Surgical management of metastatic disease of long bone

Objective To improve the life quality of cancer patients with metastasis to long bone and to long bone and to select suitable surgical treatment. Methods Fifty-two patients with metastasis 27 men and 25 women, were June 2003 Vol12 No2 treated from 1990 to 1999. Their average age was 56. 8 years (33 - 74). In 16 patients with multiple lesions, underwent surgery at bone shaft (29 patients) and bone epiphysis (26). Thirty patients were treated for pathologic fracture and the rest for impending fracture. Operations included limb-salvage (51 patients) and amputation (4) Limb salvage consisted of intralesional curettage (3 patients ), intramedullary nailing reconstruction (29 ), endoprosthesis ( 18 ), and temporary spacer ( 1 ). 21 patients accepted postoperative chemotherapy or radiotherapy. Results Follow-up of 52 patients for a mean of 28. 2 months (2 - 122 months) showed pain relief (41 patients), (75%) and full or part weight-bearing stability ( 36 ) 69 % . Local tumor recurrence occurred in 11 patients.

Vulvar Swelling in a 12-Year-Old Girl: An Early Manifestation of Crohn’s Disease

Vulvar Crohn’s disease (VCD) is a rare complication of Crohn’s disease, especially in pediatric population. An early diagnosis can result difficult if the complication does not present in conjunction with the classic gastrointestinal symptoms that characterize this disease. In this study we present the case of a 12-year-old girl whose initial symptom of Crohn’s disease was a symptomatic vulvar swelling promoted by a rectovaginal fistula. We also provide an overview of Crohn’s disease and the vulvar changes found in the course of this disease.

Unexpected Metastatic Recurrent Myxofibrosarcoma: A Scenario That May Be More Common than You Think

Soft tissue sarcomas represent only 1% of all adult cancers;myxofibrosarcoma is the most common type that arises in adult extremities, particularly lower limbs (77%), other less common locations are the trunk (12%) and neck (3%). Usually presenting as a painless, subcutaneous, slow growing mass with tendency for recurrence, they are prone to have higher histological grade and metastatic potential after recurrence;even in optimal multidisciplinary settings patients can have incomplete resections, making metastatic disease more common after misdiagnosis. We present the case of a 69-year-old male patient with a right infraescapular tumor, presenting as a painless 15 × 8 cm, mobile mass, with a slow but progressive growth, history of a previous tumor excised at the same location 5 years prior without histopathological report.

Surgical treatment of metastatic bone disease of the distal extremities

Metastatic bone disease of the distal extremities,also known as acrometastasis,is very rare.Thus,there is very limited information regarding the clinical manifestations and methods of surgical treatment.The current available literature shows that acrometastases are often encountered in the context of advanced disease and are thus associated with poor patient survival.As metastatic bone disease is generally uncurable,the goal of surgical treatment is to provide the patient with good function with as few complications as possible.In this article,we discuss the clinical manifestation of acrometastases,the methods of surgical intervention,and the expected clinical outcome.Non-surgically managed pathological fractures generally remain ununited;therefore,conservative treatment is reserved for patients with poor general condition or dismal prognosis.The current evidence suggests that in lesions of the lower arm and leg,osteosynthesis(plate and screw fixation or intramedullary nail)is the most common method of reconstruction,whereas local excision or amputation are more commonly used in cases of more distal lesions(such as ankle,foot and hand).Following surgery most patients receive adjuvant radiotherapy,even though its role is poorly documented.Close collaboration between orthopedic surgeons and medical oncologists is necessary to improve patient care and treatment outcome.Further studies are needed in order to provide stronger clinical evidence and improve decision-making,in an effort to optimize the patients’quality of life and avoid the need for revision surgery.

