Nipple Adenoma: A Benign Disease With a Suspicious Presentation

Nipple adenoma is a rare proliferative lesion that originates from the lactiferous ducts of the nipple. Though it is benign, the typical presentation includes suspicious symptoms-a firm nodule, crusting erosion, and/or discharge from the nipple. These findings can raise concern for malignancy and in particular, Paget's disease. We report two cases of this uncommon entity, highlighting the variable clinical presentation and keys to the diagnostic evaluation and management.

Isolated Asymptomatic Colonic Plasmacytoma Presenting as a Polyp at Screening Colonoscopy

Isolated extramedullary plasmacytomas (IEMPs) are rare. Extramedullary plasmacytomas (EMPs) are uncommon and mostly occur in the nasopharynx or upper respiratory tract. EMP involvement of the gastrointestinal tract occurs in approximately 10% of cases, more often in the small bowel than the colon. Less than 40 cases of colonic IEMP have been reported. Asymptomatic colonic IEMPs are extremely rare with few reported cases. We present a 57-year-old asymptomatic man with a colonic IEMP found during screening colonoscopy. A sigmoid colon polyp was removed and diagnosed as a plasmacytoma. Further investigation revealed it to be an isolated lesion.

Conventional Karyotyping and Fluorescence In Situ Hybridization for Detection of Chromosomal Abnormalities in Multiple Myeloma

Background

Multiple myeloma (MM) is a genetically heterogeneous disease, with cytogenetic findings that determine disease behavior. Genetic abnormalities can be assessed by fluorescence in situ hybridization (FISH) analysis and/or G-banded karyotyping. The two methods produce unique and overlapping information, and the clinical utility of using both is investigated here.

Methods

Seventy patients diagnosed with MM at a hospital in Southern California were retrospectively reviewed for the FISH and G-banded karyotyping results obtained from bone marrow specimens.

Results

Karyotype was normal in 71% (50/70), abnormal in 27% (19/70), and inadequate in 1% (1/70). Among patients with abnormal karyotype, FISH provided additional information about genetic aberrations in 95% of cases (18/19). Among cases with abnormal FISH, karyotype provided additional information about genetic aberrations in 27% of cases (18/66). When numerical abnormalities were present (detected by FISH and/or karyotype), FISH detected them in 95% (54/57), of which karyotype missed 70% (38/54) of the time. Karyotyping detected numerical abnormalities in 33% (19/57), which FISH missed 16% (3/19) of the time.

Conclusions

Karyotyping and FISH analysis in MM each provide unique information. For most patients, performing both tests together will provide more information than either test alone.

Biphasic Sarcomatoid Sweat Gland Carcinoma With Ductal Epithelial And Spindled Myoepithelial Cell Components (Malignant Mixed Tumor Of Skin)

Introduction/Objective

Sweat gland carcinomas are a group of malignant skin adnexal tumors that are difficult to diagnose due to their rarity, wide morphologic variation, and limited literature on diagnosis and classification. These tumors may appear bland and morphologically resemble benign skin adnexal tumors, or may appear poorly differentiated and mimic metastatic carcinoma especially from a breast primary. Biphasic sweat gland carcinomas are an even rarer entity, with only few cases reported in literature, and have been described to consist of a well- differentiated ductal epithelial component and a poorly differentiated, sarcomatoid, spindle cell component.

Methods/Case Report

Our case report describes a 53 year old female referred to our institution for diagnosis of an excised skin lesion of the right upper arm, which had been slowly growing for 8 years. The histology revealed a biphasic malignant neoplasm involving the dermis and subcutis. The tumor consisted of an epithelial cell component with glandular and squamoid morphology and positive for CK5/6, CK7, and CAM5.2, and a spindled myoepithelial cell component with sarcomatoid morphology and positive for S100, vimentin, and p63. Stains for CK20, ER, PR, PAX8, CEA, and TTF1 were negative. The histological and clinical findings favored a primary skin adnexal tumor, rather than a metastatic lesion.

The patient underwent wide local excision of the lesion given that margins of the original excision were indeterminate. The histology of this re-excision demonstrated the same biphasic tumor with ductal epithelial and sarcomatoid myoepithelial cell components positive for the same stains. Although margins were negative in this re-excision, 3-4 months later, the patient developed dyspnea with multiple new pulmonary and hilar masses discovered on imaging, and new-onset headache with a frontal lobe mass discovered on brain imaging. These masses were biopsied/resected, and revealed to be metastases of the original cutaneous tumor positive for the same markers.

Results (if a Case Study enter NA)

NA

Conclusion

This case report describes a rare, diagnostically challenging case of a biphasic sweat gland carcinoma with ductal epithelial and sarcomatoid myoepithelial cell components, which demonstrated aggressive behavior with distant metastasis. These tumors are a clinicopathological quandary given their rarity and the paucity of literature on their characterization.

Systematic literature review of burden of illness in chronic inflammatory demyelinating polyneuropathy (CIDP)

Background

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare neurological disorder characterised by muscle weakness and impaired sensory function. The present study provides a comprehensive literature review of the burden of illness of CIDP.

Methods

Systematic literature search of PubMed, Embase, and key conferences in May 2019. Search terms identified studies on the epidemiology, humanistic burden, current treatment, and economic burden of CIDP published since 2009 in English.

