Microscopic Pathologic Features Research Articles

Pathological Features of Colorectal Adenocarcinoma Patients Related to MLH1.

MLH1, one of the MMR proteins, is linked to DNA replication, its role being to repair the incorrect DNA sequences and to replace them with proper ones. The loss of the MLH1 gene expression is part of Lynch syndrome which can lead to a series of cancers like colorectal and endometrial ones. The aim of this paper is to correlate the levels of MLH1 in four different bio-logical fluids with clinicopathological features in colorectal cancer patients in order to predict them with high probability. Therefore, a mathematical model with given code in Matlab has been proposed to get the clinicopathological features with high probability by only introducing the values for MLH1 concentrations. All these data can be obtained in a very short time even before surgery which can be very helpful the surgeon and the oncologist. Four types of samples (whole blood, saliva, urine and tissue) were analyzed using stochastic microsensors; concentrations of MLH1 were determined and compared with different macroscopic and micro-scopic pathological features to obtain mathematical models for early, non-invasive diagnostic of colorectal adenocarcinoma. There have been established criteria and mathematical models for tumor location, TNM grading system, depth of the tumor, lymphatic, vascular and perineural invasions and the presence of mucus in the tumoral mass. By using whole blood, saliva and urine samples, the location can be approximated. The proposed mathematical models aimed to allow a minim/noninvasive characterization of the tumor and its location which can help the surgeon and the oncologist to choose faster the personalized treatment.

Correlations between MSH2 and MSH6 Concentrations in Different Biological Fluids and Clinicopathological Features in Colorectal Adenocarcinoma Patients and Their Contribution to Fast and Early Diagnosis of Colorectal Adenocarcinoma.

(1) Background: The human MutS homolog, hMSH2, is known to be involved in DNA mismatch repair and is responsible for maintaining the stability of the genome. When DNA damage occurs, MSH2 promotes cell apoptosis via the regulation of ATR/Chk2/p53 signal transduction, and MSH2 deficiency is also related to accelerated telomere shortening in humans. MSH2 missense mutations are involved in a defective DNA reparation process, and it can be implied in carcinogenesis, as it is already involved in well-known cancer-related syndromes such as Lynch syndrome. Human MSH6, which stands for mutS homolog 6, is a member of the MMR family that is responsible for the repair of post-replicative mismatched DNA bases. It is also one of the proteins with gene mutations that are associated with a high risk of developing Lynch syndrome, leading to a large series of tumors. (2) Methods: Patients and their clinical and pathological features were selected from the database of the project GRAPHSENSGASTROINTES and used accordingly, with ethics committee approval no. 32647/2018 awarded by the County Emergency Hospital from Targu-Mures. Analyses were conducted on whole blood, saliva, urine, and tumoral tissue samples using a stochastic method with stochastic microsensors. (3) Results: The results obtained using stochastic sensors were correlated with a series of macroscopic and microscopic pathological features for each sample type. Criteria or relationships were established for tumor location, vascular and perineural invasions, lymph node metastases, the presence of tumor deposits, and the presence of a mucus compound in the tumor mass. (4) Conclusions: The correlation between the concentrations of MSH2 in the four types of samples and the pathological features allowed for the fast characterization of a tumor, which can help surgeons and oncologists choose personalized treatments. Also, the colorectal tumor location was correlated with the concentration of MSH2 in whole blood, urine, and saliva. MSH6, which stands for mutS homolog 6, is not only useful in immunohistochemistry but in pathology practice as well. In this paper, the relationships between MSH6 levels in four biological fluids-whole blood, saliva, urine, and tissues-and tumor locations among the colorectal area, gross features, presence of a mucinous compound, molecular subtype, stroma features, and vascular invasions are presented.

