Multiple Biopsies Research Articles

Light chain (AL) amyloidosis following gastrointestinal symptoms that involve multiple organs: a case report

Light chain (AL) amyloidosis is a complex and rare disease characterized by low incidence and diverse clinical manifestations. At the time of diagnosis, most patients exhibit involvement of multiple organs or tissues, leading to severe illness and a poor prognosis. Therefore, early diagnosis, active treatment, and a comprehensive assessment of the disease hold paramount importance. The initial presentation of this rare condition often manifests as gastrointestinal symptoms, posing challenges in clinical identification and differential diagnosis. In this case report, we describe a 70-year-old man with AL amyloidosis, initially misdiagnosed as irritable bowel syndrome and colon polyps. Subsequently, he experienced a series of complications including renal function impairment, pulmonary nodule, pleural effusion, mediastinal lymph node enlargement, spleen enlargement, reduction of white blood cells, red blood cells and platelets, and small intestinal obstruction. Despite multiple pulmonary nodule biopsy and lymph node biopsy, as well as concurrent splenectomy and partial resection of the small intestine, a clear diagnosis remained elusive. Before admission, diarrhea was aggravated, accompanied by emaciation and fatigue. Following the completion of serum immunofixed protein electrophoresis, renal biopsy, bone marrow and rectal biopsy, a conclusive diagnosis of AL amyloidosis involving multiple organs (Mayo 2012 revision stage III) was finally confirmed after a 12-year period. Treatment with proteasome inhibitors, immunomodulators, and glucocorticoids was recommended. The patient underwent methylprednisolone treatment and was discharged after symptom improvement. However, eight months into the follow-up, the patient succumbed to multiple organ failure. The repeated misdiagnoses over the past 12 years were attributed to limited perspectives among some specialists who did not conduct a systematic and detailed medical history analysis or comprehensive physical examinations. Additionally, they did not strictly follow the principle of "monism" in diagnosis. On the contrary, early diagnosis and active treatment of the disease are of great significance to improve the prognosis.

Epstein-Barr virus-positive mucocutaneous ulcer in a patient with ulcerative colitis: a recently described entity to take into account.

Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a new entity recently included in the classification of B-cell lymphoproliferative disorders associated with Epstein-Barr virus (EBV). It is related to immunosuppression and it usually appears in the oropharynx or the skin, being the colon an uncommon location. We present the case of a 31-year-old man with ulcerative proctitis being treated with azathioprine (AZA) and adalimumab (ADA), who was admitted to the hospital due to suspicion of a moderate-severe flare of ulcerative proctitis. Microbiological stool analyses were negative, with a positive fecal calprotectin test (2700 mg/kg). Rectoscopy showed severe endoscopic activity, taking multiple biopsies. Intravenous steroids were started at a dose of 60 mg/day. He presented a favorable clinical and analytical evolution, being discharged from the hospital. The histological results were received at gastroenterology consultation, being compatible with EBVMCU. AZA and ADA were withdrawn, whereas descending steroid regimen and oral and topical mesalazine were continued, being the clinical response adequate.

Two Sides of the Same Coin: Eosinophilic and Herpetic Esophagitis in an Immunocompetent Young Adult.

Dear Editor, We report a case of a 30-year-old woman with an 8-year diagnosis of eosinophilic esophagitis (EoE) treated with swallowed fluticasone propionate throughout this period. She presented to the emergency room with a two-day history of severe odynophagia, aphagia, retrosternal pain, and fever. The patient was febrile and hemodynamically stable, with no visible oropharyngeal lesions. She presented with elevated C-reactive protein (37 mg/L). An esophagogastroduodenoscopy was performed, which revealed white plaque-like lesions with "volcano-like" shallow ulcerations with raised edges on the distal esophagus (Figure 1aandb). Multiple biopsies were taken from both the center and edges of the lesions. The patient was empirically started on intravenous fluconazole due to the suspicion of candida esophagitis. However, the patient's symptoms worsened over the next two days, and acyclovir at a dose of 5 mg/kg was started. The initial work-up showed a positive titer for Herpes Simplex Virus (HSV)-2 IgM (1.6 U/L) and a negative titer for IgG (2.24 U/L), as well as a negative serological study for HSV-1, cytomegalovirus, and human immunodeficiency virus (HIV). Histological examination revealed multinucleated giant cells with nuclear molding and chromatin margination and cells with "ground glass" nuclei, along with typical Cowdry type A intranuclear inclusion bodies and immunohistochemical staining for HSV type 2, confirmed the diagnosis of herpetic esophagitis (Figure 1candd). The patient experienced rapid improvement and was discharged on oral acyclovir therapy at 400 mg/day, completing a total of 14 days of treatment with a total resolution of symptoms.