Results

Forty-five full texts and nineteen conference proceedings were identified on the epidemiology (n = 9), humanistic burden (n = 7), current treatment (n = 40), and economic burden (n = 8) of CIDP. Epidemiological studies showed incidence and prevalence of 0.2–1.6 and 0.8–8.9 per 100,000, respectively, depending on geography and diagnostic criteria. Humanistic burden studies revealed that patients experienced physical and psychosocial burden, including impaired physical function, pain and depression. Publications on current treatments reported on six main types of therapy: intravenous immunoglobulins, subcutaneous immunoglobulins, corticosteroids, plasma exchange, immunosuppressants, and immunomodulators. Treatments may be burdensome, due to adverse events and reduced independence caused by treatment administration setting. In Germany, UK, France, and the US, CIDP economic burden was driven by direct costs of treatment and hospitalisation. CIDP was associated with indirect costs driven by impaired productivity.

Conclusions

This first systematic review of CIDP burden of illness demonstrates the high physical and psychosocial burden of this rare disease. Future research is required to fully characterise the burden of CIDP, and to understand how appropriate treatment can mitigate burden for patients and healthcare systems.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-09998-8) contains supplementary material, which is available to authorized users.

In utero ileal volvulus and intestinal perforation associated with enteric duplication cyst presenting with preterm labour and acute abdomen in newborn

Enteric duplication cysts are a rare cause of intestinal obstruction in the neonatal period. We present the unusual case of an in utero ileal volvulus secondary to an enteric duplication cyst causing an acute abdomen in a 35-week estimated gestational age newborn female delivered to a mother in preterm labour.

Clinical decision making in the selection of analgesia

This article uses findings from a case study and an evaluation of decision-making theories to provide an evidence-based rationale for the selection outside departmental guidelines of analgesia for the reduction of closed, dislocated fingers.

Analysis of chromosomal instability in human colorectal adenomas with two mutational hits at APC

In vitro data show that the adenomatous polyposis coli (APC) protein associates with the mitotic spindle and that mouse embryonic stem cells with biallelic Apc mutations are karyotypically unstable. These findings led to suggestions that APC acts in chromosomal segregation and that APC inactivation leads to chromosomal instability (CIN). An alternative hypothesis based on allelic loss studies in colorectal adenomas proposes that CIN precedes and contributes to genetic changes at APC. We determined whether colorectal adenomas with two mutations at APC show features consistent with these models by studying 55 lesions (average size 5 mm; range 1-13 mm) from patients with familial adenomatous polyposis. A variety of methods was used depending on available material, including flow cytometry, comparative genomic hybridization, and loss of heterozygosity (LOH) analysis. Selected adenomas were assessed for proliferative activity by Ki-67 immunocytochemistry. Seventeen of 20 (85%) tumors were diploid, two were near-diploid, and one was hypotetraploid. Just one (near-diploid) tumor showed increased proliferative activity. LOH was found occasionally on chromosome 15q (2 of 49 tumors), but not on chromosome 18q (0 of 48). In 20 adenomas, LOH at APC was associated with loss at 5q but not 5p markers, with the former encompassing a minimum of 20 Mb. However, three of these lesions analyzed by comparative genomic hybridization displayed normal profiles, suggesting, together with other data, that the mechanism of LOH at APC is probably somatic recombination. Our results therefore do not support the hypothesis that CIN precedes APC mutations in tumorigenesis. Regarding the model in which APC mutations lead directly to CIN, if APC mutations do have this effect in vivo, it must be subtle. Alternatively, CIN associated with APC mutations might be essentially an in vitro phenomenon.

Performance-based and physiological measures of situational awareness

Several situational awareness (SA) and workload measurement techniques were investigated in simulated air-to-ground missions. These techniques included measures of effectiveness, subjective ratings, performance measures, and physiological measures. The results demonstrated strengths and weaknesses in all of these techniques. Measures of effectiveness and subjective ratings suggested that the experimental manipulations were effective in altering SA. The performance measures produced mixed results. Physiological measures detected some intriguing effects in the EEG. Overall, the complexity of the relationship between SA and workload encourages the use of multiple tools in any SA evaluation.

Cranial Doppler ultrasonography correlates with criteria for ventriculoperitoneal shunting

Using pulsed Doppler ultrasound through the sonic window of the anterior fontanelle in infants, 46 children with ventriculomegaly had sequential evaluations of Resistive Index for comparison with the need for ventriculoperitoneal shunting. Hydrocephalus was associated with myelomeningocele in 17 patients and posthemorrhagic, postmeningitic, or congenital hydrocephalus accounted for the rest. The Resistive Index was obtained by dividing the difference between the peak systolic and end diastolic frequencies by the systolic frequency. Criteria for shunting included massive ventriculomegaly, increasing ventriculomegaly with an abnormal increase in head circumference, and clinical evidence of symptomatic hydrocephalus. Those patients requiring shunts had a Resistive Index of 84 +/- 13% prior to shunting. The Resistive Index fell to 72 +/- 11% postshunting with the difference being statistically significant at p less than 0.001. Moreover, the postshunting values compared favorably to data on 29 normal newborns, having Resistive Indices of 71 +/- 7% and to the Resistive Indices of three patients never shunted who had values of 74%, 66%, and 71%. Variations included primarily low Resistive Indices in myelomeningocele patients whose ventricles were decompressed by the leaking spinal lesions. Resistive Index used in conjunction with clinical observations may be extremely helpful not only in predicting the need for ventriculoperitoneal shunt, but also in evaluating children suspected of shunt malfunctions.