Uveal melanoma:Recent advances in immunotherapy

Uveal melanoma(UM)is the most common primary intraocular cancer in adults.The incidence in Europe and the United States is 6-7 per million population per year.Although most primary UMs can be successfully treated and locally controlled by irradiation therapy or local tumor resection,up to 50%of UM patients develop metastases that usually involve the liver and are fatal within 1 year.To date,chemotherapy and targeted treatments only obtain minimal responses in patients with metastatic UM,which is still characterized by poor prognosis.No standard therapeutic approaches for its prevention or treatment have been established.The application of immunotherapy agents,such as immune checkpoint inhibitors that are effective in cutaneous melanoma,has shown limited effects in the treatment of ocular disease.This is due to UM’s distinct genetics,natural history,and complex interaction with the immune system.Unlike cutaneous melanomas characterized mainly by BRAF or NRAS mutations,UMs are usually triggered by a mutation in GNAQ or GNA11.As a result,more effective immunotherapeutic approaches,such as cancer vaccines,adoptive cell transfer,and other new molecules are currently being studied.In this review,we examine novel immunotherapeutic strategies in clinical and preclinical studies and highlight the latest insight in immunotherapy and the development of tailored treatment of UM.

Metastatic Lobular Carcinoma of the Breast Presenting with Small Bowel Metastases:Case Report and Literature Review

Introduction: Invasive lobular carcinoma (ILC) is the second most common histologic type of breast cancer, representing 5% to 15% of invasive tumors. ILC tends to spread to bones, lungs, central nervous system, reproductive organs, and the gastrointestinal tract (GI tract). The most commonly affected organs in the GI tract are the stomach, small intestine, followed by colon and rectum. Case presentation: A 78-year-old woman who was referred to our institution after having a bowel obstruction that required a diagnostic laparoscopy where they identified an obstructing ulcerative lesion in the distal ileum that was managed with a segmental bowel resection. Pathology report showed an invasive lobular breast carcinoma that occluded 90% of the bowel lumen. A PET/CT scan revealed a left breast tumor with increased metabolism. The patient was staged as a clinical cT4b, cN0, cM1 left breast invasive lobular carcinoma (ER/PgR positive, HER-2 negative). She was managed with endocrine therapy with Letrozole (an eight-week course). A follow-up PET/CT showed a peritoneal hypermetabolic nodule adjacent to the previous ileal anastomosis. The lesion decreased in size and metabolic activity. In a multidisciplinary fashion, the endocrine therapy was extended for another three months. Another follow-up PET/CT scan was performed three months after the identification of the peritoneal implant that showed that the nodule increased in size and in metabolism. The lesion continued to decrease significantly in size and became metabolically inactivity. Due to the good breast response and the possibility that the ileal nodule could be a granuloma, she underwent an exploratory laparoscopy with excision of the peritoneal nodule, and a modified left radical mastectomy with immediate breast reconstruction (complex wound closure). The final pathology report of the nodule was negative for malignancy. She continued on endocrine therapy and underwent whole breast irradiation four weeks after the operation. Currently, she is free of disease with no evidence of local, regional, or distant recurrence, and she is still on endocrine therapy. Discussion: The time interval between primary breast cancer and gastrointestinal involvement may range from synchronous presentation to as long as 30 years. The clinical manifestations in GI lobular breast cancer metastasis may range from non-specific complaints to acute GI symptoms, such as a bowel obstruction. There are multiple controversies in the management of ILC. Systemic treatment should be initiated as soon as possible. Indications for postmastectomy radiotherapy are also controversial, given the propensity for multifocal/multicentric tumors and late recurrences, sometimes in atypical locations. Five years of postoperative adjuvant hormonal therapy is an option for women with poor prognosis. Remissions are observed in 32% to 53% of patients. Conclusion: Metastatic lobular carcinoma of the breast has a wide range of clinical presentations. Patients with a history of breast cancer who present with new GI tumors should have these lesions evaluated for evidence of metastasis through histopathologic and immunohistochemical analysis, this will allow for appropriate management. Currently, breast cancer management involves a multidisciplinary approach including surgery, radiotherapy, and systemic medical therapy, and the treatment must be tailored to the patient’s needs.

