Polypoid Nodules Research Articles

Endometrial carcinoma with cervical stromal invasion: Three case reports

BACKGROUND Endometrial cancer is a kind of well-known tumors of female genitourinary system. Cervical stromal invasion is an adverse factor for poor prognosis of endometrial cancer. There is still controversy regarding the use of magnetic resonance imaging (MRI) in the diagnosis of cervical stromal invasion of endometrial cancer. The diagnosis of cervical stromal invasion varies significantly between different observers and institutions. We present a limited case series of the particular pattern of endometrial cancer, which infiltrates the cervical stroma and is often overlooked. CASE SUMMARY We present three cases of endometrial carcinoma with cervical stromal invasion with cancer-free uterine cavity. One patient, a reproductive-aged woman, exhibited irregular menstruation and was diagnosed with endometrial polyps by hysteroscopy and segmental curettage. A MRI scan revealed polypoid nodules within the internal cervical orifice. The other two cases were postmenopausal women who presented with abnormal vaginal bleeding. Hysteroscopy and segmental curettage suggested atypical hyperplasia of the endometrium. MRI scans did not detect any malignant signs in the endometrium. In one case, a non-thickened endometrium was observed, while in another, hyperplasia of the endometrium was seen. Notably, none of these patients had malignant tumors identified in the uterine cavity via MRI scans. However, postoperative pathological results following hysterectomy consistently indicated cervical stromal invasion. CONCLUSION Cervical stromal invasion is easily missed if no cancer is found in the uterine body on MRI. Immunohistochemistry of endoscopic curettage specimens should be conducted to avoid underestimation of the disease.

Polypoid non-neural granular cell tumor of the oral cavity

Aim: To report a case of non-neural granular cell tumor (NN-GCT), an uncommon neoplasm, with only six studies worldwide describing cases involving the oral cavity. Methods: A 26-year-old male patient with an erythematous, firm, polypoid nodule in the floor of the mouth that exhibited areas of ulceration and mild bleeding to the touch. A biopsy was performed to aid in the diagnosis. Results: Based on the histopathological and immunohistochemical results (vimentin +, CD68 +, S100 -), the diagnosis was compatible with S100-negative (primitive polypoid non-neural) granular cell tumor. No recurrence was observed over two years of follow-up. Conclusion: The diagnosis of NN-GCT is extremely challenging because this tumor shares histological and immunophenotypic features with many benign and malignant tumors. Although oral NN-GCT may exhibit unusual and atypical histological features, it has an indolent behavior. Thus, until more cases of oral involvement are reported, complete resection and close follow-up are recommended.

Clinical Characteristics of Basal Cell Carcinomas of the Scrotum: An Institutional Retrospective Review

Objective. To analyse the clinical and pathologic features, discuss therapeutic strategies, and possibly cause and identify prognostic factors of scrotal basal cell carcinoma (BCC) in Chinese patients. Materials and Methods. Between January 2012 and December 2022, 12 patients with scrotal BCC were diagnosed and treated at our institution. A review was conducted based on the clinical characteristics, pathology slides, and tissues of these patients. Results. The median patient age was 69.26 ± 11.23 years. The skin lesions presented as red papules, blue-grey polypoid nodules, erythematous patches, brownish plaques, and so on. All patients were treated using wide excision, but the margins varied from 0.5 cm to 2 cm. HPV infection was checked in all lesions, with 4 out of 12 testing positive for P16 and 1 for HPV16 DNA. We found mottled positive expression of P16 in the cytoplasm and membrane. One patient developed left inguinal lymph node metastasis and was successfully treated using bilateral inguinal lymphadenectomy. The rest recovered well without relapse. Conclusions. BCC of the scrotum is rare, but long-term surveillance is recommended for BCC patients, and whether genital HPV infection is a noteworthy feature for these patients remains under investigation.

Gastric Gastrointestinal Stromal Tumor Associated With Hyperplastic Polypoid Nodules

Gastric Gastrointestinal Stromal Tumor Associated With Hyperplastic Polypoid Nodules

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.

