Superficial Biopsy Research Articles

Uterine Tumors Resembling Sex Cord Stromal Tumors: A Distinctive Entity to Consider in Evaluating the Adenosarcoma

Abstract Objectives Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are rare neoplasms. Approximately 60 cases of UTROSCT are reported in the literature. Methods A 53-year-old female was referred to our institution for definitive surgery following an endometrial biopsy diagnosed as adenosarcoma of the uterus. Her history and physical examination were unremarkable. CT scan showed no evidence of metastatic disease. She underwent a staging hysterectomy with bilateral salpingo-oophorectomy. Grossly, a polypoid mass was seen in the uterine cavity with extension into the myometrium. Results Histologic examination of the mass revealed anastomosing cords and nests of epithelioid cells with bland ovoid nuclei, inconspicuous nucleoli, and scant eosinophilic cytoplasm, embedded within a fibromuscular stroma, resembling sex cord stromal tumors of the ovary. Cellular atypia, necrosis, or mitotic activity were not noted. Immunohistochemically, the neoplastic cells expressed cytokeratin AE1/AE3, WT1, CD99, calretinin, inhibin, melan A, and estrogen receptor. These features were consistent with the diagnosis of UTROSCT. Conclusion UTROSCT accounts for less than 0.5% of all uterine malignancies. These tumors arise in perimenopausal females and historically follow a benign course. Although their histomorphologic and polyphenotypic immunoprofile such as sex cord, epithelial, and myoid seems to be unique among uterine mesenchymal neoplasms and can be diagnostically useful, their diagnosis can be confused with more common tumors such as low-grade stromal sarcomas, carcinosarcoma, and adenosarcoma, especially in superficial endometrial biopsies. As in our case, the initial endometrial biopsy, being superficial, revealed endometrial polyp with rare component of sex cord stromal elements, misleading to the diagnosis of adenosarcoma. However, microscopic examination of the hysterectomy specimen revealed the bulk of the sex cord tumor elements within the myometrium, which was not accessible to biopsy. This case, apart from being rare, also highlights the importance of considering this tumor in the differential diagnosis in superficial endometrial biopsies.

Architecture of the Cutaneous Autonomic Nervous System.

The human skin is a highly specialized organ for receiving sensory information but also to preserve the body's homeostasis. These functions are mediated by cutaneous small nerve fibers which display a complex anatomical architecture and are commonly classified into cutaneous A-beta, A-delta and C-fibers based on their diameter, myelinization, and velocity of conduction of action potentials. Knowledge on structure and function of these nerve fibers is relevant as they are selectively targeted by various autonomic neuropathies such as diabetic neuropathy or Parkinson's disease. Functional integrity of autonomic skin nerve fibers can be assessed by quantitative analysis of cutaneous responses to local pharmacological induction of axon reflex responses which result in dilation of cutaneous vessels, sweating, or piloerection depending on the agent used to stimulate this neurogenic response. Sensory fibers can be assessed using quantitative sensory test. Complementing these functional assessments, immunohistochemical staining of superficial skin biopsies allow analysis of structural integrity of cutaneous nerve fibers, a technique which has gained attention due to its capacity of detecting pathogenic depositions of alpha-synuclein in patients with Parkinson's disease. Here, we reviewed the current literature on the anatomy and functional pathways of the cutaneous autonomic nervous system as well as diagnostic techniques to assess its functional and structural integrity.

The Presence of Demodex Mites in Patients with Dermatologic Symptoms of the Face

The aim of the study was to investigate the Demodex prevalence in patients with dermatological complaints who were admitted to our hospital, and to evaluate the socio-demographic characteristics and risk factors of the patients. A total of 133 patients who were sent for Demodex screening were included and questionnaire for risk factors was administered. Samples were taken by standard superficial skin biopsy method and the different developmental stages were investigated under microscope. Demodex species were found in 93 (69.9%) of the patients. Demodex folliculorum was found in 58 (62.4%) of the patients, Demodex brevis in 13 (14%), Demodex folliculorum and Demodex brevis in 4 (4.3%) and Demodex species in 18 (19.4%) of the patients. At least one of the Demodex species was found in 77.1% of patients with acne rosacea. No statistically significant relation was found between Demodex positivity and age, gender, number of weekly baths, use of makeup, and common towel use. Though statistically not significant, an increase of Demodex infestation with increasing age was observed. Demodex mite infestations are widespread worldwide without showing important racial and gender differences. In the present study, prevalence of Demodex infestation in patients with acne rosacea was high and this should be taken into consideration, when such patients are treated for their symptoms.

