The diagnostic yield of colonoscopic surveillance following resection of early age onset colorectal cancer

BACKGROUND

The primary benefit of post-colorectal cancer (CRC) colonoscopic surveillance is to detect and remove premalignant lesions to prevent metachronous CRC. Current guidelines for long-term colonoscopic surveillance post early age onset CRC (EOCRC) resection are based on limited evidence. The aims of this study were to assess the diagnostic yield of colonoscopic surveillance post-EOCRC resection and identify molecular and clinicopathological risk factors associated with advanced neoplasia.

METHODOLOGY

A retrospective cohort study of prospectively collected data was conducted at St Mark's hospital, London, United Kingdom, for patients diagnosed with EOCRC who underwent at least one episode of post-CRC colonoscopic surveillance between 1978 and 2022. We collected clinicopathological data including tumour molecular status and neoplasia detection rates.

RESULTS

In total, 908 colonoscopic surveillance procedures were performed in 195 patients over 2581.3 person-years of follow-up. The diagnostic yields of metachronous CRC, advanced adenomas and non-advanced adenomas were 1.76%, 3.41% and 22.69% respectively. Sixteen patients (8.21%) developed metachronous CRC, and the majority (87.5%) were detected more than 3 years post index EOCRC diagnosis. Detection of advanced neoplasia was significantly higher in EOCRC patients with Lynch syndrome (26.15%) compared with those in whom Lynch syndrome was excluded (13.13%) (OR, 2.343; 95% CI, 1.014-5.256; p = 0.0349).

CONCLUSIONS

During colonoscopic surveillance post-EOCRC resection, the long-term risk of developing metachronous advanced neoplasia remains high in the context of Lynch syndrome, but this trend is not as clearly evident when Lynch syndrome has been excluded.

Tomotherapy in synchronous and metachronous bilateral breast cancer: Clinical experience

PURPOSE OF STUDY

The objective of this research is to present our firsthand experience and provide up-to-date data for the further study of cases involving simultaneous breast irradiation using helical Tomotherapy, ©Accuray Inc.

METHODS

The radical treatment options for bilateral breast cancer are surgery, chemotherapy, and radiation therapy. Being that radiotherapy for bilateral breast cancer is challenging due to limitations in the geometry of modern radiotherapy equipment, helical Tomotherapy was chosen as an appropriate technique of irradiation. The retrospective review focused on the records of patients who underwent bilateral irradiation of the breast or chest wall and regional lymph nodes using helical Tomotherapy.

RESULTS

Only four patients with bilateral breast cancer completed a radiation therapy course in our center from 2018 to 2023. Two patients underwent radical mastectomy with lymph node dissection on both sides before irradiation. For the other two patients, radical mastectomy was done after neoadjuvant chemotherapy. Acute radiation toxicity scoring was based on Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Only mild adverse effects, such as general weakness and slight skin irritation below Grade 3, were observed, with no instances of skin swelling, dryness, or pigmentation noted. Evaluation of late complications revealed tissue fibrosis in the area of the internal mammary nodes and respiratory failure with various severity. Complications and deterioration in the cardiovascular system were not observed during the follow-up period, which varied from 3 to 48 months.

CONCLUSION

Our results show the efficacy of using helical Tomotherapy considering positive outcomes, being that three out of four patients are in remission with low acute toxicity and late complications. There are a small number of articles describing bilateral breast cancer treatment with helical Tomotherapy. On this occasion, our data could contribute to the studies of tolerant doses for organs at risk and improve the parameters of treatment plans for bilateral breast cancer. Since the small sample of patients with bilateral breast cancer limits the study, a larger cohort of patients is essential to obtain statistically reliable results.

Associations between pathological features and risk of metachronous colorectal cancer

Survivors of colorectal cancer (CRC) are at risk of developing another primary colorectal cancer - metachronous CRC. Understanding which pathological features of the first tumour are associated with risk of metachronous CRC might help tailor existing surveillance guidelines. Population-based CRC cases were recruited from the United States, Canada and Australia between 1997 and 2012 and followed prospectively until 2022 by the Colon Cancer Family Registry. Metachronous CRC was defined as a new primary CRC diagnosed at least 1 year after the initial CRC. Those with the genetic cancer predisposition Lynch syndrome or MUTYH mutation carriers were excluded. Cox regression models were fitted to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for the associations. Of 6085 CRC cases, 138 (2.3%) were diagnosed with a metachronous CRC over a median follow-up time of 12 years (incidence: 2.0 per 1000 person-years). CRC cases with a synchronous CRC were 3.4-fold more likely to develop a metachronous CRC (adjusted HR: 3.36, 95% CI: 1.89-5.98) than those without a synchronous tumour. CRC cases with MMR-deficient tumours had a 72% increased risk of metachronous CRC (adjusted HR: 1.72, 95% CI: 1.11-2.64) compared to those with MMR-proficient tumours. Compared to cases who had an adenocarcinoma histologic type, those with an undifferentiated histologic type were 77% less likely to develop a metachronous CRC (adjusted HR: 0.23, 95% CI: 0.06-0.94). Existing surveillance guidelines for CRC survivors could be updated to include increased surveillance for those whose first CRC was diagnosed with a synchronous CRC or was MMR-deficient.

A Rare Presentation of Lymph Node Metastasis of VIPoma After Three Years of Resection: A Case Report

Vasoactive intestinal peptide-producing tumor of the pancreas (VIPoma) is one of the rarer subtypes of neuroendocrine tumor (NET) of the pancreas. It usually represents intractable diarrhea, weight loss, and electrolyte abnormalities secondary to diarrhea. The most common site of metastasis of VIPoma is the liver. Furthermore, lymph node metastasis (LNM) is rare, and no metachronous LNM with a resectable situation has been reported before. A 60-year-old male patient (height: 181 cm, body weight: 74 kg) with a history of operated pancreatic VIPoma three years ago was referred to our department due to the detection of lymphadenomegaly which was suggestive of lymph node metastasis by routine follow-up computed tomography (CT). Preoperative CT showed a lymph node on the left side of the abdominal aorta and caudal side of the left renal vein with a size of 1 cm. Lymphadenectomy was performed without significant complications and blood loss. This is the first report of metachronous LNM in a patient with operated VIPoma. Although much rarer than solid organ metastasis of VIPoma, LNM in these patients can also be seen synchronously and metachronously. Close follow-up and vigilance are key to preventing recurrence-related morbidity and mortality in these patients.

Metachronous Primary Lung Cancer Occurring during the Spontaneous Regression of Locally Advanced Lung Cancer: A Rare Case Report

A 71-year-old man was diagnosed as having right primary lung squamous cell carcinoma, clinical stage IIIA, but he refused treatment. However, the right upper lobe nodule and lymph node (LN) #4R showed gradual shrinking without treatment. Four years after the diagnosis, a new nodule was detected in the left lung field. We considered that this new nodule might be metachronous primary lung cancer, and hence resected it for diagnosis and treatment. The tumor in the left lung was diagnosed as basaloid squamous cell carcinoma, and that in LN #4R was diagnosed as squamous cell carcinoma with keratinization. Therefore, the patient was diagnosed as having metachronous primary lung cancer that developed during the spontaneous regression of locally advanced lung cancer.

A case of immunoglobulin G4-related retroperitoneal fibrosis and hypophysitis with antecedent respiratory disease followed by spontaneous remission and recurrence

A 65-year-old man presented with apparent bronchopneumonia. After treatment with antibiotics, he showed eosinophilia. Computed tomography (CT) imaging revealed bilateral consolidation, ground-glass opacities with nodular consolidations, and pleural effusion. Lung biopsy showed organising pneumonia with lymphoplasmacytic infiltration in the alveolar septa and in the thickened pleura and interlobular septa. All pulmonary abnormalities spontaneously went into remission within 12 months. At 73 years old, a follow-up CT scan revealed small nodules in both lungs and the review of the head CT scan showed thickening of the pituitary stalk in studying prolonged headache. Two years later, he visited the hospital complaining of severe oedema on the lower extremities with high serum immunoglobulin (Ig)G4 186 mg/dl. A whole-body CT scan showed retroperitoneal mass surrounding aortic bifurcation and compressing inferior vena cava, pituitary stalk thickening and gland swelling, and enlarged pulmonary nodules. Anterior pituitary stimulation tests showed central hypothyroidism, central hypogonadism, and adult growth hormone deficiency with partial primary hypoadrenocorticism. Retroperitoneal mass biopsy showed storiform fibrosis and obliterative phlebitis with marked lymphoplasmacytic infiltration with moderate IgG4-positivity. Immunostaining of the former lung specimen revealed dense interstitial infiltration of IgG4-positive cells. These findings indicated metachronous development of IgG4-related disease in lung, hypophysis, and retroperitoneum, according to the recent comprehensive diagnostic criteria of IgG4-related disease. Glucocorticoid therapy ameliorated oedema, on the other hand, unmasked partial diabetes insipidus at the initial dose of the treatment. Hypothyroidism and retroperitoneal mass regressed at 6 months of the treatment. This case warns us that long-term follow-up from prodromal to remission is necessary for the treatment of IgG4-related disease.

