Case 19-2009: A 63-Year-Old Woman with Carcinoma of the ...rigld.sbmu.ac.ir/uploads/136_4553_1473137406230_021.pdfComputed tomography (CT) of the chest, abdo - men, and pelvis revealed

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From the Divisions of Hematology– Oncology (E.L.K.) and Gastroenterology (D.G.F.), Department of Medicine, and the Departments of Radiation Oncology (T.S.H.), Surgery (D.L.B.), Radiology (R.N.U.), and Pathology (G.Y.L.), Massa-chusetts General Hospital; and the De-partments of Medicine (E.L.K., D.G.F.), Radiation Oncology (T.S.H.), Surgery (D.L.B.), Radiology (R.N.U.), and Pathol-ogy (G.Y.L.), Harvard Medical School.

N Engl J Med 2009;360:2656-64.Copyright © 2009 Massachusetts Medical Society.

Pr esen tation of C a se

Dr. Stephanie Heon (Hematology–Oncology): A 63-year-old woman was seen in the Cancer Center at this hospital for management of adenocarcinoma of the gastro-esophageal junction.

The patient had been well until approximately 2 months before this evaluation, when chest and epigastric discomfort developed after she ate solid foods, lasting from minutes to an hour. She had no difficulty swallowing liquids. Eighteen days before this evaluation, radiographs of the upper gastrointestinal tract, obtained at another hospital, showed severe erosive changes in the distal esophagus, an ec-centric filling defect in the anterolateral portion of the esophagus, and minimal gastroesophageal reflux. Three days later, upper gastrointestinal endoscopy showed a mass in the distal esophagus, 32 cm from the incisors, that extended to the gas-troesophageal junction. Pathological examination of a biopsy specimen showed moderately to poorly differentiated adenocarcinoma infiltrating glandular mucosa and lying beneath squamous mucosa, focal intestinal metaplasia in the glandular mucosa consistent with Barrett’s esophagus, and changes in the squamous mucosa consistent with reflux esophagitis. Computed tomography (CT) of the chest, abdo-men, and pelvis revealed an enlarged lymph node (1.0 cm in diameter) in the gas-trohepatic ligament, mild thickening of the distal esophageal wall, cholelithiasis with no intrahepatic or extrahepatic biliary-duct dilatation, bilateral renal cysts, and diverticulosis. There were no pulmonary nodules or enlarged mediastinal lymph nodes. Positron-emission tomographic (PET) scans obtained after the administra-tion of 18F-fluorodeoxyglucose (18F-FDG) showed an area of increased uptake in the distal esophagus and in the gastrohepatic ligament. She was referred to the Cancer Center at this hospital.

The patient had had gastroesophageal reflux disease for 3 years. One year ear-lier, she had had an episode of difficulty swallowing, for which she went to the emergency department of another hospital; medication for anxiety was adminis-tered, and the symptoms resolved. She had lost 4.5 kg during the previous 6 months while dieting. She did not have melena, hematemesis, fevers, chills, night sweats, shortness of breath, fatigue, nausea, vomiting, abdominal pain, numbness, or weak-ness. She had hypertension, mild arthritis, and postpartum urinary incontinence.

Case 19-2009: A 63-Year-Old Woman with Carcinoma of the Gastroesophageal Junction

Eunice L. Kwak, M.D., Ph.D., Theodore S. Hong, M.D., David L. Berger, M.D., David G. Forcione, M.D., Raul N. Uppot, M.D., and Gregory Y. Lauwers, M.D.

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Previous surgical procedures included bunion surgery, tonsillectomy, and trigger-finger repair. She lived with her husband and worked at home; she was fully active (functional Eastern Coopera-tive Oncology Group [ECOG] performance status of 0). She drank alcoholic beverages rarely, had smoked cigarettes for 25 years but stopped 20 years earlier, and did not use illicit drugs. Her father died of encephalitis at 54 years of age; her mother died of a myocardial infarct in her 60s; and her brother died of lung cancer at 52 years of age. She had no known allergies. Medications included daily atenolol, pantoprazole, tolterodine tartrate, and a multivitamin, with lorazepam and acetaminophen as needed.

On examination, she appeared anxious but well. The temperature was 37.2°C, the pulse 98 beats per minute, the blood pressure 140/80 mm Hg, the weight 82.1 kg, the height 155 cm, and the respiratory rate 18 breaths per minute. The abdomen was soft, with normal bowel sounds and no tenderness, rebound, or distention. The remainder of the examination was normal.

