Pavlos Papavasiliou

Case report and literature review: Metastatic lobular carcinoma of the breast an unusual presentation

INTRODUCTION Invasive lobular carcinoma is the second most common type of invasive breast carcinoma (between 5% and 15%). The incidence of invasive lobular carcinoma has been increasing while the incidence of invasive duct carcinoma has not changed in the last two decades. This increase is postulated to be secondary to an increased use of combined replacement hormonal therapy. Patients with invasive lobular carcinoma tend to be slightly older than those with non-lobular invasive carcinoma with a reported mean age of 57 years compared to 64 years. On mammography, architectural distortion is more common and microcalcifications less common with invasive lobular carcinoma than invasive ductal carcinoma. The incidence of extrahepatic gastrointestinal (GI) tract metastases observed in autopsy studies varies in the literature from 6% to 18% with the most commonly affected organ being the stomach, followed by colon and rectum. Gastric lesions seem to be slightly more frequent, compared to colorectal lesions (6-18% compared to 8-12%, respectively). PRESENTATION OF CASE We present the case of a 70-year-old woman who was referred to our institution with a concurrent gastric and rectal cancer that on further evaluation was diagnosed as metastatic invasive lobular carcinoma of the breast. She has a stage IV clinical T3N1M1 left breast invasive lobular carcinoma (ER positive at 250, PR negative, HER-2/neu 1+ negative) with biopsy proven metastases to left axillary lymph nodes, gastric mucosa, peritoneum, rectal mass, and bone who presented with a partial large bowel obstruction. She is currently being treated with weekly intravenous paclitaxel, bevacizumab that was added after her third cycle, and she is also receiving monthly zoledronic acid. She is currently undergoing her 12-month of treatment and is tolerating it well. Discussion Breast cancer is the most common site-specific cancer in women and is the leading cause of death from cancer for women aged 20-59 years. It accounts for 26% of all newly diagnosed cancers in females and is responsible for 15% of the cancer-related deaths in women.(9) Breast cancer is one of the most common malignancies that metastasize to the GI tract, along with melanoma, ovarian and bladder cancer. CONCLUSION We present one of the first reports of metastatic lobular breast cancer presenting as a synchronous rectal and gastric tumors. Metastatic lobular carcinoma of the breast is a rare entity with a wide range of clinical presentations. A high level of suspicion, repetition of endoscopic procedures, and a detailed pathological analysis is necessary for early diagnosis, which might help to avoid surgical treatment due to incorrect diagnosis. Patients with a history of breast cancer who present with new gastrointestinal lesions should have these lesions evaluated for evidence of metastasis through histopathologic evaluation and immunohistochemical analysis. Differentiating between a primary GI lesion and metastatic breast cancer will allow initiation of appropriate treatment and help prevent unnecessary operations.

A better prognosis for Merkel cell carcinoma of unknown primary origin

BACKGROUND There is limited evidence that Merkel cell carcinoma (MCC) arising from a nodal basin without evidence of a primary cutaneous (PC) site has better prognosis. We present our experience at 2 tertiary care referral centers with stage III MCC with and without a PC site. METHODS Fifty stage III MCC patients were identified between 1996 and 2011. Clinical data were analyzed, with primary endpoints being disease-free survival and overall survival. RESULTS Of stage III patients, 34 patients presented with a PC site and 16 patients with an unknown primary (UP) site. Treatment strategies varied; of patients with UP vs. PC sites, 25% vs. 44% underwent combined regional lymphadenectomy and radiation, with an additional 25% vs. 15% receiving chemotherapy. The median disease-free survival for a UP site was not reached vs. 15 months for a PC site (hazards ratio = .48, P = .18). The median overall survival for a UP site was not reached vs 21 months for a PC site (hazards ratio = .34, P = .03). Multivariate analysis showed that UP status was a significant factor in overall survival (P = .002). CONCLUSIONS Stage III MCC with a UP site portends a better prognosis than MCC with a PC site.

The anatomic course of the first jejunal branch of the superior mesenteric vein in relation to the superior mesenteric artery.

Introduction. The purpose of this study is to determine the anatomic course of the first jejunal branch of the superior mesenteric vein (SMV) in relation to the superior mesenteric artery (SMA). Methods. Three hundred consecutive contrast-enhanced computed tomography (CT) scans were reviewed by a surgical oncologist with confirmation of findings by a radiologist. Results. The overall incidence of a first jejunal branch coursing anterior to the SMA was 41%. There was no correlation between patient gender and position of the jejunal branch. In addition, there was no correlation between size of the first jejunal branch and its location in relation to the SMA. The IMV drained into the SMV in 27% of the patients. The IMV drained into the SMV-portal vein confluence in 17% of patients and inserted into the splenic vein in 54%. An anterior coursing first jejunal branch statistically correlated with an IMV that drained into the SMV-portal vein confluence (P = 0.009). Conclusion. The first jejunal branch of the SMV has a highly variable course in relation to the SMA and has a higher incidence of an anterior location in this population than previously reported.

