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Aim To evaluate the number of interval cancers (IC) within one screening cycle and the overall 10-year survival of IC, including its four main classifications, and compare that to screen-detected cancers (SDC). Materials and methods Within Breast Test Wales (BTW), all SDC between the years 1998 and 2001 were included. IC that occurred between 1998 and 2003 that had undergone screening between the years 1998 and 2001 were also included. These IC were classified into true interval (TI), false negative (FN), occult cancer (OCC), and unclassified cancer (UCC). BTW received notification of all deaths of women that had undergone screening; thus, the 10-year all-cause survival rate was calculated from the date of diagnosis and death. Results During the study period, 199,082 women attended screening. Of these, 1020 (0.51%) women had SDC and 692 (0.38%) women developed IC. Of the 692 IC, 391 (57.8%) were TI, 120 (17.7%) were FN, 68 (10%) were OCC, and 98 (14.5%) were UCC; 15 (2.2%) were not classified. After a 10-year follow-up period, the 10-year survival rate (all-cause) for SDC was 81.6%, overall for all of IC was 72.4% (OR = 1.67 , p 0.001), TI was 77.5% (OR = 1.00 , p = 0.99), FN was 55% (OR = 2.36 , p 0.001), OCC was 54.4% (OR = 3.17 , p 0.001), and UCC was 87.8% (OR = 0.61 , p = 0.19). Conclusions The overall 10-year survival of IC was significantly different to SDC. However, within this, the prognosis of TI was similar to SDC, whereas FN and OCC had significantly worse long-term survival. Further research is required to identify the underlying cause of poor survival of FN and OCC.

We thank Drs Jin-shan and Xue-bin for their interest in our recent study suggesting that pericarditis signals an occult cancer.1 Drs Jin-shan and Xue-bin address the potential economic and patient-related costs of offering screening to all patients presenting with pericarditis, and they inquire about additional characteristics categorizing patients at high risk of cancer. We did not deduce a cost-benefit analysis because such calculations require additional information not captured in our registry and because there are no current strong quality health-economic reports that may bring our results into perspective. In the recent update of the National Institute for Health …

Video Objective This video is intended for any gynecologic surgeon who is performing risk-reducing surgery in their practice. We intend to review the “best practices” recommended by ACOG when performing a risk-reducing bilateral salpingo-oophorectomy (RR-BSO) in patients with Hereditary Breast and Ovarian Cancer Syndrome. Setting Academic Medical Center Interventions This video describes the case of a 36-year-old female diagnosed with a BRCA 1 mutation who has completed childbearing and desires RR-BSO. There are four elements that are critical to include in risk-reducing procedures: 1. A thorough visualization of all peritoneal surfaces and accessible intraperitoneal organs should be performed. 2. Washings should be obtained. 3. The ovary should be removed in its entirety, and the fallopian tubes should be removed at their uterine insertion point at the cornua. 4. Complete serial sectioning of the ovaries and fallopian tubes performed by pathology is necessary, with microscopic examination for occult cancer. Conclusion These “best practices” should be employed by all surgeons when performing a RR-BSO in order to most effectively increase detection of early neoplastic changes and occult malignancy, and to decrease their patient's risk of developing ovarian and fallopian tube cancer.

Synopsis Over the course of the 2 years following power morcellation during laparoscopic hysterectomy in the presence of an occult cancer in a Boston area physician, the previously frequently used tool has been banned in the majority of hospitals following warnings from the US FDA. An increasing number of hysterectomies and myomectomies performed annually in the USA are done using laparoscopic or robotic techniques. Power morcellation, which allows removal of surgical specimens through a narrow tube via a sharp circular rotating cutting knife has greatly facilitated this increase. First FDA approved for gynecologic surgery in 1995, laparoscopic power morcellation was used to allow removal of uterine tissue from the peritoneal cavity after myomectomy or hysterectomy via