Serum levels of CA 19-9, carcinoembryonic antigen, plasma iron, ferritin, and vitamin B12; iron-binding capacity; a complete blood count; levels of electrolytes, calcium, and albumin; and tests of coagulation and renal, hepatic, and thy-roid function were normal. Laparoscopy revealed no evidence of intraabdominal metastases. Path-ological and cytologic examination of tissue from peritoneal washings revealed no malignant tumor cells. Endoscopic ultrasonography showed a non-obstructing, hypoechoic mass in the distal esoph-agus (34 to 37 cm from the incisors) that ex-tended to the muscularis propria and focally into the periesophageal fat (stage uT3, according to the tumor–node–metastasis [TNM] classifica-tion criteria). A hypoechoic lymph node, 2.1 cm in diameter, was seen in the gastrohepatic area. Fine-needle aspiration of the lymph node was performed. Pathological and cytologic examina-tion showed adenocarcinoma.

A treatment plan was established.

Differ en ti a l Di agnosis

Dr. Eunice L. Kwak: May we see the imaging and endoscopic findings?

Dr. Raul N. Uppot: An upper gastrointestinal se-ries performed at another hospital, approximately 3 weeks before presentation at our Cancer Cen-

ter, showed an eccentric filling defect in the right anterolateral portion of the esophagus (Fig. 1A). There were severe erosive changes in the distal esophagus that were consistent with gastroesoph-ageal reflux (Fig. 1B). The findings of a mass, reflux, and erosive changes suggested esopha-geal adenocarcinoma in a patient with Barrett’s esophagus.

CT of the chest, abdomen, and pelvis, per-formed 6 days later at the other hospital, showed right anterolateral thickening of the wall of the distal esophagus (Fig. 1C), corresponding in lo-cation to the mass on the upper gastrointestinal study. There was an enlarged lymph node mea-suring 1.0 cm in diameter in the gastrohepatic ligament (Fig. 1D), a finding suspicious for meta-static disease. Six days after the CT scan, 18F-FDG PET performed at the other hospital showed an area of increased uptake in the region of the distal esophagus (Fig. 1E) that corresponded to soft-tissue thickening on the CT scans. There was also intense 18F-FDG uptake in the region of the gastrohepatic ligament, a finding suspicious for metastatic lymphadenopathy (Fig. 1F).

Dr. David G. Forcione: We identified on upper en-doscopy a partially circumferential, nonobstruc-tive mass in the distal esophagus (34 to 37 cm from the incisors) arising from Barrett’s mucosa (31 to 37 cm from the incisors) (Fig. 2A). Endo-scopic ultrasonography was performed with a linear echoendoscope. Images at 5 MHz showed a hypoechoic mass (Fig. 2B) in the esophageal wall and evidence of transmural involvement (TNM classification, stage uT3). A hypoechoic, round, well-defined lymph node, 2.1 cm in diam-eter, was noted. Fine-needle aspiration was per-formed with the use of Doppler guidance (Fig. 2C). The endoscopic ultrasonographic stage was uT3N1MX.

Dr. Kwak: This patient has an adenocarcinoma of the gastroesophageal junction. The incidence of this cancer is increasing at a rate higher than that of any other cancer. The reasons are unclear, but gastroesophageal reflux and Barrett’s esoph-agus, both present in this case, and obesity may have roles in the increased incidence of this dis-ease.1 Adenocarcinomas of the gastroesophageal junction anatomically straddle the distal esopha-gus and proximal stomach, and the management of local disease thus reflects approaches for both esophageal and gastric cancer. The central ques-tion that must be addressed is whether the dis-





ease is resectable, and therefore potentially cur-able. In the present case, staging with CT scans, endoscopic ultrasonography, and PET scans indi-cated locally advanced disease with involvement of a regional gastric lymph node, confirmed by ex-amination of a biopsy specimen. Laparoscopy was performed to detect occult metastatic cancer.

Dr. David L. Berger: As demonstrated by this case, preoperative staging for tumors of the gas-troesophageal junction begins with endoscopy, which defines important anatomical information assessing the proximal and distal extent of the tumor while providing a tissue diagnosis. This is followed by abdominal and chest CT to assess for metastatic disease. Provided there is no evidence of metastasis and there is a qualified endoscopist (endoscopic ultrasonography results are extreme-ly operator-dependent), patients should then un-dergo an endoscopic ultrasound to delineate the depth of invasion (T staging), since this will af-fect treatment decisions. The role of laparoscopy is somewhat controversial, but recent evidence showed that findings at the time of staging lap-aroscopy changed management decisions in roughly 20 to 30% of cases.2,3 I performed a lap-aroscopy in this case and found no evidence of distant metastases within the abdomen.

