We report a case of a 31-year-old man with metastatic fibrolamellar hepatocellular carcinoma (FLHCC) treated with gemcitabine and oxaliplatin complicated by hyperammonemic encephalopathy biochemically consistent with acquired ornithine transcarbamylase deficiency. Awareness of FLHCC-associated hyperammonemic encephalopathy and a pathophysiology-based management approach can optimize patient outcome and prevent serious complications. A discussion of the management, literature review, and proposed treatment algorithm of this rare metabolic complication are presented. The Oncologist 2016; 21:514-520Implications for Practice: Pathophysiology-guided management of cancer-associated hyperammonemic encephalopathy can improve patient outcome and prevent life-threatening complications. Community and academic oncologists should be aware of this serious metabolic complication of cancer and be familiar with its management.

We performed a multicenter retrospective comparative study to assess the impact of age on potential differences in clinical characteristics, treatment patterns, and outcome in HCC patients. Characteristics that distinguish elderly from younger HCC patients include lower M/F ratio, worse performance status, lower rate of HCV infection, and less advanced underlying cirrhosis. Elderly patients were less likely to have a liver transplant and more likely to receive supportive care only. However, overall and HCC-specific survival were similar between the two groups.

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Syringocystadenocarcinoma papilliferum (SCACP) is an extremely rare cutaneous neoplasm of the apocrine or eccrine sweat glands. Solid and cystic glandular structures with cribriform and tubular architecture along with CK5/6, pankeratin and p63 immuno-profile set apart SCACP from other cutaneous malignancies. Wide local excision (WLE) has been the mainstay treatment for localized SCACP; however, no standard treatment has yet been established for unresectable or metastatic disease. Herein, we report a 74-year-old male with SCACP, who initially presented with a painful nodule on the upper back and later developed metastatic disease. He was treated with carboplatin and paclitaxel with concurrent intensity-modulated radiation therapy (IMRT), which resulted in disease stabilization for 12 months. Next generation sequencing (NGS) revealed a total of 18 genomic alterations associated with potential benefit from targeted therapeutics. PD-L1 expression was identified in 70% of tumor cells. These findings suggest that the opportunity of targeted therapeutics and immunotherapy exist as for metastatic SCACP. Reporting molecular profile of the rare tumors with no established standard treatment options should be encouraged.

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A 72-year-old man initially presented with a 2-month history of severe dysphagia and a 25-pound weight loss. Endoscopy demonstrated an infiltrating mass in the distal esophagus. A biopsy revealed high-grade infiltrating adenocarcinoma with signet ring cells (Fig 1). The initial abdominal computed tomography (CT) showed a 6-cm length circumferential thickening of the distal esophagus with extension to the gastroesphageal junction and adjacent adenopathy. The chest, abdomen, and pelvis CT scans showed no evidence of metastatic disease in the liver, pancreas, or adrenal glands.At this point, the patient was referred to University of Miami Sylvester Comprehensive Cancer Center (Miami, FL) for further evaluation and treatment. An endoscopic ultrasound was performed, and the tumor was staged as T3N1Mx. Whole-body [ 18 F]fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/ CT) was obtained for further staging and demonstrated avid pathologic uptake (max, 15.8 standardized uptake value [SUV]) in the distal esophagus corresponding with the known esophageal tumor. Avid nodular uptake within left deltoid muscle posteromedial to acromioclavicular joint, peak SUV measured 6.0. Avid nodular uptake in three locations within the right gluteus maximus muscle with peak SUV was 11.8. More superiorly there was an additional nodule of uptake in the right gluteus muscle measuring 4.8, and more inferomedially there was a third nodule of uptake in the right gluteus muscle, SUV measuring 10.3. There was a focal nodular uptake in the left gluteus maximus muscle, SUV 5.5 and additional focus of abnormal uptake in the left gluteus muscle was identified just dorsal to the left ischial tuberosity, peak SUV measuring 4.3. Focal intense nodular uptake within paraspinous musculature at the level of mid-dorsal spine, SUV measured 5.2 (Fig 2).A CT-guided percutaneous biopsy of the biggest (2 cm) right gluteal lesion was performed and revealed a moderately differentiated adenocarcinoma consistent with primary esophageal cancer. The tumor cells are positive for CK7 and negative for CK20 and CDX-2 by immunohistochemistry (Fig 3). Due to the presence of multiple muscle metastases, surgery was not indicated, and the patient underwent systemic chemotherapy with oxaliplatin, docetaxel, floxuridine, and leucovorin. FDG-PET/CT was repeated after two cycles of chemotherapy and demonstrated an average of 50% decrease of SUVs in the distal esophagus as well in musculature. However, there was a new identified region within left sartorius muscle, just lateral to the femoral vessels with a maximum SUV of 4.6 (Fig 4). The patient's muscles metastasis remains asymptomatic, and the patient is receiving systemic chemotherapy.Metastasis to the skeletal muscles is very rare and represents less than 1% of all hematogenous metastases from solid tumors. 1,2,3,4 Some researchers reported only 15 cases of muscle metastasis during a 16-year period in which more than 54,000 newly diagnosed cancers were diagnosed. 5 Muscle metastases account for les...

Background COVID-19’s precise impact on cancer patients and their oncologic care providers remains poorly understood. This study aims at comparatively analyzing COVID-19’s effect on cancer care from both patient and provider perspectives. Methods A multi-institutional survey was developed to assess COVID-19-specific concerns regarding treatment, safety, and emotional stress through 5-point Likert-type prompts and open-ended questions before and during the pandemic. Wilcoxon signed-rank and rank-sum tests were used to analyze before/during answers for providers and patients independently. Open-ended responses were assessed using inductive thematic analysis. Results The survey was completed by 104 (69.3%) patients and 50 (50%) providers. Patients demonstrated a significant change in only 1 of 15 Likert prompts. Most significant were increased concern regarding susceptibility to infection [ z = 2.536, p = 0.011] and concerns regarding their cancer outcome [ z = 4.572, p < 0.001]. Non-physician providers demonstrated significant change in 8 of 13 Likert prompts, whereas physicians had all 13 Likert prompts change in the COVID-19 setting. Physicians believed care to be more poorly planned [ z = −3.857, p ≤ 0.001], availability of protective personal equipment to be more limited [ z = −4.082, p < 0.001], and were significantly concerned infecting family members [ z = 4.965, p < 0.001]. Conclusions While patients had more difficulty coping with their cancer, they did not perceive significant differences in their actual treatment. This suggests the need for a renewed focus on patients coping with cancer. Among providers, physicians more than any other provider group had a strong negative perception of COVID-19’s impact on healthcare, suggesting the need for novel approaches to target physician burnout.