Search

Familial adenomatous polyposis [FAP] is a rare autosomal disorder. FAP presenting with Gardner syndrome is even rarer. Gardner syndrome as the first manifestation of FAP without any prior family history is even scarcer. We hereby report the case of 32 years healthy male referred to our otolaryngology clinic with a neck mass and ultimately diagnosed with a case of Gardner syndrome with FAP and advanced rectal Cancer. The patient had a successful gastrointestinal surgery with follow up chemotherapy. Subsequently the patient was followed up at the gastroenterology, oncology and surgical clinic. Literature searched was done and the extra colonic manifestations of the diseases are highlighted in our discussion.

Background Clinically, metastatic rectal cancer has been considered a subset of left-sided colon cancer. However, heterogeneity has been proposed to exist between high and middle/low rectal cancers. We aimed to examine the efficacy of anti-epidermal growth factor receptor (EGFR) treatment for middle/low rectal and left-sided colon cancers. Methods This study enrolled 609 patients with metastatic colorectal cancer who were treated with anti-EGFR therapy. They were divided into groups based on primary tumour locations: the right-sided colon, the left-sided colon or the middle/low rectum. The efficacy of first-line and non-first-line anti-EGFR treatment was analysed. Genomic differences in colorectal cancer data from The Cancer Genome Atlas (TCGA) were investigated and visualised with OncoPrint and a clustered heatmap. Results On first-line anti-EGFR treatment, patients with middle/low rectal tumours had significantly lower progression-free survival, overall survival, and overall response rates (6.8 months, 27.8 months and 43%, respectively) than those with left-sided colon cancer (10.1 months, 38.3 months and 66%, respectively). Similar outcomes were also identified on non-first-line anti-EGFR treatment. In TCGA analysis, rectal tumours displayed genetic heterogeneity and shared features with both left- and right-sided colon cancer. Conclusions Anti-EGFR treatment has lower efficacy in metastatic middle/low rectal cancer than in left-sided colon cancer.

SUMMARY Introduction Colorectal cancer is the third most common cancer and one of the leading causes of cancer-related deaths in men and women worldwide. The contemporary multidisciplinary approach has decreased rates of local recurrence and improved outcomes in metastatic colorectal cancer. We present a case of a primarily metastatic rectal cancer patient who underwent multidisciplinary planned treatment and showed complete response with now three years disease-free survival. Case outline A 61-year-old female was diagnosed with a T4N2M1a rectal adenocarcinoma at the age of 58. She underwent six cycles of systemic chemotherapy capecitabine-oxaliplatin plus bevacizumab with partial response confirmed by diagnostic imaging procedures. According to multidisciplinary board decision, preoperative radiotherapy treatment was administered with concomitant capecitabinebased chemotherapy. A 50.4 Gy total dose was delivered with 1.8 Gy fraction dose. After concomitant chemoradiotherapy treatment, two more cycles of systemic chemotherapy capecitabine-oxaliplatin plus bevacizumab were administered. One month after completion of systemic chemotherapy, primary rectal cancer was operated with a complete response on histopathologic specimens. Six weeks following previous surgery, metastasectomy of lung deposits was performed; histopathology confirmed metastatic adenocarcinoma of colorectal origin. Three more cycles of postoperative chemotherapy capecitabineoxaliplatin plus bevacizumab were administered. Conclusion On regular follow-up, no evidence of disease was shown, with disease-free survival of three years. The treatment improved the patient’s quality of life. Keywords: chemotherapy; radiotherapy; rectal cancer; stage IV; surgical treatment

