Exophytic Growth Research Articles

Gastric schwannoma: CT findings and clinicopathologic correlation.

The purpose of this study was to evaluate the computed tomography (CT) imaging characteristics of gastric schwannoma. Eight cases of gastric schwannomas confirmed by surgery and pathology were retrospectively analyzed by CT. We reviewed the CT findings of gastric schwannomas for the following characteristics: tumor location, size, contour, margin, growth pattern, enhancement pattern, the presence or absence of necrosis, and perigastric lymph nodes. The tumors were located in the lesser curvature of gastric body (n = 5) and greater curvature of the gastric antrum (n = 3) with a median size of 4.8 cm (range 1.7-11.4 cm). Gastric schwannomas appeared as submucosal tumors with CT features of ovoid (7/8 patients), well-defined (8/8) and exophytic (4/8) or mixed (3/8) growth patterns. On dynamic CT examination, the tumors displayed homogeneous enhancement in seven cases and heterogeneous enhancement in one case. Solid parts of eight tumors demonstrated mild enhancement during the arterial phase and strengthened progressive enhancement during the venous and delayed phases. Two cases had perigastric lymph nodes. Gastric schwannomas typically manifested as ovoid, well-defined, exophytic, or mixed growth pattern masses on CT. Homogeneous progressive enhancement on dynamic CT is a characteristic finding of gastric schwannoma.

Abstract 3327: Epidermal growth factor receptors and penile carcinoma: The role of EGFR and HER2 expression as prognostic and predictive markers

Abstract BACKGROUND: Growth factor receptors have recently been described as potential therapeutic targets for penile carcinoma patients, and there are reports on benefits from the clinical use of monoclonal antibodies against EGFR. However, knowledge on the molecular basis of the disease is scarce. For that, we have addressed the expression of EGFR and HER2, as well as mutational and amplification status of EGFR in samples from penile squamous cell carcinoma (PSCC) patients. METHODS: Clinicopathologic features and survival data from 183 PSCC patients were reviewed from hospital records and immunohistochemistry (IHC) against EGFR and HER2 was performed. Positive cases were those showing strong and complete membrane staining in more than 10% of the tumor cells. HER2 was also classified as positive according to the presence of cytoplasmic staining (cHER2). Sixty cases were submitted to dual-color fluorescence in situ hybridization (FISH) and were classified as unaltered (those harboring 2 signals for each probe) or FISH positive (either if polysomic - harboring more than 2 signals for each probe - or amplified - cases with an EGFR signal:centromeric signal ratio exceeding 2). EGFR exons 18, 19, 20 and 21 from 27 independent frozen cases were sequenced. Variables were compared by the Pearson chi-square or Fisher´s exact test. Survival rates were calculated using the Kaplan-Meier method and compared by log-rank test. Alpha error was set at 5%. RESULTS: IHC analysis showed that, for EGFR expression, 91 cases (49.7%) were positive and 92 negative, out of which 9 (4,9%) showed no staining at all. Positive cases were associated with higher incidence of recurrence and exophytic growth (p=0.031 and p=0.023, respectively). Membrane staining of HER2 was not seen in any case whereas cHER2 was found in 20.3% (29) of cases, all of them high grade tumors. No low grade tumor presented this staining pattern. cHER2 was also associated with EGFR expression (p=0.017). Regarding FISH, 36 cases were unaltered whereas 32 were FISH positive (out of which 16 presented chromosome 7 polysomy and 6 EGFR amplifications). FISH positivity did not associate with EGFR expression (p=0.403). No mutation in the studied EGFR exons was observed. A polymorphism without clinical significance (p.Q787Q in exon 20) was found in 19/27 cases. cHER2 expression and FISH positivity were an independent risk factor for cancer-specific and overall survival, respectively. CONCLUSIONS: Success of targeted therapies is highly linked to appropriate patients selection and our findings might indicate that EGFR has a key role in penile carcinogenesis, making PSCC patients potential candidates for EGFR-targeted therapies since both EGFR expression and chromosome 7 polysomy are associated with poor prognosis. A possible interaction between membranous EGFR and cytoplasmic HER2 could favor the use of tyrosine-kinase inhibitors instead of monoclonal antibodies. Citation Format: Alice M. T. Silva-Amancio, Isabela W. Cunha, Gustavo C. Guimaraes, Fernando A. Soares. Epidermal growth factor receptors and penile carcinoma: The role of EGFR and HER2 expression as prognostic and predictive markers. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3327. doi:10.1158/1538-7445.AM2014-3327