Firm smooth polypoid nodule within a skin graft

Firm smooth polypoid nodule within a skin graft

Gallbladder Paraganglioma- A Rare Case Report

A 34-years-old married middle-class housewife without diabetes, hypertension or betel-nut- chewing hailing from Manikganj, Dhaka; came with the outside diagnosis as neuroendocrine tumor of the gallbladder to the Oncology Department of Khwaja Yunus Ali Medical College and Hospital (KYAMCH). She was admitted in the hospital with complaints of upper abdominal pain, abdominal bloating, weakness, anorexia, nausea and heartburn while taking fatty food. According to her Ultrasonography (USG) of the abdomen, a soft tissue mass was found in the gallbladder with unremarkable routine blood examination including tumor markers. She underwent open cholecystectomy with the suspicion of cancer. Grossly, gallbladder was measures 7.0x 5.0 cm with 0.3 cm wall thickness and on opening a polypoid nodule is found. Before treatment on request from the Oncology Department of KYAMCH, all slides were reviewed and a histopathological diagnosis of paraganglioma was made on the basis of organoid, nested or lobules (Zellballen pattern) of tumor cells in the lamina propria surrounded by a prominent fibrovascular stroma. Atypical mitoses, tumor necrosis, lymphovascular or perineural invasion was not found. The IHC reveals diffuse and strong positive reactions to NSE and CD56 for chief cells and strong positive reaction to S-100 protein for sustentacular cells. The epithelial tumor was ruled out by CK negative reaction. Therefore, the diagnosis of paraganglioma of the gallbladder was established. Because of the positive reaction to sustentacular cells, the neuroendocrine tumor has been excluded. To our knowledge, this type of case has not been reported in our country. On clinical follow-up the patient was found healthy. KYAMC Journal Vol. 14, No. 01, April 2023: 57-61

Histological and clinical analysis of knee cyclops lesions.

Cyclops Syndrome, first described by Jackson and Schaefer in 1990, is known as a complication of anterior cruciate ligament reconstruction (ACLR). However further researches have demonstrated that cyclops can be present even without symptoms and/or in absence of ACLR, simply configuring itself as a lesion in patients with rupture of the native ligament. This is a retrospective cohort study in which we report our experience of 13 cyclops lesions found between 126 patients during a primary arthroscopic ACLR. Preoperative examination with tests of joint stability and range of movement measurement was performed and recorded. Accurate joint examination was performed during arthroscopy and the cyclops lesions found were removed and analyzed with haematoxylin-eosin coloration. Post-operative clinical examination was performed until 6 months of follow-up. Histological analysis showed proliferation of dense fibroelastic polypoid nodules with a macroscopically histological aspects of a "blue eye", hence the name Cyclops. At 6 months of follow-up after surgery, none of the patients reported pain at terminal extension or instability and they were all able to resume their previous activities. Our study confirmed that surgical reconstruction of the ACL is not the only condition in which the Cyclops Syndrome develops; in fact our histological analysis indicate that the Cyclops lesions develop like a reactive fibroproliferative process following the rupture of the native ACL fibers, as scar reaction to the trauma: for this reason an accurate arthroscopic detection of these Cyclops lesions is crucial during primary ACL reconstruction in order to obtain the best surgical outcomes.

Inflammatory myofibroblastic tumor of the bladder: Computed tomographic features.

Inflammatory myofibroblastic tumor (IMT) is a rare tumor with intermediate biologic potential, in which lack of understanding often poses difficulties in preoperative diagnosis and treatment. The aim of the present study was to characterize the computed tomography (CT) features of the bladder IMT. The CT images of nine pathologically confirmed bladder IMT were retrospectively reviewed. All patients underwent both unenhanced CT and contrast-enhanced CT. The diameter, location, contour, growth pattern, margin, boundary, density and enhancement pattern of the lesions were assessed. The mean Ki67 value of an irregular blood clot was 18% and that of no blood clot was 12%. A total of eight (89%) patients had one tumor and 1 (11%) patient had multiple tumors. An endophytic growth pattern was observed in 4 (44%) patients, an exophytic growth pattern in 2 (22%) patients, and a mixed growth pattern in 3 (33%) patients. The tumor manifests morphologically as either polypoid (n=5), or cauliflower-like (n=1) soft-tissue mass with a wide base in the cavity, or a limited thick-walled (n=3). The tumor margins were smooth (n=8) or lobulated (n=1), and the tumor boundaries were either clear (n=7) or ill-defined (n=2). The lesions showed either ring-shaped (n=3) or heterogeneous (n=6). The polypoid and cauliflower-like soft-tissue mass showed a symmetrical change in the center of the lesion after enhancement. The bladder IMT is mostly a single polypoid nodule in the superior wall, mostly endophytic growth, with ring-haped enhancement and symmetrical change after enhancement as its characteristic manifestations.