Background For rectal cancer with unresectable metastases, current practice favors omitting interventions directed at the primary tumor in asymptomatic patients. Objective This study aimed to determine the proportion of patients with primary tumor-related complications, characterize salvage outcomes, and measure survival in patients with metastatic rectal cancer who did not undergo upfront intervention for their primary tumor. Design This is a retrospective analysis. Setting This study was conducted at a comprehensive cancer center. Patients Patients who presented between January 1, 2008, and December 31, 2015, with synchronous stage IV rectal cancer, an unresected primary tumor, and no prior primary tumor-directed intervention were selected. Main outcome measures The main outcome measured was the rate of primary tumor-related complications in the cohort that did not receive any primary tumor-directed intervention. The Kaplan-Meier method and Cox regression analysis were used to determine whether complications are associated with survival. Results The cohort comprised 358 patients with a median age of 56 years (22-92). Median follow-up was 26 months (range, 1-93 months). Among the 168 patients (46.9%) who eventually underwent elective resection of the primary tumor, the surgery was performed with curative intent in 66 patients (18.4%) and preemptive intent in 102 patients (28.5%). Of the 190 patients who did not undergo an upfront or elective intervention for the primary tumor, 68 (35.8%) experienced complications. Nonsurgical intervention for complications was attempted in 34 patients with an overall success rate of 61.8% (21/34). Surgical intervention was performed in 47 patients (including 13 patients for whom nonsurgical intervention failed): diversion in 26 patients and resection in 21 patients. Of those 47 patients, 42 (89.4%) ended up with a colostomy or ileostomy. Limitations This study was conducted at a single center. Conclusion A significant proportion of patients with metastatic rectal cancer and untreated primary tumor experience primary tumor-related complications. These patients should be followed closely, and preemptive intervention (resection, diversion, or radiation) should be considered if the primary tumor progresses despite systemic therapy. See Video Abstract at http://links.lww.com/DCR/B400. COMPLICACIONES RELACIONADAS CON EL TUMOR PRIMARIO Y RESULTADOS DE RESCATE EN PACIENTES CON CANCER DE RECTO METASTASICO Y UN TUMOR PRIMARIO NO TRATADO: Para el cancer de recto con metastasis no resecables, la practica actual favorece la omision de las intervenciones dirigidas al tumor primario en pacientes asintomaticos.Determinar la proporcion de pacientes con complicaciones relacionadas con el tumor primario, caracterizar los resultados de rescate y medir la supervivencia en pacientes con cancer rectal metastasico que no se sometieron a una intervencion inicial para su tumor primario.Analisis retrospectivo.Centro oncologico integral.Pacientes que se presentaron entre el 1 de enero de 2008 y el 31 de diciembre de 2015 con cancer de recto en estadio IV sincronico, un tumor primario no resecado y sin intervencion previa dirigida al tumor primario.Tasa de complicaciones relacionadas con el tumor primario en la cohorte que no recibio ninguna intervencion dirigida al tumor primario. Se utilizo el metodo de Kaplan-Meier y el analisis de regresion de Cox para determinar si las complicaciones estan asociadas con la supervivencia.La cohorte estuvo compuesta por 358 pacientes con una mediana de edad de 56 anos (22-92). La mediana de seguimiento fue de 26 meses (rango, 1 a 93 meses). Entre los 168 pacientes (46,9%) que finalmente se sometieron a reseccion electiva del tumor primario, la cirugia se realizo con intencion curativa en 66 pacientes (18,4%) y con intencion preventiva en 102 pacientes (28,5%). De los 190 pacientes que no se sometieron a una intervencion inicial o electiva para el tumor primario, 68 (35,8%) experimentaron complicaciones. Se intento una intervencion no quirurgica para las complicaciones en 34 pacientes con una tasa de exito global del 61,8% (21 de 34). La intervencion quirurgica se realizo en 47 pacientes (incluidos 13 pacientes en los que fallo la intervencion no quirurgica): derivacion en 26 pacientes y reseccion en 21 pacientes. De esos 47 pacientes, 42 (89,4%) terminaron con una colostomia o ileostomia.Unico centro.Una proporcion significativa de pacientes con cancer de recto metastasico y primario no tratado experimentan complicaciones relacionadas con el tumor primario. Se debe hacer un seguimiento estrecho de estos pacientes y considerar la posibilidad de una intervencion preventiva (reseccion, derivacion o radiacion) si el tumor primario progresa a pesar de la terapia sistemica. Consulte Video Resumen en http://links.lww.com/DCR/B400.

Fused imaging with FDG-PET/CT is a hybrid technique that provides a unique combination of functional and anatomic imaging. It has recently emerged as a very useful tool in the management of rectal carcinoma despite its limitation in defining local invasion of tumors in adjacent tissues. As a whole-body, noninvasive imaging modality, PET/CT has an established role in the detection of suspected recurrent disease in patients with unexplained progressive rise of CEA serum levels, staging before surgical resection of recurrence, and assessment of residual disease after treatment. Furthermore, this technique appears to be able to monitor and predict tumor response to preoperative radiochemotherapy in locally advanced or metastatic rectal cancer and also seems to have a role in planning radiotherapy.

