Exophytic Component Research Articles

Bronchial Sialadenoma Papilliferum in a 10-Year-Old Boy.

Sialadenoma papilliferum (SP) is a rare salivary gland tumor mostly reported in the oral cavity. Here we describe a bronchial SP in the left upper lobe bronchus of a 10-year-old boy. At bronchoscopy, a well-circumscribed polypoid lesion protruding into the bronchial lumen was identified. The tumor was excised, but eventually, the patient had to undergo a sleeve resection after 2 recurrences. Pathology revealed a papillocystic lesion with exophytic and endophytic components. The cells lining the exophytic surface and papillary structures were columnar and squamous, and the cells lining endophytic cystic and papillary structures were cuboidal to columnar, all of which were diffusely reactive with antibodies to SOX10 protein. The presence of basal cells was demonstrated by p63 immunoreactivity. The cells failed to immunohistochemically express BRAF V600E. Fluorescence in situ hybridization analysis revealed no MAML2 or RET gene rearrangement. The patient is alive 24 years after resection with no additional recurrences. Bronchial SP needs to be recognized and distinguished from other benign and malignant salivary gland and pulmonary neoplasms so that patients can receive appropriate treatment and follow-up.

A subepithelial lesion algorithm for endoscopic (SAFE) resection in the upper gastrointestinal tract.

Complete excision of upper gastrointestinal subepithelial lesions (U-SELs) eliminates diagnostic uncertainty, obviates the need for surveillance, and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. We describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection. U-SELs were enrolled prospectively over 115 months until March 2023. All subjects underwent axial (computed tomography) imaging and endoscopic ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria (MP) involvement. 106 U-SELs (41 esophageal, 65 gastric) were resected (mean patient age 60.6 [SD 13.4]; 51.9% male). Esophageal U-SELs underwent endoscopic submucosal dissection (ESD; n = 22) or submucosal tunneling endoscopic resection (STER) if MP involvement was suspected (n = 19). Gastric U-SELs underwent STER (n = 6 at cardia), ESD (n = 47), or exposing endoscopic full-thickness resection (e-EFTR; n = 12). Technical success rates were 97.6% and 92.3%, respectively. Among the noncardiac gastric U-SELs, five resections (9.6%) were completed laparoscopically owing to deep and broad full-thickness involvement; five (9.6%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure owing to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation, or recurrence at 13 months. U-SELs may be effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Esophageal U-SELs suspected of involving the MP should undergo STER. Gastric SELs are best managed by ESD, with a view to proceeding to e-EFTR. A laparoscopic upper gastrointestinal surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

Nondysraphic Intramedullary Spinal Cord Lipomas in the Adult Population

ObjectiveIntramedullary spinal cord lipomas without spinal dysraphism are rare. Although they are benign tumors, they can cause significant neurological deficits. Their tight adherence to the spinal cord presents a challenge for resection. Therefore, we review our institutional experience treating adult patients with intramedullary lipomas in the absence of dysraphism and report long-term outcomes after resection. MethodsAll adult patients undergoing resection of intramedullary spinal cord lipomas at a comprehensive cancer center between June 2011 and June 2023 were retrospectively identified. Patients with spinal dysraphism or extramedullary lipomas were excluded. Patients were included if they had microscopic surgical debulking with tissue sampling confirming the diagnosis. ResultsSix patients were identified with a mean age of 35.0±11.5 years and 67% were female. Four cases localized to the thoracic spine. Symptoms included pain, numbness, and lower extremity motor weakness; only one patient reported bowel and bladder dysfunction. All patients experienced transient neurological decline in the immediate post-operative period. Five recovered to independent ambulation at long-term follow-up, including one recovering to full strength. One patient required a repeat resection after four years due to tumor progression and functional decline. Tumor progression was not recorded in the other patients. ConclusionsSubtotal resection is a safe and effective treatment. Detethering of the spinal cord, resection of exophytic components, and tumor debulking can improve symptoms and prevent further deterioration in most cases. The resection can be assisted using a laser to vaporize the fatty tissue of the lipoma without physical manipulation of the spinal cord.