Pathological features of West Nile and Usutu virus natural infections in wild and domestic animals and in humans: A comparative review

Mosquito-borne flaviviruses are emerging pathogens with zoonotic potential. Due to the recent climate and environmental changes, they are spreading across Europe, becoming a major threat for public and veterinary health. West Nile virus (WNV) and Usutu virus (USUV) are arboviruses that are responsible for multiple disease outbreaks in different species of birds, reptiles, and mammals, including humans. This review reports and compares the clinical signs as well as the gross and microscopic pathological features during natural infection with WNV and USUV in wild and domestic animals, as well as in humans. The main objective of this comparative review is to delineate the common features and the specific differences that characterize WNV- and USUV-induced diseases in each group of species and to highlight the main gaps in knowledge that could provide insight for further investigation on the pathogenesis and neurovirulence of these viruses.

Hereditary neuropathies: Genetics and utility of nerve biopsy.

Peripheral neuropathy is one of the most common neurological conditions of the nervous system. Hereditary neuropathies (HNs) form an important group with varying degrees of severity, causing a significant disease burden. Accurate diagnosis is essential for management, counseling, and preventing unnecessary extended workups for acquired etiologies and inappropriate treatment. Several hereditary neuropathies have characteristic or diagnostic histologic findings; however, in the era of molecular diagnostics, the role of nerve biopsy in the diagnosis of hereditary neuropathy has reduced significantly. Nevertheless, in sporadic cases, cases without a clear family history, clinical mimics, cases with rare mutations, and genetic variants of unknown significance, a nerve biopsy can confirm the diagnosis, provide an unexpected diagnosis, or direct a targeted molecular testing. HN may be non-syndromic, affecting predominantly the peripheral nervous system or syndromic where it is a part of more widespread neurological or multisystem involvement. This review summarizes the microscopic pathological features in a nerve biopsy in some of the more commonly encountered inherited peripheral neuropathies highlighting their utility in selected cases.

Muerte súbita cardíaca asociada a enfermedades mitocondriales

Mitochondrial diseases (MD) constitute a heterogeneous group of genetic disorders that result from the dysfunction of the final common pathway of energy metabolism. The responsible mutation can be found in genes encoded in nuclear DNA or in mitochondrial DNA, causing differences in the clinical presentation and inheritance pattern. Most of these diseases have a multisystemic impact, mainly affecting tissues with a high oxidative energy requirement (heart muscle, skeletal muscle, and brain, for instance). Although death in DM is usually related to the clinical severity of the disease, sudden cardiac death (SCD) is possible also in patients with mild manifestations or even in asymptomatic individuals. This review aims to identify reported cases of SCD in MD (either diagnosed in life or at post mortem studies) and comprehensively analyze the macroscopic and microscopic pathological features described. There are only few documented cases (27), but the lack of notable cardiac phenotypic features in some cases, their low specificity, the scarce clinical personal and family information when the autopsy is performed and the little awareness of these diseases among doctors raise the suspicion that MD are infradiagnosed and many cases remain overlooked. Definitely, a correct diagnosis requires a high level of suspicion and a multidisciplinary approach with pathological and cardiological specialized tests both in the deceased proband and in the at-risk relatives to confirm or discard DM in order to tailor the follow-up, treatment and genetic counselling.

Histopathology of Third Trimester Placenta from SARS-CoV-2-Positive Women

Background: This study aims to investigate whether maternal SARS-CoV-2 status affects placental pathology. Methods: A retrospective case-control study was conducted by reviewing charts and slides of placentas delivered between April 1 to July 24, 2020. Clinical history of “COVID-19” was searched in Pathology Database (CoPath). Controls were matched with SARS-CoV-2-negative women with singleton deliveries in the 3rd-trimester. Pathological features were extracted from placental pathology reports. Results: Twenty-one 3rd trimester placentas from SARS-CoV-2-positive women were identified and compared to 20 placentas from SARS-CoV-2-negative women. There were no significant differences in individual or group gross or microscopic pathological features. Within the SARS-CoV-2+ group, there are no differences between symptomatic and asymptomatic women. Conclusion: Placentas from SARS-CoV-2-positive women do not demonstrate a specific pathological pattern. Pregnancy complicated with COVID-19 during the 3rd trimester does not have a demonstrable effect on placental structure and pathology.