Nano albumin bound-paclitaxel in pancreatic cancer: Current evidences and future directions

Pancreatic cancer(PDAC) is an aggressive and chemoresistant disease, representing the fourth cause of cancer related deaths in western countries. Majority of patients have unresectable, locally advanced or metastatic disease at time of diagnosis and the 5-year survival rate in these conditions is extremely low. For more than a decade gemcitabine has been the cornerstone of metastatic PDAC treatment, although survival benefit was very poor. PDAC cells are surrounded by an intense desmoplastic reaction that may create a barrier to the drugs penetration within the tumor. Recently PDAC stroma has been addressed as a potential therapeutic target. Nano albumin bound(Nab)-paclitaxel is an innovative molecule depleting tumor stroma, through interaction between albumin and secreted protein acidic and rich in cysteine. Addition of nab-paclitaxel to gemcitabine has showed activity and efficacy in metastatic PDAC first-line treatment improving survival and overall response rate vs gemcitabine alone in the MPACT phase Ⅲ study. This combination represents one of the standards of care in advanced PDAC therapy and is suitable to a broader spectrum of patients compared to other schedules. Nab-paclitaxel is under investigation as a backbone of chemotherapy in novel combinations with target agents or immunotherapy in locally advanced or metastatic PDAC. In this article, we provide an updated and critical overview about the role of nab-paclitaxel in PDAC treatment based on the latest advances in preclinical and clinical research. Furthermore, we focus on the use of nab-paclitaxel within the context of metastatic PDAC treatment landscape and we discuss about future implications in the light of current clinical ongoing trials.

Role of taxanes in pancreatic cancer

Pancreatic cancer is one of the most deadly cancers and is characterized by a poor prognosis. Single agent gemcitabine, despite its limited activity and modest impact on disease outcome, is considered as the standard therapy in pancreatic cancer. Most of the combination regimens used in the treatment of this disease, also including the targeted agents, did not improve the outcome of patients. Also, taxanes have been tested as single agent and in combination chemotherapy, both in first line and as salvage chemotherapy, as another possible option for treating pancreatic cancer. The inclusion of taxanes in combination with gemcitabine as upfront therapy obtained promising results. Accordingly, taxanes, and above all, new generation taxanes, appear to be suitable candidates for further testing to assess their role against pancreatic cancer in various clinical settings.

Immunotherapy in triple-negative breast cancer:A literature review and new advances

Triple-negative breast cancer(TNBC)is a highly complex,heterogeneous disease and historically has limited treatment options.It has a high probability of disease recurrence and rapid disease progression despite adequate systemic treatment.Immunotherapy has emerged as an important alternative in the management of this malignancy,showing an impact on progression-free survival and overall survival in selected populations.In this review we focused on immunotherapy and its current relevance in the management of TNBC,including various scenarios(metastatic and early-neoadjuvant,adjuvant-),new advances in this subtype and the research of potential predictive biomarkers of response to treatment.

Breast cancer immunotherapy:Realities and advances

Breast cancer(BC)is the most common malignant tumor and the main cause of death in women worldwide.With increased knowledge regarding tumor escape mechanisms and advances in immunology,many new antitumor strategies such as nonspecific immunotherapies,monoclonal antibodies,anticancer vaccines,and oncolytic viruses,among others,make immunotherapy a promising approach for the treatment of BC.However,these approaches still require meticulous assessment and readjustment as resistance and modest response rates remain important barriers.In this article,we aim to summarize the most recent data available in BC immunotherapy to include the results of ongoing clinical trials and approved therapies used as monotherapies or in combination with conventional treatments.

Metastatic well-differentiated pancreatic neuroendocrine tumors to the liver: a narrative review of systemic and surgical management

