Complete response of hepatocellular carcinoma with right atrium and pulmonary metastases treated by combined treatments (a possible treatment effect of natural killer cell): A case report and literature review.

RATIONALE: Hepatocellular carcinomas (HCCs) with metastases to the right atrium (RA) and lungs are rare, with a poor prognosis. Furthermore, the treatment outcomes in patients with advanced HCCs remain unsatisfactory. PATIENT CONCERNS: A 46-year-old man presented to our hospital for dyspnea on exertion and abdominal pain. DIAGNOSES: HCC and extra-hepatic metastases to the lung and RA. INTERVENTIONS: Multidisciplinary treatment including radiotherapy (RT), transarterial chemoembolization (TACE), and sorafenib. During a follow-up evaluation computed tomography, he experienced a radio-contrast-induced anaphylaxis. After the event, treatment such as RT, TACE, and sorafenib were continued. OUTCOMES: His tumor burden decreased, finally leading to a complete response as per the modified Response Evaluation Criteria in Solid Tumors. The patient is still alive, 30 months after the episode. Subsequent blood tests showed increased natural killer (NK) cell activity, which was significantly higher than that seen in other age-matched HCC patients with an identical stage of the tumor, receiving sorafenib. This suggests that the increase in NK cells induced by anaphylaxis influenced the tumor burden. LESSONS: We report here a rare case of long-term survival of an HCC patient with multiple metastases treated with multidisciplinary modalities, in which high NK cell activity was observed after a radio-contrast-induced anaphylactic reaction during follow-up investigations.

Identification and characterization of myocardial metastases in neuroendocrine tumor patients using 68Ga-DOTATATE PET-CT.

BACKGROUND: Focal 68Ga-DOTATATE PET lesions within the myocardium of neuroendocrine tumor (NET) patients are observed in clinical practice. We determined the frequency and characteristics of lesions that are consistent with cardiac metastasis and assessed the lesion detection rate of conventional imaging. METHODS: 629 patients who underwent 68Ga-DOTATATE PET-CT at a supraregional comprehensive cancer center on NET were included from a consecutive registry. Inclusion criteria were: (1) focal 68Ga-DOTATATE tracer uptake within the myocardium in more than two sequential PET exams, and (2) contrast-enhanced CT. To determine the diagnostic accuracy of conventional CT imaging, a case-control cohort with a ratio of 1:3 was used. PET and CT were independently analyzed by two blinded readers. Cohen's κ was assessed for interreader agreement. Descriptive statistics were applied for frequencies and characteristics and group comparisons were analyzed using the Fisher's exact test. RESULTS: The prevalence of myocardial metastases related to the registry was 2.4% (15 of 629 NET patients fulfilling the inclusion criteria), for a total of 21 myocardial 68Ga-DOTATATE foci detected. Myocardial lesions were most frequently located in the left ventricle (43%) and the septum (43%). No patient demonstrated a pericardial effusion. Patients with myocardial metastases did not differ in demographics, tumor grading, disease stage or circulating tumor markers compared to the overall registry (all p > 0.05). Higher Ki67-Indices were observed (p = 0.049) for patients with myocardial metastases. Interreader agreement for PET assessment was excellent (Cohen's κ = 1.0). CT reading showed a sensitivity of 19% (95% confidence interval: 6-43%) at a specificity of 100% (95% confidence interval: 90-100%). CONCLUSIONS: 68Ga-DOTATATE PET enables detection of myocardial metastatic lesions in NET patients. In contrast, standard morphologic CT imaging provides very limited sensitivity.

Pericardial breast cancer metastasis 25 years after mastectomy.

Pericardial effusion in a patient with a history of cancer should always prompt a hypothesis of malignant involvement. We report the case of a 66-year-old white woman presenting with pericardial effusion 25 years after a mastectomy for ductal breast carcinoma. This is one of the cases with the latest recurrence ever reported.

[Myocardial metastasis from renal cell carcinoma treated with sorafenib].

We present a case of myocardial metastasis from renal cell carcinoma (RCC) during the treatment with sorafenib. A 63-year-old male, who had undergone right radical nephrectomy, received interferon-alpha (IFN), interleukin (IL-2) and 5-flurouracil (5-FU) for the treatment of lung and pleural metastases. However, since this metastasis showed progressive disease, we administered sorafenib. Nine months after the introduction of sorafenib, he complained of dyspnea. Chest computed tomography and cardiac ultrasonography revealed a low density mass at the cardiac muscle of the left cardiac ventricle, suggesting myocardial metastasis of RCC. Molecular targeted therapy achieved a longer survival in advanced RCC patients in comparison with the immunotherapy using cytokines. Therefore, in metastasis evaluation, some organs which have been regarded as rare sites should be carefully evaluated.

