Retrospective Analysis of Mortality Cases in Advanced and Metastatic Solid Tumors With Concurrent Prerenal Azotemia.

BACKGROUND/AIM: A retrospective study of cases with metastatic or advanced solid tumors complicated with AKI (acute kidney injury) with prerenal azotemia. PATIENTS AND METHODS: Criteria included: (1) advanced or metastatic solid tumors that led to mortality; (2) prerenal azotemia identified upon renal function evaluation and (3) BUN to Cr ratio (BCR)≥15. We also compared the outcomes of patients with BCR>20 with those of patients with BCR=15-20. RESULTS: A total of 218 patients with solid tumors were enrolled. One hundred and forty (64%) and 78 (36%) patients had BCR>20 and 15-20, respectively. Before AKI occurrence, 136 (62%) had thromboembolic complications and 96 (44%) paraneoplastic syndromes. Median survival time was 1 week in all patients. Median survival time was statistically different between the groups with BCR15-20 and BCR>20 (p<0.005, log-rank test). CONCLUSION: Cancer patients with concurrent AKI and prerenal azotemia carry a very poor prognosis.

Extrahepatic Portal Venous Obstruction With Hepatic Enzyme Elevation Resembling Hepatitis in Patients With Cancer.

BACKGROUND/AIM: Chemotherapy is often halted due to abnormal liver function resembling hepatitis. But the cause can be extrahepatic portal venous obstruction (EHPVO) with hepatic enzyme elevation rather than being an adverse effect of chemotherapy. We investigated EHPVO with hepatic enzyme elevation in patients with cancer. PATIENTS AND METHODS: Data of these hospitalized patients with solid tumors between January 2013 and September 2017 were collected. The criteria for study inclusion were: (i) Extrahepatic malignancy; (ii) computed tomographic scans showing a tumor with external compression of the extrahepatic portal vein; and (iii) serum aminotransferase (AST) or alanine transaminase (ALT) level three times above the normal value. RESULTS: Thirteen out of 377 (3%) patients developed EHPVO with hepatic enzyme elevation, as demonstrated from computed tomographic scan. Four cases (31%) also had vascular thrombosis (three portal vein and one inferior vena cava). Serum AST increased from 34±11 to 169±94 U/l. ALT increased from 9±38 to 177±104 U/l. There was no relationship of EHPVO with viral markers and cirrhosis. Six cases received chemotherapy with liver function improvement. CONCLUSION: EHPVO occurred in patients with metastatic cancer, leading to hepatic enzyme elevation resembling hepatitis without hepatitis risk factors and cirrhosis. Before withholding chemotherapy due to hepatic enzyme elevation, the possibility of EHPVO should firstly be excluded.

Survival Benefit for Patients With Metastatic Urothelial Carcinoma Receiving Continuous Maintenance Chemotherapy.

BACKGROUND/AIM: Urothelial carcinoma is a chemo-sensitive cancer. We investigated the contributory factors to survival benefit of metastatic urothelial carcinoma (MUC) patients receiving continuous maintenance chemotherapy. PATIENTS AND METHODS: Inclusion criteria were: i) pathology-confirmed urothelial carcinoma, ii) metastatic lesions identified mainly on pre-therapy computed tomography (CT) scans, and iii) inpatient-administered chemotherapy of at least three cycles. Chemotherapy regimens included 5-fluorouracil, leucovorin, cisplatin, and gemcitabine. RESULTS: A total of 139 cases were enrolled in this study. The overall objective response rate was 60% and the median survival time was 17 months. Eight-two (59%) patients had inflammation-related symptoms following the course of chemotherapy. Fifty-five (41%) patients survived more than two years. All patients exhibited various fibrosis formations. No patient experienced unfavorable metastatic conditions. Inflammation-related symptoms remained in 28 (51%) patients. We found that surgery, invasive procedures, and infection likely led to a rapid tumor progression. CONCLUSION: Continuous maintenance chemotherapy targeting chemo-sensitive tumors, administered at metronomic intervals and focus on tumor microenvironment, can increase MUC survival benefits.