Synchronous Malignancies: Pathological Analysis of Three Patients, Each with Dual Malignancies

Multiple primary malignancies are defined as two or more malignancies arising independently to each other in the same or different anatomical sites, while excluding the possibility of metastasis from the primary malignancy. Here, we present three cases, each with dual malignancies involving different anatomical locations.

Deciphering the Patterns of Dual Primary Cases Registered at the Hospital-Based Cancer Registry: First Experience from Rural Cancer Center in North India

Objectives  The objective is to present the patterns of dual primary malignancies diagnosed at the Pathology Laboratory of Cancer Hospital with the support from hospital-based cancer registry (HBCR), Sangrur, Punjab, India for the years 2018 and 2019. Methods  HBCR abstracts data from electronic medical records. Trained cancer registry staff abstracts cases in standard pro forma. Dual primary was coded as per the International Agency for Research on Cancer rule and was rechecked by the pathologist. Statistical Analysis  Data about multiple primary was entered and documented in an Excel sheet. Time interval was calculated by subtracting the date of diagnosis for second primary and first primary. Results  A total of 6,933 cases were registered, 45 cases are dual primary (26 females, 19 males) of which 64.4% are synchronous and 35.6% metachronous cases. Seventy-nine percent received cancer-directed treatment for synchronous and 87% for metachronous. The most common sites of the primary tumor were breast (33%), head and neck (22.2%), gynecological sites (11%), prostate (9%), esophagus (4%), and remaining other tumors (20.8%). Most common sites for second malignancies were gastrointestinal (GI) tract (31%), gynecological sites (18%), head and neck (16%), hematological malignancies (7%), soft tissue sarcoma (4%), breast (2%), and other sites (22%). Conclusion  More than 70% of cases of primary tumors were in breast, head and neck, gynecological, and prostate. Of these, more than 60% of the second malignancy was found in the GI tract, gynecological, and head and neck sites. Around two-thirds of dual tumors are synchronous. Breast cancer cases have higher incidence of second malignancy. Regular follow-up is necessary to assess the survival of the second primary.

IDH-negative chondrosarcoma with metachronous dedifferentiation only in the metastatic site-A diagnostic pitfall

Dedifferentiated chondrosarcoma is a subtype of chondrosarcoma with a biphasic histological appearance of a chondrosarcoma component transitioning to a high-grade, noncartilaginous sarcoma. It is particularly difficult to confirm the diagnosis when a sarcoma lacking cartilaginous component occurs at a distant location from the primary lesion. The patient was a 72-year-old woman with multiple lesions in the pelvis, lungs, and liver, 18 months after resection of grade 2 central chondrosarcoma of the sternum. Imaging showed no cartilage component in any location. Although a needle biopsy from the pelvic region confirmed the diagnosis as high-grade sarcoma without a cartilage component, it was difficult to distinguish between a new primary sarcoma and metachronous metastatic lesions from patient's known prior dedifferentiated chondrosarcoma. We therefore performed a comparative molecular analysis by whole-exome sequencing of the biopsy sample and the resected sternal central chondrosarcoma. Both lesions had no IDH1/2 mutations but shared 19 somatic mutations and wide-range chromosomal losses, indicating similar origin. This case illustrates the challenge is coupling a diagnosis of metastatic dedifferentiated chondrosarcoma when no chondroid component is evident. Our study also highlights the benefit of genomic analysis in this differential diagnosis, especially in the context of dedifferentiated chondrosarcoma lacking IDH1/2 mutations.

The potential of exome sequencing of paired colorectal tumors and synchronous liver metastases to improve treatment

Tweetable abstract Sequencing exomes of synchronous and metachronous liver metastases of colorectal cancer has potential to enhance treatment, since they can have molecular profiles distinct from primary tumors.

Transcriptomic and clinical heterogeneity of metastatic disease timing within metastatic castration-sensitive prostate cancer

BACKGROUND

Metastatic castration-sensitive prostate cancer (mCSPC) is commonly classified into high- and low-volume subgroups which have demonstrated differential biology, prognosis, and response to therapy. Timing of metastasis has similarly demonstrated differences in clinical outcomes; however, less is known about any underlying biologic differences between these disease states. Herein, we aim to compare transcriptomic differences between synchronous and metachronous mCSPC and identify any differential responses to therapy.

PATIENTS AND METHODS

We performed an international multi-institutional retrospective review of men with mCSPC who completed RNA expression profiling evaluation of their primary tumor. Patients were stratified according to disease timing (synchronous versus metachronous). The primary endpoint was to identify differences in transcriptomic profiles between disease timing. The median transcriptomic scores between groups were compared with the Mann-Whitney U test. Secondary analyses included determining clinical and transcriptomic variables associated with overall survival (OS) from the time of metastasis. Survival analysis was carried out with the Kaplan-Meier method and multivariable Cox regression.

RESULTS

A total of 252 patients were included with a median follow-up of 39.6 months. Patients with synchronous disease experienced worse 5-year OS (39% versus 79%; P < 0.01) and demonstrated lower median androgen receptor (AR) activity (11.78 versus 12.64; P < 0.01) and hallmark androgen response (HAR; 3.15 versus 3.32; P < 0.01). Multivariable Cox regression identified only high-volume disease [hazard ratio (HR) = 4.97, 95% confidence interval (CI) 2.71-9.10; P < 0.01] and HAR score (HR = 0.51, 95% CI 0.28-0.88; P = 0.02) significantly associated with OS. Finally, patients with synchronous (HR = 0.47, 95% CI 0.30-0.72; P < 0.01) but not metachronous (HR = 1.37, 95% CI 0.50-3.92; P = 0.56) disease were found to have better OS with AR and non-AR combination therapy as compared with monotherapy (P value for interaction = 0.05).

CONCLUSIONS

We have demonstrated a potential biologic difference between metastatic timing of mCSPC. Specifically, for patients with low-volume disease, those with metachronous low-volume disease have a more hormone-dependent transcriptional profile and exhibit a better prognosis than synchronous low-volume disease.

Solitary metachronous adrenal metastasis after radical resection of gastric large cell neuroendocrine carcinoma: a case report and literature review

Surgical resection is rarely employed for the treatment of metastatic gastric cancer, especially in patients with adrenal metastases, which usually indicate advanced systemic dissemination. Few published case reports have thus described the use of adrenalectomy for adrenal metastases from gastric cancer. In addition, most primary gastric malignancies are gastric adenocarcinomas, and gastric large cell neuroendocrine carcinoma (GLCNEC) is less common and has a poor prognosis. We report the case of a 71-year-old man who was diagnosed with solitary adrenal metastases 10 months after radical resection for GLCNEC and who was treated by adrenalectomy. He was followed-up for 9 months after adrenalectomy, with no further evidence of disease at his last follow-up examination. This case indicates that elective surgical resection may be feasible, even in rare cases of GLCNEC metastases to the adrenal glands, provided that the patient meets certain criteria, including solitary, metachronous tumors less than 4 cm.

Bilateral metachronous breast malignancies: Malignant phylloides and invasive breast carcinoma-a case report

A 57-year-old Malay nullipara initially presented with a right breast lump that was increasing in size but defaulted follow-up. Two years later, she developed a contralateral breast lump. She only returned to the hospital when the right breast lump had become painful, 4 years from its onset. The biopsy of the right breast lump was a phylloides tumor and that of the left breast lump was a carcinoma. She had bilateral palpable axillary lymph nodes. She underwent bilateral mastectomy and axillary dissection. The pathology report confirmed the right breast lesion to be a malignant phylloides and the left breast lesion to be a carcinoma (pT3N2). She declined adjuvant treatment. A year after the surgical operation of the metachronous lesions, she had a right chest wall recurrence with widespread pulmonary metastases. She was given palliative chemotherapy but succumbed several months later.

Risk of metachronous contralateral breast cancer in patients with primary invasive lobular breast cancer: Results from a nationwide cohort

Lobular primary breast cancer (PBC) histology has been proposed as a risk factor for contralateral breast cancer (CBC), but results have been inconsistent. We investigated CBC risk and the impact of systemic therapy in lobular versus ductal PBC. Further, CBC characteristics following these histologic subtypes were explored. We selected 74,373 women diagnosed between 2003 and 2010 with stage I-III invasive PBC from the nationwide Netherlands Cancer Registry. We assessed absolute risk of CBC taking into account competing risks among those with lobular (n = 8903), lobular mixed with other types (n = 3512), versus ductal (n = 62,230) histology. Hazard ratios (HR) for CBC were estimated in a cause-specific Cox model, adjusting for age at PBC diagnosis, radiotherapy, chemotherapy and/or endocrine therapy. Multivariable HRs for CBC were 1.18 (95% CI: 1.04-1.33) for lobular and 1.37 (95% CI: 1.16-1.63) for lobular mixed versus ductal PBC. Ten-year cumulative CBC incidences in patients with lobular, lobular mixed versus ductal PBC were 3.2%, 3.6% versus 2.8% when treated with systemic therapy and 6.6%, 7.7% versus 5.6% in patients without systemic therapy, respectively. Metachronous CBCs were diagnosed in a less favourable stage in 19%, 26% and 23% and less favourable differentiation grade in 22%, 33% and 27% than the PBCs of patients with lobular, lobular mixed and ductal PBC, respectively. In conclusion, lobular and lobular mixed PBC histology are associated with modestly increased CBC risk. Personalised CBC risk assessment needs to consider PBC histology, including systemic treatment administration. The impact on prognosis of CBCs with unfavourable characteristics warrants further evaluation.

