Imaging findings in mucin-containing carcinomas of the breast: correlation with pathologic features

OBJECTIVE

Breast carcinomas may contain varying quantities of extracellular mucin. The purpose of this study was to correlate the mammographic and sonographic appearance of mucin-containing carcinomas of the breast with the histologic features of these tumors.

MATERIALS AND METHODS

The tumor registry and breast imaging files at our institution identified 34 women with 37 mucin-containing breast carcinomas for which mammographic and histologic slides were available for review. By consensus, two radiologists determined the mammographic margin characteristics (circumscribed, microlobulated, indistinct, spiculated) and, when available, the sonographic properties of the carcinomas. Doubling time in days was estimated from sequential mammograms when possible. A pathologist reviewed the histologic slides and divided the 37 carcinomas into three categories based on the percentage by volume of mucin seen: pure mucinous (> or = 90% mucin), 23 cases; moderately mucinous (< 90% and > 30% mucin), seven cases; and minimally mucinous (< or = 30% mucin), seven cases. To determine the contribution of varying percentages of mucin to the radiologic appearance of the tumors, the margin characteristics were correlated with the histologic percentage of mucin, microscopic margin appearance (displacing or infiltrating), nuclear grade (I, II, III), and lymph node status.

RESULTS

Tumors with circumscribed and microlobulated margins on mammography had a higher percentage of mucin histologically (p < .01; chi 2). A trend of slower growth rate on mammograms, lower histologic nuclear grade, and less frequent axillary node involvement were also seen in tumors with a higher percentage of mucin. Spiculated mammographic margins were seen when there were decreasing volumes of mucin and when tumor margins histologically were infiltrating; these tumors had higher nuclear grades and more frequent axillary node involvement (p < .01).

CONCLUSION

The radiologic and pathologic correlation of mucin-containing breast carcinomas demonstrates that lesions with higher percentages of mucin have mammographic appearances that reflect less aggressive histologic margins, lower nuclear grades, and slower growth rates. Carcinomas that have small percentages of mucin have mammographic and histologic characteristics of more aggressive, invasive ductal carcinomas.

Colorectal cancer in young patients: characteristics and outcome

Controversy still exists regarding the features and prognosis of colorectal cancer in young patients. We reviewed the records of 62 patients 40 years of age and younger with adenocarcinoma of the colon and rectum, treated and followed at our institution between 1968 and 1991. These patients represented 3.1 per cent of our total colorectal patient population during that time period. Their mean age was 34.5 years old, with the youngest patient being 18 years of age. Modified Dukes stages at presentation were 8 per cent A, 20 per cent B, 23 per cent C, and 48 per cent D. Underlying inflammatory bowel disease was present in 21 per cent of patients and was proportionately distributed between high (C and D) and low (A and B) stages. Half of the stage D patients had high grade lesions, compared with only 20 per cent of lower stage patients (P = 0.037). All but two patients had operative exploration; 36 (60%) had complete resection of all gross disease. With a mean follow-up of 98.2 months, the 5-year overall survival for stage A disease was 100 per cent, but dropped to 85, 40, and 7 per cent for stages B, C and D, respectively. Compared to published figures for the general population, younger patients with colon and rectal cancer tend to present at a more advanced stage, but have similar stage-related survival.

Mucinous (colloid) breast cancer: clinical and mammographic findings in 10 patients

OBJECTIVE

The purpose of this study was to review the clinical and mammographic findings in patients with mucinous (colloid) breast cancer.

MATERIALS AND METHODS

We retrospectively reviewed the pathology reports of 444 women with breast cancers diagnosed between May 1988 and October 1993 after mammographic evaluation. Of these, 10 women 31-88 years old (mean, 67 years) had pure mucinous adenocarcinoma of the breast. We reviewed the clinical and mammographic findings in these 10 patients.

RESULTS

Three patients (30%) had palpable masses. Mammographic abnormalities were detected on screening studies in the seven patients (70%) who were asymptomatic. The mammographic findings included poorly defined, lobulated, solitary masses in seven patients, poorly defined, clustered masses in two patients, and a well-circumscribed mass in one patient. No tumors had calcifications as the primary finding, and only one tumor had a few scattered, round, calcifications associated with clustered masses. Two patients had areas of noncomedo ductal carcinoma in situ without calcifications adjacent to the invasive mucinous adenocarcinoma. The tumors were 7-35 mm in diameter. No metastases were found in the axillary lymph nodes in the eight patients in whom biopsies of these nodes were done.