STAT6 gain-of-function variant exacerbates multiple allergic symptoms

Allergic diseases were long considered to be complex multifactorial disorders. However, recent findings indicate that severe allergic inflammation can be caused by monogenic immune defects. We sought to clarify the molecular pathogenesis of a patient with early-onset multiple allergic diseases, a high serum IgE level, hypereosinophilia, treatment-resistant severe atopic dermatitis with increased dermal collagen fiber deposition, and eosinophilic gastrointestinal disorder with numerous polypoid nodules. A missense variant in STAT6 was identified, and its function was examined using peripheral blood, transfected HEK293 cells, lymphoblastoid cell lines, and knock-in mice with the corresponding mutation. Whole-exome sequencing identified a de novo heterozygous missense variant in signal transducer and activator of transcription 6 (STAT6) (p.Asp419Asn). Luciferase reporter assay revealed that the transcriptional activity of this STAT6 mutant was upregulated even without IL-4 stimulation. Phosphorylation of STAT6 was not observed in either the patient's TH2 cells or lymphoblastoid cell lines without stimulation, whereas it was induced more strongly in both by IL-4 stimulation compared with healthy controls. STAT6 protein was present in the nuclear fraction of the lymphoblastoid cell lines of the patient even in the absence of IL-4 stimulation. The patient's gastric mucosa showed upregulation of STAT6-, fibrosis-, and germinal center formation-related molecules. Some of the knock-in mice with the corresponding mutation spontaneously developed dermatitis with skin thickening and eosinophil infiltration. Moreover, serum IgE levels and mRNA expression of type 2 cytokines were increased in the knock-in mice-with or without development of spontaneous dermatitis-compared with the wild-type mice. A novel STAT6 gain-of-function variant is a potential cause of primary atopic disorders.

A Rare Case of Paratesticular Cystadenoma with Ovarian Stroma Found by Scrotal Ultrasound on a Cirrhotic Patient with Elevated Alpha-fetoprotein

Abstract Introduction/Objective Paratesticular cystadenoma with ovarian stroma is a rare benign cyst-forming neoplasm with less than 10 cases reported in the literature. Typically, it presents in men aged 11 to 68 years (average 30) and is asymptomatic. The tumor is hypothesized to represent the efferent ductulus undergoing metaplastic change, the vestigial remnants of Mullerian duct, or mesothelium of the tunica vaginalis. Most tumors are considered benign, but a few cases of malignant transformation have been reported. Methods/Case Report We present a case of a 54-year-old male with a history of cirrhosis and elevated alpha-fetoprotein (17.85 ng/ML) who was found to have a paratesticular mass by scrotal ultrasound. Clinical history was obtained from review of electronic medical record. CD10 (Novocastra Clone 56C6) and progesterone receptor (PR) (Leica Clone 16) Immunoperoxidase stains were performed following the vendor recommendations. Surgical excision revealed a 0.6-cm polypoid nodule on tunica albuginea that was entirely submitted. Microscopically, the tumor was comprised of cystic spaces lined by cuboidal epithelium identical to that of the Fallopian tubes. There was a sparse spindle-shaped stroma underlying the epithelium similar to ovarian stroma. No nuclear atypia or mitosis was found. Immunoperoxidase stains showed the epithelium was positive for PR, and the stroma was positive for CD10. No evidence of germ cell tumor was identified. Results (if a Case Study enter NA) NA. Conclusion Characteristic histologic and immunophenotypic findings can aid in the diagnosis of paratesticular cystadenoma with ovarian stroma. Surgical resection for histological confirmation and long-term monitoring for the potential recurrence and metastatic spread are required.

