Primary thyroid biphasic synovial sarcoma and synchronous papillary carcinoma: report of a remarkable case

Synovial Sarcoma (SS) is the fourth most common soft tissue sarcoma, characterized by translocation t(X;18) (p11.2;q11.2). Although its histological features have been extensively described, this entity is characterized by a wide morphological spectrum so that the recognition can be very challenging at atypical anatomical localization, like the thyroid. We describe a case of a 42-ys-old female patient complaining a cervical swelling due to left intrathyroid nodule, measuring 35 mm in its greatest dimension. A Fine Needle Aspiration Cytology (FNAC) was performed and diagnosis of indeterminate neoplastic lesion, indefinite whether primary or metastatic, was formulated. After complete thyroidectomy, the histological picture of the nodule was characterized by a dual cellular population: several glandular structures composed by columnar cells with clear cytoplasm were embedded in a highly cellular stroma composed of spindle-shaped elements. Immunohistochemistry and molecular biology confirmed the morphological suspicion of SS identifying the fusion transcript SYT-SSX1 and thus ruling out several differential diagnoses which include more common thyroid malignancies. Moreover a synchronous papillary microcarcinoma was detected in the controlateral lobe. This case is noteworthy since it describes the synchronous presence in the thyroid of two completely different malignancies, the first one belonging to the soft tissue neoplasm category and the other one originating from the thyroid follicular epithelium.

A case of multifocal medulloblastoma in an adult patient

Only five cases of multifocal medulloblastoma in the adult have been reported to date. We present a case in a male patient in his 50th decade of life who presented with three extra-axial lesions associated with a parenchymatous lesion of the right middle cerebellar peduncle. Sputum sample examination revealed larvae compatible with strongyloides stercoralis, which was our main differential diagnosis. Histological and immunohistochemical studies revealed the existence of a desmoplastic medulloblastoma.

Role of serial EUS-guided FNA on pancreatic cystic neoplasms: a retrospective analysis of repeat carcinoembryonic antigen measurements

BACKGROUND AND AIMS

Pancreatic cystic neoplasms (PCNs) often need interval surveillance, including repeat EUS, but the role of repeat FNA with fluid analysis is poorly defined. The aim of this analysis is to evaluate the potential clinical significance of serial carcinoembryonic antigen (CEA) measurements by EUS-guided FNA (EUS-FNA) in the surveillance for PCNs.

PATIENTS

Patients who underwent EUS-FNA for PCNs were studied retrospectively. EUS-FNA findings were compared between index and prior procedures among patients who underwent repeat EUS-FNA.

RESULTS

A total of 400 patients with PCNs underwent EUS-FNA. Eighty-seven of those patients had prior EUS-FNA with cyst fluid analysis. Patients with repeat FNA were significantly more likely to have multiple cysts (57% vs 41%; P = .008), multilocular cysts (75% vs 62%; P = .042), connection to pancreatic duct (33% vs 18%; P = .005), and higher initial CEA levels (94.8 vs 25.6 ng/mL; P = .003) compared with patients who had only a single FNA. A comparison of prior and index FNAs did not show significant differences in EUS or cyst fluid analysis findings. After log transformation, the association between CEA level at prior and index FNA was moderate (R² = 0.626; P < .001), but cystic fluid CEA classification with a cutoff value of 192 ng/mL changed in 17 patients (20%), without significant changes in EUS findings.

CONCLUSIONS

Repeat surveillance EUS-FNA resulted in stable CEA levels in the majority of patients, with spurious fluctuations of CEA in approximately 20% of patients. These data call into question any clinical significance attributed to an isolated interval rise in CEA level, especially in light of a stable EUS examination.

Molecular diagnosis in patients with retinoblastoma: Report of a series of cases

OBJECTIVES

To report the benefits of genetic diagnosis in patients with retinoblastoma.

METHOD

Observational study. Patients with retinoblastoma and their families were included. Demographic and clinical data were recorded. Blood and tumour samples were obtained. Next generation sequencing was performed on the samples. When deletion 13 q syndrome was suspected, cytogenetics microarray was performed (Cytoscan® HD, Affymetrix, Santa Clara, CA, USA), with a high density chip of 1.9 million of non-polymorphic probes and 750 thousand SNP probes.

RESULTS

Of the 7 cases were analysed 4 were male. The mean age at diagnosis was 21 months (range 5-36). Three cases had bilateral retinoblastoma, and 4 unilateral. None had family history. In all patients, blood was analysed, and a study was performed on the tissue from 2 unilateral enucleated tumours, in which 6 mutations were identified, all de novo. Just one was novel (c.164delC; case 1). One case of unilateral tumour revealed blood mosaicism, showing that his condition was inheritable, and that there is a high risk of developing retinoblastoma in the unaffected eye. The patient also has an increased risk of presenting with other primary tumours.

CONCLUSION

Molecular diagnosis of RB1 in patients with retinoblastoma impacts on the decision process, costs, treatment, and prognosis of patients, as well as their families.