Differences in Pain Intensity of Tumors Spread to the Anterior versus Anterolateral/Lateral Portions of the Vertebral Body Based on CT Scans.

We investigated whether the intensity of cancer pain differs for malignant tumors that have spread to anterior or anterolateral/lateral portions of the vertebral body. We hypothesize that tumor spread to the anterolateral/lateral vertebral body elicits more serious pain due to increased irritation of the spinal nerve. The selection criteria were as follows: (1) advanced or metastatic solid tumor; (2) radicular pain without extremity weakness; (3) malignant lesions anteriorly, anterolaterally, or laterally located at the vertebral body either spread locoregionally or over a greater distance via metastasis based on CT scan diagnosis; and (4) patient needs to use opioids for pain relief. Severe spinal pain intensity was defined as spinal pain for which patients required either strong opioids or spinal irradiation for relief. Eighty-six patients were enrolled in the study. Bone lesions were mainly osteolytic. Thirty-nine tumors spread to the vertebral body in the anterior direction, and 47 in the anterolateral/lateral direction. Severe pain intensity related to vertebral body lesions was due to anterolateral/lateral spread, primary sites of nonurothelial carcinoma, metastatic vertebral lesions, multiple lesions within a vertebrum, and location within the cervical-thoracic spine. In conclusion, patients with tumor spread to the anterolateral/lateral portion of vertebrae bodies based on CT scan diagnosis experienced severe cancer pain. These patients needed strong opioids or palliative spinal irradiation for pain relief.

Invasion of Adjacent Lumbar Vertebral Body from Renal Pelvis Carcinoma: Associated With Bone Metastasis But Easily Overlooked on Initial CT Scan.

BACKGROUND/AIM: We hypothesized that regional tumor growth into L1 and L2 vertebral bodies from renal pelvis carcinoma was linked to the development of bone metastases. MATERIALS AND METHODS: Criteria for the study were: (i) Metastatic renal pelvis carcinoma confirmed via pathology and computed tomographic (CT) scan, (ii) L1 and L2 invasion confirmed from retrospective CT scan review, and (iii) detection of bone metastases using radionuclide images/CT scans. RESULTS: A total of 71 cases were enrolled in the study. Initial L1 and L2 vertebral body invasion. were detected in 45 (63%) patients. As well as L1 and L2 invasion, 32 (71%) had development of bone metastases. All bone lesions were osteolytic. Initial L1 and L2 invasion (p<0.00001) was associated with the development of bone metastasis. CONCLUSION: CT scan can help to detect L1 and L2 vertebral body invasion in patients with renal pelvis carcinoma. Early identification and optimal management of such patients is necessary.

Pre-therapy CT scan showing peritoneal thickening from metastatic renal pelvis carcinoma patients.

We investigated clinical significance of peritoneal thickening from metastatic renal pelvis based on pretherapy computed tomography (CT) scan findings. The criteria for inclusion were as follows: (1) pathology and CT scan confirmed metastatic renal pelvis carcinoma and (2) peritoneal thickening based on pre-therapy CT scan findings. We investigated the route of spread, gastrointestinal (GI) complications, and response to chemotherapy. A total of 68 cases were enrolled in this study, including seven patients with liver metastases and three with abdominal wall invasion. GI complications included obstruction in ten patients and bleeding in three. Response to chemotherapy demonstrated by reduced peritoneal thickening was noted in 24 patients. IN CONCLUSION: peritoneal thickening with clinical suspicion of peritoneal involvement can get indirect evidence from route of spread (liver or abdominal wall), GI complications (obstruction or bleeding) or response to chemotherapy (obvious decrease peritoneal thickening) from metastatic renal pelvis carcinoma patients. Pretherapy CT scan with peritoneal thickening should be alert that tumor has spread to the peritoneum.

