Patterns in the Reporting of Aggressive Histologic Subtypes in Papillary Thyroid Cancer

INTRODUCTION

The tall cell, columnar, and diffuse sclerosing subtypes are aggressive histologic subtypes of papillary thyroid cancer (PTC) with increasing incidence, yet there is a wide variation in reporting. We aimed to identify and compare factors associated with the reporting of these aggressive subtypes (aPTC) to classic PTC (cPTC) and secondarily identify differences in outcomes.

METHODS

The National Cancer Database was utilized to identify cPTC and aPTC from 2004 to 2017. Patient and facility demographics and clinicopathologic variables were analyzed. Independent predictors of aPTC reporting were identified and a survival analysis was performed.

RESULTS

The majority of aPTC (67%) were reported by academic facilities. Compared to academic facilities, all other facility types were 1.4-2.0 times less likely to report aPTC (P < 0.05). Regional variation in reporting was noted, with more cases reported in the Middle Atlantic, despite there being more total facilities in the South Atlantic and East North Central regions. Compared to the Middle Atlantic, all other regions were 1.4-5 times less likely to report aPTC (P < 0.001). Patient characteristics including race and income were not associated with aPTC reporting. Compared to cPTC, aPTC had higher rates of aggressive features and worse 5-y overall survival (90.5% versus 94.5%, log rank P < 0.001).

CONCLUSIONS

Aggressive subtypes of PTC are associated with worse outcomes. Academic and other facilities in the Middle Atlantic were more likely to report aPTC. This suggests the need for further evaluation of environmental or geographic factors versus a need for increased awareness and more accurate diagnosis of these subtypes.

Spinal Intramedullary Meningiomas: A Systematic Review with a Case Illustration

BACKGROUND

Intramedullary meningiomas are an exceptionally rare subtype of spinal tumors, accounting for only 5% of primary spinal neoplasms. Given their scarcity and unique characteristics, understanding optimal management approaches is crucial for improved clinical decision-making. This systematic review aims to consolidate existing literature and present a detailed case illustration to enhance understanding of this uncommon spinal tumor entity.

METHODS

A systematic search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Eligible studies included case reports, case series, cohort studies, reviews, and meta-analyses. Data extraction and synthesis focused on demographic characteristics, tumor location, clinical presentation, imaging findings, surgical interventions, histopathological features, and outcomes.

RESULTS

A total of 15 high-quality scientific articles were included in the systematic review, providing insights into various aspects of intramedullary meningiomas. Demographic analysis revealed a broad age distribution with an equal gender distribution among affected patients. Common clinical presentations included difficulty walking, sensory disturbances, spastic paraparesis, and urinary incontinence. Neuroimaging findings demonstrated heterogeneous signal intensity variations on T1- and T2-weighted images, with variable enhancement patterns on gadolinium-enhanced images. Surgical interventions, predominantly total resection, resulted in favorable postoperative outcomes in most cases.

CONCLUSIONS

Intramedullary meningiomas pose diagnostic and therapeutic challenges due to their rarity and unique characteristics. Tailored surgical approaches, incorporating techniques such as intraoperative neurophysiological monitoring and fluorescence-aided resection, are crucial for minimizing neurological deficits and optimizing patient outcomes. Despite their infrequency, recognizing intramedullary meningiomas in the differential diagnosis of spinal tumors is essential for prompt diagnosis and timely intervention, ultimately improving patient prognosis.

Primary sclerosing liposarcoma of the ovary: Case report and a review of the literature

INTRODUCTION

Primary soft tissue sarcoma of the ovary is uncommon, with most literature reports being in the format of a single case report or small case series.

PRESENTATION OF CASE

We report a case of a primary sclerosing liposarcoma of the ovary in a 67-year-old lady. She presented with a rapidly growing ovarian mass, which was surgically excised. Histologically, the lesion appeared nodular with alternating hypercellular and low-cellularity areas, with areas of necrosis. It comprised atypical spindled, oval and stellate cells set in abundant myxoid and fibrous hyalinised stroma. Immunohistochemistry showed expression of p16, CDK4, CD34, S-100 and MDM2. The case was sent to a referral centre where MDM2 gene amplification was detected by interphase fluorescent in-situ hybridisation (FISH) analysis, rendering a diagnosis of well-differentiated sclerosing liposarcoma with focal low-grade dedifferentiation.

DISCUSSION

To the best of our knowledge, this is the first reported example of a sclerosing variant of liposarcoma in the ovary. Differential diagnosis includes microcystic stromal tumour (MST), sclerosing stromal tumour (SST), atypical spindle cell lipoma, myxoid liposarcoma, myxofibosarcoma, solitary fibrous tumour and low grade fibromyxoid sarcoma.