Recurrent gastric neuroendocrine tumors treated with total gastrectomy

Gastric neuroendocrine tumors are rare; however, the incidence has recently increased due to the increasing use of upper endoscopy. Neuroendocrine tumors arise from the excess proliferation of enterochromaffin-like (ECL) cells. The proliferative changes of enterochromaffin cells evolve through a hyperplasia-dysplasia-neoplasia sequence that is believed to underlie the pathogenesis of gastric neuroendocrine tumors. Endoscopic resection is recommended as the initial treatment if the tumor is not in an advanced stage. However, there is no definite guideline for the treatment of recurrent gastric neuroendocrine tumors following endoscopic resection. Here, we report a rare case of gastric neuroendocrine tumors in a 56-year-old male who experienced two recurrences within 11 years after endoscopic resection. The patient finally underwent a total gastrectomy. The pathological features of the resected stomach exhibited the full hyperplasia-dysplasia-neoplasia sequence of the ECL cells in a single specimen.

Intraductal papillary neoplasm of the bile ducts: A case report and literature review

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare bile duct neoplasm mostly found in far eastern nations where hepatolithiasis and clonorchiasis infections are endemic. In western countries, it is very rare and the etiology is unknown. In this article, we report the first IPNB patient we encountered in our clinic and a literature review. The patient is a 38-year-old female with a history of choledocholithiasis who presented with obstructive jaundice. She was found to have a papillary mass at the junction of the right hepatic duct and common hepatic duct with six masses in the liver parenchyma. The immunophenotypic and histologic features of the tumor are consistent with IPNB, gastric subtype. The patient had a partial hepatectomy and has been receiving palliative chemotherapy. In a search of PubMed database, we collected 354 IPNB patients reported in 22 articles. In these patients, 52.8% were from Japan and 27.7% were from western countries including the United States (11.0%). The age of the patients ranged from 35 to 80 years old with an average of 64.6. Male/female ratio was 1.5. Macroscopically, 57.5% of the tumors were in the left lobe and 29.5% were in the right lobe. The average size of the tumor were 4.2 cm at the time of diagnosis. Histologically, pancreato-biliary subtype accounted for 41.8%, intestinal 28.0%, gastric 13.5% and oncocytic 16%. An invasive component is most often present in the pancreato-biliary and gastric subtypes. Despite recent advanced technologies, diagnosis of IPNB is still challenging, especially in western countries due to its rarity. Defined clinico-pathologic features are in demand for the accurate diagnosis and proper treatment.

Metastasis of breast cancer to renal cancer: report of a rare case

Tumor-to-tumor metastasis (TTM) is a rare phenomenon. We present a case of an invasive ductal carcinoma (IDC) of the breast metastasizing to a clear cell renal cell carcinoma (RCC). Breast cancer (BC) metastasis to the RCC is rarely reported, especially in resected kidney tumor. In several cases reported, IDC was the exclusively histologic type of BC metastasized to RCC. It seems that the different molecular type of IDC doesn't affect the metastatic tendencies to RCC. TTM was an indicator of diffuse disease. For any patient with a history of breast cancer, especially with multi-organs metastasis, resection of kidney tumor should be carefully considered.

Two independent primary mucinous tumors involving the appendix and ovary accompanied with acellular pseudomyxoma peritonei

We report a case of a 30-year-old woman who had complained of lower abdominal distension. She was noted to have a history of primary mucinous tumor of the left ovary (13.2 × 9.9 × 10.4 cm) that was removed surgically. Two years later she developed the same tumor on her left ovary (8.7 × 6.0 × 6.9 cm) and also had appendiceal mucinous tumor accompanied with acellular PMP. Final pathology revealed two truly independent primary mucinous tumors involving the appendix and ovary accompanied with acellular PMP. We recommend a minimum follow-up of 5 years for the patient to detect any development of mucinous tumors and the acellular pseudomyxoma peritonei.

Synchronous double primary gastric and endometrial cancer: a case report and literature review

Multiple primary malignant neoplasms (MPMN) are two or more malignancies in an individual without any relationship between the tumors. In recent years, increasing number of cases were reported. However, Synchronous double primary gastric and endometrial cancer are relatively rare to be reported. Here we present a rare case of synchronous double cancer involving the stomach and endometrium, which is resected simultaneously and received six times chemo. After reviewing lots of literatures at home and abroad, we discuss the risk factors, the diagnostic criteria, the treatment modalities and the prognosis of these rare MPMN. Although a number of risk factors have been proposed in a mass of literatures, but the mechanism of MPMN is still unclear. We didn't discover a detailed explanation for the mechanism of MPMN from our patient. Therefore, further research should focus on the etiology and mechanism of MPMN.

Coexistence of multiple myeloma and clear cell renal cell carcinoma: a case report and review of literature

Coexistence of multiple myeloma (MM) and renal cell carcinoma (RCC) is an extremely rare condition. Nevertheless, there is a higher than expected incidence of co-occurrence of these two malignancies. Several case series, in the recent past, have postulated an association between MM and RCC. Population-based data analyses have revealed a bi-directional association between these two malignancies. However, the cause still remains speculative up to date. Here, we aim to describe a patient with MM and clear cell renal cell carcinoma (CCRCC) one after another for the second time from China. Clinical implications are discussed with a critical review of existing literature and we expect to draw much more awareness among clinicians regarding such association.

Multiple primary Ewing's sarcomas in cerebral cranium of a child: a case report and review of the literature

Ewing's sarcoma is the second most common pediatric bone tumor. Primary Ewing's sarcoma occurring in the cerebral cranium is exceptionally rare, with only one reported case of multiple tumor lesions in adolescence to date. We report a case of a 5-year-old male patient with multiple primary Ewing's sarcomas associated with the cranial bones, the first pediatric case report to date. We also review 71 cases Ewing's sarcoma involving intracranial extension. The purpose of this article is to provide data concerning the clinical and therapeutic course of multiple primary Ewing's sarcomas in associated with cerebral cranium.

