Full-thickness Biopsy Research Articles

Paget Disease of the Breast

Paget disease of the breast is an in situ malignancy located within the epidermal layer of the nipple-areolar complex. It accounts for 0.5% of all breast cancers in women and 1 to 3% of new breast cancers diagnosed annually in the United States. Patients most likely present with erosion at the tip or base of the nipple. These symptoms are often confused with the symptoms of eczema. Persistent itching can occur. As the disease progresses, ulceration of the nipple expands outward over the areola. Full-thickness biopsy of the nipple or involved skin is needed to confirm diagnosis. Further workup includes mammography and, frequently, breast magnetic resonance imaging to rule out an associated breast parenchymal malignancy. Surgical excision requires removal of the nipple and involved areolar complex as well as any underlying malignancy. Mastectomy is also an option and may be required if additional multicentric disease is present. This review contains 10 figures, 6 tables, and 52 references. Key words: breast conservation, breast magnetic resonance imaging, eczema, intraepithelial adenocarcinoma, nipple abnormalities, nipple biopsy, occult malignancy, Paget disease

Elusive Enteritis: A Case of Rapidly Evolving Lupus

A 33 year old woman with history of systemic lupus erythematosus (SLE) presented with epigastric pain and watery diarrhea for one month duration. Further history revealed she had been off maintenance medications for SLE including belimumab and prednisone for the past month. Initial exam was notable for tachycardia 34 beats/min, tachypnea 22 breaths/min, fever to 102.9F and diffuse abdominal tenderness. CT abdomen was obtained showing thickened bowel loops concerning for nonspecific enteritis. Given fevers and CT findings, broad spectrum antibiotics were initiated with no improvement in symptoms as well as worsening shortness of breath. Repeat CT abdomen 24 hours later showed significantly worsening enteritis and new ascites. C. difficile toxin and stool cultures were negative. Initial lab data was notable for albumin 2.0 g/dL (down from baseline 3.6 g/dL) and platelets of 574 k/u, with normal liver function tests, no anemia or leukocytosis. The constellation of diarrhea and hypoalbuminemia with enteritis on CT raised concern for a protein-losing enteropathy. GI was consulted, and EGD was performed showing moderate inflammation and duodenal biopsy obtained with non-specific findings. Elevated ESR (95 mm/hr,) and CRP (141.4 mg/L) suggested an acute inflammatory process. An ANA titer of 1:160, anti-RNP and anti-SM antibodies, dsDNA greater than 180 IU/L and low complement levels supported active SLE flare or mesenteric vasculitis. Rheumatology was consulted and began prompt treatment with methylprednisone. At follow up weeks, her symptoms diarrhea and abdominal pain drastically improved suggesting resolution of her enteritis. This case emphasizes the importance of early identification of lupus enteritis and distinguishing it from infectious colitis. About 25-33% of patients with SLE may present with lupus enteritis. Presenting symptoms include abdominal pain, diarrhea and may be insidious in onset as in our case. Complement levels are typically low with elevated inflammatory markers. Duodenal biopsies are often normal and full thickness biopsies may be required. A high suspicion of the diagnosis is needed. Our patient was started on high dose steroids with rapid improvement in diarrhea and pain. CT findings can be dramatically altered depending on how early steroids are initiated. This case demonstrates that timely initiation of steroid therapy can control vasculitis and lead to drastic symptom resolution in patients with lupus enteritis.

WATS 3D Brush Biopsy Variability Compared to Traditional Forceps Biopsy in the Identification of Barrettʼs Esophagus and Dysplasia Diagnosis

