Squamous cell carcinoma of the pancreas

About two unusual cases of pancreatic primary squamous cell carcinoma

Pancreatic primary squamous cell carcinoma (PPSCC) is very uncommon. The major diagnostic method is histology, and it requires the exclusion of a metastasis from a different primary location (lung, esophagus…). Herein, we describe two cases of a PPSCC (one in the head and the other one in the tail and the body of the pancreas) with a brief review of literature. When it comes to the poorly differentiated PPSCC, immunohistochemistry (IHC) is crucial. Regretfully, there is currently no unanimity on treatment, and the outcome is dismal.

Simultaneous presentation and resection of esophageal cancer and metastasis to the pancreas: Α case report and literature review

The frequency of metastasis to the pancreas is limited, and the frequency of metastasis of a squamous cell carcinoma of the esophagus is limited even further. The curative resection of this type of metastatic lesion has been reported for some patients; however, the survival benefit that can be attributed to these procedures has not yet been clearly determined. The patient examined in the present study was a 54-year-old man who was diagnosed with a lower thoracic esophageal cancer. Computed tomography revealed a 2-cm tumor at the tail of the pancreas. Since no other obvious distal metastases were observed, the patient underwent simultaneous surgical procedures, excising the esophageal squamous cell carcinoma and the pancreatic metastasis. A histopathological examination confirmed squamous cell carcinoma in both specimens. The patient has been free of disease for 9 months since the resection. A literature review of all relevant cases to date also demonstrated that the primary tumor site in all cases of patients with esophageal cancer presenting with metastasis to the pancreas was the lower thoracic esophagus. Complete simultaneous resections of esophageal squamous cell carcinoma and a solitary metastasis to the pancreas is beneficial and may produce favorable outcomes. However, due to the reduced number of corresponding reports, further studies are required for the confirmation of the benefits of surgery.

Primary squamous cell carcinoma of pancreas in a patient with chronic pancreatitis: A rare case report

Primary squamous cell carcinoma of pancreas is a rare malignant neoplasm. It has been reported as case reports only, hence clinical information is limited. Here, we present a case of primary squamous cell carcinoma of pancreas in a 47-year-old female with a background history of chronic pancreatitis. Patient was treated with systemic chemotherapy; however, she did not respond to the treatment protocol. Follow-up CT scan showed increase in the size and extension of the lesion. It is an aggressive tumor and does not respond well to chemotherapy or radiotherapy.

Cancer cell states recur across tumor types and form specific interactions with the tumor microenvironment

Transcriptional heterogeneity among malignant cells of a tumor has been studied in individual cancer types and shown to be organized into cancer cell states; however, it remains unclear to what extent these states span tumor types, constituting general features of cancer. Here, we perform a pan-cancer single-cell RNA-sequencing analysis across 15 cancer types and identify a catalog of gene modules whose expression defines recurrent cancer cell states including 'stress', 'interferon response', 'epithelial-mesenchymal transition', 'metal response', 'basal' and 'ciliated'. Spatial transcriptomic analysis linked the interferon response in cancer cells to T cells and macrophages in the tumor microenvironment. Using mouse models, we further found that induction of the interferon response module varies by tumor location and is diminished upon elimination of lymphocytes. Our work provides a framework for studying how cancer cell states interact with the tumor microenvironment to form organized systems capable of immune evasion, drug resistance and metastasis.

Epidemiology, Treatment, and Outcome of Pancreatic Squamous Cell Carcinoma and Pancreatic Adenocarcinoma: A Propensity Score-Matching Analysis Based on SEER-Database

Background: Pancreatic squamous cell carcinoma (PSCC) is a rare pancreatic malignancy compared to most common pancreatic adenocarcinoma (PAC). Aims: To analyze the prognostics factors of PSCC and compare PAC with PSCC in demographic patterns, clinicopathologic characteristics and treatment modalities. Methods: Data of PSCC and PAC patients from January 1, 2004 to December 31, 2015 were extracted from Surveillance, Epidemiology and End Results (SEER) database for case-control study. Kaplan-Meier method and Cox proportional hazards analysis were used in survival analysis. A 1:3 propensity-score matching (PSM) was performed to compare the overall survival (OS) and cancer specific survival (CSS) between PAC and PSCC in each variable. Results: PAC patients (n = 38 968) and PSCC patients (n = 124) were analyzed. After PSM, 372 PAC patients and 124 PSCC patients were obtained. PSCC tends to happen to elders, white and female with a predilection site of pancreatic head, followed by tail, then body. PSCC have a higher proportion to be poorly differentiated and metastatic when diagnosed. The prognosis of PSCC patients was significantly worse than PAC patients in both univariate and multivariate analyses. Surgery and chemotherapy were independent prognostic factors for PSCC. Conclusions: PSCC patients were identified associated with a worse prognosis than PAC patients. PSCC tend to be poorly differentiated and more easily to be metastatic. Surgery and chemotherapy may be effective therapies to improve the OS of PSCC significantly.