CONCLUSION

Ovarian sarcomas are characterised by a rapid and aggressive clinical course, requiring multidisciplinary team input for ongoing management. Complete surgical resection with clear margins is the mainstay of treatment.

Comparison of the long-term outcomes between proximal and distal IgG4-related sclerosing cholangitis: A multicenter cohort study

BACKGROUND AND AIMS

Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is considered a biliary manifestation of IgG4-related diseases. However, there has been a controversy on the clinical outcomes according to the location of the involved bile duct. We therefore compared the clinical outcomes and long-term prognosis of IgG4-SC with proximal bile duct involvement (proximal IgG4-SC) and IgG4-SC with distal bile duct involvement (distal IgG4-SC).

METHODS

We reviewed the data of patients with IgG4-SC that were prospectively collected at 10 tertiary centers between March 2002 and October 2020. Clinical manifestations, outcomes, association with autoimmune pancreatitis (AIP), steroid-responsiveness, and relapse of IgG4-SC were evaluated.

RESULTS

A total of 148 patients (proximal IgG4-SC, n = 59; distal IgG4-SC, n = 89) were analyzed. The median age was 65 years (IQR, 56.25-71), and 86% were male. The two groups were similar in terms of jaundice at initial presentation (51% vs 65%; P = 0.082) and presence of elevated serum IgG4 (66% vs 70%; P = 0.649). The two groups showed significant differences in terms of steroid-responsiveness (91% vs 100%; P = 0.008), association with AIP (75% vs 99%; P = 0.001), and occurrence of liver cirrhosis (9% vs 1%; P = 0.034). During a median follow-up of 64 months (IQR, 21.9-84.7), the cumulative relapse-free survival was significantly different between the two groups (67% vs 79% at 5 years; P = 0.035).

CONCLUSIONS

Relapse of IgG4-SC frequently occurred during follow-up. Proximal IgG4-SC and distal IgG4-SC had different long-term outcomes in terms of steroid-responsiveness, occurrence of liver cirrhosis, and recurrence. It may be advantageous to determine the therapeutic and follow-up strategies according to the location of bile duct involvement.

Imaging features of COVID-19-associated secondary sclerosing cholangitis on magnetic resonance cholangiopancreatography: a retrospective analysis

Background

Despite emerging reports of secondary sclerosing cholangitis (SSC) in critically ill COVID-19 patients little is known about its imaging findings. It presents as delayed progressive cholestatic liver injury with risk of progression to cirrhosis. Diagnosis cannot be made based on clinical presentation and laboratory markers alone. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) can aid in the diagnosis. The aim of this study was to describe MRI/MRCP imaging features of COVID-19-associated SSC.

Results

Seventeen patients (mean age 60.5 years, 15 male) who underwent MRI/MRCP were included. All had been admitted to intensive care unit (ICU) (median duration of ICU stay 10 weeks, range, 2–28 weeks) and developed acute respiratory distress syndrome requiring mechanical ventilation. On imaging, all patients had intrahepatic bile duct strictures and 10 (58.8%) had associated upstream dilatation. Intrahepatic bile duct beading was seen in 14 cases (82.3%). Only one patient (5.9%) had extrahepatic bile duct stricturing. Patchy arterial phase hyperenhancement and high signal on T2- and diffusion-weighted images were seen in 7 cases (53.8%) and 9 cases (52.9%), respectively. Biliary casts were seen in 2 cases (11.8%). Periportal lymphadenopathy and vascular complications were not seen.

Conclusion

On MRI/MRCP, COVID-19-associated SSC presents with multiple intrahepatic bile duct strictures with or without upstream dilatation and intrahepatic bile duct beading. Surrounding hepatic parenchymal changes including alterations in enhancement and T2 signal are common. The extrahepatic biliary tree was typically spared and periportal lymphadenopathy was missing in all patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01266-9.

Digital single-operator video cholangioscopy improves endoscopic management in patients with primary sclerosing cholangitis-a retrospective observational study

BACKGROUND

Patients with primary sclerosing cholangitis (PSC) are at a high risk of developing cholestatic liver disease and biliary cancer, and endoscopy is crucial for the complex management of these patients.

AIM

To clarify the utility of recently introduced digital single-operator video cholangioscopy (SOVC) for the endoscopic management of PSC patients.

METHODS

In this observational study, all patients with a history of PSC and in whom digital SOVC (using the SpyGlass DS System) was performed between 2015 and 2019 were included and retrospectively analysed. Examinations were performed at a tertiary referral centre in Germany. In total, 46 SOVCs performed in 38 patients with a history of PSC were identified. The primary endpoint was the evaluation of dominant biliary strictures using digital SOVC, and the secondary endpoints were the performance of selective guidewire passage across biliary strictures and the diagnosis and treatment of biliary stone disease in PSC patients.