P12.13 * SURGICAL TREATMENT OF BRAINSTEM TUMORS

OBJECTIVE: To determine the extent of resection and neurological outcomes after surgical treatment of brainstem tumors. METHODS: 34 patients with brainstem tumors operated in Regional Centre of Neurosurgery and Neurology from January, 2008 till January, 2014 were retrospectively analyzed. 20 (58.8%) patients were male, and 14 (41.2%) – female. Mean age of the patients was 22.7 years. Among them 16 (47.1%) were of pediatric age, 18 (52.9%) – adults. In 20 cases (58.8%) tumor had exophytic growth pattern into fourth ventricle. In purely intrinsic tumors (14 cases, 41.2%) the localization was: midbrain – 5 patients (14.7%), ponto-mesencephalic junction – 2 cases (5.9%), pons – 2 patients (5.9%), ponto-medullary junction – 2 cases (5.9 %), medulla oblongata – 3 patients (8.8%). Patients were examined neurologically on admission and one month after surgery. The extent of tumor resection was evaluated on early postoperative MRI (first 48 hours). RESULTS: Surgical approach was chosen individually in each case according to tumor location, using a 2-point method. In patients with midbrain tumors 3 different approaches were used: subtemporal (2 cases, 5.9%), occipital transtentorial (2 cases, 5.9%) and supracerebellar (1 patient, 2.9%). In 2 patients (5.9%) retrosigmoid approach was used. The “workhorse” approach in our series was median suboccipital with telo-velar entrance into the cavity of IV ventricle, which was used in 27 cases (79.4%). The tumors were resected through “safe entry” zones in the brainstem. In 28 cases (82.4%) gross total resection was achieved, in 6 patients (17.6%) the resection was subtotal (>90%). 5 patients (14.7%) deteriorated neurologically after surgery on 30 day follow-up, 29 patients (85.3%) improved or remained stable. None of the operated patients died. Histologic results: anaplastic ependymoma – 9 patients (26.5%), ependymoma – 5 patients (14.7%), pilocityc astrocytoma – 6 patients (17.6%), anaplastic astrocytoma – 4 patients (11.8%), medulloblastoma with significant brainstem invasion – 4 patients (11.8%), choroid plexus papilloma – 2 patients (5.9%), metastasis – 2 patients (5.9%), germinoma – 1 patient (2.9%), dermoid – 1 patient (2.9%). CONCLUSION: Surgical treatment of brainstem tumors can be done effectively (gross total removal in 82.4%) and relatively safe (morbidity – 14.7%, mortality – 0%).

Primary Anorectal Melanoma : A Rare Case Report with Review of Literature

Anorectal melanoma is very rare malignant tumor, accounting 0.2-1% of all malignant melanomas and has a poor prognosis. The median survival of 8-23 months after the time of diagnosis. The typical treatment modalities includes surgery radiotherapy and chemotherapy. We present the case of a 75 year-old female with history of bleeding per rectum for 5 months with rectosigmoidoscopy showing an exophytic growth measuring about 5cm in diameter, multiple biopsies were taken showing tiny foci of submucosal infiltration by malignant cells. Abdomino-perineal resection was performed and pathologic examination revealed anorectal melanoma. Early diagnosis and treatment of this aggressive tumor for better out come and long term survival is highly recommended.

Radiation-induced undifferentiated high-grade pleomorphic sarcoma (malignant fibrous histiocytoma) of the mandible: Report of a case arising in the background of long-standing osteomyelitis with a review of the literature

We report a rare case of radiation-induced undifferentiated high-grade pleomorphic sarcoma (UPS) (malignant fibrous histiocytoma, MFH) in the right mandible of a 44-year-old woman. The patient had suffered from osteomyelitis of the same region of the mandible for several years, which was considered to be due to radiotherapy for a malignant lymphoma in her right neck 19 years before. The tumor appeared as an exophytic and invasive growth in the molar region of the mandible. Histopathologically, the tumor consisted of an interlacing proliferation of vimentin-immunopositive spindle-shaped fibroblastic cells with bizarre nuclei with high Ki-67 labeling scores, and tumor cells showed storiform patterns mixed with pleomorphic cells. Taking the history of radiation into consideration, we diagnosed the lesion as radiation-induced MFH/UPS. Including the present case, there have been only 14 documented cases of radiation-induced UPS in the jawbone, and this is the first UPS case arising in the follow-up period of long-standing osteomyelitis.

