An 11-year survivor who underwent ten sequential resections of colonic adenocarcinoma metastases

Hepatectomy is an established treatment for colorectal carcinoma liver metastases. However, the benefit of multiple repeat metastasectomies in the management of colorectal carcinoma patients remains uncertain. We report the case of a 47-year-old man who underwent ten sequential resections of intra- and extrahepatic colonic adenocarcinoma metastases. Metastasectomy procedures in this case included: 6 hepatic resections, 2 pulmonary resections, 1 pulmonary resection combined with wide resection of the abdominal wall, and 1 wide resection of the abdominal wall. The patient finally died, from unresectable metastases to the liver and pancreas, 133 months after the initial hepatectomy. The aggressive multiple repeat metastasectomies may have provided this unusual long-term palliation. Colorectal carcinoma patients with sequential resectable recurrences may be candidates for multiple repeat metastasectomies. Surgeons should pursue resection for colorectal carcinoma metastases, regardless of frequent operations and sites involved, as reliable medical treatment remains unestablished.     

Pancreatic metastases from renal cell carcinoma: the state of the art

Pancreatic metastases are rare,with a reported incidence varying from 1.6%to 11%in autopsy studies of patients with advanced malignancy.In clinical series,the frequency of pancreatic metastases ranges from 2%to 5%of all pancreatic malignant tumors.However,the pancreas is an elective site for metastases from carcinoma of the kidney and this peculiarity has been reported by several studies.The epidemiology,clinical presentation,and treatment of pancreatic metastases from renal cell carcinoma are known from si...     

Uncommon etiology of gastrointestinal bleeding: duodenal metastases from renal cell carcinoma

Because of its unpredictable behavior, renal cell carcinoma is one of the most controversial neoplasms. On the one hand, patients frequently show metastases at diagnosis because of its slight manifestations, while on the other, the neoplasm can remain stable after nephrectomy and can then metastasize many years later. When this happens, the metastases usually involve more than 2 organs. The most frequent sites of metastases are the lung and lymph nodes, followed by the bones and liver, while duodenal involvement is rare. Indeed, intestinal metastases are found in only 2% of autopsies and of these, renal cell carcinoma metastases account for 7.1%. We present a case of a solitary late recurrence presenting as upper gastrointestinal bleeding 19 years after nephrectomy for clear cell renal carcinoma.     

Metastases of esophageal carcinoma to skeletal muscle: Single center experience

Metastases of esophageal carcinoma to the skeletal muscle are rare, but the incidence may be increasing because of better diagnosis resulting from widespread use of positron emission tomography/computed tomography (PET/CT). A cohort of 205 patients with esophageal carcinoma treated at our center who had PET/CT between 2006 and 2010 was retrospectively evaluated for the presence of skeletal muscle metastases. Four patients had skeletal muscle metastases of esophageal carcinoma, including two patients with squamous cell carcinoma. In another patient with squamous cell carcinoma of the esophagus and synchronous skeletal muscle metastases, muscle metastases were subsequently shown to be related to second primary pancreatic adenocarcinoma. In all cases, skeletal muscle metastases were the first manifestation of systemic disease. In three patients palliation was obtained with the combination of external beam radiation therapy, systemic chemotherapy or surgical resection. Skeletal muscle metastases are a rare complication of esophageal carcinoma.     

PITUITARY PRO-OPIOMELANOCORTIN-CELL CARCINOMA OCCURRING IN CONJUNCTION WITH A GLIOBLASTOMA IN A PATIENT WITH CUSHING''S DISEASE AND SUBSEQUENT NELSON''S SYNDROME

Pituitary carcinoma is defined as a malignant pituitary tumour associated with blood- or lymph-borne metastases. Cushing's disease is frequently present in patients with this condition. After adrenalectomy for Cushing's disease, a 37-year-old man developed Nelson's syndrome resulting from a pituitary carcinoma with metastases to the spinal cord, cauda equina, heart, liver, and pancreas. The primary tumour and its metastases showed immunocytochemical staining for ACTH, beta-lipotrophin, and variably for beta-endorphin and alpha-melanocyte stimulating hormone (alpha-MSH). A coincidental glioblastoma was also present. Nine cases of Cushing's disease associated with pituitary carcinoma, including the present patient, are documented in the literature. The case reported is only the second in which immunohistochemical staining of the primary pituitary tumour and its metastases was performed, and the first in which ACTH-related peptides, in addition to ACTH itself, were demonstrated in the carcinoma cells.     