Under-stage and Overlook of Peritoneal Spread from Bladder Urothelial Carcinoma.

BACKGROUND/AIM: Bladder cancer can spread from the sub-peritoneal space superior and posterolateral to the peritoneal cavity via the peritoneal lining. The aim of this study was to improve the identification of peritoneal spread from bladder urothelial carcinoma based on computed tomography (CT) scans. MATERIALS AND METHODS: This is a retrospective study including patients selected with the following criteria: (i) pathology-confirmed urothelial carcinoma; (ii) peritoneal spread identified on CT scans from axial and corona views, either initially or after radical/partial cystectomy, concomitant chemoradiotherapy (CCRT), or radiotherapy. One hundred and fifty-nine cases met the selection criteria. RESULTS: Routes of spread to the peritoneum included the superior to anterior direction in 59 patients (37%), the superior to posterolateral direction in 19 (12%), and the superior to both anterior and posterolateral directions in 81 (51%). Invasion of specific sites included the abdominal wall in 101 patients (70%), bowel/mesentery in 84 (53%), prostate, uterus, and rectum in 30 (19%), and circumferential tumors that outlined the whole bladder wall in 59 (37%). Initial modes of therapy were chemotherapy in 86 patients (54%), cystectomy in 55 (35%), CCRT in eight (5%), radiotherapy in two (1%), and no therapy in eight (5%). Peritoneal spread due to under-staging (clinical/pathological stage) after local therapy was found in 84 patients (53%). CONCLUSION: Initial pre-therapeutic staging is easily overlooked regarding peritoneal spread from bladder urothelial carcinoma. Combined axial and coronal views of CT scans can help identify peritoneal involvement.

Renal Pelvis Carcinoma with Renal Vein or Inferior Vena Cava Involvement Linked to Early-onset Lung Metastasis Based on CT Scan Diagnosis.

BACKGROUND/AIM: Renal pelvis cancer with invasion of the renal vein or inferior vena cava (IVC) carries a poor prognosis. The present study investigated whether early-onset lung metastasis in these patients contributes to their poor outcome. PATIENTS AND METHODS: Data were retrospectively collected from hospitalized patients with metastatic renal pelvis urothelial cancer. The parameters used to estimate the risk of lung metastasis were based on computed tomographic (CT) scans. The parameters included sex, age (≤65 years or >65 years), site (right or left side), metastasis to para-aortic lymph nodes (LNs), suspicion of peritoneal spread, IVC involvement, and renal vein involvement. There were 71 cases including: 40 (56%) patients with lung metastasis (22 early-onset and 18 late-onset), 68 (96%) with suspicion of peritoneal spread, 38 (54%) with para-aortic LN metastasis, 10 (14%) with IVC involvement, and 53 (74%) with renal vein involvement. Sixty-four cases were evaluated to estimate the risk of lung metastasis. RESULTS: Tumor involvement in the IVC (p=0.01) and in the renal vein (p<0.00001) were high risk factors for lung metastasis. CONCLUSION: Tumor involvement of the renal vein or IVC is linked to early-onset lung metastasis in renal pelvis cancer based on CT scan diagnosis.

Avascular Necrosis of Bone following Chemotherapy in Cancer Patients with Coagulopathy: Report of Two Cases.

We report 2 cases of patients with solid tumors and coagulopathy who experienced avascular necrosis (AVN) of the bone following chemotherapy. Both cases exhibited nontraumatic bilateral AVN of the femoral heads, and one also showed bilateral AVN of the humeral heads. One case had multiple thromboembolic complications, including pulmonary obstructive syndrome and paraneoplastic pain. The other showed multiple paraneoplastic syndromes, with hypercalcemia and thrombocytosis. Groin pain and claudication of the lower extremities developed and persisted. Both patients eventually received bilateral hip arthroplasty due to AVN of both femoral heads.

Bladder Urothelial Carcinoma with Peritoneal Involvement: Benefit of Continuous Maintenance Chemotherapy.