Mucinous cystic neoplasm of the liver: A rare case report

Mucinous cystic neoplasm of the liver is a rare cystic neoplasm accounting for approx. 5% of cystic liver in the liver parenchyma. We describe the histomorphology and immunophenotyping features of MCN-L in a 52-year-old woman who came to the surgical department with complaints of pain abdomen for 1.5 months. The ultrasonography showed a septated cyst located centrally in the liver. The CT abdomen showed a large hypodense multiloculated cystic lesion in the liver with thin enhancing septae and multiple small cysts involving the entire left lobe with extension into the right lobe and having a large infra-hepatic exophytic component. A provisional diagnosis of a Hydatid cyst was made. Drainage of the cyst with laparoscopic deroofing was done. Histopathology examination showed a cyst lined by cuboidal to columnar epithelium with mucinous cytoplasm and basally oriented nuclei. Subepithelium shows ovarian-like stroma. MCN-L has a lower frequency as compared to the counterpart of MCN in the pancreas, and further molecular studies are necessary to clarify the biology of MCN-L. The relevance of this rare entity's clinical and radiological suspicion, histological recognition and immunohistochemistry is emphasised.

Ultrasound diagnostics: assessment of tumor thickness and depth of invasion in squamous cell carcinoma of the oral cavity

Aim. To evaluate the capabilities of ultrasound using various approaches in determining the depth of invasion of squamous cell carcinoma of the oral cavity and to compare the results obtained with data obtained by the use of other diagnostic methods. Materials and methods. In our reserch, ultrasonography was performed on 193 patients with primary malignant tumors of the mobile part of the tongue, floor of the oral cavity and tumors of rare locations (mucous membranes of the lip, cheek, alveolar processes). The age of the patients ranged from 15 to 85 years. In all patients, tumors were squamous cell carcinoma. ultrasound was performed using submandibular, intraoral and transbuccal approaches. ultrasonic data were compared with the results of pathomorphological examination, as well as of X-ray computed tomography and of magnetic resonance imaging with contrast. Results. A statistically significantly high correlation was obtained for all ultrasound approaches (submandibular, intraoral and transbuccal) with the depth of invasion of the oral tumor determined pathomorphologically (r = 0.78; r = 0.89; r = 0.93; p <0.001). Ultrasound using all approaches shows statistically significantly better results in determining the thickness of tumorsof the tongue and mouth floor in comparison with X-ray computed tomography and magnetic resonance imaging (p <0.001). All diagnostic methods are characterized by an overestimation of the tumor invasion depth (overdiagnosis) as compared with pathomorphological examination. for exophytic tumors and oral cavity tumors of mixed growth with an exophytic component, the depth of invasion was less than the tumor thickness. Conclusion. Ultrasound is an accessible, easily reproducible, radiation-free method, the resolution of which makes it possible to accurately determine not only the depth of invasion of oral tumors, but also the distance from the tumor to the midline of the tongue, that represents an important information when choosing the extent of surgical intervention.

Sialadenoma papilliferum-like intraductal papillary tumour: an emerging entity with intercalated duct differentiation showing MAPK pathway activation in both ductal and myoepithelial cells

Sialadenoma papilliferum-like intraductal papillary tumour (SP-IPT) is a recently described salivary gland tumour that shows identical morphology to sialadenoma papilliferum (SP) except for the lack of an exophytic papillary component. However, the immunohistochemical phenotypes and molecular profiles of SP-IPT remain unclear. This study aims to report new cases of SP-IPT and to determine its cellular differentiation and molecular basis. After histopathological review, four cases of SP-IPT were retrieved. Immunohistochemical staining was performed to analyse the expression patterns of cytokeratin 7 (CK7), p63, smooth muscle actin (SMA), vimentin, S100, mammaglobin, androgen receptor, SOX10, BRAF V600E-mutated protein, and phosphorylated ERK. Sanger sequencing was performed to determine the mutation status of the BRAF, KRAS, NRAS, and HRAS genes. All four cases affected the posterior mandible with a mean age of 62 years and a male-to-female ratio of 3:1. Histologically, all cases consisted of multiple tubular and cystic structures with varying sizes and shapes. The tubulocystic components were lined by a double or few-layered epithelium frequently showing a micropapillary pattern. The outer layer consisted of a rim of myoepithelial cells, which were CK7+/p63+/SMA+/vimentin+/S100+/SOX10+. The inner ductal cells were CK7+/S100+/SOX10+, consistent with intercalated duct differentiation. All cases harboured BRAF V600E mutations, but no other mutations were detected. The BRAF V600E-mutated protein and phosphorylated ERK were expressed in both ductal and myoepithelial cells. These findings demonstrate the immunohistochemical and molecular similarities between SP-IPT and SP and the role and extent of MAPK pathway activation in the pathogenesis of SP-IPT.