Metastasis to the thyroid gland: a case report and review of the literature

Metastatic cancer to the thyroid is uncommon. Although the thyroid is richly supplied with blood, there are a few reports of metastatic cancer spreading to this gland. The overall incidence in autopsy series has been quite varied, with rates from 1.2 to 24% of malignant tumors. Most of this metastases are not detected in clinical practice. The majority of these patients had widespread metastases and, as a result, had very short survival times. Although detection of metastases to the thyroid gland often indicates poor prognosis, aggressive surgical and medical treatment may be effective, especially for renal carcinoma. In this report, we present a case of renal carcinoma with thyroid metastases and a review of the literature.     

血清ALpb对前列腺癌骨转移的预测价值

用放射免疫电泳法对２０例伴有骨转移、１５例无骨转移的前列腺癌者及１２例前列腺增生症患者于手术或内分泌治疗前进行了血清碱性磷酸酶同工酶和前列腺特异性抗原水平测定。结果血清ＡＬｐｂ和ＰＳＡ在有骨转移的前列腺癌患者中均显著升高。     

Isolated splenic metastases from gastric carcinoma:A case report and literature review

Isolated metastases to the spleen from gastric carcinoma is very rare.Only a few cases have been reported in the literature.We herein present a case of isolated splenic metastases in a 62-year-old man,occurring 12 mo after total gastrectomy for gastric carcinoma.The patient underwent a laparoscopic exploration,during which two lesions were found at the upper pole of the spleen,without involvement of other organs.A laparoscopic splenectomy was performed.Histological examination confirmed that the splenic tumor was a poorly differentiated adenocarcinoma similar to the primary gastric lesion.The postoperative course was uneventful and the patient has been well for 9 mo,with no tumor recurrence.The clinical data of 18 cases of isolated splenic metastases from gastric carcinoma treated by splenectomy were summarized after a literature review.To our knowledge,this is the first reported case of isolated splenic metastases undergoing laparoscopic splenectomy.     

Análisis de supervivencia de la cirugía de resección de metástasis pulmonares de cáncer colorrectal

Introduction

The publication of the International Registry of Lung Metastases (IRLM) in 1997 was a turning point in favor of surgical resection of lung metastases. Prognostic groups were defined according to resectability, number of metastases, and disease-free interval. The objective of this study was to determine survival in patients who underwent resection of lung metastases from colorectal carcinoma and to evaluate how applicable the prognostic factors established by the IRLM are in this specific patient group.

Patients and Methods

Patients with lung metastases from colorectal carcinoma who underwent resection between January 1, 2000, and November 30, 2006, were retrospectively analyzed. Survival was calculated using the Kaplan-Meier method, with log-rank comparisons between groups.

Results

Survivals at 1, 3, 5, and 6 years was 92%, 75%, 54%, and 43%, respectively. The main finding was that 3-year survival was better in patients who underwent atypical resection of the metastasis (75%) than those who required lobectomy (55%). There were no significant differences in survival in terms of number of lung metastases resected or disease-free interval.

Conclusions

Survival in patients requiring lobectomy for resection of lung metastases from colorectal carcinoma was worse than in those who underwent atypical resection. The number of metastases and disease-free interval may be questionable prognostic factors in the case of lung metastases from colorectal carcinoma.     

Arterial, portal, or systemic chemotherapy for patients with hepatic metastasis of colorectal carcinoma

Hepatic metastases from colorectal carcinoma are common and may be resected for cure. The response of liver metastases to systemic chemotherapy is low. In contrast, hepatic arterial chemotherapy produces higher response rates than systemic chemotherapy, but randomized trials have not definitely proved a survival advantage because they allowed cross over. Most adjuvant portal vein chemotherapy studies have shown a survival advantage over the control group, but it is not clear whether this benefit is from the portal vein therapy or from immediate postoperative chemotherapy, since there is rarely a reduction in liver metastases. We describe the results of systemic, hepatic artery infusion, and portal therapy for patients with liver metastases of colorectal carcinoma.     