Deep learning pathological microscopic features in endemic nasopharyngeal cancer: Prognostic value and protentional role for individual induction chemotherapy.

BackgroundTo explore the prognostic value and the role for treatment decision of pathological microscopic features in patients with nasopharyngeal carcinoma (NPC) using the method of deep learning.MethodsThe pathological microscopic features were extracted using the software QuPath (version 0.1.3. Queen's University) in the training cohort (Guangzhou training cohort, n = 843). We used the neural network DeepSurv to analyze the pathological microscopic features (DSPMF) and then classified patients into high‐risk and low‐risk groups through the time‐dependent receiver operating characteristic (ROC). The prognosis accuracy of the pathological feature was validated in a validation cohort (n = 212). The primary endpoint was progression‐free survival (PFS).ResultsWe found 429 pathological microscopic features in the H&E image. Patients with high‐risk scores in the training cohort had shorter 5‐year PFS (HR 10.03, 6.06‐16.61; P < .0001). The DSPMF (C‐index: 0.723) had the higher C‐index than the EBV DNA (C‐index: 0.612) copies and the N stage (C‐index: 0.593). Furthermore, induction chemotherapy (ICT) plus concomitant chemoradiotherapy (CCRT) had better 5‐year PFS to those received CCRT (P < .0001) in the high‐risk group.ConclusionThe DSPMF is a reliable prognostic tool for survival risk in patients with NPC and might be able to guide the treatment decision.

1164P - Development and validation a nomogram based on pathological microscopic features to predict survival in nasopharyngeal carcinoma and guide treatment decision

BackgroundIn various types of solid tumor, pathological microscopic features can be used as prognostic biomarkers. We intended to develop a pathological microscopic features (PMFs) pattern for individual survival assessment in patients with nasopharyngeal carcinoma (NPC). MethodsWe retrospectively included 1229 patients with NPC who had received radical radiotherapy with/without chemotherapy. The PMFs differently digitized were extracted using the software QuPath (version 0.1.2.Queen’s University Belfast, Belfast, Northern Ireland, UK) in the training cohort (Guangzhou training cohort, n=739) to bulid a pathological feature classifier using a penalized regression model. The prognostic accuracy of the pathological feature classifier was validated in the internal validation cohort (Guangzhou validation cohort, n=316) and one external validation cohort (Chenzhou validation cohort, n=170).The primary end point was progression-free survival (PFS) and distant metastasis-free survival (DMFS). ResultsWe found 143 PMFs in the H&E image of NPC with the whole slide image (WSI) scanning. In the training cohort a pathological micromarker of survival risk in NPC (PMSRN) that consisted of 14 PMFs was generated to classify patients into high-risk and low-risk groups. Patients with high-risk scores in the training cohort had shorter PFS (HR 2.16, 1.61 -2.89; p=0.000), and DMFS (HR 1.87, 1.27 -2.75; p=0.001) than patients with low-risk scores. We developed a nomogram based on the PMSRN and other variables that predicted an individual’s survival risk and the c-index of this nomogram (C-index=0.759, 95% CI: 0.717 -0.801) was equal to other nomograms. Furthermore, among patients with high-risk scores in the combined training and internal cohorts, ICT had better PFS to those who received CCRT alone (p=0.033), whereas those with low-risk scores ICT had similar PFS to CCRT alone (p=0.363). These results were validated in the internal external validation cohort. ConclusionsThe PMSRN is a reliable prognostic tool for survival risk in NPC patients and might be able to predict which patients need to receive ICT or not. It might guide treatment decisions for NPC patients. Clinical trial identificationChiECRCT20190034. Legal entity responsible for the studySun Yet-sen University Cancer Center. FundingNational Natural Science Foundation of China. DisclosureAll authors have declared no conflicts of interest.