Background A metastatic lesion located in the ampulla of Vater is considered extremely rare, with only 32 cases reported globally. Case A 65-year-old patient was primarily diagnosed with a rectal adenocarcinoma. Twenty-four months later as part of the oncological follow-up, the patient was diagnosed with a single secondary tumor in the ampulla of Vater. After undergoing a pancreaticoduodenectomy (Whipple procedure), the patient experienced an uneventful recovery and received adjuvant chemotherapy. Sixteen months later the patient remained disease-free. Conclusion To the best of our knowledge, the present case represents the first reported metastatic tumor in the ampulla of Vater, originating from a rectal adenocarcinoma. This case underlines the critical role of immunohistochemistry in arriving at a correct diagnosis in order to guide clinical decision-making.

BACKGROUND: A significant proportion of patients with rectal cancer will present with synchronous metastasis at the time of diagnosis. Rates of OS for these patients are highly variable and previous attempts to build predictive models often have low predictive power, with concordance indexes (c-index) less than 0.70. METHODS: Using the National Cancer Database (2010–2014), we identified patients with synchronous metastatic rectal cancer. The data was split into a training dataset (diagnosis years 2010–2012), which was used to build the machine-learning model, and a testing dataset (diagnosis years 2013–2014), which was used to externally validate the model. A nomogram predicting 3-year overall survival was created using Cox proportional hazard regression with lasso-penalization. Predictors were selected based on clinical significance and availability in NCDB. Performance of the machine-learning model was assessed by c-index. RESULTS: A total of 4,098 and 3,107 patients were used to construct and validate the nomogram, respectively. Internally validated c-indexes at 1, 2, and 3 years were 0.816 (95% CI 0.813 – 0.818), 0.789 (95% CI 0.786 – 0.790), and 0.778 (95% CI 0.775 – 0.780), respectively. External validated c-indexes at 1, 2, and 3 years were 0.811, 0.779, and 0.778, respectively. CONCLUSIONS: There is wide variability in the OS for patients with metastatic rectal cancer, making accurate predictions difficult. However, using machine learning techniques, more accurate models can be built. This will aid patients and clinicians in setting expectations and making clinical decisions in this group of challenging patients.

Background In non-small cell lung cancer, response rates to chemotherapy given after immune checkpoint inhibitors has been reported to be higher compared to response rates to chemotherapy given before immune checkpoint inhibitors. However, this phenomenon has not been reported in patients with gastrointestinal cancers nor with the use of multi-targeted kinase inhibitors. Case presentation We present a series of six patients who received multi-targeted kinase inhibitors or chemotherapy after progression on immune checkpoint inhibitors and showed unexpected response. Five of these patients had metastatic hepatocellular carcinoma and received salvage multi-targeted kinase inhibitors. Two of these five patients had no response to initial multi-targeted kinase inhibitors but had unexpected response to re-challenge with multi-targeted kinase inhibitors after immune checkpoint inhibitors exposure. The sixth patient had metastatic rectal cancer and showed response to salvage chemotherapy following immune checkpoint inhibitors. Conclusion We postulate that the sequencing of immune checkpoint inhibitors prior to other forms of systemic therapy may potentially lead to an immunomodulatory effect in gastrointestinal cancers with potential improvement in response rates.

Approximately 50–60% of patients diagnosed with rectal cancer either present with or will develop metastatic disease. Treatment for metastatic rectal cancer has evolved due to advances in both medical and surgery therapy and involves a combination of chemotherapy, radiation therapy and surgery. This multimodal therapy requires individualization due to a variety of patient and tumor characteristics and results in variability of regimens and the sequence of treatment for metastatic disease. In this article we will review various approaches to the treatment of metastatic rectal cancer combining multimodal chemotherapy, radiation and surgery.