Follicular thyroid carcinomas with lung metastases: a 23-year retrospective study

Limited clinical information is specified in the presentations, results of treatment and prognostic factors of follicular thyroid carcinoma with lung metastases. In order to better characterize the information, we retrospectively analyzed the data of 2,003 thyroid cancer patients who received treatment and follow-up at the Chang Gung Memorial Hospital during the period from January 1979 to December 2002. There were 1,516 cases of papillary and 272 cases of follicular thyroid carcinomas. In the study, lung metastases of the follicular thyroid carcinomas were defined as post-operative or follow-up chest X-ray, diagnostic or therapeutic (131)I scan with positive finding of lung metastases. Serum thyroglobulin (Tg) levels under thyroxine treatment of patients with lung metastases had to be over 1.5 ng/mL. Of the follicular thyroid carcinomas, there were 70 (25.7%) with lung metastases including 50 females (mean age 54.1 +/- 12.6 years old) and 20 males (mean age 59.4 +/- 12.0 years old). Of the 70 patients, there were 53 patients (75.7%) who presented with lung metastases at the time of diagnosis. Of the 70 patients of follicular thyroid carcinoma with lung metastases, 30 patients (42.9%) died at the end of the follow-up, and only 4 patients improved to disease free status. The 5, 10, 15, and 20 year survival rates in these patients were 68.5%, 54.0%, 41.6%, 27.7%, respectively. Age, post-operative Tg level and tumor size are important prognostic factors which are demonstrated to be significantly different statistically between lung metastases group and the group of the patients without distant metastasis. Otherwise, only the tumor size and accumulative dose of (131)I therapy demonstrate a significant difference between survival and mortality groups. Seventeen of the 70 patients developed lung metastases during the follow-up period. Mean period between diagnosis and recurrence of these patients was 3.6 +/- 0.9 years. Over 75% of follicular thyroid carcinoma with lung metastases was diagnosed at the time of presentation. Forty percent (28/70 cases) of the follicular thyroid carcinoma with lung metastases had history of thyroid surgery in this study. If lung metastases are diagnosed in follicular thyroid carcinoma, it will be followed by a poor prognosis. Older patients, higher postoperative Tg, and larger tumor size in follicular thyroid carcinoma need aggressive postoperative treatment.     

Embolization for vertebral metastases of follicular thyroid carcinoma

The technique of selective embolization has been applied for years in the treatment of vascular anomalies, severe hemorrhage and benign or malignant tumors, notably vertebral metastases of renal cell carcinoma. Because this technique is relatively easy to perform and offers immediate relief of symptoms, it is an attractive option for patients with vertebral metastases of thyroid carcinoma with signs of spinal cord compression. In these patients, other treatment modalities like radioactive iodine, external irradiation, or surgery are more cumbersome or less effective in the short term. We describe four patients with metastasized follicular thyroid carcinoma, presenting with neurological symptoms due to vertebral metastases. All patients had undergone total thyroidectomy, ranging from 1 month to 4 yr before embolization. Embolization was combined with iodine-131 therapy when appropriate. Selective catheterization of the arteries feeding the metastases was performed, followed by infusion of polyvinyl alcohol particles (Ivalon). The procedure was technically successful in all patients without adverse effects. In the patients described, embolization resulted in rapid resolution of neurological symptoms, sometimes within hours. The therapeutic effect lasted from months to years. We conclude that embolization of vertebral metastases of follicular thyroid carcinoma is an attractive palliative therapeutic option that may offer rapid relief of symptoms.     