Pyogenic granuloma of the gastrointestinal tract

Abstract Introduction: Pyogenic granuloma (PG) or granuloma pyogenicum is essentially a capillary hemangioma on the skin or a mucosal surface which shows an exophytic growth pattern and has a lobulated appearance. The most common sites are skin (40%) and mucosal surfaces (predominantly oral cavity, 60%). We intend to report all available cases of PG of gastrointestinal (GI) tract, diagnosed at the Henry Ford hospital, a tertiary referral center. Patients and Methods: A retrospective review of pathological database was performed on all GI biopsies in the last 10 years using diagnostic codes and pathology codes searching for PG of the GI tract. Results: A total of 23 cases of pathologically diagnosed PG was diagnosed over a 10 year period. The median age of patients was 64 with almost equal gender distribution (47.8% were males, and 52.2% were females). The most common location of PG was sigmoid colon (65.2%), esophagus (17.4%) and transverse colon (13%). PG presented as a polyp in 16 patients (69.6%). The most common indication for endoscopy in these cases was screening colonoscopy (30.4% cases). Discussion: PG of GI tract is rare. To date, only about 15–20 cases have been reported in the literature and most cases have been reported from Japan and Korea. This is the largest case series of this rare pathological lesion of the GI tract. Most cases of PG were diagnosed on an endoscopy done for an unrelated reason in our series. Hence, most cases were asymptomatic, unlike previously reported cases which were mostly associated with GI bleeding.

An Uncommon Complication of Percutaneous Endoscopic Gastrostomy Tube Placement

Question: A 75-year-old nursing home resident was referred by her local medical officer with a 5-month history of an enlarging exophytic growth from around her percutaneous endoscopic gastrostomy (PEG) site. Her initial PEG was placed 7 years prior, when she suffered a large cerebral hemorrhage, with secondary oropharyngeal dysphagia. At the time, she was already suffering from early cognitive impairment, which had progressed over the subsequent years. The growth was noticed after a new feeding tube was replaced percutaneously, without endoscopic assistance, when the previous PEG was accidentally dislodged. In the months leading up to her assessment, there were observations from the patient’s family of altered behavior, including frequent gesturing at the PEG site, suggestive of some associated discomfort. Examination of the PEG site revealed a 3-cm, exophytic, fleshy mass that encircled the PEG tube (Figure A). No ulceration was evident. The origin of the lesion seemed to arise deep to the cutaneous layer. The PEG tube seemed to be freely mobile and was in good position. No evidence of organomegaly, ascites, or peritonism was identified on examination. A biopsy was performed of the lesion (Figure B). Computed tomography was performed (Figure C–E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Robot-assisted Partial Nephrectomy for ≥7 cm Renal Masses: A Comparative Outcome Analysis

To present our robotic partial nephrectomy (RPN) experience for renal masses ≥ 7 cm and compare the surgical outcomes in this cohort with those obtained for small (≤ 4 cm) renal masses. We retrospectively reviewed our institutional review board-approved RPN database and identified patients undergoing RPN for tumors ≥ 7 cm. Surgical technique, renal function, oncologic, and pathologic data were analyzed and compared with the RPN for renal masses ≤ 4 cm. Overall, 441 patients were identified for the purpose of this study, including 29 cases and 412 controls. Median operative time (200 vs 180 min; P = .005), warm ischemia time (26.5 vs 19 min; P <.001), and estimated blood loss (250 mL [353] vs 150 mL [150]; P <.001) were significantly lower in the control group. Postoperative complications were significantly higher in the case group (37.9% vs 15.8%; P = .005). However, the percentages of major complications (Clavien grade ≥ III) were comparable (18.2% vs 17%; P = .57 for cases and controls respectively). Postoperative blood transfusion was higher for larger tumor group (24.1% vs 4.1%; P <.001). Positive margins were similar between groups (5.9% vs 3.3%; P = .45 for cases and controls respectively). There was no difference in estimated glomerular filtration rate decline between the two groups (12.2% vs 15.8% decline; P = .98). RPN represents a feasible and safe nephron-sparing surgery approach for highly selected (mostly exophytic growth pattern, polar location, and likelihood of benign histology) renal masses ≥ 7 cm in diameter.