Introduction: Barrett's esophagus (BE) is a premalignant condition that requires surveillance to monitor for progression to dysplasia and esophageal adenocarcinoma. Wats 3D transepithelial biopsy (Wats3D) has been developed to augment traditional biopsy and with the intent to better detect dysplasia and esophageal adenocarcinoma. The aim of this study was to compare the variability of detection of Barrett's esophagus, degree of dysplasia and adenocarcinoma of Wats 3D brush biopsy to traditional forceps biopsy. Methods: 27 patients who have a clinical history of GERD and who had an EGD had both traditional forceps biopsies utilizing Seattle protocol and Wats 3D biopsy were identified. Any patient who had traditional biopsy but not Wats or vice versa were excluded. The results of identification of Barrett's esophagus, degree of dysplasia, or adenocarcinoma were compared between the two biopsy types using a Kappa coefficient Results: Kappa coefficient was calculated at 0.49 indicating moderate agreement between the two biopsy types (P=0.01, 95% confidence interval). Of the 27 patient's in the study 6 patients had Wats biopsy and forceps biopsies that did not agree. Of these six patient's, four patients (14.8%) had forceps biopsies that had more advanced pathology (low grade dysplasia vs barrett's in two cases, and barrett's vs no barrett's in two), while two patients (7.4%) had more advanced pathologic diagnosis with Wats 3D vs forceps biopsies. One of these patients had esophageal adenocarcinoma on Wats 3D but only Barrett's with high grade dysplasia on forceps biopsies Conclusion: Esophageal adenocarcinoma has a high mortality rate and a poor prognosis. As such screening for and surveillance of BE are critical in preventing progression. Wats transepithelial biopsy allows an endoscopist to obtain a wide area, full thickness biopsy and then a computer assisted 3D analysis is made in which the 200 of the most suspect cells and cell clusters are analyzed by a pathologist. By taking a wider biopsy with Wats technology, it stands to reason that the rate of detection of Barrett's esophagus and adenocarcinoma may be higher, or can at the very least be used to augment traditional biopsy for better detection rates. We found that there was a moderate amount of agreement between the two biopsy types. The data shows that while Wats 3D biopsy cannot replace traditional biopsies, the two can be combined to increase sensitivity when diagnosing Barrett's. It is our practice to treat the biopsy with the highest degree of severity in accordance with ACG guidelines. Overall, Wats should be considered an adjunct to traditional forceps biopsy in the screening and surveillance of patient's with Barret's.

Comparison between small bowel manometric patterns and full-thickness biopsy histopathology in severe intestinal dysmotility.

Intestinal manometry is the current standard for direct evaluation of small bowel dysmotility. Patients with abnormal motility can either be diagnosed of pseudo-obstruction when there are radiological findings mimicking mechanical intestinal obstruction or of enteric dysmotility when these findings are absent. The aim of the present study was to prospectively compare small bowel manometric abnormalities with histopathological findings in intestinal full-thickness biopsies in patients with severe dysmotility disorders. We investigated 38 patients with intestinal manometry and a subsequent full-thickness intestinal biopsy. Manometric recordings were read by 4 investigators and a diagnostic consensus was obtained in 35 patients. Histopathological analysis, including specific immunohistochemical techniques of small bowel biopsies was performed and compared to manometric readings. Patients with abnormal intestinal manometry had abnormal histopathological findings in 73% of cases. However, manometric patterns did not match with the specific neuromuscular abnormalities. Among patients with a neuropathic manometry pattern and abnormal histopathology, only 23% had an enteric neuropathy, whereas 62% had neuromuscular inflammation, and 15% an enteric myopathy. On the other hand, patients with a myopathic manometry pattern all had abnormal histopathology, however, none of them with signs of enteric myopathy. Small bowel dysmotility detected by intestinal manometry is often associated with abnormal neuromuscular findings in full-thickness biopsies. However, there is no correlation between the specific manometric patterns and the histopathological findings.

Minimally invasive small intestinal exploration and targeted abdominal organ biopsy with a wound retraction device in 42 cats (2005-2015).

To describe the surgical technique and evaluate short-term outcome after minimally invasive small intestinal exploration and targeted organ biopsy with a wound retractor device (WRD) in cats. Multi-institutional retrospective study. Forty-two cats. A wound retractor was inserted into the abdomen on the ventral midline through a 2-4 cm incision at the level of the umbilicus. Short segments (6-10 cm long) of intestinal tract were sequentially exteriorized and explored through the WRD. Full thickness, small intestinal biopsies were obtained extracorporeally via the WRD. A commercially available single-port device was inserted through the WRD for laparoscopic exploration of the abdomen. The majority of the small intestine could be exteriorized and explored through the WRD. In all cases, full thickness biopsies of the small intestine of diagnostic quality were obtained. The most common histological findings were inflammatory bowel disease (n = 16), intestinal lymphoma (n = 14), and eosinophilic enteritis (n = 7). Two cases required conversion to a traditional open laparotomy due to abdominal pathology diagnosed after placement of the WRD (abdominal adhesions and need for a splenectomy). Postoperative complications occurred in 4 of 39 cats (10.3%), leading to 2 deaths after discharge from the hospital. MISIETB with a WRD alone or combined with laparoscopy is a safe technique for small intestinal exploration and targeted abdominal organ biopsy in cats. Single-port laparoscopy can effectively be performed through the WRD for complete abdominal exploration and biopsy of abdominal organs.