Metachronous squamous cell carcinoma of pancreas and stomach in an elderly female patient: A case report

BACKGROUND

Squamous cell carcinoma (SCC) in pancreas and stomach is a rare histologic subtype with aggressive behavior, poor prognosis, and no standardized therapy. Pancreatic SCC or gastric SCC has been previously reported. However, case of SCC occurring in both the pancreas and the stomach has not been reported yet.

CASE SUMMARY

A 75-year-old female with prior history of hypertension and diabetes mellitus visited our hospital with complaint of abdominal pain that started three months ago. Computed tomography (CT) scan of the abdomen showed 3.3 cm mass at the distal pancreas. She received surgical resection which was histologically found to be SCC of the pancreas with clear resection margins. After she was discharged, she no longer visited the hospital. Three years later, she was referred to our hospital after showing abnormal findings on a gastroscopy performed at another hospital. Gastroscopy revealed a single, 2cm sized, ill-defined irregular flat and hyperemic mass at high body. Histologic finding of the mass was SCC. CT scan and positive emission tomography CT showed metastatic lesions to the liver and the peritoneum. She received combination chemotherapy with capecitabine and oxaliplatin. However, she passed away 6 mo after diagnosis of gastric SCC.

CONCLUSION

To the best of our knowledge, this is the first case of metachronous SCC of stomach occurring after diagnosis of pancreatic SCC.

An extremely atypical presentation of esophageal squamous cell carcinoma with pancreatic and hepatic metastases: A case report and overview of the literature

RATIONALE

Esophageal carcinoma is an aggressive cancer with extremely poor therapeutic outcomes due to its high metastatic potential and a significant risk of recurrence after radical resection. Liver is the most common metastatic target organ of esophageal carcinoma, followed by the lungs, bones, and brain. Few cases of solitary pancreatic and hepatic metastases of esophageal carcinoma have been reported.

PATIENT CONCERNS

We report the case of a 67-year-old male presenting with pancreatic and hepatic lesions. In addition, a friable lesion with an irregular nodular surface in the distal esophagus was detected by esophagogastroduodenoscopy.

DIAGNOSIS

Pathohistological examination confirmed esophageal squamous cell carcinoma. The pancreatic lesion was also biopsied via ultrasound-guided fine needle aspiration, which also revealed squamous cell carcinoma. The hepatic lesion was also identified as metastatic carcinoma by magnetic resonance imaging, most likely of the same origin.

INTERVENTIONS

Due to comorbidities that precluded surgery, the patient was administered adjuvant therapy and a multidisciplinary decision was made for palliative care.

OUTCOMES

The patient died 1 month later due to multiorgan failure caused by hemorrhage from a peptic ulcer.

CONCLUSION

To our knowledge, this is only the sixth case of pancreatic metastasis of esophageal squamous cell carcinoma. This case report suggests to clinicians the importance of considering potential comorbidities in every patient with advanced cancer, such as gastric ulcer and cachexia.

Primary squamous cell carcinoma of pancreas: a population-based study

Background

Primary squamous cell carcinoma of pancreas (SCCP) is an extremely rare pathological subtype of pancreatic cancer of ductal origin. Due to its rarity, most previous studies on SCCP focused on case reports or series and the clinio-pathological characteristics of SCCP patients remain unclear.

Methods

A retrospective analysis of SCCP patients registered in the Surveillance, Epidemiology and End Results (SEER) database from 1988 to 2016 were performed, and clinical characteristics and prognosis of these patients were also further determined.