49. Giant cell arteritis and Takayasu arteritis: two sides of the same coin in an elderly female?

49. Giant cell arteritis and Takayasu arteritis: two sides of the same coin in an elderly female?

Renal Cell Carcinoma Antigen Expression in Primary Cutaneous Endocrine Mucinous Carcinomas: A Case Series of 14 Patients and Review of the Literature

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) and primary cutaneous mucinous carcinoma (PCMC) are both uncommon low-grade cutaneous adnexal tumors with predilection for the eyelids of elderly women. Their clinical appearance is nonspecific, typically presenting as a slowly growing poorly circumscribed papule, nodule, plaque, or swelling. Histological features of EMPSGC include a lobulated dermal neoplasm with bland cytology and an invasive mucinous component in up to half of the cases. PCMC exhibits tumor nests suspended in abundant pools of mucin with focal strands or nests of tumor cells infiltrating the dermis. Because of their rarity and banal cytological features, both entities pose a risk for misdiagnosis with other benign/malignant cutaneous adnexal neoplasms. Histomorphological features can suggest a diagnosis of EMPSGC or PCMC, but immunohistochemistry is necessary for confirmation. A review of the literature showed variable results of antigens present in EMPSGC, and many of the positive markers only show sparse or focal immunoreactivity of tumor cells. As a result, diffusely positive markers play a crucial role in identification of these tumors, particularly with initial superficial biopsies. We present 9 cases of EMPSGC and 5 cases of PCMC with strong and diffuse immunoreactivity to renal cell carcinoma antigen. This novel finding can be useful in the diagnosis of EMPSGC and PCMC in combination with other known positive markers to differentiate them from other cutaneous neoplasms. In addition, it provides further evidence that EMPSGC could be a precursor lesion to PCMC with both existing on a spectrum.

Application of OCT in the Gastrointestinal Tract

Optical coherence tomography (OCT) is uniquely poised for advanced imaging in the gastrointestinal (GI) tract as it allows real-time, subsurface and wide-field evaluation at near-microscopic resolution, which may improve the current limitations or even obviate the need of superficial random biopsies in the surveillance of early neoplasias in the near future. OCT’s greatest impact so far in the GI tract has been in the study of the tubular esophagus owing to its accessibility, less bends and folds and allowance of balloon employment with optimal contact to aid circumferential imaging. Moreover, given the alarming rise in the incidence of Barrett’s esophagus and its progression to adenocarcinoma in the U.S., OCT has helped identify pathological features that may guide future therapy and follow-up strategy. This review will explore the current uses of OCT in the gastrointestinal tract and future directions, particularly with non-endoscopic office-based capsule OCT and the use of artificial intelligence to aid in diagnoses.

Superficially Invasive Oral Squamous Cell Carcinoma Presenting With Features Of Oral Verrucous Hyperplasia – A Case Report

Brief Background : Verrucous lesions of the oral cavity with warty and exophytic clinical presentations can have varied histopathology. Oral Verrucous hyperplasia (OVH) is a potentially malignant disorder, which may transform into oral carcinoma. Case Report : We report a 56-year-old male patient who presented with a verruco-proliferative pinkish white growth on the lateral border of the tongue. The patient was diagnosed with superficially invasive squamous cell carcinoma in verrucous hyperplasia based on histopathological features. Summary and Conclusion : The diagnosis of this entity poses difficulty as it can be underdiagnosed as oral verrucous hyperplasia particularly in superficial biopsies. Key words : Verrucous hyperplasia, Squamous cell carcinoma, superficially invasive.