Rare Intraosseous Cavernous Hemangioma of the Orbit

A healthy 52-year-old man presented with a painless, enlarging, right lateral orbital nodule of 1-year duration (A, arrow). Clinical examination revealed a 2.3-cm firm immobile lateral orbital rim mass. Computed tomography displayed an expansile and osteolytic neoplasm of the zygoma with orbital and extraorbital extension (B). Lateral orbitotomy exposed a porous neoplasm of the anterior zygomatic face (C). The exophytic component was resected, and histopathological examination demonstrated multiple, dilated, blood-filled cavities between bony trabeculae, consistent with a benign intraosseous cavernous hemangioma (D). Orbital intraosseous cavernous hemangiomas are rare, and malignancy should be ruled out in the setting of a progressive osteolytic neoplasm (Magnified version of Figure A-D is available online at www.aaojournal.org/).

Successful management of a rare case of gallbladder neuroendocrine carcinoma with tumor thrombi.

A gallbladder neuroendocrine neoplasm (GB‑NEN) is a bizarre heterogeneous neoplasm arising from neuroendocrine cells, which are present in minimal amounts on the GB mucosa either due to conversion of undifferentiated stem cells, chronic inflammation and resulting in pathological metaplasia or switching of GB adenocarcinoma to neuroendocrine one. Among all the GB malignancies, GB-NEN accounts for approximately 2.1%. A 41-year-old lady presented with right upper abdomen pain and distension for 2weeks. Contrast CT showed heterogeneously enhancing wall thickening involving fundus-body of the GB with large exophytic component involving segments IV/V of liver, peripheral enhancement and central low attenuating necrotic areas. Middle hepatic and left branch of portal vein was filled with enhancing lesion, tumor thrombi. She underwent left trisectionectomy followed by adjuvant chemotherapy. Postoperative biopsy reported as poorly differentiated unifocal small cell GB-neuroendocrine carcinomas (GB-NEC). Resected margins were free of tumor with periportal lymph nodes negative for tumor. Follow-up PET-CT after six months of treatment completion shows no tumor recurrence or metastases. She has completed 12months following the surgery and is asymptomatic. As the occurrence of GB-NEC is rare, there are little data regarding etiology, pathogenesis, treatment and prognosis of it. Even though metastasis is early and most frequent to lymph nodes, liver, lung and peritoneum, the presence of tumor thrombus in GB-NEC is rarely reported. Though most reports suggest very poor outcomes, radical surgery followed by adjuvant chemotherapy can yield good short-term results as seen in this case.

A new surgical technique for sutureless partial nephrectomy: renal sutureless device.

