Lymphatic mapping for Merkel cell carcinoma

Merkel cell trabecular carcinoma of the skin has a prognosis poorer than expected for a small skin lesion. An early diagnosis and prompt treatment can contribute to improve survival in cases of this aggressive skin tumor. A wide local excision is indicated for localized disease. Elective lymph node dissection is controversial. The authors report a rare case of Merkel cell tumor treated with wide local excision and sentinel lymph node biopsy.     

Merkel cell tumor: diagnosis, prognosis, and management

The histologic features of the Merkel cell and the pathologic characteristics of the Merkel cell tumor are described. From a literature review, 68 cases are examined; 23 cases that have been followed up accurately are presented from the Mayo Clinic. A representative case is used to demonstrate the problems of diagnosis and suggested treatment. The latter should be wide local resection with removal of nodal metastases if present. When indicated, this should be followed up with radiation therapy. Chemotherapy is of little or no value. Survival rates are presented.     

Merkel cell carcinoma: five case reports using sentinel lymph node biopsy and a review of 110 new cases

Merkel cell carcinoma is an uncommon cutaneous tumor that is considered locally aggressive and often spreads regionally through lymphatic channels. Evaluation of surgical treatment methods has been hampered by the low incidence of this tumor. Current standards of treatment include wide surgical excision and regional lymphadenectomy if clinically suspicious nodes are present. However, the development and increasing use of sentinel node imaging and biopsy have expanded the diagnostic options. This article presents information on 110 Merkel cell carcinomas treated in Connecticut between 1990 and 1997. Statistics on gender, age, disease location, treatment, and mortality are reviewed. Using the census data for Connecticut, the annual incidence for this disease was calculated to be 0.42 cases per 100,000 people. A series of five cases treated with wide excision and sentinel lymph node biopsy is also presented.     

Extensive distal subcutaneous metastases of a "benign" giant cell tumor of the radius

A case of distant metastases of a giant cell tumor of the radius is presented. The tumor within the radius was excised, followed by arthrodesis of the wrist and bone grafting with tibia. At the time she came to us, the patient presented distal dissemination, so we performed curettage of each one of the multiple metastases of soft tissues of the hand. After 9 months, a local recurrence in the radius was resected, and reconstruction was done with a vascularized graft of fibula. Later treatment consisted of intraarterial chemotherapy. The patient is in satisfactory condition 1 year after surgery.     

Isolated skeletal muscle metastasis following successful treatment of laryngeal cancer: case report

Skeletal muscle metastases from tumors are a rare occurrence and can present difficult management decisions. We report here on a patient that had been previously treated for squamous cell laryngeal cancer with surgical resection and adjuvant systemic chemotherapy that presented with a metastasis to the rectus abdominis muscle without evidence of recurrent disease at the primary site. After a metastatic workup with PET/CT scan suggested this to be an isolated lesion, surgical excision with negative margins was performed based upon limited treatment options secondary to the location of the tumor and his favorable prognosis suggested by his pathological staging at the time of the initial resection. Here we discuss the incidence of distant metastases from laryngeal cancer and appropriate screening methods. Additionally, skeletal muscle metastases and treatment considerations are discussed.     

Evidence for the role of natural immunity in the control of metastatic spread of head and neck cancer

Summary Deficient natural killer (NK) cell activity may contribute to the development of distant metastases in the head and neck cancer patient. A total of 246 previously untreated patients expressed deficient NK activity against K562 target cells when compared to 110 age-matched healthy controls (70±48 lytic units (LU) versus 95±52 LU) (P<0.001). Some 164 consecutive patients have undergone definitive therapy subsequent to NK cell assessment and have been followed for a minimum of 12 months (median=16 months), and 23 have developed recurrent disease in distant sites. The risk of subsequently (1) developing distant metastases, (2) developing regional metastases, and (3) dying of progressive cancer was inversely related to pretreatment NK LU values (P<0.02, <0.02, <0.005, respectively, by the Cox proportional hazards model). NK cell function within the peripheral blood of the patient with head and neck cancer could be related to the percentage of Leu 11+ NK cell subsets (P<0.01 by linear regression analysis) as determined by both single-parameter and multiparameter flow cytometric assessment. Contrastingly, no relationship could be identified between NK function with the percentage of circulating Leu 7+ cell subsets. In vitro measured NK cell function identifies a population at increased risk for developing distant metastases, thus supporting the role of natural immunity as defense mechanism against blood-borne disease.Funded in part by a grant from the Kimberly-Clark Corporation and by grant CA16672 awarded by The National Cancer Institute, Department of Health and Human Services     