To compare the cost-performance between planned short-course radiation and upfront concurrent chemoradiation on metastatic rectal cancer. A total of 75 patients with metastatic rectal cancer who underwent planned short-course radiation or upfront concurrent chemoradiation were enrolled. The Kaplan-Meier method was used to compute the survival rates. The χ2 test was used to compare baseline characteristics. The Cox proportional hazards model was applied to determine the prognostic influence of clinicopathological factors. The planned short-course radiation is superior to upfront concurrent chemoradiation in overall survival for the patients with metastatic rectal cancer (34.8 vs. 20.2 months, P = 0.010). The planned short-course radiation was an independent prognostic factor (P = 0.009, HR (95% CI) = 0.319(0.135–0.752)). The efficacy of radiation on downstaging was similar between planned short-course radiation and upfront concurrent chemoradiation. The total cost of concurrent chemoradiation is 4.52-fold more expensive than that of short-course radiation (340,142 vs. 75,106 NT dollars, respectively). Based on the impressive cost-performance of planned short-course radiation compared with upfront concurrent chemoradiation (better OS, modest downstaging and lower cost), planned short-course radiation should be the preferred radiation approach for managing metastatic rectal cancer.

Introduction: There was an improvement in therapeutic regimens for advanced colorectal cancer (CRC) in the last few decades. The low dose metronomic palliative chemotherapy in patients with advanced CRC after the failure of standard chemotherapy led to a dramatic increase in efficacy, reduction of mortality rates, and improves survival in the form of control symptoms, and enhances or improves quality of life which is an important issue in that group of patients. Patients and Methods: We include 60 Patients with recurrent or metastatic colorectal cancer after failure of multiple lines of chemotherapy. The patients were randomized in two groups either to receive supportive treatment in group A (30 patients) or low dose weekly leucovorin 20 mg/m² plus 5-flourouracil 425 mg/m² for 3 weeks and 1 week rest in group B (30 patients). Patients in group B received palliative chemotherapy for 4 months at least. Results: After a follow up period of 19 months, the mean time to progression (TTP) is 4.9 months for the group (A) but is higher in group (B) as it is 7.8 months and it shows a statistically significant difference (P value

Preoperative chemoradiation followed by surgery has been recommended as a standard treatment for patients with stage II/III rectal cancer. However, the optimal sequencing of radiotherapy for metastatic rectal cancer remains unclear. Between 2004 and 2014, patients diagnosed with metastatic rectal cancer who underwent the resection of primary site and received radiotherapy were retrospectively selected using the Surveillance, Epidemiology, and End Results (SEER) database. The propensity score matching analyses were used to lessen the effects of confounding factors including age, sex, race, marital status, serum carcinoembryonic antigen level, histologic type, differentiation status, tumor size, T stage, N stage and resection of the distant lesions. The cancer-specific survival (CSS) were compared based on the sequencing of radiotherapy. Ultimately, 686 matched pairs were formed for comparison of preoperative versus postoperative radiotherapy. The 5-year CSS estimates were 33.4% (95% CI: 28.9%-37.9%) and 26.8% (95% CI: 22.7%-30.9%) for patients underwent preoperative radiotherapy followed by resection of primary lesion and postoperative radiotherapy after surgery, respectively. Patients underwent preoperative radiotherapy had better CSS as compared to patients received postoperative radiotherapy (p

Objective : to analyze short-term and long-term outcomes of surgical, combination, and comprehensive treatment in patients with metastatic rectal cancer. Materials and methods . We performed a retrospective analysis of prospectively collected data on the outcomes of rectal cancer patients receiving surgical, combination (surgery + chemotherapy), or comprehensive (chemoradiotherapy + surgery + chemotherapy) treatment in the Department of Proctology at the N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia, between 1999 and 2015. We assessed overall survival, frequency of postoperative complications, postoperative death rates and frequency of complications associated with chemoradiotherapy. Results . The study included 366patients that were divided into 3 groups according to the treatment strategy. The 2-year survival rate was 83 % in group 3 (comprehensive treatment) vs 40 % in groups 1 and 2. Median survival was 43 months in group 3 compared to 18 and 14 months in groups 2 and 1 respectively. The number of postoperative complications was 19 %, 13.4 %, and 15.1 % in groups 1, 2 and 3 respectively. There was one postoperative death (1.1 %) in group 3. Conclusion . Comprehensive treatment significantly improves overall survival of rectal cancer patients without increasing the risk of postoperative complications.

