Gradually progressive cholangiolocellular carcinoma: a case report

Background: Immune checkpoint inhibitors (ICIs) are changing the paradigm of non-small cell lung cancer (NSCLC) treatment. However, in assessing tumor response, hyperprogression or pseudoprogression can cause difficulties in accurately identifying therapeutic response. We analyzed the usefulness of positron emission tomography-computed tomography (PET-CT) in treatment response assessment of ICI. Methods: We retrospectively analyzed 12 advanced NSCLC patients who used ICI (pembrolizumab) as the first-line treatment. Chest CT was taken at two cycle intervals, and PET-CT was taken before ICI treatment and after the 2nd cycle. Comparison of response evaluation of tumor size was analyzed using chest CT, and the standardized uptake value (SUV) max was compared using PET-CT. Results: Among 13 patients, eleven cases were male and one case was female. The mean age was 66.2 ± 6.7 years. Seven patients were treated with pembrolizumab monotherapy, and five patients were treated with pembrolizumab plus cytotoxic chemotherapy. 8 of the 12 patients received more than four cycles of treatment. The mean tumor size before treatment was 7.3 ± 3.3 cm and after treatment was 6.2 ± 3.7 cm, which was not statistically significant (P-value = 0.099). The mean SUV maximum value before treatment was 10.1 ± 3.3 and after treatment was 5.8 ± 2.6 cm, which was statistically significant (P-value = 0.004). SUV max showed a more pronounced trend than tumor size. Two of the five patients who showed stable disease in the first response assessment showed a partial response in the second response assessment. The mean SUV max value was decreased at 58.2% in these two patients. Conclusion: In evaluating the response of ICIs, PET-CT showed more predictive change compared to CT scan. In predicting the therapeutic response of an ICIs, measuring the metabolic activity of a tumor may be more important than comparing tumor size. PET CT may be a useful tool in evaluating the treatment response of ICI. Citation Format: JuWhan Choi, Hyun Seock Shin, Jee Youn Oh, Young Seok Lee, Kyung Hoon Min, Jae Jeong Shim, Sung Yong Lee. PET CT might be better than CT scan when evaluating immune checkpoint inhibitor response [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr B79.

BackgroundDespite considerable advances in preoperative imaging, up to one-third of patients operatively explored for hepatic colorectal metastases are unexpectedly found to harbor unresectable intrahepatic or extrahepatic disease.MethodsThe current study is a prospective, blinded study comparing utility of [18F]2-fluoro-2-deoxyglucose positron emission tomography (18F-FDG-PET) to computed tomography (CT) and CT arterial portography (CTAP) as preoperative staging.ResultsThe 125 planned subjects were enrolled. Findings seen on FDG-PET alone changed therapy for 23 of 125 patients (18%). FDG-PET confirmed other radiologic findings in 16 cases (13%), for an overall influence on therapy in 39 cases (31%). FDG-PET was the most sensitive diagnostic imaging test for extrahepatic cancer; it was 80–90% sensitive for extrahepatic cancer and 70–90% specific. For the 28 cases of unresectable disease due to extrahepatic disease, FDG-PET findings solely changed therapies in 16 cases (57%) and influenced therapy in seven other cases (25%). Of the 21 unresectable cases due to extent of intrahepatic disease, FDG-PET did not solely change therapy in any. Overall, FDG-PET had the lowest sensitivity for hepatic sites compared with CT or CTAP. In particular, small (<1 cm) liver tumors were particularly poorly detected by FDG-PET. The area under the receiver operating characteristic (ROC) curve for small tumors was 0.58 and for patients on chemotherapy it was 0.66, a modest improvement over no imaging.ConclusionsFDG-PET is an important test for preoperative staging of patients with hepatic colorectal metastases, affecting treatment decisions in nearly one-third of patients. The high yield is due mainly to detection of extrahepatic disease. It is therefore recommended in patients with extrahepatic lesions suspected to be disseminated cancer or those with high risk for extrahepatic disease. It is not a good test for identification of small tumors in the liver.