Several factors impact the preservation of renal function after partial nephrectomy. Warm ischemia time is the main modifiable surgical factor. Renorrhaphy represents the key of hemostasia, but it is associated with increase of warm ischemia time and complications. The aim of this study was to describe our initial surgical experience with a new surgical technique for sutureless partial nephrectomy, based on the application of our own developed renal-sutureless-device-RSD. Between 2020-2021, 10 patients diagnosed with renal cell carcinoma stage cT1a-b cN0M0 with an exophytic component were operated using renal-sutureless-device-RSD. Surgical technique of sutureless partial nephrectomy with renal-sutureless-device-RSD is described in a step-by-step fashion. Clinical data was collected in a dedicated database. Presurgical, intraoperative, postoperative variables, pathology and functional results were evaluated. Medians and ranges of values for selected variables were reported as descriptive statistics. Partial nephrectomy was carried out with the use of renal-sutureless-device-RSD without renorrhaphy in all cases (70%cT1a-30%cT1b). Median tumor size was 3.15 cm (IQR: 2.5-4.5). R.E.N.A.L Score had a range between 4a-10. Median surgical time was 97.5 minutes (IQR 75-105). Renal artery clamping was only required in 4 cases, with a median warm ischemia time of 12.5 minutes (IQR 10-15). No blood transfusion, intraoperative and postoperative complications were noted. Free-of-disease margin rate achieved was 90%. Median length of stay was 2 days (IQR 2-2). Laboratory data on hemoglobin and hematocrit levels, as well as renal function tests, remained stable after partial nephrectomy. Our initial experience suggests that a sutureless PN using the RSD device is feasible and safe. Further investigation is needed to determine the clinical benefit of this technique.

Polypoid melanoma is associated with aggressive histopathological characteristics and poor clinical prognosis: A retrospective cohort study

To the Editor: Polypoid melanoma is a rare growth pattern of melanoma characterized by a pedunculated exophytic component. Most polypoid melanomas have a thick Breslow depth, which likely contributes to their poor prognosis.1,2 Of note, the most recent comprehensive study on polypoid melanoma was performed in 1986.2 There are currently no data to date to indicate if melanomas with a polypoid configuration should be managed differently than tumors of similar thickness and clinical stage in the era of modern treatment.

An Unusual Presentation of Primary Hepatic Lymphoma

Primary hepatic lymphoma (PHL) is a rare disease that usually manifests as a heterogenous solitary intrahepatic mass, multiple lesions or a diffuse infiltrative form. PHL presenting as a small focal area of hepatic involvement and a large predominant extrahepatic component is uncommon. We report a histopathologically proven case of primary hepatic lymphoma that caused significant diagnostic dilemma on contrast-enhanced computed tomography due to its unusual imaging appearance as a hypo-enhancing intra-abdominal solid mass with relatively small area of hepatic parenchymal involvement and a large exophytic component.

Mesenchymal tumors of the stomach: radiologic and pathologic correlation.

Mesenchymal tumors of the stomach are uncommon, with gastrointestinal stromal tumor (GIST) being the most common among them. Majority of the tumors may arise from cells of Cajal, smooth muscle cells, neural cells, totipotent stem cells, adipocytes or fibroblasts. Imaging plays an important role not only in staging but also in characterizing these tumors. Many of these tumors have characteristic imaging features. GISTs usually present as large cavitating and necrotic tumors with exophytic component. Presence of fat tissue within the tumor suggests a lipoma or a teratoma, early phase hyperenhancement indicates glomus tumor and hemangioma, and delayed contrast enhancement is seen in schwannoma. Their differentiation from epithelial tumors like carcinoma and neuroendocrine tumors is often possible based on the location (mesenchymal tumors are intramural), spread, morphological appearance and enhancement patterns. However, overlapping features exist between these tumors with imaging often being only suggestive. A biopsy is necessary for a definitive diagnosis in many cases.

The role of imaging features and resection status in the survival outcome of sporadic optic pathway glioma children receiving different adjuvant treatments.