Synchronous breast carcinoma and chronic lymphocytic leukemia in a Chinese young female: a rare combination

Chronic lymphocytic leukemia (CLL) is one of the most common lymphoid malignancies in western countries, however, infrequent in Eastern countries. We report on a rare case of synchronous breast carcinoma and chronic lymphocytic leukemia in a Chinese female patient. A 47-year-old female patient who presented with right breast lump for three month was admitted to our hospital. An ultrasound scan showed two mass in right breast and axillary swollen lymph node. Then, this patient was given right mastectomy and axillary lymph node dissection. Histology report showed invasive ductal carcinoma of the breast (grade I) and small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL). Bone marrow was infiltrated by CLL cell. To the best of our knowledge, this is the first report of a Chinese patient suffering from breast carcinoma and chronic lymphocytic leukemia.

P16-positive continuous minimal deviation adenocarcinoma and gastric type adenocarcinoma in a patient with Peutz-Jeghers syndrome

We report a case of Peutz-Jeghers syndrome (PJS) in a 33-year-old female patient with synchronous uterine cervical minimal deviation adenocarcinoma (MDA) and gastric type adenocarcinoma (GTA). The patient was diagnosed with PJS at the age of 10. At the time of consultation, she complained of watery discharge. Magnetic resonance imaging of the pelvis showed a poorly circumscribed mass in the uterine cervix. Histologically, both MDA and GTA components, as well as their transitional area, were observed. Both components were diffusely positive for MUC6, CK7 and, robustly, for p16. Moreover, the components were negative for ER, PgR and CEA, while HIK1083 and CK20 positive cells were found focally. Ki-67 labeling index in the MDA component was 5% while that in the GTA component was 50%. This case of GTA accompanied by MDA in a patient with PJS is distinct from the single previously-reported comparable case of which we are aware, with respect to the overexpression of p16 protein, an event considered rare in these tumors, and the continuity between the MDA and GTA components. This continuity favors the hypothesis that GTA arises from the dedifferentiation of MDA.

Hepatocellular carcinoma with concomitant hepatic angiomyolipoma and cavernous hemangioma in one patient

The risk of developing hepatocellular carcinoma (HCC) is strongly associated with hepatitis B virus infection. Hepatic angiomyolipoma (AML), a rare benign tumor, is composed of a heterogeneous mixture of adipose cells, smooth muscle cells and blood vessels. Here, we report the case of a 44-year-old man who developed HCC with a concomitant hepatic AML and a cavernous hemangioma, in the absence of cirrhosis. To our knowledge, based on an extensive literature search using the www.pubmed.gov website, this is the first report of an HCC case with both concomitant AML and cavernous hemangioma at the same position in the liver. The presence of the hepatitis B surface antigen was detected, but the liver function was normal. Clinical and pathological data were collected before and during the treatment. Hepatic AML was diagnosed based on the typical histological characteristics and immunohistochemical staining, which revealed, a positive staining with a melanocytic cell-specific monoclonal antibody. There was no evidence of tuberous sclerosis complex in this patient. Although the HCC was poor- to moderately-differentiated, the characteristics of the AML and the cavernous hemangioma in this patient did not match any criteria for malignancy. Hepatectomy followed by transarterial chemoembolization treatment were effective therapeutic methods for the adjacent lesions in this patient. This case is an interesting coincidence.

Recurrent intussusception as initial manifestation of primary intestinal melanoma: Case report and literature review

Enteric intussusception caused by primary intestinal malignant melanoma is a very rare cause of intestinal obstruction. We herein present a case of a 42-year-old female patient with no prior medical history of malignant melanoma, who was admitted with persistent abdominal pain, nausea, and vomiting. A computed tomography scan revealed an intestinal obstruction due to ileocolic intussusception. An emergency laparoscopy and subsequent laparotomy revealed multiple small solid tumors across the whole small bowel. An oncologic resection was not feasible due to the insufficient length of the remaining small bowel. Only a small segment of ileum, which included the largest tumors causing the intussusception, was resected. The pathologic examination revealed two intestinal malignant melanoma lesions. A systematic clinical examination, endoscopic procedures, and fluorodeoxyglucose positron emission tomography-computed tomography scan all failed to reveal any indication of cutaneous, anal, or retinal melanoma. Hence, the tumor was classified as a primary intestinal malignant melanoma with multiple intestinal metastases. Since a complete oncologic resection of tumors was not possible, in order to prevent future intestinal obstruction, a surgical resection of the largest lesions was performed with palliative intention. The epidemiology, clinical manifestations, diagnosis and management of primary intestinal malignant melanoma, and intestinal intussusception in adults are discussed along with a review of the current literature.