CONCLUSION

The most common and distinctive mammographic feature of mucinous breast carcinoma is a poorly defined, lobulated mass. The absence of axillary nodal metastases, even in patients with large palpable tumors, supports the notion that biologically, mucinous carcinomas are slower growing, less aggressive tumors than infiltrating ductal carcinomas not otherwise specified.

Carcinoma of the prostate in young patients: a report of two cases

Carcinoma of the prostate is rare in young patients and has an aggressive biological behavior and rapidly fatal outcome, irrespective of the treatment modality. Presentation and clinical course of the carcinoma in 2 patients 28 and 31 years of age are described with a brief review of the relevant literature.

Colloid carcinoma of rectum in a 11 year old child

The rarity of rectal carcinoma in children has prompted us to report this patient who presented with bleeding per rectum and constipation. Histopathological examination of biopsy revealed the growth to be a colloid carcinoma of rectum and it was inoperable on exploratory laparotomy. There are three factors which contribute to an overall poor prognosis of rectal carcinoma in children viz. delay in diagnosis, advanced stage of disease and poorly differentiated histology.

Trends in colorectal cancer incidence and histologic findings in Maori and Polynesian residents of New Zealand

BACKGROUND

The aim of this study was to combine an epidemiologic survey of colorectal cancer among Maori, Polynesian, and white inhabitants of New Zealand with a detailed analysis of tumor subsite and histopathology.

METHODS

Data were obtained from the New Zealand National Cancer Registry and included all registrants from 1970 to 1984. Sections of histologic specimens of colorectal cancer of Maori and non-Maori were retrieved from three Auckland hospitals.

RESULTS

The annual age-adjusted incidence rates of large intestinal cancer among male and female Maoris and male and female Polynesians were 40%, 40%, 39%, and 29%, respectively, of the total population incidence. Time-trend analysis showed the incidence of large intestinal cancer to be increasing among all racial groups. The relative proportion of rectal cancers was higher in male and female Maoris and female Polynesians than in the general population, whereas male Polynesians had a relatively high proportion of right colonic cancers. High-grade carcinoma and mucinous carcinoma occurred more frequently in young individuals regardless of race. Carcinomas were diagnosed at a more advanced stage in Maoris.

CONCLUSION

Given the similar environmental characteristics of the three racial groups, the findings indicate the presence of powerful protective factors in Maoris and Polynesians. These could be constitutional or mediated by unrecognized dietary constituents.

Identification of hereditary nonpolyposis colorectal cancer in the general population. The 6-year experience of a population-based registry

BACKGROUND

Hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome) is an autosomal dominant disease characterized by early-onset intestinal neoplasms, localization of tumors in the proximal colon, and frequent association with cancers at other sites, especially the endometrium, skin, and stomach. The identification of HNPCC is often difficult, owing to the lack of biomarkers and the extreme frequency of sporadic colorectal cancer in the Western World.

METHODS

The authors reviewed the clinical data and the family trees of all patients (n = 817) with colorectal malignancies registered in the local health district between 1984-1989 with the following objectives: (1) to identify families with HNPCC and (2) to establish the frequency of the syndrome in northern Italy. Six clinical criteria were defined (vertical transmission, familial aggregation, early age at onset, right colon localization, multiple tumors, and mucinous carcinoma), all indicative of an increased possibility of HNPCC:

RESULTS

The registered families were divided into various subgroups according to the presence (in the nuclear pedigree) of four or more criteria (41 families, 5.0% of total), three criteria (58 families, 7%), two criteria (73, 8.9%), or less than two criteria (203 families, 24.8%). The remaining 380 case families did not show criteria suggesting a genetic component. One hundred thirty-three genealogic trees were extended further to gather information on second-degree and third-degree relatives. The expanded pedigrees were further analyzed to ascertain if they met the recently proposed requisites for HNPCC: Nineteen of 37 (51%) families with four criteria met the minimum requisites and could therefore be considered HNPCC: Similarly, HNPCC was diagnosed in six extended pedigrees of the three-criteria (16.6%) and in three families (8.5%) of the two-criteria subgroups. The difference in the detection of HNPCC among various subgroups was statistically significant (P < 0.001). From the observed findings, the frequency of HNPCC in this population can be estimated to be between 3.4-4.5% of all cases of colorectal cancer.

