Parenchymal Invasion Research Articles

S3098 Vanishing Bile Duct Syndrome in the Setting of Newly Diagnosed Hodgkin Lymphoma

Introduction: Vanishing bile duct syndrome (VBDS) is characterized by cholestatic liver disease in the setting of disappearing intra-hepatic bile ducts. It can resemble other forms of cholestatic liver disease; however, imaging and biochemical tests will be unrevealing. We describe a case of a woman with Hodgkin lymphoma (HL) who developed cholestatic hepatitis with loss of intra-hepatic bile ducts. Case Description/Methods: A 23-year-old woman with a history of HL who presented for evaluation and treatment of HL. Two months prior she had been treated for CMV-associated gastroenteritis and sepsis. Initial examination revealed jaundice and bilateral conjunctival icterus. Lab results showed total bilirubin of 18.1 mg/dL, ALT 363 U/L, AST 149 U/L, alkaline phosphatase (ALP) of 2392 U/L, direct bilirubin of 15.5 mg/dL, INR of 2.07, and cytomegalovirus (CMV) PCR at 670 IU/mL. Other acute viral hepatitis studies, tests for intrinsic liver disease, and autoimmune markers were negative. Computerized tomography (CT) of the abdomen and pelvis showed extensive lymphadenopathy, sclerotic changes throughout the skeleton, splenomegaly, and hepatomegaly without focal liver lesions. Magnetic resonance cholangiopancreatography (MRCP) of the abdomen showed no evidence of biliary ductal dilatation. Treatment for her HL was initiated, as well as foscarnet for her CMV viremia. Liver biopsy showed benign liver parenchyma with marked cholestasis and paucity of bile ducts, no cirrhosis, and no viral inclusions. The patient was initiated on ursodeoxycholic acid (UDCA) at 15 mg/kg/d without resolution of symptoms or cholestasis. Given no improvement in her cholestasis, the prospects of liver transplantation (LT) were discussed, but the patient was not a candidate (Figure 1). Discussion: Liver involvement in HL typically manifests as parenchymal invasion, external compression, or paraneoplastic destruction of bile ducts (VBDS). VBDS tends to signify a poor prognosis with patients frequently progressing to liver failure. The pathogenesis of VBDS in HL is not yet defined with current evidence suggesting an immune-mediated response. Typically, viral causes should be excluded. In this case, the patient did have CMV viremia. Given her prior treatment, low viral load, and absence of viral inclusions on liver biopsy, CMV was excluded as a cause. Treatment for VBDS revolves around treating the underlying cause. UDCA can be used as a temporizing measure, but, if no improvement is observed over time, patients are referred for liver transplant.Figure 1.: Parenchymal liver biopsy: (A) and (B) Lobular cholestasis. The hepatic lobules show cholestasis within the hepatocytes and bile canaliculi. (C) Paucity of intrahepatic bile duct. No bile duct is seen in the portal tract. (D) CK-7 positive hepatocytes in chronic cholestasis. The hepatocytes in this case stain positive for CK-7.

Adenoma metanéfrico: diagnóstico diferencial del carcinoma urotelial del tracto urinario superior. Reporte de un caso

Introduction: Metanephric adenoma is a rare benign kidney tumor. Patients with these tumors are usually asymptomatic, although polycythemia occurs in up 12% of cases. These masses are often described on diagnostic imaging as solid, single, well-defined, oval-shaped, unilateral lesions, located primarily in the renal medulla and without extrarenal involvement. These neoplasms are difficult to differentiate from malignant neoplasms of the upper urinary tract, so the definitive diagnosis is achieved by histopathology. Currently, the treatment of choice is radical nephrectomy. Case presentation: A 51-year-old woman from Bogotá (Colombia) was referred to the urology service of a tertiary care hospital due to bilateral lumbar pain of non-specific characteristics. At the time of consultation, the patient was asymptomatic. Renal and urinary tract ultrasound showed hydronephrosis and right renal mass. Computed tomography urography was requested, which revealed a lesion in the right renal pelvis with parenchymal invasion highly suggestive of high-risk upper urinary tract urothelial carcinoma, as well as adenopathies in the para-aortic lymph nodes. The patient underwent a radical nephroureterectomy with bladder cuff, which allowed establishing a final diagnosis of metanephric adenoma according to the histopathological study. Conclusions: Metanephric adenoma is a rare tumor that is difficult to diagnose through imaging, so it is necessary to explore additional tools to establish an accurate pre-surgical diagnosis that allows preserving the affected renal unit. Also, given their non-specificity, these tumors should be included in the differential diagnosis of lesions suggestive of upper tract urothelial carcinoma.