Re-biopsy and liquid biopsy for patients with non-small cell lung cancer after EGFR-tyrosine kinase inhibitor failure.

BackgroundRe‐biopsy is important for exploring resistance mechanisms, especially for non‐small cell lung cancer (NSCLC) patients who develop resistance to EGFR‐tyrosine kinase inhibitors (TKIs). Liquid biopsy using circulating tumor DNA has come into use for this purpose. This retrospective study investigated the status of re‐biopsy and liquid biopsy in NSCLC patients with EGFR mutations and evaluated their effect on clinical strategies and prognosis.MethodsFive hundred fifty‐five NSCLC patients with resistance to EGFR‐TKIs were included and divided into three groups: re‐biopsy, liquid biopsy, and no re‐biopsy. Amplification refractory mutation system (ARMS) PCR or super ARMS PCR was used to detect EGFR mutations.ResultsThree hundred eight (55.5%) patients underwent re‐biopsy; 45.5% (140/308) were positive for T790M. The most common re‐biopsy procedure was computed tomography‐guided percutaneous core needle biopsy (60.1%), followed by effusion drainage (29.5%) and superficial lymph node biopsy (6.5%). One hundred eighteen (21.3%) patients underwent liquid biopsy; the T790M detection rate was 41.5% (49/118.) Of the 308 patients who underwent re‐biopsy, 69 were examined for EGFR mutations with plasma. The concordance rate of T790M detection between tissue and plasma was 66.7%. A statistical difference in further treatment after EGFR‐TKI failure was observed among all groups (P = 0.014). Patients in the biopsy groups were more likely to receive third‐generation EGFR‐TKIs. Multivariate analysis showed that re‐biopsy had a significant impact on overall survival (P < 0.001).ConclusionRe‐biopsy plays a pivotal role in the management of patients with NSCLC and resistance to EGFR‐TKIs. Liquid biopsy may be an alternative if difficulties performing re‐biopsy exist.

Routine retrieval of pelvic sentinel lymph nodes for melanoma rarely adds prognostic information or alters management

Pelvic sentinel lymph nodes (SLNs) are commonly identified during inguinal SLN biopsy for melanoma, but retrieval is not uniform among surgeons/centers. Few studies have assessed rates of micrometastases in pelvic versus superficial inguinal SLNs. Previous studies suggested that presence of pelvic SLNs was predicted by aggressive pathologic features and that their presence portended a worse prognosis. The objectives of this study were to examine presurgical predictors of pelvic SLNs among patients undergoing inguinal SLN biopsy, assess rates of micrometastases in superficial inguinal versus pelvic SLNs, and determine whether presence of pelvic SLNs was associated with long-term outcomes. Multivariable regression was used to assess presurgical factors associated with presence of pelvic SLNs. Rates of micrometastases in superficial inguinal versus pelvic SLNs in patients who had a pelvic SLN were compared with McNemar's test. Groin recurrence, disease-free survival (DFS), and disease-specific survival were analyzed by Kaplan-Meier method. A multivariable Cox model for DFS was performed. Pelvic SLNs were retrieved in 100/537 (18.6%) superficial inguinal SLN biopsies and no preoperative factors predicted their presence. In patients with a pelvic SLN, micrometastases were present in 3.0% of pelvic versus 34.0% of superficial inguinal SLN biopsies (P<0.001). There were no differences in groin recurrence, DFS, and disease-specific survival for patients with/without pelvic SLNs in univariate analyses (all P>0.2) or in the multivariable Cox model for DFS (hazard ratio: 1.1, 95% confidence interval: 0.6-2.1). In conclusion, pelvic SLNs harbor micrometastases less frequently than superficial inguinal SLNs do, suggesting that omission of pelvic SLN biopsy may be reasonable.

Blocked by a Ring: A Case of Gastric Linitis Plastica Presenting as Large Bowel Obstruction Secondary to Rectal Stenosis.