Treatment strategies to resectable metachronous colorectal liver metastases after adjuvant oxaliplatin-based chemotherapy for primary colorectal cancer

BACKGROUND

outcome of patients who develop resectable metachronous colorectal liver metastases (CLM) after adjuvant oxaliplatin-based chemotherapy for Stage III colorectal cancer (CRC) is not well defined and the value of preoperative chemotherapy is controversial.

METHODS

From 2006 to 2013, all patients undergoing liver resection for Class I metachronous CLM after adjuvant oxaliplatin-based chemotherapy for CRC, across 32 French academic centers, were included.

RESULTS

Sixty-two patients with an average of 2 ± 1 CLM were included. Thirty-two (52%) patients received preoperative chemotherapy. There was no significant difference in the characteristics of CLM between patients with or without preoperative chemotherapy. After a median follow-up of 29 months, 3-year overall and disease-free survival rates were 79.8% and 34.6%, respectively. The median disease-free survival was not different in patients with or without preoperative chemotherapy (17 vs. 35 months respectively, p = 0.112). In multivariate analysis, only CEA level > 200 ng/ml was associated with the risk of recurrence (p = 0.027; OR = 4.7, 95% CI = 1.2-18.7).

CONCLUSION

Liver resection provides a good outcome in patients with limited metachronous CLM after adjuvant oxaliplatin-based chemotherapy for CRC. The interest of preoperative chemotherapy is not obvious and should be tested in a prospective controlled study.

Aspirin Use Is Not Associated with the Risk of Metachronous Gastric Cancer in Patients without Helicobacter pylori Infection

Introduction: Helicobacter pylori (H. pylori) eradication can prevent metachronous gastric cancer (MGC) after the performance of an endoscopic resection for early gastric cancer (EGC). However, 50% of infections persist after eradication, and the identification of MGC protective factors is important. The anti-tumor activity of aspirin has been demonstrated, but its efficacy in preventing MGC remains controversial. We evaluated the effect of aspirin on metachronous recurrence in H. pylori-negative patients. Methods: A total of 4351 patients were evaluated between January 2007 and December 2016, and 2151 patients who met the inclusion criteria were analyzed. The primary outcome was the cumulative incidence of MGC after an endoscopic resection for EGC. Results: During a 5-year median follow-up (interquartile range, 3.5–6.2), MGC developed in 176 (7.7%) patients, with a cumulative incidence of 89.4% in aspirin users and 92.7% in non-users; this difference was not statistically significant (p = 0.64). The duration of aspirin uses and the occurrence of MGC in both groups were not significantly different. There was no significant difference between groups when the duration of aspirin use was categorized into ≤1 year (hazard ratio (HR), 0.64; 0.20–2.01, p = 0.45), 1–4 years (HR, 1.35; 0.66–2.76, p = 0.41), and >4 years (HR, 1.17; 0.67–2.03, p = 0.58). Conclusions: Aspirin use was not associated with a lower risk of MGC in H. pylori-negative patients. Further prospective studies are needed.

Utility of exome sequencing in routine care for metastatic colorectal cancer

Metastatic colorectal cancer (mCRC) is a heterogenous disease and its prognosis depends on clinical features, such as tumor sidedness, and whether it is metachronous or synchronous. However, little is known about the overall genomic characterization of mCRC in these clinical subtypes. This single-center observational study included 77 patients with mCRC who underwent somatic and germline exome analysis during the first or second line of therapy in 2018. Somatic and germline variants were determined in addition to tumor mutational burden, ploidy, clonality, human leucocyte antigen typing, neoantigens, and mutational and copy number signatures. Variables associated with sidedness, synchronous status and RAS status were determined using Fisher's test; and variables associated with overall survival were determined using univariate Cox survival models. The present study successfully generated whole exome sequencing analysis in 77 mCRC cases. Among them, 50 were left- and rectal-sided, while 27 were right-sided. Furthermore, 27 were metachronous and 46 were RAS-mutated. The median OS was 3.75 years. It was observed that signature single nucleotide variation (SNV) 26, oncogenic alterations in receptor tyrosine kinase and nucleotide excision repair pathways were associated with tumor sidedness. SNV signature 3, Hedgehog signaling and mismatch repair pathways were associated with synchronous status. Phosphatidylinositol signaling system, ERK signaling and chromatin organization pathways were associated with RAS mutant status. In the whole cohort, metachronous metastasis was associated with improved survival. On gene variation, PTEN, PDGFRA, MYCN and SMAD4 were associated with poor prognosis, as was SNV signature 15. In conclusion, this study highlighted that structural and pathway genomic features are associated with sidedness, synchronous status, RAS status and overall survival and could be helpful to improve the stratification of patients with colorectal cancer.

An Unusual and Rare Metachronous Ipsilateral Ureteric Stump Metastasis Post Radical Nephrectomy

We report a case of recurrence of chromophobe renal cell cancer in the ipsilateral ureteric stump eight years later after the primary tumor was excised successfully. Before this detection of the recurrence, the patient had presented with recurrent episodes of hematuria four years after the radical nephrectomy was performed and the investigations were inconclusive. Eventually, the lesion was detected on flexible cystoscopy in the area of the right ureteric orifice protruding in the bladder. Transurethral resection of the tumor surprisingly revealed a chromophobe renal cancer with similar features seen in the primary tumor specimen. The patient underwent robotic-assisted laparoscopic excision of the ureteric stump with a cuff of the bladder and has been recurrence-free for five years on regular surveillance scans.

Metachronous small bowel adenocarcinoma after rectal adenocarcinoma: A case report

RATIONALE

Small bowel adenocarcinoma (SBA), an uncommon gastrointestinal malignant tumor, is difficult to diagnose at an early stage because of its non-specific disease presentation. Metachronous SBA is a special type of SBA that is rarely reported. We herein report a case of metachronous primary SBA following resection of rectal adenocarcinoma.

PATIENT CONCERNS

A 65-year-old man presented to our hospital after having experienced recurrent bowel obstruction for 6 months. He had undergone a Dixon operation 30 months previously followed by adjuvant chemotherapy with capecitabine plus oxaliplatin.

DIAGNOSIS

Abdominal computed tomography showed thickened bowel walls in the right lower abdomen, and the patient was initially misdiagnosed with intestinal adhesion. After the operation, he was diagnosed with primary SBA (T3N0M0, stage IIA).

INTERVENTIONS

Treatment with a transnasal ileus tube was ineffective. Therefore, we performed small intestinal segmental resection and side-to-side anastomosis through open surgery.

OUTCOMES

The patient completed all postoperative adjuvant chemotherapy, and posttreatment surveillance revealed no further abnormalities.

LESSONS

This case suggests that patients with colorectal adenocarcinoma may have an increased risk of metachronous SBA. Corresponding symptoms in high-risk patients should raise clinicians' suspicion for SBA, and further detailed examinations are imperative. Early screening for SBA may help to improve the patients' prognosis.

Risk Factors for Metachronous Isolated Peritoneal Metastasis after Preoperative Chemotherapy and Potentially Curative Gastric Cancer Resection: Results from the CRITICS Trial

Simple Summary

Around 20% of gastric cancer patients develop peritoneal metastasis after preoperative chemotherapy and curative surgery. Patients with peritoneal metastasis as a single site of metastasis may potentially benefit from prophylactic strategies. In this post-hoc analysis of the international phase III CRITICS trial, we aim to identify factors that can distinguish patients at high risk for developing peritoneal metastasis as a single site. Diffuse or mixed histological subtype, tumors with serosal involvement (ypT4) and advanced lymph node stage (ypN3 or a tumor positive lymph node ratio >20%) were independent risk factors for isolated peritoneal metastasis after preoperative chemotherapy and curative surgery. The combination of these risk factors identifies a subgroup that may benefit from treatment strategies that aim to prevent peritoneal metastasis.

Abstract

Gastric cancer (GC) patients at high risk of developing peritoneal metastasis (PM) as a single site of metastasis after curative treatment may be candidates for adjuvant prophylactic strategies. Here we investigated risk factors for metachronous isolated PM in patients who were treated in the CRITICS trial (NCT00407186). Univariable and multivariable analyses on both metachronous isolated PM and ‘other events’, i.e., (concurrent) distant metastasis, locoregional recurrence or death, were performed using a competing risk model and summarized by cumulative incidences. Isolated PM occurred in 64 of the 606 (11%) included patients. Diffuse or mixed histological subtype, ypT4 tumor stage and LN^high (ypN3 lymph node stage or a lymph node ratio >20%) were independent risk factors for isolated PM in both univariable and multivariable analyses. Likewise, LN^high was an independent risk factor for ‘other events’. Patients with tumors who were positive for all three independent risk factors had the highest two-year cumulative incidence of 43% for isolated PM development. In conclusion, diffuse or mixed histological subtype, ypT4 and LN^high were identified as independent risk factors for isolated PM in patients treated with preoperative chemotherapy followed by surgical resection. The combination of these factors may identify a subgroup that may benefit from PM-preventing treatment strategies.