Unusual metastasis of differentiated thyroid carcinoma

Distant metastases of differentiated thyroid cancer are usually localised in the lung and bone; less common sites of metastases are the brain, liver, and skin. To find it in other sites it is exceptional. This work shows the clinical, histological and therapeutical characteristic of primary tumour in three cases of non-typical distant metastases of differentiated thyroid cancer. Follicular thyroid carcinoma was displayed in two cases, the first presented one metastases in right adrenal gland and the second in left kidney. Both cases were initially treated only with hemithyroidectomy, without posterior radioiodine. In one case, elevated serum thyroglobulin did not receive radioiodine treatment because Whole-Body Scintigraphy was negative. The thirst case was a papillary thyroid carcinoma treated with total thyroidectomy, ablative radioiodine and suppressor therapy with levothyroxine. However, posterior evolution was unfavourable and tumour presented metastases in common and less common sites like choroid. Histological study showed tall cell variant of papillary thyroid carcinoma. In summary, when the initial treatment of well-differentiated thyroid carcinoma it is inaccurate, it is possible to find common and less common sites metastases. Some variants of papillary thyroid carcinoma, like tall cell, have a worse prognosis and they can present metastases in less common sites.     

Papillary thyroid carcinoma metastatic to the pituitary gland.

Many malignancies may present with metastases to the pituitary gland. The association of thyroid carcinoma with pituitary metastases is, however, very rare. This report describes two patients in whom metastases from a papillary thyroid carcinoma to the pituitary gland resulted in panhypopituitarism with blunted endogenous thyrotropin (TSH) production following withdrawal of levothyroxine. Both required the use of recombinant human TSH prior to radioiodine therapy. Symptoms of hypopituitarism may be difficult to distinguish clinically from those of hypothyroidism in the setting of levothyroxine withdrawal. Clinicians should be aware of the clinical and biochemical manifestations of this rare association.     

Patterns of mediastinal metastases in bronchogenic carcinoma

The location and frequency of metastases to the lymph nodes were documented in a review of 200 patients with bronchogenic carcinoma who underwent pulmonary resection and total lymph node resection. No nodal metastases were found in 120 patients (60 percent). Metastases were present in only lobar or hilar nodes (or both) in 32 patients (16 percent), and 34 (17 percent) had metastases in mediastinal nodes as well as in lobar or hilar nodes. Only mediastinal nodal metastases were found in 14 patients (7 percent). Previously described lymphatic pathways can explain the presence of metastases in mediastinal nodes alone. Unexplained findings were the higher prevalence of mediastinal nodal metastases in adenocarcinoma vs squamous cell carcinoma and a much higher frequency of mediastinal metastases without lobar or hilar involvement (or both) in patients with adenocarcinoma compared to those with squamous cell carcinoma.     

Transformation of p53-positive papillary thyroid carcinoma to anaplastic carcinoma of the liver following postoperative radioactive iodine-131 therapy

Multiple liver metastases were incidentally detected in the lobe of the liver of an 81-year-old woman following total thyroidectomy and ablative radioactive iodine administration for the treatment of papillary thyroid carcinoma. A biopsy specimen taken from the metastatic liver tumor was histologically diagnosed as anaplastic carcinoma. Immunohistochemical staining for p53 was positive in both the primary tumor and liver biopsy specimens. We considered this to have been caused by anaplastic transformation from papillary thyroid carcinoma during treatment. We report a rare case of multiple liver metastases from a papillary thyroid carcinoma, which we believe to be the result of anaplastic transformation during postoperative radioactive iodine-131 therapy.     

Factors related to the survival of papillary and follicular thyroid carcinoma patients with distant metastases.

There is limited clinical information comparing presentations and results of treatment of papillary and follicular thyroid carcinoma patients with distant metastases. We retrospectively analyzed data of 1,257 thyroid cancer patients who received their treatment and follow-up at Chang Gung Memorial Hospital. We found 992 patients with papillary carcinoma and 205 patients with follicular thyroid carcinoma. Of these, 68 patients with papillary thyroid carcinoma (6.9%) had distant metastases at the time of diagnosis or during the follow-up period. Of the follicular thyroid carcinoma patients, 69 (33.7%) had distant metastases. Of the 68 patients with papillary carcinoma, only 33 were categorized as stage IV at the time of diagnosis. Nine of the patients were categorized as clinical stage I carcinoma, 10 as stage II, and 16 as stage III. Sixteen patients (23.5%) died during the study period, all but 2 of thyroid cancer. Twelve of the 68 patients were disease-free after treatment. Of the 69 patients with follicular thyroid carcinoma, 58 were categorized as stage IV at the time of diagnosis. Six of the patients were categorized as clinical stage I carcinoma, 2 as stage II, and 3 as stage III at the time of diagnosis; all of these patients deteriorated to stage IV during the follow-up period. Of the 42 patients with follicular thyroid carcinoma involving bone, 24 presented with bone metastases during the initial diagnosis. After treatment, 25 of 69 patients with follicular carcinoma died of follicular carcinoma. Only 3 patients were disease-free after the treatment. In patients with follicular carcinoma, only tumor size was an important prognostic factor. In this study, 8 patients categorized as clinical stages I to III at the time of operation had thyroglobulin (Tg) levels less than 5 ng/mL and developed distant metastases during the follow-up period. In conclusion, at diagnosis a large group of Asian patients with metastatic well-differentiated thyroid cancer was more likely to have follicular than papillary histology, and that, as expected, metastases from follicular cancer were present earlier and more frequently, were more likely to involve bone, were more likely to be associated with mortality, and were linked to tumor size but not gender. Also unlike some other reports, treatment producing a low Tg did not always produce a good outcome. More aggressive surgical procedures may be able to improve outcomes.     

