Mullerian Serous Cystadenoma Occurring in the Scrotum Post-Orchidopexy: A Rarely Reported Yet Distinctive Entity.

Serous cystadenoma is a rare lesion in the para-testicular tissue, with even rarer reports of this entity occurring in the scrotum post-orchidopexy. We present such an occurrence, adding support for its existence as a distinct entity.

Extramammary Paget's Disease of the Scrotal and Penile: A Case Report and Review of the Literature.

INTRODUCTION: Extramammary Paget's disease of the scrotum and penis is a relatively rare cutaneous malignant tumor. At present, its pathogenesis, and clinical and pathological characteristics are not very clear. This is controversial regarding surgical margin width to decrease the high recurrence rate. This paper aimed to report the case and review the literature of extramammary Paget's disease of scrotum and penis. CASE PRESENTATION: We presented the case of a 74-year-old male patient with the patchy erythema and pruritus in the perineum who was admitted to our department. Biopsy of the large plaque revealed Paget disease. Under the condition of ensuring negative surgical margins by rapid frozen pathology, a wide local excision of the lesion, bilateral orchiectomy, and adnexectomy were performed on the patient. Pathology revealed that many scattered vacuolated Paget cells were observed in the epidermal layer, and the diagnosis was Paget's disease of the scrotum and penis. The 2 cm outside the skin lesion was used as the initial surgical margin, and free skin flap transplantation was used to repair the surgical wound. The patient recovered well and was discharged 1 week after surgery. CONCLUSION: Currently, histopathologic biopsy is the most important diagnostic method for EMPD. Once confirmed, for patients eligible for surgical intervention, wide local excision of the lesion and rapid intraoperative frozen pathological examination should be performed as soon as possible. The skin flap transplantation is the first choice for the repair of large-scale wound after surgery.

Multiple Penile and Scrotal Schwannomas in an Adult Patient: A Case Report.

INTRODUCTION: Schwannomas originate from the peripheral nerve sheaths and are mainly detected in the head, neck, or extremities. They are rarely encountered in the penoscrotal region. CASE PRESENTATION: Herein, we present a case of a penoscrotal schwannoma diagnosed and successfully treated in our center. A 40-year-old patient with a history of resection of a dorsal penile schwannoma presented with multiple nodular lesions at the scrotum, penile shaft, and radix, which were first noticed 5 years before his current presentation. He complained about penile pain and dyspareunia. Magnetic resonance imaging was performed for preoperative diagnosis. All nodular lesions were resected while preserving the neurovascular structures. The histopathological examination revealed benign lesions. The patient's complaints were resolved, and there was no recurrence during the 1-year follow-up. CONCLUSION: The primary treatment is surgical excision. The patients need close follow-up regarding the risks of recurrence and malignant transformation.

A Giant Scrotal Neurofibroma in a Child Masquerading as Filariasis: Uncommon Presentation of a Common Disease.

Neurofibroma of the scrotum is a very uncommon benign neoplasm, specifically when it affects teenagers and is not associated with neurofibromatosis type I. To the best of our knowledge, only a couple of cases of neurofibroma in children have been documented. Here, we report a case study of a 17-year-old boy who had a giant scrotal lump for ten years masquerading clinically as filariasis. A provisional diagnosis of benign nerve sheath neoplasm was made based on cytology findings. The lump was surgically removed from the patient, and a histopathological and immunohistochemistry examination established the diagnosis of neurofibroma. The combined clinical, preoperative cytological, histological, and immunohistochemistry findings were not presented in the literature in any of the formerly documented cases of scrotal neurofibroma. The current case expands the spectrum of differential diagnoses for scrotal tumours that clinicians have previously observed.

WHO 2022 classification of penile and scrotal cancers: updates and evolution.