Conventional paraffin embedding technique and double-embedding technique for minute oral biopsies and delicate pulp tissue - a comparative study

Among oral biopsies, small incisional tissues, have to be preserved all through the processing and embedding to ensure optimal visualization of all the mucosal layers without compromise. Optimal tissue orientation is the most critical step in tissue processing for demonstration of definitive morphology in the sections, which is often more challenging in cases of minute/small or thinner sections using routine paraffin techniques to evaluate accurate diagnosis. Some modification is needed to handle these samples to get a better result. Double embedding technique with some modification has been widely used for small/ thin/ multiple biopsies and gives excellent results in many other fields like general pathology and biotechnology. The double embedding technique though produced excellent and significant results in mucosal biopsies yet, it is of minimal interest among oral pathologists. To best of our knowledge, this is the first study to use double embedding technique for pulp tissues. The present study was aimed to evaluate and compare the ease of embedding and sectioning sections using Agar-Paraffin double embedding technique for small oral mucosal biopsies and thin pulp tissues. A total of 40 oral tissue samples categorized into two groups were taken for the present study. Group I included 20 small oral mucosal biopsy samples of size ranging from 0.2 to 0.5 cm and Group II included 20 pulp tissues obtained from freshly extracted non carious tooth. 10 blocks were prepared by routine paraffin method and 10 blocks were prepared by modified double embedding method for each group. Scores were given by comparing all the criteria with that of the routine paraffin technique. Chi-square test was used for statistical analysis. The average ease score for the Agar-Paraffin double embedded small/minute biopsies showed better scores than the pulp tissue with that of the routine technique. However, no statistically significant difference was seen among embedding and sectioning sections between the two groups. Modified double embedding method is simple and reliable alternative technique that helps in better orientation, processing and sectioning especially for oral small or thin biopsies and delicate pulp tissues.

Hepatic Epithelioid Hemangioendothelioma Mimicking Liver Metastases in a Young Woman.

Teaching point: When confronted with multifocal "metastasis-like" liver lesions without a known primary tumor, in particular in younger female patients, considering hepatic epithelioid hemangioendothelioma (HEHE) in the differential diagnosis can guide pathological examination and potentially avoid the need for multiple invasive biopsies.

Diagnosis and management of erythroderma; a systematic review

Erythroderma, a condition characterized by diffuse erythema and scaling covering at least 90 percent of the skin\'s surface, poses a serious and potentially life-threatening threat. This systematic study aimed to establish diagnosis and management guidelines for erythroderma. Following PRISMA guidelines, a comprehensive review was conducted using PubMed/Medline, Scopus, and Embase databases focusing on English-language articles from 2010 to 2023. From 279 studies, seven articles were included, mainly comprising surveys and analyses of national databases. Erythroderma, as a clinical sign, can manifest as a consequence of various cutaneous and systemic diseases, drug hypersensitivity reactions, and rarely, Sezary syndrome. In pediatric patients, the clinical presentation encompasses a spectrum of acquired and inherited diseases, including infections, inflammatory skin conditions, ichthyoses, and congenital immunodeficiencies. Diagnosing erythroderma proves challenging due to its syndromatic nature, presenting with nonspecific clinical features. Dermatologists must diligently seek cause-oriented clues, employing multiple biopsies to enhance diagnostic accuracy. Initial management should include nutritional expert evaluation, assessment of fluid imbalance, skin barrier maintenance, sedative anti-histamines, and exclusion of secondary bacterial infection. Given its life-threatening potential, erythroderma might necessitate hospitalization. This study provides valuable insights into the complexities of erythroderma diagnosis and highlights essential considerations for effective management.