RESULTS

The 22 of 38 patients had a dominant biliary stricture (57.9%). In 4 of these 22 patients, a cholangiocellular carcinoma was diagnosed within the stricture (18.2%). Diagnostic evaluation of dominant biliary strictures using optical signs showed a sensitivity of 75% and a specificity of 94.4% to detect malignant strictures, whereas SOVC-guided biopsies to gain tissue for histopathological analysis showed a sensitivity of 50% and a specificity of 100%. In 13% of examinations, SOVC was helpful for guidewire passage across biliary strictures that could not be passed by conventional methods (technical success rate 100%). Biliary stone disease was observed in 17.4% of examinations; of these, in 37.5% of examinations, biliary stones could only be visualized by SOVC and not by standard fluoroscopy. Biliary stone treatment was successful in all cases (100%); 25% required SOVC-assisted electrohydraulic lithotripsy. Complications, such as postinterventional cholangitis and pancreatitis, occurred in 13% of examinations; however, no procedure-associated mortality occurred.

CONCLUSION

Digital SOVC is effective and safe for the endoscopic management of PSC patients and may be regularly considered an additive tool for the complex endoscopic management of these patients.

Possible role of the HMGB1 and RAGE inflammatory pathway in primary sclerosing cholangitis

BACKGROUND

Activation of the receptor for advanced glycation end products (RAGE) and its ligand High Mobility Group Box Protein 1 (HMGB1), a nuclear protein with proinflammatory properties, has been implicated in several inflammatory disorders.

OBJECTIVE

To analyse the influence of RAGE and HMGB1 signalling in patients with primary sclerosing cholangitis (PSC).

METHODS

Levels of HMGB1 and bile acid in serum and bile samples of 69 PSC patients and 32 controls were measured. Additionally, 640 patients with PSC and other liver diseases were analysed for the gain-of-function RAGE G82S SNP by PCR. Laboratory and clinical parameters were retrieved by chart review.

RESULTS

ELISA analysis showed significantly higher biliary HMGB1 concentrations in PSC patients (n=69, median 124,1 ng/ml) than in the control group (n=32, median 6,85 ng/ml, p<0,001). Median serum HMGB1 (n=22, median 2,4 ng/ml) was significantly lower than median biliary HMGB1 of the concomitant bile samples (n=22, median 151 ng/ml, p =0,001). There was no correlation of biliary HMGB1 levels with laboratory parameters or clinical end points. Analysis of the gain-of-function G82SSNP RAGE SNP in PSC patients showed 8 patients with heterozygote mutant alleles (8/324, 2,5%). Patients carrying the mutation developed more often dominant strictures of the large bile ducts (100.0% vs. 61.3%; p=0.04) and had reduced transplantation-free survival in the mutant allele group (p<0.001).

CONCLUSIONS

Biliary HMGB1 levels are elevated in PSC patients compared to controls and a gain-of-function SNP in RAGE is associated with development of dominant strictures and reduced survival in PSC patients.

Abdominal cocoon syndrome, a case report of a rare disease entity causing intestinal obstruction

INTRODUCTION AND IMPORTANCE

Abdominal cocoon syndrome is a rare condition characterized by small bowel encapsulation by a fibrous membrane or a cocoon-like sac. It is an uncommon cause of intestinal obstruction. Less than 300 cases have been reported from all over the world. This is the first case of such a disease entity to be reported from Sudan.

CASE PRESENTATION

A young female patient, presented with features of intestinal obstruction that was managed conservatively. Failure of the conservative management has warranted a laparotomy.

CLINICAL FINDINGS AND INVESTIGATIONS

Her features were suggestive of intestinal obstruction that was confirmed radiologically.

INTERVENTIONS AND OUTCOME

Laparotomy revealed a membrane-like fibrous material and extensive multiple loops adhesions, findings consistent with primary sclerosing encapsulating peritonitis (PSEP), also known as abdominal cocoon's disease. The membrane was excised and adhesiolysis was done. Intestinal obstruction was relieved after surgery and the patient showed good outcome.

CONCLUSIONS

Abdominal cocoon syndrome is a rare cause of intestinal obstruction.

RELEVANCE AND IMPACT

The takeaway lesson from this case would be that the PSEP should be sought in any patient with no clear cause for obstruction can be identified. A contrast-enhanced CT scan is the diagnostic modality of choice. Finally, we think that the disease is underreported from Africa and more efforts should be carried out to increase patients' access to healthcare especially in rural areas with no access to hospitals in order to bring more cases to light. This case report has been reported in line with the SCARE Criteria (Agha et al., 2020 [17]).

First description of hematogenously metastasized sclerosing epithelioid fibrosarcoma arising in the uterine cervix

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First Case of hematogenously metastasized sclerosing epithelioid fibrosarcoma arising primarily in the cervix uteri.

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Tumor cells were strongly and diffusely positive for MUC4.