Optic pathway glioma (OPG) is a rare brain tumor affecting children, with no standard treatment strategy. This study described the sporadic OPG survival outcomes after surgical treatment and analyzed the role of imaging features and resection status in children receiving different adjuvant treatments. This retrospective study included 165 OPG patients whose clinical information were obtained from the hospital record system. Tumor volume and residual tumor volume were calculated by delineating the lesion area. Kaplan-Meier method and Cox proportional hazards model were conducted to analyze the independent prognosis factor. A total of 165 patients were included in this study. Respectively, the 5-year overall survival (OS) and progression-free survival (PFS) were 87.58% and 77.87%. Residual tumor size and first adjuvant treatment (AT) after surgery were both associated with PFS. In patients with small-size residual tumors, there was no significant difference in PFS between the AT treatment groups. Moreover, age, exophytic cystic components, leptomeningeal metastases, and AT were associated with OS. In patients with exophytic cystic components and those with leptomeningeal metastases, there was no significant difference in OS. Our results revealed that OPG patients could avoid or defer AT by maximized resection. Age ≤ 2years was a disadvantageous factor for OS. Patients with exophytic cystic components were more likely to benefit from primary surgery, and CT or RT was not beneficial for these patients. Patients with leptomeningeal metastases had a poor prognosis regardless of the treatment they received. Future prospective clinical studies are needed to develop more effective treatment regimens.

Diagnostics, Treatment of Tumors of the Urinary Duct (Clinical Observations)

Despite low prevalence in the population, urachus tumors are of clinical interest because some of them may be malignant with a high degree of aggression. The most common malignant tumor of urachus is mucinous adenocarcinoma (MA). In the absence of reliable MA biomarkers, careful evaluation of clinical data is essential to determine the risk of its presence and radical treatment. The objective: a comparative analysis of complaints, symptoms, instrumental / imaging data and treatment results in patients with MA and benign tumor of the urachus. Materials and methods. We report three clinical cases of urachus tumors (2 malignant and 1 benign), which were detected among patients of the Institute of Urology of the National Academy of Medical Sciences of Ukraine for the period from 2016 to 2020. Standard preoperative examination of patients included: collection of complaints, medical history, physical examination (including palpation of the abdomen in the umbilical and hypogastral areas), general clinical laboratory tests, ultrasound, urethrocystoscopy with TUR biopsy (2 patients), imaging (CT in 2, MRI in 1). All patients underwent surgical treatment: laparoscopic removal of urachus with resection of the bladder within the “healthy tissues”. The postoperative follow-up period lasted from 1 to 33 months. Results. In 2 patients (man and woman) according to the results of pathohistological examination of the surgical material was detected MA, in 1 man – leiofibromyoma (LFM). MA was clinically manifested by macrohematuria – 2 (100%) and low back pain – 1 (50%). Pollakiuria and discomfort in the bladder area were observedIn case of LFM. Palpation did not allow to diagnose urachus tumor in any of the patients. On MRI scans, MA was defined as a soft tissue formation with uneven clear contours, with moderate enhancement by contrast, cystic component and calcification, located in the urachus area. On CT scans – as a heterogeneous neoplasm at the apex of the bladder with endo- and exophytic components. Instead, LFM was identified as a soft tissue formation (+34 .. +50 .. +70 units H) with predominantly endophytic growth, which accumulates contrast in the arterial and venous phases. At cystoscopy MA has the form of a papillary neoplasm in the area of the apex of the bladder on the type of “cauliflower”, while LFM has no papillary component. After laparoscopic removal of urachus with wedge-shaped resection of the bladder for a period of 1 to 33 months, cystoscopy did not reveal recurrence of tumors. Conclusions. In the absence of reliable biomarkers, clinical characteristics remain the only “tool” that can predict the risk of MA. Compared with benign tumors of urachus, the characteristic clinical signs of MA are: macrohematuria, exophytic growth, the appearance of “cauliflower” on cystoscopy, the presence of calcifications and cysts in the structure. Even with high aggression potential of MA (low-grade tumors), laparoscopic removal of urachus with resection of the bladder within the “healthy tissues” at an early stage can provide a fairly long recurrence-free period (up to 33 months). Further research is needed to develop MA biomarkers.