Relationship Between Clinical and Histologic Periodontal Biotypes in Humans.

Histologic and histomorphometric evaluations of gingival biopsy samples of patients presenting either a thick or a thin gingival biotype were performed. Full-thickness gingival biopsy samples were obtained and processed for histologic and histometric evaluations. Thickness of the keratinized mucosa or gingiva was found to be increased in the thick biotype. Specifically, the connective tissue layer was thicker with no change in epithelial thickness. In conclusion, gingival transparency appears to be an adequate, clinically useful method to classify the gingival biotype. The thin gingival biotype is manifested by reduced connective tissue thickness; therefore, biotype conversion or enhancement may be based on augmentation of the connective tissue portion of the gingival tissues.

The incidence of surgical site dehiscence following full-thickness gastrointestinal biopsy in dogs and cats and associated risk factors.

The objectives of this study were to: (1) document the incidence of surgical site dehiscence after full-thickness gastrointestinal biopsy in dogs and cats and (2) identify potential risk factors. Data relating to dogs and cats undergoing full-thickness gastrointestinal biopsy were reviewed retrospectively following submission of a completed questionnaire by 12 referral institutions. Outcome measures were definite dehiscence, possible dehiscence (clinical records suggestive of dehiscence but not confirmed), suspected dehiscence (definite and possible combined) and death within 14 days. Logistic regression was planned for analysis of association of dehiscence with low preoperative serum albumin, biopsy through neoplastic tissue, biopsy alongside another major abdominal surgical procedure and biopsy of the colon. Of 172 cats, two (1·2%) had definite dehiscence, and four (2·3%) had possible dehiscence. Low preoperative serum albumin was significantly associated with definite dehiscence in univariable analysis and with suspected dehiscence and death within 14 days in univariable analysis, but all odds ratios had wide 95% confidence intervals. A histopathological diagnosis of neoplasia was significantly associated with death within 14 days in univariable analysis. Of 195 dogs, two (1·0%) had definite dehiscence, and three (1·5%) had possible dehiscence. In dogs, there was no association between any outcome measure and the putative risk factors. Incidence of dehiscence following full-thickness gastrointestinal biopsy was low in this study. When determining the appropriateness of biopsy in individual cases, this information should be balanced against the potentially life-threatening consequences of dehiscence.

Rectal Suction Biopsy in Patients With Previous Anorectal Surgery for Hirschsprung Disease.

The aim of the study was to determine rates of histologically positive, negative, and inconclusive rectal suction biopsies in post-pull-through patients with Hirschsprung disease evaluated for potential residual aganglionosis at our institution and to determine how patients were managed after a post-pull-through rectal suction biopsy. Thirty-nine post-pull-through suction biopsies from our institution were reviewed. Samples, stained with H&E and often acetylcholinesterase and/or calretinin, were categorized as "histologically" positive, negative, or inconclusive for aganglionosis. Subsequent clinical action was categorized as bowel resection, no further procedure, or rebiopsy. Agreement between histologic diagnosis and clinical action was assessed. Histologically, all biopsies were inconclusive (46%) or negative (54%) for residual aganglionosis. Postbiopsy clinical action included redo pull-through (5%), no further procedure (59%), or rebiopsy (36%). Rebiopsy was sought in 2 of 21 histologically negative patients and in only 12 of 18 histologically indeterminate patients. Eventual redo pull-through procedures in 6 of 39 patients showed 4 with residual aganglionosis and 2 with abnormalities suggesting residual "transition zone." Our findings show that suction biopsy after pull-through was frequently histologically indeterminate and never definitively positive for residual aganglionosis. When biopsy was histologically indeterminate, rebiopsy was pursued less commonly than may be expected. Our findings emphasize that suction biopsy examination is not a "criterion standard" for residual aganglionosis, but instead a component of a diagnosis that ultimately combines clinicopathologic factors, the constellation of which can sometimes spare patients from a more invasive full-thickness biopsy.