Introduction The role and optimal regimen of radiotherapy in curative-intent treatment of metastatic rectal cancer is unclear and hence a single arm meta-analysis was performed. Method Medline, Embase and Cochrane Library databases were searched up to 16 May 2020. A Meta-analysis of binomial data was performed using a Freeman-Tukey double arcsine transformation, and pooled estimates were used to construct risk ratios and confidence intervals via the Katz-logarithmic method. Additionally, comparative meta-analysis was performed with the Mantel Haenszel model. Results 18 studies were included. Rectal pathological complete response (pCR) was observed in 14% of tumours treated with radiotherapy (n = 57/388, CI 0.07 to 0.23). Comparative meta-analysis of cohort studies showed that treatment regimens including radiotherapy were associated with higher pT1 tumour and better oncological outcomes compared to regimens without radiotherapy. Katz-logarithmic method showed that neoadjuvant radiotherapy had a higher proportion of pN0 staging (RR = 1.81, 95% CI 1.06 to 3.09, p = 0.029) and better oncological outcomes compared to adjuvant radiotherapy, and that short course radiotherapy (SCRT) had a lower proportion of pT3 tumours (RR = 0.778, 95% CI 0.609 to 0.994, p = 0.044) and similar oncological outcomes compared to long course radiotherapy (LCRT). Conclusions This study supports the evidence that radiotherapy should be used in curative intent metastatic rectal cancer.

Penile secondary malignancies are rare. Clinical suspicious along with imaging gave fair indication of the metastatic rectal cancer in a 58 year male in our institute. The biopsy of penile lesion confirmed the diagnosis in the patient who was treated for stage III rectal cancer with sandwich approach (neadjuvant chemotherapy followed by surgery and then adjuvant therapy).

Recurrent rectal cancer is more aggressive than the primary disease. Tri-modality treatments including surgery, chemotherapy (CT), and radiotherapy (RT) are effective for disease control in proper patients. Surgery may be recommended after RT for patients with good performance who have not previously received RT. Salvage therapies may be applied both with external RT and intraoperative RT. Re-irradiation is an option in selected patients who have previously received RT. Palliative RT can be applied in patients who have a poor prognosis and symptoms like pain and hemorrhage.

Background: The liver is the most common site for rectal cancer metastases and metastases to the liver is the major cause of death. A significant proportion of liver metastases cannot surgically remove. However, very limited data are available in the literature regarding the survival outcomes of these patients. This study aims to investigate the survival pattern of unresectable metastatic rectal cancer patients after both chemoradiotherapy and primary tumor resection.Methods: A total of 51178 rectal cancer patients were identified from Surveillance, Epidemiology, and End Results (SEER) database, of whom 448 patients were with synchronous liver metastasis and underwent both chemoradiotherapy and primary site resection. Kaplan-Meier analysis was used to compare the survival differences between the two groups. Cox proportional hazard regression model was used to analyses independent prognostic factors and exact 95% confidence intervals (CIs).Results: Among the 448 metastatic rectal cancer patients with both chemoradiotherapy and primary site resection, 270 (60.3%) patients were undergone hepatic resection. The mean survival, 2-year overall survival, 5-year overall survival were 37.0 months, 68.5%, 32.9% among patients who did not undergo hepatic resection compared with 56.0 months, 87.4%, 48.0% among patients who underwent hepatic resection (PConclusions: Primary site resection and chemoradiotherapy might be able to accomplish a satisfying survival outcome in unresectable metastatic rectal cancer patients. Non-hepatic resection is the strongest risk factor associated with poor prognosis.

BACKGROUND: For rectal cancer with unresectable metastases, current practice favors omitting interventions directed at the primary tumor in asymptomatic patients. OBJECTIVE: To determine the proportion of patients with primary tumor-related complications, characterize salvage outcomes, and measure survival in metastatic rectal cancer patients who did not undergo upfront intervention for their primary tumor. DESIGN: Retrospective analysis. SETTING: Comprehensive cancer center. PATIENTS: Patients who presented between January 1, 2008, and December 31, 2015, with synchronous stage IV rectal cancer, an unresected primary, and no prior primary tumor-directed intervention. MAIN OUTCOME MEASURES: Rate of primary tumor-related complications in the cohort that did not receive any primary tumor directed intervention. The Kaplan-Meier method and Cox regression analysis were used to determine whether complications are associated with survival. RESULTS: The cohort comprised 358 patients with median age of 56 years (22–92). Median follow-up was 26 months (range, 1 to 93 months). Among the 168 patients (46.9%) who eventually underwent elective resection of the primary tumor, the surgery was performed with curative intent in 66 patients (18.4%) and preemptive intent in 102 patients (28.5%). Of the 190 patients who did not undergo an upfront or elective intervention for the primary tumor, 68 (35.8%) experienced complications. Nonsurgical intervention for complications was attempted in 34 patients with an overall success rate of 61.8% (21 out of 34). Surgical intervention was performed in 47 patients (including 13 patients for whom nonsurgical intervention failed): diversion in 26 patients and resection in 21 patients. Of those 47 patients, 42 (89.4%) ended up with a colostomy or ileostomy. LIMITATIONS: Single center. CONCLUSION: A significant proportion of patients with metastatic rectal cancer and untreated primary experience primary tumor-related complications. These patients should be followed closely and preemptive intervention (resection, diversion, or radiation) considered if the primary progresses despite systemic therapy. See Video Abstract at http://links.lww.com/DCR/B400.