Patient with Fibroadenoma on Biopsy, Found to have Phyllodes on Final Pathology: A Case Report

Distinguishing between fibroadenomas and phyllodes tumors is a challenge in breast surgery, despite advances in both radiology and pathology. In this case report, we analyze a patient presenting with a breast mass with multiple core needle biopsy results consistent with fibroadenoma, who underwent enucleation and was found to have phyllodes tumor on final pathology, thereby requiring surgical re-excision. This case report highlights the importance of patient clinical presentation in differentiating fibroadenomas and phyllodes tumors and explores how to achieve appropriate margins upon surgical re-excision after prior enucleation of phyllodes tumor via ultrasound localization of a seroma.

Retrospective assessment of immunologic and histologic heterogeneity in granuloma annulare by cytokine staining.

Type 1 (Th1) and Type 2 (Th2) immunity have both been implicated in granuloma annulare (GA). To what extent these pathways contribute to clinical/histologic heterogeneity and/or distinct disease endotypes remains unexplored. We retrospectively analyzed 30 GA biopsies with either palisaded or interstitial histology with and without eosinophils. We performed RNA in situ hybridization to assess how markers of Type 1 (interferon gamma), Type 2 (interleukin [IL]4, IL13, IL5), and Type 3 (IL17A) immunity in GA compared with canonical inflammatory disorders and whether markers correlated with histology. We analyzed another cohort of 14 patients who had multiple biopsies across anatomic space and time for individual conservation of histologic features. Interferon (IFN)G staining is highest in GA relative to other cytokines. Type 2 cytokine staining is less prominent, with IL4 increased in interstitial pattern cases. Eosinophils did not correlate with Type 2 markers. Patients with multiple biopsies display intrapatient variability in histology. Type 1 inflammation predominates over Type 2 inflammation in GA irrespective of histologic pattern. Distinct disease endotypes were not detected.

Microscopic Colitis: A Diagnostic Challenge in Patients with Irritable Bowel Syndrome.

Irritable Bowel Syndrome (IBS) is one of the most frequently diagnosed gastrointestinal disease with a prevalence of 4.1% in the general population. It is diagnosed using the Rome IV criteria. Microscopic colitis (MC), collagenous/lymphocytic colitis is a cause of chronic, watery, non-bloody diarrhea. It is a real challenge to diagnose MC in patients with IBS. The aims of the study were to determine the prevalence of MC in patients initially diagnosed with IBS, as well as to correlate fecal calprotectin levels with the endoscopic findings and microscopic inflammation in MC. This is a retrospective study conducted in a single tertiary center with over 89 IBS patients for a period of 4 years. The patients included were patients diagnosed with IBS predominant diarrhea (IBS-D) and mixed IBS (IBS-M) using the Rome IV criteria. Total colonoscopy was performed in these patients, multiple biopsies being taken and calprotectin levels were measured. Out of a total of 89 IBS-D patients, 58 patients (65.2%) had no microscopic lesions, 12 patients (13.5%) had diverticular disease, 9 patients (10.1%) had non-specific chronic inflammation of the colon mucosa and 10 patients (11.2%) were diagnosed with MC. The calprotectin levels ranged from 49 μg/g to 213 μg/g. Of a total of 10 patients diagnosed with MC, 6 (60%) of them had calprotectin levels <100 μg/g and 4 (40%) had calprotectin levels >100 μg/g. The fecal calprotectin levels were higher in patients diagnosed with MC compared to those who had no microscopic lesions at the histological exam and it was also correlated with the grade of colonic microscopic inflammation. Microscopic colitis is less familiar to physicians and can be clinically misdiagnosed as IBS-D. An early and correct diagnosis is important for an accurate therapy.

Image-localized biopsy mapping of brain tumor heterogeneity: A single-center study protocol.

