Background: Renal cell carcinoma (RCC) has unpredictable and diverse behaviour. The classic triad of hematuria, loin pain and abdominal mass is uncommon at time of presentation. About 25%-30% of patients are found to have metastases at the time of diagnosis. Bones, lungs, liver and brain are the frequent sites of metastases. RCC with metastasis to the cervix uteri is rarest manifestation and only four case reports have been published so far.

Case Presentation: Herein we present a case of 70 year old Saudi female presenting with 4 months history of vaginal bleeding and weight loss. Her past medical history revealed left sided radical nephroectomy for RCC. She had no other co-morbidities. On physical examination, she was found emaciated and per vaginal examination showed fragile fungating mass of cervix. The punch biopsy of cervical mass confirmed the diagnosis of metastatic RCC. Further, staging workup showed bilateral pulmonary metastasis. She was given palliative Radiotherapy 30 Gy in 10 fractions followed by Sunitinib 50 mg oral daily, but patient died of progressive disease 4 months of palliative radiotherapy.

Conclusion: Metastatic RCC to cervix uteri is very rare manifestation. The physicians should consider metastasis from another primary as the differential diagnosis in order to plan optimal treatment. Reported treatment is radical hysterectomy with bilateral salpingo-oophorectomy followed by Tyrosine Kinase Inhibitors (TKIs). Patients who are not candidate for surgery; radiotherapy and TKIs is a reasonable option.

With the technologic advancements in image guidance and dose delivery, stereotactic body radiotherapy (SBRT) is being widely used for cancer treatment in various anatomical locations as a noninvasive alternative to surgery. To deliver ablative doses to tumors with limited normal tissue toxicity, SBRT requires high accuracy in treatment setup which requires taking tumor motion into account. Techniques are also applied in SBRT to minimize tumor motion during dose delivery. This paper reviews techniques for motion management in SBRT.

Leiomyosarcoma of the broad ligament is a rare tumor and according to our knowledge only twenty cases have been reported in the English literature. Gardner et al. emphasize that, “these tumors occur on or in the broad ligament, but are completely separated from and in no way connected with either the uterus or the ovary” [1]. On the other hand metastasis of leiomyosarcoma to the abdominal wall is very rare and there is no any report of leiomyosarcoma of broad ligament with more than 33 months fallow up and metastasis to the abdominal wall [2]. In this paper an Iranian 60 year old lady with metastatic leiomyosarcoma of abdominal wall five years following to than resection of lieomyosarcoma of the broad ligament is presented. It seems that the tumor’s grade has worsened by time.metastatic tumor became worst with timing

The melanoma of the vagina accounts for 5% of all vaginal cancers and for 0.3-0.8% of all malignant melanomas. Due to its rarity, there are not evidence or recommendation to treat this tumor. We reported a case of vaginal malignant melanoma (VMM) in an older patient treated with palliative surgery and adjuvant radiotherapy.

Objective: concomitant chemoirradiation with cisplatinum and intracavitary brachytherapy (BT) is the standard of care in patients with locally advanced cervix cancer. Treatment planning for BT provides for the use of three dimensional imaging, such as CT scan or MRI. Positron emission Tomography with [18F] FDG currently used in staging and restaging of this malignancy, is an imaging modality that can aid in image- guided radiation treatment planning. The purpose of our feasibility study was to compare two tumour volumes during BT planning, the CT-based and PET/CT-based clinical target volume (CTVs), in order to evaluate the value of functional imaging in BT planning and if it could be related to a CT standard data set. Moreover a correlation with some clinical data after a median follow up of 47 months is reported. Methods: From June 2007 to May 2010, thirteen women with advanced cervical carcinoma were enrolled into the study. All the patients had a pretreatment PET/CT for staging. All BT fractions have been planned by CT scan and, in the first (BT1) and in the fourth fraction (BT4), FDG-PET/CT was also employed. Two volumes (CTVs) were defined: a CTVstandard, based on clinical information and on CT scan; and a CTVPET-influenced, created with the additional information brought by PET scan. Results: We compared the dimension of the two volumes and the intersection of CTVstandard and CTVPET-influenced at BT1 and BT4. A non-parametric sum rank test was used to determine the statistical significance for comparison of the two series of volumes (CTVstandard and CTVPET-influenced at BT1 and BT4). All patients completed the protocol, but out of 26 attempts of double CTVdefinition, only for 21 cases a comparison between CTVstandard and CTVPET-influenced was made. For two patients at the first BT fraction PET was negative. In the 21 valuable cases, considering both fractions together (BT1 and BT4), the difference between CTVstandard (25.8 ± 7.5 ml) and CTVPET-influenced (21.6 ± 9.5 ml) was statistically significant (p=0.01). In our small population the changes of GTVPET was unpredictable with residual tracer uptake areas often located far from the applicator and not consistent with clinical evaluation and or CT information. Conclusions: Even if the results of the study are preliminary because of the limited number of patients, our data suggests that PET scan cannot be used to define target volume in BT plan as the only source of information. It could be necessary an integration preferably with MRI for much more individualized brachytherapy treatment.