Coincidence between malignant perivascular epithelioid cell tumor arising in the gastric serosa and lung adenocarcinoma

A 4-mo history of both epigastralgia and back pain was presented in a 39-year-old male. Computed tomography showed right lung nodule and abdominal mass attached to the gastric wall, measuring approximately 30 mm and 70 mm in diameter. Since biopsy samples from the lung and abdomen revealed poorly differentiated adenocarcinoma and malignant tumor, clinicians first interpreted the abdominal mass as metastatic carcinoma, and a right lower lobectomy with following resection of the mass was performed. Gross examination of both lesions displayed gray-whitish to yellow-whitish cut surfaces with hemorrhagic and necrotic foci, and the mass attached to the serosa of the lesser curvature on the gastric body. On microscopic examination, the lung tumor was composed of a proliferation of highly atypical epithelial cells having abundant eosinophilic cytoplasm, predominantly arranged in an acinar or solid growth pattern with vessel permeation, while the abdominal tumor consisted of sheets or nests with markedly atypical epithelioid cells having pleomorphic nuclei and abundant eosinophilic to clear cytoplasm focally in a radial perivascular or infiltrative growth pattern. Immunohistochemically, the latter cells were positive for HMB45 or α-smooth muscle actin, but the former ones not. Therefore, we finally made a diagnosis of malignant perivascular epithelioid cell tumor (PEComa) arising in the gastric serosa, combined with primary lung adenocarcinoma. Furthermore, small papillary carcinoma of the thyroid gland was identified. The current case describes the coincidence of malignant PEComa with other carcinomas, posing a challenge in distinction from metastatic tumor disease.

Intracranial multiple germ cell tumors: a case report and review of literature

Intracranial multiple germ cell tumors (GCTs) are rare. In this article, we reported a case of intracranial multiple GCTs in an 18-year-old boy with symptoms of psychosis for 8 months also. Tumors in the pineal, sellar region, corpus callosum, bilateral lateral ventricles and fourth ventricle were confirmed by enhanced magnetic resonance imaging (MRI) and stereotactic biopsy. Immunohistochemical analysis results demonstrated that the tumor cells were positive for CD117 and placental alkaline phosphatase (PLAP). The patient was treated by radiotherapy and the prescribed radiation doses were 18 Gy. After near 24 months of follow-up, no local recurrence and distant metastasis has been found.

Synchronous poorly-differentiated neuroendocrine carcinoma and gastrointestinal stromal tumor of the stomach: a case report with immunohistochemical and molecular genetic analyses of KIT and PDGFRA

Although the stomach is the most common location for gastrointestinal stromal tumor (GIST) with co-primary tumors, the synchronous appearance of a poorly differentiated neuroendocrine carcinoma (NEC) and GIST in the stomach is extremely rare. To the best of our knowledge, this is the first case of gastric GIST coexisting with gastric NEC to be reported in the literature. The current study reports the case of a 71-year-old male with gastric poorly differentiated NEC and GIST discovered incidentally during surgical treatment of the NEC. Immunohistochemistry analysis showed that the NEC tumor cells were positive for CK (cytokeratin), CD57, synaptophysin, chromogranin, CD117 (KIT protein), Dog-1 (discovered on GIST-1 protein) and CD34. The synchronous GIST immunophenotype showed positivity for CD117, Dog-1 and CD34 (100%), whereas staining for CK, SMA, desmin and S100 was negative. Ki-67 labeling of proliferating cells was 90% in NEC and 1% in GIST. An accurate diagnosis was confirmed by immunohistochemical findings. Furthermore, genetic analysis using PCR direct sequencing identified no mutations in the KIT (exons 9, 11, 13 and 17) and PDGFRA (exons 12 and 18) genes. The patient developed lymph node metastases and underwent cisplatin-based chemotherapy after the operation. This is the first documented case of synchronous gastric GIST and NEC with the examination of protein expression and gene mutations in KIT and PDGFRA, which will help to further understand the etiology and pathogenesis of NEC coexisting with GIST in a gastric location.

A colonization of basal cell carcinoma by malignant melanoma in situ resembling a malignant basomelanocytic tumor

We report a case of colonization of basal cell carcinoma (BCC) by malignant melanoma in situ (MIS) simulating a malignant basomelanocytic tumor. A biopsy of a pigmented lesion present on an 83-year-old man's scalp displayed intimate admixing of basaloid and melanocytic cells. This seemingly inseparable combination of BCC and neoplastic melanocytes has been referred to as a malignant basomelanocytic tumor. However, our case also displays an adjacent component of MIS, thus favoring colonization of BCC by MIS as the etiology. To our knowledge, this is the third case report of colonization of BCC by MIS resembling a malignant basomelanocytic tumor.

Multicentric study on ¹⁸F-FDG-PET/CT breast incidental uptake in patients studied for non-breast malignant purposes

AIM

Our study has aimed to establish the prevalence and pathological nature of fluorine-18-fluorodeoxyglucose ((18)F-FDG) breast incidental uptake (BIU) in patients studied for non-malignant breast tumours and then to compare our data obtained in three Italian nuclear medicine centres with those available in literature.

MATERIAL AND METHODS

We retrospectively evaluated 42,927 (18)F-FDG-PET/CT scans performed on patients studied in three Italian Nuclear Medicine Centres. All patients underwent (18)F-FDG-PET/CT for oncologic purposes not related to breast disease.