Squamous cell carcinoma (SCC) is the most common malignant tumour of the penis. The 2022 WHO classification reinforces the 2016 classification and subclassifies precursor lesions and tumours into human papillomavirus (HPV)-associated and HPV-independent types. HPV-associated penile intraepithelial neoplasia (PeIN) is a precursor lesion of invasive HPV- associated SCC, whereas differentiated PeIN is a precursor lesion of HPV-independent SCC. Block-type positivity of p16 immunohistochemistry is the most practical daily utilised method to separate HPVassociated from HPVindependent penile SCC. If this is not feasible, the term SCC, not otherwise specified (NOS) is appropriate. Certain histologies that were previously classified as "subtypes" are now grouped, and coalesced as "patterns", under the rubric of usual type SCC and verrucous carcinoma (e.g. usual-type SCC includes pseudohyperplastic and acantholytic/pseudoglandular carcinoma, and carcinoma cuniculatum is included as a pattern of verrucous carcinoma). If there is an additional component of the usual type of invasive SCC (formerly termed hybrid histology), the tumour would be a mixed carcinoma (e.g. carcinoma cuniculatum or verrucous carcinoma with usual invasive SCC); in such cases, reporting of the relative percentages in mixed tumours may be useful. The consistent use of uniform nomenclature and reporting of percentages will inform the refinement of future reporting classification schemes and guidelines/recommendations. The classification of scrotal tumours is provided for the first time in the fifth edition of the WHO Blue book, and it follows the schema of penile cancer classification for both precursor lesions and the common SCC of the scrotum. Basal cell carcinoma of the scrotum may have a variable clinical course and finds a separate mention.

NIRVANA-1: maintenance therapy with niraparib versus niraparib-bevacizumab in patients with advanced ovarian cancer.

Following the results of the PRIMA and PAOLA-1 trials, the most effective maintenance strategy for International Federation of Gynecology and Obstetrics stage III patients is still debated, raising the question which of those two maintenance strategies is the most effective: PARP inhibitors alone or PARP inhibitors in combination with bevacizumab. The ongoing NIRVANA-1 study will try to answer this question by assessing the efficacy and safety of niraparib + bevacizumab in comparison with niraparib alone after adjuvant chemotherapy for completely resected stage III patients. Stratification factors include tumor BRCA status, International Federation of Gynecology and Obstetrics stage (IIIA vs IIIB/IIIC) and the use of hyperthermic intraperitoneal chemotherapy during surgery - within the OVHIPEC-2 trial. The primary end point will be progression-free survival rate at 24 months. Safety, median progression-free survival and overall survival will also be studied.

In many patients with ovarian cancer who are treated with platinum-based chemotherapy after surgery, the tumor comes back several months later. In order to minimize this risk, one treatment approach that has shown promising results is PARP inhibitors. This treatment works by inhibiting cancer cells' ability to repair themselves after DNA damage. One of the PARP inhibitors approved by medical authorities is niraparib, used as a solo therapy after surgery and chemotherapy. Nevertheless, the most effective maintenance strategy for patients in this setting is still debated. In a worldwide clinical trial called NIRVANA-1, researchers are investigating how niraparib would work if combined with another treatment called bevacizumab, which stops the growth of new blood vessels in tumors. Patients who participate in this trial will be randomly assigned to one of two treatment groups: the combination of niraparib + bevacizumab or niraparib by itself. The main purpose of NIRVANA-1 is to understand whether the combination of niraparib and bevacizumab prevents the cancer from returning in patients with completely resected stage III ovarian cancer. The trial will also assess the safety of this combination compared with niraparib alone. At the time of this writing, NIRVANA-1 is open for new patients to join. Sponsored by ARCAGY-GINECO, the NIRVANA-1 trial is currently recruiting patients from France, Spain, Italy, Belgium, Japan and Korea. The duration of the inclusion period is estimated to be around 36 months. The study is registered on ClinicalTrial.gov with registration number NCT05183984.

Extremely rare pediatric primary scrotum tumor: spermatic cord hemolymphangioma for a case report and literature review.

Hemolymphangioma is an uncommon benign tumor type that commonly occurs in the head and neck. Primary spermatic cord hemolymphangioma (SCH) with only several reported, however, is extremely rare. Clinical diagnosis can be challenging because of its rarity. Although spermatic cord hemolymphangiomas are benign tumors, there is still a high recurrence rate in postoperative. A 15-year-old boy presented to our hospital with complaints of scrotal for 15 days and did not have other associated symptoms. The male genital color Doppler ultrasound revealed that a cystic echo in the left spermatic cord region and above the testes was about 32 mm × 20 mm × 14 mm. He underwent left en bloc scrotum tumor resection under general anesthesia, and pathologic examination showed SCH. He was discharged from the hospital in the second postoperative day. After 1-month follow-up, the patient recovered well without recurrence. The patient is currently in follow-up phase. Up to date, only a few cases have been reported in the literature about SCH. So, we hope to raise the awareness of the diagnosis of SCH in clinical practice although this case.