Tumors of the gastroesophageal junction are defined as lesions that arise between 5 cm prox-imal to the gastroesophageal junction and 5 cm distal to it. Carcinoma of the gastroesophageal junction can be staged according to the TNM classification system for either esophageal or gastric cancers. Siewert et al. recently proposed the following classification for cancers of the gastroesophageal junction: type I tumors arise in the distal esophagus within intestinal meta-plasia and extend distally; type II tumors origi-nate at the true gastroesophageal junction; and type III tumors are subcardial gastric carcino-mas that extend proximally.4 This patient ap-pears to have a Siewert type I tumor. Surgical resection offers the only chance of cure for this patient. Surgical approaches vary among institu-tions and surgeons. Traditionally, thoracic sur-geons have viewed tumors of the gastroesopha-geal junction as esophageal tumors and have performed esophagectomy with partial gastrec-tomy, whereas gastrointestinal surgeons have viewed them as gastric cancers and have per-formed extended gastrectomy, with or without thoracotomy. No consistent difference between

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Figure 1. Radiographic Images from the Other Hospital at Diagnosis.

Radiographs from a double-contrast upper gastrointestinal series show an eccentric filling defect in the anterolateral portion of the distal esophagus (Panel A, arrow). There is irregularity of the distal esophageal wall (Panel B, arrows), a finding consistent with severe erosive changes, probably from re-flux. Axial CT of the upper abdomen (Panel C) without the administration of intravenous contrast material shows thickening of the right anterolateral wall of the distal esophagus (arrow), corresponding in location to the mass seen on the upper gastrointestinal study. There is an enlarged (1.0 cm) lymph node in the gastrohepatic ligament (Panel D, arrow). Positron-emis-sion tomography (PET) with 18F-fluorodeoxyglucose shows an intense area of increased uptake in the region of the distal esophagus (Panel E, arrow), corresponding in location to the area of soft-tissue thickening on the CT scan (Panel C). There is also intense uptake in the region of the gastro-hepatic lymph node (Panel F, arrow), a finding that arouses suspicion of metastases to gastrohepatic lymph nodes.





these approaches in terms of patient outcome has been shown.5-8 However, complete resection (R0) with a 5-cm esophageal margin, a 4-cm gastric margin, and a sampling of 15 or more nodes is necessary, regardless of the surgical approach.5,6 To maximize the likelihood of achieving this, the surgical approach should be tailored for indi-vidual patients.

Based on the complete evaluation, including endoscopic ultrasonography and laparoscopy, this patient’s cancer was stage T3N1M0. The tumor was resectable, but since it was deeply invasive and had metastasized to a regional lymph node,

resection alone was deemed unlikely to be cura-tive. Therefore, radiation therapy, chemotherapy, or both needed to be considered.

Dr. Kwak: With surgery as the cornerstone of treatment, consideration in this case was given to three methods of treatment: preoperative (neo-adjuvant) treatment with both chemotherapy and radiation (chemoradiation), postoperative (adju-vant) treatment with chemoradiation, or periop-erative (both preoperative and postoperative) treat-ment with chemotherapy alone. Patients with adenocarcinomas of the gastroesophageal junc-tion make up a minority of cases included in neo-adjuvant, perioperative, and adjuvant trials for ei-ther esophageal or gastric cancer, and therefore the best treatment approach for this disease is unclear.

Dr. Theodore S. Hong: Positive margins are found after surgical resection in more than 20% of cases of esophageal cancer, including cancers of the gastroesophageal junction.8,9 In addition, even after complete resection, patients with both gas-tric cancer and cancer of the gastroesophageal junction have a high rate of locoregional relapse (ranging from 40 to 60%); 15 to 20% of these patients have locoregional relapse without distant metastases, suggesting that prevention of local recurrence could reduce mortality.10,11 Because of these observations, the efficacy of both neo-adjuvant and adjuvant treatment with chemo-radiation has been studied. A U.S. Intergroup ran-domized trial (INT-0116) evaluating the role of postoperative chemoradiation after resection in patients with completely resected adenocarcino-ma of the stomach or gastroesophageal junction (stage IB to stage IV [M0])12 showed a significant

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Figure 2. Endoscopic Ultrasound Study.