RESULTS

Among 42,927 scans, a BIU was identified in 79 (0.18%) patients, 75 (95%) female and 4 (5%) male with an average age of 62 ± 17 years. Twenty-five out of 35 (71.5%) BIUs were malignant and 10/35 (28.5%) benign. Among the 25/35 incidentalomas that were malignant, 12/25 (48%) were infiltrating ductal carcinoma, 5/25 (20%) ductal carcinoma (infiltrating and in situ), 4/25 (16%) lobular carcinoma, 2/25 (8%) ductal carcinoma in situ and 2/25 (8%) were metastases from the primary tumour under investigation. Of the 10 BIUs that were benign in the histological examination, after further investigations it was found that 9/10 (90%) were fibroadenomas and 1/10 (10%) was a benign lesion not better specified. The lesion to liver or to blood-pool SUVmax ratio in malignant lesions is significantly higher than in benign ones.

CONCLUSIONS

Our multicenter study demonstrates that, although they are uncommon, BIUs show a high percentage of malignancy and therefore requires further research.

Malignant combined squamomelanocytic tumor: a clinical case

A combined squamomelanocytic tumor is an exceedingly rare occurrence; little is known about its pathogenesis. A definitive diagnosis can only be made via histological examination. We describe herein an 83 year-old man who was discovered to have this combined tumor and recommend the appropriate management for such a lesion.

An invasive extragastrointestinal stromal tumor curably resected following imatinib treatment

Extragastrointestinal stromal tumors (EGISTs) are rare tumors located outside the gastrointestinal tract. While curable resection is accepted as a noninvasive EGIST treatment, the therapeutic strategy for invasive EGISTs has not yet been established. The present report is the first to show a case of invasive EGIST completely resected after downsizing the tumor with imatinib treatment. A 69-year-old female had multiple masses adjacent to the stomach and ileocecum. The primary lesion measured 18 cm in size and had invaded the stomach, pancreas and liver. The histological findings of fine-needle aspiration samples revealed a proliferation of dysplastic spindle cells that exhibited immunoreactivity for anti-c-kit antibodies. The masses were therefore diagnosed as multiple GISTs with invasion to other organs, with origin difficult to determine at the time. Nineteen months after the imatinib treatment, the tumors were downsized and distinct from the stomach, pancreas and liver. Accordingly, the tumors were regarded to be EGISTs derived from the mesentery. Because they slightly regressed 26 months after treatment, surgery was applied to remove the EGISTs. The intraoperative findings showed no invasive signs, and the tumors were completely removed. The histological findings revealed the presence of dysplastic and c-kit-positive spindle cells in the tumor with an MIB-I index of more than 5%, resulting in a final diagnosis of high-risk EGIST derived from the mesentery. No recurrence was detected for 16 months after resection. In conclusion, preoperative treatment with imatinib followed by curable resection is a feasible option to cure invasive EGISTs.

A case of rapidly progressing leiomyosarcoma combined with squamous cell carcinoma in the esophagus

Esophageal leiomyosarcoma is a rare tumor that accounts for less than 1% of all malignant esophageal tumors. Esophageal leiomyosarcoma combined with squamous cell carcinoma is even rarer than solitary leiomyosarcoma. We experienced a case of leiomyosarcoma combined with squamous cell carcinoma that progressed very rapidly.

Synchronous pancreatic solid pseudopapillary neoplasm and intraductal papillary mucinous neoplasm

Solid pseudopapillary neoplasm (SPN) is a rare and low-grade malignant pancreatic neoplasm composed of poorly cohesive monomorphic neoplastic cells forming solid and pseudopapillary structures with frequent hemorrhagic-cystic degeneration. Intraductal papillary mucinous neoplasm (IPMN) is a pancreatic exocrine tumor composed of intraductal papillary growth of mucin containing neoplastic cells in the main pancreatic duct or its major branches. In the case presented here, a 53-year-old, Japanese man was found to have multiple cystic lesions and dilatation of the main pancreatic duct in the neck of the pancreas. Histological examination revealed a main-duct and branch-duct type IPMN, of the gastric-type, involving the neck of the pancreas, associated with a 0.5 cm SPN in the caudal side of the IPMN. We diagnosed this case as synchronous SPN and IPMN. As far as we know, only one other case of synchronous SPN and IPMN has been reported. Both the present case and the previously reported case showed abnormal nuclear expression of β-catenin in SPN, whereas IPMN showed no abnormal nuclear expression. These results suggest that β-catenin abnormality is not a common pathogenetic factor of synchronous SPN and IPMN.

Intraductal papillary neoplasm of the bile duct accompanying biliary mixed adenoneuroendocrine carcinoma

We present the first case of an intraductal papillary neoplasm of the bile duct (IPNB) accompanying a mixed adenoneuroendocrine carcinoma (MANEC). A 74-year-old woman presented with fever of unknown cause. Laboratory data revealed jaundice and liver injury. Contrast-enhanced computed tomography revealed a 20 mm polypoid tumor in the dilated distal bile duct, which exhibited early enhancement and papillary growth. Upper gastrointestinal endoscopy revealed mucus production from the papilla of Vater, characterized by its protruding and dilated orifice. Endoscopic ultrasonography visualized the polypoid tumor in the distal bile duct, but no invasive region was suggested by diagnostic imaging. Therefore, the initial diagnosis was IPNB. After endoscopic nasobiliary drainage, a pylorus-preserving pancreaticoduodenectomy was performed. Pathological examination of the resected bile duct revealed papillary proliferation of biliary-type cells with nuclear atypia, indicating pancreaticobiliary-type IPNB. In addition, solid portions comprised of tumor cells with characteristic salt-and-pepper nuclei were evident. Immunohistochemistry revealed expression of the neuroendocrine marker synaptophysin in this solid component, diagnosing it as a neuroendocrine tumor (NET). Furthermore, the MIB-1 proliferation index of NET was higher than that of IPNB, and microinvasion of the NET component was found, indicating neuroendocrine carcinoma (NET G3). This unique case of MANEC, comprising IPNB and NET, provides insight into the pathogenesis of biliary NET.

