patient had progressive breathlessness and dysphagia. On examination, he had supraclavicular lymphadenopathy showing squamous carcinoma pathology. Since laryngeal papillomas have a high propensity to transform into laryngeal squamous cell carcinoma, he was first evaluated for laryngeal carcinoma which was negative. Esophagoscopy showed a growth in the esophagus, the biopsy of which was positive for squamous malignant cells. Patient was then started on palliative chemotherapy with combination of paclitaxel and carboplatin, and at progression with weekly nanoxel with stable disease. This is a rare case of childhood laryngeal papillomatosis progressing to metastatic esophageal carcinoma. This case has been presented to highlight the fact that patients with laryngeal papillomas are not only at high risk of progressing to laryngeal carcinoma but can also have other malignancies of the upper aerodigestive tract and lung. Most of them have been correlated to human papilloma virus (HPV), but in our patient HPV DNA was negative.

Unbalanced 11;18 translocation in an acute erythroid leukemia after radioactive iodine therapy

Therapy-related acute myeloid leukemia (t-AML) is well described after chemotherapy or radiotherapy for diverse malignancies. Radioisotope therapy is also recognized as a less-common cause of t-AML. We describe a patient with acute erythroid leukemia after radioactive iodine administration for papillary thyroid cancer, with an unbalanced 11;18 translocation resulting in three copies of 11q, including the MLL gene. Although an increased incidence of chronic myeloid leukemia has been documented after radioactive iodine exposure, acute leukemia in this setting has been less frequently seen. Moreover, to our knowledge, the chromosome abnormality present in our patient has not been previously reported. The literature on cytogenetic abnormalities in t-AML after radioactive iodine administration is reviewed.

Metastatic renal cell carcinoma to the pancreas: diagnostic significance of fine-needle aspiration cytology

BACKGROUND

Renal cell carcinoma rarely metastasizes to the pancreas. Diagnosing a neoplasm that is metastatic to the pancreas by fine-needle aspiration (FNA) cytology is often challenging. A detailed clinical history may prove to be beneficial.

CASE REPORTS

A total of 729 pancreatic FNAs were performed from January 2005 through August 2012 at our institution. Among these, we found 3 patients with a prior history of a malignant renal neoplasm who presented with a pancreatic mass: 2 in the tail and 1 in the head. Radiographically, they ranged in size from 2.5 to 7.0 cm. Microscopic evaluation of cytologic material obtained during endoscopic ultrasound-guided FNA (EUS-FNA) revealed cohesive clusters of atypical cells with clear cytoplasm and prominent nucleoli surrounded by a thin capillary network. The neoplastic cells were immunoreactive with CD10 (cases 2 and 3). A diagnosis of metastatic clear cell renal cell carcinoma was rendered for each case based on the morphologic features and immunohistochemical staining pattern of the neoplastic cells. Histologic comparison with the available slides of the corresponding primary renal neoplasm confirmed the diagnosis.

CONCLUSION

We conclude that EUS-FNA of pancreatic masses is an important, effective, and accurate diagnostic modality for early diagnosis of both primary and metastatic neoplasms of the pancreas.