Results

A total of 373 patients diagnosed with SCCP were identified. Most SCCP patients 154/243 (63.4%) SCCP patients had distant metastases. The prognosis of SCCP patients was poor with a median overall survival (mOS) of only 3.0 months (95% CI, 2.0-5.0). The 6-month, 1-year and 2-years survival rate were 25.6%, 13.2% and 5.7%, respectively. The prognosis of SCCP patients became much worse with the increasing age (P=0.01) and distant metastases (P<0.01). Cancer-directed surgery, chemotherapy and radiotherapy could significantly prolong the survival time for SCCP patients (P<0.01 for all). Multivariate Cox analysis showed that only distant metastases were independent prognostic factors of worse survival in SCCP patients (HR =1.58, 95% CI, 1.18-2.12). Conversely, both cancer-directed surgery and chemotherapy were an independent protective factor that decreased the risk of death by 66% (HR =0.18, 95% CI, 0.11-0.29) and 46% (HR =0.54, 95% CI, 0.43-0.68) for SCCP patients.

Conclusions

SCCP is a rare type of pancreatic malignancies with poor prognosis. The present study could provide some useful information for future management and prospective studies for SCCP patients.

One size does not fit all for pancreatic cancers: A review on rare histologies and therapeutic approaches

Exocrine pancreatic neoplasms represent up to 95% of pancreatic cancers (PCs) and are widely recognized among the most lethal solid cancers, with a very poor 5-year survival rate of 5%-10%. The remaining < 5% of PCs are neuroendocrine tumors that are usually characterized by a better prognosis, with a median overall survival of 3.6 years. The most common type of PC is pancreatic ductal adenocarcinoma (PDAC), which accounts for roughly 85% of all exocrine PCs. However up to 10% of exocrine PCs have rare histotypes, which are still poorly understood. These subtypes can be distinguished from PDAC in terms of pathology, imaging, clinical presentation and prognosis. Additionally, due to their rarity, any knowledge regarding these specific histotypes is mostly based on case reports and a small series of retrospective analyses. Therefore, treatment strategies are generally deduced from those used for PDAC, even if these patients are often excluded or not clearly represented in clinical trials for PDAC. For these reasons, it is essential to collect as much information as possible on the management of PC, as assimilating it with PDAC may lead to the potential mistreatment of these patients. Here, we report the most significant literature regarding the epidemiology, typical presentation, possible treatment strategies, and prognosis of the most relevant histotypes among rare PCs.

The impact of squamous cell carcinoma histology on outcomes in nonmetastatic pancreatic cancer

BACKGROUND

The prognosis for nonmetastatic, primary pancreatic squamous cell carcinoma (SCC) is thought to be poor compared with adenocarcinoma (AC); however, this is based on limited data. Additionally, the optimal definitive treatment strategy for nonmetastatic pancreatic SCC is unknown.

METHODS

We analyzed patients with nonmetastatic pancreatic cancer using the National Cancer Database for patients diagnosed from 2006 to 2014. Patients were analyzed according to histology-only AC, adenosquamous carcinoma (A-SCC), and SCC were included. The primary endpoint was overall survival (OS) from the time of diagnosis.

RESULTS

A total of 94 928 cases were included; 94 016 AC, 757 A-SCC, and 155 SCC. Median OS was lower for SCC (8.67 months), compared to AC (13.93 months) and A-SCC (12.71 months, P < .001). SCC was resected less often (25.5% vs 46.7% and 74.5%). On subgroup analysis of patients with pancreatic SCC, factors on multivariate analysis associated with improved survival included surgery (HR 0.19, P < .001), and chemotherapy (HR 0.22, P = .01). In 38 patients with SCC undergoing surgical resection, median OS improved (MS = 6.8 months without surgery vs 21.3 months with surgery, P < .001).

CONCLUSIONS

Nonmetastatic pancreatic SCC presents with more advanced disease, which is less often surgically resected or treated with any definitive local therapy. In contrast, AC and A-SCC behave more similarly and have higher surgical resection rates and improved survival. In patients with nonmetastatic SCC of the pancreas, surgical resection provides the most significant survival benefit, with systemic chemotherapy providing a less significant benefit, and localized radiation providing no statistical benefit for any subgroup.

Long-term survival after surgery of pancreatic primary squamous cell carcinoma: A case report and literature review

Pancreatic primary squamous cell carcinoma is rarer and no optimal treatment has been validated according to the tumor stage. The surgical resection was the only curative option. The radiotherapy or chemotherapy was performed for the other cases.

