Towards an optimal treatment algorithm for metastatic pancreatic ductal adenocarcinoma (PDA).

Chemotherapy remains the mainstay of treatment for advanced pancreatic ductal adenocarcinoma (pda). Two randomized trials have demonstrated superiority of the combination regimens folfirinox (5-fluorouracil, leucovorin, oxaliplatin, and irinotecan) and gemcitabine plus nab-paclitaxel over gemcitabine monotherapy as a first-line treatment in adequately fit subjects. Selected pda patients progressing to first-line therapy can receive secondline treatment with moderate clinical benefit. Nevertheless, the optimal algorithm and the role of combination therapy in second-line are still unclear. Published second-line pda clinical trials enrolled patients progressing to gemcitabine-based therapies in use before the approval of nab-paclitaxel and folfirinox. The evolving scenario in second-line may affect the choice of the first-line treatment. For example, nanoliposomal irinotecan plus 5-fluouracil and leucovorin is a novel second-line option which will be suitable only for patients progressing to gemcitabine-based therapy. Therefore, clinical judgement and appropriate patient selection remain key elements in treatment decision. In this review, we aim to illustrate currently available options and define a possible algorithm to guide treatment choice. Future clinical trials taking into account sequential treatment as a new paradigm in pda will help define a standard algorithm.

Elevated chromogranin A serum levels in ovarian carcinoma patients.

Background: The observation of neuroendocrine activity during clinical course of ovarian cancer, suggested the use of neuroendocrine serum markers to detect this tumor. Aim: To evaluate the usefulness of serum measurements of chromogranin A (CgA) in the various stages of ovarian cancer. Materials and Methods: We measured serum concentrations of CgA and cancer antigen 125 (CA125) in 79 women at different clinical stages of ovarian cancer, enrolled between 2000 and 2007, and in a control group of 50 female volunteers. Results: CgA showed increased levels in patients with ovarian cancer as compared with healthy subjects, as it has been seen for CA125 serum levels. We also observed significant increase in CgA and CA125 serum levels when comparing patients with ovarian cancer in stage I versus stage II (P < 0.001); stage I versus stage III (P < 0.001); stage I versus stage IV (P < 0.001); stage II versus stage III (P < 0.001); stage II versus stage IV (P < 0.001). In patients with ovarian carcinoma in stage IV we observed a correlation between CgA and CA125 with a difference of 0.718 (P < 0.001). Conclusions: CgA serum levels were elevated in ovarian cancer and increased with the stage. Further studies are needed to elucidate the role of CgA as a prognostic indicator during treatment for ovarian cancer.

Osteoblastoma of cervical spine causing an unusual neck pain.

Osteoblastoma is a rare benign tumor of bone that accounts for approximately 1% of primary skeletal neoplasms, with around 90% of cases diagnosed in the second and third decades of life. Cervical spine is an usual localization of osteoblastoma. The main clinical manifestation in case of cervical spine location is a progressive and resistant pain, possibly accompanied by stiffness, scoliosis or other ailments, including severe neurological deficits. Owing to a non-specific clinical presentation of osteoblastoma, the delay in diagnosis is common. Osteoblastomas may have an aggressive behavior, tend to enlarge and damage the bone and adjacent structures. The treatment of choice is, therefore, a wide and complete surgical excision of the lesion in order to achieve full recovery and prevent recurrence or, in some cases, malignant transformation. In the case of persistent neck pain, not readily relieved by aspirin and possibly accompanied by stiffness, scoliosis or neurological deficits, especially in young subjects, osteoblastoma of cervical spine may be one of the diagnostic options to be considered, in order to avoid delay in diagnosis. We report the case of a 41-year-old male affected by cervical spine osteoblastoma causing a lasting neck pain.

A large calcified retroperitoneal extraskeletal osteosarcoma with consequent bilateral hydronephrosis.

Extraskeletal osteosarcoma (ESOS) is a rare malignant mesenchymal neoplasm that accounts for less than 4% of all osteosarcomas and approximately 1-2% of all soft tissue sarcomas. The tumor is typically located in the deep soft tissues, without attachment to skeletal bones. Although ESOS has been found todevelop virtually in every organ, its most common locations are the limbs. In the case of abdominal or pelvic lesions the diagnosis can be very difficult, thus it necessarily requires confirmation after exploratory laparotomy and histopathology. Such tumors may reach enormous sizes before detection because the enlarging mass may not be associated with pain. ESOS may be one of the differential diagnoses to be considered in the case of calcified masses arising in retroperitoneal space. Here we describe a bulky, bilateral, metastatic ESOS arising from the retroperitoneum and causing obstructive uropathy with consequent hydronephrosis.