Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression—a case report

Background Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer. Case presentation A 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later. Conclusion Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Is adjuvant chemotherapy necessary in older patients with breast cancer?

Background Due to the lack of clinical trials on the efficacy of chemotherapy in older patients, an optimal treatment strategy has not been developed. We investigated whether adjuvant chemotherapy could improve the survival of older patients with breast cancer in Japan. Methods We retrospectively analyzed data of patients with breast cancer aged ≥ 70 years who underwent breast cancer surgery in eight hospitals between 2008 and 2013. Clinical treatment and follow-up data were obtained from the patients’ medical electric records. Results A total of 1095 patients were enrolled, of which 905 were included in the initial non-matched analysis. The median age and follow-up period were 75 (range 70–93) and 6.3 years, respectively. Of these patients, 127 (14%) received adjuvant chemotherapy (Chemo group) while the remaining 778 (86%) did not (Control group). The Chemo group was younger (mean age in years 73 vs 76; P < 0.0001), had a larger pathological tumor size (mean mm 25.9 vs 19.9; P < 0.0001), and more metastatic axillary lymph nodes (mean numbers 2.7 vs 0.7; P < 0.0001) than the Control group. The disease-free survival (DFS) and overall survival (OS) did not differ significantly between the two groups (P = 0.783 and P = 0.558). After matched analyses, DFS was found to be significantly prolonged with adjuvant chemotherapy (P = 0.037); however, OS difference in the matched cohort was not statistically significant (P = 0.333). Conclusion The results showed that adjuvant chemotherapy was associated with a reduced risk of recurrence, but survival benefits were limited.

Longitudinal CT Imaging to Explore the Predictive Power of 3D Radiomic Tumour Heterogeneity in Precise Imaging of Mantle Cell Lymphoma (MCL)

The study’s primary aim is to evaluate the predictive performance of CT-derived 3D radiomics for MCL risk stratification. The secondary objective is to search for radiomic features associated with sustained remission. Included were 70 patients: 31 MCL patients and 39 control subjects with normal axillary lymph nodes followed over five years. Radiomic analysis of all targets (n = 745) was performed and features selected using the Mann Whitney U test; the discriminative power of identifying “high-risk MCL” was evaluated by receiver operating characteristics (ROC). The four radiomic features, “Uniformity”, “Entropy”, “Skewness” and “Difference Entropy” showed predictive significance for relapse (p < 0.05)—in contrast to the routine size measurements, which showed no relevant difference. The best prognostication for relapse achieved the feature “Uniformity” (AUC-ROC-curve 0.87; optimal cut-off ≤0.0159 to predict relapse with 87% sensitivity, 65% specificity, 69% accuracy). Several radiomic features, including the parameter “Short Axis,” were associated with sustained remission. CT-derived 3D radiomics improves the predictive estimation of MCL patients; in combination with the ability to identify potential radiomic features that are characteristic for sustained remission, it may assist physicians in the clinical management of MCL.

Frequency and intensity of [18F]-PSMA-1007 uptake after COVID-19 vaccination in clinical PET

Objectives: To assess the frequency and intensity of [18F]-PSMA-1007 axillary uptake in lymph nodes ipsilateral to COVID-19 vaccination with BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) in patients with prostate cancer referred for oncological [18F]-PSMA PET/CT or PET/MR imaging. Methods: One hundred twenty six patients undergoing [18F]-PSMA PET/CT or PET/MR imaging were retrospectively included. [18F]-PSMA activity (SUVmax) of ipsilateral axillary lymph nodes was measured and compared with the non-vaccinated contralateral side-and with a non-vaccinated negative control group. [18F]-PSMA active lymph node metastases were measured to serve as quantitative reference. Results: There was a significant difference in SUVmax in ipsilateral and compared to contralateral axillary lymph nodes in the vaccination group (n = 63, p < 0.001) and no such difference in the non-vaccinated control group (n = 63, p = 0.379). Vaccinated patients showed mildly increased axillary lymph node [18F]-PSMA uptake as compared to non-vaccinated patients (p = 0.03). [18F]-PSMA activity of of lymph node metastases was significantly higher (p < 0.001) compared to axillary lymph nodes of vaccinated patients. Conclusions: Our data suggest mildly increased [18F]-PSMA uptake after COVID-19 vaccination in ipsilateral axillary lymph nodes. However, given the significantly higher [18F]-PSMA uptake of prostatic lymph node metastases compared to “reactive” nodes after COVID-19 vaccination, no therapeutic and diagnostic dilemma is to be expected. Advances in knowledge: No specific preparations or precautions (e.g., adaption of vaccination scheduling) need to be undertaken in patients undergoing [18F]-PSMA PET imaging after COVID-19 vaccination.

CD8+ mycosis fungoides: A wolf in sheep’s clothing?