// Duo Tong 1, 3, * , Fei Liu 2, 3, * , Wenhua Li 1, 3, * and Wen Zhang 1, 3 1 Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China 2 Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China 3 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China * These authors contributed equally to this work Correspondence to: Wen Zhang, email: zw65242@163.com Keywords: rectal cancer, surgery, radiotherapy, SEER, survival Received: January 04, 2017 Accepted: June 28, 2017 Published: July 11, 2017 ABSTRACT The role of surgery of the primary cancer and radiation in metastatic colorectal cancer (mCRC) is still controversial currently, and evidence implied that colon cancer (CC) and rectal cancer (RC) should be treated with difference. Hence we focused on metastatic rectal cancer (mRC) solely to compare the cancer cause-specific survival (CSS) of patients receiving varied treatments of the primary cancer: no treatment, surgery only, radiation only, and surgery plus radiation, based on the records of the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8669 patients were included. Results demonstrated that the 2-year CSS was 28.1% for no treatment group, 30.7% for only radiation group, 50.2% for only surgery group, and 66.5% for surgery plus radiation group, reaching statistical difference ( P < 0.001). Furthermore, the CSSs of mRC patients in the surgery group were similar regardless of resection ranges ( P = 0.44). Besides, we analyzed the prognostic factors for mRC and found carcinoembryonic antigen (CEA) level, metastasis (M) stage, Tumor (T) stage, tumor size, differentiate grade, age and marital status should be taken into consideration when estimating the prognosis. Particularly, patients with normal CEA level or M1a stage showed a significant survival advantage. Overall, present study suggested that surgery of the primary cancer and radiation might help to improve the survival of mRC patients, especially when both treatments were conducted. Our results may assist clinicians to make better treatment strategy for patients with mRC.

Background: Various etiologies account for bilateral adrenal masses including infections, malignancies and adrenal hemorrhage. Accurate diagnosis is needed to provide the best care for the patient. Clinical case: A 63-year-old Thai male patient with locally advanced rectal cancer was treated with concurrent chemoradiotherapy in 2013. He had been followed up at the oncology clinic regularly after his cancer treatment and there was no evidence of cancer recurrence. In early 2018, he presented with anorexia, weight loss and non-productive cough. His chest X-ray showed the presence of patchy opacity of the left lung. The CT of the chest and whole abdomen revealed multiple bilateral pulmonary nodules, bilateral adrenal masses (sized 3.4x5.4 and 4.3x5.5 cm) and an enlarged spleen without definite space-taking lesion. At that time, he was diagnosed with recurrent rectal cancer and presented at the emergency department due to acute diarrhea and hypotension. Multiple discrete umbilicated papules at face, tongue and hands were noted on the physical examination. Hypotension persisted after volume resuscitation. Random cortisol level was 11 µg/dL before hydrocortisone was initiated. Wright stain of the skin lesion showed intracellular yeast-like organism and culture of the skin biopsy showed Histoplasma capsulatum. Bone marrow involvement from the same organism was also documented. After reviewing his clinical course, the diagnosis was compatible with disseminated histoplasmosis (skin, pulmonary, adrenal, spleen and bone marrow involvement). He was treated with amphotericin B for 3 weeks before switching to itraconazole. Two months after antifungal treatment, CT showed increased in size and number of multiple hypodensity lesions at spleen. Therefore, bilateral adrenalectomy with splenectomy was performed without complication. Pathological findings showed diffuse necrotizing areas with surrounded histiocytes, foamy macrophages and multinucleated giant cells in both adrenal glands and spleen. GMS showed presence of numerous small ovoid yeasts, compatible with histoplasmosis. This patient had been doing well with his long-term treatment with itraconazole and glucocorticoid replacement. Conclusion: This was the case of disseminated histoplasmosis whose presentation mimicked metastatic rectal cancer. Misdiagnosis caused delay in the diagnosis and treatment of adrenal insufficiency. References: Koene RJ, Catanese J, Sarosi GA. Adrenal hypofunction from histoplasmosis: A literature review from 1971 to 2012. Infection. 2013;41:757-9.