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Tumor showed a rare EWSR1-CREB3L2 gene fusion.

Sclerosing mucoepidermoid carcinoma of the salivary glands: report of three cases with special concern to the counterpart accompanied by eosinophilia

Sclerosing mucoepidermoid carcinoma (SMC) is described as a "sclerosing variant" of mucoepidermoid carcinoma, and it is characterized by dense fibrosis and sclerosis of the stroma. SMC with eosinophilia (SMCE) is another and more rare subtype characterized by eosinophilia in addition to the sclerotic stroma common to SMC. However, unlike SMC, SMCE is not listed in the current 4th edition of WHO classification. Here, we describe three cases: one SMC in the parotid gland, one SMCE in the submandibular gland and one SMCE in the minor salivary gland of the oral cavity. The patients included a 71-year-old Japanese male, a 74-year-old Japanese female, and an 81-year-old Japanese female. They each complained of mass formation and underwent surgical resection. Histologically, the tumors mainly consisted of squamous cells with scarce keratinization that formed irregular large and small nests along with cystic structures containing mucous cells against the background of sclerotic stroma. One oral SMCE showed fine nesting and trabecular invasion. The two SMCEs included dense aggregates of eosinophils as well as more prominent lymphoid infiltration. Fluorescence in situ hybridization for MAML2 confirmed split signals in SMC, but not in SMCE.

Challenges in the Diagnosis of Pediatric Spindle Cell/Sclerosing Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common pediatric soft tissue sarcoma, representing approximately 40% of all pediatric soft tissue sarcomas. The spindle cell/sclerosing subtype of RMS (SSRMS) accounts for roughly 5% to 10% of all cases of adult and pediatric RMS. Historically, SSRMS were described as paratesticular tumors with an excellent outcome. However, more recent studies have identified unique molecular subgroups of SSRMS, including those with MYOD1 mutations or VGLL2/NCOA2 fusions, which have widely disparate outcomes. The goal of this article is to better describe the biological heterogeneity of SSRMS, which may allow the pathologist to provide important prognostic information.

A literature survey and discussion of a unique index case

BACKGROUND

Dural thickening is observed in lymphoma, dural carcinomatosis, meningioma, tuberculosis, and autoimmune diseases. We encountered a patient with dural thickening and complaints of neck and back pain, numbness and loss of strength in the hands. The patient also suffered from polychondritis and had previously received steroid and methotrexate treatment for this indication. The patients' serum was also positive for ANA, yet she did not have any other findings suggesting lupus. Our radiological and pathological analysis revealed IHSP (IgG4-related hypertrophic sclerosing pachymeningitis). In this review study, we provided a detailed literature survey to increase the awareness about IHSP in the neurosurgical community.

METHODS

MRI (magnetic resonance imaging)-based radiological analyses revealed a posterior extramedullary spinal mass extending from C2 to T2-T3 level. The dural mass was surgically excised and a broad panel of immunohistochemical markers including S100, EMA, CD246/ALK-1, CD45, CD20, CD79a, CD138, CD68, CD1a and CD34 was studied. Immunoglobulin heavy chain/kappa chain gene rearrangement analysis was performed which ruled out a lymphoproliferative disorder.

RESULTS

MRI and pathological findings suggested IHSP. As the disease relapsed with a new anterior extramedullary multilobulated lesion extending from C5 to T1 level, the patient is now closely monitored for further medical and surgical treatment.

CONCLUSIONS

IHSP is a relatively novel entity of hypertrophic pachymeningitis and should be included in the differential diagnosis of dural thickening. The fibrosis accompanying IHSP may not respond to medical treatment, which includes steroids and immunosuppressive agents. Additionally, neurological deficits, seizures, spinal decompression, hydrocephalus, or brainstem compression necessitate early surgical intervention. A continued vigilance is also necessary as the disease may relapse long-term following surgical treatment.

Sclerosing Signet Ring Cell Carcinoma of the Lacrimal Gland: A Potentially New Primary Entity

An 88-year-old man presented with diplopia, limitation of extraocular movements, and a firm palpable mass in the superolateral orbit. Biopsy revealed a sclerosing signet ring cell carcinoma with histopathologic features mimicking those of a primary signet ring cell (histiocytoid) carcinoma of the eyelid of eccrine or apocrine gland origin, a metastasis from an invasive lobular breast carcinoma or a metastatic diffuse-type gastric carcinoma. An extensive panel of immunohistochemical stains and molecular genetic analyses unequivocally failed to establish a precise diagnosis. Electron microscopy demonstrated features of a primary lacrimal gland lesion with intracytoplasmic lumens and zymogen granules typical of lacrimal secretory pyramidal cells. A thorough initial systemic work-up failed to reveal a primary visceral malignancy. Fifteen months of follow-up have failed to detect the emergence of another primary malignancy. To the best of our knowledge, a tumor with the morphology of the current lesion has not been previously described in the major or accessory lacrimal glands.