Rare Case of Pediatric Disseminated Choroid Plexus Papilloma: Literature Review and Call for Reclassification

Introduction: Choroid plexus tumors are rare neuroectodermal tumors that arise from the choroid plexus. Choroid plexus papillomas (CPPs) represent the lowest grade of these types of tumors and have a WHO grade I designation. Despite their typical low grade, some CPPs can exhibit aggressive behaviors including parenchymal invasion and dissemination throughout the neuro-axis. Due to their association with the choroid plexus, patients with CPP commonly present with signs and symptoms of hydrocephalus and increased intracranial pressure. Case Presentation: A 2-year-old male presented in extremis with acute hydrocephalus and seizure. He was found to have a large left intraventricular mass with innumerable intraparenchymal and extra-axial cysts throughout his neuro-axis. A literature review revealed five similar disseminated CPP cases with innumerable lesions. This is the youngest reported patient with disseminated CPP and the first with multiple compressive lesions. Following cranial resection and thoracic decompression, the patient’s lesions have remained stable (2 years of follow-up). A literature search of the PubMed/Medline databases was performed using the search terms [“disseminated choroid plexus papilloma” OR “choroid plexus papilloma” OR “metastatic choroid plexus papilloma”] up to March 2021. Articles were then screened for similar patient radiographic presentation and histological diagnosis. To mitigate publication bias, referenced articles were utilized to identify other case reports and case series. Discussion/Conclusion: We describe a rare case of a lateral ventricle CPP with widespread leptomeningeal dissemination causing acute obstructive hydrocephalus and compressive myelopathy requiring cerebrospinal fluid diversion and intracranial resection followed by thoracic spine decompression. This case report serves to broaden knowledge of disseminated CPP and to encourage complete neuro-axis imaging for choroid plexus tumors. Additionally, we propose a naming paradigm refinement that includes radiographic characteristics.

Unusual presentation of lepidic adenocarcinoma in a healthy female

BackgroundLepidic adenocarcinoma represents a histologic pattern of non-small cell lung cancer that characteristically arises in the lung periphery with tracking alongside pre-existing alveolar walls. Noninvasive and invasive variants of lepidic adenocarcinoma are dependent on parenchymal destruction, vascular, or pleural invasion. The lepidic-predominant lung malignancies are collectively recognized as slow growing with rare metastasis and excellent prognosis. The World Health Organization classification of lung malignancies depends on molecular and histopathological findings. CT findings most commonly include ground-glass characteristics, commonly mistaken for inflammatory or infectious etiology. These tumors are generally surgically resectable and associated with better survival given infrequent nodal and extrathoracic involvement. Rarely these tumors present with diffuse pneumonic-type involvement associated with worse outcomes despite lack of nodal and distant metastases.Case presentationA 63-year-old Caucasian athletic immunocompetent female presented with 2 months of progressive shortness of breath, fatigue, loss of appetite and 15 pound weight loss. History was only notable for well controlled essential hypertension and hypothyroidism. Contrast computed tomography angiogram and positron emission tomography revealed diffuse hypermetabolic interstitial and airspace abnormalities of the lungs without lymphadenopathy (or distant involvement) in addition to right hydropneumothorax and left pleural effusion. Baseline laboratory testing was unremarkable, and extensive bacterial and fungal testing returned negative. Bronchoscopy and video-assisted thoracoscopic surgery was subsequently performed with pleural fluid cytology, lung and pleural biopsies returning positive for lepidic adenocarcinoma with 2% programmed death ligand 1 expression and genomic testing positive for PTEN gene deletion. Prior to treatment, the patient perished on day 15 of admission.ConclusionWe present a rare case of lepidic predominant adenocarcinoma with extensive bilateral aerogenous spread in the context of no lymphovascular invasion in a healthy, low risk patient. This case presentation may add to the body of knowledge regarding the different behavior patterns of lepidic predominant adenocarcinomas.