Risk factors for bleeding in hepatocellular adenoma.

Hepatocellular adenoma (HCA) is a benign hepatic lesion that may be complicated by bleeding, although the risk of bleeding is ill-defined. The aim of this study was to assess risk factors for bleeding in patients diagnosed with HCA. Patients with HCA were included prospectively from January 2008 to July 2012. Patient characteristics were noted. Patients underwent dynamic magnetic resonance imaging (MRI) and/or computed tomography (CT) at presentation and during follow-up. Lesion characteristics on (follow-up) imaging were noted, and bleeding was graded as intratumoral (grade I), intrahepatic (grade II) or extrahepatic (grade III). The standard of reference for diagnosis was histopathology, or dynamic MRI and/or CT findings. Possible risk factors were included if mentioned in literature (lesion size, body mass index), or based on clinical experience (lesion location, visible vessels on imaging). A total of 45 patients (median age 39 (range 22-60) years; 44 women) with 195 lesions (median size 24 (10-250) mm) were evaluated. Bleeding occurred in 29 patients (64 per cent) and in 42 lesions (21.5 per cent) with a median size of 62 (10-160) mm. Size was a risk factor for bleeding (P < 0.001), with an increased number of bleeding events in lesions of 35 mm or more. Exophytic lesions (protruding from liver) had more bleeding (16 of 24, 67 per cent) than intrahepatic (9 of 82, 11 per cent) or subcapsular (17 of 89, 19 per cent) lesions (P < 0.001). Lesions in segments II and III had more bleeds than those in the right liver (11 of 32 versus 31 of 163; P = 0.049), as did lesions in which peripheral or central arteries were visualized on imaging (10 of 13 versus 32 of 182 lesions with no visible vascularization; P < 0.001). Risk factors for bleeding of HCA include diameter of 35 mm or more, visualization of lesional arteries, location in the left lateral liver, and exophytic growth.

Anal canal melanoma misdiagnosed and treated as prolapsed hemorrhoids in a male patient

Malignant melanoma of the anal canal is a rare, but aggressive, tumor with a poor prognosis. It represents less than 1% of all melanomas and 4% of anorectal tumors. We are reporting this case because of its rarity in men and because, in this instance, the tumor was misdiagnosed as prolapsed thrombosed hemorrhoids and excised. Examination showed a visible exophytic irreducible growth measuring about 3 × 3 cm and protruding outside the anal verge and involving the anterior two-thirds of the circumference of the anal canal. A biopsy sample showed round to oval cells with prominent nucleoli and marked intracytoplasmic pigmentation. A magnetic resonance imaging scan showed a tumor with nearly complete luminal obstruction and liver metastasis. The patient received chemotherapy and radiotherapy, but the response was very poor and he died 2 months later.