Colorectal cancers typically metastasize to the lymph nodes, liver or lungs. Metastasis to the heart is rare and although a few cases of cardiac metastases from colon cancer are described in the literature, cases of metastatic rectal cancer to the heart are far fewer. A 69-year-old woman with a history of rectal adenocarcinoma treated with neo-adjuvant chemotherapy and radiation, followed by resection and adjuvant chemotherapy, presented with increasing dyspnea on exertion and lower extremity edema 5 years after oncology follow-up. Echocardiography revealed a mass within the right atrium, which was biopsied and found to be consistent with metastatic rectal adenocarcinoma and a thrombus. The patient was deemed to be a poor surgical candidate given her co-morbidities and overall prognosis. Chemotherapy was offered and refused by the patient. The medical literature has a paucity of similar cases of rectal adenocarcinoma metastasizing to the right atrium. Further studies are needed to help guide standardized treatment options. J Clin Med Res. 2017;9(10):886-888 doi: https://doi.org/10.14740/jocmr3123w

Using a large national registry, we investigated patterns of care and overall survival (OS) for metastatic rectal cancer patients treated with chemotherapy or radiotherapy (RT), or with a multimodal approach.Adult patients with metastatic rectal cancer who did not undergo resection diagnosed from 2004 to 2014 were included. Kaplan-Meier, log-rank, and Cox regression analyses were performed.We identified 2385 patients. Of these, 1020 patients (43%) received chemotherapy alone, 228 (10%) received RT alone, 850 (36%) received chemotherapy and RT, and 287 (12%) received no treatment. Receipt of chemotherapy alone increased over the study period, and receipt of chemoradiotherapy decreased (P .01). The only factor predictive of receiving any RT on multivariate analysis was clinical stage T3 disease. Factors predictive of OS on multivariate analysis included receipt of chemotherapy, Hispanic race, income greater than $46,000, and presence of lung metastasis. The OS for patients treated with chemotherapy and RT was not significantly different than chemotherapy alone. Five-year OS with chemotherapy alone, RT alone, chemoradiotherapy, and no treatment were, respectively, 84%, 56%, 79%, and 46%.Metastatic rectal cancer patients with T3 tumors were more likely to receive RT. Local RT does not improve survival for patients with metastatic rectal cancer who do not also undergo surgery. The use of chemotherapy alone for metastatic rectal cancer is increasing, and chemotherapy is associated with higher OS compared to no treatment and RT alone. This remained true even in patients older than 80 years.

Purpose: Radiotherapy (RT) has been reported to effectively palliate many symptoms of patients with metastatic rectal cancer (mRC). The objective of this study was to evaluate the survival benefit of RT in mRC. Methods: A retrospective population-based cohort study was performed using the Surveillance, Epidemiology, and End Results Program (SEER) database. Patient baseline demographic characteristics between the RT and no-RT groups were compared using Pearson chi-square tests. The outcome of interest was cause-specific survival (CSS). Propensity score (PS) matching and Cox proportional hazards regression analyses were performed to evaluate the prognostic power of variables on CSS. Results: A total of 8851 patients with mRC were identified in the SEER database. Multivariable Cox regression analysis showed that RT was a protective factor in mRC (hazard ratio [HR]= 0.702, 95% confidence interval [CI]=0.665-0.741, p

The aim was to evaluate the outcome of treatment-naive patients with synchronous metastatic rectal cancer after chemotherapy with FOLFOXIRI followed by local therapeutic procedures of all tumor lesions as complete as possible. We reviewed data of 30 patients with synchronous distant metastatic rectal cancer who underwent chemotherapy with FOLFOXIRI and subsequent local therapy in our institution. Median follow-up was 28 months (range: 8; 74). Cumulative overall survival (OS) and progression-free survival (PFS) was 93.3, 76.9, 55.6% and 46.2, 29.7, 29.7% after 1, 2, 4 years. Non-response to chemotherapy with FOLFOXIRI was associated with a highly significant decreased OS (p