Comparison of clinicopathological characteristics of mucinous adenocarcinoma and conventional adenocarcinoma of gallbladder

BackgroundGallbladder mucinous adenocarcinoma (GBMAC) is a rare type of gallbladder malignant tumor, whereas little is known regarding the clinicopathological features and surgical outcomes of GBMAC. MethodsFrom January 2000 till December 2015, 54 GBMAC patients who underwent curative-intent surgical resection at our institution were retrospectively reviewed. We compared the clinicopathological features and surgical outcomes of these GBMAC patients with a relatively large cohort of surgically resected conventional gallbladder adenocarcinoma (GBAC) patients without existence of mucinous components. ResultsThe clinicopathological features of GBMAC were significantly different from conventional GBAC, including poorer tumor differentiation (P < 0.001), higher CA19-9 levels (P < 0.001), larger tumor sizes (P = 0.020), advanced AJCC tumor stage (P = 0.002), higher frequency of liver parenchyma invasion (P = 0.020), portal vein invasion (P = 0.003), lymph node metastasis (P = 0.016), lympho-vascular invasion (P < 0.001) and perineural invasion (P = 0.025). Relative to conventional GBAC patients, GBMAC patients showed significantly worse overall survival (OS) (29.0 vs 15.0 months; P < 0.001). Multivariate analysis confirmed the surgical margin (P = 0.046), tumor differentiation grade (P = 0.018), lymph node metastasis (P = 0.024), and presence of signet-ring cell component (P = 0.005) as independent prognostic factors influencing OS of patients with GBMAC. ConclusionGBMAC always had more aggressive biological behaviors and poor survival outcomes even after curative surgery. GBMAC patients with the presence of signet-ring cell component showed even worse survival outcome.

Invasive Aspergillosis Manifesting As An Intracardiac Mass In A Heart Transplant Patient

<h3>Introduction</h3> Invasive aspergillosis (IA) is the third most common form of invasive fungal infections in immunocompromised patients, and has the second highest mortality rate at 30-70%. Invasion of lung parenchyma is the most common presentation, but can rarely present as aspergillus endocarditis. To our knowledge, IA presenting as a mass lesion in the heart is very rare and has never been reported in an orthotopic heart transplant (OHT) patient. We present a case of invasive aspergillus manifesting as an intracardiac mass in the right atrium (RA) in a heart transplant patient who survived. <h3>Patient presentation</h3> This is a 68 year-old-male with ischemic cardiomyopathy s/p OHT in June 2019 complicated by Aspergillus fumigatus sternal osteomyelitis requiring complete sternectomy on chronic antifungal therapy who was readmitted for right shoulder pain and failure to thrive. On admission, the patient was afebrile and hemodynamically stable. Pertinent workup showed transthoracic echocardiogram (TTE) with right atrial (RA) mass confirmed to be 3.5 × 3.3 cm by transesophageal echocardiogram (TEE) attached to interatrial septum. Initial malignancy workup was negative. Further infectious work up was remarkable for Aspergillus antigens. Intra-cardiac echocardiogram (ICE) and TEE techniques were utilized to locate and culture the mass. Argon epitome was placed into the mass under fluoroscopic and intracardiac echo guidance, extracting two specimens. Gross examination suggested identical specimens without any evidence of endocardium or lipomatous tissue. Initial pathology showed findings consistent with a thrombus but no evidence of fungal organisms, inflammation or malignancy. However, cultures from the specimen revealed Aspergillus fumigatus. Unfortunately, the patient was deemed a poor surgical candidate for resection due to other comorbidities and attempts are being made for long term antifungal therapy in management. <h3>Discussion</h3> Opportunistic infections such as invasive fungal infections are the leading cause of mortality in heart transplant recipients. Approximately 65% of OHT cases will have an infection within the first year of surgery. In a single institution, both incidence and mortality of IA in heart transplant recipients declined over the years. Despite this decrease, it remains a common pathogen observed in immunocompromised populations, specifically in solid organ transplantations. Most IA present as pulmonary disease as the route of entry for aspergillus conidia particles is inhalation, but rarely has intracardiac manifestations. To our knowledge, this is the first case report of invasive aspergillosis in a heart transplant recipient who had rare systemic manifestations including intra-cardiac mass and sternal osteomyelitis.