Long term control of luteinized thecoma with sclerosing peritonitis with leuprorelin and tamoxifen treatment

Background

Luteinized thecoma with sclerosing peritonitis (LTSP) is a very rare condition, and its clinical management is not evidence-based. Here we describe a case of long-term disease control achieved with leuprorelin and tamoxifen therapy.

Case presentation

A 18-year-old woman with acute abdomen underwent surgical removal of an ovarian mass and received diagnosis of LTSP. Treatment plan consisted of leuprorelin and tamoxifen, followed by a good instrumental response. After 5 years, leuprorelin was stopped, and the patient continued tamoxifen alone. Ten years after diagnosis, she is still disease free.

Conclusion

Even in the absence of solid evidence, the combination of leuprorelin and tamoxifen could be considered as a possible medical treatment of LTSP. Considering the limitations related to the rarity of disease, further studies are needed to improve its management.

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Luteinized thecoma with sclerosing peritonitis (LTSP) is a rare condition characterized by a very hard management.

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Few cases are described in literature and no evidences about the best treatment of this condition are available.

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We present a case of a very long control (ten year) of LTSP with tamoxifen and leuprorelin treatment.

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Based on the lack of evidences, this approach could be considered as treatment of LTSP.

A mismatch of tumor grade and biologic behaviour in a rare case of Sclerosing Mucoepidermoid Carcinoma of Parotid - with review of literature

Although mucoepidermoid carcinoma is the most common primary malignancy of the salivary glands, the sclerosing morphologic variant of this tumor is extremely rare and only 26 cases have been reported till date in the english literature. This report describes a case involving a 35-year-old female with an intermediate-grade sclerosing mucoepidermoid carcinoma of parotid gland and we review the litreture. Immunohitochemical markers, Her-2/neu and MIB-1 evaluated to help predict the clinical outcome and to determine whether an association exists between the histologic grade and immunohistochemical findings. A PAS stain revealed cytic spaces filled with basophilic material. We found MIB-1 labeling indices of >50% and strong positivity for Her-2/neu suggesting poor prognosis. Our case did not show any correlation between MIB-1 index and tumor grade as shown in other case reports. This unusual but distinctive variant of mucoepidermoid carcinoma can be difficult to recognize and is frequently misdiagnosed as a benign lesion.

No beneficial effect of Polidocanol treatment in Achilles tendinopathy: a randomised controlled trial

PURPOSE

Polidocanol injections have been used to treat chronic Achilles tendinopathy in clinical settings, but the few studies published show inconsistent results. The aim of this study was to evaluate the mid-term effect of Polidocanol in patients with chronic Achilles tendinopathy. It was hypothesised that patients treated with Polidocanol would have significant improvements in the outcome measures investigated compared to patients treated with a placebo treatment at mid-term follow-up.

METHODS

This randomised controlled trial included forty-eight patients aged 32-77 years with a history of Achilles tendinopathy for at least 3 months and with neovascularisation demonstrated by ultrasonography was included. A minimum of 3 months of eccentric exercise treatment was required before participating. The patients were allocated to a maximum of two injection of either Polidocanol or Lidocaine (placebo). The primary outcome measure was pain during walking reported on a visual analogue scale. Secondary outcome measures were Foot and Ankle Outcome Score (FAOS), patient satisfaction with treatment and, shortly after inclusion, the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) was also included. Follow-up examinations were performed after 3 and 6 months.

RESULTS

Pain during walking decreased during the 6-month follow-up period, but no significant differences were seen between the two groups. The same tendency was seen for FAOS and VISA-A in which both groups showed an improvement at 3- and 6-month follow-up, but no mid-term differences between the groups were seen. An equal number of patients in the two groups were satisfied with the treatment at follow-up.

CONCLUSIONS

The results indicate that Polidocanol is a safe treatment, but the mid-term effects are the same as a placebo treatment. This further questions the use of Polidocanol in the treatment of chronic Achilles tendinopathy.

LEVEL OF EVIDENCE

I.

Incidentally discovered well-differentiated retroperitoneal liposarcoma with inguinal canal herniation: report of 2 cases

Well-differentiated retroperitoneal liposarcomas are slow growing and low-grade tumors, reaching usually huge size before being symptomatic and so diagnosed, therefore with increase of the surgical risk and of the probability of dedifferentiation. Inguinal location of these tumors is unusual and rarely diagnosed.