Objective: We undertook a retrospective analysis of the incidence of complications of carbon dioxide (CO2) laser excision for high-grade vaginal intraepithelial neoplasia (HG-VaIN).Materials and Methods: Retrospective large case series on 128 CO2 laser excisions for HG-VaIN in 106 women treated at the Department of Gynecologic Oncology, Oncologic Referral Center, Aviano, Italy. These procedures were performed under local anesthesiawith a 20-Wcontinuous laser beam focused to a 0.2-mm spot size. Complications were defined as "minor" when limited to vagina, and "major" when surrounding organs were injured or the vaginal vault was opened. To identify possible factors associated with surgical complications, we performed a univariate analysis with the t test for continuous variables and x(2) or Fisher exact test for qualitative variables as appropriate.Results: The overall rate of complication was 7.8% (10/128); nine of themwere vaginal bleeding, and only one (0.8%) was amajor complication with vaginal vault perforation. A greater number of previous destructive treatments and of two or more previous laser vaginal excisional treatments was present in patients with complications compared with ones without complications (10% vs 3.9 %, p = .92, and 30% vs 15.2%, p = .44, respectively), although these differences were not statistically significant. A total of 10.5% (6/57) of occult vaginal cancer was detected in women with initial diagnosis of VaIN3 (HG-VaIN) on biopsy.Conclusions: Carbon dioxide laser excision for HG-VaIN seems to be a safe approach with low rate of complications, probably because of the better accuracy achieved by CO2 laser resections, and permits diagnosis of occult invasive disease.

Accurate diagnosis of high-risk benign breast lesions is crucial in patient management since they are associated with an increased risk of invasive breast cancer development. Since it is not yet possible to identify the occult cancer patients without surgery, this limitation leads to retrospectively unnecessary surgeries. In this paper, we present a computational pathology pipeline for histological diagnosis of high-risk benign breast lesions from whole slide images (WSIs). Our pipeline includes WSI stain color normalization, ductal regions of interest (ROIs) segmentation, and cytological and architectural feature extraction to classify ductal ROIs into triaged high-risk benign lesions. We curated 93 WSIs of breast tissues containing high-risk benign lesions based on pathology reports and collected ground truth annotations from three different pathologists for the ductal ROIs segmented by our pipeline. Our method has comparable performance to a pool of expert pathologists.

Background: There is controversy about what patients with acute venous thromboembolism (VTE) should be investigated for occult cancer. Patients and Methods: We used data from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry to perform a nested case control study. VTE patients diagnosed with cancer beyond the first 30 days were identified as cases, and compared with those followed-up for 24 months and without cancer. Results: Of 5,863 eligible patients, 444 (7.6%) were diagnosed with occult cancer. Its proportion progressively increased with the patient9s age, from 3.5% (in men) and 2.4% (in women) among those aged 70 years.The most common sites of cancer were the lung (26%), prostate (17%) and colorectal (12%) in men; colorectal (19%) and breast (12%) in women. On multivariable analysis, male gender, age >70 years, chronic lung disease, raised platelet count, anaemia, prior VTE and recent surgery independently predicted the risk for occult cancer. The proportion of cancer in patients scoring ≤ 2 points was 5.8%, and 12% in those scoring >2 points. C-statistic was 0.636 (95% CI, 0.61-0.66). Their rate of VTE recurrences (odds ratio: 13.8; 95%CI: 0.77-249; p=0.07)) was higher than in patients with no cancer. Conclusions: Our prognostic score identified VTE patients at increased risk for occult cancer. We also identified the most common sites of cancer according to sex and age.

There has been a longstanding concern about whether there is an association between breast cancer and breast implants. This concern has served as the stimulus for many studies. Although there are data to support both sides, after our critical review of the literature, several conclusions can be drawn. (1) Augmented patients are not at a greater risk than the nonaugmented population for developing breast cancer. (2) Early detection of occult cancer is possible in augmented patients. (3) Submuscular placement allows for greater mammographic visualization. (4) Eklund views (displacement techniques) should be used when obtaining mammograms in augmented patients and should be interpreted by radiologists experienced in the evaluation of augmented patients. (5) Silicone and saline implants demonstrate the same radiodensity on mammograms; neither is superior to the other. (6) The current recommendations for getting screening/preoperative mammograms are no different for augmented patients, although the ultimate decision lies with each surgeon and patient.