Bilateral breast cancer in China: A 10-year single-center retrospective study (2006-2016)

Bilateral breast cancer (BBC) is an uncommon subset of breast cancer (BC), and it may present as synchronous bilateral breast cancer (sBBC) or metachronous bilateral breast cancer (mBBC). Through this study, we aimed to evaluate the proportion of BBC in BC and compare the clinicopathological characteristics, treatment, and outcomes of sBBC and mBBC at an academic cancer center in China. Patients with BC consecutively treated between 2006 and 2016 were retrospectively reviewed. Patients with BBC were included. In total, 3924 patients with BC were analyzed and 127 patients with BBC (28 sBBC, 99 mBBC) with a median follow-up of 98 months were identified. The proportion of BBC was 3.2% (0.7%, sBBC; 2.5%, mBBC). The median age at the first diagnosis of mBBC was significantly younger than that at the first diagnosis of sBBC (p = 0.027). Patients diagnosed as having sBBC were more likely to have a positive family history (p = 0.047). The first tumors of mBBC were detected at a significantly earlier tumor stage compared with those of sBBC (p = 0.028). The concordance rates of histopathologic type in the first and second tumors were 60.7% and 58.0% in sBBC and mBBC, respectively. sBBC had a significantly poorer disease-free survival than mBBC did (p = 0.001). BBC is a rare disease affecting the Chinese population. sBBC is associated with a greater prevalence of a family history of breast cancer and poorer prognosis, compared with mBBC.

Synchronous Metastatic Clear Cell Renal Cell Carcinoma to the Gallbladder With Metachronous Contralateral Recurrence

Renal cell carcinoma (RCC) classically metastasizes to the lungs, bones, adrenals, lymph nodes, liver, and brain. RCC metastasis to the gallbladder is rare occurring in less than 1% of metastases. We present a case of a 60-year-old male who at initial diagnosis of his large left renal mass was incidentally found to have a gallbladder mass. He underwent simultaneous open radical nephrectomy and cholecystectomy with pathology confirming solitary metastatic clear cell RCC (ccRCC). The patient chose surveillance and was without evidence of disease for three years. At three years, imaging showed a 2 cm contralateral renal mass which was cryoablated percutaneously. This case demonstrates not only the importance of a thorough review of initial and surveillance imaging but also of maintaining a broad differential for other solid organ masses in the setting of a primary RCC of the kidney.

A narrative review of oligometastatic prostate cancer-an evolving paradigm

There has been growing interest in oligometastatic prostate cancer (OMPC) with a mounting body of evidence to suggest that it is a distinct disease state, both biologically and prognostically, when compared to polymetastatic prostate cancer. Three subgroups have been recognised; de novo synchronous, metachronous/oligorecurrent and oligoprogressive disease. The belief that patients with OMPC can be treated more aggressively to improve survival is transforming patient care. Identifying these patients poses the first challenge, and we explore the imaging modalities currently utilised and those that are promising. For patients with de novo synchronous OMPC, both early systemic treatment in addition to androgen deprivation therapy (ADT) and radiotherapy to the prostate increase overall survival (OS), and both are increasingly being integrated into routine clinical practice. Metastasis-directed therapy (MDT) has predominantly been delivered using stereotactic body radiotherapy (SBRT) in prostate cancer and studies have shown SBRT is well-tolerated, provides excellent local control and can be used to delay ADT in the metachronous setting. We discuss the current management strategies in OMPC, review the evidence supporting the use of SBRT and outline ongoing trials.

Oral multicentric carcinoma arising from four different sites in a female patient

This report discusses a case of a 75-year-old female patient with metachronous multicentric carcinomas in the oral cavity at 4 different sites. In this patient, there were no generally associated characteristics, such as drinking alcohol, chewing betel quid or smoking cigarettes. However, her elder sister died due to oral carcinoma. Although well-known risk factors for oral carcinoma were not detected, a previous family history was found. These findings suggest the potential for an unknown genetic anomaly associated with oral carcinoma. This is the first report to describe a female patient with oral multicentric carcinoma arising from four different sites.

Timing of Development of Symptomatic Brain Metastases from Non-Small Cell Lung Cancer: Impact on Symptoms, Treatment, and Survival in the Era of Molecular Treatments

Simple Summary

In order to clarify whether an early development of brain metastases from non-small cell lung cancer represents a poor prognostic factor for further survival we analyzed 377 patients with brain metastases, treated by radiosurgery or surgery at two German institutions. Our results show that an early appearance of brain metastasis does not influence further survival in a comprehensive treatment setting.

Abstract

Objective: We attempted to analyze whether early presentation with brain metastases (BM) represents a poor prognostic factor in patients with non-small cell lung cancer (NSCLC), which should guide the treatment team towards less intensified therapy. Patients and methods: In a retrospective bi-centric analysis, we identified patients receiving surgical treatment for NSCLC BM. We collected demographic-, tumor-, and treatment-related parameters and analyzed their influence on further survival. Results: We included 377 patients. Development of BM was precocious in 99 (26.3%), synchronous in 152 (40.3%), and metachronous in 126 (33.4%) patients. The groups were comparable in terms of age (p = 0.76) and number of metastases (p = 0.11), and histology (p = 0.1); however, mutational status significantly differed (p = 0.002). The precocious group showed the worst clinical status as assessed by Karnofsky performance score (KPS) upon presentation (p < 0.0001). Resection followed by postoperative radiotherapy was the predominant treatment modality for precocious BM, while in syn- and metachronous BM surgical and radio-surgical treatment was balanced. Overall survival (OS) did not differ between the groups (p = 0.76). A good postoperative clinical status (KPS ≥ 70) and the application of any kind of adjuvant systemic therapy were independent predictive factors for OS. Conclusion: Early BM presentation was not associated with worse OS in NSCLC BM patients.

A Rare Incidence of Metachronous Neurovascular Lesions in a Child

Neurofibroma is an uncommon benign tumor arising from nerve sheath fibroblasts. The diagnosis of solitary lesions becomes difficult in patients who do not have any family history of neurofibroma. An intra-oral solitary neurofibroma comprises 6.5% of reported cases of neurofibroma. Few cases of intraosseous solitary neurofibroma have been published as per literature. Treatment-surgical resection of tumor has an excellent prognosis with extreme rare malignant transformation which is more commonly seen in neurofibromatosis. A periodic follow-up is necessary in solitary tumors to rule out syndromic cases. Leiomyoma is a benign tumor of smooth muscle origin, which is usually diagnosed in the gastrointestinal tract, uterus, and skin. The most effective treatment for solid, vascular, and epithelioid angioleiomyomas is surgical resection along with tumor capsule. Here we report an uncommon occurrence of multiple benign tumors in a pediatric patient.

Metachronous Brain Metastasis in patients with EGFR-mutant NSCLC indicates a worse prognosis

Purpose: NSCLC patients with EGFR mutation were associated with high incidence of brain metastasis (BM). BM could be grouped by the time of occurrence, including synchronous BM at initial diagnosis and metachronous BM during disease course. The primary aim of the study was to investigate the survival of patients with metachronous BM.

Methods: A total of 99 EGFR-mutant advanced NSCLC patients in our institute between 2012 and 2018 were grouped into synchronous BM and metachronous BM. Comparisons of OS were performed based on BM status. The independent prognostic factors of OS were investigated, and extracranial and intracranial PFS were further analyzed.

Results: Patients with metachronous BM (mOS: 22.1 months) had poorer outcomes than synchronous BM (mOS: 30.3 months) (P=0.016). Moreover, multivariate analysis indicated that BM status (P=0.015), local therapy for BM (P=0.013) and subsequent treatment of Osimertinib (P=0.008) impact significantly on OS. Significantly, the proportion of local therapy for BM had no difference between patients with synchronous and metachronous BM. And patients with metachronous BM harbored a more favorable prognostic factor (higher proportion of subsequent Osimertinib treatment), but also harbored a poorer prognostic factor (metachronous BM), which confirmed BM status was the most significant prognostic factor of OS. At last, results of extracranial and intracranial PFS indicated that patients with metachronous BM tended to have a higher risk of intracranial disease progression.

Conclusions: Patients developing metachronous BM during EGFR-TKIs treatment have worse outcomes than synchronous BM. Our findings suggested that the patients with metachronous BM should receive more aggressive treatments.

Distinguishing multiple lung primaries from intra-pulmonary metastases and treatment implications

INTRODUCTION

The distinction between multiple primary lung cancers and intra-pulmonary metastases has been extensively investigated because of its important clinical and therapeutic implications.