Reclassifying pT3 renal pelvic urothelial carcinoma with renal parenchyma invasion to pT2 improves correlation with overall survival

The American Joint Cancer Committee pT categorization in renal pelvic carcinoma defines pT3 as invasion of renal parenchyma, invasion of peripelvic fat, or both. However, survival heterogeneity within the pT3 category has been demonstrated. This investigation sought to compare survival between pT categories of renal pelvic urothelial carcinoma and identify modifications to improve correlation with survival. Pathology reports from nephroureterectomies performed at our institution from 2010 to 2019 were analyzed to identify primary renal pelvic urothelial carcinoma (n=146). Tumors were stratified based on pT, pN, and invasion of renal parenchyma vs invasion of peripelvic fat with or without renal parenchyma invasion. Kaplan-Meier survival curves and Cox regression multivariate analysis were used to compare overall survival between groups. Similar survival curves were observed for pT2 and pT3 tumors. Multivariate analysis confirmed overlapping hazard ratios (HRs) for pT2 (HR=2.64, 95% confidence interval [CI] = 0.69, 10.06)and pT3 (HR=4.42, 95% CI = 2.08, 9.37). pT3 tumors with peripelvic fat invasion, regardless of renal parenchyma involvement, had a 3.3-fold worse overall survival than pT3 tumors with only renal parenchyma involvement. Additionally, pT3 tumors with only renal parenchyma invasion had similar survival compared to pT2, while pT3 tumors with peripelvic fat invasion had worse overall survival (p=0.00091). Reclassifying renal parenchyma invasion as pT2 yielded greater survival curve separation and greater difference in HRs. For renal pelvic urothelial carcinoma, modifying the pT3 category to only include tumors with peripelvic fat invasion and expanding the pT2 category to include renal parenchyma invasion may improve pT correlation with overall survival.

Interferon gamma constrains type 2 lymphocyte niche boundaries during mixed inflammation

Allergic immunity is orchestrated by group 2 innate lymphoid cells (ILC2s) and type 2 helper T (Th2) cells prominently arrayed at epithelial- and microbial-rich barriers. However, ILC2s and Th2 cells are also present in fibroblast-rich niches within the adventitial layer of larger vessels and similar boundary structures in sterile deep tissues, and it remains unclear whether they undergo dynamic repositioning during immune perturbations. Here, we used thick-section quantitative imaging to show that allergic inflammation drives invasion of lung and liver non-adventitial parenchyma by ILC2s and Th2 cells. However, during concurrent type 1 and type 2 mixed inflammation, IFNγ from broadly distributed type 1 lymphocytes directly blocked both ILC2 parenchymal trafficking and subsequent cell survival. ILC2 and Th2 cell confinement to adventitia limited mortality by the type 1 pathogen Listeria monocytogenes. Our results suggest that the topography of tissue lymphocyte subsets is tightly regulated to promote appropriately timed and balanced immunity.

Multiple Myeloma Involving Left Hemicranium

AbstractMultiple myeloma (MM) is a malignant neoplasm of bone marrow affecting plasma cells. It is commonly seen as multiple punched-out lesions in the skull bone as a characteristic feature. Its presentation as hemicranial involvement with intracranial extension is rare. A 46-year-old male presented with left side scalp swelling, prominent over parietal region. X-ray showed multiple punched out lesions involving left hemicranium. CT and MRI brain showed intracranial extension of lesion without brain parenchyma invasion. He was treated with biopsy of lesion followed by chemotherapy.

Prognostic Enigma of Pancreatic Solid Pseudopapillary Neoplasm: A Single-Center Experience of 63 Patients.