V5-13 A NEW APPROACH FOR THIRD LEVEL DIAGNOSIS FOR COMPLEX RENAL CYSTS

You have accessJournal of UrologyRenal Oncology/Robotics1 Apr 2014V5-13 A NEW APPROACH FOR THIRD LEVEL DIAGNOSIS FOR COMPLEX RENAL CYSTS Francesco Porpiglia, Marco Cossu, Massimiliano Poggio, Riccardo Bertolo, Nicoletta Serra, Diletta Garrou, Daniele Amparore, Enrico Checcucci, Roberta Aimar, and Cristian Fiori Francesco PorpigliaFrancesco Porpiglia More articles by this author , Marco CossuMarco Cossu More articles by this author , Massimiliano PoggioMassimiliano Poggio More articles by this author , Riccardo BertoloRiccardo Bertolo More articles by this author , Nicoletta SerraNicoletta Serra More articles by this author , Diletta GarrouDiletta Garrou More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Roberta AimarRoberta Aimar More articles by this author , and Cristian FioriCristian Fiori More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1716AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Complex renal cysts may cause diagnostic matters, since it is often difficult to exclude malignancies. The Bosniak classification of renal cysts is a well-established worldwide method based on CT findings to categorize cystic renal masses but, expecially for cysts classified as Bosniak II and III, some studies highlight a not trascurable frequency of false negative and positive malignancy diagnoses. To overcome this limitation, cysts puncture for evacuation and core biopsies can be used trying to make a diagnosis but a recent Literature review emphasized the higher risk of biopsy failure, false-negative results, and potential spreading of tumour cells resulting from cystic rupture: these aspects lead many urologists to limit the indications of core biopsies. Trying to give an answer in this field we present a new “third-line” diagnostic tool for complex cysts renal tumors. Methods We present the case of a male patient, 35 years old, BMI 22. After an incidental US detection of a large cyst a the lower pole of the left kidney with exophytic growth pattern, the diagnosis was confirmed by an imaging workup consisting of contrast-enhanced abdominal CT-scan and abdominal MRI. In addition, they highlighted an involvement of renal pelvis and lower calyceal system. The MRI dynamic study showed the presence of 2 small intraluminal prominence. To specify the diagnosis in this complex cysts renal tumor, we proceeded as follows: patient was placed in a Galdakao-modified supine Valdivia position. Under US guidance a puncture of the cyst was performed by 16 G needle, named MICROPERC®, endowed by a dedicated sheet (4.85 F). The needle was then removed, the 4.85 F sheath was left in place. 20 mL of citrine fluid were suctioned and sent for extemporary cytological examination with unconclusive result. An adapter with “Luer-lock” junction was connected to the needle. After its setup, the optical fiber was inserted through the sheath and moved forward to the cyst. Endoscopic exploration of the cyst was performed and finally, two intraluminal prominence were identified. We therefore decided to perform a laparoscopic radical nephrectomy. Results Operative time was 165 minutes. No perioperative complications occurred. Patient was discharged at third postoperative day. At histopahological examination a papillary malignant renal tumor was found. Conclusions The percutaneous needlescopic exploration of renal cysts according the described technique offers a new perspective in the diagnostic assessment of complex renal cysts. This approach could be used as a third-line diagnostic tool when either imaging or biopsy were inconclusive. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e620 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Francesco Porpiglia More articles by this author Marco Cossu More articles by this author Massimiliano Poggio More articles by this author Riccardo Bertolo More articles by this author Nicoletta Serra More articles by this author Diletta Garrou More articles by this author Daniele Amparore More articles by this author Enrico Checcucci More articles by this author Roberta Aimar More articles by this author Cristian Fiori More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Low Condylectomy and Orthognathic Surgery to Treat Mandibular Condylar Osteochondroma: A Retrospective Review of 37 Cases

To evaluate the outcomes from surgical treatment of mandibular condylar osteochondroma (condylar hyperplasia [CH] type 2) using a specific surgical protocol. CH type 2 is a unilateral benign pathologic condition, with progressive proliferation of osseous and cartilaginous tissues in the condylar head. This causes condylar enlargement, often with exophytic growth, resulting in significant facial deformity, pain, and masticatory and occlusal dysfunction. This was a retrospective cohort study of 37 patients (28 females and 9 males), with an average age of 26.3 years (range 13 to 48), with CH type 2, and associated dentofacial deformity. The condylar pathologic features were confirmed by histologic analysis. All patients were treated with low condylectomy, recontouring of the condylar neck to form a new condyle, repositioning of the articular disc over the condylar stump and repositioning of the contralateral disc, if displaced, and any indicated orthognathic surgical procedures. Postoperative follow-up averaged 48 months (range 12 to 288). Patients were assessed preoperatively and at the longest follow-up point for incisal opening, lateral excursions, pain, jaw function, diet, disability, and occlusal and skeletal stability. The pre- and postoperative assessments were compared using paired t test. At the longest follow-up point, a nonsignificant decrease (2.3 mm) was seen in the maximum incisal opening; however, the excursive movements had decreased significantly an average of 2.5 mm on the right and 2.2 mm on the left. A statistically significant improvement was seen in pain, jaw function, diet, and disability. A stable Class I skeletal and occlusal relationship was maintained in 34 of the 37 patients (92%). Two patients developed relatively minor postoperative malocclusions that were managed with orthodontics. In 1 patient, a high condylectomy was performed, and the tumor continued to grow, causing malocclusion and jaw deformity to recur. A low condylectomy and sagittal split were performed 14 months later, with a stable result at 4 years after surgery. The results of the present study have demonstrated that a low condylectomy procedure with recontouring of the condylar neck to function as a condyle and repositioning of the articular discs, combined with orthognathic surgery, is a viable option for the treatment of osteochondroma of the mandibular condyle and associated jaw deformity.