V11-08 CRYOTHERAPY-ASSISTED ROBOTIC PARTIAL NEPHRECTOMY: DESCRIPTION OF A NOVEL SELECTIVE ISCHEMIA TECHNIQUE

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-08 CRYOTHERAPY-ASSISTED ROBOTIC PARTIAL NEPHRECTOMY: DESCRIPTION OF A NOVEL SELECTIVE ISCHEMIA TECHNIQUE Eusebio Luna, Luanda Perez, Edward Gheiler, Ariel Kaufman, Dailianys Barrios, and Fernando Bianco Eusebio LunaEusebio Luna More articles by this author , Luanda PerezLuanda Perez More articles by this author , Edward GheilerEdward Gheiler More articles by this author , Ariel KaufmanAriel Kaufman More articles by this author , Dailianys BarriosDailianys Barrios More articles by this author , and Fernando BiancoFernando Bianco More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Warm or cold ischemia can be deleterious at the time of partial nephrectomy. Selective ischemia approaches have been proposed to ameliorate potential adverse events. Herein, we present a novel technique using cryoablation probes as means of selective ischemia at the time of robotic partial nephrectomy. METHODS: 11 patients participated in URN20-011 protocol between September and December 2020. Inclusion criteria called for renal tumors between 2.5 and 5 cm with an exophytic component and GFR greater than 45. The video shows the procedure conducted on a 77-year-old-male with a 4.2 cm mass. The mass is isolated, cryoprobes are placed at its base, upon freezing, enucleation takes place and the margins on the renal side are frozen as shown. RESULTS: Median surgical time and EBL for the 11 patients was 68’ and 80cc, respectively. One patient has a 500cc blood loss. The histological results are shown on the video. No transfusions were required. All patients were discharged at POD1. Two patients attended ER within 7 days, one was admitted for ileus. CONCLUSIONS: Cryotherapy-assisted partial nephrectomy is feasible and safe. Notwithstanding, longer follow up is necessary, pathological outcomes are encouraging. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e860-e860 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eusebio Luna More articles by this author Luanda Perez More articles by this author Edward Gheiler More articles by this author Ariel Kaufman More articles by this author Dailianys Barrios More articles by this author Fernando Bianco More articles by this author Expand All Advertisement Loading ...

Surgical considerations for maximal safe resection of exophytic brainstem glioma in the pediatric age group.

Background: Brainstem glioma is the leading cause of morbidity and mortality among all central nervous system tumors, especially in childhood as it represents about 20% of all pediatric brain tumors. Therefore, this study aimed to present our experience in a tertiary center in a developing country with limited resources for the surgical management of exophytic brainstem gliomas.Methods: This retrospective study included pediatric patients with brainstem (midbrain, pontine, or medullary) focal or diffuse gliomas whether low or high grade that had dorsal, ventral, or lateral exophytic component who were presented to our hospitals from January 2019 to January 2021. The patients’ data were collected, such as age, sex, preoperative and postoperative clinical condition, radiological data, surgical approach, extent of tumor removal, histopathology, follow-up period, and adjuvant therapy.Results: A total of 23 patients were included in this study. The telovelar approach was used in 17 patients, the supracerebellar infratentorial approach in three patients, and the retrosigmoid, transcerebellar, and occipital transtentorial approach once for each patient. Twenty patients underwent near-total excision, and three underwent subtotal excision. Two-thirds of our cases (17 patients) were low-grade gliomas, with the remaining one-third comprising entirely of either anaplastic astrocytoma (five patients) or glioblastoma multiforme (one patient). The follow-up period of the patients extended from 3 months to 24 months.Conclusion: Exophytic brainstem glioma surgery can result in good outcomes with minimal complications when near-total excision is attempted through a properly chosen approach and adherence to some surgical techniques and considerations.

Sialadenoma papilliferum: clinicopathologic, Immunohistochemical, molecular analyses of new five cases and review of the literature