[Diagnosis of a metastatic valvular tumor in a living patient]. / Tumeur métastatique valvulaire diagnostiquée du vivant du malade.

INTRODUCTION: The discovery of an endocardial mass always raises the question of its nature. Infectious endocarditis is the most frequent cause, but others diagnoses must be considered. EXEGESIS: We report a case of endocardial metastasis originating from an upper respiratory tract epidermoid carcinoma in a 48-years-old man. The diagnosis was established while the patient was alive, and survival at the time of writing is 8 months. This case report provides an opportunity for discussion of the differential diagnosis when confronted with an endocardial tumor, i.e. bacterial endocarditis, non-bacterial thrombotic endocarditis, primary cardiac tumors, metastatic osteogenic sarcoma and Libman-Sachs endocarditis. CONCLUSION: Non bacterial thrombotic endocarditis and valvular metastasis should be considered upon discovery of a valvular tumor, in the context of neoplastic disease. The prognosis of endocardial metastasis is poor, but early diagnosis and appropriate management should eventually prolong survival.

Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery.

The purpose of this study was to work out an adequate operative technique for patients with malignant tumors who also need open heart surgery or procedures on major blood vessels. We had 8 such patients. In 6 of them, a tumor (3 cases hypernephroid cancer and 3 cases retroperitoneal sarcoma) had grown through the inferior vena cava (IVC) up to the right atrium. Two patients had lung cancer together with severe coronary artery disease. All of these patients were operated on using a heart-lung machine (HLM) and cell saver (CS). In 6 patients the intravascular portion of the tumor was extracted as much as possible through a right atrium approach (in 3 cases a nephrectomy was performed). Two patients had a one-stage coronary artery bypass graft (CABG) and a lobectomy. All of the patients had uneventful postoperative periods and were alive when checked on 1 year after the procedures. During cytological investigation after each operation, tumor cells were found only on the internal surface of the HLM arterial filters with 20 microns holes. We suggest that special cardiovascular devices such as the HLM and CS might be used in borderline situations in oncology without increasing the risk of hematogenous tumor dissemination.

Percutaneous balloon pericardiotomy as a therapeutic alternative for cardiac tamponade and recurrent pericardial effusion.

A terminally ill patient with cardiac tamponade secondary to metastatic breast cancer was successfully treated by percutaneous balloon pericardiotomy. The procedure was performed through subxiphoid approach under local anaesthesia and its beneficial effect was maintained until the patient's death from her primary disease. A second, 86-year-old, debilitated patient and a third 52-year-old patient were managed likewise and both left hospital relieved from recurrent severe pericardial effusions. The later two patients have shown no signs of recurrence for fifteen and twelve months respectively.

Effectiveness of chemoembolization therapy for metastatic right atrial tumor thrombus associated with hepatocellular carcinoma.

A rare case of hepatocellular carcinoma (HCC) was complicated by metastatic right atrial tumor thrombus (RATT), which diminished in size on echocardiograms and showed necrotic change on computed tomography (CT) scans after chemoembolization therapy.

Emergency subxiphoid pericardial decompression for malignant pericardial effusion.

Malignant pericardial effusion can result in acute cardiac tamponade with serious hemodynamic compromise. This condition requires prompt pericardial decompression for relief of symptoms; however, the risks of general anesthesia in this setting are considerable. In a series of 12 patients, all operated on under local anesthesia without operative mortality, there were six patients with malignant pericardial effusion secondary to lung carcinoma; four patients, secondary to breast carcinoma; one patient, secondary to squamous cell carcinoma of the oral cavity; and one patient, secondary to an unknown primary. The clinical presentation of each was abrupt and echocardiography was definitive. The procedure is performed through an upper abdominal midline incision. The xiphoid process is excised, the diaphragm is visualized, and a pericardial window is created through which two chest tubes are placed through separate stab incisions. The tubes are removed when the drainage has subsided, usually 3-7 days. No medication or irritant is instilled. There was no recurrence following this treatment. The average survival time was 27 weeks with a range of 2-153 weeks. This operation should be part of the repertoire of the general surgeon who treats breast cancer and of the thoracic surgeon who treats lung cancer.