Brain cancers pose a novel set of difficulties due to the limited accessibility of human brain tumor tissue. For this reason, clinical decision-making relies heavily on MR imaging interpretation, yet the mapping between MRI features and underlying biology remains ambiguous. Standard (clinical) tissue sampling fails to capture the full heterogeneity of the disease. Biopsies are required to obtain a pathological diagnosis and are predominantly taken from the tumor core, which often has different traits to the surrounding invasive tumor that typically leads to recurrent disease. One approach to solving this issue is to characterize the spatial heterogeneity of molecular, genetic, and cellular features of glioma through the intraoperative collection of multiple image-localized biopsy samples paired with multi-parametric MRIs. We have adopted this approach and are currently actively enrolling patients for our 'Image-Based Mapping of Brain Tumors' study. Patients are eligible for this research study (IRB #16-002424) if they are 18 years or older and undergoing surgical intervention for a brain lesion. Once identified, candidate patients receive dynamic susceptibility contrast (DSC) perfusion MRI and diffusion tensor imaging (DTI), in addition to standard sequences (T1, T1Gd, T2, T2-FLAIR) at their presurgical scan. During surgery, sample anatomical locations are tracked using neuronavigation. The collected specimens from this research study are used to capture the intra-tumoral heterogeneity across brain tumors including quantification of genetic aberrations through whole-exome and RNA sequencing as well as other tissue analysis techniques. To date, these data (made available through a public portal) have been used to generate, test, and validate predictive regional maps of the spatial distribution of tumor cell density and/or treatment-related key genetic marker status to identify biopsy and/or treatment targets based on insight from the entire tumor makeup. This type of methodology, when delivered within clinically feasible time frames, has the potential to further inform medical decision-making by improving surgical intervention, radiation, and targeted drug therapy for patients with glioma.

Primary duodenal tuberculosis in an 8-year-old child with gastric outlet obstruction

Primary duodenal tuberculosis (TB) is a rare condition, particularly among children that is easily misdiagnosed even in endemic areas. We present a rare case report of primary duodenal TB in an 8-year-old child who presented with gastric outlet obstruction. Endoscopy-guided biopsies were non-conclusive. The patient underwent exploratory laparotomy and during surgery, a 5 cm×5 cm mass was observed in the first part of the duodenum with thickening of the duodenal wall and mesenteric lymphadenopathy. Multiple biopsies were taken from the mass and lymph nodes, and a gastrojejunostomy was performed to relieve the obstruction. Histopathological examination of the duodenal mass and the lymph node samples showed caseating granuloma and giant cells, which are consistent with duodenal TB. The patient received a 6-month regimen of anti-tubercular treatment including 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by 4 months of isoniazid and rifampicin; he has remained asymptomatic on 3 monthly follow-ups for the past 18 months.

Functional and Molecular Heterogeneity in Glioma Stem Cells Derived from Multiregional Sampling.

Glioblastoma (GBM) is an aggressive and highly heterogeneous primary brain tumor. Glioma stem cells represent a subpopulation of tumor cells with stem cell traits that are presumed to be the cause of tumor relapse. There exists complex tumor heterogeneity in drug sensitivity patterns between glioma stem cell (GSC) cultures derived from different patients. Here, we describe that heterogeneity also exists between GSC cultures derived from multiple biopsies within a single tumor. From biopsies harvested within spatially distinct regions representing the entire tumor mass, we established seven GSC cultures and compared their stem cell properties, mutations, gene expression profiles, and drug sensitivity patterns against 115 different anticancer drugs. The results were compared to 14 GSC cultures derived from other patients. Between the multiregional-derived GSC cultures, we observed only minor differences in their phenotype, proliferative capacity, and global gene expression. Further, they displayed intratumoral heterogeneity in mutational profiles and sensitivity patterns to anticancer drugs. This heterogeneity, however, did not exceed the extensive heterogeneity found between GSC cultures derived from other GBM patients. Our results suggest that the use of GSC cultures from one single focal biopsy may underestimate the overall complexity of the GSC population and display the importance of including GSC cultures reflecting the entire tumor mass in drug screening strategies.