AREAS COVERED

Rapidly improving imaging technology and genomic analysis has led to a finer discrimination between multiple primary lung tumors and pulmonary metastases. However, over the past few decades, standardized criteria for the identification of multiple lung tumors have been lacking. Therefore, in 2017 a multidisciplinary international committee composed of the Union for International Cancer Control (UICC), American Joint Committee on Cancer (AJCC) and International Association for the Study of Lung Cancer (IASLC) addressed this problem when drawing up the 8th edition of TMN stage classification, that now represents a specific consensus on this topic. The most advanced diagnostic strategies associated with screening allow for the detection of early stage synchronous lung cancers.

EXPERT OPINION

Although diagnostic confirmation relies on pathologic and clinical examination, new molecular analyses help in the discrimination between primary and secondary tumors. The treatment of multiple primary lung tumors remains, whenever possible, a local treatment based on surgical resection, providing the absence of distant or local (lymph node) metastases.

Late-onset distant metastases confer poor prognosis in patients with well-differentiated thyroid cancer

Background

Distant metastases from well-differentiated thyroid carcinoma (WDTC) occasionally occur over a wide range of time intervals after primary thyroid surgery. The prognostic impact of the timing of distant metastasis onset remains unclear.

Methods

We retrospectively reviewed the clinicopathologic features and clinical outcomes of 57 patients with WDTC and distant metastases, and evaluated the mutational profiles of BRAF, RAS, and TERT promoter genes. All patients underwent thyroidectomy and radioactive iodine (RAI) ablation using the same treatment protocol. Synchronous distant metastases were defined as those detected within 12 months of the primary WDTC diagnosis. Metachronous metastases were considered early- and late-onset diseases if detected 1-5 and ≥5 years after the primary diagnosis, respectively.

Results

In all patients, the 5- and 10-year cancer-specific survival (CSS) rates after the diagnosis of distant metastasis were 86% and 57%, respectively. Late-onset (≥5 years) metachronous distant metastasis was associated with age of ≥55 years (P=0.043) and patients refractory to RAI therapy (P=0.026). TERT promoter mutations were associated with RAI refractivity (P=0.026). BRAF V600E and RAS mutations had no prognostic significance. Bone metastasis (P=0.002) and the onset time of distant metastasis (P=0.004) were associated with poor CSS. There was no significant difference in CSS between patients with synchronous distant metastases and those with early-onset (1-5 years) metachronous distant metastases. In the multivariate analysis, bone metastasis [hazard ratio (HR) =10.24; 95% confidence interval (CI): 1.25-83.74; P=0.030] and late-onset (≥5 years) metachronous distant metastasis (HR =5.20; 95% CI: 1.01-26.63; P=0.048) were independent predictors for worse CSS.

Conclusions

The prognosis of patients with WDTC was poorer for late metachronously detected metastases than for synchronous or early metachronous metastases. Patients with distant metastasis occurring 5 years later after primary thyroid diagnosis should, therefore, be more carefully treated.

Lung-molGPA Index Predicts Survival Outcomes of Non-Small-Cell Lung Cancer Patients with Synchronous or Metachronous Brain Metastases

Background

Graded prognostic assessment for lung cancer using molecular markers (Lung-molGPA) for brain metastases is a powerful prognostic tool. However, it has not been validated for non-small-cell lung cancer (NSCLC) patients with synchronous or metachronous brain metastases.

Methods

A total of 1184 NSCLC patients with synchronous or metachronous brain metastases were reviewed in this study. Comparative clinicopathological variables and survival analysis for these two groups (synchronous vs metachronous), as well as complimentary analysis of prognostic factors for the entire patient cohort, were performed. Afterward, patients were stratified using Lung-molGPA to evaluate the accuracy of the survival estimates.

Results

A total of 763 patients (64.4%) had synchronous metastases while 35.6% (421 patients) had metachronous metastasis. Patients with synchronous metastases were more likely to have a smoking history, limited metastatic lesions, and absence of cerebral symptoms (P<0.05). Patients with metachronous metastatic NSCLC had an overall survival (OS) period of 16.5 (95% CI 14.5–18.6) months and were longer compared to patients with synchronous metastases (16.5 vs 13.5 [12.5–14.6] months, P=0.004). In Cox regression multivariable analysis, age (HR=1.25, P=0.008), Karnofsky performance status (HR=1.30, P=0.005), extracranial metastases (HR=1.57, P<0.001), number of brain metastases (HR=1.22, P=0.043), gene mutation (HR=1.40 [wild type vs mutation], P=0.050; HR=1.42 [unknown vs mutation], P=0.007), and treatment (including TKI, chemotherapy, and local brain treatment, P<0.05) were independent prognostic predictors of OS. Additionally, metachronous metastatic patients were at lower risk for disease-related death compared to synchronous metastatic patients (HR=0.69, P<0.001). Importantly, median OS stratified by Lung-molGPA of 0–1, 1.5–2, 2.5–3 and 3.5–4 scores were 11.0, 14.0, 24.9, and 26.3 months for synchronous brain metastases, and 13.1, 17.0, 37.2, and 66.5 months for metachronous metastases, respectively (P<0.001).

Conclusion

Lung-molGPA could estimate the prognosis of NSCLC patients with synchronous or metachronous brain metastases. Hence, patients should be carefully stratified for consideration of aggressive therapy.

Is it worth to explore the contralateral side in unilateral childhood inguinal hernia?: A PRISMA-compliant meta-analysis

BACKGROUND

It is still not clear if the contralateral side should be explored in children with unilateral inguinal hernias. The primary aim of the present study was to assess the incidence of metachronous contralateral inguinal hernias (MCIHs) in the pediatric population. The second aim was to assess factors associated with increased risk of MCIH development.

METHODS

Prospective studies including patients from 0-19 years undergoing unilateral inguinal hernia repair without surgical exploration of the contralateral side between 1947 and April 2020 with a minimal follow-up of one year were searched. Searches included EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials.

RESULTS

Seven studies involving 1774 children (1452 boys (82%) and 322 girls (18%) were identified. Overall the incidence of MCIH was 6%. Incidence of MCIH development was significantly higher in children with initial left-sided (9%) versus right-sided (3%) hernia (OR 2.55 with 95% CI from 1.56 to 4.17; P = 0.0002), in female (8%) versus male (4%) children (OR 1.74 with 95% CI from 1.01 to 3.01; P = 0.0469) and in patients with open (14%) versus closed (3%) contralateral processus vaginalis (CPV) (OR 4.17 with 95% CI from 1.25 to 13.9; P = 0.0202). There was no significant difference in MCIH development depending on follow-up duration (follow-up of ≤2 years (i.e. 1-2 years): calculated MCIH incidence 5% (95% CI from 0.00 to 0.11%; 3 studies; 569 patients), follow-up of ≥3 years (i.e. 3-4 years): 6% (95% CI from 0.03 to 0.09; 3 studies, 983 patients)) or patients' age (MCIH incidence in children <1 year: 6.9%; older children: 4.5%; OR 1.87 with 95% CI from 0.97 to 3.62; P = 0.0618).

CONCLUSIONS

Overall incidence of MCIH development is 6%. Initial left-sided hernia, female gender and open CPV are risk factors for MCIH development.

A Rare Case of Triple Positive Metachronous Breast Cancer

Metachronous contralateral breast cancer (MCBC) is defined as contralateral breast cancer (BC) diagnosed more than 1 year after previous BC diagnosis. More BC survivors are at risk of MCBC given improved life expectancy with the availability of advanced cancer care. Estrogen receptor/progesterone receptor negative and HER-2-positive status of first BC are independent risk factors for the development of MCBC. We present a rare case of triple positive (estrogen receptor, progesterone receptor, HER-2 positive) MCBC patient who eventually developed brain metastasis within 15 months despite a near complete pathologic response of primary tumor. This case highlights that even in this era of antiestrogen and anti-HER-2 therapies, triple positive MCBC can have an aggressive clinical course, especially with brain metastasis as the first sign of metastasis.

Primary adenocarcinoma of the esophagogastric junction, combined with an obscure hepatoid adenocarcinoma component, as discovered after the development of a metachronous liver metastasis

BACKGROUND

Esophageal hepatoid adenocarcinomas (HACs) belong to alpha fetoprotein (AFP)-producing adenocarcinomas and are relatively sparse.

CASE PRESENTATION

A 35-year-old man suffering from adenocarcinoma of the esophagogastric junction (EGJ), with negative preoperative studies for metastatic disease, underwent Ivor Lewis esophagectomy. The histologic examination demonstrated a poorly differentiated, IIA (T₃N₀M₀) staged EGJ adenocarcinoma. The patient had been advised not to receive any adjuvant therapy, with the follow-up studies at six months being negative for recurrence. Eleven months postoperatively, he was diagnosed with a bulky mass in the liver's right lobe, accompanied by elevated AFP serum levels. The percutaneous biopsy revealed the presence of HAC, immunohistochemically positive for AFP. The surgical specimen was re-evaluated and was also found immunohistochemically positive for AFP, re-defining the tumor as combined adenocarcinoma and HAC of the EGJ. The patient received two sessions of transarterial chemoembolization (TACE) of the liver mass. However, following the 2^nd TACE session, he developed signs of hepatic insufficiency and expired twenty days later.