Rhabdomyosarcoma, Spindle Cell/Sclerosing Variant: A Clinical and Histopathological Examination of this Rare Variant with Three New Cases from the Oral Cavity

Spindle cell/sclerosing rhabdomyosarcoma (S-ScRMS) was recently recognized in 2013 by the World Health Organization (WHO) as a stand-alone entity (Parham et al., WHO classification of tumours of soft tissue and bone, IARC Press, Lyon, 2013). Historically, the spindle cell and sclerosing variants were subcategorized under embryonal type rhabdomyosarcoma. Current data supports that certain S-ScRMS cases have a more aggressive clinical course with reduction of long-term survival, and those found in the head and neck region often exhibit extensive local recurrence. Furthermore, due to variable histopathologic appearances and immunohistochemical findings, misdiagnosis is common. We aim to report the variability in histopathologic patterns, immunohistochemical findings, radiographic features, and clinical data on three new cases of S-ScRMS presenting in the oral cavity of young adult males (ages 22, 24, and 39 years). The English-language literature on S-ScRMS is briefly reviewed as well.

Sclerosing mucoepidermoid carcinoma of the sublingual gland

INTRODUCTION

Sclerosing mucoepidermoid carcinoma of the salivary gland is a rare subtype of mucoepidermoid carcinoma. The most common site of sclerosing mucoepidermoid carcinoma of the salivary glands is the parotid gland, followed by the submandibular gland, and the minor salivary glands.

OBSERVATION

Here we report the first case of sclerosing mucoepidermoid carcinoma of the sublingual gland.

DISCUSSION

Clinicians should consider sclerosing mucoepidermoid carcinoma in the differential diagnosis of salivary gland neoplasm. Surgical excision with clear margins seems to be a sufficient initial treatment option for sclerosing mucoepidermoid carcinoma of the salivary gland.

Whorling cellular perineurioma: A previously undescribed variant closely mimicking monophasic fibrous synovial sarcoma

The authors present a distinctive perineurioma (PN) variant which morphologically strongly resembles monophasic fibrous synovial sarcoma (MSS). The patients were 3 males and 1 female. The age ranged from 15 to 61years (mean: 44years). Locations included the sole, lower jaw, palm and foot. The tumor size ranged from 1.3cm to 2.5cm in the largest dimension (mean 1.8cm). Morphologically, all tumors had an identical, monotonous appearance. The perineurial cells were closely packed and created a confluent cellular whorls and/or sheets in a scarce stroma, with only focally discernible long, slender cytoplasmic processes typical for perineurial differentiation. The nuclei were rounded or slightly elongated to tapered, without nuclear atypia. Mitoses were rare to completely absent. Atypical mitoses, hemorrhage, necrosis or calcifications were not present. The proliferative index (Ki-67) was 1-3%. All analyzed tumors were positive for EMA, Claudin-1, GLUT-1 and negative with S100 protein, CD34, OSCAR, CK7 and TLE-1. Two cases were tested by fluorescence in situ hybridization and neither showed alterations of the SYT gene. One case studied by electron microscopy showed characteristic features of perineurial differentiation. Follow-up was available for two patients both of which showed no evidence of disease at 8years and 6months, respectively. Based on their bland morphology, perineurial features and presumably benign clinical outcome we propose the term "whorling cellular perineurioma" for these tumors, which may represent an extremely cellular variant of sclerosing PN. Awareness of this PN subtype and its distinction from MSS is of utmost clinical significance.

To screen or not to screen? Celiac antibodies in liver diseases

Celiac disease (CD) is a systemic immune-mediated disorder triggered by dietary gluten in genetically predisposed individuals. The typical symptoms are anemia, diarrhea, fatigue, weight loss, and abdominal pain. CD has been reported in patients with primary sclerosing cholangitis, primary biliary cholangitis, autoimmune hepatitis, aminotransferase elevations, nonalcoholic fatty liver disease, hepatitis B, hepatitis C, portal hypertension and liver cirrhosis. We evaluate recommendations for active screening for CD in patients with liver diseases, and the effect of a gluten-free diet in these different settings. Active screening for CD is recommended in patients with liver diseases, particularly in those with autoimmune disorders, steatosis in the absence of metabolic syndrome, noncirrhotic intrahepatic portal hypertension, cryptogenic cirrhosis, and in the context of liver transplantation. In hepatitis C, diagnosis of CD can be important as a relative contraindication to interferon use. Gluten-free diet ameliorates the symptoms associated with CD; however, the associated liver disease may improve, remain the same, or progress.

Sclerosing Mucoepidermoid Carcinoma of the Parotid Gland

INTRODUCTION

Mucoepidermoid carcinoma represents one of the most common malignant salivary gland tumors. However, the sclerosing morphologic variant is extremely rare with only 23 reported cases in the English-language literature since it was discovered in 1987.

CASE REPORT

Herein, we describe another case that was diagnosed in a 25-year-old woman presenting with a posterior auricular mass, as well as a review of the literature, which demonstrates that this is an extremely rare malignancy with no strict protocol for treatment.