15 - Gastrointestinal Stromal Tumor: Computed Tomography

To evaluate the relationship between the signal intensity of hepatobiliary phase images on gadoxetic acid-enhanced magnetic resonance imaging (MRI) and histological grade. Fifty-nine patients with 82 hepatocellular lesions were evaluated retrospectively. Hepatobiliary phase images on gadoxetic acid-enhanced MRI were classified into 3 groups: low, iso or high. Angiography-assisted computed tomography (CT) findings were also classified into 3 groups: CT during arterial portography, and CT hepatic arteriography: A: iso, iso or low; B: slightly low, iso or low; and C: low, high. We correlated angiography-assisted CT, hepatobiliary phase findings during gadoxetic acid-enhanced MRI and histological grades. Furthermore, correlations between MRI findings and histological grade for each hemodynamic pattern were performed. Correlations among radiological and pathological findings were statistically evaluated using the chi-square test and Fisher' s exact test. There was a significant correlation between histological grade and hemodynamic pattern (P < 0.05). There was a significant correlation between histological grade and signal intensity in the hepatobiliary phase (P < 0.05) in group A lesions. There was no significant correlation between histological grade and signal intensity in the hepatobiliary phase in group B or C lesions (P > 0.05). Signal intensity in the hepatobiliary phase correlated with histological grade in the lesions that maintained portal blood flow, but did not correlate in lesions that showed decreased or defective portal blood flow.

Radiotherapy for Centrally Recurrent Cervical Cancer of the Vaginal Stump Following Hysterectomy

The prognostic value of tumor size in colon cancer remains controversial. This study aimed to reveal the correlation between tumor size and prognosis of colon cancer. A total of 491 patients with colon cancer were included in this study. The correlation of tumor size with prognosis, mismatch repair status, and other clinicopathological characteristics as well as tumor microenvironment was analyzed. For stage IIA microsatellite stable (MSS) colon cancer, tumors sized <3.5cm and ≥5cm were associated with a poorer disease free survival (DFS) compared with tumors sized between 3.5 and 5cm (P = .002). Small tumor size (HR = 5.098, P = .001) and large tumor size (HR = 2.749, P = .029) were found to be independent prognostic factors for stage IIA MSS colon cancer. Moreover, high expression of transgelin (TAGLN), a marker of cancer-associated fibroblasts (CAFs), was found to be an independent prognostic factor for poorer DFS (HR = 9.651, P = .009), which was also associated with smaller tumor size (P = .027). Small (<3.5cm) and large (≥5cm) tumor sizes are associated with decreased DFS in stage IIA MSS colon cancer. Enrichment of TAGLN+ CAFs is associated with decreased DFS and small tumor size.

A 70 year old white male with history of small cell carcinoma of the left parotid gland, status post total parotidectomy presents with 4 week history of worsening upper abdominal pain, mainly in the epigastric region. A CT scan of abdomen showed a large ill-defined inhomogeneous mass involving the head, neck and uncinate process of the pancreas with peri-pancreatic lymphadenopathy. EUS with FNA was performed, which revealed a large 4.5 cm mass in the head of the pancreas with a large 1.5 cm peri-pancreatic lymph node and a 2.5 cm celiac lymph node were seen. Cytology from the pancreatic mass and lymph nodes revealed a neuroendocrine carcinoma with small cell features. Immunohistochemistry showed positive staining for neuron specific enolase, synaptophysin and cytokeratin 20. These immunostains support a diagnosis of neuroendocrine tumor and showed an identical pattern with the parotid tumor. Small cell neuroendocrine carcinoma is extremely rare and is often difficult to distinguish from malignant lymphoma, adenoid cystic carcinoma, and undifferentiated carcinoma This is a rare and interesting case of neuroendocrine tumor of parotid gland, now presenting with a metastatic disease involving pancreas. We will present EUS, CT and histological images of small cell neuroendocrine tumor, both from the pancreas and parotid gland.

Pancreatic ductal adenocarcinomas often cause marked pancreatic duct dilatation and associated parenchymal atrophy. We present the case of a small pancreatic neuroendocrine tumor with upstream pancreatic duct dilatation and severe parenchymal atrophy. A small enhancing tumor was observed at the head of the pancreas on computed tomography (CT). Endoscopic ultrasonographyguided fine-needle aspiration was negative for malignancy. We performed a pylorus-preserving pancreatoduodenectomy since we could not exclude the presence of pancreatic ductal adenocarcinoma. The pathological and immunohistochemical examination revealed a serotonin-positive neuroendocrine tumor, measured 1.0 × 0.5 cm. The pathological specimen was remarkable for the marked stromal fibrosis in the area of the tumor, which resulted in narrowing of the main pancreatic duct. Here, we report a rare small pancreatic neuroendocrine tumor, the CT image of which resembled that of pancreatic ductal adenocarcinoma, in which the expression of serotonin and associated fibrosis might be a possible mechanism for the marked main pancreatic duct dilatation. (Korean J Med 2014;86:598-602)