Background: Studies investigating prognostic factors of solid pseudopapillary neoplasm (SPN) have been published with conflicting findings.Methods: Retrospective analysis of 63 consecutive cases of SPN in our institution from January 2010 to December 2019 was carried out. The clinicopathological features, treatment practices along with survival associations were collected and analyzed.Results: Fifteen patients (23.8%) were male, and 48 (76.2%) were female, with a median age of 34.0 ± 14.5 years. The larger tumor size was correlated with the more mixed components (p = 0.000) and the higher Ki-67 index (p = 0.042). No recurrence was found in the nine patients whose tumors fulfilled the WHO criteria for malignancy due to the presence of at least perineural invasion (6.4%), angiovascular invasion (2.3%), and/or adjacent organ invasion (6.4%). Microscopic infiltrative growth was detected in 9 (14.3%) tumors, which was correlated significantly with the WHO criteria (p = 0.002), capsule invasion (p = 0.005), and pancreatic parenchyma invasion (p = 0.001), but not with disease-free survival (p = 0.13). CD99 was found to be positively expressed in 88.9% (40/45) of tumors and more likely to have depressed Ki-67 index (p = 0.016). After a median follow-up of 58 months, only two patients (3.2%) had a recurrence after their first operation outside of our hospital. No patient died due to tumor progression.Conclusions: Although survival is favorable with aggressive surgery, it is actually difficult to assess the prognostic factors of resected SPNs. Future investigations into the role of clinicopathological evaluation will unveil the prognostic enigma of pancreatic SPN after resection.

Anti-brain protein autoantibodies in parenchymal neurocysticercosis *

Neurocysticercosis (NC) is the most common parasite infection of the CNS worldwide, and a main cause of seizures and epilepsy in endemic countries. The objective of this work has been to screen for the presence of autoantibodies to brain proteins in the cerebrospinal fluid (CSF) of clinically defined NC patients, representative of the two main clinical forms of NC, extraparenchymal (EP-NC) and parenchymal (P-NC) invasion.

PD64-09 COMPARATIVE EVALUATION OF ONCOLOGIC OUTCOMES ACCORDING TO THE ANATOMIC LOCATION OF SURGICAL MARGIN POSITIVITY AFTER PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (PD64)1 Sep 2021PD64-09 COMPARATIVE EVALUATION OF ONCOLOGIC OUTCOMES ACCORDING TO THE ANATOMIC LOCATION OF SURGICAL MARGIN POSITIVITY AFTER PARTIAL NEPHRECTOMY Alp T. Beksac, Soodong Kim, Umberto Carbonara, Margaret Meagher, Alessandro Tafuri, Mahmoud Abou Zeinab, Louis Lenfant, Alessandro Antonelli, Riccardo Autorino, Ithaar Derweesh, and Jihad Kaouk Alp T. BeksacAlp T. Beksac More articles by this author , Soodong KimSoodong Kim More articles by this author , Umberto CarbonaraUmberto Carbonara More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , Alessandro TafuriAlessandro Tafuri More articles by this author , Mahmoud Abou ZeinabMahmoud Abou Zeinab More articles by this author , Louis LenfantLouis Lenfant More articles by this author , Alessandro AntonelliAlessandro Antonelli More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002108.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We sought to assess if the anatomical location of positive surgical margins (PSM) can affect the oncological outcomes following partial nephrectomy (PN). METHODS: From a multi-institutional dataset, we performed a retrospective analysis of 115 patients who were found to have PSM following PN. Surgeries were performed between from January 2010 to May 2020. Patients with benign pathology, less than 6 months follow up, baseline metastatic disease, bilateral tumors, familial renal cell carcinoma, and pathological node positive disease were excluded from analysis. Patients with PSM were stratified into two groups according to the anatomical location (parenchymal invasion, sinus fat invasion). Due to uneven sample size a 1:2 matched pair analysis was performed (by cT stage) to limit confounding effect of stage on recurrence. Demographics, clinical and tumor characteristics, and poncological outcomes were compared using Chi-square, Fisher’s exact, Mann-Whitney U, and student’s t tests. Kaplan-Meier analysis performed to analyze recurrence free survival (RFS). RESULTS: Overall 84 patients were included in analysis (56 parenchymal vs. 28 sinus). Median follow-up was 25 months (IQR 11-41). Baseline characteristics were comparable between the two groups. Pathological tumor size was comparable. In the parenchymal group, more patients had multifocal PSM, whereas more patients had pT3a upstaging in the sinus group. Local recurrence rate was higher in the sinus group (17.9% vs. 10.9%, p=0.377), however this association did not reach statistical significance. Distant recurrence rate was comparable as well (5.5% vs. 7.1%, p=0.76). Kaplan-Meier analysis did not show any difference in terms of RFS (p=0.68). CONCLUSIONS: At 25 months follow up, the location of positive surgical margin did not alter distance recurrence rates following PN. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1147-e1148 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alp T. Beksac More articles by this author Soodong Kim More articles by this author Umberto Carbonara More articles by this author Margaret Meagher More articles by this author Alessandro Tafuri More articles by this author Mahmoud Abou Zeinab More articles by this author Louis Lenfant More articles by this author Alessandro Antonelli More articles by this author Riccardo Autorino More articles by this author Ithaar Derweesh More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement Loading ...