Mucinous cystic neoplasm of the liver with polypoid nodule prolapsing into the bile duct: a case report and review of literature

BackgroundMucinous cystic neoplasm of the liver (MCN-L) is a rare cystic tumor as defined by the 2010 World Health Organization classification. MCN-L usually does not communicate with or grow into the bile duct. Herein, we present a rare case of MCN-L with a polypoid nodule protruding into the bile duct.Case presentationA 69-year-old woman was referred to our hospital for elevated serum liver enzyme levels and obstructive jaundice. The patient also complained of abdominal pain in the right hypochondriac region. Abdominal ultrasonography showed a cystic lesion in segment 4 (S4) of the liver. Computed tomography revealed a 4-cm multilocular cystic lesion with a thick wall and multiple septal formations, showing a cyst-in-cyst appearance in S4. Endoscopic retrograde cholangiography showed a contrast defect between the left hepatic duct and the common bile duct, which was suspected to be a nodular lesion in the bile duct. Bile cytology and biopsy of the nodular lesion showed no malignant findings. Based on these findings, the differential diagnosis in this patient included intraductal papillary neoplasm of the bile duct and MCN-L, which had malignant potential. The patient underwent left hemihepatectomy, including caudate lobe excision with bile duct resection and right hepatocholangiojejunostomy. Macroscopic findings showed a 40 × 29 mm multilocular cystic lesion with a polypoid nodule that protruded into the left intrahepatic bile duct. As an ovarian-like stroma was observed in both cystic and polypoid lesions microscopically, the histopathological diagnosis was MCN-L. The postoperative course was uneventful, and the patient was discharged 24 days after surgery. The patient is currently alive without recurrence 22 months after the surgery.ConclusionAlthough MCN-L rarely communicates with the bile duct, it is necessary to consider that MCN-L could grow into the bile duct, occasionally causing obstructive jaundice.

Dermal nonneural granular cell tumor: a case report

Dermal nonneural granular cell tumor is a rare neoplasm of uncertain histogenesis that Le Boit and colleagues originally described in 1991. It arises commonly from the back, extremities and head and neck. To the best of our knowledge, only 50 cases have been reported in adults in the English literature. A 42-year-old man presented with a polypoid skin nodule of the front side of the chest wall, measuring 1,8 × 1,5 cm. The lesion was removed completely with tumor-free margins. Microscopically, the tumor was composed of a diffuse infiltrate of polygonal cells, S 100 negatives, with abundant granular cytoplasm and vesicular nuclei. The diagnosis of dermal nonneural granular cell tumor was retained. No recurrence was noted during follow up of 6 months. The prognosis is good.

EXTRA-NODAL PULMONARY MARGINAL ZONE LYMPHOMA ASSOCIATED WITH SJÖGREN DISEASE

TOPIC: Lung Cancer TYPE: Fellow Case Reports INTRODUCTION: Mucosal-associated lymphoid tissue (MALT), is a system of lymphoid tissue found within various organs that plays a role in regulating local immunity. As this tissue contains T, B, and plasma cells, it is the potential site for the development of lymphoma. MALT lymphomas are a form of B-cell extranodal lymphoma that can originate from marginal zone lymphocytes within the lung, referred to as pulmonary marginal zone lymphoma (PMZL). CASE PRESENTATION: We present a 42-year-old female referred to our clinic for evaluation of pulmonary nodules and mediastinal adenopathy. She had a one year history of Sjogren's syndrome. At that time she had no pulmonary or B symptoms. To evaluate her mediastinal adenopathy, she was referred for endobronchial ultrasound where pathologic evaluation revealed only a polymorphous lymphoid population and was negative for malignancy. She had several endobronchial hypervascular and polypoid nodules within the mainstem airways. Pathology from these nodules demonstrated an atypical lymphoid infiltrate, but was unable to be characterized any further.Given ongoing concern for a lymphoproliferative process, she was referred for video-assisted thoracoscopic surgery (VATS). Pathology from her left upper and lower lobar wedge resections demonstrated follicular bronchiolitis. Biopsy of a pleural nodule demonstrated a lymphoproliferative process concerning for a low-grade B-cell neoplasm, thought to be extranodal PMZL. She was referred to oncology where PET/FDG demonstrated hypermetabolic multi-station adenopathy suggesting stage IV disease. Given her asymptomatic nature and anticipated indolent course, it was decided to defer chemotherapy pending resolution of the COVID-19 pandemic. DISCUSSION: MALT lymphoma can develop in response to continuous antigen stimulation, as is seen in Sjogren's syndrome or tobacco use. Radiographic features of MALT lymphoma are numerous, including consolidations, nodules, and masses being the most frequent patterns observed in ~50% of patients. Endobronchial lesions as observed in this patient occur in ~85% of cases. PET/FDG imaging commonly demonstrates mild uptake within identifiable lesions. It has a very favorable prognosis with an overall 5-year survival of 90% due to its indolent nature and excellent response rate to chemoimmunotherapy, typically combination Bendamustine and Rituximab. CONCLUSIONS: MALT lymphoma is an uncommon neoplasm that can occur due to chronic antigen stimulation, especially in patients with Sjogren's syndrome. It has numerous radiographic features, the most common being endobronchial lesions. When given these clinical features, establishing a diagnosis is of utmost importance due to the excellent response rate to therapy and favorable long-term prognosis. REFERENCE #1: Borie R, Wislez M, Thabut G, et al. Clinical characteristics and prognostic factors of pulmonary MALT lymphoma. Eur Respir J. 2009;34(6):1408-1416. REFERENCE #2: Husnain M, Kuker R, Reis IM, et al. Clinical and radiological characteristics of patients with pulmonary marginal zone lymphoma: A single center analysis. Cancer Med. 2020;9(14):5051-5064. REFERENCE #3: Stefanovic A, Morgensztern D, Fong T, Lossos IS. Pulmonary marginal zone lymphoma: a single centre experience and review of the SEER database. Leuk Lymphoma. 2008;49(7):1311-1320. DISCLOSURES: No relevant relationships by Brandon Jakubowski, source=Web Response No relevant relationships by Rosechelle Ruggiero, source=Web Response