Extrapulmonary Tuberculosis – a Rare Cause of Difficult Evolution in a Case Of Extensive Anoperianal Suppuration

Extrapulmonary tuberculosis is very rare, representing around 15% of all tuberculosis (TB) cases. Intestinal localization of extrapumonary TB occurs in 1% of the cases and is usually associated with HIV infection. The last portion of the ileum and the ileocecal region are most frequently involved, while perianal localization is extremely rare and has clinical and paraclinical aspects similar to Crohn’s disease, thus leading to difficulties in establishing the diagnosis. We present the case of a 41-year-old patient who came to the proctology department with perianal pain and purulent discharge. He was diagnosed by clinical examination and colonoscopy with multiple simple and complex perianal fistulas complicated with a supralevator abscess. Multiple biopsies were taken and the result was necrotizing granulomatous inflammation. The Ziehl-Neelsen test confirmed the suspicion of perianal TB.

10020-ML-1 SENTINEL LESION PRECEDING PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA

Abstract It has been reported that there are rare cases of spontaneous resolution, which are referred to as sentinel lesions in the early stages of primary malignant lymphoma of the central nervous system (PCNSL). In this study, we examined cases of PCNSL that presented with a sentinel lesion. Of the 43 PCNSL cases biopsied at our institution between 2011 and 2022, three cases were difficult to diagnose on initial biopsy. No preoperative steroids were used in all patients, and postoperative CT or MRI confirmed that the lesions were appropriately sampled from the targeted lesions. Since the diagnosis was not confirmed by the initial biopsy and symptoms were stable, the patients were followed up without chemotherapy, but symptoms worsened around 6 months later, and MRI showed recurrent large lesions. Another biopsy was performed in all patients, and a definitive diagnosis of diffuse large B-cell lymphoma (DLBCL) was finally obtained. It has been reported that sentinel lesions in PCNSL are characterized by demyelination or nonspecific inflammation on initial pathology and spontaneous resolution of lesions, which are estimated to be changes mediated by immunological mechanisms. In the present study, the course of symptoms was characterized by a relatively slow progression, and diffusion-weighted images at the initial onset did not show as high a signal as in usual PCNSL. Multiple biopsies are required to make a definitive diagnosis, and careful follow-up of symptoms and images and determination of the appropriate timing of biopsy are important.

THE ROLE OF HISTOLOGICAL FINDINGS IN H. PYLORI-INDUCED GASTRITIS: CLINICAL IMPLICATIONS AND BEYOND

This study aimed to determine the role of histological findings in H. Pylori-induced gastritis. This cohort study involved 80 patients of both genders. The patients were endoscopically and histopathologically examined and followed up within six months after treatment, from April 2023 to September 2023. Multiple biopsies were taken from different stomach regions and compared to the endoscopic findings. Eighty patients were enrolled with a mean age of 38.80±17.24 years. The study showed that most of the patients improved. There was a significant relationship between the histopathological grading of gastritis (Sydney system) and the degree of gastritis observed through an endoscope among H. Pylori intensity, chronic inflammation, neutrophil activation, glandular atrophy, and degree of gastritis. However, other parameters, such as intestinal metaplasia and surface epithelium damage of the Sydney system, revealed no significant relationship. Our study found a very strong positive correlation between the degree of gastritis (endoscope) and the degree of gastritis (histopathology) before treatment. There was also a significant relationship between the degree of induced gastritis in endoscopy and histopathology after treatment. The p-value was 0.003, and the two variables had a moderate positive correlation after treatment. It was concluded that biopsies performed during endoscopy are essential for diagnosing and treating gastritis and associated disorders. Healthcare providers can customize treatment regimens to target specific underlying causes and handle potential problems using the information gathered from biopsies.

Dynamic profiling of immune microenvironment during anti-PD-1 immunotherapy for head and neck squamous cell carcinoma: the IPRICE study