Objective To report the frequency and features of occult carcinomas and the incidence of subsequent cancers following risk-reducing salpingo-oophorectomy (RRSO) in BRCA mutation carriers. Methods 257 consecutive women with germline BRCA mutations who underwent RRSO between January 1, 2000 and December 31, 2014 were identified in an Institutional Review Board approved study. All patients were asymptomatic with normal physical exams, CA 125 values, and imaging studies preoperatively, and had at least 12months of follow-up post-RRSO. All patients had comprehensive adnexal sectioning performed. Patient demographics and clinico-pathologic characteristics were extracted from medical and pathology records. Results The cohort included 148 BRCA1 , 98 BRCA2 , 6 BRCA not otherwise specified (NOS), and 5 BRCA1 and 2 mutation carriers. Occult carcinoma was seen in 14/257 (5.4%) of patients: 9 serous tubal intraepithelial carcinomas (STIC), 3 tubal cancers, 1 ovarian cancer, and 1 endometrial cancer. Three patients (1.2%) with negative pathology at RRSO subsequently developed primary peritoneal serous carcinoma (PPSC), and 2 of 9 patients (22%) with STIC subsequently developed pelvic serous carcinoma. 110 women (43%) were diagnosed with breast cancer prior to RRSO, and 14 of the remaining 147 (9.5%) developed breast cancer following RRSO. Median follow-up of the cohort was 63months. Conclusion In this cohort, 5.4% of asymptomatic BRCA mutation carriers had occult carcinomas at RRSO, 86% of which were tubal in origin. The risk of subsequent PPSC for women with benign adnexa at RRSO is low; however, the risk of pelvic serous carcinoma among women with STIC is significantly higher.

Background and purpose Cancer patients with cryptogenic stroke often have high plasma D-dimer levels and lesions in multiple vascular regions. Hence, if patients with cryptogenic stroke display such characteristics, occult cancer could be predicted. This study aimed to investigate the clinical characteristics of cryptogenic stroke as the first manifestation of occult cancer and to determine whether plasma D-dimer levels and lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke. Methods Between January 2006 and October 2015, data on 1225 patients with acute ischaemic stroke were extracted from the stroke database of Osaka University Hospital. Among them, 184 patients were classified as having cryptogenic stroke, and 120 patients without a diagnosis of cancer at stroke onset were identified. Clinical variables were analyzed between cryptogenic stroke patients with and without occult cancer. Results Among 120 cryptogenic stroke patients without a diagnosis of cancer, 12 patients had occult cancer. The body mass index, hemoglobin levels and albumin levels were lower; plasma D-dimer and high-sensitivity C-reactive protein levels were higher; and lesions in multiple vascular regions were more common in patients with than in those without occult cancer. Multiple logistic regression analysis revealed that plasma D-dimer levels (odds ratio, 3.48; 95% confidence interval, 1.68–8.33; P = 0.002) and lesions in multiple vascular regions (odds ratio, 7.40; 95% confidence interval, 1.70–39.45; P = 0.01) independently predicted occult cancer. Conclusions High plasma D-dimer levels and lesions in multiple vascular regions can be used to predict occult cancer in patients with cryptogenic stroke.

Background: Idiopathic venous thrombosis (IVT) is associated with occult malignancy in 10% of patients. The Trousseau study investigated whether extensive screening using abdominal and chest computed tomography (CT) scans and mammography in women would decrease mortality, compared with limited screening. Here, the costs and test characteristics of these screening strategies are presented, including true-and false-positive findings, sensitivity and specificity.Methods: All investigations performed because of a suspicion of malignancy in the limited or extensive screening groups were collected. Costs were calculated using Dutch healthcare tariffs.Results: A total of 342 and 288 patients with IVT were included in the extensive and the limited screening group, respectively. The prevalences of malignancy and mortality were comparable between these two groups, as were the abnormal findings during routine screening. In 30% of the extensively screened patients, the CT scans or mammography showed abnormalities necessitating further diagnostic work-up; this yielded six malignancies and resulted in a positive predictive value of 6.6%, sensitivity of 33% and specificity of 70%. Mean costs per patient were (sic) 165.17 for the routine and (sic) 530.92 for the extensive screening.Conclusion: Screening using CT scans and mammography results in extra costs due to the high percentage of false-positive findings for which a further diagnostic work-up is indicated.