CONCLUSION

Pathologists must be aware of recognizing low grade sclerosing mucoepidermoid carcinoma which has metastatic potential and is frequently misdiagnosed as a benign lesion.

Sclerosing Lesions of the Orbit: A Review

Orbital sclerosing inflammation is a distinct group of pathologies characterized by indolent growth with minimal or no signs of inflammation. However, contrary to earlier classifications, it should not be considered a chronic stage of acute inflammation. Although rare, orbital IgG4-related disease has been associated with systemic sclerosing pseudotumor-like lesions. Possible mechanisms include autoimmune and IgG4 related defective clonal proliferation. Currently, there is no specific treatment protocol for IgG4-related disease although the response to low dose steroid provides a good response as compared to non-IgG4 sclerosing pseudotumor. Specific sclerosing inflammations (e.g. Wegener's disease, sarcoidosis, Sjogren's syndrome) and neoplasms (lymphoma, metastatic breast carcinoma) should be ruled out before considering idiopathic sclerosing inflammation as a diagnosis.

Inhibition of intestinal bile acid absorption improves cholestatic liver and bile duct injury in a mouse model of sclerosing cholangitis

BACKGROUND AND AIMS

Approximately 95% of bile acids (BAs) excreted into bile are reabsorbed in the gut and circulate back to the liver for further biliary secretion. Therefore, pharmacological inhibition of the ileal apical sodium-dependent BA transporter (ASBT/SLC10A2) may protect against BA-mediated cholestatic liver and bile duct injury.

METHODS

Eight week old Mdr2(-/-) (Abcb4(-/-)) mice (model of cholestatic liver injury and sclerosing cholangitis) received either a diet supplemented with A4250 (0.01% w/w) - a highly potent and selective ASBT inhibitor - or a chow diet. Liver injury was assessed biochemically and histologically after 4weeks of A4250 treatment. Expression profiles of genes involved in BA homeostasis, inflammation and fibrosis were assessed via RT-PCR from liver and ileum homogenates. Intestinal inflammation was assessed by RNA expression profiling and immunohistochemistry. Bile flow and composition, as well as biliary and fecal BA profiles were analyzed after 1week of ASBT inhibitor feeding.

RESULTS

A4250 improved sclerosing cholangitis in Mdr2(-/-) mice and significantly reduced serum alanine aminotransferase, alkaline phosphatase and BAs levels, hepatic expression of pro-inflammatory (Tnf-α, Vcam1, Mcp-1) and pro-fibrogenic (Col1a1, Col1a2) genes and bile duct proliferation (mRNA and immunohistochemistry for cytokeratin 19 (CK19)). Furthermore, A4250 significantly reduced bile flow and biliary BA output, which correlated with reduced Bsep transcription, while Ntcp and Cyp7a1 were induced. Importantly A4250 significantly reduced biliary BA secretion but preserved HCO3(-) and biliary phospholipid secretion resulting in an increased HCO3(-)/BA and PL/BA ratio. In addition, A4250 profoundly increased fecal BA excretion without causing diarrhea and altered BA pool composition, resulting in diminished concentrations of primary BAs tauro-β-muricholic acid and taurocholic acid.

CONCLUSIONS

Pharmacological ASBT inhibition attenuates cholestatic liver and bile duct injury by reducing biliary BA concentrations in mice.

Inhibition of intestinal bile acid absorption improves cholestatic liver and bile duct injury in a mouse model of sclerosing cholangitis

BACKGROUND AND AIMS

Approximately 95% of bile acids (BAs) excreted into bile are reabsorbed in the gut and circulate back to the liver for further biliary secretion. Therefore, pharmacological inhibition of the ileal apical sodium-dependent BA transporter (ASBT/SLC10A2) may protect against BA-mediated cholestatic liver and bile duct injury.

METHODS

Eight week old Mdr2(-/-) (Abcb4(-/-)) mice (model of cholestatic liver injury and sclerosing cholangitis) received either a diet supplemented with A4250 (0.01% w/w) - a highly potent and selective ASBT inhibitor - or a chow diet. Liver injury was assessed biochemically and histologically after 4weeks of A4250 treatment. Expression profiles of genes involved in BA homeostasis, inflammation and fibrosis were assessed via RT-PCR from liver and ileum homogenates. Intestinal inflammation was assessed by RNA expression profiling and immunohistochemistry. Bile flow and composition, as well as biliary and fecal BA profiles were analyzed after 1week of ASBT inhibitor feeding.