‘Unexplained intermittent hemoptysis with normal chest radiograph necessitates bronchoscopy’— mucoepidermoid carcinoma of lung: Case report

Abstract Hemoptysis is the predominant symptom of tuberculosis and is considered as important clue toward evaluation of tuberculosis and treatment accordingly, especially in high burden countries like India where disease is endemic. 8-25% cases of pulmonary tuberculosis are having hemoptysis during course of their illness. Unexplained hemoptysis with normal chest radiograph needs further evaluation including CT thorax and bronchoscopy. Bronchoscopy would be ideal choice for confirming diagnosis and to localize exact site of bleeding as well. In this case report, we describe a case of a young male who presented with cough and intermittant hemoptysis. During fiberoptic video-bronchoscopy we noted exophytic endobronchial growth in right main stem bronchus. Histopathological evaluation suggests mucoepidermoid carcinoma (MEC) of salivary gland type originating from main stem bronchus right side. PAS and mucicarmine staining differentiated MEC from Adenocarcinoma in our case.

Laparoscopic partial nephrectomy with diode laser: a promising technique.

The aim of this study was to evaluate application of diode laser in laparoscopic partial nephrectomy (LPN), and to question this technique in terms of ease of tumor excision and reduction of warm ischemia time (WIT). LPN is the standard operative method for small renal masses. The benefits of LPN are numerous, including preserving renal function and prolonging overall survival. However, reduction of WIT remains main challenge in this operation. In order to shorten WIT, many techniques have been developed, with variable results. We performed a prospective collection and analysis of health records for patients who were operated on between March 2011 and August 2012. Inclusion criteria were single tumor ≤ 4 cm, predominant exophytic growth and intraparenchymal depth ≤ 1.5 cm, with a minimum distance of 5 mm from the urinary collecting system. We operated on 17 patients. Median operative time was 170 min. In all but two patients, we had to perform hilar clamping. Median duration of WIT was 16 min. Pathohistological evaluation revealed clear cell renal cancer and confirmed margins negative for tumor in all cases. Median size of the tumor was 3 cm. Median postoperative hospitalization was 5 days. Average follow up was 11.5 months. There were no intraoperative complications. One postoperative complication was noted: perirenal hematoma. Laser LPN is feasible, and offers the benefit of shorter WIT, with effective tissue coagulation and hemostasis. With operative experience and technical advances, WIT will be reduced or even eliminated, and a solution to some technical difficulties, such as significant smoke production, will be found.