Case Report: Diagnosis of a Rare Plaque-Like Dermal Fibroma Successfully Treated With Mohs Surgery

CD34-positive plaque-like dermal fibroma (PDF) is a poorly characterised benign dermal neoplasm that has a wide differential diagnosis. It can be mistaken for other entities on superficial biopsy and be overtreated, leading to unnecessary worry and extensive surgery. To report on an uncommon presentation of this entity, the histopathologic differential diagnosis of PDF, and a novel treatment method. Clinical and histopathological information was obtained for a PDF lesion on a 75-year-old man. On superficial biopsy, the PDF lesion was misinterpreted as a possible neurothekeoma. Successful Mohs surgery and genetic testing confirmed the diagnosis of PDF, and the patient received appropriate tissue-sparing surgical management. This case adds to our current knowledge about PDF and highlights the importance of early recognition of these lesions to direct appropriate diagnostic testing (full-thickness biopsy) and management. This case confirms successful management with Mohs surgery.

Narrow-band imaging (NBI) for improving the assessment of vocal fold leukoplakia and overcoming the umbrella effect.

BackgroundIt is crucial to find a balance between functional and oncological outcome when choosing an adequate method for the management of vocal fold leukoplakia. Therefore, a detailed examination is a milestone in the decision-making process.AimTo examine whether narrow-band imaging (NBI) can be helpful in vocal fold assessment in the case of leukoplakia and how to overcome the “umbrella effect”- understood as the submucosal vascular pattern hidden under the plaque.Material and methodsProspective cohort of 41 consecutive patients. Inclusion criteria: vocal fold leukoplakia, no previous procedures (surgery, radiotherapy), and preoperative endoscopy with an optical filter for NBI. Two groups: “suspicious” and “normal”, according to the submucosal microvascular pattern of peripheral regions of the mucosa surrounding the plaque, were distinguished. Patients were qualified for a full-thickness or partial-thickness biopsy, respectively. Criteria defining suspected characters were well-demarcated brownish areas with scattered brown spots corresponding to type IV, Va, Vb, and Vc NI classifications.ResultsIn 22/41 (53.7%) patients with “suspected” microvascular pattern, full-thickness biopsy was performed. Moderate and severe dysplasia was revealed in 15 type IV and 7 type Va NI patients. In 19/41 (46.3%) patients with proper NBI vessel pattern treated by partial-thickness biopsy, hyperkeratosis was diagnosed. There was a strong correlation between the NBI pattern and final histology: Chi2 (2) = 41.0 (p = 0.0000).ConclusionThe results demonstrate that NBI endoscopic assessment of the submucosal microvascular pattern of mucosa surrounding the plaque can be an effective method to categorise the risk in vocal fold leukoplakia prior to treatment.

Unusual presentation of Gastrointestinal Basidiobolomycosis in a 7-year-old Child – Case Report

Gastrointestinal basidiobolomycosis (GIB) is a rare fungal infection caused by basidiobolus ranarum. It has been recognized increasingly in the southern region of Saudi Arabia. Here, we report an unusual case of pediatric GIB with anorectal involvement in a 7-year-old Yemeni boy living in the south of Saudi Arabia. He had abdominal pain, abdominal distension, rectal bleeding, weight loss, perianal swelling and redness, and peripheral eosinophilia. The abdominal computed tomographic (CT) scan revealed significant wall thickness of the rectum. Histopathological findings of full thickness biopsy were consistent with basidiobolomycosis. The patient was treated with voriconazole and showed marked improvement. This case highlights the importance of considering GIB in children presenting with bleeding per rectum and eosinophilia associated with anorectal mass.