CONCLUSIONS

It is crucial to identify the presence of a HAC, as HAC seems to have an aggressive course, with limited therapeutic options as well as therapeutic response. HIPPOKRATIA 2020, 24(3): 138-142.

Rare case of acinar cell carcinoma with multiple lesions in the pancreas

We present the first case of pancreatic acinar cell carcinoma (PACC) with multiple lesions. A 55‐year‐old man with a pancretic tail mass on abdominal computed tomography (CT) was admitted to our hospital. Endoscopic ultrasound (EUS) showed a hypoechoic mass, and EUS‐guided fine‐needle aspiration (EUS‐FNA) revealed the mass to be PACC. The patient underwent distal pancreatectomy, and two masses were identified in the pancreatic tail and body. Histologically, both masses had tumor cells similar to acinar cells and were positive for BCL‐10. The patient was thus diagnosed with synchronous PACC. Ten months after the surgery, abdominal CT revealed a mass in the remnant pancreas. EUS showed a hypoechoic mass, and EUS‐FNA determined it to be PACC. The patient underwent total remnant pancreatectomy. The histological imaging results were similar to those of the first resection. Finally, the patient was diagnosed with synchronous and metachronous PACC. The possibility of multiple occurrences in the pancreas should be considered with PACC.

Metachronous Bone Metastasis

Background: The impact of the timing of bone metastasis (BM) diagnosis on colorectal cancer (CRC) patients is unclear. Our study aimed to explore the differences in clinicopathological characteristics, treatments and prognosis between synchronous BM (SBM) and metachronous BM (MBM) from CRC.

Methods: We retrospectively investigated clinical data of CRC patients with SBM or MBM from 2008 to 2017 at Chinese National Cancer Center. Cancer specific survival (CSS) after BM diagnosis was estimated using the Kaplan-Meier method. The multivariable COX regression model identified the prognostic factors of CSS.

Results: Finally, 63 CRC patients with SBM and 138 CRC patients with MBM were identified. Compared to SBM from CRC, MBM significantly was more involving multiple bone lesions (63.0 vs. 7.9%; p < 0.001), and more frequently originated from rectal cancer (60.9 vs. 41.3%; p = 0.033). The therapeutic strategies in SBM and MBM group were contrasted including systemic treatment, bisphosphonates, radiotherapy and metastasectomy for BM. 85.5% of patients in MBM group and 25.4% of patients in SBM group underwent primary tumor resection at initial diagnosis (p < 0.001). The median CSS was 11 months in both SBM and MBM group (p = 0.556), yet MBM patients developed from CRC in early AJCC stage presented obviously longer survival than those from advanced stage. Furthermore, patients could have improved CSS from primary tumor resection while there might be no survival benefit from targeted therapy in both SBM and MBM groups. Bisphosphonates was associated with a better CSS for patients with SBM, while radiotherapy for BM was related to a better CSS for patients with MBM.

Conclusion: The CRC patients in SBM and MBM group represented different clinicopathological characteristics and treatment modalities, which affected the prognosis in different ways. Distinct consideration for CRC patients with SBM and MBM in clinical decision making is required.

Indicators for secondary carcinoma in head and neck cancer patients following curative therapy: A retrospective clinical study

Patients with head and neck squamous cell carcinoma (HNSCC) are at risk for local and regional relapse, as well as for occurrence of synchronous or metachronous secondary carcinoma. The aim of this retrospective study was to evaluate the frequency of secondary malignancies amongst HNSCC patients and their association with age, sex and TNM classification, as well as smoking and alcohol abuse. Data from 394 patients with HNSCC who were treated at the Department of Otorhinolaryngology-Head and Neck Surgery of the University Hospital Mannheim between 2011 and 2015 were retrieved and analyzed using t-tests and P≤0.05 was considered statistically significant. Of the 394 patients, 50 (12.7%) developed a secondary carcinoma. In this cohort, >70% of secondary malignancies were diagnosed using clinical inspection or microlaryngoscopy. The majority of secondary malignancies were identified in the oropharynx, with men being more often affected overall. Continued abuse of carcinogenic substances appeared to increase the incidence of secondary carcinoma, whereas the localization of the primary tumor, age, sex or TNM classification were not identified as significant indicators of the occurrence of a secondary carcinoma. The purpose of the present study was to emphasize the importance of intensive follow-up to ensure early detection of secondary malignancies. The aim was to help predict numbers and occurrence within smaller cohorts, and to evaluate the quality of data collected during the establishment of a certified tumor center. To fully evaluate the role of continued exposure to noxious substances and other possible contributing factors, and in order to improve the rate of early diagnosis and establish preventive strategies, multicentered studies with larger cohorts are required.

Clinicopathological Characteristics, Treatment and Outcome of 123 Patients with Synchronous or Metachronous Bilateral Breast Cancer in a Swiss Institutional Retrospective Series

Objective

To evaluate the prognosis, the patient and tumor characteristics, and the treatment of bilateral breast cancer (BBC) and to compare synchronous (sBBC) and metachronous BBC (mBBC).

Materials and Methods

For this retrospective study, data from 123 consecutive BBC patients (56 sBBC and 67 mBBC) that were presented at the Sion Hospital tumor board between 2007 and 2018 were collected retrospectively.

Results

Mean follow-up was 85 months. 2^nd tumors in both groups were more often diagnosed radiologically. Mean time interval between mBBC was 115 months. A shorter interval was positively correlated with a negative hormonal receptor (HR) status and higher grade for the 2^nd tumor. There was no difference in overall survival (OS) and relapse-free survival (RFS) between sBBC and mBBC. OS was longer if both tumors were hormonal receptor (HR) positive. mBBC exhibited a higher local recurrence rate than sBBC (p=0.03).

Conclusion

sBBC and mBBC patients did not show any difference in OS or RFS, although mBBC patients were more prone to local relapses.

Triple Metachronous Malignancies with Thyroid Involvement: A Brief Overview of Five Case Reports over 20 Years of Institutional Experience

Multiple primary malignant tumors are defined by the development of more than one malignancy in a single patient. These can be subdivided into synchronous or metachronous malignant tumors, depending on their time of appearance, relative to the first malignancy. Triple primary malignancies are a relatively rare occurrence in day-to-day practice and triple synchronous or metachronous carcinomas involving a thyroid localization are even less common. In this case series, we report our 20-year experience in diagnosing and managing five patients with triple malignant tumors with thyroid involvement.

A Case of Metachronous Triple Carcinoma with Synchronous Double Primary Carcinoma on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography

Multiple primary malignancies in a single patient are exceedingly rare, but their prevalence has increased in recent decades due to prolonged survival rates supported by the advent of newer and better generation of chemotherapeutic agents as well as advances in cancer detectability facilitated by sophisticated modalities such as positron emission tomography-computed tomography. Here, we discuss a case of a 66-year-old male who recovered completely from lung carcinoma but subsequently developed synchronous gall bladder and gastric carcinoma after 1 year.

Metachronous Sudden Sensorineural Hearing Loss: Patient Characteristics and Treatment Outcomes

OBJECTIVES

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a distressing condition that can significantly affect quality of life. Unilateral ISSNHL, occurring first in 1 ear and then the contralateral ear at a separate and discrete time, is a rare presentation that we refer to as metachronous ISSNHL. Our objective was to characterize the presentation of metachronous ISSNHL and report on management and hearing outcomes.

STUDY DESIGN

Retrospective case series.

SETTING

Otology clinic at an academic tertiary referral center.

SUBJECTS AND METHODS

Patients ≥18 years old presenting with metachronous ISSNHL between April 2008 to November 2017 were identified through review of the clinic electronic medical record. Metachronous ISSNHL was defined as unilateral ISSNHL occurring in temporally discrete episodes (>6 months apart) affecting both ears. Patients with identifiable causes for sudden hearing loss were excluded. Patient demographics, comorbidities, management, and audiologic outcomes were recorded.

RESULTS

Eleven patients with metachronous ISSNHL were identified out of 558 patients with ISSNHL. In patients with metachronous ISSNHL, the mean ± standard deviation age at the time of ISSNHL in the second ear was 58.6 ± 15.2 years (range, 31-77 years). The mean interval between episodes was 9.6 ± 7.5 years (range, 1-22 years). Patients were treated with systemic and intratympanic steroids with variable hearing recovery; 5 patients with resultant bilateral severe to profound hearing loss underwent successful cochlear implantation.

CONCLUSION

Metachronous ISSNHL is uncommon. Treatment is similar to ISSNHL, and cochlear implantation can successfully restore hearing in individuals who do not experience recovery.

The risk of second primary tumors in head and neck cancer: A systematic review

BACKGROUND

Second primary tumors (SPTs) are a common cause of reduced life expectancy in patients treated for head and neck cancer (HNC). This phenomenon forms an area to be addressed during posttreatment follow-up.

METHODS

We conducted a systematic review of literature following PRISMA guidelines, from 1979 to 2019, to investigate incidence of SPTs, synchronous, and metachronous, in HNC population.