Synchronous adenocarcinoma and gastrointestinal stromal tumors in the stomach

AIM: To review the clinicopathological characteristics of concurrent gastrointestinal stromal tumors (GISTs) and gastric adenocarcinoma.

METHODS: We retrospectively analyzed eight cases of synchronous adenocarcinoma and GIST in the stomach that had been surgically resected with curative intent between March 2003 and December 2008 in Xinhua hospital and Ruijin hospital. The adenocarcinoma was determined to be the primary tumor based on the histological features. The GIST cells were diffusely and strongly positive for CD34 and CD117.

RESULTS: The patients were six men and two women aged 47-80 years (average, 68.6 years). GIST was preoperatively detected in only one patient. The average sizes of the gastric adenocarcinomas and GISTs were 6.000 ± 2.6186 cm and 1.825 ± 1.4370 cm, respectively. All GISTs were very low- or low-risk lesions that were detected during evaluation, staging, operation or follow-up for gastric adenocarcinoma.

CONCLUSION: We hypothesized that the stomach was influenced by the same unknown carcinogen, resulting in a simultaneous proliferation of different cell lines (epithelial and stromal cell).

Synchronous ovarian dysgerminoma and breast carcinoma in a patient with positive immunostain of BRCA1

Breast cancer is the most common malignant neoplastic process and the second cause of death for women. Ovarian cancer, despite having a lower incidence, represents an important cause of morbidity and mortality because it is usually discovered in advanced stages. The presence of both forms of cancer in a patient is associated with a high risk of BRCA1 gene mutations, which are responsible, together with BRCA2 gene mutations, for most of the breast and ovarian cancer family. Our case is special because it presents a synchronous and a rare association of a primary ovarian dysgerminoma (with an incidence of less than 1% of ovarian cancers) and a primary breast carcinoma in a patient of 46 years old. Immunohistochemical examination was performed using a panel of five biomarkers: oestrogen receptor, progesterone receptor, Herceptest, p53 and BRCA1. In our case, we identified a negative hormonal status and the absence of HER2/neu expression but a positive immuno-expression for p53 protein and BRCA1 protein. Postoperative course was favourable for the patient after each surgery, and she was discharged with the recommendation to perform a genetic counselling.

A prospective study of the utility of magnetic resonance imaging in determining candidacy for partial breast irradiation

PURPOSE

Retrospective data have demonstrated that breast magnetic resonance imaging (MRI) may change a patient's eligibility for partial breast irradiation (PBI) by identifying multicentric, multifocal, or contralateral disease. The objective of the current study was to prospectively determine the frequency with which MRI identifies occult disease and to establish clinical factors associated with a higher likelihood of MRI prompting changes in PBI eligibility.

METHODS AND MATERIALS

At The University of Chicago, women with breast cancer uniformly undergo MRI in addition to mammography and ultrasonography. From June 2009 through May 2011, all patients were screened prospectively in a multidisciplinary conference for PBI eligibility based on standard imaging, and the impact of MRI on PBI eligibility according to National Surgical Adjuvant Breast and Bowel Project protocol B-39/Radiation Therapy Oncology Group protocol 0413 entry criteria was recorded. Univariable analysis was performed using clinical characteristics in both the prospective cohort and in a separate cohort of retrospectively identified patients. Pooled analysis was used to derive a scoring index predictive of the risk that MRI would identify additional disease.

RESULTS

A total of 521 patients were screened for PBI eligibility, and 124 (23.8%) patients were deemed eligible for PBI based on standard imaging. MRI findings changed PBI eligibility in 12.9% of patients. In the pooled univariable analysis, tumor size ≥ 2 cm on mammography or ultrasonography (P=.02), age <50 years (P=.01), invasive lobular histology (P=.01), and HER-2/neu amplification (P=.01) were associated with a higher likelihood of MRI changing PBI eligibility. A predictive score was generated by summing the number of significant risk factors. Patients with a score of 0, 1, 2, and 3 had changes to eligibility based on MRI findings in 2.8%, 13.2%, 38.1%, and 100%, respectively (P<.0001).

CONCLUSIONS

MRI identified additional disease in a significant number of patients eligible for PBI, based on standard imaging. Clinical characteristics may be useful in directing implementation of MRI in the staging of PBI candidates.

The molecular and clinicopathologic characteristics of bilateral breast cancer

In this study, we compared the clinicopathologic characteristics between the bilateral breast cancer (BiBC) and unilateral breast cancer (UBC) and investigated the role of CXC chemokine receptor type 4 (CXCR4) in BiBC. 48 BiBC and 1650 UBC were studied. We found BiBC patients were associated with family history of cancer, invasive lobular histology in the first tumor and an advanced nodal status as compared with UBC patients with. Survival analysis indicated that BiBC was not associated with impaired survival. The time interval between the development of first breast cancer and the contralateral cancer did not correlate with the prognosis. Patients with BiBC were more likely to have bone metastasis (P = 0.011) and visceral metastasis (P < 0.001) than those with UBC. However, CXCR4 was not found in any association with poor clinical outcome and increasing visceral metastasis in BiBC patients.