Low-grade endometrial stromal sarcoma-like tumors in male with JAZF1 gene fusions.

Low-grade endometrial stromal sarcoma (ESS) is a hormone-responsive low-grade sarcoma typically occurring in the uterine corpus in women. Their genetic hallmarks are recurrent gene fusions involving JAZF1, partnering with either SUZ12 gene or less commonly with PHF1. Low-grade ESS-like sarcoma, or endometrioid stromal sarcoma, is exceptionally rare in males and has been reported to date only in two cases, one in the paratesticular area and the other of prostatic stromal origin. We report herein two new cases of low-grade ESS-like sarcoma in male patients, one presenting as a periprostatic/peri-rectal mass with a JAZF1-GLI3 fusion, while the other as a paratesticular mass with a JAZF1-PHF1 fusion. As the GLI3 fusion appeared novel, we searched the transcriptional signature of 35 low-grade ESS from our archives and found a similar JAZF1-GLI3 fusion in a low-grade ESS arising from the uterine corpus, supporting a common pathogenesis. Histopathologically, both cases demonstrate cellular, monotonous proliferation of ovoid to fusiform cells with a background of arteriolar vascular network. Immunohistochemically, the neoplastic cells express ER, PR, and CD10, similar to ESS. One case also expresses diffuse and strong AR. On follow-up, the patient with the periprostatic mass recurred 2 years after initial surgery with peritoneal "sarcomatosis." We describe the salient diagnostic morphologic, immunohistochemical, and molecular features and discuss the differential diagnosis and possible pathogenesis of this unusual entity.

A case of spermatic cord B-cell lymphoma relapsing to the brain in a dog.

A 13-year-old, intact male mixed-breed dog was referred to our clinic for lethargy and asthenia following an episode of gastroenteritis. As an incidental finding during abdominal ultrasound, a mass on the right spermatic cord was seen. Cytology of the mass revealed a monomorphic population of large, round cells with a lymphoid appearance. A bilateral orchiectomy was conducted, and histopathology revealed the presence of a B-cell lymphoma in the right spermatic cord. Based on clinical staging, which showed no involvement of other sites, no additional treatment was administered. Recheck evaluations were scheduled for every 3 mo thereafter. Five months after surgery, the dog developed left central vestibular syndrome with a paradoxical right-sided head tilt. An MRI of the brain showed multifocal lesions and, due to a rapidly worsening clinical condition, the dog was humanely euthanized. The histopathology of the brain lesions was consistent with B-cell lymphoma. Key clinical message: This is the first report of a primary spermatic cord lymphoma relapsing to the brain in a dog. Although rare, spermatic cord tumors should be included among the differential diagnoses for masses arising from the spermatic cord. If lymphoma is diagnosed, location to other sites, especially to the central nervous system, should be considered.

Un cas de lymphome à cellules B du cordon spermatique récidivant au cerveau chez un chien. Un chien de race mixte mâle intact de 13 ans a été référé à notre clinique pour léthargie et asthénie à la suite d'un épisode de gastro-entérite. Comme découverte fortuite lors d'une échographie abdominale, une masse sur le cordon spermatique droit a été observée. La cytologie de la masse a révélé une population monomorphe de grosses cellules rondes d'aspect lymphoïde. Une orchidectomie bilatérale a été réalisée et l'histopathologie a révélé la présence d'un lymphome à cellules B dans le cordon spermatique droit. Sur la base du stade clinique, qui n'a montré aucune implication d'autres sites, aucun traitement supplémentaire n'a été administré. Des évaluations de contrôle étaient programmées tous les 3 mois par la suite. Cinq mois après la chirurgie, le chien a développé un syndrome vestibulaire central gauche avec une inclinaison paradoxale de la tête du côté droit. Une IRM du cerveau a montré des lésions multifocales et, en raison d'une détérioration rapide de l'état clinique, le chien a été euthanasié sans cruauté. L'histopathologie des lésions cérébrales correspondait à un lymphome à cellules B.Message clinique clé :Il s'agit du premier rapport d'un lymphome primaire du cordon spermatique récidivant au cerveau chez un chien. Bien que rares, les tumeurs du cordon spermatique doivent être incluses dans les diagnostics différentiels des masses provenant du cordon spermatique. Si un lymphome est diagnostiqué, la localisation vers d'autres sites, en particulier vers le système nerveux central, doit être envisagée.(Traduit par Dr Serge Messier).

