KCMC-FCCT Tumor Board May 2024

By Randy Hurley MD, cTropMed

HealthPartners and Regions Hospital Cancer Care Centers

Global Health Faculty, University of Minnesota

KCMC-FCCT TUMOR BOARD

Three cases were discussed at the May 2024 KCMC-FCCT tumor board. Only one case was presented in March 2024 and April 2024. All five cases are summarized below.

A 64 year-old female with localized rectal cancer presented with significant rectal bleeding after undergoing neoadjuvant rectal radiation therapy and 5 cycles of neoadjuvant capecitabine-oxaliplatin chemotherapy. A CT scan now showed ascites and a right pleural effusion. The rectal bleeding was severe, requiring transfusion of 6 units of blood and use of tranexamic acid. The concern was that the rectal bleeding could represent radiation proctitis or local tumor progression. The ascites and pleural effusion could represent disease progression or anasarca from cancer and chemotherapy. A diagnostic paracentesis and sigmoidoscopy were recommended.

A 68 year-old man with a family history of esophageal cancer presented with dysphagia and a 7cm esophageal mass with peri-esophageal adenopathy. Although squamous cell carcinoma of the esophagus was suspected, a biopsy was consistent (but not confirmatory) for malignant melanoma of the esophagus. Appropriate immunohistochemistry stains were pending. Malignant melanoma of the esophagus is exceedingly rare and treatment paradigms are lacking. In the USA, next generation sequencing is used to identify targetable BRAF mutations, and less commonly, c-kit mutations. Immune therapy is typically the mainstay of therapy. Consideration was given for placement of a gastric feeding tube followed by palliative chemotherapy and or chemo-radiotherapy.

A 57 year-old man had undergone a right hemicolectomy in February of 2023 for a locally advanced colon cancer and was lost to follow up. He now presents with abdominal symptoms and significant melena. A CEA was markedly elevated at 790 and a CT scan identified a large complex right lower quadrant mass with areas of necrosis and evidence of peritoneal carcinomatosis. Courses of palliative FOLFOX chemotherapy have been interrupted due to significant anemia from on-going melena. Palliative surgery for tumor debulking and to relieve bleeding is only rarely recommended in the United States especially in the face of peritoneal carcinomatosis. Unfortunately, advanced radiologic imaging with angiography to identify sources of intestinal bleeding are not available in Tanzania.

A 21 year-old man presented with an 8 year history of an enlarging anterior neck mass that now measured 30cm in size with areas of necrosis and skin breakdown. Eight years previously, a small neck mass had been removed surgically at another hospital but the pathology of this specimen was not available. A very impressive looking CT scan of the neck and chest was reviewed showing a mass deviating the trachea in the neck and extending into the anterior chest. Pathologic material from a biopsy was reviewed. This showed a vascular, fairly uniform tumor of uncertain etiology. A thymic carcinoma, dedifferentiated thyroid cancer, hemangiopericytoma and sarcoma were in the differential. Additional immunohistochemistry was recommended to confirm a diagnosis.

A 40 year-old woman presented in a second trimester of pregnancy with a 3cm breast mass the biopsy of which disclosed infiltrating ductal carcinoma. Receptor studies were pending. Recommendations were made to stage the axilla with ultrasound and perform a limited metastatic evaluation with chest x-ray and ultrasound. Lumpectomy and axillary node sampling can safely be performed in the second trimester of pregnancy and chemotherapy can safely be offered, when necessary, as well.