Samed Rahatli

An Unusual Case: Gastric Metastasis of Hepatocellular Carcinoma

Introduction: Gastrointestinal tract involvement of hepatocellular carcinoma (HCC) is a rare entity with a poor prognosis and can occur via hematogenous route or direct invasion. Here we report a case with de novo HCC after liver transplantation who had rising alfa-fetoprotein (AFP) levels and was found to have gastric metastases incidentally. Case: A 62 year old man underwent liver transplantation with a diagnosis of hepatocellular carcinoma Three years after the liver transplantation, bone and liver metastasis developed and palliative treatment plan was made. During follow-up AFP levels began to rise subsequently and computed tomography of chest and abdomen revealed stable liver lesions and a suspicious gastric luminal nodule. Upper endoscopy showed polypoid lesions in stomach and the pathology of the biopsies taken from these lesions were consistent with HCC metastasis. Discussion: Patterns of metastases in patients with recurrent HCC after liver transplantation might be different. Immunsuppressive treatment in transplant patients might have a negative effect on disease biology and may result in more disseminated disease and atypical sites of metastases as in our case. In patients with rising AFP in the absence of progressive disease on radiologic evaluation, gastrointestinal system metastases via hematogenous route should be kept in mind and upper endoscopy should be considered even in the absence of gastric symptoms, particularly if the presence of extrahepatic disease will change treatment decisions.

Good Outcomes of Patients with Stage IB Endometrial Cancer with Surgery Alone

BACKGROUND Most patients with endometrial cancer have stage I disease. Adjuvant therapy in stage IB (formerly IC) endometrial cancer is controversial, treatment options including observation or brachytherapy/ radiotherapy in grade 1-3 patients with or without chemotherapy. The purpose of this study was to assess the outcomes of our patients with stage IB endometrioid endometrial cancer. MATERIALS AND METHODS Sixty two patients with stage IB endometrial cancer and endometrioid histology were retrospectively evaluated. All patients were initially treated surgically by the same surgeon with comprehensive staging, i.e. total abdominal hysterectomy, bilateral salphingooopherectomy, bilateral pelvic and paraaortic lymph node dissection and omentectomy. Adjuvant radiotherapy was discussed with patients and utilized by those who accepted. Adjuvant chemotherapy was not given to any of the patients. RESULTS Median age was 62 (range, 42-95). Ninety percent of the patients had grade 1-2 disease. Thirteen patients (21%) received intra vaginal brachytherapy (IVBT) and one received whole pelvic radiotherapy (WPRT). Median follow-up time was 46 months (range, 9-77 months). Three patients experienced recurrence (4.8%), two of them died on follow-up and one was still alive at last visit. Two patients with recurrence had FIGO grade 2 tumors and one had a grade 3 tumor. Two patients (3.2%) died without evidence of recurrent disease. Relapse free survival at 5 years was 94.4% and overall survival was 93.1%. CONCLUSIONS Patients with stage IB disease in our study demonstrated relatively low recurrence rates although the majority of them received no adjuvant treatment. Surgery alone may be sufficient for most patients with this stage of endometrial cancer.

Impact of Treatment Strategies on Local Control and Survival in Uterine Carcinosarcomas in Turkey

BACKGROUND The purpose of this study was to determine the clinical characteristics, patterns of recurrence and survival outcomes in patients with uterine carcinosarcomas treated in our institution. MATERIALS AND METHODS Records of 26 patients diagnosed between 2007 and 2011 with uterine carcinosarcoma were retrospectively evaluated for demographic features, tumor characteristics, treatment regimens and patient outcomes in terms of DFS and OS RESULTS: Median age was 61 (range 43-78). 10 patients (38%) had stage I disease at diagnosis, 3 (12%) had stage II, 4 (15%) had stage III and 9 (35%) had stage IV. Sixteen patients (62%) received chemotherapy with paclitaxel and carboplatin for 6 cycles. One patient underwent radiotherapy. Median follow up was 17 months. Sixteen patients relapsed and 13 died during follow up. Considering recurrence, 5 out of 16 patients had lung metastases, one had brain metastases and 9 had only intraabdominal recurrence. The 3 year DFS was 37% and the 3 year OS was 30%. CONCLUSIONS Our data show that uterine carcinosarcomas tend to be at advanced stage at diagnosis and despite the use of chemotherapy, overall prognosis is poor. Surgery remains the mainstay of treatment. More effective adjuvant strategies are needed to reduce relapse and death rates.

Trastuzumab in metastatic breast cancer after complete remission: How long is enough?