CONCLUSIONS

HNPCC can be identified in the general population through the data of a colorectal cancer registry if the nuclear pedigrees of all incident cases are traced and a proportion of them selectively expanded. The observed frequency of HNPCC was rather consistent with previous estimates in other populations.

Primary mucinous adenocarcinoma of renal pelvis in solitary pelvic kidney

Mucinous adenocarcinoma of the renal pelvis is a rare tumor. We report the case of a fifty-three-year-old man with this unusual cancer and review the literature. Usual features of this tumor include long duration of symptoms, an association with calculi and hydronephrosis, and a preoperative appearance of an inflammatory condition.

Mucinous component in colorectal carcinoma--prognostic significance: a study in a south Indian population

One hundred eighteen specimens of colorectal carcinoma have been studied with a view to assess the clinicopathological significance of the mucinous component in these neoplasms. When 50% or more of high-power fields examined consisted of "mucinous" tumour tissue, the term mucinous carcinoma was applied. Such mucinous carcinomas (MCa) constituted 19% of the total neoplasms studied. Predilection for the younger age group, a higher incidence in the proximal colon as against the rectosigmoid, and a lower distribution in the rectosigmoid as against nonmucinous carcinomas in that region were some of the features that characterised MCa. Clinical and histological features suggestive of aggressive behaviour and poor prognosis were more frequently observed in MCa. These features correlated with the percentage of mucinous component independently of the histological grade. It is concluded that colorectal mucinous carcinomas form a distinct group of neoplasms with certain clinical and pathological characteristics. These neoplasms tend to follow an aggressive clinical course, which is directly influenced by the mucinous component.

Calcified bladder tumors. CT features

CT scans of the pelvis in 132 patients with bladder tumor were reviewed. Calcifications in the bladder tumor were found in 11 men (8%) including transitional cell carcinoma (n = 6), mucinous adenocarcinoma (n = 4), and malignant mixed mesodermal tumor (n = 1). Calcifications in transitional cell carcinoma were located on the surface of the tumor in all 6 cases: they were nodular in 4 cases, nodular and arched in one, and plaque-like massive calcification in one. In mucinous adenocarcinoma multiple fine punctate calcifications were scattered within the mass in all 4 cases. The CT appearance of calcifications in bladder tumors may be helpful in predicting the histologic type of the tumor.

Quantitative DNA analysis and proliferation in breast carcinomas. A comparison between image analysis and flow cytometry

The DNA content and proliferation in 100 invasive breast carcinomas were evaluated by computerized image analysis (IA) and flow cytometry (FCM). For DNA content, image analysis of Feulgen-stained slides of fresh tumor imprints were compared with flow cytometry of propidium iodide-stained disaggregated fresh tumor tissue. The DNA indices obtained by the two methods showed close correlation by linear regression analysis (r = 0.89, p less than .001). There were 44 (44%) diploid and 56 (56%) aneuploid tumors. There was agreement between the two methods in detection of aneuploidy in 81% of tumors. Image analysis required smaller tissue samples, permitted direct visualization and selection of tumor cells, and was more sensitive in detecting tetraploid and highly aneuploid cell populations. In contrast, flow cytometry histograms provided better resolution, and were more effective in detecting multiploid tumors and near-diploid aneuploid tumors. Aneuploidy was significantly related to various adverse prognostic parameters, namely, negative estrogen receptor, high mitotic rate, high histologic and nuclear grades. Proliferation was evaluated by measuring the FCM S phase fraction (SPF), and by image analysis quantitation of immunohistochemical staining using Ki-67 monoclonal antibody. SPF and Ki-67 count showed modest correlation (r = 0.42). Both SPF and Ki-67 count were significantly related to the mitotic rate, histologic and nuclear grades. Our results indicate that the two methods provide comparable results, but offer individual advantages and are complementary techniques in analyzing DNA ploidy and proliferation in breast carcinomas.