Impairment of early fracture healing by skeletal muscle trauma is restored by FK506

BackgroundHeightened local inflammation due to muscle trauma or disease is associated with impaired bone regeneration.MethodsWe hypothesized that FK506, an FDA approved immunomodulatory compound with neurotrophic and osteogenic effects, will rescue the early phase of fracture healing which is impaired by concomitant muscle trauma in male (~4 months old) Lewis rats. FK506 (1 mg/kg; i.p.) or saline was administered systemically for 14 days after an endogenously healing tibia osteotomy was created and fixed with an intermedullary pin, and the overlying tibialis anterior (TA) muscle was either left uninjured or incurred volumetric muscle loss injury (6 mm full thickness biopsy from middle third of the muscle).ResultsThe salient observations of this study were that 1) concomitant TA muscle trauma impaired recovery of tibia mechanical properties 28 days post-injury, 2) FK506 administration rescued the recovery of tibia mechanical properties in the presence of concomitant TA muscle trauma but did not augment mechanical recovery of an isolated osteotomy (no muscle trauma), 3) T lymphocytes and macrophage presence within the traumatized musculature were heightened by trauma and attenuated by FK506 3 days post-injury, and 4) T lymphocyte but not macrophage presence within the fracture callus were attenuated by FK506 at 14 days post-injury. FK506 did not improve TA muscle isometric torque productionConclusionCollectively, these findings support the administration of FK506 to ameliorate healing of fractures with severe muscle trauma comorbidity. The results suggest one potential mechanism of action is a reduction in local T lymphocytes within the injured musculoskeletal tissue, though other mechanisms to include direct osteogenic effects of FK506 require further investigation.

Gastroparesis Updates on Pathogenesis and Management.

Gastroparesis (Gp) is a chronic disease that presents with clinical symptoms of early satiety, bloating, nausea, vomiting, and abdominal pain. Along with these symptoms, an objective finding of delayed gastric emptying, along with a documented absence of gastric outlet obstruction, are required for diagnosis. This article focuses on updates in the pathogenesis and management of Gp. Recent studies on full thickness biopsies of Gp patients have shed light on the complex interactions of the central, autonomic, and enteric nervous systems, which all play key roles in maintaining normal gut motility. The management of Gp has evolved beyond prokinetics and antiemetics with the use of gastric electrical stimulators (GES). In addition, this review aims to introduce the concept of gastroparesis-like syndrome (GLS). GLS helps groups of patients who have the cardinal symptoms of Gp but have a normal or rapid emptying test. Recent tests have shown that patients with Gp and GLS have similar pathophysiology, benefit greatly from GES placement, and likely should be treated in a similar manner.

Acellular Biological Scaffold Repair Does Not Overcome the Pathobiology of Volumetric Muscle Loss Injury

Volumetric muscle loss (VML) resulting from extremity trauma presents chronic and persistent functional deficits, restricted joint range of motion, and fibrosis, which ultimately manifest disability. Currently, there is a clinical need for therapies aimed at addressing the debilitating outcomes due to VML injuries. Recent investigations have examined the use of commercially available biological scaffolds as a regenerative medicine approach for VML. However, there is a paucity of large animal data to advance clinical translation. We hypothesized that repair of VML injuries with an acellular biologic scaffold would improve function, specifically neuromuscular strength following injury. To test this hypothesis, female Yorkshire Cross pigs (n=10) were randomized to sham or an ~20% VML injury to the peroneous tertius muscle, and injuries were left non‐repaired, or surgically repaired with an acellular biologic scaffold derived from either porcine small intestinal submucosa (SIS) or urinary bladder matrix (UBM) using standard clinical surgical implantation procedures. Analysis of muscle volume using CT imaging and muscle function via peroneal nerve stimulation was conducted through 12 weeks post‐injury. At this terminal time‐point, full thickness biopsy samples were used for histological analysis and sequencing of RNA extracted from the injured muscle tissue. All studies were conducted in compliance with the Animal Welfare Act, the Implementing Animal Welfare Regulations and in accordance with the principles of the Guide for the Care and Use of Laboratory Animals. Unexpected adverse advents occurred in 80% of the VML injuries repaired with the SIS scaffold. Both the repair with SIS and UBM resulted in a significant fibrotic response and increased volume of the anterior compartment. However, this volume could not be attributed to increased muscle, as histologic analysis of the muscle indicated sub‐physiologic islands of muscle fibers (~50 fibers). To understand the quality of muscle, peak muscle torque was normalized to the CT‐derived volume of the anterior compartment at 10 weeks post‐injury. Collectively in the non‐ and ECM‐repaired limbs there was ~45% deficit compared to sham operated limbs. Additionally, in both the non‐ and ECM‐repaired limbs there was an ~30% deficit in absolute peak isometric torque through 12 weeks post‐injury. Tissue level RNA sequencing analysis of the non‐repaired and surgically repaired samples compared to Sham controls revealed increases in expression of sets of genes associated with inflammatory signaling and fibrogenesis and downregulation of myogenic repair gene sets. Quantitative comparison of the transcriptomes from surgically repaired samples against the non‐repaired samples indicated high degrees of correlation amongst the differentially expressed genes. These results indicate the gene expression programs induced from a VML insult are not appreciably augmented when treated with surgical repair of an acellular biologic scaffold. Collectively, these data indicate that VML results in extensive and continued disruption of the remaining musculature and that ECM repair does not ameliorate the resulting pathobiology.