An increase in naturally-occurring porphyrins has been described in the blood of subjects bearing different kinds of tumours, that has been proposed as an additional parameter for the diagnosis of occult cancer, although at present the reason for the phenomenon is not exactly defined. In this work the increase of porphyrins in plasma of tumour-bearing subjects has been investigated in parallel with their occurrence in other tissues, considering the systemic iron homeostasis subversion taking place in the presence of cancer. The transgenic female MMTV-neu mouse-developing spontaneous mammary adenocarcinoma has been used as an experimental model, in comparison to non-transgenic C1 mouse as a control. The spleen, accomplishing both hemocatheretic and hemopoietic functions in rodents, and the liver have been considered because of their deep engagement in heme metabolism, entailing both the fate of protoporphyrin IX (PpIX) as its ultimate precursor, and iron homeostasis. Investigations have been performed by means of microspectrofluorometric and image analysis of tissue autofluorescence (AF), and histochemical detection of non-heme iron. In tumour-bearing mouse, along with a marked PpIX presence in tumour, a PpIX enhancement in spleen and liver is observed, that is accompanied by a significant increase in plasma. The phenomenon can be related to a systemic alteration of heme metabolism induced by tumour cells to face their survival and proliferation requirements.

Tumors are like new organs and are made of multiple cell types and components. The tumor competes with the normal microenvironment to overcome antitumorigenic pressures. Before that battle is won, the tumor may exist within the organ unnoticed by the host, referred to as ‘occult cancer’. We review how normal tissue homeostasis and architecture inhibit progression of cancer and how changes in the microenvironment can shift the balance of these signals to the procancerous state. We also include a discussion of how this information is being tailored for clinical use. “We find ourselves at the present time in the era of molecular biology, and we are perhaps unduly influenced by the genetic code as the dominant principle in biology. Perhaps, in a decade or two from now, the dominant principle may shift to another plane, which in turn will influence our speculations about tumour causation.”1. —Isaac Berenblum

Breast magnetic resonance imaging (MRI) is indisputably the highest sensitivity test available to detect breast cancer, revealing more extensive cancer in the ipsilateral and otherwise occult cancer in the contralateral breasts when used before surgery. The use of preoperative breast MRI has become somewhat controversial, because the clinical benefit of the heightened detection provided by MRI has been questioned in the context of multidisciplinary breast cancer treatment, relatively low local recurrence, and metachronous contralateral cancer rates. Also, MRI detection rates have been compared with the high rates reported in the pathology literature. The emerging clinical outcome literature is showing conflicting results to demonstrating actual overall benefit. Critical review of this literature reveals several misconceptions about MRI detection rates and limitations of many of the published outcome studies to date, which render the results not necessarily generalizable to contemporary optimized breast MRI practices. This article addresses some of the misconceptions raised by critics, provides a critical review of the clinical outcome literature, reviews patient subgroups anticipated to have the highest yield when using preoperative MRI, makes recommendations for optimizing breast MRI practice, and suggests areas for potential future research.

Background: The diagnosis of an unprovoked (i.e., in the absence of any risk factors) venous thromboembolism (VTE) may be a sign of an underlying cancer. Previous estimates of the incidence rate of occult cancer in patients with unprovoked VTE are as high as 5-10%. However, screening methods to detect cancer early in these patients are of limited clinical value and previous identification of risk factors focused on short-term cancer diagnosis. Therefore, this study will assess the long-term incidence and risk factors of cancer in unprovoked VTE patients. Methods: This retrospective study is a post-hoc analysis of the REVERSE (Recurrent Venous Thromboembolism Risk Stratification Evaluation) study. Patient data was collected following an initial six-month course of anticoagulation therapy and were followed for a mean time period of 5.0 years (range 1 month-8 years). We performed univariable analysis to test the strength of association between each potential predictor variable and occult cancer diagnosis. Furthermore, using forward model selection we created a multivariable model with optimal predictive value for cancer diagnosis. Results: Among 663 patients presenting with unprovoked VTE, 38 (5.7%) subsequently developed a new cancer diagnosis during the follow-up period. The most common types of cancers diagnosed were prostate (21%) and colorectal cancer (16%). Univariate analysis revealed age > 65 (OR 2.59; 95% CI 1.31-4.49, P= 0.0036), elevated D-Dimer (OR 2.71; 95% CI 1.38-5.31, P=0.026) and pulmonary vein obstruction (PVO) score (OR 4.34 95% CI 1.26-14.92, P=0.023) as the strongest predictors of occult cancer. Only D-Dimer (Adj.-OR 2.72 95% CI 1.39-5.32) remained in the multivariate model and no other factor significantly improved the model's fit. Conclusion: Patients with an unprovoked VTE remain at an elevated risk of developing cancer following anticoagulation therapy. Age > 65 years old, elevated D-Dimer, and PVO in pulmonary embolism patients are among potential risk factors for developing occult cancer. More studies are needed to validate these potentially important risk factors. Disclosures Carrier: BMS: Honoraria, Research Funding; Leo Pharma: Research Funding; Pfizer: Honoraria; Bayer: Honoraria. Rodger:Biomerieux: Research Funding. Kovacs:Daiichi Sankyo Pharma Development: Research Funding; Bayer: Research Funding.