Prediction of Recurrence Risk in Solid Pseudopapillary Neoplasm of the Pancreas: Single-Institution Experience.

Background: Solid pseudopapillary neoplasm (SPN) of the pancreas is a low-grade malignant neoplasm with unpredictable behavior. Factors associated with recurrence were not conclusively identified. The aim of this study is to define the clinicopathological criteria for recurrence risk prediction in SPNs based on the most recent scientific evidence and to present our experience with SPNs.Methods: A retrospective review of patients with SPNs operated on in our institution from June 2012 to June 2018 was completed. Patient characteristics and clinical outcomes were analyzed. A detailed literature review was performed to evaluate the factors associated with the recurrence of SPNs.Results: The cohort consisted of 13 female patients with a median age of 24 years and a mean tumor size of 7.7 cm. Body and tail (53.8%) were the most common location, and distal pancreatectomy with splenectomy was the prevalent surgical procedure. One patient of SPN operated on for local recurrence after 11 years which had high-grade malignant histological features on the previously resected tumor. At a median follow-up of 42 months (range 36 to 108), all patients were disease free and alive. The proposed criteria for predicting recurrence in SPNs include tumor size >8 cm, synchronous metastasis, malignant SPN (according to 2000 or 2010 World Health Organization [WHO] criteria), lymphovascular invasion, pancreatic parenchymal invasion, and high Ki-67 index (>4%). All these are worse prognostic factors and should be considered as high-risk factors for postoperative relapse.Conclusion: The above-mentioned criteria can better predict SPN recurrence. Patients with high-risk features should undergo an extended follow-up.

Matrine treatment induced an A2 astrocyte phenotype and protected the blood-brain barrier in CNS autoimmunity

Type 1 astrocytes (A1), which are highly proinflammatory and neurotoxic, are prevalent in multiple sclerosis (MS). In addition, in MS and its animal model, experimental autoimmune encephalomyelitis (EAE), immune cells must cross the blood-brain barrier (BBB) and infiltrate into the parenchyma of the central nervous system (CNS) in order to induce neurological deficits. We have previously reported that treatment of EAE with matrine (MAT), a quinazine alkaloid derived from Sophorae Flavescens, effectively inhibited CNS inflammation and promoted neuroregeneration. However, the impact of MAT treatment on astrocyte phenotype is not known. In the present study, we showed that MAT treatment inhibited the generation of neurotoxic A1 astrocytes and promoted neuroprotective A2 astrocytes in the CNS of EAE, most likely by inhibiting production of the A1-inducing cytokine cocktail. MAT also downregulated the expression of vascular endothelial growth factor-A (VEGF-A) and upregulated tight junction proteins Claudin 5 and Occludin, thus protecting the BBB from CNS inflammation-induced damage. Moreover, MAT treatment promotes the formation of astrocyte tight junctions at glia limitans, thereby limiting parenchymal invasion of the CNS by immune cells. Taken together, the inhibition of A1 astrogliogenesis, and the dual effects on the BBB and astrocytic glia limitans, may be the mechanisms whereby MAT significantly improves EAE clinical scores and neuroprotection.

Recurrent liver metastasis in ovarian cancer

The most common sites of metastasis in ovarian cancer is liver, peritoneum, and lymph nodes resulting from hematogenous spread or secondary to liver parenchymal invasion from perihepatic peritoneal metastases. The case was retrieved from routine reporting at our hospital. A 34-year-old female presented with lump in left side of abdomen for six months. Ultrasonography showed Left complex tubo-ovarian mass. Serum level of CA125 was 19.8U/mL. Upfront surgery was done. Histopathology showed malignant lesion, positive for WT1, P53 & CK7 and negative for CK 20. Retroperitoneal lymph nodes and omentum were involved. The cases was diagnosed as epithelial ovarian cancer, high grade papillary serous cyst adenocarcinoma stage III. Three months after surgery repeat contrast enhanced computed tomography showed lung and liver metastasis lymphadenopathy. Patient was given 6 cycles of paclitaxel + carboplatin to achieve complete clinical response (CR). Lesions of lung, liver & lymph node subsided. She spent 33 months of treatment free interval, after which lymph node enlargement was noticed and its fine needle aspiration cytology showed metastasis. Patient was put on to oral metronomic therapy with etoposide, cyclophosphamide, and celecoxib (COX-2 inhibitor) for 8 months, which showed CR. Again after 4 months, lesion in liver reappeared with raised CA 125, suggesting second relapse. The patient is on oral metronomic therapy till date with improved clinical condition. This study highlights the need of early diagnosis, adjuvant chemotherapy with frequent follow up in this case. Liver is an early site for metastasis. Second relapse in also not uncommon.