Clinical and pathological analysis of small renal cell carcinoma

To analyze the clinical and pathological features of small renal cell carcinoma (RCC), especially of those with diameter less than 4 cm and to understand the characteristics and factors related to recurrence and progression. A total of 200 patients with RCC were stratifiedly selected for retrospective analysis. Their baseline demographic features, tumor-specific clinical features, pathological features of renal lesions, especially microscopic features were collected. The patients were divided according to the largest diameter of renal tumor lesions. Univariate analysis was used to compare the differences between tumor staging and microscopic pathological features between the groups. Binary multivariate Logistic regression was used to investigate factors related to tumor progression and prognosis in the patients with small RCC. The tumor diameters of 127 RCC patients were less than 4 cm and most of them had clear cell renal cell carcinoma (ccRCC). The increase in tumor diameter resulted in significantly higher T stage (P<0.01), higher WHO/International Society of Urological Pathology (ISUP) grade (P<0.05) and increasing chance of lymph node metastasis (P<0.01). Even when the tumor diameter was less than 4 cm, the patients might still have perirenal fat invasion, renal sinus invasion and greater elevated tumor grade (greater than grade 3) and synchronous lung metastasis. The incidences of intravascular thrombus (9.3% vs. 0) and tumor necrosis (27.8% vs. 5.5%) in the patients with RCC between 4-7 cm were significantly higher than those with RCC less than 4 cm (P<0.01). Sub-group analysis of small RCC (less than 4 cm) indicated that the patients with RCC between 2-4 cm were more likely to have intratumoral hemorrhage (44.7% vs. 23%, P<0.05) and necrosis than those with RCC less than 2 cm (8.2% vs. 0, P=0.095). Logistic regression analysis of small RCC showed that the incidence of tumor invasion to renal capsule was higher in ccRCC (OR=5.15, 95%CI: 1.36-19.52). Necrosis was closely related to the formation of peritumor pseudocapsule in small RCC (OR=14.90, 95%CI: 1.41-157.50). Increase in the tumor diameter was related to higher tumor grade (greater than grade 3) (OR=3.49, 95%CI: 1.11- 10.93). The tumor stage and grade of small RCC (less than 4 cm) are low, but extra-renal invasion and synchronous distant metastasis may occur. Internal hemorrhage and necrosis in tumor, ccRCC subtype, along with microscopic features, such as the renal capsule invasion and perirenal pseudocapsule formation are relevant factors of malignant behavior of small RCC and could be considered in prognosis evaluation.

Adaptive optics ophthalmoscopy: Application to age-related macular degeneration and vascular diseases.

Adaptive optics (AO)-enhanced en face retinal imaging, termed here AO ophthalmoscopy (AOO) has reached a level of robustness which fuels its increasing use in research and clinical centers. Here we will review the contribution of clinical AOO to the understanding and monitoring of 1) age-related macular degeneration and 2) vascular diseases. The main contributions of AOO to the phenotyping of AMD are a better identification of drusen, a better delineation of the limits of atrophy, and the identification of novel features such as punctate hyperreflectivity and mobile melanin-containing clumps. Characterization of progression of atrophy is facilitated by time-lapse imaging. In vessels, AOO enables the observation and measurement of parietal structures and the observation of microscopic pathological features such as small hemorrhages and inflammatory cell accumulations.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Pathology Standards and Datasets.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Pathology Standards and Datasets.