BackgroundImmune checkpoint inhibitors of programmed cell death protein 1 (PD-1) represent a significant breakthrough in treating head and neck squamous cell carcinoma (HNSCC), with long-lasting responses and prolonged survival observed in first- and second-line therapy. However, this is observed in < 20% of patients and high primary/secondary resistance may occur. The primary objective of the identification of predictive factors for the response to anti-PD-1 immunotherapy in head and neck squamous cell carcinoma (IPRICE) study is to identify predictive factors of response to anti-PD-1 immunotherapy.MethodsThe IPRICE study is a single-center, prospective, non-randomized, open-label, and interventional clinical trial. Liquid and tumor biopsies will be performed in 54 patients with recurrent/metastatic (R/M) HNSCC undergoing anti-PD-1 immunotherapy alone to compare the evolution of gene expression and immunological profile between responders and non-responders. We will use a multidisciplinary approach including spatial transcriptomics, single seq-RNA analysis, clinical data, and medical images. Genes, pathways, and transcription factors potentially involved in the immune response will also be analyzed, including genes involved in the interferon-gamma (IFN-γ) pathway, immunogenic cell death and mitophagy, hypoxia, circulating miRNA-mediated immunomodulation, cytokines, and immune repertoire within the tumor microenvironment (TME). With a follow-up period of 3-years, these data will help generate effective biomarkers to define optimal therapeutic strategy and new immunomodulatory agents based on a better understanding of primary/secondary resistance mechanisms. Tumor biopsy will be performed initially before the start of immunotherapy at the first tumor assessment and is only proposed at tumor progression. Clinical data will be collected using a dedicated Case Report Form (CRF).DiscussionIdentifying predictive factors of the response to anti-PD-1 immunotherapy and optimizing long-term immune response require a thorough understanding of the intrinsic and acquired resistance to immunotherapy. To achieve this, dynamic profiling of TME during anti-PD-1 immunotherapy based on analysis of tumor biopsy samples is critical. This will be accomplished through the anatomical localization of HNSCC, which will allow for the analysis of multiple biopsies during treatment and the emergence of breakthrough technologies including single-cell RNA sequencing (scRNA-seq) and spatial transcriptomics.Trial registrationClinicaltrial.gov. Registered April 14, 2022, https://www.clinicaltrials.gov/study/NCT05328024.

Imaging and Pathological Features and Recurrence Causes of Cystic Meningioma

Objective: This study aims to establish preoperative imaging features, establish how they are correlating with post-operative pathological features, and discover the causes of recurrence. Results: Data on imaging procedures in the preoperative period, records of surgical operations, and reports from pathology conclusions were collected. Among 623 patients who were undergoing neurosurgery resection of intracranial meningioma, 24 cases of cystic meningioma were identified, corresponding to a world incidence of 3.8 %. The hemispheric convexity was the most frequent place of localization. The apparent diffusional coefficient was significantly lower in grade 2 and grade 3 tumors if compared to grade 1. Full resection of the cystic component was possible in 18/24 cases. Partial resection in 3/24 cases. In 2/24 cases, it was not possible to make total or partial resection, but multiple biopsies were performed from the cystic walls.

The roles of type 2 diabetes and obesity in disease activity and progression of non-alcoholic fatty liver disease/non-alcoholic steatohepatitis

Objective We examined the roles of type 2 diabetes (T2D) and obesity in disease activity and fibrosis progression/regression in patients with non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH). Methods This multi-center, retrospective study included patients with suspected or histologically proven NAFLD/NASH from the NASH Clinical Research Network. Outcomes included disease activity and rate of fibrosis, assessed using liver-biopsy driven measures (NAFLD activity score [NAS] and fibrosis score [FS]). Logistic regression and doubly robu estimation of causal effects tested relationships among T2D, obesity, and NAFLD/NASH. Results The analytical sample included 870 adult patients with baseline biopsy data and 157 patients with multiple biopsy data. Patients with NAFLD/NASH and T2D had significantly higher baseline average NAS (4.52 vs. 4.13; p = 0.009) and FS (2.17 vs. 1.56; p < 0.0001); those with T2D had a significantly greater reduction in average NAS over time (−0.77/year vs. −0.17/year; p = 0.0008). Change in FS over time did not differ significantly by T2D status (−0.23/year vs. −0.04/year; p = 0.34). Baseline NAS, baseline FS, and change in average NAS over time did not differ significantly by obesity status (4.17 vs. 4.47; p = 0.16; 1.73 vs.1.92; p = 0.31; −0.40/year vs. −0.59/year; p = 0.62, respectively). Patients with obesity had a slight increase in FS but those without obesity had a reduction in average FS over time (0.07/year vs. −0.27/year; p = 0.008). Conclusions Patients with NAFLD/NASH and T2D had greater baseline disease activity versus those without T2D, but there was greater regression of disease activity over time among those with T2D. Patients with NAFLD/NASH and obesity had worsening of fibrosis versus those without obesity. NCT00063622

