We report a rare presentation of metastatic renal cell carcinoma (RCC) in a 71-year-old man who presented with persistent shoulder pain. MRI revealed widespread lytic lesions within the bones ...suggestive of metastatic disease but extensive imaging including CT chest, abdomen and pelvis with contrast and fluorodeoxyglucose-positron emission tomography did not identify a primary cancer. The diagnosis was ultimately made from a targeted bone and subsequently targeted liver biopsy, whereby immunohistochemistry was consistent with metastatic RCC (mRCC). While bone metastases in RCC are very common, it is extremely rare for patients to present with mRCC and no identifiable renal primary.
Chemotherapy (CT) is widely used for neuroendocrine tumours (NETs), but there are no validated biomarkers to predict response. The Ki-67 proliferation index has been proposed as a means of selecting ...patients for CT, but robust data are lacking. The aim of this study was to investigate the relationship between response to chemotherapy and Ki-67 in NET. We reviewed data from 222 NET patients treated with CT. Tumours were graded according to Ki-67 index: G1 ≤2%, G2 3-20% and G3 >20%. Response was assessed according to RECIST and survival calculated from start of chemotherapy to death. To explore Ki-67 as a marker of response, we calculated the likelihood ratio and performed receiver operating characteristic analysis. Overall, 193 patients had a documented Ki-67 index, of which 173 were also evaluable for radiological response: 10% were G1, 46% G2 and 43% G3; 46% were pancreatic NET (PNET). Median overall survival was 22.1 months. Overall response rate was 30% (39% in PNET vs 22% in non-PNET) and 43% of patients had stable disease. Response rate increased with grade: 6% in G1 tumours, 24% in G2 and 43% in G3. However, maximum likelihood ratio was 2.3 at Ki-67=35%, and the area under the ROC curve was 0.60. As reported previously, a high Ki-67 was an adverse prognostic factor for overall survival. In conclusion, response to CT increases with Ki-67 index, but Ki-67 alone is an unreliable means to select patients for CT. Improved methods to stratify patients for systemic therapy are required.
Abstract Introduction The presence of positive nodal disease (LND) and the number of lymph nodes involved (LNB) are known to be significant prognostic markers for resected adenocarcinoma of the ...pancreas. In addition, the ratio of the number of involved nodes to the number of nodes resected known as the lymph node ratio (LNR) is emerging as an important prognostic marker. The role of the resection margin (RM) as presently defined (R1 ≤ 1 mm) is unclear as results differ based on the dataset. The aim of this study was to assess the impact of nodal disease and a redefined RM on outcome. Material and methods Retrospective analysis of pancreatic head resections for adenocarcinomas from 2003–2009. The RM was re‐analysed based on tumour clearance and categorized into: histopathological evidence of a tumour; ≤0.5 mm, ≤1 mm, ≤1.5 mm, or ≤2.0 mm of the actual surgical resection margin. The impact of histopathological variables on cancer‐specific survival (CSS) and disease‐free survival (DFS) was analysed. Results LND, LNB and LNR were independent prognostic markers for CSS ( P = 0.048, 0.003, 0.016) but, did not influence DFS. A LNR < 0.143 was associated with a higher CSS 38.16 ± 4.69 versus 20.59 ± 2.20 months, P = 0.0042, hazard ratio (HR) 3.74 (95% confidence interval (CI) 1.52–9.23). An R1 RM was not associated with CSS or DFS on multivariate analysis, irrespective of the distance. LNB and LNR maintained independent significance irrespective of the size of the RM. Conclusion LNB and LNR are the only prognostic factors for CSS in patients with pancreatic head adenocarcinoma, but do not predict recurrence. Microscopic RMs does not seem to influence the outcome even when redefined. Further prospective studies are indicated to substantiate these findings.
A 63-year-old man, a wheelchair user, from primary progressive multiple sclerosis (MS), presented with an episode of expressive dysphasia and confusion. Cerebral imaging revealed a solitary cerebral ...mass that was radiologically felt to be a primary brain tumour, but a brain biopsy demonstrated an adenocarcinoma in keeping with brain metastasis. Further immunohistochemistry suggested a probable colorectal primary. Subsequent staging confirmed a primary cancer within the caecum/terminal ileum, with extensive bilobar unresectable liver metastases. Unfortunately, as a consequence of the heavy tumour burden and rapid disease progression, the patient deteriorated rapidly and, due to his poor performance status, palliative chemotherapy was not deemed suitable. He was offered palliative whole brain radiotherapy to help control his symptoms, but he declined. He subsequently died at home a few weeks later, as per his wishes.
Cytotoxic T lymphocytes (CTLs) specific for an HLA-A2–presented peptide epitope of the Wilms tumor antigen-1 (WT1) can selectively kill immature human leukemia progenitor and stem cells in vitro. In ...this study we have used retroviral gene transfer to introduce a WT1-specific T-cell receptor (TCR) into T lymphocytes obtained from patients with leukemia and from healthy donors. TCR-transduced T cells kill leukemia cells in vitro and display WT1-specific cytokine production. Intravenous injection of TCR-transduced T cells into nonobese diabetic–severe combined immunodeficiency (NOD/SCID) mice harboring human leukemia cells resulted in leukemia elimination, whereas transfer of control T cells transduced with an irrelevant TCR was ineffective. The data suggest that adoptive immunotherapy with WT1-TCR gene–modified patient T cells should be considered for the treatment of leukemia.
Systemic lupus erythematosus (SLE) is known as the ‘great imitator’ mimicking a myriad of conditions often resulting in a delayed diagnosis. We report a case with multisite adenopathy radiologically ...suggestive of lymphoma who initially was referred to the ‘Cancer of Unknown Primary’ team. Following a re-evaluation of the case the patient was diagnosed with SLE and was started on appropriate therapy. Many conditions presenting to oncology may mimic cancer which needs to be borne in mind when assessing referred cases.
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