A view through the endoscope (Panel A) shows an ulcerated mass in the distal esophagus at the gastro-esophageal (GE) junction, which appears malignant. It is arising from abnormal, pink mucosa (Barrett’s mucosa), which contrasts with the normal, white squamous mucosa, and is a feature consistent with Barrett’s esophagus. An endoscopic ultrasonographic image (Panel B) of the gastroesophageal mass (delineat-ed by the double-headed arrow) shows full-thickness esophageal-wall involvement (single arrow), a feature consistent with stage T3. An endoscopic ultrasono-graphic image shows a malignant-appearing, hypoechoic lymph node (Panel C). A 22-gauge needle is passed across the gastric wall with the use of endoscopic ultra-sonographic guidance to perform fine-needle aspiration for cytologic and histologic examination.





survival benefit for adjuvant chemoradiation as compared with surgery alone (overall survival, 36 months vs. 27 months; P = 0.005). Patients with tumors in the gastroesophageal junction (approxi-mately 20% of the patients) appeared to derive the same benefit as other patients. Other studies have had similar findings.13 Chemoradiation after sur-gery is thus a reasonable approach for manage-ment of cancer of the gastroesophageal junction. A recent randomized trial showed significantly improved 5-year overall survival in patients with cancer of the esophagus or gastroesophageal junc-tion who received preoperative chemoradiation followed by esophagectomy as compared with those who underwent esophagectomy alone (39% vs. 16%, P = 0.002).14 Thus, neoadjuvant chemora-diation would also be an option for our patient.

Dr. Kwak: Cancers of the gastroesophageal junc-tion have also been included in clinical trials of perioperative chemotherapy in gastric cancer, in which half of the planned dose is given preop-eratively and the remainder postoperatively. In the Medical Research Council Adjuvant Gastric Infu-sional Chemotherapy (MAGIC) trial of perioper-ative epirubicin, cisplatin, and infused fluoro-uracil (ECF), a chemotherapy regimen widely used in the treatment of metastatic disease, 25% of the cases were adenocarcinomas of the gastroesopha-geal junction and distal third of the esophagus.15 Patients who received ECF had an overall survival of 36% as compared with a rate of 23% in the group undergoing surgery alone (Table 1). In addition, patients who received chemotherapy

tended to have smaller tumors and a decreased burden of nodal disease at the time of resection.15 Because the continuous-infusion fluorouracil that is required for the administration of ECF is incon-venient for patients, a regimen of epirubicin, ox-aliplatin, and capecitabine (EOX) was compared with ECF in a randomized trial designed to assess noninferiority in patients with metastatic dis-ease16; the rate of overall survival in the EOX group was similar to that in the ECF group (11.2 months vs. 9.9 months).

Because cancers of the gastroesophageal junc-tion have been included in studies of both gastric and esophageal cancer, it remains unclear wheth-er there is an optimal regimen. Perioperative che-motherapy, postoperative chemoradiation, and pre-operative chemoradiation have never been directly compared with each other. All these approaches are reasonable, and the decision currently is made on a case-by-case basis. Preoperative chemora-diation might be favored for a tumor that is lo-calized but initially appears to be unresectable, since a high response rate would increase the likelihood of a response that would render it re-sectable. Surgery might be considered first for a clearly resectable tumor when there is a concern that the patient may not tolerate preoperative therapy. Perioperative chemotherapy may be fa-vored when the tumor appears resectable but there is a high clinical suspicion of occult metastatic disease, or when there is bulky infradiaphrag-matic disease.

We thought that this patient, with a deeply in-

Table 1. Randomized Clinical Trials of Gastric and Esophageal Cancer That Included Cases of Adenocarcinoma of the Gastroesophageal Junction.*

Study TreatmentNo. of

PatientsMedian Survival

5-Year Overall Survival Rate† P Value

mo %

MAGIC15 Surgery 253 NR 23.0 0.009

ECF × 3, then surgery, then ECF × 3 250 NR 36.3

INT-011612 Surgery 275 27 41 0.005

Surgery, then chemoradiation 281 36 50

CALGB 978114 Surgery 26 21.5 16 0.002

Chemoradiation, then surgery 30 53.8 39

* CALGB denotes Cancer and Leukemia Group B; ECF × 3 three cycles of epirubicin, cisplatin, and infused fluorouracil; INT-0116 Intergroup trial; MAGIC Medical Research Council Adjuvant Gastric Infusional Chemotherapy; and NR not recorded.