EBV positive plasmacytoma in immunocompetent patients: A diagnostically challenging rare entity

Abstract Introduction/Objective Epstein-Barr Virus (EBV)-positive plasmacytoma is a rare entity that shows morphological and immunophenotypic overlap with plasmablastic lymphoma and can cause a diagnostic dilemma. Here we discuss a unique case of EBER-positive plasmacytoma arising from nasal polyps. Methods/Case Report A 61-year-old immunocompetent male presented with nasal polyps, right maxillary sinus lesions, and an enlarging sternal lesion. Multiple biopsies were obtained which revealed a diffuse infiltration by atypical plasma cells, that were positive for CD138, MUM1, CD79a, CD56, lambda-in situ hybridization, and Ki67- proliferation index of 20-30%. In situ, hybridization for EBV-encoded viral RNA (EBER) was positive in the neoplastic cells. B- and T- cell markers were negative. The flow cytometry studies detected monotypic lambda-restricted CD38/CD138 positive plasma cells with an aberrant expression of CD56 and CD117. Molecular studies for B-and T- cell gene rearrangement were also negative. A final diagnosis of EBER-positive plasmacytoma was made. The patient was treated with cyclophosphamide, vincristine, doxorubicin, and carboplatin followed by four cycles of RVD, and is doing well. Results (if a Case Study enter NA) NA Conclusion EBER-positive plasmacytoma poses a diagnostic challenge with plasmablastic lymphoma, specifically in immunocompetent individuals. The useful differentiating clues pointing towards EBER positive plasmacytoma could be a spectrum of morphology ranging from mature to anaplastic, low Ki67 proliferation index, aberrant CD56 and CD117 positivity, and high M- spike on protein studies. Comprehensive clinical, morphologic phenotypic, and genetic investigations are necessary to make a specific diagnosis as the two entities differ in their management.

10-year Observation of A Rare Presentation of Pure Fibromyxoid Nephrogenic Adenoma in the Renal Pelvis

Abstract Introduction/Objective Pure fibromyxoid NA is an unusual rare variant that typically presents with a well circumscribed bulbous, or tumefacient architecture composed of mitotically inactive bland spindled cells and rare tubular structures within a myxoid or collagenized stroma. Here we report a rare case of pure fibromyxoid NA involving the renal pelvis with over 10-year clinical observation and comparison and correlation of biopsy and resection findings. To the best of our knowledge, this is the first reported case of pure fibromyxoid NA in renal pelvis with close comparison and correlation of biopsy and resection findings with over 10-year clinical manifestation, hoping that knowledge of this long-term rare spindle cell lesion will enhance awareness of pathologists to carefully consider this unusual entity, especially in the biopsy specimen in which typical histologic features of fibromyxoid NA are usually absent, as well as prevent misdiagnosis and overtreatment of a typically benign process. Methods/Case Report A retrospective case study of a 37-year-old female with multiple previous biopsy of the nodule in the renal pelvis, and final resection specimen. Biopsies of the mass showed predominantly bland spindle cell lesion with smooth muscle differentiation and scant urothelial epithelial cells, but no tubular structure identified at the biopsy specimen. On the final resection specimen, a urothelium-lining polypoid nodule composing of abundant bland spindle- shaped cells and scattered conventional tubules lined by a single layer of cuboidal epithelial cells in hobnail arrangement that are positive for PAX8 and GATA3 was identified. These morphological and immunohistochemical findings were consistent with the diagnosis of pure fibromyxoid NA. Results (if a Case Study enter NA) NA Conclusion To the best of our knowledge, this is the first description of a pure fibromyxoid NA of the renal pelvis with more than 10-year clinical observation, as well as comparison and correlation of biopsy and resection findings.Close observation and comparison of the findinigs between biopsy and resection specimen will enhance awareness of pathologists to carefully consider this unusual entity, especially in the biopsy specimen in which typical histologic features of fibromyxoid NA are usually absent, as well as prevent misdiagnosis and overtreatment of a typically benign process.