FCCT Blog Post #19

KCMC-FCCT Tumor Board

Four cases were presented in February 2025.

The first case involved a 34 year-old woman with locally advanced and possibly metastatic leiomyosarcoma of the orbit. She had presented with one year of left eye symptoms including pain, vision loss and proptosis. A CT of the head identified a 2.6cm mass infiltrating the orbit with bone erosion. Enucleation was performed; the pathology revealed leiomyosarcoma. A staging CT of the chest/abdomen and pelvis identified multiple bilateral micronodular lung nodules worrisome, but not definitive, for metastatic disease. The discussion revolved around whether sending the patient off for PET imaging would help clarify a diagnosis of metastatic disease. Another option, initiation of palliative systemic therapy with gemcitabine and docetaxel, was discussed. Given cost constraints and the patient’s limited financial resources, it was ultimately decided to refer her to Dar es Salaam for orbital radiation for local control and repeat the chest CT in several months to look for growth of the pulmonary nodules that would be more consistent with metastatic disease.

The second case involved a 46 year-old woman with metastatic adenocarcinoma of unknown primary with papillary histologic features. She presented with a large 40cm palpable anterior chest wall mass invading the sternum and involving the mediastinum, surrounding the aortic arch and associated with a pericardial effusion. There was bilateral axillary lymph node involvement, a large splenic mass and a 5cm liver lesion. The differential diagnosis included a lung or breast primary, a dedifferentiated mediastinal germ cell tumor or GI malignancy. In the USA, a battery of immunohistochemical stains, including differential cytokeratin stains, lung cancer, breast cancer and ovarian cancer markers would be helpful to identify a site of origin. Cell-of-origin next generation sequencing technology is also available in the USA. In this way, palliative chemotherapy could be best targeted to potential site of origin to maximize the chance of response. In the absence of this technology, the patient was initiated on palliative carboplatin and paclitaxel chemotherapy and had just received her first cycle

A third case involved a 68 year-old man with metastatic non-clear cell renal cell carcinoma. CT imaging disclosed bilateral renal masses (8cm right renal mass and 2.7cm left renal mass) and a 6.8cm metastatic deposit in the left pelvis infiltrating the left femoral neck and medial compartment muscles. A CT guided biopsy of the right kidney mass revealed a high- grade carcinoma with spindle shaped cells suggestive of a renal cell carcinoma with sarcomatoid features. In the USA, a plethora of treatment options exist for advanced renal cell carcinoma including numerous tyrosine kinase inhibitors, angiogenesis inhibitors and several immunotherapy options. Sunitinib, sorafenib and bevacizumab are the available treatment options for renal cell carcinoma in Tanzania.

The final case was presented by a Tanzanian OB/GYN resident in conjunction with a visiting OB/GYN resident from Duke University. This was a tragic case of a 29 year-old woman with newly diagnosed metastatic breast cancer with bilateral breast, axillary and bone involvement. She had newly diagnosed HIV with wasting syndrome. She was critically ill with sepsis, obtundation, multisystem organ failure and had an ECOG performance status of 4. She was also 20 weeks pregnant but had suffered a spontaneous miscarriage the night before tumor conference. The overwhelming complexity of her case was appreciated and palliative care services were discussed.

Randy Hurley MD, cTropMed

HealthPartners and Regions Hospital Cancer Care Centers

Global Health Faculty, University of Minnesota