RESULTS

Our review includes data of 456 130 patients from 61 articles. With a minimum follow-up of 22 months, mean incidence of SPTs was 13.2% (95% CI: 11.56-14.84): 5.3% (95% CI: 4.24-6.36) for synchronous SPTs and 9.4% (95% CI: 7.9-10.9) for metachronous SPTs. The most frequent site for SPTs was head and neck area, followed by the lungs and esophagus.

CONCLUSION

Although with wide variations between studies, the rate of SPTs in HNC patients is high. Given the impact in the prognosis, we must develop strategies for the early diagnosis of SPTs.

High Risk of Proximal and Local Neoplasms in 2206 Patients With Anogenital Extramammary Paget's Disease

BACKGROUND

Extramammary Paget's disease is an uncommon intraepidermal adenocarcinoma with poorly defined clinical implications.

OBJECTIVE

The purpose of this research was to estimate the risk of second primary neoplasms in patients with extramammary Paget's disease.

DESIGN

This was a retrospective analysis of the Surveillance, Epidemiology, and End Results Registry (1973-2014).

SETTINGS

The study included population-based cancer registries from the United States.

PATIENTS

Patients who were diagnosed with anogenital Paget's disease were included.

MAIN OUTCOME MEASURES

Risk of second primary development was measured.

RESULTS

We identified 108 patients with anal Paget's disease, 421 patients with male genital (scrotum or penis) Paget's, and 1677 patients with female genital (vagina or vulva) Paget's. Median follow-up time was 5.9 years. The risk of developing colorectal adenocarcinoma was 18.5% for patients with anal Paget's disease. Eighty percent of colorectal adenocarcinoma diagnoses were synchronous (within 2 mo) to anal Paget's diagnoses, whereas metachronous tumors occurred at a median time of 2.4 years. Of patients with anal Paget's disease, 8.3% developed an anal adenocarcinoma or nonsmall cell cancer. In male patients with genital Paget's, the risk of proximal genitourinary malignancy was 9.7%, scrotal or testicular adenocarcinoma was 0.4%, and penile or scrotal squamous carcinoma was 1.7%. In female patients with genital Paget's, the risk of proximal genitourinary malignancy was 3.0%, vaginal or vulvar adenocarcinoma was 1.4%, and vaginal or vulvar squamous neoplasm was 1.0%. Five-year overall survival was 59.7%, 73.5%, and 80.7% in patients with anal, male genital, and female genital Paget's (p < 0.001).

LIMITATIONS

The registry did not record surveillance schedule, provider specialty, or nonprocedural therapies for extramammary Paget's disease.

CONCLUSIONS

In the largest published cohort of patients with extramammary Paget's disease, patients with anal Paget's had a much higher risk of both proximal and local neoplasms as compared with patients with genital Paget's. Patients with anal Paget's also experienced worse survival as compared with those with purely genital Paget's. See Video Abstract at http://links.lww.com/DCR/B20. ALTO RIESGO DE NEOPLASIAS PROXIMALES Y LOCALES EN 2206 PACIENTES CON ENFERMEDAD DE PAGET EXTRAMAMARIA ANOGENITAL:: La enfermedad de Paget extramamaria es un adenocarcinoma intraepidérmico poco frecuente con implicaciones clínicas poco definidas.Estimar el riesgo de segundas neoplasias primarias en pacientes con enfermedad de Paget extramamaria.Análisis retrospectivo del Registro de Vigilancia, Epidemiología y Resultados Finales (1973-2014).Registros de base poblacional en cáncer de los Estados Unidos.Pacientes que fueron diagnosticados con enfermedad de Paget anogenital.Riesgo de desarrollo un cáncer primario adicional.Se identificaron 108 pacientes con Paget anal, 421 pacientes con Paget genital masculino (escroto o pene) y 1677 pacientes con Paget genital femenino (vagina o vulva). Tiempo mediano de seguimiento fue de 5,9 años. El riesgo de desarrollar adenocarcinoma colorrectal fue del 18,5% para los pacientes con Paget anal. El ochenta por ciento de los diagnósticos de adenocarcinoma colorrectal fueron sincrónicos (dentro de los 2 meses) a los diagnósticos de Paget anal, mientras que los tumores metacrónicos ocurrieron en un tiempo promedio de 2,4 años. De los pacientes con Paget anal, el 8.3% desarrolló un adenocarcinoma anal o cáncer de células no pequeñas. En los pacientes masculinos con Paget genital, el riesgo de malignidad genitourinaria proximal fue del 9,7%, el adenocarcinoma escrotal o testicular fue del 0,4% y el carcinoma escamoso del pene o escroto fue del 1,7%. En pacientes femeninas con Paget genital, el riesgo de malignidad genitourinaria proximal fue de 3.0%, el adenocarcinoma vaginal o vulvar fue de 1.4% y la neoplasia escamosa vaginal o vulvar fue de 1.0%. La supervivencia general a cinco años fue del 59.7%, 73.5% y 80.7% en pacientes con anal, genital masculino y genital femenino, respectivamente (p <0.001).El registro no señalo el cronograma de vigilancia, la especialidad del proveedor o las terapias sin procedimiento para la enfermedad de Paget extramamaria.En la cohorte más grande publicada de pacientes con enfermedad de Paget extramamaria, los pacientes con Paget anal demostraron un riesgo mucho mayor de neoplasias proximales y locales en comparación con los pacientes con Paget genital. Los pacientes con Paget anal además demostraron una peor supervivencia en comparación con aquellos con Paget aislada genital. Vea el Resumen del Video en http://links.lww.com/DCR/B20.

Incidence, timing, presentation, treatment, and outcomes of second primary head and neck squamous cell carcinoma after oral cancer

After their initial presentation of oral squamous cell carcinoma (SCC), patients have a lifelong risk of developing another new SCC of the head and neck. The aim of this study was to establish second primary rates, baseline characteristics (site, clinical or pathological stage, and smoking and alcohol history), timing, presentation, treatment, and outcomes. From the regional unit we analysed records of patients treated with curative intent for their first oral cancer between 2002 and 2007 inclusive. All patients had had at least 10 years of follow up either to death or the end of 2017. A total of 347 patients had been treated with curative intent, and of them, 29 had a second primary at a median (IQR) of 52 (30-79) months after the index operation. The incidence of developing a second primary tumour within two years was 1.7% (95% CI: 0.7% to 3.7%), within five years was 4.9% (95% CI: 2.9% to 7.7%), and within 10 years was 7.8% (95% CI: 5.1% to 11.1%). Early stage of first cancer was the only significant factor (p=0.001) for development of a second primary within 10 years, reflecting survivorship. Most second primaries (21 patients) were staged as early, and by visual inspection. Most (n=20) were within the oral cavity, one of which overlapped the oropharynx; eight others were in the oropharynx, and one in the larynx. Most patients (n=22) were treated by operation with curative intent. Three were treated palliatively. Patients need to be aware of the risk of a second primary and, as most are in the mouth or oropharynx, there is a role for surveillance by primary dental care practitioners.

Metachronous Contralateral Male Breast Cancer: Case Report and Literature Review

Male breast cancer (MBC) is rare and consequently understudied. Here we present the case of contralateral breast cancer in a male patient nearly a quarter century following his initial breast cancer diagnosis and treatment. The epidemiology, risk factors, diagnosis, characterization, treatment, and prognosis of male breast cancer are reviewed. MBC accounts for <1% of all breast cancer with an estimated incidence nearly 1.25 per 100,000 person years. Our patient tested positive for ATM mutation of undetermined significance. More commonly in males, a BRCA2 mutation confers a >1 in 15 lifetime risk of breast cancer and is present in >11% of MBC patients, while BRCA1 is present in an estimated <1.5% of MBC patients. The risk of contralateral breast cancer developing in a male with a unilateral lesion is much higher than for a primary male breast cancer in the general population. Men tend to be diagnosed at a later age and stage than females. Prognosis for male and female breast cancer is similar considering both age of patient and stage of the tumor at diagnosis, and similar treatment paradigms have resulted in similar outcomes. Although lumpectomy with radiation therapy may have the same prognosis as mastectomy, the standard of care for male breast cancer continues to be simple mastectomy with sentinel lymph node biopsy.

Characteristic And Novel Therapeutic Strategies Of Nasopharyngeal Carcinoma With Synchronous Metastasis

Nasopharyngeal carcinoma (NPC) is rare in Western countries, but its incidence in China and Southeast Asia is notably high. NPC shows a high rate of distant metastasis including metachronous metastasis (mmNPC, metastasis after definitive chemo-radiotherapy) and synchronous metastasis (smNPC, metastasis at initial diagnosis). 4–10% of patients would be diagnosed as smNPC annually, and the survival outcomes of these patients are quite poor. As with few clinical trials exclusively focusing on this population, treatment on smNPC is not unified and many problems remain unsolved. To date, systematic chemotherapy (CT) still remains a fundamental treatment in smNPC. Although no randomized trial has been conducted to compare different CT regimens in smNPC, gemcitabine and taxanes in combination with platinum seem optimal in first-line setting. In second-line CT, there is no consensus: mono-chemotherapy with drugs such as gemcitabine, taxanes or capecitabine could be taken into consideration. Immunotherapy based on checkpoint inhibitors shows promising efficacy both in first-line and in the following lines of therapy. In addition to CT, local therapy in smNPC is also very important. Locoregional radiotherapy (RT) for primary tumor in combination with CT could strikingly increase OS with acceptable toxicities. And local treatment, such as surgery and RT, for metastatic lesions could bring extra survival benefit in patients with solitary or limited metastases. Overall, the present study provides an overview of the literature on the various studies of smNPC.