Esophageal Stenosis Caused by a Rare Entity

Question: A 45-year-old man presented in our surgical department with progressive dysphagia for solids and liquids and weight loss over the last 6 month, he had a long history of tobacco abuse (25 pack-years), but no history of trauma or alcohol use. Physical examination showed his cachexia, but was otherwise unremarkable without palpable lymphadenopathy. He had been treated with long-term bouginage over 4 years for a long segment esophageal stenosis starting 30 cm distal to the dental arch. Repeatedly performed biopsies over that time course had been nondiagnostic, with only chronic inflammation and hyperkeratosis. He presented in our institution owing to shorter bouginage intervals and weight loss. Upper endoscopy showed a thickened, white, contact-vulnerable, exophytic, and lumen-constricting polypoid mass in the esophagus over a distance of 15 cm (Figure A; star = esophageal lumen). Multiple deep biopsies were taken; they revealed keratosis and chronic inflammation but no evidence of malignancy. The subsequent computed tomography with contrast enhancement revealed a long-segment thickening of the thoracic esophagus (Figure B, arrows) without any lymphadenopathy or metastases. What is the most likely diagnosis? Look on page 871 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The verrucous carcinoma (VC) of the esophagus is a rare, well-differentiated, squamous cell carcinoma with about 20 cases described worldwide. It is associated with long-term local inflammation; tobacco abuse1Alkan A. Bulut E. Gunhan O. et al.Oral verrucous carcinoma: a study of 12 cases.Eur J Dentistry. 2010; 4: 202-207Crossref PubMed Google Scholar and recent studies suggest a potential role for human papillomavirus in carcinogenesis.2Viera C.L. Lopes J.C. Velosa J. A case of esophageal squamous cell carcinoma with positive HPV 11.Gastroenterol Hepatol. 2013; 36: 311-315Crossref PubMed Scopus (12) Google Scholar Despite its high degree of differentiation and slow growth, the outcome of patients with VC is unsatisfactory owing to late diagnosis and perioperative complications.3Osborn N.K. Keate R.F. Trastek V.F. et al.Verrucous carcinoma of the esophagus: clinicopathophysiologic features of a rare entity.Dig Dis Sci. 2003; 48: 465-474Crossref PubMed Scopus (42) Google Scholar Local invasion and its spread within the submucosa and paraesophageal layer leave it invisible for superficial biopsies, which usually show nonspecific acanthosis and hyperkeratosis associated with acute or chronic inflammation. The tumor invades the surrounding tissue, grows locally destructive, and has a very low potential for metastasis. Typical endoscopic appearances—mostly the only “proof” for this malignancy—include wart-like polypous, exophytic, spiked, or cauliflower like masses.3Osborn N.K. Keate R.F. Trastek V.F. et al.Verrucous carcinoma of the esophagus: clinicopathophysiologic features of a rare entity.Dig Dis Sci. 2003; 48: 465-474Crossref PubMed Scopus (42) Google Scholar Surgery is adequate therapy for early stages that are locally resectable; patients with esophageal VC do not benefit from chemotherapy. Our patient underwent thoracoabdominal esophagectomy. Intraoperatively, we found a thin, dilated, proximal esophagus with a thick wall in the stenotic area and inflamed adhesion to the mediastinum. The macroscopic pathological specimen showed the strong hyperkeratotic, exophytic growth of the tumor (Figure C, arrows); final histology revealed the VC of the esophagus pT2, pN0, L0, V0, Pn0, R0, G1. The microscopic image displays the invasive component of the squamous cell carcinoma (Figure D, arrow). The patient was dismissed after an uneventful postoperative course on postoperative day 15. VC of the esophagus is not only a rare entity, its preoperative diagnosis also is extraordinary challenging and relies on clinical suspicion induced by typical endoscopic appearance. An esophageal resection should be performed in case of severe, progressive dysphagia in combination with typical endoscopic appearance even without histologic proof, because definitive diagnosis can mostly first be seen in the resected specimen.

Ultrasonographic features of renal oncocytoma with histopathologic correlation

To analyze the sonographic (US) features of renal oncocytoma and correlate them with histopathologic findings. The medical records of 12 patients with a histologic diagnosis of renal oncocytomas were reviewed. The location, size, shape, margin, echogenicity, homogeneity, and blood flow distribution of the lesions were analyzed, and the US features were compared with histopathologic findings. Oncocytomas appeared as solid, solitary, well-marginated, unencapsulated, fairly homogeneous renal cortical masses (n = 10), with regular shape, relatively isoechoic (n = 5) or slightly hyperechoic (n = 7) to the adjacent renal parenchyma, and an exophytic growth pattern was exhibited in most cases (n = 9). Two larger masses (≥9 cm) demonstrated a central stellate scar and a characteristic of spoke-wheel vascular pattern. The tumors with a low percentage of stroma (<20%) were associated with an echotexture isoechoic to renal parenchyma, whereas oncocytomas with a higher percentage of stroma (>20%) were slightly hyperechoic. Although the US features are not pathognomonic, their presence should alert to the possible diagnosis of renal oncocytoma.

Marjolin's ulcer: A rare report.