Pancreatic neuroendocrine tumors(PNETs)are a rare group of neoplasms originating from the endocrine pancreas.PNETs are classified as functional or non-functional tumors.PNETs are more often diagnosed at a higher stage with distant metastases or advanced locoregional disease.The majority of individuals with hepatic metastases will ultimately die of liver failure;therefore,the treatment of liver tumor burden is critical to providing a survival impact.While surgical resection remains the only chance of cure for disease confined to the pancreas or for locoregional disease,the treatment of advanced or metastatic PNETs is more complex and often requires a multimodal approach.This review focuses on treatment options for well and moderately differentiated PNETs with metastatic disease to the liver.These include surgery,liver-directed therapies including ablative and intra-arterial therapies,and systemic therapies such as somatostatin analogues,targeted therapies,chemotherapy,and peptide receptor radionuclide therapy.Developing an individualized treatment strategy requires careful assessment of liver tumor burden and predicted biological behavior.Aggressive surgical resection of hepatic metastases secondary to PNET primary tumors is associated with improved survival in multiple retrospective studies.General goals of treatment for metastatic disease include prolonging overall survival and progression free survival,improving quality of life,and control of symptoms.

Updated evidence of primary tumor resection in stage IV breast cancer: a systematic review and meta-analysis

Background:In stage IV breast cancer,surgical resection of the primary tumor was traditionally performed solely to palliate symptoms such as bleeding,infection,or pain.The ongoing discussion has shown that there are many research gaps in the current literature and differences in clinical practice.Thus,this systematic review and meta-analysis was designed to evaluate how primary tumor resection(PTR)affects the overall survival(OS)of patients with stage IV breast cancer.Method:A thorough literature search was completed using different databases(PubMed,Google Scholar,Scopus,ScienceDirect,and Cochrane Library)to find papers contrasting PTR with no PTR.The quality of research articles was evaluated using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale(NOS).Review Manager 5.4 was used to determine how much demographic and clinical factors contribute to heterogeneity through subgroup and meta-regression analysis.Results:Data derived from 44 observational studies(OS)and four randomized controlled trials(RCTs)including 227,889 patients were analyzed.Of all cases,150,239 patients were included in the non-PTR group,and 70,795 patients in the PTR group(37 observational studies and 4 randomized control trials).The pooled outcomes of four RCT studies(Hazard Ratio(HR)=1.03,95%CI:0.67-1.58;I2=88%;P<0.0001;chi-square 24.57)favor non-PTR.While pooled outcomes of 43 observational studies showed PTR significantly improved OS(HR=0.66,95%CI:0.61-0.71;I2=87%;P<0.00001;chi-square 359.12).Additionally,subgroup analysis that compared PTR with non-PTR in patients with stage IV breast cancer for progression free-survival(HR=0.89,95%CI:0.62-1.28;P=0.03;I2=71%)and locoregional progression-free survival(LPFS)(HR=0.33,95%CI:0.14-0.74;P=0.0004;I2=87%)was found to be significant favoring the PTR group.Distant progression-free survival(DPFS)had a non-significant relationship(HR=0.42,95%CI:0.29-0.60;P=0.12;I2=53%),while overall,there was a significant relationship(HR=0.49,95%CI:0.32-0.75;P<0.00001;I2=90%).Subgroup analysis revealed that PTR is beneficial in patients with bone metastasis(HR=0.83,95%CI:0.68-1.01;P=0.01;I2=56%),with one metastatic site(HR=0.75,95%CI:0.63-0.59;P=0.006;I2=62%),but not in patients with positive margins(HR=0.84,95%CI:0.67-1.06;P=0.07;I2=61%),negative margins(HR=0.61,95%CI:0.59-0.63,P=1.00;I2=0%).Most of the patients in PTR and non-PTR groups belonged to white compared to other ethnic groups.Overall,observational studies were of high quality,while RCTs were of low quality.Conclusion:The current research suggests that PTR may be discussed as a possible option.

Proximal humerus reconstruction in orthopedic oncology

Proximal humeral reconstructive options following radical resection of proximal humeral primary and metastatic bone malignancies have evolved over time.With the relatively recent advent of the reverse total shoulder(RTSA),this technique has been increasingly employed in this setting over hemiarthroplasty techniques.An array of options,including proximal humeral allograft-prosthetic composites(including both RTSA and hemiarthroplasty),megaprostheses,and osteoarticular allografts,is reviewed from the perspective of their indications,techniques,complications,and published results.An extensive case-based pictorial presentation illustrates these options.