We read with great interest the article by Sogaard and colleagues1 about pericarditis as a marker of occult cancer. The article indicates that pericarditis may be a marker of occult lung and breast cancer, as well as hematologic and unspecified metastatic cancers, and it is associated with worse survival among …

In this introductory chapter a story has been reviewed concerning the evolution of the concept of "cancer and thrombosis", since its first description by Armand Trousseau in 1865. From scattered reports on experimental material (tumor extracts) or on animal models of tumor/metastasis growth, through the progress of cell biology and experimental pharmacology, during the last 20 years interest has moved to clinical questions, such as: how to prevent and treat thrombosis, a frequent complication of both solid and hematologic malignancies? Has an occult cancer to be suspected in the majority of cases of idiopathic deep vein thrombosis? Do we need to prevent pharmacologically the occurrence of chemotherapy-associated thrombosis? Do anticoagulants have an impact on the natural history of some tumors? Why antiangiogenetic agents may be associated to a thrombotic risk? Presently, a continuous cross-talk between clinical results and experimental data is required to provide answers to these questions, taking advantage of a multidisciplinary approach to this old but still partially mysterious issue.

Risk factors predictive of occult cancer detection in patients with a first unprovoked symptomatic venous thromboembolism (VTE) are unknown. Cox proportional hazard models and multivariate analyses were performed to assess the effect of specific risk factors on occult cancer detection within 1 year of a diagnosis of unprovoked VTE in patients randomized in the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial. A total of 33 (3.9%; 95% CI, 2.8%-5.4%) out of the 854 included patients received a new diagnosis of cancer at 1-year follow-up. Age ≥ 60 years (hazard ratio [HR], 3.11; 95% CI, 1.41-6.89; ITALIC! P= .005), previous provoked VTE (HR, 3.20; 95% CI, 1.19-8.62; ITALIC! P= .022), and current smoker status (HR, 2.80; 95% CI, 1.24-6.33; ITALIC! P= .014) were associated with occult cancer detection. Age, prior provoked VTE, and smoking status may be important predictors of occult cancer detection in patients with first unprovoked VTE. This trial was registered atwww.clinicaltrials.govas #NCT00773448.

Objective The aim of this study was to analyze women treated with excisional procedures for vaginal high-grade squamous intraepithelial lesions (HSILs). The histopathological upgrading of the lesions previously detected on vaginal biopsy and the presence of occult invasive vaginal cancer in the specimens excised were investigated, to identify a higher risk subset of women.Materials and Methods A retrospective analysis of the medical records of 86 women with a biopsy histopathologic diagnosis of vaginal HSIL (vaginal intraepithelial neoplasias [VaINs]: VaIN2 and VaIN3) and subsequent excisional therapy, consecutively referred to the Aviano National Cancer Institute (Aviano, Italy) from January 1991 to April 2014, was performed.Results Of the 86 patients, 4 cases (4.6%) of occult vaginal cancer were detected, all of them in women previously diagnosed with VaIN3 on biopsy (4/39 cases, 10.3%). Women with diagnosis of VaIN2 on biopsy showed an upgrading of lesions, with diagnosis of VaIN3 on the final specimen in 5 (10.6%) of 47 cases, with no cases of VAIN2 upgraded to invasive cancer. In 33.3% of the women initially diagnosed with VaIN2 and with previous hysterectomy for human papillomavirus-related disease, a final histopathological upgrading of lesions emerged. Furthermore, tobacco use was significantly related to the histopathological upgrading of lesions previously detected on vaginal biopsy.Conclusions Women diagnosed with VaIN3 should be treated with excisional procedures as first-line surgical approach, given the risk of occult invasive disease in 10% of the cases. Women diagnosed with VaIN2 and with previous hysterectomy for human papillomavirus-related cervical diseases should always be carefully evaluated and possibly excised, given the higher risk of histopathological upgrading of lesions and thus the potential risk of occult vaginal cancer. Tobacco users should be considered as high-risk group.