Metastatic gut lesions from primary gastric carcinoma occur via hematogenous, lymphatic, or peritoneal seeding. We report an unusual case of large bowel obstruction secondary to rectal stenosis due to metastatic signet ring cell gastric cancer. A 61-year-old woman with a history of 8 weeks' duration of alternation in bowel movements presented with symptoms of bowel obstruction. Computed tomography revealed rectal wall thickening, and sigmoidoscopy demonstrated edematous and fibrotic rectal mucosa. Superficial biopsies were negative for malignant disease. Because of worsening of obstructive symptoms, an emergent surgical diversion was performed. Surgical biopsies were consistent with poorly differentiated adenocarcinoma. Gastroscopy established diagnosis of gastric adenocarcinoma with signet ring type cells. Rectal stenosis on examination and demonstration of rectal wall thickening on imaging should raise suspicion for Schnitzler's metastasis, and an upper endoscopy should be performed.

Follicular induction and CK20+ Merkel cells overlying cutaneous focal mucinosis.

Cutaneous focal mucinosis (CFM) or focal dermal mucinosis is a benign reactive process categorized as a primary mucinosis. Skin biopsy is essential for diagnosis, as the clinical appearance is often non-specific. Follicular induction is a phenomenon whereby the epidermis is induced by an underlying process to form primitive or mature hair follicles, and is commonly seen overlying dermatofibromas. Follicular induction has been rarely described in CFM. We performed a retrospective histological review of lesions of CFM confirmed by skin biopsy from 2010 to 2015 in our department. We found that 11% (11/98) of CFM lesions showed follicular induction. Cytokeratin 20 (CK20) immunostaining was performed on all 11 of these biopsies that showed follicular induction and highlighted an increased density of CK20+ Merkel cells within the basaloid epidermal proliferations. As superficial basal cell carcinomas (BCC) often show a mucinous stroma around the basaloid islands, CFM with follicular induction may closely mimic a BCC histologically, particularly in superficial shave biopsies. Therefore, it is important that dermatopathologists be aware of this phenomenon. Furthermore, CK20+ staining within the basaloid epithelial proliferations may be helpful in differentiating CFM with follicular induction from a BCC.

Incidence and density of Demodex folliculorum and Demodex brevis (Acari: Demodicidae) in patients with acne in the province of Erzincan, Turkey

ABSTRACTThe present study was carried out to determine the incidence and density of Demodex folliculorum (Simon, 1842) and Demodex brevis Akbulutova, 1963 in patients with acne. The study included 210 patients diagnosed with acne during clinical examination, and 150 healthy controls without any facial dermatoses. In the study, samples were taken from the right cheek, left cheek, nasolabial area, and chin of the participants using the Standard Superficial Skin Biopsy technique. Samples were examined under a light microscope, and Demodex species were identified and counted. Demodex positivity (≥5 mites) was detected in 62.4% of the patients and 16.7% of the controls in the study (p < 0.001). A total of 3325 (mean: 25.4/cm2) mites were isolated from Demodex-positive patients. A total of 2015 (mean: 19.2/cm2) mites were isolated from patients infested with D. folliculorum only, 52 (mean: 7.4/cm2) mites were isolated from patients infested with D. brevis only, and 1058 (mean: 65.2/cm2) mites were isolated from patients infested with both species. The mean density of both mites (co-infection D. folliculorum and D. brevis) was detected as 21.0, 43.5, and 117.1/cm2 respectively, in patients with mild, moderate, and severe acne. In the controls who was Demodex positive, only D. folliculorum or co-infection with both mites were detected, not D. brevis alone. A total of 167 (mean: 6.7/cm2) mites were isolated from these controls. As a result, Demodex mites were found to be very common and intense in patients with acne in Erzincan, Turkey. It was also concluded that there was a positive correlation between Demodex mites and degree of acne, and that the co-infection of D. folliculorum and D. brevis aggravated the clinical picture in patients with acne. It may be helpful to consider these findings in clinical assessments of patients with acne.