Signet ring cell carcinoma of the stomach

Between 1965 and 1985, 51 of 1500 patients (3.4%) with gastric cancer who had gastric resection had signet ring cell gastric cancer. Patients with this form of cancer tended to be younger and female; the tumors were smaller and involved the stomach body, serosal invasion was less prominent, and lymph node metastases were less likely to be present. Early mucosal and submucosal cancer was present in 54.9% of the patients with the signet ring cell and in 24.6% with other types of gastric cancer. In 15.7% of patients with signet ring cell cancer, a noncurative resection was performed. The 5-year survival rate was 74.5% for patients with signet ring cell cancer and 52.4% for those with other types of gastric cancer (P less than 0.01). In patients with signet ring cell gastric cancer, the lesion is less extensive; thus, these patients probably can expect a longer survival time.

Therapy of small breast cancer: A prospective study on 1036 patients with special emphasis on prognostic factors

In 1983, The German Breast Cancer Study Group, sponsored by the Federal Ministry of Research and Technology, started a prospective multicenter trial on the treatment of early breast cancer pT1 pN0 M0. Treatment consisted of initial tumorectomy with microscopically free margins and lower axillary dissection. After conformation of a pT1 pN0-stage, additional treatment was either mastectomy or adjuvant radiotherapy (50 Gy in 25 fractions to the entire breast plus 12 Gy electron boost). In medially located tumors, the parasternal and supraclavicular area was also irradiated with 50 Gy. A randomization between both treatment modalities was initially planned but was not feasible and abandoned. Nearly all patients were treated according to their own choice. From November 1983 through December 1989, 1119 patients were recruited. Eighty-three were excluded from the protocol. Out of the remaining 1036 patients, 733 (71%) underwent breast preservation and 303 (29%) mastectomy. A detailed pathohistological examination of all tumorectomy specimens was performed in a pathologic reference center. Oncogen overexpression was evaluated by immunohistological detection of the transmembrane protein p-185 (corresponding to c-erb-B2) in 425 cases. After a median follow-up of 48 months, the frequency of local recurrences (4.7%), regional recurrences (1%), and distant metastases (5.4%) was the same in the breast preservation group and the mastectomy group. The 3-year disease-free survival was 90% after breast preservation and 88% after mastectomy (p = 0.21). In the breast preserving group, 24 patients with microscopically involved margins had a poorer disease-free survival than the study group (75% vs 90% after 3 years). The width of the margins had no impact on prognosis. Other prognostic factors in an univariate and multivariate analysis were tumor size and tumor grade. Age, menopausal status, hormone receptor status, histological tumor type, and treatment (mastectomy vs breast preservation) were not significant. P-185-expression was dependent on tumor grade and was the strongest prognostic factor in an univariate and multivariate analysis (p less than 0.001). The results emphasize the central role of tumor grade for prognosis and suggest the independent prognostic significance of the c-erb-B2 oncogen (corresponding to p-185) in pN0-patients.

Outcome of conservative therapy for invasive breast cancer by histologic subtype

Between 1977 and 1986, 879 patients with Stage I and II breast cancer underwent excisional biopsy, axillary dissection, and radiation. Median follow-up was 61 months (range 2-159 months). The patients were divided into seven groups based on histologic subtype: (a) 368 patients with both infiltrating and intraductal ductal carcinoma, (b) 389 infiltrating ductal carcinoma, (c) 41 infiltrating lobular carcinoma, (d) 23 combined infiltrating ductal and lobular carcinoma, (e) 28 medullary carcinoma, (f) 12 colloid carcinomas, and (g) 18 tubular carcinomas. Significant differences in clinical T status, pathologic nodal involvement, administration of chemotherapy, estrogen receptor positivity, progesterone receptor positivity, and age were observed between some histologic subgroups. Tubular and colloid carcinomas were more likely to present with T1 lesions, hormone receptor positivity, and node negative status than the other histologic subtypes. Most medullary carcinomas were hormone receptor negative and were younger than 50 years old. Infiltrating lobular carcinoma patients were more frequently lymph node negative, older, node negative, and estrogen receptor positive compared to the other groups (except for tubular and colloid patients). Differences in the administration of chemotherapy primarily reflected differences in lymph node involvement. Location of the tumor in the breast and menopausal status did not correlate with histologic subtype. There were no significant differences in 5-year actuarial overall survival, cause-specific survival, or relapse-free survival between the histologic categories. In addition, patterns of first failure were not significantly different among the histologic groups in terms of local-only first failure, any local component of first failure, regional-only first failure, or any regional component of first failure. There was, however, a difference among the seven groups in distant metastasis-only at first failure with invasive ductal carcinomas having the highest rate. Despite this difference, histologic subtype had no impact on survival. The site of in-breast failure relative to the location of the original tumor was not significantly different between groups. The histologic subtype of invasive breast cancer is not an independent risk factor in predicting survival or pattern of failure. Conservative surgery and radiation therapy is effective treatment of ductal, lobular, medullary, colloid, and tubular invasive breast cancer.