Chronic bowel inflammation and inflammatory joint disease: Pathophysiology

Bowel inflammation is closely linked to chronic joint inflammation. Research reported in the 1980s demonstrated bowel inflammation with gross and microscopic pathological features identical to those of Crohn's disease in over 60% of patients with spondyloarthritis (SpA). Numerous prospective studies have evidenced joint involvement in patients with chronic inflammatory bowel disease (IBD) and bowel inflammation in patients with SpA. Nevertheless, the interactions of joint disease and chronic bowel inflammation remain incompletely elucidated. Two main hypotheses have been suggested to explain potential links between inflammation of the mucosal immune system and peripheral arthritis: one identifies gut bacteria as potentially implicated in the development of joint inflammation and the other involves the recruitment of gut lymphocytes or activated macrophages to the joints. Pathophysiological investigations have established that HLA-B27 is a pivotal pathogenic factor. Here, we review current data on links between chronic bowel inflammation and inflammatory joint disease.

Clinicopathologic Review of 31 Cases of Solid Pseudopapillary Pancreatic Tumors: Can We Use the Scoring System of Microscopic Features for Suggesting Clinically Malignant Potential?

A solid pseudopapillary tumor (SPT) is a pancreatic neoplasm of low malignant potential. The potentially malignant pathologic features of SPTs were regarded as angioinvasion, perineural invasion, deep invasion of the surrounding acinar tissue, and nuclear pleomorphism. We retrospectively reviewed 31 cases of SPTs (25 female and 6 male patients, with an average age of 35 ± 14 years). The mean follow-up period was 132.0 ± 55.9 months. To evaluate the clinical impact of above pathological parameters, we analyzed their correlation with actually observed clinical malignancy. In three cases, the SPTs were clearly clinically malignant: one patient had recurrences three times, one showed lymph node metastases, and one deep soft tissue invasion around the gastroduodenal artery. Tumor infiltration to the peripancreatic soft tissue was observed in 17 cases (54.8%). The pathologic features considered suggestive of malignant potential were angioinvasion (25.8%), perineural invasion (6.5%), presence of mitosis in 10 high-power fields (16.1%), and moderate nuclear pleomorphism (19.4%). The presence of at least three of these features was not correlated with clinically confirmed malignant behavior (P = 0.570). Microscopic pathologic features of SPTs cannot be reliably associated with aggressive clinical behavior. Moreover, the absence of these microscopic features cannot exclude clinical malignancy.

Eumycetoma Osteomyelitis of the Calcaneus in a Child: A Radiologic-Pathologic Correlation following Total Calcanectomy.

Fungi are unusual causes of pedal osteomyelitis in children and adolescents. Eumycetoma is a chronic cutaneous and subcutaneous infection caused by various genera of fungi. A provisional diagnosis of foot mycetoma is made after clinical assessment. Radiologic-pathologic correlation is an essential supplement for the accurate diagnosis of osteoarticular infections. This paper aims to sensitize orthopedic surgeons, radiologists, and pathologists to the importance of correlative imaging findings in relation to surgical and microscopic pathology in osteoarticular infections, specifically eumycetoma osteomyelitis of the foot. From our review of the published data, the present case is the first report of radiologic-pathologic correlation in eumycetoma osteomyelitis of the calcaneus. This paper describes a case of eumycetoma osteomyelitis of the calcaneus in a child in which diagnostic X-rays and magnetic resonance imaging (MRI) were correlated with the surgical and microscopic pathologic features, for establishing an appropriate diagnosis and treatment. We conclude that there is a significant agreement between radiologic and pathologic evaluation for assessment of eumycetoma osteomyelitis of the calcaneus. Radiologic-pathologic correlation amplified our interpretation of imaging information available on plain radiographs and MRI and augmented diagnostic confidence. Similarly, anatomic-histopathological correlations consolidated diagnostic accuracy.

Identification of pathologic features associated with "ulcerative colitis-like" Crohn's disease.