Occult lymph node metastases as a predictor of tumor relapse in patients with node-negative esophageal carcinoma

BACKGROUND & AIMS: Esophageal carcinoma is an aggressive disease with a very poor prognosis. Early tumor relapse after surgical resection in patients with node-negative esophageal carcinoma suggests that occult metastases may have been missed at the original pathologic examination. The aim of this study was to determine the prevalence of immunohistochemically detected occult lymph node microscopic metastases in patients with pathologic N0 esophageal carcinoma and the impact of these occult metastases on relapse-free survival. METHODS: All patients (n = 124) with pathologic N0 esophageal carcinoma undergoing resection at our institution between January, 1994, and October, 1998, constituted the study population. Esophagectomy specimens were reevaluated by immunohistochemistry (monoclonal antibody against cytokeratin AE1/AE3). Clinical and pathologic features were summarized, and patient relapse-free survival was estimated. RESULTS: Among the total of 124 patients, occult lymph node microscopic metastases were identified by immunohistochemistry in 14 patients (11%) (T1 mucosa, 4%; T1 submucosa, 6%; T2, 22%; and T3, 14%). Patients were followed for a median of 3.2 years. Relapse-free survival was not significantly associated with the presence of occult lymph node microscopic metastases as detected by immunohistochemistry (P = 0.12). Advanced T stage (T3; P < 0.001) and lymphovascular invasion (P < 0.001) were found to be associated with tumor relapse. CONCLUSIONS: In the present study, occult lymph node microscopic metastases in pathologic N0 esophageal carcinoma patients were less frequent than previously reported. T stage and lymphovascular invasion were significantly associated with relapse-free survival, although a significant association with occult lymph node metastases was not detected.     

A study of factors influencing prognosis after resection of hepatic metastases from colorectal and gastric carcinoma

OBJECTIVE: The aim of this study is to determine the absolute contraindication for hepatic resection for colorectal metastases and investigate the value of hepatectomy for gastric metastases by comparing it with the results of colorectal metastases performed with the same criteria. METHODS: A retrospective cohort study was conducted in patients undergoing hepatic resection for metastatic colorectal (n = 64) and gastric (n = 17) carcinomas. Common predictive factors for both metastases were analyzed by the stratified Cox proportional hazard model. In this model, the different baseline hazard was set for each disease, whereas the risk of each covariate was assumed to be equal in both gastric and colorectal metastases. RESULTS: Overall 1-, 2-, and 5-yr survival rates after hepatectomy for colorectal and gastric metastases were 90%, 73%, 42%, and 47%, 22%, 0%, respectively. Factors controlling prognosis were as follows: age > or = 60, extrahepatic metastases, serosal invasion, grade of lymph node metastases, tumor cell differentiation of the primary lesion(s), carcinoembryonic antigen level, tumor-exposed surgical margin, and blood transfusion. In particular, presence of extrahepatic metastases showed the markedly high-risk ratio among these eight variables. CONCLUSIONS: Hepatectomy, if possible, is indicated in patients with hepatic metastases from colorectal carcinoma if there are no extrahepatic metastases and if the primary disease is controlled. It is indicated only in carefully selected patients with metastases from gastric carcinoma.