Nodular malignant melanoma in vulvar skin without pigmentation: a case report

BackgroundPolypoid nodule growing without apparent pigmentation on the vulvar skin usually reminds us of the diagnostic pitfall, which is commonly and mistakenly diagnosed as other types of tumors. Although there are several manifestations of amelanotic melanoma are known, these malignancies are usually pigmented because they are derived from melanocytes containing melanin. However, amelanotic melanomas are easily misdiagnosed or their diagnoses were commonly delayed due to lack of pigmentation. Therefore, a solitary polypoid nodule is worth noting and further reporting. Particularly, the clinical characteristics and outcomes of the solitary polypoid nodule are rare in Asian patients.Case presentation We presented an interesting case of a 33-year-old female with a solitary polypoid nodule without apparent pigmentation on her vulvar skin. Her medical history was unclear, no ulcer was seen in the lesion area, and dermatoscopy was indicated a possible tumorous change, which has caught the attention of clinicians, and then further examined by the pathologist. The final diagnosis was nodular malignant melanoma (NM) (Breslow thickness 9.5mm, Clark level 4).ConclusionsHence, though reviewing this case record, the relevant literature and NM-related materials, we suggest that the combination of skin imaging technology and histopathological examination could provide us a better understanding and reduce the possibility of misdiagnosis in clinic practice.

Criteria to Characterize Polypoid Nodule Scar after Gastric Endoscopic Submucosal Dissection in Order to Differentiate It from Tumor Recurrence.

Criteria to Characterize Polypoid Nodule Scar after Gastric Endoscopic Submucosal Dissection in Order to Differentiate It from Tumor Recurrence.

S1704 Mantle Cell Lymphoma Presenting as Colonic Polypoid Nodules in a Crohn’s Disease Patient With History of Azathioprine Use