Flow cytometric detection of multifocal DNA aneuploid cell populations in mastectomy specimens containing a primary breast carcinoma

DNA flow cytometry was used to study the presence of DNA aneuploid cell populations in macroscopically normal glandular tissue in mastectomy specimens from 30 patients with breast cancer. In the 13 patients with a DNA diploid primary tumor, no DNA aneuploidy could be found in any of the 39 distant specimens assessed. However, DNA aneuploid cell populations were demonstrated in four of the 17 (23%) patients with a primary DNA aneuploid carcinoma and in seven out of 54 (13%) distant tissue samples (P = 0.02). In all cases the DNA index of the DNA aneuploid cells found in the distant samples was identical to that of the primary tumor. The replicate aneuploid DNA indices and histologic controls taken in parallel very strongly suggest that these distant DNA aneuploid cell populations are metastases.     

Brain metastasis from cervical carcinoma--a case report

Brain metastases from cervical carcinomas are extremely rare. We report a patient with squamous cell carcinoma of the cervix who developed an isolated left parietooccipital lobe metastasis within 4 months of treatment of the primary disease. The presenting symptoms of the metastatic disease were visual disturbance, headache, and vomiting. The patient was successfully treated by surgical excision of the metastasis and adjuvant whole brain radiation therapy, and she was disease-free at the 6-month follow-up after treatment of the recurrence.     

Progression of mammary adenocarcinomas as reflected by nuclear DNA content

In 18 breast cancer patients the DNA histograms observed in the primary tumor at the date of diagnosis were compared with those found in the corresponding local and distant metastases at autopsy up to more than 12 yr later. All patients, except one, exhibited the same type of DNA histogram in both the primary tumor and its metastases. In one patient the DNA histogram changed from an euploid type in the primary breast carcinoma to an aneuploid type in the metastases. The results are interpreted as indicating that mammary adenocarcinoma in general exhibit a high degree of stability of the nuclear DNA content during the history of the disease. It is suggested that in breast cancer progression of the tumor disease is more likely due to a net increase and/or dissemination of tumor cells exhibiting similar genetic properties and malignancy potential than to a progressive dedifferentiation and increase of malignancy of the tumor cells.     

131I]metaiodobenzylguanidine therapy in 20 patients with malignant pheochromocytoma.

Twenty patients, 16 male and 4 female (aged 11-76 years), with metastatic pheochromocytoma were treated in our Institution between 1985 and 1990. Metastases occurred in all patients: at presentation in 11 patients, with a 10 to 30 month delay in 7 patients, and 9 and 28 years later respectively in 2 patients. Catecholamines hyperproduction was present in all patients. Metaiodobenzylguanidine (MIBG) uptake was found in 16 patients after a diagnostic dose and only after a therapeutic dose in 1 patient. Surgery was performed on primary tumor (18 patients) and on distant metastases (10 patients). 131I-MIBG therapy was performed in 11 patients, 9 of whom were evaluable. The cumulative activity ranged from 3.7 to 26.3 GBq (100 to 711 mCi) in 1 to 6 courses. We observed symptomatic improvement (5 patients) and partial tumor response in 2 patients, which lasted for 28 and 9 months respectively, terminating with a rapidly progressing disease involving the bone marrow. Stabilisation was observed in 3 patients. Moderate myelosuppression occurred in 4 patients. Fifteen patients died with a median survival of 16 months (range 3-60). Response to therapy was poor and further evaluation of the presently available therapeutic approaches is needed.     

HLA class I expression in metastatic melanoma correlates with tumor development during autologous vaccination

Our knowledge of the mechanisms underlying tumor-specific immune response and tumor escape has considerably increased. HLA class I antigen defects remain an important tumor escape mechanism since they influence the interactions between tumor cells and specific T and NK cells in the course of malignant disease. We have studied here HLA class I expression in six subcutaneous metastases obtained from a melanoma patient immunized with an autologous melanoma cell vaccine (M-VAX). We report in this paper that HLA class I antigen expression on these metastatic lesions strongly correlated with the course of the disease. The three metastases that were partially regressing at the time of their excision showed a strong HLA class I expression, whereas the progressing ones showed a very weak or negative staining with most of the anti-HLA class I mAbs used. Real-time quantitative PCR of the samples obtained from microdissected tumor tissue revealed a significant difference in the mRNA levels of HLA-ABC heavy chain and beta2m between the two types of metastases, i.e., lower levels in progressing metastases and high levels in regressing ones, confirming the immunohistological findings. This is, to our knowledge, the first report where the clinical outcome of different HLA class I positive and negative melanoma metastases can be clearly correlated with the regression and progression of the disease, respectively.     