BackgroundSialadenoma papilliferum (SP) is an extremely rare benign neoplasm of salivary glands. To explore and define the clinicopathological features of SP, we retrospectively analyzed 89 cases previously reported and five new cases.MethodsThe clinical features, histopathology, immunohistochemistry and molecular analysis of our cases were further performed and the related literatures were reviewed and analyzed.ResultsCombining 89 cases from the literature with our cases, the hard palate was the most common locations for SP. However, two of our cases were rarely located in the esophageal mucosa. Among all cases, the male gender was more affected, with the average age and median age of 61.8 and 62 years, respectively. Conventional histomorphologically, SP was characterized by complex papillary structures with a biphasic growth pattern of exophytic squamous component and endophytic glandular component. The glandular structures were lined by a double layer of epithelium composed of flattened or cuboidal basal cells and a cuboidal or columnar luminal cells formed papillary infoldings into the ductal lumina. Immunohistochemically, the luminal epithelial configurations showed strong expression of CK7 along the luminal cell membrane, while the basal myoepithelia displayed strong nuclear p63 expression. In both the glandular and squamous tumour components showed BRAF V600E-positive immunostaining and BRAF V600E mutation.ConclusionFor the first time, we have comprehensively aggregated and analyzed 90 cases sialadenoma papilliferum from almost all previous publications, and further explored the clinicopathological features of SP; concordantly, this study demonstrated that SP shows a papillomatous growth pattern with exophytic and endophytic proliferation of ductal epithelium composed of double-layered cells harboring BRAF V600E mutation. Additionly, adequate treatment for SP is surgical excision, with a favorable prognosis in patients.

A137 LAPAROSCOPIC ENDOSCOPIC COOPERATIVE SURGERY FOR GASTROINTESTINAL STROMAL TUMOURS: EARLY EXPERIENCE IN A CANADIAN ACADEMIC CENTRE

Abstract Background Surgical resection with laparoscopic gastric wedge resection is commonly conducted for local management of gastrointestinal stromal tumours (GIST). However, resection margins are often difficult to appreciate for lesions with larger endophytic components. As a result, tumour margins may be compromised or excess tissue resected. Laparoscopic endoscopic cooperative surgery (LECS) was developed in Japan to overcome these technical challenges in the resection of subepithelial lesions, including GISTs. Here, we present a case report of an early Canadian experience utilizing LECS in the management of gastric GIST. Aims To describe a case report of an early Canadian experience of LECS for the resection of a gastric GIST. Methods We performed a review of the literature and describe a case of LECS. Results We present a 70-year-old female referred to our centre for endoscopic resection of a 2.5x2.5cm histologically confirmed gastric GIST (low mitotic index and no known metastases). Repeat endoscopic evaluation at our centre confirmed a 25-30mm subepithelial lesion with both exophytic (small) and endophytic (large) components. After tumour board review, we opted for a LECS approach. In the OR, the lesion was identified endoscopically and marked with a Dual J-Knife (Olympus). The margins were injected with a combination of Voluven, methylene blue, and dilute epinephrine. A circumferential incision was then completed using standard ESD technique. The lesion was subsequently identified laparoscopically, with endoscopic guidance, along the lesser curvature. The lesser omentum was mobilized for clear visualization of the serosa around the lesion. A full thickness incision was made endoscopically along the distal aspect of lesion. Full thickness resection was continued endoscopically for one third of the circumference of the lesion until gastric insufflation became compromised. Full thickness resection was completed laparoscopically under endoscopic guidance with grossly negative margins. The defect was closed with running laparoscopic sutures. Endoscopic leak test was performed which was negative. The specimen was retrieved and follow up pathology demonstrated a GIST with low mitotic index and negative margins without tumour rupture. Conclusions In a review of the literature, LECS appears to minimize tissue resection while maintaining R0 resection rates. This technique is especially useful for subepithelial lesions with larger endophytic and transmural components. It has an excellent safety profile with a less than 5% anastomotic leak rate. As such, the literature supports LECS as a suitable procedure for gastric subepithelial lesions <50 mm. However, further studies are needed to compare it systematically to conventional laparoscopic wedge resection in addition to other innovative endoscopic techniques such as STER and EFTR. Funding Agencies None