Tumor dormancy, a complex and still poorly understood phenomenon, has been defined by the long-term persistence of occult cancer cells during tumor progression. Recurrence and metastasis may occur just because of an activation of a small portion of the tumor cells. In our view, sustained angiogenesis is considered essential in triggering invasive tumor growth. Here we analyze the correlation between angiogenesis and tumor dormancy, the establishment of tumor dormancy models, the imaging strategies and the new biomarkers for dececting microscopic tumors before or during the angiogenic switch. It imperative to understand the role of angiogenesis in tumor dormancy, as this will accelerate the development of anti-angiogenesis techniques to induce dormancy and/or eradicate dormant disease.

There is a strong association between deep venous thrombosis and cancer. In this review, we will discuss the increased incidence of cancer following an idiopathic venous thrombotic event (VTE) and the increased incidence of VTE and its recurrence in cancer patients. Furthermore, we will review the adverse impact VTE has on cancer patients’ morbidity and mortality. Finally, the potential influence of anticoagulation on survival of cancer patients is discussed. Although the data are encouraging, anticoagulation is still of limited value for routine clinical practice in anticancer treatment.

Intracorporeal electromechanical morcellation has been available for nearly 2 decades, and has allowed hundreds of thousands of women to undergo hysterectomy and myomectomy in a minimally invasive approach. Despite gains in postoperative pain, complications, quality of life, hospital stay, and return to work, it has recently come under attack. The risk of inadvertent morcellation of a uterine malignancy, and subsequent dissemination of occult cancer, must be balanced by the risks of increased numbers of laparotomies. Power morcellation should be available to appropriate surgical candidates.

International audience; Venous thromboembolism may be the earliest sign of cancer. Currently, there is a great diversity in practices regarding screening for occult cancer in a person who has an unprovoked venous thromboembolism. We sought to assess the efficacy of a screening strategy for occult cancer that included comprehensive computed tomography (CT) of the abdomen and pelvis in patients who had a first unprovoked venous thromboembolism. We conducted a multicenter, open-label, randomized, controlled trial in Canada. Patients were randomly assigned to undergo limited occult-cancer screening (basic blood testing, chest radiography, and screening for breast, cervical, and prostate cancer) or limited occult-cancer screening in combination with CT. The primary outcome measure was confirmed cancer that was missed by the screening strategy and detected by the end of the 1-year follow-up period. Of the 854 patients who underwent randomization, 33 (3.9%) had a new diagnosis of occult cancer between randomization and the 1-year follow-up: 14 of the 431 patients (3.2%) in the limited-screening group and 19 of the 423 patients (4.5%) in the limited-screening-plus-CT group (P=0.28). In the primary outcome analysis, 4 occult cancers (29%) were missed by the limited screening strategy, whereas 5 (26%) were missed by the strategy of limited screening plus CT (P=1.0). There was no significant difference between the two study groups in the mean time to a cancer diagnosis (4.2 months in the limited-screening group and 4.0 months in the limited-screening-plus-CT group, P=0.88) or in cancer-related mortality (1.4% and 0.9%, P=0.75). The prevalence of occult cancer was low among patients with a first unprovoked venous thromboembolism. Routine screening with CT of the abdomen and pelvis did not provide a clinically significant benefit. (Funded by the Heart and Stroke Foundation of Canada; SOME ClinicalTrials.gov number, NCT00773448.).