Laparoscopic Surgery for Gallbladder Neuroendocrine Carcinoma: a Case Series and Literature Review

Gallbladder neuroendocrine carcinomas (GB-NECs) are a group of rare and heterogeneous neoplasms. There are few reports regarding laparoscopic surgery for GB-NEC cases diagnosed at advanced stage. Three patients, two females and one male, were admitted to our hospital. Two patients had the chief complaint of upper quadrant pain and one patient was found to have gallbladder occupation during a routine health checkup. No patient complained of jaundice, weight loss, or carcinoid syndrome–related symptoms including diarrhea, edema, flushing, and wheezing. Contrast-enhanced computed tomography (CT) examination showed local wall thickening of the gallbladder. In addition, one patient showed focal liver parenchymal invasion, and none of the three patients’ preoperative imaging examination revealed lymph node (LN) metastases. All three patients underwent laparoscopic radical cholecystectomy according to intraoperative frozen pathological examination, and they were diagnosed as GB-NEC based on postoperative pathology and immunohistochemistry. TNM stages of these patients were IIIA (T3N0M0), IIIB (T3N1M0), and IVB (T3N2M0), respectively. Chromogranin A (CgA) and synaptophysin (Syn) were positive in all cases. No patient encountered postoperative bleeding, bile leakage, abdominal abscess, gastrointestinal fistulas, or pulmonary complication. Two patients underwent postoperative chemotherapy with two cycles and seven cycles of etoposide plus cisplatin, respectively. Another patient did not receive postoperative chemotherapy due to his poor general condition. The overall survival time of the three patients was 4.6 months, 16.8 months, and 8.5 months, respectively. All three patients presented with liver and/or bile duct recurrence after surgery with a tumor-free survival time of 2.3 months, 3.3 months, and 3.0 months, respectively. Laparoscopic surgery may be considered a potential treatment for advanced GB-NEC in selected patients. However, further studies are needed to investigate the tumor-free survival benefit of laparoscopic surgery, and whether expanding the resection scope could reduce postoperative recurrence.

Importance of amino acids in brain parenchyma invasion by cancer cells.

Importance of amino acids in brain parenchyma invasion by cancer cells.

Is Preoperative Magnetic Resonance Imaging in a Daily Clinical Setting Useful to Evaluate Tumor Invasion Beyond the Pseudocapsule in Renal Cell Carcinoma?

We wanted to clarify whether preoperative magnetic resonance imaging (MRI) in the clinical setting can evaluate the pathologic pseudocapsule (PC) morphology with high accuracy in renal cell carcinoma (RCC). We retrospectively analyzed 34 consecutive patients who underwent MRI (1.5 or 3.0T, 5 mm slices) prior to partial nephrectomy (PN) for RCC at our institution between January 2010 and December 2019. First, the correlation between PC morphology (complete or incomplete) and tumor infiltration to the renal parenchyma was examined as pathologic validation. Second, the concordance rate of PC morphology between pathologic tissue and preoperative MRI was evaluated as radiologic validation. Third, risk factor for renal parenchymal invasion in RCC was analyzed. In the pathologic validation, parenchymal invasion rates were 11% and 28% in the "complete PC" and "incomplete PC" groups, respectively. In the radiologic validation, pathological PC morphology could be diagnosed on preoperative MRI in 17 patients (50.0%). "None PC" on MRI had the lowest positive predictive value (PPV) (0%), "partial PC" on MRI had a good PPV (76.5%), "complete PC" on MRI had a relatively low PPV (33.3%). Unfortunately, these data were insufficient for diagnostic accuracy. As risk factor for renal parenchymal invasion in RCC, only pathologic subtype (non-clear cell) was found to have significant differences in the multivariate analysis. The results of this study suggest that renal tumors with pathologically incomplete PC have a high possibility of renal parenchymal invasion. However, it is currently difficult to accurately evaluate pathologic PC morphology by preoperative MRI in the clinical setting.