K-ras activation occurs frequently in mucinous adenocarcinomas and rarely in other common epithelial tumors of the human ovary

To explore the role of mutational activation of members of the ras family of cellular protooncogenes in the development of human ovarian neoplasms, a series of 37 ovarian tumors from Japanese patients was studied. These included 30 common epithelial tumors (1 mucinous tumor of borderline malignancy, 7 mucinous adenocarcinomas, and 22 nonmucinous carcinomas: 10 serous, 3 clear cell, 8 endometrioid, and 1 undifferentiated), 5 tumors of germ cell origin, and 2 sex cord/stromal cell tumors. Polymerase chain reaction was performed from selected areas of deparaffinized sections of formalin-fixed paraffin-embedded tissue, and the presence of activating point mutations in codons 12, 13, and 61 of the H-, N-, and K-ras genes was probed by dot-blot hybridization analysis with mutation specific oligonucleotides. Mutations in K-ras were also looked for by direct genomic sequencing. The overall frequency of ras gene mutations was 10/37 (27%). Mutations were detected only in K-ras, and were found in most of the mucinous tumors, including the one such tumor of borderline malignancy (6/8; 75%). In one mucinous adenocarcinoma, two mutations were detected in paraffin-embedded material that had not previously been found in high molecular weight DNA isolated from frozen tissue from the same case. K-ras mutations occurred significantly more frequently in mucinous tumors (6/8, 75%) than in serous carcinomas (2/10, 20%; P = 0.031) or in all nonmucinous types of epithelial ovarian tumors combined (3/22, 14%; P = 0.0031).

Adenocarcinoma of the vermiform appendix. A population study

We report seven cases of adenocarcinoma of the vermiform appendix occurring in Iceland during 1974-1989. The patients ranged in age from 25-83 years, mean age 55.1 years. There were five males and two females. Five had mucinous adenocarcinoma, two had adenocarcinoma. Four patients presented with symptoms and signs of acute appendicitis and all had surgically resectable disease. Three of these patients were alive with no evidence of disease four months, two years and 15 years after presentation; one death of disease occurred seven years after ileocecal resection. In three cases, the clinical presentation was that of metastatic adenocarcinoma of unknown origin. Of these patients two were diagnosed at autopsy and one after appendectomy for perforated appendicitis. Survival in this group was six weeks, three months and twelve months, respectively. In none of our patients was the diagnosis made preoperatively and no tumors were found in appendices removed incidental to other intra-abdominal operations. The incidence of adenocarcinoma of the vermiform appendix in Iceland during 1974-1989 was approximately 0.2 cases/100.000/year.

[Signet-ring cell colorectal carcinoma. Study of 2 cases]

The signet-ring cell colorectal carcinoma is very uncommon. During the period 1985-89, we have diagnosed two cases among 1,135 adenocarcinomata located in the same place. They are the two first cases described in Spain, according to a computerized bibliographic search. We have to point up as clinical features of the tumor, the occurrence of its first signs in advanced stages of the disease and the small survival of the patients suffering from this tumor. Its great content of mucin facilitates the thromboembolic disease which was the first sign and the cause of legth in one of our patients. This type of tumor has worse prognosis than the usual colorectal carcinomata, including the mucinous one, and it is similar to the one of the poorly differentiated carcinoma.

Histologic characteristics and outcome of familial non-polyposis colorectal carcinoma

Familial cases of non-polyposis colorectal cancer have recently attracted much interest. Little is known about the characteristic histology or natural history of disease in such cases. Our aim was to determine, through a population-based study, whether mucin-secreting tumours were associated with a positive family history and whether 'familiality' was an independent prognostic variable. All patients under 55 years of age with histologically verified colorectal cancer in Northern Ireland during 1976-78 were studied. The family history was validated in 95% of all non-polyposis cases (n = 205), and the proband's histologic specimen reviewed in over 99%. Mucin-secreting tumours were significantly associated with a positive family history, but familiality was not found predictive of survival in a multivariate analysis controlling for age, sex, stage, site, symptom duration, differentiation, and histologic type.