INTRODUCTION: The gastrointestinal (GI) tract is the most common extra nodal site affected by lymphoma, accounting for 5–20% of all cases. Of all GI lymphoma subtypes, mantle cell lymphoma (MCL) is more frequently noted in the ileum and colon. We present a case of MCL presenting as mucosal polypoid nodules in a Crohn's disease patient with history of azathioprine use. CASE DESCRIPTION/METHODS: A 71-year- old male presented to the clinic for management of Crohn’s disease (CD). He was diagnosed at the age of 25 when he developed acute small bowel obstruction secondary to a terminal ileum (TI) stricture and required resection and ileo-colonic anastomosis. He had treatment failure with infliximab due to antibody formation and was managed with azathioprine for over 30 years. Surveillance colonoscopy a year ago showed active ileo-colonic disease and ustekinumab was initiated. Past medical history was remarkable for generalized lymphadenopathy involving the supraclavicular, mediastinal and mesenteric regions. Previously, patient had undergone an excisional lymph node biopsy that was negative for lymphoma. Laboratory testing showed leukocyte count of 5.5 × 109/L with normal differential, hemoglobin of 14.1 g/dL, and a platelet count of 106 L K/uL. Colonoscopy showed scattered erosions and friable mucosa in the entire examined colon and TI. Interestingly, a 2 cm submucosal nodule was noted in the proximal colon that appeared to be a lipoma with mucosal inflammation. Similar small submucosal nodules were noted in the rectum and biopsies were obtained. Pathology of the biopsied nodules revealed atypical lymphoid proliferation. On immunohistochemical staining, B cells were identified, positive for CD 20, CD5, BCL-1, BCL-2, CD43 but negative for CD10 and CD23. The findings were consistent with mantle cell lymphoma. PET scan and bone marrow biopsy revealed disseminated disease with bone marrow involvement. The patient’s immunosuppression was discontinued, and he was referred to oncology for chemotherapy. DISCUSSION: MCL is an aggressive subtypes of B-cell non-Hodgkin lymphoma and most patients have advanced-stage disease at diagnosis. Patients with MCL and GI involvement could be asymptomatic or may present with abdominal pain, obstruction, diarrhea, or overt bleeding. Endoscopic findings may include normal mucosa, nodules, polyps, ulcers, and masses. It is important to biopsy seemingly benign lesions as in our case, if index of suspicion is high. Further history of azathioprine is known to increase lymphoma risk.Figure 1.: A 2 cm smooth submucosal nodule with erythematous mucosal changes noted in the proximal colon.

S2766 Sunburn of the Upper GI Tract: A Case of Metastatic Melanoma of the Stomach and Duodenum

INTRODUCTION: Malignant Melanoma is the fifth most common cancer among the population, and it is known to spread to most organs in the body. Severity of this dastardly disease is predicated based on the stage of the cancer. It is one of the most common cancers that can disseminate to the gastrointestinal tract (GIT). To the best of our knowledge as per literary review, there are fewer than 10 reported case reports discussing cutaneous melanoma with metastasis to both stomach and duodenum simultaneously. This case report aims to add yet another example of this phenomenon to the literature. Here, we present a 49-year old female with biopsy proven melanoma of the back, who presented three years later with nausea and vomiting, and was found to have metastasis to the stomach and duodenum. CASE DESCRIPTION/METHODS: Our patient is a 49-year-old female who presented with chief complaints of intractable nausea and vomiting for eight weeks. She was diagnosed with benign superficial spreading melanoma of the back three years prior. Two years later she had a CT chest suggestive of metastatic disease (stage IV), and she was subsequently started on immunotherapy with nivolumab. Given her persistent nausea and vomiting, an EGD was performed which showed three mucosal polypoid nodules, approximately 5–10 mm with tip ulcerations, in the gastric body and multiple mucosal nodules, approximately 5–10 mm, in the duodenum (Figure 1). Biopsies of these nodules showed S-100 and MART-1 positive metastatic melanoma (Figure 2). Genetic sequencing revealed mutations in the following genes: BRAF V600E, PTEN, PD-L1 28-8. DISCUSSION: This case highlights the severity of melanoma and its negative impact on the GIT. Metastatic melanoma of the GIT is a common postmortem finding, however antemortem diagnosis of this lethal disease is quite rare. The most widely used “melanoma markers” are: S-100, HMB-45, and MART-1/Melan-A [6]. It is also important to appreciate that due to their wide differences in sensitivity and specificity, these markers are often tested together to optimize statistical yield. It has been shown that the incidence of metastatic melanoma of the GIT is as follows: Jejunum and ileum 58%, stomach 26%, colon 22%, duodenum 12%, and the least common being to the rectum and anus. GI symptoms in a melanoma patient should always prompt one to explore further endoscopic investigation. In the event of a negative endoscopy in a melanoma patient, one should consider a capsule endoscopy to ensure complete examination of the GIT.Figure 1a.: Mucosal nodules seen in duodenum.Figure 1b.: Mucosal nodule seen in gastric body.Figure 2.: Gastric nodule seen at 100x, stained MART-1 positive (brown). Metastatic infiltration of glands seen (yellow arrows).