Somatic MDC1 Mutation in Putative Pre-Leukaemic Stem Cell of a Biclonal Case of Chronic Lymphocytic Leukaemia

Chronic lymphocytic leukaemia (CLL) is an inherently heterogeneous disease in which founding lesions and cell of origin remain a subject of debate. This case of truly biclonal CLL provides evidence of the presence of a pre-leukaemic stem cell, supporting other lines of evidence that pathogenic genetic and epigenetic lesions in CLL arise early in haematopoiesis.An individual with trisomy 12 containing CLL, present at a frequency of 30%, was identified. Two distinct CD5/19-positive CLL clones were separated by flow cytometry, based on bimodal expression of CD49d. Each leukaemic clone was subjected to targeted immunoglobulin heavy chain variable region gene (IGHV) sequencing, whole exome sequencing (WES) and single-nucleotide polymorphism (SNP) microarray. CD5-positive T cells and a non-malignant superficial skin biopsy sample from the same individual were analysed as comparators.The CD49d-positive and CD49d-negative fractions harboured completely different IGHV rearrangements and mutational statuses (V4-34*02, hypermutated, and V3-21*02, unmutated, respectively) indicative of two unique leukaemic clones. Furthermore, trisomy 12, a relatively common aneuploidy in CLL, was present at high frequency (89.9%) in the CD49d-positive fraction but was absent in the CD49-negative and T-cell fractions. A mutation in the known CLL driver SF3B1 (c.1866G>T) was present in the CD49-negative, unmutated clone alone, along with a 17p deleted subclone in around 20% of this fraction. The presence of a 17p deletion is highly clinically relevant in this disease, and it is noteworthy that this subclone was not detected by routine fluorescence in situ hybridisation (FISH) at diagnosis. Two putative driver mutations in KMT2D and BCL11B were detected in the CD49d-positive, trisomy 12 clone alone (c.15256C>T and c.1387G>A respectively). A TET2 mutation (c.3609C>G) was found in all three fractions. The mutation in this epigenetic regulator has previously been described in clonal haematopoiesis of indeterminate potential (CHIP) and was hypothesised to have been acquired in a haematopoietic stem cell predisposing the individual to the development of haematological malignancy. However, the presence of this mutation was confirmed by Sanger sequencing of genomic DNA extracted from the skin sample, and is therefore of germline origin. The role of germline TET2 variants has not been described in lymphoid malignancy.Importantly, eight coding mutations were found common to both leukaemic clones but were absent from T-cells, implicating a common cell of origin prior to IGHV rearrangement but following B-lineage commitment (that is, a putative pre-leukaemic stem cell). One of these mutations was a disruptive 123 base pair deletion (c.4824_4946del) in MDC1 (mediator of DNA damage checkpoint 1) and was present at a variant allele frequency (VAF) of approximately 50% in both CLL clones, suggesting it was a founder mutation prior to subclone divergence. MDC1 is a mediator in the Ataxia Telangiectasia Mutated (ATM)-dependent DNA damage repair pathway and has not been previously implicated in CLL pathogenesis unlike ATM, which is frequently lost in del11q CLL. The proposed evolution of CLL in this case is presented in Figure 1.In summary, this highly unusual case of CLL provides insights into the evolution of CLL and adds another line of evidence to support the proposed early origins of CLL in haematopoiesis. The role that MDC1 may contribute to CLL pathogenesis, in particular its association with ATM dysregulation, remains to be elucidated. Further work to delineate critical pathways based on the discovered mutations is underway, and includes global transciptomic analysis of the purified leukaemic clones by RNAseq. DisclosuresNo relevant conflicts of interest to declare.