Spermatic cord leiomyosarcoma in a young male: A case report and literature review.

Spermatic cord Leiomyosarcoma is an extremely rare intrascrotal tumour. Owing to its rarity, no definitive management guidelines have been formulated as yet. The majority of published literature comprises of case reports or case series and show varying outcomes depending upon multiple patient- and disease-related factors. Almost all cases are older adults with majority in the sixth or seventh decades of life. It is commonly labelled as an indolent curable tumour if treated Spermatic cord Leiomyosarcoma is an extremely rare intrascrotal tumour. Owing to its rarity, no definitive management guidelines have been formulated as yet. The majority of published literature comprises of case reports or case series and show varying outcomes depending upon multiple patient- and disease-related factors. Almost all cases are older adults with majority in the sixth or seventh decades of life. It is commonly labelled as an indolent curable tumour if treated early by radical orchiectomy. The role of lymphadenectomy, adjuvant radiotherapy or chemotherapy is unclear. This case report concerns a young 38-year-old man who suffered from a painless firm left hemiscrotal mass for the past two years. Ultrasonography showed an intrascrotal paratesticular mass. Metastatic workup was negative. Left radical orchiectomy was performed and histopathology of the surgical specimen revealed leiomyosarcoma of the spermatic cord. The patient is on post-surgery follow-up and disease-free for six months. A literature review is also presented.

Paratesticular Dedifferentiated Liposarcoma with Rhabdomyoblastic Differentiation: A Case Report and Review of the Literature.

Liposarcomas of the paratesticular tissue is a rare pathological entity. The symptoms are similar to inguinal hernias or hydroceles. We present the case of an 84-year-old man with a rare paratesticular liposarcoma that manifested as painless right hemiscrotal swelling. Testicular tumour markers were negative. Imaging revealed a heterogeneous mass with a fat component. He underwent a radical orchiectomy on the left side to remove the associated mass. This revealed dedifferentiated liposarcoma (DDLS) with rhabdomyoblastic differentiation and MDM2 amplification. The surgical margins were negative, and the patient had a metastatic workup that included magnetic resonance imaging (MRI) of the abdomen and pelvis. Because of the disease's rarity, there is no clear agreement on radiotherapy and chemotherapy roles.

Multiparametric Ultrasound Diagnostic Approach to Malignancy-Mimicking Adenomatoid Tumors of the Scrotum: Is Strain Elastography Enough?

Background: Paratesticular tumors (PTs) are very uncommon, accounting for almost 5% of intrascrotal tumors. Of these, adenomatoid tumors (ATs) represent about 30% and most frequently arise in the tail of the epididymis. Ultrasound (US) examination is the first-choice imaging method employed for the evaluation of the scrotum. Unfortunately, there are no specific US-imaging features useful for distinguishing an AT from a malignant lesion. To increase diagnostic accuracy and confidence, new sonographic techniques have incorporated real-time tissue elastography (RTE) under the assumption that malignant lesions are "harder" than benign lesions. Case report: In our paper, we describe a very rare case of a 60-year-old patient with a giant paratesticular mass mimicking malignancy when examined using RTE, i.e., it was stiffer than the surrounding tissue (a hard pattern), which, upon histologic examination, was identified as an AT. Discussion: Our case underscores that there is also a significant overlap between different types of scrotal lesions when RTE is used for examination. Thus, if a PT is found, the imaging approach should always be supplemented with more definitive diagnostic methods, such as FNAC or FNAB, which are the only diagnostic methods capable of leading to a certain diagnosis. Conclusions: Alongside underlining the importance of pre-operative imaging for making correct diagnoses and selecting the correct therapy, we wish to draw our readers' attention to this report in order to demonstrate the clinical implications of a giant AT presenting as stiff lesions when examined using SE.

[Primary Leiomyosarcoma of the Epididymis : A Case Report].