Gallbladder Carcinoma in Portugal: A Single Center Experience and Prognostic Factors for Survival

Purpose: To identify clinicopathological prognostic factors for survival in patients with gallbladder carcinoma (GBC) submitted to surgery in our institution–a tertiary centre. Methods: 41 patients underwent surgical treatment for GBC between 2008-2019. 26(63.4%) were female, 28(68.3%) had associated cholelithiasis and the majority of tumours, 35(85.4%), were adenocarcinomas. 41.5% were diagnosed incidentally, 65.9% had symptoms and 26.8% presented with acute cholecystitis. 46.3% were stage III (AJCC) or higher. 39% were submitted to cholecystectomy alone and 61% were also submitted to hepatic resection. 46.3% had vascular invasion, 26.8% hepatic parenchyma invasion and 9.8% bile duct invasion. Survival analysis was conducted on SPSS. Our institution ethics committee approved this work. Results: Median overall survival (OS) was 20.5 months (IQR 8.8-53.8). 3-year and 5-year survival rates were of 43.2% and 39.6%, respectively. On immunohistochemistry analysis, 6 patients (14.6%) were HER2+, but the HER2 status didn't show influence on OS (median OS 18 vs 20 months, p=0.649); all had microsatellite stability. There was no association between HER2 expression and staging (p=0.35). On univariate regression, the following factors were associated with worse OS: acute cholecystitis(HR 2.59 (95%CI 1.11-6.06), p=0.028), jaundice(HR 3.18 (95%CI 1.37-7.334), p=0.007), other carcinomas (HR 3.32 (95%CI 1.19-9.23), p=0.022), stage ≥ III(HR 10.35 (95%CI 2.34-45.75), p=0.002), N+(HR 6.55 (95%CI 2.38-18.03), p<0.001), vascular invasion(HR 8.96 (95%CI 2.78-28.89), p<0.001), hepatic invasion(HR 6.86 (95%CI 2.51-18.75), p<0.001), bile duct invasion(HR 3.50 (95%CI 1.11-11.02), p=0.033), ≥R1 resection(HR 11.79 (95%CI 3.8-36.6), p<0.001), CA 19.9 ≥500 U/mL(HR 2.5 (95%CI 1.05-5.98), p=0.039), CEA ≥5 ng/mL(HR 2.99 (95%CI 1.10-8.14), p=0.032); hepatic resection was associated with better OS(HR 0.24 (95%CI 0.11-0.67), p<0.001). On multivariate regression, stage ≥ III(HR 8.58, (95%CI 1.786-41.171), p=0.007), hepatic resection(HR 0.288, (95%CI 0.091-0.910), p=0.034) and vascular invasion(HR 4.06, (95%CI 1.035-15.918), p=0.045) were independently associated with OS. Conclusions: This study on GBC is, as far as the authors know, the first in Portugal. Surgery is still the gold standard for curative treatment and some patients with favourable prognosis may be identified. The overexpression of HER2 could select patients for targeted treatment and prompt tissue sampling in unresectable patients.

Comparative Study of CT Severity Index and Outcome in Hospitalised Vaccinated and Non Vaccinated Patients of Covid 19 Pneumonia

SARS-CoV-2 virus typically causes lung infiltration causing acute respiratory distress syndrome (ARDS) and in later stages pulmonary fibrosis. Vaccines provide immunity against desired pathogen. Vaccines available in India against this virus are Covishield and Covaxin (majority of the patients are vaccinated with Covishield). COVID-19 causes lung parenchymal infiltration which leads to pneumonitis. The best modality available to study this is the HRCT. Analysis of the extent of lung parenchyma invasion of patients despite taking one or both the doses was done by us. For which , we did a single centered retrospective observational study in laboratory confirmed COVID-19 positive patients with sample size (n=274) being duration dependent (2 months). We found a statistically significant correlation between vaccination status and lung involvement based on HRCT Thorax. In conclusion the presence of vaccination reduces the severity of the CT severity score and improves the outcome in terms of survival of the patient.