TÜRKİYE’DE KUZEY-DOĞU ANADOLU BÖLGESİNDEKİ MİDE BİYOPSİLERİNİN İNCELENMESİ İLE: MORFOLOJİK-KLİNİK UYUMUN ÖNEMİ

OBJECTIVE: In our study we aimed to make a generallyreview of gastric biyopsies in North-Eastern Anatoliaregion in Turkey such as; percentages of malignancy ordysplasia, reasons of re-biopsy recommendations andresults of second biopsies if taken.MATERIAL AND METHODS: 1840 gastric biopsies whichexamined by 3 pathologists at 2 centers were analyzedretrospectively. Percentages of malignancy or dysplasia,cases which were recommended for re-biopsies, reasonsof recommendations and results of re-biopsies wereexamined. In the results of the second biopsies, dysplasia,malignancy and gastritis were accepted as a significantresult.RESULTS: The mean age of our cases was 52.9 ± 16.6 years(range: 18-95 years). 1012 (55%) patients were femalesand 828 (45%) patients were males. In 90 out of 1840cases, biopsies were taken for suspect of malignancy,clinically. 35 of 90 cases were reported as malignancy. In61 out of 1840 cases re-biopsy were recommended. Reasonsof recommendations for re-biopsy categorized inthree groups: suspect of malignancy- clinically, suspectof malignancy- morphologically, insufficient (superficial)biopsies. 12 (46.2%) of 26 cases which were taken secondbiopsies were reported as malignancy and gastricdysplasia. Only in 2 (7.6%) of 26 cases the results wereinsignificant (insufficient biopsy).CONCLUSIONS: Endoscopic findings provide informationabout the diagnosis but are not pathognomonicwhich also need histological confirmation. Closeworking relationship and a good dialogue between thepathologist and the gastroenterologist is essential forclinical-morpological consistency, morphological-clinicalconsistency and final diagnosis.

Nerve and skin biopsy in neuropathies.

To give an overview of recent data on the use of nerve and skin biopsy as a diagnostic tool in neuropathies. Axonal damage in a biopsy from a patient with chronic inflammatory demyelinating polyradiculoneuropathy may point to the presence of autoantibodies to paranodal proteins. In nonsystemic vasculitis of the peripheral nervous system, nerve biopsy is still the only means to make a definite diagnosis. Increased autophagy has been found in idiopathic neuropathy and may also be a common final pathway in various types of neuropathy. Nerve biopsy has unexpectedly revealed familial amyloid neuropathy in a number of cases that were taken for idiopathic, for Charcot-Marie-Tooth disease, or for chronic inflammatory demyelinating polyradiculoneuropathy. Skin biopsy can differentiate between length-dependent and non-length-dependent small fiber neuropathy, which aids in the etiological differential diagnosis. It can also be used to identify small fiber involvement in mixed neuropathies and for follow-up studies. Nerve biopsy is still the gold standard for the diagnosis of peripheral nerve vasculitis. In other indications, sural or superficial peroneal nerve biopsies are less frequently done, because less invasive methods have become available. Modern imaging methods allow localization of nerve damage, such that targeted fascicular biopsies can be done. Immunofluorescence staining of teased nerve fibers has contributed to the understanding of the pathophysiology of inflammatory neuropathies. Skin biopsy has become a routine method to diagnose small fiber neuropathy.

A Case of Endoscopic Mucosal Resection of Gastric Metastasis From Renal Cell Carcinoma Without Recurrence