Introduction: Insulinoma is an uncommon pancreatic neuro-endocrine tumour characterized by hyperinsulinemic hypoglycemia. It is important to surgically remove this tumor as it can cause potentially lethal hypoglycemia. The conventional imaging techniques have limitations in accurate pre-operative localization of small duodeno-pancreatic neuroendocrine tumors. The high spatial resolution of endoscopic ultrasound (EUS) permits better detection of such small tumors. We describe a report of 12 patients supporting the above observation. Results: 12 patients with insulinoma who had surgery at our institution were reviewed. (7 enucleation, 3 distal pancreatectomy, 2 unresectable). One of the patient with unresectable tumor was locally invasive and other had vascular invasion not detected on EUS prior to surgery. 9 of the tumors were located in the tail, 2 in head of pancreas and 2 in the body of pancreas (one patient had two tumors). The mean size of tumors was 2.72×2.18cm. Three patients had surgical resection done before EUS was available at our center. Pre-operative CT scan failed to localize the tumor in these patients. EUS done in the other nine patients accurately localized the tumor prior to surgical resection. Immunological staining on fine needle aspiration obtained at the time of EUS was consistent with insulinoma and revealed malignancy in one patient. One patient had two tumors which were detected on EUS prior to surgery. Conclusion: Our experience with 12 patients is in accordance with previous reports claiming EUS to be the method of choice for preoperative imaging and localization of pancreatic islet cell tumors. Preoperative evaluation is necessary for planning pancreatic surgery to assess for resectability

Liver and tumor segmentation from CT images is a complex and crucial step in achieving full-course adaptive radiotherapy and also plays an essential role in computer-aided clinical diagnosis systems. Deep learning-based methods play an important role in achieving automatic segmentation. This research aims to improve liver tumor detection performance by proposing a dual path feature extracting strategy and employing Swin-Transformer. The hierarchical Swin-Transformer is embedded into the encoder and decoder and combined with CNN to form a dual coding path structure incorporating long-range dependencies and multi-scale contextual connections to capture coarse-tuned features at different semantic scales. The features of the two encoding paths and the upsampling path are fused, tested and validated with LITS and in-house datasets. The proposed method has a DG of 97.95% and a DC of 96.2% for liver segmentation; a DG of 80.6% and a DC of 68.1% for tumor segmentation; and a classification study of the tumor dataset shows a DG of 91.1% and a DC of 87.2% for large and continuous tumors and a DG of 71.7% and a DC of 66.4% for small and scattered tumors. Swin-Transformer can be used as a robust encoder for medical image segmentation networks and, combined with CNN networks, can better recover local spatial information and enhance feature representation. Accurate localization before segmentation can achieve better results for small and scattered tumors.

Rationale:Neuroendocrine tumors (NETs) are neoplasms that can arise from the neuroendocrine cells distributed widely throughout the body. Majority of NETs overexpress somatostatin receptors (SSTR) on their cell surface. This biologic characteristic is exploited by SSTR-based imaging such as 111In octreotide scintigraphy and 68Ga DOTATATE positron emission tomography (PET)/computed tomography (CT), which are considered standard for initial evaluation of NETs. Although highly sensitive and specific, recent reports demonstrate a concerning incidence of “false-positive” physiologic uptake of these tracers in the pancreatic head – a common site of neuroendocrine tumor (NET) involvement. We present false positive uptake on 68Ga DOTATATE PET/CT along with false positive CT findings. Role of other imaging modalities is discussed.Patient concerns:A 78-year-old woman presented with a year-long history of diarrhea.Diagnosis:Serum vasoactive intestinal peptide (VIP) levels were slightly elevated at 134.2 pg/mL (normal <75 pg/mL). CT showed a mildly enhancing 2.5 cm × 1.8 cm × 2.8 cm area in the pancreatic uncinate process which corresponded to focal uptake with 68Ga DOTATATE PET/CT. A presumptive diagnosis of pancreatic NET (vipoma) was made, and the patient was scheduled to undergo Whipple's surgery.Interventions:She sought a second opinion and a subsequent magnetic resonance imaging (MRI) showed no lesion and the patient's surgery was deferred. Thereafter, her VIP levels spontaneously normalized. Endoscopic ultrasound (EUS) with fine needle aspiration cytology of the uncinate process showed normal pancreatic acini with no evidence of NET.Outcomes:Patient is currently pursuing workup for alternative etiologies for chronic diarrhea.Lessons:Conspicuous physiological uptake has been reported in the pancreatic head on 16% to 70% of 68Ga DOTATATE or 68Ga DOTANOC PET/CT scans, and 26% of the 111In octreotide scintigraphy scans. Image-based quantitative attempts to distinguish physiologic from pathologic uptake using SUVmax have rendered mixed results. When evaluating SSTR-based imaging uptake in the pancreatic head, patients can benefit from a higher index of suspicion of false positive uptake. Such cases require additional confirmation by MRI or EUS. Interestingly, the patient described also had mild contrast enhancement on CT, but without an MRI correlate. Because of potential morbidity and mortality related to false positive uptake, a systematic review with evidence-based recommendations for imaging may benefit patient care.

