Download Radiologic Evaluation

CLINICAL CASE
CASE REPORT
 Men
 68 years old
 Healthy
 Outpatient Clinic
 Right Scrotal Discomfort
 2 months evolution
 No Fever
 No urethral discharge
 No other constitucional symptoms
Physical Examination:
 Hard nodule at right spermatic cord
(independent from testis), no painfull, no local
inflamatory signs
RADIOLOGIC EVALUATION
INGUINO-SCROTAL ULTRASSONOGRAPHY
“Solid nodule,
heterogeneous; 2 cm´s…”
“…difuse hyperreflectivity, with no
evidence of collections…”
Right Side
QUESTION 1
NEXT STEP…
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RADIOLOGIC EVALUATION – X-RAY; CT; MRI
PERCUTANEOUS BIOPSY
EXCISIONAL BIOPSY – INGUINAL APPROACH
TESTICULAR TUMOR BIOMARKERS
OTHER...
RADIOLOGIC EVALUATION
CHEST X-RAY
QUESTION 2
DIAGNOSIS HYPOTHESIS
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TESTICULAR CANCER
LIPOSARCOMA SPERMATIC CORD
LEIOMIOSARCOMA SPERMATIC CORD
INFECTIOUS DISEASE
PULMONARY NEOPLASM
OTHER
QUESTION 3
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RADIOLOGIC EVALUATION – CT; MRI
PERCUTANEOUS BIOPSY
EXCISION BIOPSY – INGUINAL APPROACH
RADICAL ORQUIDECTOMY
OTHER...
SURGERY
RIGHT RADICAL ORQUIDECTOMY
28th May 2009
PATHOLOGY
“…tumor 1.9 cm in diameter…
irregular but clear boundaries,
fibroelastic consistency. Not observed
any relation to the testicle. Testis with
7x3, 5x3, 5 cm in size without changes
in the macroscopic study ...”
”
“… neoplasm of large cells, clear
cytoplasm, small oval nuclei, some with
monotonous prominent nucleoli, a
pattern of solid growth…”
“…Immunohistochemical study:
immunoreactivity for cytokeratin CAM
5.2, vimentin, and CD10”
SPERMATIC CORD METASTASIS FROM
RENAL CELL CARCINOMA
IMAGIOLOGIC STAGING
“…pulmonary nodular formations observed numerous solid pericentimetrics
dimensions of metastatic nature. ... right kidney shows nodule with approximately 55
mm, heterogeneous, infiltrating the renal sinus. ... "
QUESTION 4
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NEO ADJUVANT THERAPY + RN
RADICAL NEPHRECTOMY + ADJUVANT THERAPY
RADICAL NEPHRECTOMY
EMBOLIZATION
OTHER...
SURGERY
RIGHT RADICAL NEPHRECTOMY
right spermatic vein drained directly into the
renal vein
6th August 2009
PATHOLOGY
CLEAR CELL CARCINOMA with 5,5 cm x 4,5 cm x 3,5 cm in the middle
third of the right kidney,
nuclear grade 3/4 with invasion of perinephric fat and renal vein
STAGING AND PROGNOSIS
International TNM/ American Joint Commitee on
Cancer 2002
pT3NxM1
Performance Status ECOG
Grade 0 – active, normal life, without restrictions
Performance Status Karnofsky
> 90 % – Normal activity, some signs of disease
QUESTION 4
PALIATIVE/ADJUVANT TREATMENT
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SUNITINIB – 50 MG ID
IL-2 HIGH DOSE
TEMSIROLIMUS
SORAFENIB
OTHER...
PALIATVE THERAPY
SUNITINIB; 50 mg; id; oral – 4 weeks + 2 weeks off
CLINICAL EVALUATION
Before treatment…
CLINICAL EVALUATION
No Hypertension
No Cardiac Problems or Congestive Heart Failure
No Vascular Pathology – including transient cerebral vascular attack
No Seizures
No Kidney problems
No Liver problems
No Depression History
No Hypothyroidism
No Anemia
No dermatologic lesions (including keratosis)
No Medication (ocasionally or dietary supplements)
LABORATORY EVALUATION
Before treatment…
LABORATORY EVALUATION
Before treatment…
LABORATORY EVALUATION
Before treatment…
CARDIOLOGIC EVALUATION
Before treatment…
STAGING AND PROGNOSIS
MSKCC Model *
* “Validation and Extension of the Memorial Sloan- Kettering Prognostic Factors Model
for Survival in Patients With Previously Untreated Metastatic Renal Cell Carcinoma “
STAGING AND PROGNOSIS
MSKCC Model *
* “Validation and Extension of the Memorial Sloan- Kettering Prognostic Factors Model
for Survival in Patients With Previously Untreated Metastatic RenalCell Carcinoma “
ADJUVANT/PALIATIVE THERAPY
SUNITINIB ; 50 mg; id; oral – 4 weeks + 2 weeks off
Initiated 4 weeks after surgery
Adverse Effects
Fatigue/Asthenia
Diarrhoea
Nausea
Vomiting
Stomatitis
Hypertension
Hand-Foot Syndrome
Hematologic Alterations
1 2nd
Yes; Grade I-II 1
Yes; Grade I-II
Yes; Grade I-II
Yes; Grade I-II
Yes: Grade I 2
No
No
Yes; Leucopenia; G I
week after initiation
2 2nd week; alleviated at 2 weeks off
EVALUATION AND FOLLOW-UP
After 6 Cycles of therapy with SUNITINIB
No Grade III-IV adverse effects
PS > 80%
Grade I-II adverse effects
Diarrhoea
Vomiting
Nausea
Astenia
Tolerable without
discontinuation
EVALUATION AND FOLLOW-UP
Response Evaluation Criteria in Solid Tumors
(RECIST) version 1.1 Criteria
EVALUATION OF TARGET LESIONS
COMPLETE RESPONSE
PARCIAL RESPONSE
PROGRESSIVE DISEASE
We achieved STABLE
Disappearance of all target lesions
Redution in all pathologic LN to
<10 mm
»30% decrease in the sum of the
longest diameter of target lesions
»20% increase in the sum of
target lesions and
5 mm´s absolute increase of
target lesions
DISEASE after 3 cycles of Sunitinib
EVALUATION AND FOLLOW-UP
Response Evaluation Criteria in Solid Tumors
(RECIST) version 1.1 Criteria
Begin
After 6 cycles - SUNITINIB
EVALUATION AND FOLLOW-UP
Response Evaluation Criteria in Solid Tumors
(RECIST) version 1.1 Criteria
We achieved PARCIAL RESPONSE after 6 cycles of Sunitinib
Begin
After 6 cycles - SUNITINIB
THERAPEUTICS
DURATION ?
WHEN TO STOP?
OBRIGADO