Sir, Marjolin ulcer is the term commonly used to describe squamous cell carcinoma (SCC) arising on scar tissue. It is a malignant transformation of a chronic ulcer, sinus tract, fistula or long-standing scar of various etiologies. Jame Nicholas Marjolin in 1828 published the classical description of Marjolin's ulcer. The most frequent malignancy that develops in burns scars is squamous in type.[1] Melanoma, schwannoma, sarcoma, trichilemmal carcinoma have also been described.[2] Limbs are the common site for Marjolin's ulcer. Two different clinical presentations are common ulcerative form and less frequent, exophytic papillary form.[3] We report a case of a 58-year-old lady who developed ulcerative and exophytic mass from a 10 year old burns scar over the back She reported with discomfort over the back to the family physician who found and ulcer over the scar and suspected malignancy. Within four months, the ulcer rapidly progressed to a cauliflower-shaped growth. She was not a diabetic or hypertensive. There was no family history of malignancy. On examination, there was a large exophytic ulcerated growth and a small superficial ulcer arising from a large depigmented atrophic scar over the back [Figure 1]. There was no lymphadenopathy. The other skin and mucosal sites appeared normal. Relevant investigations were normal. Histopathology showed a well-differentiated SCC with horn pearls [Figure 2]. She was advised radiation therapy. Figure 1 An exophytic ulcerated growth and a small superficial ulcer with intervening erosion over a large depigmented atrophic scar Figure 2 Histopathology H and E, ×400 showing well-differentiated squamous cell carcinoma with horn pearls The exact pathogenesis of Marjolin's ulcer remains unclear. Theories suggest that cellular mutations as a result of toxins released by damaged, ischaemic and nutritionally deficient tissues are responsible for neoplastic change, with a locally impaired immune function contributing as trigger. Persistence of burns ulcer, induration or elevation of margin of such ulcer, ulceration or nodule formation over a burns scar may indicate malignant transformation. The latent period is shorter in elderly and in cases of basal cell epithelioma. Metastasis among squamous carcinomas following a burns scar is much more common than among those associated with actinic damage.[4] Punch biopsy should be avoided, due to the focal nature of the malignant changes in burn scar.[5] In our case, the spine region being more prone for pressure-induced damage, the resultant necrosis could have initiated the malignant process. This case is reported the rarity of occurrence of Marjolin's ulcer over the back, presenting as both ulcerative and exophytic growth. Even a small abrasion over a long standing burns scar should be viewed with suspicion. All burn scars should be grafted as the incidence of carcinoma is reduced if such wounds are grafted at an early stage.

Buschke-Lowenstein tumor in a patient with decompensated cirrhosis.

Sir, A 57-year-old Caucasian male presented with continuous oozing of blood from a large exophytic growth over the abdomen and penile shaft. The patient reported a slowly enlarging exophytic growth over his penis [Figure 1a] and abdomen [Figure 1b] for past 35 years. He never sought medical attention for these; however, for the past 2 weeks, he was continuously oozing blood from these growths, requiring him to change clothes and bed sheets several times a day. Past medical history was significant for end-stage liver disease from untreated hepatitis C. At presentation, his hemoglobin was 6.6 and INR 1.9. During the course of hospitalization, patient was transfused as needed with reversal of coagulopathy; however the bleeding continued. Biopsy from both abdominal and penile growth showed increased mitosis and atypia, causing push effect, but lacked basement membrane invasion, [Figure ​[Figure2a2a and ​andb]b] consistent with diagnosis of Buschke-Lowenstein tumor (BLT). Our patient failed radiotherapy and surgery was not an option because of decompensated cirrhosis with irreversible coagulopathy. Figure 1 (a) Large, exophytic lesions over the penile shaft and scrotum; (b) Large, exophytic lesions on the abdomen Figure 2 (a and b) Histopathology of lesions illustrates papillomatosis, acanthosis, and keratin pearls with increased mitosis and atypia

Glioblastomamultiforme with exophytic growth in young adult: a case report

Glioblastomamultiforme with exophytic growth in young adult: a case report

Intraductal dissemination of papillary adenocarcinoma of the ampulla of Vater in the pancreatic duct

It has been speculated that intraductal dissemination, via the pancreatic duct, bile duct, or mammary duct, is a unique form of cancer cell spread. However, clinical evidence to confirm this form of dissemination has been lacking. Here we report a case of papillary adenocarcinoma of the ampulla of Vater in which retrograde dissemination to the pancreatic duct was strongly suggested. A 79-year-old woman underwent pancreatoduodenectomy for a 22 mm microinvasive papillary adenocarcinoma of the ampulla. Multiple carcinomas in situ were found in the pancreatic duct distant from the ampulla. Seven months later, she underwent a second operation for a recurrent papillary adenocarcinoma at the pancreato-jejunal anastomosis showing exophytic and expansive growth into the jejunal lumen that connected to an intraductal adenocarcinoma in the pancreatic body. None of these tumors showed invasive growth, or vascular or neural invasion, being separate from each other but sharing identical histological, immunohistochemical, and molecular features; papillary growth, a pancreatobiliary phenotype, the same pattern of genomic loss of heterozygosity, and no mutation of the KRAS, TP53, and GNAS genes. These results imply that this papillary adenocarcinoma of the ampulla of Vater had disseminated to the pancreatic duct in a retrograde manner and recurred in the remnant pancreas.