Metachronous bilateral testicular cancer: Case reports and review of literature

BACKGROUND

It is well recognised that men with unilateral testicular cancer may go on to develop metachronous cancer in the contralateral testis. Here, we present two cases of metachronous bilateral testicular cancer and a literature review.

CLINICAL CASES

In both cases, the second testicular cancer occurred several years after the initial cancer, and both cases were not screened for presence of contralateral germ cell neoplasia in situ upon the first diagnosis.

DISCUSSION

We also present a literature review on the need for screening biopsies of contralateral testis for germ cell neoplasia in situ and the risk factors which should encourage screening. Furthermore, we also explore the effect of chemotherapy on the incidence of contralateral testicular cancer and the effectiveness of radiotherapy in the treatment of germ cell neoplasia in situ.

CONCLUSION

We believe that screening biopsies of the contralateral testis upon diagnosis of unilateral testicular cancer should be encouraged as it can lead to better management of the condition and a relatively favourable outcome on functional fronts.

The prognostic comparison among unilateral, bilateral, synchronous bilateral, and metachronous bilateral breast cancer: A meta-analysis of studies from recent decade (2008-2018)

Background

The incidence of bilateral breast cancer (BBC) is increasing nowadays comprising 2%‐11% of all breast cancer (BC). According to the interval time between the first and second cancer, BBC could be divided into synchronous (SBBC) and metachronous (MBBC). However, this interval time is quite different across studies. It remains controversial whether the survival of BBC, SBBC, and MBBC is similar or worse compared to that of unilateral breast cancer (UBC), and whether the survival of SBBC is similar or worse compared to MBBC. To better understand the survival of UBC, BBC, SBBC, and MBBC and how the interval time would influence the prognosis of SBBC and MBBC, we performed this meta‐analysis on studies from recent 10 years (2008‐2018).

Methods

Databases of PubMed, Embase, and Web of Science were searched for relevant studies within recent 10 years. Hazard ratio (HR) was adopted to evaluate the difference of overall survival (OS) of UBC, BBC, SBBC, and MBBC. HR of OS comparisons were performed between BBC vs UBC, SBBC vs UBC, MBBC vs UBC, and SBBC vs MBBC with 3, 6, 12 months as the interval time, respectively.

Results

There were 15 studies of 72 302 UBC and 2912 BBC included in the meta‐analysis. The summary HR of OS comparison between BBC vs UBC was 1.68 (95% CI: 1.28‐2.20), SBBC vs UBC was 2.01 (95% CI: 1.14‐3.55), MBBC vs UBC was 3.22 (95% CI: 0.75‐13.78). When 3, 6, 12 months were used as the interval time, the summary HR of the OS comparison between of SBBC vs MBBC were 0.64 (95% CI: 0.44‐0.94), 1.17 (95% CI: 0.84‐1.63) and 1.45 (95% CI: 1.10‐1.92), respectively.

Conclusion

BBC and SBBC showed worse prognosis in terms of OS compared to UBC while MBBC manifested similar or non‐superior survival as UBC. The OS comparison between SBBC and MBBC changed with different interval time used. The longer the interval time used, the worse the survival of SBBC. SBBC with interval of 3‐12 months between the two cancers had the worst prognosis. When 6 months was used to differentiate SBBC from MBBC, these two clinical entities showed similar OS.

Risk factors for metachronous bilateral renal cell carcinoma: A surveillance, epidemiology, and end results analysis

BACKGROUND

Patients treated for renal cell carcinoma (RCC) may be diagnosed with a metachronous, contralateral tumor. We evaluated the risks of contralateral tumor development using the Surveillance, Epidemiology, and End Results database.

METHODS

Among RCC patients, we identified those with a metachronous, contralateral RCC diagnosed ≥1 year after primary diagnosis. We performed a competing risks analysis to evaluate associations between clinicopathologic factors and metachronous, bilateral RCC. Cumulative incidence and standardized incidence ratios (SIRs) were calculated.

RESULTS

There were 80,403 cases of RCC identified, with a median follow-up of 8.3 years; of these, 1063 (1.3%) developed metachronous, contralateral RCC (median of 6 years after diagnosis). The cumulative incidence at 10, 20, and 30 years of follow-up was 1.5%, 3.1%, and 4.7%, respectively. An increased risk was observed among men (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.20-1.55), blacks (HR, 2.00; 95% CI, 1.71-2.33), and those with papillary histology (HR, 1.72; 95% CI, 1.41-2.10). Risk of metachronous disease decreased with increasing age at primary diagnosis (HR per 1-year increase, 0.97; 95% CI, 0.96-0.97). The SIRs were highest among those diagnosed at a younger age and remained elevated even after extended follow-up (>10 years).

CONCLUSIONS

Our findings suggest that the cumulative incidence of metachronous, contralateral RCC may be higher than previously reported. Younger age, black race, papillary histology, and male sex increase the risk of metachronous, contralateral RCC development. The high SIRs seen in all demographic groups may support a rationale for lifelong surveillance, especially in high-risk subgroups with early disease onset.

Genetic Drivers of Pancreatic Cancer Are Identical Between the Primary Tumor and a Secondary Lesion in a Long-Term (>5 Years) Survivor After a Whipple Procedure

Background: A new mass in the remnant pancreas of a patient with previously resected pancreatic ductal adenocarcinoma (PDA) typically represents either a recurrence of the initial primary tumor or a second primary tumor. Recent advances in next-generation sequencing (NGS) strategies allow us to compare the genetic makeup of primary and secondary lesions. Case presentation: A 50-year-old Caucasian female presented for a surgical evaluation of a new biopsy-proven PDA at the junction of the body and tail of the pancreas. Six years prior, in 2011, the patient was found to have a T3N0M0 PDA of the pancreatic head, which was surgically resected with a classic Whipple procedure and concurrent hemicolectomy. Pathology showed pancreatic intraepithelial neoplasia grade 2 and PDA with negative surgical margins, positive perineural spread, and negative lymphovascular spread, and the patient received adjuvant chemotherapy and local radiation. In 2017, she was diagnosed with a new PDA lesion in the remaining pancreatic body far from the previous anastomosis site and was taken to surgery for a completion pancreatectomy and revision of the gastrojejunostomy. NGS was performed on both specimens. Both lesions shared identical mutations in KRAS, TP53, and CDKN2A genes. Amplifications of MYC and mutant KRAS were identified in the 2017 tumor and an ACVR1B mutation was identified in the 2011 tumor, but was not found in the 2017 tumor. Conclusions: This case demonstrates the ability to evaluate similarities between key genetic drivers from a resected primary tumor and a PDA lesion that presented in the same patient 6 years later. Histological analysis and NGS can be used to understand potential differences and similarities between lesions and may be useful in future studies as predictive markers or to provide insight into resistance mechanisms (e.g., MYC amplification).

Changes in the Ki-67 labeling index between primary breast cancer and metachronous metastatic axillary lymph node: A retrospective observational study

BACKGROUND

The Ki-67 labeling index (LI) is a well-known prognostic factor for primary breast cancer, but its clinical significance for metachronous axillary lymph node (ALN) recurrence has not been well documented.

METHODS

Ki-67 expression in primary tumors (PTs) and ALN metastases (ALNMs) was evaluated in 21 patients and quantified to investigate the relationship between Ki-67 LIs in PTs and metachronous ALNMs.

RESULTS

The median Ki-67 LIs in the PTs and ALNMs were 25.2% (range: 2.3-80.2%) and 70% (range: 10.4-97.4%), respectively. A majority of patients had higher Ki-67 LIs in ALNMs than in PTs (76.2%, 16/21). Disease-specific survival was significantly better in patients with a lower-than-median ALNM Ki-67 LI (P = 0.019, log-rank test). Receiver operating characteristic curves showed a PT Ki-67 LI of 62.8% as the optimal cutoff value and an ALNM Ki-67 LI of 65.1%. Accordingly, we divided the patients into four groups: PT Ki-67 LI lower than 62.8%/ALNM Ki-67 LI lower than 65.1%, PT Ki-67 LI lower/ALNM Ki-67 LI higher, PT Ki-67 LI higher/ALNM Ki-67 LI higher, and PT Ki-67 LI higher/ALNM Ki-67 LI lower. Disease-specific survival was significantly better in patients with Ki-67 LI lower/ALNM Ki-67 LI lower than in the other groups.

CONCLUSION

This is the first study to show that the Ki-67 LI in metachronous ALNM is a prognostic factor for patients with metachronous ALN recurrence of breast cancer.