PURPOSE OF REVIEW: Standard therapy for muscle-invasive bladder cancer is radical cystectomy and pelvic-lymph-node dissection. Because 50% of patients will die at 5 years as a result of micrometastases, improvements have been sought to increase the survival rates. Two specific approaches include administration of neoadjuvant chemotherapy or extending the boundaries of the lymph-node dissection. We reviewed the current literature to define present trends and studies that involve these adjunct treatments. RECENT FINDINGS: The benefits of extended lymphadenectomy have been demonstrated by several groups. These include mapping nodal metastatic sites and defining the requisite number of nodes removed to optimize survival. Though not universal, it is frequently concluded that increasing the number of nodes removed improves survival without worse morbidity. Neoadjuvant chemotherapy has been proposed to eliminate occult cancer cells outside the margins of resection. Results have been variable and modest, though emerging data from the Southwest Oncology Group may further support such an approach and improve organ preservation. SUMMARY: Extended lymphadenectomy has consistently shown benefit with minimal morbidity and should be considered--especially in cystectomy patients that are T3. The results from neoadjuvant chemotherapy are more modest. Further studies await further elucidation to confirm this.

Occult thyroid carcinoma is mostly discovered by autopsy or by other causes of thyroid surgery. To the best of our knowledge, there have been only a few reports concerning the situation that cervical mass was the initial manifestation of occult papillary thyroid carcinoma. The three patients in our report were all admitted to hospital because of the masses on their necks. Although pathology reports showed the nodal presence of thyroid cancer, we did not find the primary tumor on the same side of thyroid. We reported the clinical data of patients, including chief complaint, ultrasonography, computed tomography, and pathology results. We attempt to raise awareness regarding this particular disease and as a reference for clinical diagnosis and treatment. Examinations are needed to confirm the diagnosis for occult cancer of the thyroid. Surgical procedure is the major treatment method at present.

Malignancy related hypercoagulobility can manifest as acute arterial infarction, non-bacterial thrombotic endocarditis and thrombophlebitis. Rarely, ischemic stroke may be first symptom for a systemic occult cancer. We presented 62-year-old man who had recurrent stroke as the initial manifestation of an occult neoplastic process. Subsequently, the patient had venous thrombotic disease that led to the diagnosis of the malignancy. Conclusions: Acute or sub-acute multiple ischemic stroke may be the first manifestation of in an occult cancer.

The mainstay of cancer treatment typically includes surgery, chemotherapy, and radiation. If cancer is confined to one area, surgery alone can be curative, although it is often combined with adjuvant therapy (1). Radiation is limited to treatment of cells within the scope of the radiation beam, although radio immunotherapy has enhanced radiation therapy particularly in B-cell lymphomas (2). Chemotherapy has a number of forms, including systemically toxic drugs and both drugs and antibodies targeted to specific proteins that are driving the growth of the cancer cells. Chemotherapy can be used to treat systemically both visible and occult cancer cells. However, therapy resistance in tumors is a continuing problem for patients and oncologists alike despite an aggressive treatment regimen. In some cases, early mutations give resistance to tumors, or to a sub-population of tumor cells within a heterogeneous tumor, even prior to treatment. In this case treatment can cause death to sensitive cells allowing the few resistant cells to become the dominant population and lead to tumor recurrence. On the other hand, tumors that initially respond to treatment often become resistant over time as new mutations develop that allow cells to evade death. Such resistance, which may lead to multi-drug resistance, results in tumor recurrence and, ultimately, death (3).

A female patient suffered from gradual decline of vision for few months. She presented with bilateral multiple pigmented choroidal tumours, associated with overlying retinal changes. The clinical presentation suggested bilateral diffuse uveal melanocytic proliferation (BDUMP) syndrome, which is a paraneoplastic disease, although there was no evidence of any concurrent malignancy. The periodic systemic surveillance that was undertaken for the following 4 years failed to reveal any occult cancer. Nevertheless, there has been relentless progressive deterioration in vision as a consequence of BDUMP syndrome. The management of the declining vision in BDUMP syndrome is challenging and controversial.

Lesser-Trelat is generally known to be one of the cutaneous findings of vicceral occult cancer and is associated with diffuse seboreic ceratosis. That finding is an important clue for a clinicianand when is noticed it has to be cleared up whether there is a vicceral oc cult cancer. We report a case with leser-trelat syndrome, thought to be associated both with renal adenocarsinoma and benign prostat hypertrophia present in a same patient.