RESULTS

A4250 improved sclerosing cholangitis in Mdr2(-/-) mice and significantly reduced serum alanine aminotransferase, alkaline phosphatase and BAs levels, hepatic expression of pro-inflammatory (Tnf-α, Vcam1, Mcp-1) and pro-fibrogenic (Col1a1, Col1a2) genes and bile duct proliferation (mRNA and immunohistochemistry for cytokeratin 19 (CK19)). Furthermore, A4250 significantly reduced bile flow and biliary BA output, which correlated with reduced Bsep transcription, while Ntcp and Cyp7a1 were induced. Importantly A4250 significantly reduced biliary BA secretion but preserved HCO3(-) and biliary phospholipid secretion resulting in an increased HCO3(-)/BA and PL/BA ratio. In addition, A4250 profoundly increased fecal BA excretion without causing diarrhea and altered BA pool composition, resulting in diminished concentrations of primary BAs tauro-β-muricholic acid and taurocholic acid.

CONCLUSIONS

Pharmacological ASBT inhibition attenuates cholestatic liver and bile duct injury by reducing biliary BA concentrations in mice.

A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

Primary esophageal sclerosing mucoepidermoid carcinoma with “tissue eosinophilia”

Mucoepidermoid carcinoma (MEC) is a rare primary esophageal malignancy. It is characterized by poor clinical recognition, pre-operative diagnostic challenges and a lack of standardized therapeutic guidelines. We report the clinicopathological features of a hitherto unreported variant of esophageal MEC, sclerosing MEC with “tissue eosinophilia”, in a mid-esophageal location in a 51-year-old female. The diagnosis of the initial biopsy was challenging, because of the small size, poor orientation and inadequate representation of the MEC components. Recognition of the resectability of the tumor prompted surgical resection and enabled a demonstration of the low grade foci containing intermediate cells, mucin pools and the hitherto undescribed presence of stromal sclerosis and tissue eosinophils in esophageal MEC. Heightened clinicopathological awareness of esophageal MEC facilitated a definitive diagnosis and patient management. Increased recognition and global documentation of esophageal sclerosing MEC with “tissue eosinophilia” is necessary to improve the understanding and diagnosis of this malignancy in this location and to improve management guidelines.

Sclerosing peritonitis occurring in association with juvenile granulosa cell tumour - a cause of concern

Sclerosing Peritonitis (SP) is characterized by fibrous thickening and adhesions of the peritoneum and it is encountered frequently in association with peritoneal dialysis, practolol and anticonvulsant therapy. Rarely does it present as a gynaecological complication, most commonly in conjunction with luteinized thecoma of ovary. Very rarely has sclerosing peritonitis been reported to occur with ovarian cystic teratoma and a luteinized variant of adult granulosa cell tumour, among which only one case has been reported in the English literature. An 18-year-female presented with a history of lower abdominal pain, of one month's duration. At surgery, an ovarian mass was noted, along with adhesion of bowel loops which were enclosed within a diffusely thickened peritoneal membrane, forming a cocoon. Adhesions were seen in bilateral paracolic gutter and infracolic omentum, which were suggestive of metastatic deposits. Histopathology of ovarian lesion was interpreted as a juvenile granulosa cell tumour. The peritoneal process revealed sclerosing peritonitis. We emphasize this rare association of sclerosing peritonitis with juvenile granulosa cell tumour and that the peritoneal process of sclerosing peritonitis in a juvenile granulosa cell tumour should not lead to over staging of an ovarian tumour.

A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

Sclerosing stromal tumour in young women: clinicopathologic and immunohistochemical spectrum

AIM

Sclerosing stromal tumor is a benign tumor of ovary. We aimed to review the clinical findings and immunohistochemical results of SSTs through the 7 diagnosed cases in our hospital.

MATERIAL AND METHODS

As immunohistochemical, blocks were applied with estrogen receptor , progesterone receptor, inhibin, calretinin, melan-A, CD10, smooth muscle actin, desmine, vimentin, CD34, S-100, C-kit, cytokeratin , cytokeratin7.

RESULTS

Macroscopically, while 5 tumors had solid appearance, 2 tumors were composed of solid and cystic areas. All the tumors were in shape of ovarian masses with good limits. Microscopically, two types of cells were observed as fusiform fibroblast-like cells and theca-like cells with vacuolised cytoplasm. Immunohistochemical results: vimentin, smooth muscle actin, desmine, progesterone receptor, calretinin, inhibin were positive in all the cases; S-100, cytokeratin, cytokeratin7, estrogen receptor were negative in all the cases; CD-10 was positive in 2 cases; C-kit was positive in 5 cases; melan-A was positive in 4 cases.

CONCLUSIONS

The significance of these tumors is that it is necessary to distinguish the histopathology in the frozen section in order to protect the other adnexa because of the characteristics to be observed at early ages (2(nd) and 3(rd) decades). Our findings support the conclusion that sclerosing stromal tumors are benign-character tumors that stem from over stroma and are hormonally active tumors because of the detected clinical and immunohistochemical results, although no hormonal effect that could be supported with laboratory tests was observed.