To identify pathologic features associated with this "ulcerative colitis (UC)-like" subgroup of Crohn's disease (CD). Seventeen subjects diagnosed as having UC who underwent proctocolectomy (RPC) from 2003-2007 and subsequently developed CD of the ileal pouch were identified. UC was diagnosed based on pre-operative clinical, endoscopic, and pathologic studies. Eighteen patients who underwent RPC for UC within the same time period without subsequently developing CD were randomly selected and used as controls. Pathology reports and histological slides were reviewed for a wide range of gross and microscopic pathological features, as well as extent of disease. The demographics, gross description and histopathology of the resection specimens were reviewed and compared between the two groups. Patients with "UC-like" CD were on average 13 years younger than those with "true" UC (P < 0.01). More severe disease in the proximal involved region and active ileitis with/without architectural distortion were observed in 6 of 17 (35%) and 7 of 17 (41%) "UC-like" CD cases, respectively, but in none of the "true" UC cases (P < 0.05). Active appendicitis occurred in 8 of 16 (50%) "UC-like" CD cases but in only two (11%) "true" UC cases (P < 0.05). Conspicuous lamina propria neutrophils were more specific for "UC-like" CD (76% vs 22%, P < 0.05). In addition, prominent lymphoid aggregates tended to be more common in "UC-like" CD (P = 0.07). The "true" UC group contained a greater number of cases with severe activity (78% vs 47%). Therefore, the features more commonly seen in "UC-like" CD were not due to a more severe disease process. Crohn's granulomas and transmural inflammation in non-ulcerated areas were absent in both groups. More severe disease in the proximal involved region, terminal ileum involvement, active appendicitis, and prominent lamina propria neutrophils may be morphological factors associated with "UC-like" CD.

Abstract P1-17-02: Male breast carcinoma: A clinicopathological and immunohistochemical characterization study

Abstract AIM Male breast carcinoma is a relatively rare disease. This study retrospectively investigated the clinicopathological features of male breast carcinoma in Chinese population, and classified the molecular subtype based on surrogate immunohistochemical definitions. The expression of GCDFP15, MGB, AR and FOXP1 were also evaluated. METHODS Clinical and pathological data on 73 cases of male breast carcinoma were collected and microscopic pathological features were examined. Immunostaining for ER, PR, HER2, Ki-67, CK5/6, EGFR, GCDFP15, MGB, AR and FOXP1 was performed and the molecular subtype was classified. RESULTS Invasive carcinoma of no special type was the major histological type in our study group (71.2%, 52/73). Except for 4 cases of carcinoma in situ, forty-two male invasive carcinomas (42/69, 60.9%) were classified as luminal A subtype while 24 cases (24/69, 34.8%) were classified as luminal B subtype. Only 2 cases of basal-like subtype and 1 case of HER2 positive subtype were identified in this group. Nuclear immunostaining of AR and FOXP1 could be observed in 82.4% (48/57) and 71.9% (41/57) of the cases respectively. Cases of luminal A subtype expressed GCDFP15 (73.5%, 25/34) and MGB (58.8%, 20/34) more frequently than those of luminal B subtype (34.8%, 8/23 and 43.5%, 10/23, respectively). CONCLUSIONS Invasive carcinoma of no special type was the most common histological type in male breast carcinoma. Our study revealed that luminal A and B subtypes were the major types of male breast carcinoma. AR and FOXP1 were highly expressed in male breast cancer. Luminal A subtype tends to express GCDFP15 and MGB more frequently than luminal B subtype. KEYWORDS: breast carcinoma, male, molecular subtype, immunohistochemistry. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-17-02.