Morphea and Eosinophilic Fasciitis: An Update.

Morphea, also known as localized scleroderma, encompasses a group of idiopathic sclerotic skin diseases. The spectrum ranges from relatively mild phenotypes, which generally cause few problems besides local discomfort and visible disfigurement, to subtypes with severe complications such as joint contractures and limb length discrepancies. Eosinophilic fasciitis (EF, Shulman syndrome) is often regarded as belonging to the severe end of the morphea spectrum. The exact driving mechanisms behind morphea and EF pathogenesis remain to be elucidated. However, extensive extracellular matrix formation and autoimmune dysfunction are thought to be key pathogenic processes. Likewise, these processes are considered essential in systemic sclerosis (SSc) pathogenesis. In addition, similarities in clinical presentation between morphea and SSc have led to many theories about their relatedness. Importantly, morphea may be differentiated from SSc based on absence of sclerodactyly, Raynaud’s phenomenon, and nailfold capillary changes. The diagnosis of morphea is often based on characteristic clinical findings. Histopathological evaluation of skin biopsies and laboratory tests are not necessary in the majority of morphea cases. However, full-thickness skin biopsies, containing fascia and muscle tissue, are required for the diagnosis of EF. Monitoring of disease activity and damage, especially of subcutaneous involvement, is one of the most challenging aspects of morphea care. Therefore, data harmonization is crucial for optimizing standard care and for comparability of study results. Recently, the localized scleroderma cutaneous assessment tool (LoSCAT) has been developed and validated for morphea. The LoSCAT is currently the most widely reported outcome measure for morphea. Care providers should take disease subtype, degree of activity, depth of involvement, and quality-of-life impairments into account when initiating treatment. In most patients with circumscribed superficial subtypes, treatment with topical therapies suffices. In more widespread disease, UVA1 phototherapy or systemic treatment with methotrexate (MTX), with or without a systemic corticosteroid combination, should be initiated. Disappointingly, few alternatives for MTX have been described and additional research is still needed to optimize treatment for these debilitating conditions. In this review, we present a state-of-the-art flow chart that guides care providers in the treatment of morphea and EF.

Horizontal and Vertical Distribution of CD3+ Lymphocytes in the Intestine of Healthy Adult and Neonatal Dogs

T-lymphocytes are considered to play an essential role in the pathogenesis of inflammatory bowel disease. The goal of this study was an objective determination of the distribution of gastrointestinal CD3+ lymphocytes in a standardized dog population as a gold standard for further investigations. Full thickness biopsies were obtained from seven different localizations from stomach to colon from six adults and four neonatal healthy Beagle dogs. The tissue was stained with an anti-CD3 antibody. The positive cells were counted in an area of 200,000 μm2 at four different sites per localization. In adult dogs, the horizontal distribution showed a maximum of CD3+ lymphocytes in the duodenum and jejunum. In the stomach, almost no positive cells were observed. The vertical distribution revealed an accumulation in the villi. The neonatal dogs showed a similar distribution pattern, but on average ten times less CD3+ lymphocytes in the analogous localizations and smaller differences between localizations.