Merkel cell carcinoma: case report

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine carcinoma of the skin. Although it is 40 times less common than malignant melanoma, its mortality is much higher compared to melanoma. From 1986 to 2001 there was rapidly increasing incidence in reported cases of MCC, with a tripling in the rate over this 15-year period. The vast majority of MCC presents on sun-exposed skin. The head and neck area is the most common site of tumor occurrence. We present 70-year old female patient with painless red-colored nodule, size 2 x 2 x 2 cm on the dorsal side of mid left forearm. The surgical excision with negative margins was performed, and pathohistological analysis confirmed Merkel cell carcinoma. Sentinel lymph node biopsy was negative. In conclusion, as MCC is a very aggressive rare skin carcinoma with lethal outcome, it should be mandatory to perform biopsies of any suspected skin lesion.     

TPS and CA 19-9 measurements in the follow-up of patients with pancreatic cancer and chronic pancreatitis

The aim of this study was to assess the value of TPS and CA 19-9 in a long-term follow-up analysis of 11 patients with chronic pancreatitis (CP) and 15 patients with pancreatic cancer (PC). In all monitored patients with chronic pancreatitis the initial TPS level was below 200 U/L, whereas CA 19-9 was elevated in two of them. In one patient a dramatic increase in the TPS concentration (820 U/L) was measured at the last follow-up visit (after 8.6 months), which led to the detection of PC. In all patients with PC the preoperative TPS level exceeded 200 U/L, whereas CA 19-9 was elevated in only nine patients. After the Kausch-Whipple operation 11 patients showed no evidence of disease and in eight of these patients both TPS and CA 19-9 were within the reference range; however, in three patients liver metastases were detected after 8-24 months from the last tumor marker measurement. In four of the 15 patients both markers were elevated at the end of the follow-up period and distant metastases were clinically confirmed. Our results indicate that in patients with CP and PC undergoing long-term follow-up, TPS reflects the clinical status of patients more accurately than CA 19-9.     

Radiofrequency ablation as locoregional therapy for unresectable hepatic malignancies: initial results in 24 patients with 5-years follow-up

Radiofrequency ablation (RFA) is one treatment modality for unresectable liver metastases. Patients with hepatic malignancies (n = 24) underwent elective RFA. All tumors were ablated with a curative intent, with a margin of 1 cm, in a single session of RFA. The median diameter of tumor was 3.1 cm (range 1.7-6.9 cm). Studied patients were not candidates for resection due to multifocal hepatic disease, extrahepatic disease, proximity to major vascular structures or presence of cirrhosis with functional hepatic reserve inadequate to tolerate major hepatic resection. Complete tumor necrosis was achieved in 87.5% and tumor recurred in 3 patients (12.5%) with lesions larger than 5 cm. Distant intrahepatic recurrence was diagnosed in another 4 (16.7%). Distant metastases were found in 7 (29.2%) patients. Four of these 7 patients had also distant intrahepatic recurrence of disease. Two and 5-years survival rates were 41.7% (10 patients) and 8.3% (2 patients) respectively. RFA is safe and effective option for patients with unresectable hepatic malignancies smaller than 5 cm without distant metastatic disease. RF ablation resulted in complete tumor necrosis in 87.5% with 2 and 5-years survival rates much higher than with chemotherapy alone or only supportive therapy, when survival is measured in weeks or months. If RFA is unavailable, percutaneous ethanol injection therapy can be done but with inferior survival rates.     

Carcinoid tumor of the kidney: case report and review of the literature

Carcinoid tumors are low-grade malignant tumors that arise from neuroendocrine cells. Primary renal carcinoid tumors are extremely uncommon. They seem to be more indolent than renal cell carcinomas, although metastases to regional lymph nodes, liver, and bone have been described. The presence of metastases seems to indicate a more malignant course; however, even with metastases a patient might live for 3 or 4 years. Renal carcinoid tumors should be managed by radical or partial nephrectomy, and good outcomes have been obtained for organ-confined disease after radical excision. Conventional methods of imaging are inadequate for detecting smaller carcinoids, so somatostatin receptor scintigraphy should complement computed tomography and magnetic resonance imaging when searching for occult or metastatic disease. Close follow-up after surgery is necessary.     