Sir, CD8+ mycosis fungoides (MF) is a rare form of MF with an indolent course. Herein, we report a rare case of CD8+ fungoid mycosis preceded by lymphomatoid papulosis type D with an aggressive course. A 36-year-old female presented with several papular lesions on the trunk and extremities with a relapsing–remitting course. Histopathology and an immunohistochemical study confirmed CD8-positive lymphomatoid papulosis type D and methotrexate at 25 mg/week was initiated. After a temporary clinical improvement, the lesions worsened, became infiltrated, and grouped as vaguely annular and angular patches with serpiginous borders (Fig. 1). A second scalp biopsy was performed and a diagnosis of CD8+ MF was established. An extension workup was normal, and MF was classified as stage IB. PUVA therapy was started with acitretin at 25 mg/day. After four weeks from the beginning of treatment, the patches completely disappeared but with the concomitant appearance of four subcutaneous tumors. The evolution was spectacular in fifteen days, with the tumors rapidly increasing in size, becoming ulcerative and necrotic, and one being localized in the left cervical area compressing the upper respiratory tract (Fig. 2). A subsequent biopsy revealed massive epidermal and dermal large cell infiltration (Fig. 3a); the tumor cells were positive for CD3, CD8, and CD7 (Fig. 3b) and negative for CD4, CD5, CD3, CD2, and CD30. Antigen Ki-67 was expressed by more than 80% of T-cells (Fig. 3c). A cerebral and thoraco-abdominal CT scan revealed multiple axillary lymph nodes with hypermetabolism on a PET scan. An osteomedullar biopsy was normal, and lactate dehydrogenase (LDH) was increased to 358 U/L. Chemotherapy was performed, but the patient died after two cycles of CHOEP. In contrast to classical CD4+ mycosis fungoides, CD8+ MF is a rare cytotoxic phenotype constituting about 5% of all cases of MF [1]. It belongs to the first group of primary cytotoxic cutaneous lymphomas (PCCL) with a good prognosis, an indolent course, and a slow progression of the lesions over several years [2]. However, rare cases with a more aggressive course have been reported in the literature [3]. The main differential diagnosis of aggressive CD8+ MF is an aggressive epidermotropic cutaneous CD8+ lymphoma that is a rare cutaneous lymphoma with a poor prognosis due to rapid extracutaneous dissemination [4]. The prognosis of the CD8+ subtype of mycosis fungoides (MF) is controversial. More studies are necessary to clarify this subject.

Primary Small Cell Malignancies of the Breast: Are They Rare Malignancies?

In contrast with the other organs such as the lung, small cell tumors have been less studied in the breast due to their relatively less frequency. Although rare, neuroendocrine neoplasms, some lymphomas, and some small cell sarcomas such as undifferentiated small round cell sarcoma and rhabdomyosarcoma can be seen in small cell morphology in the breast. Many cytological specimens such as fine-needle aspiration biopsies and touch imprint cytology are used for diagnosis and further prognostic/predictive marker determination in primary breast masses, sentinel and axillary lymph nodes, and metastatic masses. Lobular carcinoma deserves to be considered in the small cell tumor group because of its small, monomorphic, discohesive, scant cytoplasmic cytological features. Since so many different types of tumors in the breast can have small cell characteristics, they should be divided into small cell neuroendocrine tumors and small cell nonneuroendocrine tumors. When evaluating small cell breast tumors cytologically, wide tumor diversity should be kept in mind, and clinical, hematological, and radiological features should be taken into consideration.

Computed tomographic findings and clinical features in dogs with canine cutaneous lymphoma: 10 cases (2007–2018)

OBJECTIVE To report clinical features, CT findings, treatment protocols, and outcomes for dogs in which canine cutaneous lymphoma (CCL) was diagnosed. ANIMALS 10 client-owned dogs with CCL. PROCEDURES Medical records of dogs in which a diagnosis of CCL had been made between September 2007 and July 2018 and in which CT had been performed prior to treatment were reviewed. All available CT studies were reviewed, and an anatomical reference system was developed to map observed lesions. Treatment protocols and patient outcomes were summarized. RESULTS 14 CT examinations were performed on the 10 dogs, and 9 dogs had lesions consistent with CCL on CT images. Nodular lesions were present in 8 dogs, and cutaneous or subcutaneous mass lesions were seen in 3. Well-defined, diffusely distributed, contrast-enhancing, cutaneous or subcutaneous nodules were most common; mass lesions were more variable in appearance. Nine dogs had lymphadenopathy, with the mandibular and axillary lymph nodes most commonly affected. Four dogs had confirmed nodal involvement, and 4 had confirmed visceral involvement. Nine dogs received treatment with chemotherapy, and 5 had a complete response. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that dogs with CCL may have a wide spectrum of CT findings. Many of these lesions, including affected lymph nodes, would be unlikely to be detected clinically, suggesting that CT may be a useful modality to assess the severity of disease and for guiding selection of local versus systemic treatment.

Frequency of Malignancies in Surgical Subjects and Subjects with Mass in Breast in the Surgical Department of Pumhsw Nawabshah Pakistan

Objective: To conclude frequency for malignancies in subjects with mass in breast at the PUMHSW Nawabshah department of surgery Wards. Design of Study: This is an Observational research. Duration & Location of Study: Current research was carried out in surgery at Nawabshah People's Medical College Hospital (SBA) from November 20, 2018 to November 20, 2020. Methodology: This research comprised of 200 subjects. A comprehensive history was taken from total subjects with special consideration for breast nodules & axillary lymph nodes & recorded proforma to evaluate the affected area was specifically inspected. A systematic review was also conducted to identify comorbidities. Total subjects received baseline & specific tests, especially radiological & histopathological reports. The selection criterion was that total female subjects over the age of 15 associated with mass in breast were included in this research. Exclusion criteria were subjects with breast abscesses & those who were diagnosed & treated for breast cancer with recurrent lesions. Results: the range of age started from 15-65 years, 39+4.11 years was mean age. lesion of Benign nature on biopsy were were Fibroadenoma 22%, intraductal papilloma 9%, Phylloid Tumor Benign 6% & lactating adenoma 5%. Neoplastic nature was observed on biopsy invasive ductal carcinoma 19%, Invasive lobular carcinoma 11% & malignant phylloides tumor 9%. Conclusion: Study determined that frequency of breast malignancy in breast lumps was 58%.