Collision tumour involving a rectal gastrointestinal stromal tumour with invasion of the prostate and a prostatic adenocarcinoma

BACKGROUND

Gastrointestinal stromal tumours (GISTs) are the most common primary mesenchymal neoplasia in the gastrointestinal tract, although they represent only a small fraction of total gastrointestinal malignancies in adults (<2%). GISTs can be located at any level of the gastrointestinal tract; the stomach is the most common location (60-70%), in contrast to the rectum, which is most rare (4%). When a GIST invades into the adjacent prostate tissue, it can simulate prostate cancer. In this study, we report on a case comprising the unexpected collision between a rectal GIST tumour and a prostatic adenocarcinoma.

FINDINGS

We describe the complexity of the clinical, endoscopic and radiological diagnosis, of the differential diagnosis based on tumour biopsy, and of the role of neoadjuvant therapy using imatinib prior to surgical treatment.

CONCLUSIONS

Although isolated cases of coexisting GISTs and prostatic adenocarcinomas have previously been described, this is the first reported case in the medical literature of a collision tumour involving a rectal GIST and prostatic adenocarcinoma components.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1238437468776331.

Tumor-to-tumor metastasis: pathology and neuroimaging considerations

The phenomenon of tumor-to-tumor metastasis has been reported in the literature for over a century. However, it remains fairly uncommon, with fewer than 100 cases being described during that time. Virtually any benign or malignant tumor can be a recipient, but meningiomas have been implicated as the most common intracranial neoplasm to harbor metastasis. The donor neoplasm is most frequently lung or breast carcinoma, while rare cases of metastasis from other primary tumors have been reported. We report here three examples of such rare metastases. This case series reports the first documented instance involving rectal adenocarcinoma. In addition, we report two cases of metastatic prostate adenocarcinoma to a meningioma; to date of which only three cases have been published. The terms "tumor-to-tumor metastasis" and "collision tumor" are addressed, as are details of the pathology. The limitations of standard radiological imaging techniques, such as standard CT and MR, which cannot reliably identify the presence of metastasis within a meningioma are compared with physiology-based neuroimaging methods, such as perfusion MR and MR spectroscopy, which may be more useful in noninvasively differentiating tumor histology.

Myopericytoma presenting as multiple pulmonary nodules

Myopericytoma is a benign tumor composed of cells that show apparent differentiation towards putative perivascular myoid cells called myopericytes. To date, only a small number of series describing myopericytomas have been reported. Here, we report a case of pulmonary myopericytoma presenting as multiple nodules in a 26-year-old man. Clinical presentation, radiological features and histopathologic findings of the patient are also discussed. The result of the histology combined with the immunohistochemical analysis led to a diagnosis of myopericytomas. To our knowledge, this is the first report of myopericytoma showing pulmonary involvement.

Evaluation of MMP-1, MMP-10, TIMP-1, a-SMA and TGF-b1 in angiofibromas of tuberous sclerosis

AIM

Tuberous sclerosis is a neurocutaneous syndrome characterized by affect multiple organs such as brain, kidneys, heart, eyes, lungs and skin. The aim of this study was to analyze the pattern of immunolocalization of markers MMP-1, MMP-10, TIMP-1, α-SMA and TGF-β1 in oral and facial angiofibromas in individuals affected by tuberous sclerosis.

METHODS

Microscopical analyses on hematoxilin-eosin and immunohistochemistry reactions were performed to analyze the previously cited biological markers pattern in orofacial angiofibromas.

RESULTS

Reactivity was observed for MMP-1, MMP-10 and TGF-β1, in addition to negative for TIMP-1 and α-SMA, except perivascular and epithelial staining for this. Concerning the intensity, a strong marking for MMP-1 in the basal layer of the epithelium, and a slight positivity in the suprabasal layers predominated. MMP-10 was slightly expressed in all epithelial layers. The connective tissue showed slight to moderate reactivity for MMP-1 and MMP-10. TIMP-1 demonstrated slight to moderate marking in the various layers of a single lesion and to TGF-β1 expression showed varied in intensity staining both between lesions and between tissue layers.

CONCLUSION

MMP-1, MMP-10 and TGF-β1 exhibited reactivity in oral and cutaneous angiofibromas with heterogeneous distribution patterns among both tissue elements analyzed in the intensity of marking the same among the specimens. TIMP-1 showed reactivity predominantly negative in the specimens analyzed and α-SMA presented restricted to epithelial and perivascular regions of these lesions.

Retinoblastoma and retinal astrocytoma: unusual double tumor in one eye

Retinoblastoma is the most common intraocular neoplasm in children. Glial tumor of the retina and optic nerve head are considered to be congenital and are therefore classified as hamartomas. Concurrent occurrence of these tumors in one eye is uncommon and by reviewing the studies, a few cases have been reported. We report a 9 years old boy with eye enucleation and concurrent occurrence of retinoblastoma and astrocytoma in one eye as two separate and different masses. Although retinoblastoma and astrocytoma are two distinct tumors and their concurrent occurrence in one eye is rare, concurrent occurrence of these tumors may suggest differentiation of these two tumors from a neuroectodermal primary cell.