Establishment of a Chinese bladder cancer cell line (T921) with high metastatic activity

Muscle-invasive bladder cancer is prone to metastasis without a standard organ preference. The current cell lines used to study bladder cancer have primarily been derived from individuals in Western populations, and no human bladder cancer cell line has been established from the Chinese population. A bladder cancer cell line was derived from a female Chinese patient with muscle-invasive bladder cancer, and these cells were then xenografted into the bladders of three nude mice. Five weeks later, these mice were killed to observe local invasion and distant metastasis. The metastatic tumors were also removed and analyzed to assess the metastatic mechanism. This bladder cancer cell line, named T921, was successfully established, as evidenced by karyotype and immunohistochemistry analyses. Multi-organ metastases were observed in all three of the nude mice 5 wk after the orthotopic transfer of the cell line. In addition, epithelial–mesenchymal transition (EMT)-related genes were involved in the tumor metastases. The T921 bladder cancer cell line was successfully established, and EMT was observed to play a role in bladder cancer metastasis.     

Long-term follow-up of patients treated with radical surgery for rectal cancer

In developed societies colorectal cancer (CRC) is the second most frequent malignant tumor which causes more than 5000 deaths yearly in Hungary. We have attempted to answer the question how to improve the above mentioned data by the long-term follow-up of patients operated upon for rectal cancer at our department. Of the patients operated on for rectal cancer at our department between March 1990 and April 2006, we have conducted regular follow-up of 297 patients according to a protocol developed by us. We have examined the length of time between the rectum operation and the diagnosis and the number of local recurrences, distant metastases, tumor progression in more than one organ as well as second tumors (independent of the rectal cancer). During this period we found 24 local recurrences, 32 distant metastases, 43 tumor progressions in more than one organ, and 21 second tumors. In two patients, in addition to distant metastases, we found a second CRC independent of the original rectal cancer, and in one patient with tumor progression in more than one organ we also detected breast cancer. In one patient we found 3 second tumors (CR, lung and urinary bladder) independent of the original rectal cancer. Altogether we found tumors in 117 out of 297 patients. During the same period, we performed 69/117 operations and 31/117 patients were alive at the end of our study with a median survival of 60.4 (3-184) months. In summary, we can state that this work is beneficial for curing the recurrence of rectal cancer, making the patients' life longer or making the quality of life better for the patients operated on for rectal cancer.     

Outcome of a multimodal therapy of a recurrent adenocarcinoma arising from Caesarean section scar endometriosis—A case report

Background

Endometriosis occurring in surgical scars is a well-described entity. Malignant transformation of endometriosis is a rare event, with most cases belonging to adenocarcinoma. The initial surgical treatment is a method of choice. Due to lack of therapeutic recommendations, adjuvant therapy and recurrence management are a great challenge for oncologists.

Aim

The aim of this paper was to present a long-term survival as the outcome of multimodal therapy in the patient with recurrent adenocarcinoma arising from Caesarean section scar endometriosis.

Case

We present the case of a woman with recurrent adenocarcinoma arising from Caesarean section scar endometriosis. The disease was first diagnosed in September 1997 at age 43. The patient underwent abdominal hysterectomy with tumour excision. Due to a local recurrence after 4 years, tumour excision with abdominal wall repair using a plastic mesh, regional lymphadenectomy, bilateral salpingo-ovariectomy and adjuvant radiotherapy for the pelvic region with local boost were performed; in addition hormontherapy with medroxyprogesterone was started. Because of a recurrent pelvic tumour, chemotherapy, further local palliative radiotherapy and brachytherapy were administered. Subsequently distant metastases in bilateral axillary lymph nodes were diagnosed and palliative radiotherapy was performed. The patient died of morbus neoplasmaticus generalisatus in September 2008. The follow-up period had been 132 months.

Conclusion

This paper is, to our knowledge, the only report in literature that presents a long-term survival as the outcome of multimodal therapy in the patient with this rare diagnosis. Further reports of new cases can help establish optimal treatment guidelines.