A 63-year-old man presented with right scrotal swelling. A physical examination revealed a painless, palpable mass in the right scrotum. The mass was well defined and lobulated. Subsequently, a diagnosis of right epididymal tumor was made, and right high orchiectomy was performed. Hematoxylin-eosin and immunostaining revealed leiomyosarcoma of the epididymis. When a diagnosis of epididymal malignant tumor is made, the standard treatment is radical orchiectomy.

Molecular assessment of paratesticular rhabdomyomas demonstrates recurrent findings, including a novel H3C2 p.K37I mutation.

Rhabdomyomas are benign tumors with skeletal muscle differentiation that are broadly divided into cardiac and extracardiac types. The latter demonstrate a predilection for head and neck and genital locations and are further subclassified into adult-type rhabdomyoma (ATRM), fetal-type rhabdomyoma (FTRM) and genital rhabdomyoma (GRM). Most extracardiac rhabdomyomas that arise in paratesticular tissues have a somewhat distinctive morphology and have been termed sclerosing rhabdomyomas (SRM). Therefore, we hypothesized that these tumors may harbor recurrent genetic alterations. In this study, we assessed 15 paratesticular rhabdomyomas (11 initially classified as SRM, 2 cellular FTRM and 2 ATRM) using massively parallel DNA and RNA sequencing. Five of 14 successfully sequenced cases harbored a novel H3C2 p.K37I mutation (4 SRM and 1 ATRM). This mutation replaced a highly conserved lysine residue that is a target for epigenetic modifications and plays a role in regulation of DNA replication. Moreover, 4 tumors (2 cellular FTRM, 1 case initially diagnosed as SRM and 1 ATRM) had complex copy number profiles characterized by numerous chromosome-level and arm-level copy number gains, consistent with a ploidy shift. Rereview of the SRM with copy number gains demonstrated that it was significantly more cellular and had a more prominent fascicular architecture than the rest of the SRMs included in this series. Therefore, it was retrospectively reclassified as a cellular FTRM. In conclusion, this study demonstrated that paratesticular rhabdomyomas harbor recurrent somatic H3C2 p.K37I mutations and ploidy shifts.

Successful treatment of a case of hormone receptor-positive metastatic extramammary Paget disease with tamoxifen.

Extramammary Paget disease (EMPD) is a rare cutaneous adenocarcinoma that usually is of epidermal origin and shows glandular differentiation and that is treated by wide local excision depending on the disease extent. For widely metastatic disease, however, a standard treatment remains to be established. Similar to breast cancer, EMPD has been found to overexpress human epidermal growth factor receptor 2 (HER2) or hormone receptors (HRs). Whereas HER2-directed therapy was recently shown to be effective for HER2-positive EMPD, the potential role of endocrine therapy for HR-positive EMPD has remained unknown. We here report a case of metastatic EMPD with HR positivity that was successfully treated with the selective estrogen receptor modulator tamoxifen. This first-line treatment of systemic metastasis resulted in durable tumor regression for > 20 months without any treatment-related toxicities. This is the first report to reveal the promise of tamoxifen as a safe and effective treatment for HR-positive metastatic EMPD.

A common tumor in an uncommon site: epithelioid Leiomyoma arising from the seminal vesicle-a case report.

BACKGROUND: Leiomyoma of the seminal vesicle is a rare leiomyoma characterized by the formation of benign leiomyomatous tissue within the seminal vesicle. Although histologically benign, excessive size can lead to urinary system disease if left untreated. Herein, we report a case of a seminal vesicle epithelioid leiomyoma. CASE PRESENTATION: A 36-year-old Chinese man sought medical attention at our hospital for urination pain and hemospermia. CT showed a 5.3 cm × 5.0 cm seminal vesicle mass with a mixed density in the right seminal vesicle. The gross specimen showed light yellow, gray, and white tissues, with softness and hemorrhage in some places. Histologically, it showed classic spindle cell proliferation, with spindle cells arranged in fascicles, and mitosis was rare. Immunohistochemistry showed frequent expression of smooth muscle markers, such as calponin, SMA, and desmin. A diagnosis of epithelioid leiomyoma was proposed according to the immunohistochemical findings and morphology. The patient did not receive adjuvant therapy. There was no evidence of tumor recurrence in the 10 months after surgery. CONCLUSIONS: We report the first case of epithelioid leiomyoma in the seminal vesicle. This disease should be included in the differential diagnostic list of seminal vesicle tumors with epithelioid morphology.