1966 Jejunal Submucosal Hemangioma as a Cause of Massive Gastrointestinal Bleeding: A Case Report

INTRODUCTION: Small intestinal hemangiomas are uncommon tumors that usually present with gastrointestinal bleeding (GIB). Hemangiomas account for only 0.05% of all intestinal tumors. The most common location in the small intestine is the mid-jejunum. Diagnosis, detection, and treatment can be challenging and may require surgery. CASE DESCRIPTION/METHODS: An 81-year-old female presented to the emergency department with a one-week history of melena, associated with fatigue and palpitations. She denied hematemesis, hematochezia, NSAIDs use, or the use of anticoagulants or antiplatelet agents. Her vital signs were stable, and her physical examination was unremarkable except for lower limb edema. Hemoglobin was 4.7 g/dl, which was lower than her baseline of 8 g/dl. The patient was transfused to maintain her hemoglobin above 7 g/dl, and a proton pump inhibitor infusion was initiated. Esophagogastroduodenoscopy was performed, and benign-appearing and non-bleeding polyps were detected in the gastric fundus and body. Colonoscopy did not detect significant abnormalities other than moderate diverticulosis, internal hemorrhoids and old melenic liquid throughout the colon but no active bleeding. Due to continued blood transfusion requirements, a video capsule endoscopy was performed, and active bleeding was detected. Push enteroscopy was performed, and a polypoid nodule with central umbilication and red spot was detected in the proximal jejunum [Figure 1]. The lesion was biopsied, and post-biopsy bleeding developed. Hemostasis was achieved by injection of epinephrine (1:10000 concentration) and application of three hemoclips. Subsequently, the patient underwent a laparoscopic segmental jejunal resection. Histologic examination of the resected specimen demonstrated a jejunal submucosal hemangioma with surrounding hemorrhage, an organizing hematoma, and no evidence of dysplasia or malignancy. DISCUSSION: Submucosal hemangiomas are a rare cause of GIB. They can present with melena and severe anemia. As the most common site is mid-jejunum, it is difficult to detect submucosal hemangiomas. In this case, the lesion was detected by video capsule endoscopy and was reached by push enteroscopy. Surgery is usually required for a definitive diagnosis and definitive treatment.

1600 Follicular Lymphoma Presenting as a Colon Polyp

INTRODUCTION: Follicular lymphoma (FL) is the second most common type of Non-Hodgkin's lymphoma (NHL). There are two types of follicular lymphoma, nodal and extranodal. The gastrointestinal (GI) tract is the most common site of extranodal NHL and accounting for 30%-40% of all extranodal NHL. GI-FL comprises of only 1 to 4% of GI-NHL with less than 400 reported cases. GI-FL primarily involves the duodenum, distal ileum, and stomach. A colon is an uncommon place for GI-FL with less than 20 cases reported in the literature. We present a case of GI-FL identified on colonoscopy as a pedunculated polyp. CASE DESCRIPTION/METHODS: A 72-year-old female was seen for a positive stool occult test. She denied blood in the stool, abdominal pain, any weight loss, fatigue, night sweats, fevers, and diarrhea. She had occasional constipation which resolved with a stool softener. Physical examination was unremarkable without any palpable lymph nodes or organomegaly. During the colonoscopy, a 1.5 cm benign appearing pedunculated polyp in the mid-transverse colon was found (Figure 1). Primary histology of the polyp revealed lymphoid aggregates compatible with a lymphoid polyp. Diagnosis of GI-FL was later confirmed by immunohistopathological staining. Positron emission tomography (PET) scan showed aortocaval lymphadenopathy. The diagnosis of follicular lymphoma grade 2 stage IV is made. The oncologist has scheduled a bone marrow biopsy with consideration to immunochemotherapy. DISCUSSION: Colonic GI-FL is quite a rare disease with increasing incidence. Most patients are asymptomatic and diagnosed during endoscopy. The most common endoscopic appearance is 1 to 2 mm whitish polypoid nodules scattered or confluent together forming large nodules. Other appearances of GI-FL may include mass lesions with or without ulcer, lymphomatous polyposis, or polyps. These endoscopic features are also seen in lymphoid hyperplasia, MALT, mantle cell lymphoma. Immunohistopathological testing is the only way to confirm the diagnosis. GI-FL stains positive for CD10, CD19, CD20, and CD22, and bcl-2. It stains negative for cyclin D1 and CD5. PET scan is used for initial staging and surveillance of disease. GI-FL is an indolent lymphoma with favorable survival outcomes. A “watch and wait” approach is typically adopted. GI-FL presenting as a pedunculated polyp is an extremely rare presentation. Clinicians should be cognizant of endoscopy and immunohistopathological features of GI-FL.