A study of colorectal adenocarcinoma

One hundred and seven patients with resected colorectal adenocarcinoma were studied between 1983 and 1987. These formed 3.3% of all cancer cases and 19.4% of gastrointestinal malignancies seen during the period. A majority of patients (68.7%) were between 41 and 60 years of age; 31.8% were below the age of 40 years. There was a male preponderance (62.6%). Left sided cancers were more common (65.4%). The predominant histologic patterns were well differentiated adenocarcinoma (72%) and mucinous carcinoma (20.6%). Mucinous carcinoma was more common on the left side. A majority of cases (95.3%) were in Duke's stages B and C. Only 2.8% of cases were confined to the mucosa.

Radiosurgical treatment compared to surgery alone for rectal cancer

Between February 1981 and September 1989, 144 patients with rectal cancer were treated according to a radiosurgical sandwich protocol (27Gy + surgery + 18Gy) or postoperative radiotherapy (45Gy) at the University Hospital 'A. Gemelli' in Rome. This group is compared with a group of 133 patients operated on between January 1968 and January 1981, by the same team of surgeons but who received no radiotherapy. The historical group is comparable to the radiosurgical group in terms of stage, histology, and surgical procedures. The median follow-up period of the radiosurgical group is 38 months and 68% of cases have been observed longer than 2 years. At 2 years local recurrence in the historical control group was 22% versus 17% in the prospective group (p = 0.8). For Stage C disease, local recurrence dropped from 54% to 35% with adjuvant radiotherapy (p = 0.3). Metastases were observed in 22% of the control group versus 13% of the radiosurgical group (p = 0.2). For Stage C disease the incidence of distant metastases dropped from 59% to 26% at 2 years with the use of the prospective radiosurgical protocol (p = 0.05). The Kaplan-Meier survival rate at 5 years was 46% for the historical group and 72% for the radiosurgical group (p = 0.003) (Stage A 71% & 94%, Stage B 48% & 77%, and Stage C 16% & 38%, respectively). Neither serious nor late toxicity has been detected in the radiotherapy group, nor were surgical complications observed in the pre-operative radiotherapy group. The data strongly suggest a survival advantage for patients treated with the radiosurgical combination (p = 0.003).

Analysis of stomach cancer incidence by histologic subtypes based on a mathematical model of multistage cancer induction and exponential growth

A mathematical model incorporating the processes of both cancer induction and subsequent tumor growth has been developed. The model was applied to incidence data of stomach classified into histologic subtypes: papillary adenocarcinoma (PAP), well and moderately differentiated tubular adenocarcinomas (WEL and MOD), poorly differentiated adenocarcinoma (POR), mucinous adenocarcinoma (MUC) and signet-ring cell carcinoma (SIG). The multistage theory was assumed for cancer induction as in the Armitage-Doll model. For the period of growth, exponential growth was assumed and clinical surfacing was formulated as a stochastic process related to tumor diameter. The number of stages in cancer induction and the tumor growth rate were simultaneously estimated for each histologic subtype using the maximum likelihood procedure. The present model showed better fits than the Armitage-Doll model in most histologic subtypes except WEL, PAP, WEL and MOD, which are characterized as differentiated subtypes with less mucous production, showed different features from POR, MUC and SIG: 1) the number of stages was estimated to be larger, 2) the differences in incidence rates between males and females were more marked, and 3) males tended to have larger growth rates in PAP and MOD, while in POR, MUC and SIG, females had larger values. The present study showed that an analysis by histologic subtypes is of importance in stomach cancer and that the period of tumor growth should not be ignored when formulating a model of the natural history of stomach cancer.

[Colorectal carcinoma in young patients: review of 10-year experience]

The authors, in reaffirming the high incidence of the mucin-producing type of colo-rectal adenocarcinoma in young patients, underline the considerable aggressiveness of this tumor. After a brief note on the etiopathogenetic hypothesis which could explain such behavior, the factors usually contributing to a worsening of the prognosis are reviewed. Thus, the Authors report their series and conclude affirming as indispensable to arrive to an early diagnosis.