Primary seminal vesicle epithelioid smooth muscle neoplasm of uncertain biologic potential.

We present the case of a 73-year-old male patient who presented with obstructive urinary symptoms, pelvic pressure, and hematuria. CT imaging revealed a heterogenous prostate enlargement, and MRI demonstrated the mass to be arising from the seminal vesicle. Prostate biopsies showed benign tissue. Surgical excision was completed and pathology revealed it to be an epithelioid smooth muscle neoplasm of uncertain biologic potential. This is only the second known case of such a seminal vesicle tumour. As soft tissue sarcomas of the seminal vesicle emerge in the literature, we may develop a better understanding of their biologic behaviour and prognostic potential.

Clinical challenges of scrotal lymphangioma in an adult: a rare case of scrotal swelling.

Scrotal lymphangiomas represent an extremely rare cause of scrotal swelling. We report a case of scrotal lymphangioma in an 18-year-old male who presented with painful scrotal swelling. Scrotal ultrasound revealed a complex multicystic structure in the left hemiscrotum. The patient underwent successful surgical excision of the mass. Postoperatively, he developed a hydrocele which eventually spontaneously regressed. Histopathology confirmed the diagnosis. We outline the unusual presentation, characteristic imaging and histology findings, and surgical management of scrotal lymphangiomas. With this information, urologists may exercise a heightened level of awareness for this rare cause of scrotal swelling.

Leiomyosarcoma of the spermatic cord: a rare paratesticular neoplasm case report.

BACKGROUND: Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from the male genitourinary tract. Leiomyosarcoma (LMS) is a malignant soft tissue neoplasm which originates from the mesenchyme and has a characteristic smooth muscle differentiation. Usually, it presents as a painless, firm, slow-growing unilateral scrotal mass. Investigations include imaging, tumor markers, and histopathology. CASE PRESENTATION: A 65-year-old gentleman known diabetic and beta-thalassemic trait was referred to the Urology OPD at Letterkenny University Hospital. His presenting complaint was a left groin lump that appeared 1 year ago and was growing larger in size gradually. According to the patient, his lump was slightly painful (localized) initially that later became painless. He did not report any testicular trauma/infection or UTI. There was no significant history of malignancies running through his family. Clinical examination revealed a soft and lax abdomen, normal testes. There was a non-tender 2cm x 2cm well-circumscribed, mobile, firm to cystic irreducible left inguinoscrotal mass and appeared to be attached to the spermatic cord. Cough impulse was indiscernible. Ultrasound left groin showed 1.8 cm transverse x 1.4 cm AP x 1.9 cm sagittal) well-circumscribed ovoid nodular subcutaneous lesion present in the upper left inguinal area just lateral to the left pubic tubercle that appeared solid with heterogeneous internal echotexture and no internal calcification. Some internal vascularity is demonstrated with color Doppler assessment. CONCLUSION: Because of its rareness, LMS represents a management conundrum. There is no standard protocol for treatment. We present a case and discuss the available evidence from the literature to date to help identify LMS of the spermatic cord that is highly unusual.

Primary spindle cell sarcoma of the seminal vesicle: A case report and literature review.

We report a case of primary seminal vesicle spindle cell sarcoma of a 57-year-old man who underwent multiple surgical treatment. The first diagnosis of a local hospital was a right seminal vesicle cyst, so only laparoscopic decompression was performed. Postoperatively, the patient gradually developed lower abdominal discomfort, frequent and urgent urination, dysuria and constipation. Digital rectal examination palpated a heterogeneous mass. Magnetic resonance imaging showed a multilocular cystic mass of about 4.5 cm in diameter in the right seminal vesicle, which was diagnosed as a recurrent cyst. The patient underwent a second operation in our hospital, but the tumour could not be completely removed because of severe peripheral adhesions. The postoperative pathological diagnosis was seminal vesicle cystadenoma with spindle cell sarcoma. One month later, a computed tomography scan performed at another hospital showed that the mass had invaded the bladder and sigmoid colon. The pathological diagnosis of re-examination was spindle cell liposarcoma. After neoadjuvant chemotherapy, extended resection of the tumour was performed, and adjuvant chemotherapy was continued after surgery. The total duration of follow-up was 19 months and 3 months after the third surgery. The patient survived with no recurrence or metastasis.