IntroductionRenal cell carcinoma (RCC) with gastric metastasis is extremely rare. The most common intervention is partial gastric resection; however, recently interventions including endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) have been used. We present a case of gastric metastasis from RCC that was completely resected by EMR with pathology showing clear margins. Two year follow up showed no local recurrence or distal metastasis. Case Report A 86-year-old male with history of RCC PT2N0M0 diagnosed 8 years prior s/p partial right nephrectomy presented to the ED with exertional dyspnea. Patient had a hemoglobin of 7mg/dL. Emergent EGD revealed a single 25mm sessile polyp in the gastric fundus with stigmata of recent bleeding treated with epinephrine injection. Subsequently patient underwent repeat EGD and, in view of atypical nature, polyp biopsies were performed. Pathology showed inflammatory changes and no malignancy. Five days later, the patient underwent repeat EGD. The polyp was excised completely by standard EMR technique with methylene blue saline-lift. Pathology of the polyp showed metastatic clear cell renal carcinoma with clear cauterized margin. Follow-up EGDs performed at 10 days, 4, 9 and 22 months and EUS at 9 and 24 months post EMR showed no local recurrence. PET/CT at 15 and 24 months after EMR revealed no evidence of distal metastases. Discussion In a known RCC with gastric metastasis, EUS should be performed to evaluate the involvement of gastric layers. If the fourth layer (muscularis propria) is involved, partial gastrectomy is the preferred choice. Otherwise an ESD with en bloc excision is the best option. In our case, the initial biopsy report was negative for malignancy; therefore, an EMR was done. The polyp could be lifted well with injection of methylene blue saline (lift sign is the best marker that could be used for assessing excision of lesion by EMR) hence the polyp was resected completely with negative cauterized margins. Our close surveillance in the span of 2 years with no recurrence, makes our case of a gastric metastasis resected by EMR an effective endoscopic intervention.2127_A Figure 1. (A) A single 25 mm sessile polyp with stigmata of recent bleeding was found in the gastric fundus. (B) An EGD 5 days later showing 25 mm sessile polyp found on prior endoscopy (C) EGD s/p polypectomy via an EMR with complete resection and retrieval.2127_B Figure 2. (A) This is a H&E slide with 10x magnification. Superficial biopsy showing inflammatory changes, and granulation tissue. (B) H&E slide with 2X magnification showing metastatic RCC with well visualized cauterized resection with clear margins. Cauterized margin (blue arrows) is 1.5 mm away from closest metastatic RCC (asterisks). (C) H&E slide of the RCC with 10x magnification. (D) H&E slide with 40x magnification of RCC.2127_C Figure 3. Two year follow up EUS shows endoclip in the gastric fundus with intact fourth layer (muscularis propria) and no subepithelial lesion.

PS02.035: CIRCUMFERENTIAL ENDOSCOPIC SUBMUCOSAL DISSECTION OF A LARGE SUPERFICIAL OESOPHAGUS SQUAMOUS CELL CANCER WITHOUT STRICTURES ON FOLLOW-UP

Abstract Description The optimal treatment for oesophageal superficial squamous cell cancer (SCC) is end bloc resection, that in large lesions is only possible with endoscopic submucosal dissection (ESD). Resections larger than 3cm, in the upper esophagus and encompassing more than 3/4 of the luminal circumference, are associated with high stricture rate. That risk is virtually 100% in cases of circumferential ESD. High focus had been given to preventive measurements such as steroids injection, oral steroids or cell sheet transplantation. Usually highly osmotic substances such as Glicerol ® are used for subepitelial lifting. Hyaluronic acid has high viscosity and anti-inflammatory proprieties, that due to its high cost is not widely used in ESD or is used in low concentration formulas and low volume. We report a case of a 7.5 cm long circumferential oesophageal ESD performed with injection of a high volume and concentration of hyaluronic acid that was not associated with stricture in the follow-up. A 73 years-old male patient was referred to our clinic due to the presence of a long superficial lesion and biopsies positive for SCC. We performed chromoendoscopy with lugol that revealed the presence of a ca 6cm long Paris IIa-b, circumferential SCC in the middle esophagus with ‘Tatami-no-me ‘and ‘pink-color’ signs, without ulcers or other endoscopic signs of deep invasion. The PET-CT was negative for metastasis. After multidisciplinary conference and patient's consent an ESD was performed under full narcosis using Dualknife ® and hyaluronic acid for subepitelial injection. A 7.5 cm circumferential ESD specimen was resected and the patient was discharged at day 3 without complications under proton pump Inhibitors and a step-down dose of 30mg/d of oral prednisolone. The pathological result revealed R0 resection of a SCC with invasion of the superficial muscularis mucosae (T1a) and no lymphovascular engagement. The follow-up at 2, 5, 8 weeks and 6, 9 and 12 months revealed the absence of stricture. There was no cancer recurrence in the last follow-up (1 year). Long circumferential ESD of oesophageal SCC is possible with curative intent. The combination of PPI, oral steroids and high volume/concentration of hyaluronic acid, avoided stricture formation in this case. Disclosure All authors have declared no conflicts of interest.