Survival and prognostic factors in patients with pancreatic squamous cell carcinoma

OBJECTIVES

Squamous cell carcinoma (SCC) of pancreas is rare entity with poorly defined prognostic factors and therapeutic outcomes. We sought to determine the overall survival (OS) and prognostic factors of patients with pancreatic SCC using National Cancer Database (NCDB) (2004-15).

METHODS

Kaplan-Meier method and log-rank test were used to perform OS analysis. Propensity-matched analysis was used to compare the OS of pancreatic SCC and adenocarcinoma.

RESULTS

Of the 515 cases included in our analysis, 46% were female. Approximately half of the cohort (48%) received chemotherapy or radiation therapy or both. Twenty six percent (33/125) of stage I and II disease (localized disease), 11% (8/72) of stage III, and 2% (6/318) of stage IV disease underwent surgical resection of the primary tumor. Median OS for the entire cohort was 4 months and was significantly higher in patients who underwent surgical resection of the primary tumor (17 vs 4 months, p < 0.001). In localized disease, adjuvant chemotherapy was not associated with improved OS in early stage disease (20 vs 24 months, p = 0.60). Stage IV patients treated with chemotherapy had a better OS than those without (5 vs 2 months, p < 0.0001). Propensity matched analysis demonstrated no significant differences in median OS between pancreatic adenocarcinoma (4.8 months) and SCC (4 months, p = 0.09).

CONCLUSIONS

Pancreatic SCC had a diverse OS that varied significantly according to increasing age (>70 years) and stage of the disease at presentation (p < 0.01). Surgical resection of primary tumor was associated with longer OS in stages I-II, whereas chemotherapy was associated with longer OS in stage IV disease.

Management of primary squamous cell carcinoma of the pancreas with a nanosomal paclitaxel lipid suspension-based regimen: A case report

Squamous cell carcinoma (SCC) of the pancreas is a rare tumor with only a few case reports available. It is an aggressive form of pancreatic cancer with a poor prognosis. The diagnosis and optimal management of SCC of the pancreas is poorly defined due to the lack of standard treatment or guidelines and owing to the rarity of this malignancy. Patients suffering from SCC of the pancreas do not respond well to chemotherapy or radiotherapy and isolated reports are available on the use of gemcitabine and newer taxane formulations. Surgical resection of the tumor is the most effective modality; however, due to a delay in diagnosis, the majority of pancreatic SCCs remain unresectable. Herein, a case of SCC of the pancreatic tail is reported in a 60-year-old patient who was managed with a combination of albumin-free nanosomal paclitaxel lipid suspension (NPLS) and gemcitabine in a neoadjuvant setting. To the best of our knowledge, this is the first such case report of a locally advanced SCC of the pancreatic tail showing an overall survival of 1 year following treatment with an NPLS based regimen. The treatment was well tolerated with no serious safety concerns.

Squamous cell carcinoma-A rare pancreatic exocrine malignancy

A 65-year-old Caucasian female presented with abdominal symptoms and obstructive jaundice. She reported a significant pancreatic cancer history in her family. Her CT of the abdomen and pelvis showed 3.9 × 3.5 cm centrally necrotic mass within the pancreatic head, occluding the superior mesenteric and splenic veins; peripancreatic lymph nodes were enlarged, and there were many hepatic lesions. She underwent biopsy of the hepatic lesions showing metastatic tumor cells, arranged in the form of nests, with enlarged and hyperchromatic irregular nuclei with some nucleoli and moderate eosinophilic cytoplasm. Immunohistochemical staining on cancer cells was positive for CK7, P40, GATA3. These findings were concerning for poorly differentiated metastatic squamous cell carcinoma (SCC). PET-CT showed no other hypermetabolic lesions, suggestive of another primary except pancreatic head with SUV of 17.8, hepatic metastasis and 1 cm right retroperitoneal lymph node. The patient was diagnosed with metastatic SCC of the pancreas. Contrary to the well-known genetic mutations of pancreatic adenocarcinoma, the data on pancreatic SCC-related mutations is limited; however, one such mutation is BRCA-2 exon 15 germline mutation reported in a locally advanced SCC of the pancreas. The index patient is one of those rare cases in which a significant family history of pancreatic cancer was reported. We believe that some familial mutation could be responsible for this finding, i.e., occurrence of pancreatic cancer in multiple family members. Further research is necessary to explore such association.