† For the INT-0116 trial, 3-year survival rates are listed.





vasive tumor and a large positive regional lymph node, probably indicating bulky infradiaphrag-matic disease, would benefit most from periopera-tive chemotherapy. She received three cycles of EOX therapy, which she completed with no treatment-limiting adverse events and which were followed by a combined PET–CT study to evaluate the tu-mor response.

Dr. Uppot: PET–CT images at this hospital showed a decrease in the size of the mass in the gastroesophageal junction (Fig. 3A) and of the gastrohepatic node (Fig. 3B) as compared with previous studies. The PET images showed a dra-matic decrease in 18F-FDG uptake at the gastro-esophageal junction and in the gastrohepatic node (Fig. 3C and 3D) as compared with the corre-sponding PET images obtained at the other hospital.

Dr. Berger: The patient was taken to the operat-ing room and the distal esophagus and proximal stomach were resected. We used midline abdom-inal and right thoracotomy incisions.

Pathol o gic a l Discussion

Dr. Gregory Y. Lauwers: The esophageal-biopsy spec-imen from the other hospital showed adenocar-cinoma (Fig. 4A) associated with focal glandular metaplasia, a finding consistent with Barrett’s esophagus. A needle biopsy of the gastrohepatic lymph node showed adenocarcinoma with iden-tical features.

The esophagogastrectomy specimen consisted of a 4.5-cm-long segment of esophagus and a 9.5-cm-long segment of stomach. Opening of the esophageal segment revealed a mucosal nodule

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Figure 3. Follow-up Combined PET–CT Images of the Abdomen.

An axial, contrast-enhanced CT image from a combined PET–CT study shows a decrease in the size of the mass in the right anterolateral distal esophagus (Panel A, arrow) as compared with the size shown in the images in Figure 1. The gastrohepatic lymph node (Panel B, arrow) has also decreased in size. An axial PET image of the upper abdomen from a PET–CT study shows a marked decrease in 18F-FDG uptake at the gastroesophageal junction (Panel C, arrow). There is also a marked decrease in 18F-FDG uptake in the region of the gastrohepatic node (Panel D, arrow).





(1.0 cm in diameter) adjacent to an area (2.8 cm by 2.5 cm) of tan, raised, granular Barrett’s mucosa (Fig. 4B). The nodule was 2 cm from the margin of the esophageal resection and 0.6 cm proximal to the gastroesophageal junction. The entire nod-ule and the gastroesophageal junction were sub-mitted for microscopical examination; residual clusters and cords of tumor cells were identified, which invaded the muscularis propria (Fig. 4C). Some tumor cells had large, irregular nuclei and abundant eosinophilic cytoplasm, and others were small with scant cytoplasm (Fig. 4D). The latter

component displayed chromogranin immunore-activity (inset), confirming neuroendocrine dif-ferentiation. Metastases were identified in 7 of 16 lymph nodes. The final staging was ypT2N1MX.

An incomplete response of the tumor to pre-operative chemotherapy alone, as seen in this case, is typical. Incomplete responses are also observed in 70% of patients receiving neoadjuvant chemo-radiation.17 A variation of the system devised for squamous-cell carcinoma, based on the ratio of residual tumor to fibrosis, has been shown in a multivariate analysis to be important in predict-

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Figure 4. Esophageal-Biopsy and Esophagogastrectomy Specimens.

The esophageal-biopsy specimen from the other hospital shows a glandular epithelial proliferation, a feature diag-nostic of adenocarcinoma (Panel A, hematoxylin and eosin). Hyperchromatic nuclei can be seen at higher magnifi-cation (inset). A gross photograph of the esophagogastrectomy specimen (Panel B) shows a nodule (1.0 cm in di-ameter, circle) adjacent to residual, raised, granular Barrett’s mucosa (arrowhead). On microscopical examination, residual tumor cells invade the muscularis propria (Panel C, double-headed arrow, hematoxylin and eosin). Clusters and cords of small, hyperchromatic tumor cells (Panel D, hematoxylin and eosin) are surrounded by a lymphocytic inflammatory infiltrate. Chromogranin immunoreactivity (inset) confirms the presence of neuroendocrine differenti-ation, which had not been present on the pretreatment biopsy specimen.





ing disease-free survival and overall survival in patients with esophageal cancer after neoadjuvant chemoradiation.17 Thus, it is important to submit the entire tumor site for pathological evaluation.