Impact of preoperative therapy on patterns of recurrence in pancreatic cancer

BACKGROUND A theoretical advantage of preoperative therapy in pancreatic adenocarcinoma is that it facilitates the early treatment of micrometastases and reduces postoperative systemic recurrence. METHODS Medical records of 309 consecutive patients undergoing resection of adenocarcinoma in the head of the pancreas were reviewed. Survival was calculated using the Kaplan-Meier method. Associations between preoperative therapy and patterns of recurrence were determined using chi-squared analysis. RESULTS Preoperative therapy was administered to 108 patients and upfront surgery was performed in 201 patients. Preoperative therapy was associated with a significantly longer median disease-free survival of 14 months compared with 12 months in patients submitted to upfront surgery (P = 0.035). The rate of local disease as a component of first site of recurrence was significantly lower with preoperative therapy (11.3%) than with upfront surgery (22.9%) (P = 0.016). Preoperative therapy was associated with a lower rate of hepatic metastasis (21.7%) than upfront surgery (34.3%) (P = 0.026). Preoperative therapy did not affect rates of peritoneal or pulmonary metastasis. CONCLUSIONS Preoperative therapy for pancreatic cancer was associated with longer disease-free survival and lower rates of local and hepatic recurrences. These data support the use of preoperative therapy to reduce systemic and local failures after resection.

Challenges in the treatment of angiosarcoma: a single institution experience

BACKGROUND Angiosarcomas are rare tumors that carry poor prognosis. Because of insidious growth rate, the diagnosis is often difficult and delayed. METHODS Between 1990 and 2011, 72 (41 female, 31 male) patients were treated at our institution. Pathologic confirmation was obtained and multiple prognostic factors were evaluated for survival. RESULTS Forty-four cases were sporadic and 28 cases were secondary. In the sporadic group, 16 (36%) patients had increased sun exposure, while in the secondary group, the majority (n = 23, 82%) of patients had prior exposure to radiation. The latent period between radiation exposure and diagnosis was predictive of survival (P = .037). Presentation was delayed by more than 3 months in 41% of patients. The majority of men developed head and neck angiosarcomas (n = 15, 48.5%), while women developed breast angiosarcomas (n = 21, 51%). Median survival was prolonged in patients treated initially with surgery. CONCLUSIONS A delay in the diagnosis of angiosarcoma can affect survival. Clinical suspicion and prompt diagnosis are essential for successful multimodal therapy. Initial surgical resection with adjuvant chemotherapy provides survival advantage.

Utility of PET/CT in the staging and treatment of patients with Merkel Cell Carcinoma and Melanoma

Cutaneous malignancies constitute some of the most commonly diagnosed cancers in the United States (USA), comprising more than half of all cancers diagnosed per year [1]. In this review article we aim to present our experience at a tertiary referral center using PET/CT in the staging and treatment planning in patients with Merkel cell carcinoma (MCC) and melanoma and review the current literature.

Preoperative FDG-PET/CT Is an Important Tool in the Management of Patients with Thick (T4) Melanoma.

The yield of preoperative PET/CT (PET/CT) for regional and distant metastases for thin/intermediate thickness melanoma is low. Objective of this study is to determine if PET/CT performed for T4 melanomas helps guide management and alter treatment plans. Methods. Retrospective cohort of 216 patients with T4 melanomas treated at two tertiary institutions. Fifty-six patients met our inclusion criteria (T4 lesion, PET/CT and no clinical evidence of metastatic disease). Results. Fifty-six patients (M: 32, F: 24) with median tumor thickness of 6 mm were identified. PET/CT recognized twelve with regional and four patients with metastatic disease. Melanoma-related treatment plan was altered in 11% of the cases based on PET/CT findings. PET/CT was negative 60% of the time, in 35% of the cases; it identified incidental findings that required further evaluation. Conclusion. Patients with T4 lesions, PET/CT changed the treatment plan 18% of the time. Regional findings changed the surgical treatment plan in 11% and the adjuvant plan in 7% of our cases due to the finding of metastatic disease. Additionally 20 patients had incidental findings that required further workup. In this subset of patients, we feel there is a benefit to PET/CT, and further studies should be performed to validate our findings.