MULTIMODAL IMAGING AND HISTOLOGIC CORRELATION OF ISOLATED METASTASIS OF PROSTATE ADENOCARCINOMA TO THE CHOROID

To provide correlative clinical-multimodal imaging-histopathologic findings of isolated prostatic choroidal metastasis. Ophthalmologic examination, fluorescein angiogram, spectral-domain optical coherence tomography, fundus autofluorescence, computerized tomography, magnetic resonance imaging, positive emission tomography, CSF analysis, serologies, tissue pathology with immunohistochemistry, and examination of relevant literature. A 76-year-old man with a history of prostate adenocarcinoma was referred for 2 months of unilateral blurry vision. Fundus examination revealed elevated deep orange choroidal lesions in the macula with overlying retinal pigment epithelium mottling and subretinal fluid. Fluorescein angiogram demonstrated alternating areas of hypofluorescence and hyperfluorescence (staining) without leakage. Optical coherence tomography revealed dome-shaped and lumpy choroidal lesions with surrounding undulating "lumpy bumpy" and "rippled/seasick" patterns. Workup for a primary or additional metastatic lesion including computerized tomography of head/chest/abdomen/pelvis, lumbar puncture, magnetic resonance imaging brain, and whole-body positive emission tomography scan was negative. Full-thickness excisional chorioretinal biopsy was obtained through pars plana vitrectomy with diathermy and vertical scissors. Histologic examination revealed adenocarcinoma with weak positive staining for prostate specific antigen, moderate positive staining for P501S (prostein), and strong positive staining for prostatic acid phosphatase, consistent with metastasis from a prostate primary. Treatment consisted of local radiation with regression of the metastatic tumor. The patient is also on concomitant androgen deprivation treatment because there is a very high incidence of systemic recurrence due to hematogenous involvement. The patient's vision has continued to improve 6 months past treatment. The authors present a unique case to highlight the multimodal imaging and histology of a rare presentation of biopsy-proven, isolated metastasis of prostate adenocarcinoma to the choroid. Systemic workup is required, and if unrevealing of a primary or metastatic lesion, full-thickness chorioretinal biopsy and histopathology can provide a definitive diagnosis, allowing optimal treatment. Chorioretinal biopsy is a useful technique and may allow for visual preservation while also giving superior histologic quality.

A 67-Year-Old Patient with Severe Generalized Oedema

We report a case of a 67-year-old Caucasian man who was admitted to the emergency department with severe and generalized oedema accompanied by a rash of both lower legs. The patient was treated with loop diuretics throughout four months without success. Laboratory examinations displayed a leukocytosis with a high proportion of eosinophils. A comprehensive diagnostic work up was started. Finally, a full-thickness skin biopsy including fascia showed eosinophilic infiltration suitable for an eosinophilic fasciitis. Briefly after starting a glucocorticoid therapy the patient lost 10 kg on body weight, the generalized oedema resolved.

Familiar Occurrence of Desmosis of the Colon – Report of Two Cases and Literature Review

Gastrointestinal motility disorders are relatively common in children and adolescents. The diagnosis is often difficult and time-consuming as the etiology of the problems includes different pathological entities such as enteric neuropathies, myopathies and collagenopathies. Hirschsprung's disease (HD) is one of the most common and best recognized disorders, particularly in infants. Whereas, desmosis of the colon is a rare condition characterized by total or focal lack of connective-tissue net of the circular and longitudinal muscles without any abnormalities within enteric nervous system (ENS). Its diagnosis is based on full-thickness intestinal biopsy or post-operative material followed by histological staining with pricrosirius red. We present two adolescent girls who were familiar related (the same mother, different fathers) and both of them suffered from chronic constipations. HD was excluded in these cases and surgical removal of impaired part of intestines was performed. Material from post-operative specimens proved desmosis of the colon in each patient.

Updates in Ocular Surface Tumor Diagnostics.

Purpose To evaluate technologies and techniques available for the diagnosis of ocular surface tumors. Methods A review of the literature from 1947 to 2017, through the PubMed Database, was conducted in order to evaluate current diagnostic methods for ocular surface tumors. Results Ocular surface squamous neoplasia, conjunctival melanoma, and conjunctival lymphoma are the three most common ocular surface malignancies. Technologies available to assist with diagnosis of these conditions, in addition to full thickness biopsy, include vital dyes, aspiration and impression cytology, in vivo confocal microscopy, ultrasound biomicroscopy, genetic testing, and anterior segment optical coherence tomography. Conclusions Histology remains the gold standard for diagnosis for all 3 of these malignancies. However, multiple diagnostic techniques are available to assist in making preliminary and early diagnoses, in differentiating between similar-appearing lesions, and in some cases, avoiding biopsy prior to initiating treatment. As imaging and technology continue to evolve, these adjunctive techniques will likely continue to play a greater role in clinical practice.