case_images: PMC2430011_01
case_images: Peritoneal nodule of DSRCT at diagnosis. Nodules are composed of fibrocollagenous
  tissue and irregular islands of malignant undifferentiated small round
  cells. Immunoperoxidase stains (not
  shown) in this case were strongly positive for EMA, vimentin, and desmin,
  partially positive for CD99 and negative for synaptophysin, chromogranin,
  myogenin, SMA, Bcl-2, CD3, and CD20. 
  Cytogenetic analysis demonstrated t(11;22)(p15;q12). Magnification: (a) x 10, (b) x 40, (c) high
  power.
case_images: SRCM2008-261589.001.jpg
case_images: PMC2430011_01_SRCM2008-261589.001.jpg
case_images: fig1
case_images: Pathology of tumor biopsies (see Figure 1) showed features of a highly anaplastic and somewhat pleomorphic small blue cell malignancy.
case_images: Outpatient neoadjuvant and adjuvant chemotherapy plan for DSRCT. After initial diagnosis and treatment of peritoneal, abdominal and
  pelvic disease, systemic chemotherapy
  agents were administered on an outpatient basis followed by local control with
  cytoreductive surgery + CHPP with cisplatin, then whole abdomen radiation with
  temozolomide as a radiation sensitizer, followed by temozolomide and
  irinotecan. Outpatient therapy was 15
  months.
case_images: SRCM2008-261589.002.jpg
case_images: PMC2430011_01_SRCM2008-261589.002.jpg
case_images: fig2
case_images:  Figure 2 shows a sequence of Neoadjuvant and adjuvant chemotherapy.
case_images: Continuous hyperthermic peritoneal perfusion (CHPP). The CHPP procedure involves placing
  temperature probes, inflow and outflow cannulas, and continuous perfusion
  of plasmalyte followed by cisplatin
  containing chemotherapy as the perfusate at 41-42 C. To achieve this, the inflow was usually about
  45 C. Manual agitation of the closed abdomen was done for 1.5 hours
  to ensure that all peritoneal surfaces were exposed to the cisplatin.
case_images: SRCM2008-261589.003.jpg
case_images: PMC2430011_01_SRCM2008-261589.003.jpg
case_images: fig3
case_images: PET-CT fusion imaging. (a) Residual uptake
  in the peritoneal implants after 2 cycles of therapy, SUV 3. (b) No evidence of
  FDG avid disease after cytoreductive therapy. (c) Relapse in the perihepatic
  space including dome of the liver (SUV 2.8) and retroperitoneal nodes (SUV 5).
case_images: SRCM2008-261589.004.jpg
case_images: PMC2430011_01_SRCM2008-261589.004.jpg
case_images: fig4
case_images: Although the patient continued to be healthy, attend school, and had no symptoms, routine PET-CT done 2 months after completion of therapy showed five FDG avid areas (Figure 4).
case_images: Radio frequency ablation and cryoablation procedure. Under direct CT fluoroscopic guidance, an RFA electrode was advanced
  into the perihepatic lesions. These were heated from 42 C to 43 C for 30 minutes (a) and (b) then a cryoablation probe was advanced and 2 cycles of
  freeze and thaw for 8-10 minutes (c).
case_images: SRCM2008-261589.005.jpg
case_images: PMC2430011_01_SRCM2008-261589.005.jpg
case_images: fig5
case_images: To destroy cells in the perihepatic nodules and increase chance of mounting an immune response, both radio frequency ablation and cryoablation were used (Figure 5).
case_images: Schema for local control
  of relapse foci and continuation adjuvant therapy. Radiation in combination with
  bevacizumab was used to pericaval disease. 
  Localized perihepatic lesions were treated with a combination of RFA and
  cryoablation. These measures were followed with a chronic adjuvant regimen.
case_images: SRCM2008-261589.006.jpg
case_images: PMC2430011_01_SRCM2008-261589.006.jpg
case_images: fig6
case_images: The patient received a regimen of valproate (250 mg BID), rapamycin (2 mg daily), and sorafenib (200 mg BID) and chemotherapy similar to that reported by Casanova et al., vinorelbine (25 mg/m2 IV monthly) and oral cyclophosphamide (25 mg daily) (see Figure 6). Sorafenib and vinorelbine were discontinued because of significant diarrhea (see treatment schema in Figure 6).