The number of positive lymph nodes also pre-dicts survival,18 with more than two involved lymph nodes predicting a worse 5-year survival than would no lymph nodes or one lymph node. The presence of more than four involved lymph nodes, or involvement of more than 20% of the lymph nodes examined, as seen in this case, also predicts a poor prognosis.19

Finally, this case showed diffuse neuroendo-crine differentiation, a characteristic noted after treatment in about half of residual carcinomas that has also been associated with reduced disease-free survival.20

Dr. Heon: The patient recovered promptly from surgery, and postoperative chemotherapy was ini-tiated approximately 6 weeks after the operation. She tolerated the first two cycles of postoperative EOX well but was subsequently admitted to the hospital with severe hypokalemia, dehydration, and a subsequent decline in her ECOG perfor-mance status. Cycle 6 of EOX was not given. In the MAGIC trial, only about 50% of the patients assigned to perioperative chemotherapy were able to complete all six cycles.

Dr. Hong: One unanswered question is wheth-er postoperative chemoradiation after preopera-tive chemotherapy would confer additional benefit in a patient such as this one. Perioperative chemo-therapy decreases the risk of metastatic disease but does not have as great an effect on loco-regional control as chemoradiation does, although

chemoradiation does not affect distant metasta-ses. This question is currently being addressed in the Netherlands in a phase 3 trial (ClinicalTrials.gov number, NCT00407186), where patients will be randomly assigned to six cycles of periopera-tive ECX chemotherapy (three before surgery and three after) versus three cycles of preoperative ECX chemotherapy followed by postoperative chemo-radiation.

Currently, in the absence of Level 1 evidence, our treatment decisions will be guided by suspi-cion of residual disease, risk to the patient, and most important, the clinical status of the patient and the ability to tolerate further therapy. After this patient recovered from perioperative chemo-therapy, she was offered the option of adjuvant chemoradiation, which she elected to pursue. She was treated with a 5-week regimen of radia-tion to a total of 45 Gy with concurrent fluoro-uracil by infusion, and she completed the treat-ment without difficulty. She has no evidence of local recurrence or metastases 16 months after the esophagogastrectomy.

A nat omic a l Di agnosis

Adenocarcinoma of the gastroesophageal junction, pathological stage ypT2N1MX after preoperative chemotherapy, arising in Barrett’s esophagus.

Dr. Kwak reports receiving consulting fees from Novartis and Pharmacyclics and receiving grant support from the John and Carol Barry Award. Dr. Lauwers reports receiving grant support from Almac Diagnostics. No other potential conflict of interest relevant to this article was reported.

We thank Dr. Lawrence Blaszkowsky, the patient’s oncolo-gist, for assistance in preparing the case history.

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Wang KL, Yang Q, Cleary KR, et al. 20. The significance of neuroendocrine dif-ferentiation in adenocarcinoma of the esophagus and esophagogastric junction after preoperative chemoradiation. Can-cer 2006;107:1467-74.Copyright © 2009 Massachusetts Medical Society.

Lantern Slides Updated: Complete PowerPoint Slide Sets from the Clinicopathological Conferences

Any reader of the Journal who uses the Case Records of the Massachusetts General Hospital as a teaching exercise or reference material is now eligible to receive a complete set of PowerPoint slides, including digital images, with identifying legends, shown at the live Clinicopathological Conference (CPC) that is the basis of the Case Record. This slide set contains all of the images from the CPC, not only those published in the Journal. Radiographic, neurologic, and cardiac studies, gross specimens, and photomicrographs, as well as unpublished text slides, tables, and diagrams, are included. Every year 40 sets are produced, averaging 50-60 slides per set. Each set is supplied on a compact disc and is mailed to coincide with the publication of the Case Record.

The cost of an annual subscription is $600, or individual sets may be purchased for $50 each. Application forms for the current subscription year, which began in January, may be obtained from the Lantern Slides Service, Department of Pathology, Massachusetts General Hospital, Boston, MA 02114 (telephone 617-726-2974) or e-mail [email protected].



Documents

Case 19-2009: A 63-Year-Old Woman with Carcinoma of the ...rigld.sbmu.ac.ir/uploads/136_4553_1473137406230_021.pdfComputed tomography (CT) of the chest, abdo - men, and pelvis revealed