Study design: Case reports of abnormal appearance of hemangioma in thoracolumbar spine in bone scintigraphy. Objective: To report an unusual presentation of spinal hemangioma mimicking metastasis in bone scintigraphy and SPECT-CT. Summary of back ground data: Spinal hemangiomas are usually incidental findings. Most of them are asymptomatic and bone scintigraphy will be normal in majority of them. In the back ground of an underlying malignancy, an abnormal hot spot in bone scan always arouse a high suspicion of bone metastasis. Methods: Two middle aged ladies, treated for carcinoma cervix and carcinoma breast respectively, were undergoing regular follow ups. One patient had complaints of back pain on and off and her bone scan showed abnormal increase in tracer uptake in L1 vertebra suspicious of metastasis. Second lady had suspected intra abdominal metastatic disease and her bone scan showed abnormal increase in tracer uptake in thoracolumbar spine mimicking metastasis. Results: Both patients underwent further detailed evaluations and MRI study of spine was reported as hemangioma and PET-CT ruled out the possibilities of recurrent or metastatic malignancy. During further follow up, both patients were disease free. Conclusion: Hemangioma of spine appearing as a hot spot in bone scan is rare. In the back ground of a malignancy, a ‘hot’ lesion can be studied better with metabolic imaging with PET – CT which could dispel the suspicion of a metastatic focus quite clearly. MRI could also give a diagnostic clue.

Purpose: Identification of osseous metastatic prostate adenocarcinoma (PCa) is traditionally based on bone scan and computerized tomography (CT) imaging. Positron emission tomography (PET) has been investigated to improve detection of metastatic disease. Given the high number of false positive and false negative results with 18-fluorodeoxyglucose (18F-FDG) PET, novel tracers including 11C-Choline have been investigated for earlier identification metastatic disease. We present a prospective pilot study comparing 11C-Choline PET/CT against traditional bone scan in detecting osseous metastases in newly diagnosed high risk PCa. Methods: High-risk PCa patients underwent a standard initial workup: H&P, transrectal US-guided biopsy, PSA evaluation, CT scan, and bone scan. An experimental 11C-Choline PET/CT scan served to evaluate the extent of disease and predict for occult metastases. Pre-treatment bone scan and 11C-Choline PET/CT interpretations were compared with follow-up imaging, PSA, and clinical assessments to determine the predictive value of pre-treatment 11C-Choline imaging and overall outcomes. Results: Nine patients were successfully enrolled with 11C-Choline PET imaging during the initial workup. Three patients had evidence of osseous metastases on both CT and bone scans. Two of three patients had clinical findings consistent with their imaging, with all three patients exhibiting baseline PSA levels >50. Of the three patients deemed metastatic by conventional radiography, only two of the three corresponding 11C-Choline PET/CT images were in agreement with conventional imaging. The final patient had a negative 11C-Choline study with a T10 sclerotic focus on conventional imaging that was unchanged in follow-up scans despite post-treatment biochemical failure. A fourth patient without evidence of osseous metastatic disease on conventional scans demonstrated a positive 11C-Choline PET/CT scan on initial workup. In follow-up, the patient had evidence of diffuse osseous metastatic disease visualized on conventional imaging. Conclusion: In this limited prospective series, our results suggest an increased sensitivity of 11C-Choline PET/ CT in identifying active lytic lesions and true bony metastasis.

The last decade has seen major advances in the clinical practice of radiotherapy (RT). Our understanding of the biological effects occurring after exposure of cells and tissues to ionizing radiation has also increased enormously in this period. In this article we will summarize our current knowledge and key knowledge gaps in an area that is emerging as a potentially important factor in tumor responses to RT, namely the activation of the therapy-induced cellular senescence (TCS) pathway and its associated secretory response, the so-called senescence-associated secretory phenotype or “SASP”. Although the existing literature on these responses is substantial in the chemotherapy domain, the information specific to RT has unfortunately lagged behind. This includes knowledge relating to the factors that govern the ability of tumor cells to switch from TCS to another terminal/irreversible mode of cell death or to escape from TCS and recover proliferative potential. We will therefore examine some of the implications of TCS and SASP from the perspectives of better understanding the biological basis of the various types of RT delivery. We will also consider the implications of this knowledge for the development and use of modifying agents that either reinforce the TCS phenotype and circumvent recovery pathways or switch the cells from TCS into a terminal apoptotic pathway that may represent a more desirable outcome clinically.