We present a case of invasive carcinoma of the pancreas derived from intraductal papillary adenocarcinoma without mucin hypersecretion in a 65-year-old man with a 45-year history of alcohol abuse and a 2-year follow-up of chronic pancreatitis. Two years previously, in May 1998, he was admitted for investigation of abdominal pain. Computed tomography (CT) showed diffuse dilation of the main pancreatic duct with atrophy of the pancreatic parenchyma. Endoscopic retrograde pancreatography (ERP) showed a diffusely dilated main pancreatic duct with irregular side branches in the head of the pancreas. Chronic alcoholic pancreatitis was diagnosed on the basis of the pancreatography findings. The patient was readmitted for investigation of progressive weight loss in August 2000. Serum CA19-9 levels were markedly elevated (750 U/ml) and CT showed enlargement of the head and body of the pancreas. ERP showed irregularity of the main pancreatic duct in the head of the pancreas, and the distal main pancreatic duct (which was dilated on initial ERP examination) was interrupted in the body of the pancreas. Suspected pancreatic carcinoma was diagnosed, and pylorus-preserving pancreatoduodenectomy was performed. Frozen section examination of the cut end of the pancreas revealed ductal carcinoma, and total pancreatoduodenectomy with portal vein resection was performed. Histologically, the resected tumor was diagnosed as an invasive carcinoma derived from intraductal papillary adenocarcinoma without mucin hypersecretion. We recommend observing changes in the pancreatic duct on pancreatography to diagnose invasive carcinoma of the pancreas derived from intraductal papillary adenocarcinoma in a resectable state.

Pitfalls of distal pancreatectomy for relief of pain in chronic pancreatitis

Objective To investigate the application value of sleeve pancreaticojejunostomy in digestive tract reconstruction. Methods The clinical data of 40 patients who underwent sleeve pancreaticojejunostomy at the Affiliated Hospital of Luzhou Medical College between July 2013 and February 2015 were retrospectively analyzed. The head of pancreas and duodenal descending part were drifted out through Kouch technique, sections were sutured in braid-like U shape and the small pancreatic ducts were closed. The posterior wall of pancreatic stump and jejunal wall were sutured routinely and main pancreatic tube was implanted by silica gel with the thrum retained. The reserved lines were gone through at 6 o'clock and 12 o'clock in the jejunal wall to be sutured and knotted, making the jejunal mucosa set on the surface of main pancreatic duct like sleeve, and then the anterior wall pancreatic stump was sutured. The intraoperative situation and amylase concentration of drainage at post-operative day 1, 3, 5, 7 were observed and monitored. The patients were followed up for liver function, tumor markers, abdominal color Doppler ultrasound every 3 months and enhanced abdominal computer tomography every 6 months till May 2015. Measurement data with skewed distribution were presented as M(Qn) and analyzed by rank-sum test. Measurement data with normal distribution data were presented as ±s. Repeated measurement data were analyzed by the repeated measures ANOVA. Results All the 40 patients underwent sleeve pancreaticojejunostomy successfully. The duration of operation and pancreaticojejunostomy were (6.2±1.3) hours and (15±6) minutes, respectively. The volume of intraoperative blood loss was (370±55)mL and diameter of tumor was (2.5±1.5)cm. The amylase concentrations of drainage at postoperative day 1, 3, 5, 7 were 46.300 U (35.575 U, 68.600 U), 34.900 U (21.050 U, 55.550 U), 26.750 U (0.000 U, 41.400 U) and 0.000 U(0.000 U, 30.500 U), showing decrease trend with the time gone (F=97.268, P<0.05). Among the 40 patients, 2 had increase of drainage amylase concentration at anastomotic stoma with the drain amount less than 50 mL/d, showing normal temperature, no signs of abdominal pain and peritonitis and potential pancreatic leakage, they were recovered after symptomatic and supportive treatments. The other patients had no complications such as anastomotic leakage and hemorrhage. The duration of hospital stay of 40 patients was (18±5)days. Thirty-nine patients were followed up for 3-15 months, showing no postoperative anastomotic stenosis, acute or chronic pancreatitis and pancreatolithiasis, 1 of whom with recurrence tumor. Conclusion Sleeve pancreaticojejunostomy is easy to master, safe and reliable, and it is suitable for soft pancreatic tissue. Key words: Pancreatic diseases; Pancreaticoduodenectomy; Sleeve pancreaticojejunostomy

Results of 68Gallium-DOTATATE PET/CT Scanning in Patients with Multiple Endocrine Neoplasia Type 1