Systemic Chemotherapy for Advanced Rare Pancreatic Histotype Tumors: A Retrospective Multicenter Analysis

OBJECTIVES

Two issues were put forth by clinicians in the management of the advanced stages of rare variants of pancreatic ductal adenocarcinoma and other exocrine histotypes with peculiar clinical and pathological features: Do chemotherapy regimens recommended in pancreatic ductal adenocarcinoma patients have a clinical activity in rare pancreatic tumors? Or should other chemotherapy combinations be considered in this subset of patients?

METHODS

We conducted a multicenter retrospective study that collected data from 2005 to 2016 at 14 Italian cancer centers with the aim to evaluate tumor response and time to progression for first- and second-line and overall survival.

RESULTS

Of approximately 4300 exocrine pancreatic cancer patients, 79 advanced cases affected by rare histological types were identified, with pancreatic acinar cell cancer (n = 23), pancreatic adenosquamous cancer (n = 16), and mucinous cystic neoplasm with an associated invasive mucinous cystadenocarcinoma (n = 15) most represented. Survival analyses for each subgroup in relation with the different chemotherapy regimens showed the lack of statistical significance correlations.

CONCLUSIONS

Because of the lack of clinical trials in patients affected by these rare pancreatic histotypes, only their molecular classification would help clinicians in future therapeutic choice.

Squamous cell carcinoma of the pancreas: A systematic review and pooled survival analysis

The diagnosis and treatment of squamous cell carcinoma of the pancreas pose dilemmas in the clinical practice. The present study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible articles were sought in MEDLINE up to 30th April 2016. A pooled Cox regression analysis was performed to evaluate factors potentially associated with overall survival (OS) and relapse-free survival (RFS). Fifty-four cases of pure squamous cell pancreatic carcinomas were identified in total. The mean age was 61.9 years, and most patients were males (61.1%). The median OS was 7 months. Resectability (p = 0.003) and more recent publication year (p < 0.001) were associated with better OS, as was low/intermediate tumour grade (p = 0.032) with RFS. Despite its poor prognosis, survival rates of pancreatic squamous cell carcinoma seem improved during the recent years; resectability and low/intermediate grade emerged as favourable prognostic factors. Collaborative epidemiological studies are deemed necessary to further validate the results stemming from the published case reports of this rare entity.

Pancreatic Squamous Cell Carcinoma

Pancreatic squamous cell carcinoma (SCC) is a rare event. Here, we present a 56-year-old man with pancreatic SCC. Imaging methods demonstrated a hypodense mass at the head and trunk of the pancreas. Also, some lymphadenopathy has been seen around the pancreas and para-aorta. The mass created pressure and encasement on the celiac trunk, portal vein, and arteries of the liver and spleen. Endoscopic ultrasound showed a mass lesion of 45-37 mm (mixed echoic) at the trunk of the pancreas. Histological examination of the endoscopic ultrasound-guided fine needle aspiration specimen confirmed the diagnosis of SCC. The disease is highly aggressive, most often locally advanced or metastatic at diagnosis, and poorly responsive to treatment. It also has generally poor survival rates.

Genomic characteristics of pancreatic squamous cell carcinoma, an investigation by using high throughput sequencing after in-solution hybrid capture

Squamous cell carcinoma (SCC) of pancreas is a rare histotype of pancreatic ductal carcinoma which is distinct from pancreatic adenocarcinoma (AC). Although there are standard treatments for pancreatic AC, no precise therapies exist for pancreatic SCC. Here, we screened 1033 cases of pancreatic cancer and identified 2 cases of pure SCC, which were pathologically diagnosed on the basis of finding definite intercellular bridges and/or focal keratin peal formation in the tumor cells. Immunohistochemistry assay confirmed the positive expression of CK5/6 and p63 in pancreatic SCC. To verify the genomic characteristics of pancreatic SCC, we employed in-solution hybrid capture targeting 137 cancer-related genes accompanied by high throughput sequencing (HTS) to compare the different genetic variants in SCC and AC of pancreas. We compared the genetic alterations of known biomarkers of pancreatic adenocarcinoma in different pancreatic cancer tissues, and identified nine mutated genes in SCC of pancreas: C7orf70, DNHD1, KPRP, MDM4, MUC6, OR51Q1, PTPRD, TCF4, TET2, and nine genes (ABCB1, CSF1R, CYP2C18, FBXW7, ITPA, KIAA0748, SOD2, SULT1A2, ZNF142) that are mutated in pancreatic AC. This study may have taken one step forward on the discovery of potential biomarkers for the targeted treatment of SCC of the pancreas.