Anti-human epidermal growth factor receptor 2 (HER2) therapies added to standard chemotherapy agents have been shown to improve disease-free survival (DFS) and overall survival (OS) via either single or dual blockade in HER2-amplified metastatic breast cancer patients [1]. The approved anti-HER2-directed drugs are monoclonal antibodies as trastuzumab, pertuzumab; dual tyrosine kinase inhibitor lapatinib and an antibody–drug conjugate trastuzumab emtansine. As is customary, maintanence treatment with an anti-HER2 drug until progression of disease remains the standard after response to first-line combined treatment of chemo and anti-HER2 agent that is mostly trastuzumab. Since tumors classified as HER2 positive are a heterogenous group, the optimal duration of trastuzumab for patients achieving complete response and the predictive markers for such patients is still a matter of debate. The longest relapse-free period with trastuzumab maintenance after complete remission was reported to be almost 9 years in a 46-year-old, hormone-receptor-negative breast cancer patient with liver and bone metastases at diagnosis. The reported progression-free values are between 6 months to 9 years in the literature. Among the 7 published cases with prolonged complete remission periods, all but one had metastases in the liver and 5 of them were hormone receptor negative. Six patients were reported to be in complete remission, all but one with trastuzumab maintanence [2]. In the report by Yan et al., 2 triple-negative locally advanced breast cancer patients were found to have HER2-positive, hormone-receptor-negative metastases during the follow-up. Because of financial problems, they could not receive trastuzumab at the time of metastases and anti-HER2 agent was added to treatment approximately after 1 year. Despite multiple metastatic sites including brain, both patients continued maintenance trastuzumab treatment up to now. One is still on complete remission while on trastuzumab maintenance for 28 months, and the other patient has been reported to be doing quite well with a partial response and still being on trastuzumab maintenance for 15 months [3]. In all of these cases, cardiac toxicity was not reported to be a clinically relevant adverse event. In the phase II HERLAP study, the predictive biomarkers for long-term efficacy of anti-HER2 agents without addition of chemotherapy were evaluated [4]. Although closed early with only 19 patients being enrolled, median progression-free and overall survivals were 7.3 (1.6–38?) and 43 (14–81?) months, respectively, quite similar to that reported with combined chemotherapy and single-agent anti-HER2 therapy trials [1]. Gene expression data and protein expression analysis revealed that patients with HER2-enriched tumors and with increasing values of quantitative HER2/p95HER2 (H2T/p95HER2) protein expression ratios showed significant increases in persistence on protocol, compared to patients with luminal A & B tumors and with lower H2T/p95HER2 ratios [4]. This finding can be a clue for choosing patients that will benefit most from long-term trastuzumab maintenance after achieving complete response with first-line combined therapy. Furthermore, studies analyzing the clinical outcomes with second-line trastuzumab after progression on first-line & Arzu Oguz oguzarzu@yahoo.com

Posttransplant Malignancies in Adult Renal and Hepatic Transplant Patients

Introduction The risk of some types of cancer increases after organ transplantation compared to general population and it is well documented in clinical studies. As a result of prolongation of survival and higher number of procedures cancer is a rising health concern in high volume transplantation centers. The occurrence of malignancy has an important impact on short- and long-term graft and patient survival. In this study we evaluate the cancer frequencies in transplant patient’s follow up. Materials and Methods Single center data of patients those were underwent solid organ transplatation in Baskent University Medical Faculty Hospital from 1997 to 2017 were retrospectively evaluated. Renal and hepatic transplant patients older than 16 years at the time of transplantation and diagnosed with cancer after transplantation were included the study. In total, 1176 of 2018 renal and 274 of 548 hepatic transplant patients were eligible for the analysis due to age. Results Fifty-three (4.5%) of 1176 renal and 9 (3.3%) of 274 hepatic transplant patients developed post transplant cancer during follow-up. Of the total 62 cancer patients, there were 46 males (74.1%) and 16 females (25.9%), with a median age at transplantation of 42.5 years. Overall, the incidence of cancer in transplant recipients was 4.2%. The most frequent cancers was basal and squamous skin cancers seen in 18 patients (29%) and Kaposi’s sarcoma seen in 11 patients (18%). 47 of 62 (%75.8) patients were still alive at the time of the study. Conclusion Although there are recent developments in the use of immunosuppressive drugs, posttransplant malignancy is still a health problem. Fortunately most seen cancers have good prognosis and can be cured by surgical resections. Transplant physicians must pay attention to early detection of these diseases. Table. No title available.

Breast Carcinoma with Choriocarcinomatous Differentiation: A Rare Case

Objectives : Breast carcinoma with choriocarcinomatous differentiation is a rare entity, generally presenting with high-grade disease and an aggressive clinical course with overall survival of less than a year Case : A 69-year-old woman with a diagnosis of pT1N0M0 invasive ductal carcinoma with choriocarcinomatous differentiation received six cycles of adjuvant chemotherapy and is still disease free on the 23rd month after diagnosis, showing a better prognosis than most other cases reported in the literature. Conclusion : The reason for the poor prognosis for this type of breast carcinoma remains unclear. Standard chemotherapeutic agents administered for breast carcinoma may be used for choriocarcinomatous differentiation.