Diagnostic Utility of Computed Tomographic Angiography in Giant-Cell Arteritis.

Background and Purpose- The diagnosis of giant-cell arteritis (GCA) is challenging. Superficial temporal artery biopsy and ultrasound are positive in only 50%. We evaluated computed tomographic angiography (CTA) of the head in GCA. Methods- This case-control study was performed using a prospective GCA registry. Cases presented with stroke symptoms, had a CTA, and were subsequently diagnosed with GCA. Age- and sex-matched controls presented with stroke symptoms, had a CTA, and were not diagnosed with GCA. CTAs were evaluated for the presence of superficial temporal artery abnormalities. Results- Fourteen cases met the inclusion criteria and were matched with 14 controls. Blurred vessel wall margins and perivascular enhancement was found in 10 cases (71.4%) and 2 controls (14.3%). CTA has an accuracy of 78.6%, sensitivity of 71.4%, and a specificity of 85.7% for GCA. Conclusions- CTA detects superficial temporal artery abnormalities in GCA. This may facilitate early diagnosis and prompt implementation of potentially sight-saving and stroke-preventing treatment.

Diagnostic accuracy of immunohistochemical markers in differentiation between basal cell carcinoma and trichoepithelioma in small biopsy specimens.

The distinction of trichoepithelioma from basal cell carcinoma in small superficial biopsies is important but often challenging. This has inspired many scientists to test the validity of immunohistochemical markers in the differential diagnosis. To develop an immunohistochemical protocol that helps in differentiation between both trichoepithelioma (TE) and basal cell carcinoma (BCC) with higher sensitivity and specificity. Using standard immunohistochemical techniques, we examined 10 TEs and 19 BCCs for the expression of CK19, Ki-67, androgen receptors (AR), CD10, and PHLDA1. Immunoreactivity of AR, Ki-67, and CD10 in tumor cells was significantly higher in BCC than TE with a diagnostic accuracy in BCC of 75.5%, 75.8%, and 79.3% respectively, whereas immunoreactivity of PHLDA1 in tumor cells and stromal CD10 was significantly higher in TE than BCC with a diagnostic accuracy in TE of 100% and 82.8%, respectively. In contrast, immunoreactivity for CK19 showed no statistically significant differences between both tumors. The analysis of CD10, Ki-67, and PHLDA1 can be used as a helpful immunohistochemical panel in the distinction between TE and BCC especially in small and superficial biopsies.

Chronic Eosinophillic Leukemia presenting as Peripheral Neuropathy

Chronic Eosinophilic Leukemia (CEL) is a rare form of chronic myeloproliferative disorder of unknown etiology with no data on its true incidence. The disease has a wide variety of manifestations. Literature search has not shown peripheral neuropathy as the only presentation of CEL. Our case is probably the first such report case. Here we are reporting a 45 year old male patient who presented with progressive weakness of upper and lower limbs for 6 months and weight loss for 2 months. Neurological examination revealed findings consistent with bilateral sensorimotor polyneuropathy later confirmed by nerve conduction studies. Complete blood count revealed total wbc count – 51, 870/mm3, eosinophil – 62.1% (32,315/mm3). Peripheral Blood film revealed eosinophilic leucocytosis. Superficial peroneal nerve biopsy showed mild perivascular infiltration with inflammatory cells. No granuloma or malignancy was seen. Bone Marrow examination showed hyperactive granulopoiesis with predominance of eosinophil series with progressive maturation along with presence of myeolcytes, hypersegmented eosinophils and giant eosinophils. Blast cell was around 7%. Patient was treated with imatinib and prednisolone which showed excellent response.Bangladesh Crit Care J March 2018; 6(1): 47-49