Squamous cell carcinoma of pancreas: an unusual site of relapse from early-stage lung cancer: 12-month postsurgery

A 57-year-old man presented with abdominal pain and backache, weight loss of 10 kg and irregular bowel movements. He was previously diagnosed with Stage IB squamous cell carcinoma of lung and had undergone lobectomy 12 months previously. Investigations including imaging revealed a cystic mass in the body and tail of the pancreas which was biopsied and it was confirmed to be a recurrence of the squamous lung cancer involving the pancreas. He was treated with systemic chemotherapy and has shown a partial response on repeat imaging. This case illustrates a rare and unusual site of relapse in lung cancer after adjuvant therapy and a key message for follow-up surveillance for these patients.

A case of esophageal squamous cell carcinoma with pancreatic metastasis

Solitary pancreatic metastasis of esophageal cancer is extremely rare. We report the case of a 58-year-old male admitted with esophageal cancer. Additional asymptomatic solitary hepatic and pancreatic masses were observed in the staging work-up for esophageal cancer. The hepatic mass was confirmed as a primary hepatocellular carcinoma with an ultrasound-guided needle biopsy. An esophagectomy with a distal pancreatectomy and radiofrequency ablation for hepatocellular carcinoma were performed. Histologically, the pancreatic mass was confirmed to be a metastasis from the esophageal cancer. The patient has been followed up with chemotherapy.

Primary squamous cell carcinoma of the pancreas: a case report and review of the literature

Introduction

Primary squamous cell carcinoma of the pancreas is a rare tumor with poor prognosis and is found in the literature only as case reports. The optimal management course remains poorly defined. We present a case of primary basaloid squamous cell carcinoma of the pancreas metastatic to the liver, which was treated with surgery and systemic chemotherapy. Our patient survived for 15 months: the longest survival reported in the literature to date.

Case presentation

A 70-year-old Caucasian man presented to hospital with a three-month history of weight loss, pruritus and icterus. Imaging studies confirmed the presence of an operable mass lesion in the head of the pancreas. Following a pancreaticoduodenectomy, histology results led us to make a diagnosis of squamous cell carcinoma. Postoperative restaging showed multiple metastases in the liver. He underwent palliative systemic chemotherapy with cisplatin and 5-fluorouracil achieving partial response and an excellent quality of life. He then went on to start second-line chemotherapy, but unfortunately died of sepsis soon thereafter.

Conclusions

This case report emphasizes that achievement of a worthwhile objective and symptomatic palliative response is possible using platinum-based chemotherapy in squamous cell carcinoma of the pancreas.

Mayo Clinic experience with very rare exocrine pancreatic neoplasms

OBJECTIVES

Limited data are available to guide the management of very rare exocrine neoplasms of the pancreas (VREP). Available evidence suggests that VREP have different risk factors and prognoses from those of adenocarcinoma of the pancreas. The primary objectives for this study were to determine the survival, comorbidities, and response to treatment of patients seen at Mayo Clinic with VREP.

METHODS

We reviewed patients from 1975 to 2005 who had VREP and compared them to patients with adenocarcinomas that were matched for TNM, grade, and decade of treatment.

RESULTS

Sixty-six patients with VREP were identified. The most commonly identified neoplasms were acinar cell carcinoma (n = 15), small cell carcinoma (n = 12), and squamous cell carcinoma (n = 8). Abdominal discomfort and jaundice were the most common presenting symptoms. The median overall survival for patients with VREP, 10.4 months (range, 3.7-23 months), was better than that for matched controls, 8.2 months (range, 4-15.4 months) (P = 0.01). There was no difference in the survival of patients with stage 4 disease between cases, 8 months (range, 2.3-21.8 months), and controls, 6.7 months (range, 2.3-10.8 months) (P = 0.17).

CONCLUSIONS

We present one of the largest series of VREP to date. The overall survival of all patients with VREP was better than matched controls, but no statistical difference was seen between the groups with stage 4 disease.