Cystic lesions of the adrenal gland: our experience over the last 20 years

Cystic lesions of the adrenal gland are uncommon, often presenting with nonspecific clinical and radiologic findings, and are thus underrecognized. They are occasionally associated with malignant neoplasms, which can greatly mimic benign lesions and carry detrimental clinical consequences if misdiagnosed. Here we present our 20-year experience (1992-2012) with these lesions at an academic medical center. Among more than 4500 adrenal gland specimens, 31 cases of adrenal lesions with a predominant cystic component were identified in 30 patients with an age range of 34 to 86 years (median, 55.5 years) and a male/female ratio of 13:17. Macroscopic descriptions, available histologic and immunostain slides, and available radiologic records were reviewed for all included cases. Radiologic studies and gross examination correlated well, and hemorrhage (26 cases; 84%) and encapsulation (25 cases; 81%) appeared to be nonspecific radiologic/gross features shared across histologic subtypes. Microscopic review identified 12 cases (39%) of pseudocysts, 2 cases (6%) of endothelium-derived cysts, and 17 cases (55%) of epithelium-derived cysts. Among these 31 cystic adrenal lesions, 2 cases (6%) were malignant neoplasms (1 epithelioid angiosarcoma, 1 adrenocortical carcinoma). Radiologic impression and histopathologic diagnosis were concordant in 11 (73%) of the 15 cases for which radiologic records were available. This study represents the second largest case series to date on cystic adrenal lesions and presents a comprehensive review on their demographic, clinical, radiologic, and gross and microscopic pathologic features, as well as their differential diagnoses.

Diffuse Diseases of the Myocardium: MRI-Pathologic Review of Cardiomyopathies With Dilatation

In this radiologic-pathologic review of the cardiomyopathies, we present the pertinent imaging findings of diffuse myocardial diseases that are associated with ventricular dilatation, including ischemic cardiomyopathy, nonischemic dilated cardiomyopathy, cardiac sarcoidosis, and iron overload cardiomyopathy. Correlation of the key radiologic findings with gross and microscopic pathologic features is presented, to provide the reader with a focused and in-depth review of the pathophysiology underlying each entity and the basis for the corresponding imaging characteristics.

Peliosis Hepatis Presenting as Liver Rupture in a Vulnerable Adult

Liver rupture is a serious, life-threatening event that is commonly due to blunt abdominal trauma, which should be suspected in a patient who is unconscious or unable to communicate. We report an autopsy case of a 28-year-old woman with severe developmental delay who presented to the emergency department with hemoperitoneum due to massive liver rupture and subsequently died without a diagnosis. An autopsy performed by the hospital pathology department confirmed hemoperitoneum due to hepatic rupture. The case was then referred to the medical examiner to exclude a traumatic etiology. After review of the clinical data, radiological images, and gross and microscopic pathological features, a diagnosis of peliosis hepatis was established. This rare entity has been reported previously as a cause of spontaneous, nontraumatic liver rupture and is reported here to demonstrate its characteristic features and potential to present as fatal hepatic rupture in circumstances in which occult injury must be excluded.

Management of Foot and Ankle Trauma

Foot and ankle trauma remains an area of considerable challenge for the treating physician. The confined soft tissue envelope, coupled with high concentrations of force across small joints, produces injuries associated with substantial long-term morbidity. Trauma is experienced in various facets of daily activities, and each year in the United States, fractures and dislocations account for nearly 1 million hospital admissions. 1 The incidence, severity, and mortality of patients suffering polytrauma injuries have declined significantly in the recent years; however, trauma sustained by the foot did not change in comparable ways. 2 Injuries to the foot and ankle are still commonly underestimated or even unnoticed until late in the acute care setting. Foot and ankle trauma encompasses a range of injuries that include fractures of 1 or more of the bones that constitute the foot and ankle and damage to muscles, ligaments, tendons, and neurovascular structures. Trauma is routinely detected by the bone and joint defects, but nonosseous injuries can present a complex combination of gross and microscopic pathologic features. Depending on whether the injury resulted from low or high energy or whether it presents as an open (bone protruding through the skin) or a closed fracture, a significant recovery period may be required. A fracture that heals in a deformed position can cause hindrances, including swelling, pain, inability to bear weight, and inability to wear shoes. Surgeons should initiate treatment as soon as possible, which may be the use of various splinting or bracing constructs or even immediate surgical stabilization of the foot and/or ankle in an external fixator, a metal frame that is put in place with pins inserted into the bone. 3 The external fixator preserves proper length of the joint and can be left in place as the treatment of other injuries continues. 3 Edema in the respective extremity must also be controlled, a process that may take up to several weeks. Furthermore, with