AIM: We investigated bladder urothelial carcinoma with peritoneal involvement. PATIENTS AND METHODS: Inclusion criteria were: pathology-confirmed urothelial carcinoma; peritoneal spread identified on computed tomographic (CT) scans performed initially or after either cystectomy or concomitant chemoradiotherapy (CCRT), and absence of visceral metastases; and chemotherapy administered after peritoneal spread was diagnosed. RESULTS: Forty-seven cases included initial modes of therapy with chemotherapy in 24 patients (51%), cystectomy in 17 (36%), and CCRT in six (13%), only given as a result of under-staging. After local therapy, these patients received a continuous maintenance chemotherapy regimen of 5-fluorouracil, leucovorin, cisplatin, and gemcitabine. The overall response rate was 85%, and the side-effects were mild and tolerated. The median survival time was 28 months. The survival time of cases initially treated only with chemotherapy was not statistically different to that of those with local disease. CONCLUSION: Bladder urothelial carcinomas with peritoneal involvement can benefit from continuous maintenance chemotherapy.

Iliofemoral Venous Thrombosis Mainly Related to Iliofemoral Venous Obstruction by External Tumor Compression in Cancer Patients.

BACKGROUND: To study iliofemoral venous thrombosis related to iliofemoral venous obstruction in cancer patients. METHODS: In this case series study, 829 cancer patients were surveyed for iliofemoral obstruction/thrombosis within 10 years. The criteria for inclusion were: (1) presence of unilateral lower-extremity swelling; (2) computed tomography (CT) scans showing a tumor with external compression of the iliac or femoral vein, and (3) duplex ultrasound scans showing venous thrombosis or venous flow insufficiency over a femoral vein or saphenous vein. RESULTS: Sixty-three patients (8%) developed an iliofemoral venous obstruction. The presence of iliofemoral venous thrombosis was detected in 21 of these patients (33%). The rate of iliofemoral venous thrombosis was significantly higher in patients with an invasion of the inguinal region, D-dimer levels >3,000 ng/ml, gastrointestinal cancer, or invasion of the inguinal lymph nodes. However, none of our patients with iliofemoral venous thrombosis had a detection of iliofemoral venous obstruction. Improved lower-extremity swelling was reported in 84% of the patients following combination therapy involving low-molecular-weight heparin (LMWH) and systemic therapy. CONCLUSION: Patients with an iliofemoral venous thrombosis mainly had iliofemoral venous obstruction by external tumor compression. Combination therapy with LMWH and systemic therapy were mandatory for these patients.

The Role of Pulmonary Veins in Cancer Progression from a Computed Tomography Viewpoint.

Background. We studied the role of pulmonary veins in cancer progression using computed tomography (CT) scans. Methods. We obtained data from 260 patients with pulmonary vein obstruction syndrome (PVOS). We used CT scans to investigate pulmonary lesions in relation to pulmonary veins. We divided the lesions into central and peripheral lesions by their anatomical location: in the lung parenchymal tissue or pulmonary vein; in the superior or inferior pulmonary vein; and by unilateral or bilateral presence in the lungs. Results. Of the 260 PVOS patients, 226 (87%) had central lesions, 231 (89%) had peripheral lesions, and 190 (75%) had mixed central and peripheral lesions. Among the 226 central lesions, 93% had lesions within the superior pulmonary vein, either bilaterally or unilaterally. Among the 231 peripheral lesions, 65% involved bilateral lungs, 70% involved lesions within the inferior pulmonary veins, and 23% had obvious metastatic extensions into the left atrium. All patients exhibited nodules within their pulmonary veins. The predeath status included respiratory failure (40%) and loss of consciousness (60%). Conclusion. CT scans play an important role in following tumor progression within pulmonary veins. Besides respiratory distress, PVOS cancer cells entering centrally can result in cardiac and cerebral events and loss of consciousness or can metastasize peripherally from the pulmonary veins to the lungs.