Two complicated cancer cases were discussed at this month’s tumor board.
The first case was a 7-year-old girl with a large 22cm tumor mass involving the right humerus and shoulder. Radiographically, this appeared to be an osteosarcoma. Photomicrographs of the histologic pathology specimens were available and reviewed by a participating pathologist from Froedtert Hospital at the Medical College of Wisconsin in Milwaukee. In addition, the patient had enlarged cervical lymph nodes. Part of the debate in clinical management pertained to whether the enlarged cervical lymph nodes should be biopsied. Although osteosarcomas and soft tissue sarcomas in general, rarely involve lymph nodes a consideration could be given for lymph node biopsy. This was deemed a low-risk procedure and if metastatic sarcoma were identified, it could definitely alter management. Infectious causes of enlarged cervical lymph nodes, including tuberculous lymphadenitis, could be an alternative diagnosis. The management plan included multi-agent neoadjuvant chemotherapy followed by repeat imaging and assessment of response. Unfortunately, this young girl might be faced with a “fore-quarter amputation,” a devastating procedure with amputation of her right arm and shoulder.
The second case was equally complicated and highlights the need for improved immunohistochemistry pathology capability at KCMC to more accurately classify tumors. The case involved a 47-year-old woman with two different primary cancers: colorectal cancer and ovarian cancer. She initially underwent resection of a colon cancer and adjuvant FOLFOX chemotherapy 4 years ago. Two years later she developed ovarian cancer manifesting as an ovarian mass and ascites. Following total abdominal hysterectomy and bilateral salpingectomy the patient was treated with adjuvant carboplatin and taxol much like we would offer here in Minnesota. She had been undergoing surveillance with CT scans , follow up colonoscopy and CEA and CA 125 tumor markers. Most recently, she developed a rectal mass the biopsy of which suggested a new rectal cancer primary tumor. After evaluation with colonoscopy, CT scan and pelvic MRI, she received neoadjuvant chemotherapy and radiation with only a modest radiographic response. Then, at the time of attempt at surgical resection of the rectal tumor, she was found to have peritoneal carcinomatosis. The rectal cancer excision was aborted, and she underwent an omental biopsy. The discussion revolved around whether the rectal tumor was truly a second colorectal cancer primary tumor or whether this could have been a pelvic/rectal recurrence of ovarian cancer. Typically, extended immunohistochemistry on the pathology specimens, not available in Tanzania, could distinguish recurrent ovarian adenocarcinoma from a primary rectal adenocarcinoma. Immunohistochemistry on the pathology specimen for microsatellite instability could also help detect Lynch Syndrome, a hereditary cancer family syndrome that might help explain the multiple primary tumors in this patient. An interesting discussion evolved around the goals of further systemic therapy. Although platinum-based chemotherapy with the anti-angiogenesis agent, bevacizumab, is available in Tanzania, a concern was raised regarding the potential for bevacizumab to create a rectal fistula. Such a complication, although rare, would be very difficult to manage, even in Minnesota, especially in a patient were the goals of care may primarily be palliative.