Infundibulomatosis: a case report with immunohistochemical study and literature review

Tumor of the follicular infundibulum was first described in 1961 by Mehregan and Butler in a patient presenting with multiple papules. It is more frequent, however, as an isolated lesion affecting mainly the face, neck, and upper trunk. Clinical presentation is variable, requiring histology for the diagnosis, which reveals typically a plate-like proliferation of keratinocytes in continuity with the epidermis and hair follicles; some morphological features are reminiscent of the outer root sheath of the hair follicle. A well defined network of elastic fibers surrounding the tumor is usually present using the appropriate staining and this finding is specific because it is not found in other benign follicular tumors. Multiple infundibulomas are usually sporadic and there is no apparent association with internal malignancy. The authors report the case of a 30-year-old female patient with a 5-year history of multiple small discrete hypopigmented macules and papules, scattered over the submental and submaxillary regions and anterior neck. Histopathological findings were consistent with the diagnosis of tumor of the follicular infundibulum. Immunohistochemical study was performed to further characterize the proliferation.

[Concomitant presence of a gastric adenocarcinoma and gastrointestinal stromal tumor: report of one case]

The concomitant presence of a primary gastric adenocarcinoma and a gastrointestinal stromal tumor in the stomach is uncommon. We report a 68-year-old male with an advanced gastric adenocarcinoma. During gastrectomy, a nodular intramural lesion was found. The pathological study, revealed a gastrointestinal stromal tumor, positive form CD117. After six months of follow up, there is no evidence of recurrence of either tumor).

Oligodendroglioma arising in an immature ovarian teratoma: case report

We describe the case of an 18-year-old girl with an oligodendroglioma arising in an immature ovarian teratoma. The oligodendroglioma, which closely involved the cystic teratoma, was moderately cellular, composed of monomorphic cells with uniform round nuclei and perinuclear halos with a characteristic "fried-egg" appearance. Rare microcalcifications and a dense network of branching capillaries with a chicken-wire appearance were also observed. By immunohistochemistry, tumour cells showed positivity for S-100, but were negative for GFAP, synaptophysin and neuro-specific enolase. The patient is free of disease on follow-up examination at 24 months.

P53 expression in synchronous colorectal cancer

OBJECTIVE

We reviewed cases of primary colorectal adenocarcinoma to document synchronous colon and rectum adenocarcinoma (SCRC).

METHODS

In a retrospective setting, 764 cases underwent surgical resection for primary colorectal adenocarcinoma and referred to the Department of Surgical Pathology, Uludag University, Medical Faculty for diagnoses between 1997 and 2006, were reviewed. Tumor site, depth of invasion, coexistence of adenoma, distance between these multiple primary tumors, degree of p53 expression, and p53 expression pattern indicating polyclonal or monoclonal origins were noted in order to establish a possible effect on prognosis.

RESULTS

There were 28 cases with SCRC of colon and rectum. Nine cases were female, 19 cases were male (female to male ratio was 1:2). Most of the cases were within the 5th and the 6th decades. There were statistically significant relationships between p53 expression and differentiation status (p=0.001), and invasion depth (p=0.03). Forty of 62 colorectal carcinomas showed immunohistochemical positivity for p53. Six cases showed a discordant pattern of p53 mutation among individual lesions indicating polyclonal origin.

CONCLUSION

Synchronous colon and rectum adenocarcinoma is not rare. The incidence is 3.6% in our series. We believe that further studies with larger series are needed for p53 to prove useful in predicting prognosis of SCRCs and assessing the polyclonal origin of SCRC at a genetic level.

Multifocal granular cell tumors of the gastrointestinal tract: Immunohistochemical findings compared with those of solitary tumors

Granular cell tumors (GCT) are infrequently found in the gastrointestinal tract (GIT), and only four previous reports have described lesions occurring simultaneously in different sites. The present case of 11 GCT, located in the esophagus, stomach, colon and pericolic adipose tissue, occurred in a 50-year-old Japanese woman. All GCT appeared histologically benign and there was no sign of recurrence at 3 years after surgery. Immunohistochemical analysis and comparison between this case of multifocal GCT and six cases of solitary benign GCT of the GIT, which were taken from the files of the Department of Pathology at Kitasato University (1986-2000), demonstrated the follow-ing: (1) all diffusely expressed S-100, DCC and bcl-2, and (2) median labeling indices for Ki-67, cyclin D1, p53 (Pab1801), and p21WAF1/CIP1 of 4%, 24%, 1% and 28%, respectively, for the multifocal tumors, and 3.5%, 23%, 1% and 29%, respectively, for the solitary lesions, with no significant difference between the two groups. Thus, the expression of cyclin D1 and p21WAF1/CIP1 may be involved in the tumorigenesis of both types of GCT. The present case emphasizes the need to evaluate the entire GIT when a single GCT is identified. Multifocal lesions should be treated conservatively by local excision because, as with the solitary tumors, they exhibit a benign biological behavior, consistent with their low Ki-67 immunoreactivity.

Primary pleural thymoma with coexistent incidental small hepatocellular carcinoma – An autopsy case report with brief review of literature

Primary pleural thymomas are rare tumors often mistaken for malignant mesothelioma clinically and radiologically. An autopsy case report of primary pleural thymoma associated with a coincidental small hepatocellular carcinoma is presented. This case is reported because of the rarity of pleural thymoma and the coincidental finding of a small hepatocellular carcinoma in a non-cirrhotic background. The literature on these two tumors has been reviewed.