Interesting case 17/3/53

Interesting caseES 2504 : Interesting caseES 2504 By Nongnoot Charoensin, MD.

Slide 2 : A 26 years old man CC; 2 weeks PTA ??????? ??????????? (4 kg/1mo) ???????????????? ????????????2???? ???????? No known underlying disease HIV positive (first diagnosis)

Physical examination : Physical examination A thai male, good conciousness Not pale, no icteric sclera HEENT; right cervical lymphnode about 4cm in diameter, three left cervical lymphnodes about 1-3.0 cm in diameter, not tender superior neck vein engorgement No oral hairy leukoplakia Left epitrocheal lympnode about 1.5 cm. Heart; regular, no murmur Lung; clear

Slide 4 : Abdomen; soft, the liver margin about 2 FB below right costal margin Extremities; Bilateral right groin nodes just palpable about 1-1.5 cm

Slide 5 :

CXR : CXR bilateral mediastinal node enlargement (more on the right side of the upper mediastinum)

Problem list : Problem list SVC syndrome with multiple bilateral cervical, left epitrocheal, both groin nodes enlargement and bilateral paratracheal node enlargement HIV infection

Management 15/01/08 : Management 15/01/08 Planing of radiotherapy Palliation radiotherapy at anterior chest AP/PA depth-midplane DD 200 cGy TD 3000 cGy

Pathologic exam : Pathologic exam Diagnosis: Lymph node, cervical , incisional biopsy :- Metastatic germ cell tumor , suggestive of metastatic seminoma. Note:- Immunoperoxidase staining for PLAP, pan-cytokeratin and EMA are positive, but for B-HCG, AFP, LCA, CD45RO, CD3, CD43, CD20 and CD79 a are negative.

Slide 10 : US upper abdomen and testes; no testicular mass, no liver mass

Progress note 10/03/08 : Progress note 10/03/08 ??? med ?????????????????? ????????????? 1 ????? Chemotherapy; BEP regimen

EMERGENCY CTA OF CHEST 18/12/08 : EMERGENCY CTA OF CHEST 18/12/08 IMPRESSION: - Compatible with multiple pulmonary embolism causing pulmonary infarctions at both lungs.- Large mediastinal mass with pulmonary metastasis and multiple lymph nodes metastasis along periaortic region and right axillary region.- RML and RLL bronchi encasement by the mass causing atelectasis.- Suspicious of thrombus within right ventricle and SVC thrombosis.- Bilateral pleural effusion and panlobular emphysema at right apical lung.

25/02/10 : 25/02/10 ??? consult from medicine department ?????? ????????? alteration of consciousness CT brain; multiple heterogeneous hyperdense mass, bleeding metastatic process is more likely than infectious process CXR; decrease in size of the right paratracheal node enlargement

Slide 14 : ß-Hcg1.91 AFP 2606 LDH 265 LFT normal BUN/Cr normal

Problem list : Problem list SVC syndrome with multiple bilateral cervical, left epitrocheal, both groin nodes enlargement and bilateral paratracheal node enlargement; treatment CMT HIV infection Multiple brain metastases from seminoma Pulmonary metastases

Management : Management Aim; Palliation radiotherapy WBI (2-17/03/10) DD 300 cGy x 10 F TD 3000 cGy

Slide 17 : ?????????????? (1800 cGy) ?? nausia vomiting ???????? ??????????? ??????????? Complete WBI 3000 cGy ????????? No neurological deficit AFP rising…mixed GCT Consult oncomed for CMT

Extragonadal germ cell tumors : Extragonadal germ cell tumors EGCTs Similar histology of the testicular seminoma 1-5% of all GCTs Tend to occur in young men Worse prognosis than the testicular primary Respond to platinum base CMT

Slide 19 : Most commonly arise in the midline site; Mediastinum, pineal, suprasellar region and the sacrococyx Tumor arising at retroperitoneal associate with occult testicular primary Mediastinum GCTs usually occur in anterior superior region…metastatic to lung, liver or bone is common

Slide 20 : NSGTCs or seminoma are preferred cisplatinum base CMT Surgical resection is recommend for residual mass after CMT

Slide 21 : Prognostic variables for response the outcome of treatment ; histology, presence of liver, lung or CNS metastases, elevation of ß-hCG and number of metastatic sites The excellent treatment result with chemotherapy alone of mediastinal seminoma would suggest that there is no routine role for RT in their management

Central nervous system metastases from EGCTs : Central nervous system metastases from EGCTs The optimal local therapy in patient with resectable disease is unclear In those with unrectable disease RT to a dose of 40-45 Gy should be given to a gross disease The role of total brain irradiation is unclear but if given the dose should not exceed 40 Gy

PALLIATIVE BRAIN METASTASES : PALLIATIVE BRAIN METASTASES 20-40% of all patients diagnose with cancer Most common primary tumor; lung, breast, colon, melanoma Systemic therapy untreated tumor cells beyond BBB The hematogeneous spread result in tumor emboli growth at the grey white junction The most common anatomical site are the cerebral hemispheres (80%).

Treatment : Treatment Rapid control of the symptoms Intravenous corticosteroid; rapid control of the cerebral edema Decadron loading dose 8-32 mg iv then oral administration 4mg four times a day

Slide 25 : Recurtive partitioning analysis( RPA ) by Gaspar and coworker Several prognostic factors Pretreatment and treatment-related variables Histology Number and size

RPA class : RPA class Class 1; KPS > 70 Age <65 Controlled primary tumor Median of prognostic of 7 months. Class 2; KPS<70 Age >65 Uncontrolled primary tumor Median prognostic of 4 months

Slide 27 : Class 3; KPS <70 Age >65 Uncontrolled primary tumor Median prognostic of 2 month

Treatment : Treatment Whole brain radiotherapy Surgical resection Radiosurgery

Slide 29 : Single brain metastasis with RPA class 1; surgical resection with WBI Multiple brain metastases; WBI alone Two or three metastases in class 1 or 2…single or multiple modality

Whole brain radiotherapy : Whole brain radiotherapy Multiple brain metas or uncontrolled primary tumor Goal; limit progression, limit the use of corticosteroids Optimal dose is unknown 20 Gy in 5 F -40 Gy in 20 F

Complications : Complications Alopecia Transient worsening of the neurologic symptoms Otitis media Continue corticosteroid during WBI reduce the complications Long term effects; memory loss, dementia, decrease concentration

Technique of WBI : Technique of WBI Supine Head rest and immobilization Portal films; parallel-opposed lateral fields Inferior border of the base of skull The field border should go beyond the skull anterior, superior and posterior bony limits by 2 cm The inferior border; from bony canthus to the C1/2 intervertebral disc space

Slide 33 : Gunderson and Tepper, clinical radiation oncology, 2nd edition

Slide 34 : THANK YOU