The Histopathology of Oral Cancer Pain in a Mouse Model and a Human Cohort

Oral cancer patients often have severe, chronic, and mechanically induced pain at the site of the primary cancer. Oral cancer pain is initiated and maintained in the cancer microenvironment and attributed to release of mediators that sensitize primary sensory nerves. This study was designed to investigate the histopathology associated with painful oral cancers in a preclinical model. The relationship of pain scores with pathologic variables was also investigated in a cohort of 72 oral cancer patients. Wild-type mice were exposed to the carcinogen, 4-nitroquinoline 1-oxide (4NQO). Nociceptive (pain) behavior was measured with the dolognawmeter, an operant device and assay for measuring functional and mechanical allodynia. Lesions developed on the tongues and esophagi of the 4NQO-treated animals and included hyperkeratoses, papillomas, dysplasias, and cancers. Papillomas included lesions with benign and dysplastic pathological features. Two histologic subtypes of squamous cell carcinomas (SCCs) were identified—SCCs with exophytic and invasive components associated with papillary lesions (pSCCs) and invasive SCCs without exophytic histology (iSCCs). Only the pSCC subtype of tongue cancer was associated with nociceptive behavior. Increased tumor size was associated with greater nociceptive behavior in the mouse model and more pain experienced by oral cancer patients. In addition, depth of invasion was associated with patient-reported pain. The pSCC histology identifies 4NQO-induced tongue cancers that are expected to be enriched for expression and release of nociceptive mediators.

S2868 A Serendipitous Identification of Contained Duodenal Perforation

INTRODUCTION: Peptic ulcer disease (PUD) is a condition defined by defects in the gastric and/or duodenal mucosa that extend through the muscularis mucosa. Sequalae of untreated PUD include gastrointestinal (GI) bleeding, gastric outlet obstruction and perforation. Typical presenting symptoms of upper GI perforation include sudden onset of severe sharp abdominal pain, peritoneal signs and severe sepsis or septic shock. CASE DESCRIPTION/METHODS: We present a case of a 71-year-old woman with chronic back pain on celecoxib who presented with mild progressively worsening abdominal pain, non-bilious/non-bloody vomiting and decreased oral intake. Abdomen was benign and initial laboratory tests were unrevealing. Computed tomography (CT) revealed a 6.6 cm heterogeneous complex cystic/solid mass originating from the second portion of duodenum with large exophytic component, and abutting the pancreatic head, liver, proximal duodenum, portal vein and inferior vena cava (Figure 1). Esophagogastroduodenoscopy (EGD) revealed a fistulous tract along the duodenal sweep leading into an extra-luminal cavity (Figure 2) and multiple Forrest Class III duodenal bulb ulcers. Intraprocedural surgical consultation was obtained and a decision was made to proceed with endoscopic ultrasonography (EUS). EUS revealed a 40.2 × 27.3 mm hypoechoic heterogeneous porta-hepatis lesion with ill-defined borders, containing a well-circumscribed anechoic component consistent with contained perforation cavity. Fine needle biopsy (FNB) was performed with pathology revealing a grade 1 well-differentiated duodenal neuroendocrine tumor (D-NET) with immunohistochemical stains positive for synaptophysin, negative for chromogranin A and less than 1% positivity for Ki67 (Figure 3). Of note, serum chromogranin A level was markedly elevated to 1,105 ng/mL (normal: < 93 ng/mL). A pancreaticoduodenectomy was advised, however, patient declined. DISCUSSION: Although most common cause of duodenal perforations is PUD secondary to Helicobacter pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs) use, other etiologies include diverticulum, regional infections, autoimmune conditions, ischemia, Bouveret syndrome, chemotherapy and localized tumors. NETs account for 0.5% of all cancers and D-NETs comprise 5-8% of all GI-NET. Although contained GI perforations have atypical presentations, one should always keep tumor on the differential. To our knowledge, this is the first case report of D-NET leading to perforation.Figure 1.: Intravenous and oral contrast enhanced axial (A) and coronal (B) CT images of the abdomen demonstrating a complex heterogeneous and cystic mass in the porta hepatis region. The mass is interposed between and inseparable from the duodenum (straight white arrow) and head of the pancreas (curved white arrow). The inferior aspect of the mass is heterogeneous (white arrowhead) with areas of hyper-intensity compatible with tumor enhancement. The superior aspect of the mass is cystic with complex fluid attenuation (black arrowhead) consistent with the histopathologic findings of perforation and hematoma.Figure 2Figure 3