Eosinophilic dysplasia of the gallbladder: a hitherto undescribed variant identified in association with a "porcelain" gallbladder

Malignant peripheral nerve sheath tumor of the uterine cervix: A case report and literature review

Malignant peripheral nerve sheath tumors (MPNSTs) are rare high-grade sarcomas arising from the peripheral nerves or peripheral nerve sheath cells. MPNSTs rarely occur in the soft tissue, especially in the uterine cervix. Few cases of cervical MPNST have been reported in the literature. The present study reports the case of a 36-year-old female patient who presented with vaginal bleeding. A cervical mass was detected by vaginal ultrasonography and the patient was diagnosed with MPNST via assessment of the morphological and immunohistochemical features of the tumor after surgery. The patient received chemotherapy and radiotherapy following surgery, and at 8 months post-treatment, had no recurrence or metastasis. Furthermore, the present study summarizes the characteristics of all reported cases of cervical MPNST and their potential differential diagnosis with other spindle cell tumors.

Histological and molecular diversity and heterogeneity of precancerous lesions associated with inflammatory bowel diseases

AIMS

Inflammatory bowel disease (IBD)-associated precancerous lesions may be adenomatous or non-adenomatous with various histomorphologies. We aim to validate the newly proposed classification, to explore the neoplastic nature of the non-adenomatous lesions and to elucidate the molecular mechanisms underlying the different histomorphologies.

METHODS

44 background precursor lesions identified in 53 cases of surgically resected IBD-associated colorectal and ileal carcinomas were reviewed for the histomorphological features (classified into adenomatous, mucinous, sessile serrated adenoma (SSA)-like, traditional serrated adenoma-like, differentiated, eosinophilic and serrated not otherwise specified (NOS)) and analysed for a key panel of colonic cancer-related molecular markers.

RESULTS

Approximately 60% of the lesions were adenomatous, of which some had mixed serrated, mucinous or eosinophilic changes. The remaining non-adenomatous lesions, including all other types except SSA-like type, mostly showed mixed features and focal adenomatous dysplasia. KRAS mutation and p53 mutant-type expression were found in about half cases across all types, while PIK3CA mutation only in some of adenomatous and eosinophilic lesions and MLH1/PMS2 loss in a subset of adenomatous, mucinous and eosinophilic but not in differentiated and serrated lesions. SAT-B2 or PTEN loss and IMP3 overexpression were seen in a small subset of lesions. No BRAF, NRAS or EGFR gene mutation was detected in any type. Certain molecular-morphological correlations were demonstrated; however, no single or combined molecular alteration(s) was specific to any particular morphological type.

CONCLUSIONS

IBD-associated precancerous lesions are heterogeneous both histologically and molecularly. True colitis-associated adenomatous lesions are unlikely conventional adenomas. Non-adenomatous lesions without frank cytologic dysplasia should also be regarded as neoplastic.

Ewing's sarcoma of the cervix: A case report of an unusual diagnosis in pregnancy treated with surgery, adjuvant VIDE and radiotherapy

Ewing's sarcoma of the cervix is a rare entity and presents with considerable challenges in diagnosis and therapy. Herein, we report a case of a cervical Ewing's sarcoma presenting with FIGO stage Ib, diagnosed during the first trimester of the patient's pregnancy. Imaging with CT scans, MRI of her abdomen and PET-CT verified the locoregional extension of the tumor. The diagnosis was confirmed by immunohistochemistry and molecular analysis. Fluorescence in situ hybridization and RT-PCR detected the pathognomonic EWS/FLI fusion gene. Favorable prognostic factors regarding the stage, clinocopathological and molecular characteristics of the tumor are also described. Due to the rarity of the disease, at present, there is no universal consensus on the optimal therapeutic approach. The literature has been reviewed and the therapeutic schemes and available clinical data have been discussed. The patient presented in this case report was treated aggressively with tri-modality therapy and underwent radical hysterectomy followed by adjuvant chemotherapy with Vincristine-Ifosfamide-Doxorubicin-Etoposide and radiotherapy. The patient remains free of this disease 42 months following the diagnosis of her tumor.

Personalized genomic analysis based on circulating tumor cells of extra-skeletal Ewing sarcoma of the uterus: A case report of a 16-year-old Korean female

A 16-year-old female with Ewing sarcoma, a very rare disease with poor prognosis in women, was admitted to the hospital with abdominal pain. Diagnostic laparotomy revealed the Ewing sarcoma originating from the extramural uterus. Histological examination yielded positive test results for CD99, vimentin, S-100, eosin 5-maleimide and periodic acid-Shiff. EWS-FLI1 type 1 translocation was confirmed. Fibroblast growth factor receptor (FGFR) 4 (c.1162G> A) and HRas proto-oncogene (HRAS; c.182A> G) mutations were also detected. At eight months following complete remission, pelvic lymph node metastasis was confirmed. Epithelial cell adhesion molecule-positive circulating tumor cells (CTCs) were detected in liquid biopsy. FGFR3 (c.1948A> G) and FGFR4 (c.1162G> A) mutations were found in the CTCs. FGFR4 (c.1162G> A) and HRAS (c.182A> G) mutations were confirmed in cell-free circulating tumor DNA. A sequence of EWSR1 gene was also confirmed in the CTCs. To the best of our knowledge, this is the first report of skeletal Ewing sarcoma being detected using multiple noninvasive diagnostic methods to observe genetic translocation and mutation in blood CTCs. It may be used to monitor the therapeutic effect of cancer or predict prognosis. Therefore, liquid biopsy is expected to serve a pivotal role in ultra-precise medicine in the future.

Porcelain Gallbladder: Often an Overlooked Entity

Background  Porcelain gallbladder (GB) is a rare but potentially premalignant condition with minimal symptoms. Accident and Emergency (A&E) departments often tend to investigate abdominal pain through plain radiographs, which are occasionally reported by radiologists, thereby leaving behind few uncommon conditions, such as porcelain gallbladder unreported.

Objectives  We present three cases of porcelain GB in which initial diagnosis was not considered due to the presence of various other calcifications in the upper abdomen.

Methods  In A&E, plain abdominal X-rays were routinely performed in all three patients to investigate nonspecific postprandial abdominal pain. Although GB calcification was easy to diagnose on plain films, it was initially overlooked to be a cause of the symptoms and later was diagnosed on abdominal CT scans, performed for further evaluation.

Results  Abdominal X-rays revealed thin curvilinear calcification in the GB wall, partially calcified neck and body, and gall stones. CT scan confirmed porcelain GB in all three patients.

Conclusion  Gallbladder mural calcification is a rare cause of nonspecific abdominal pain, which is often overlooked on plain abdominal X-rays causing missed diagnosis. The association of porcelain GB with adenocarcinoma entails special emphasis on timely diagnosis and prompt management.

Porcelain gallbladder: a benign process or concern for malignancy?

BACKGROUND

Gallbladder wall calcifications, otherwise known as porcelain gallbladder, have received considerable attention due to its perceived association with gallbladder carcinoma. While the perception of a strong correlation persists, more recent reports raise conceivable doubts.

STUDY DESIGN

A systematic literature search was conducted of human studies describing gallbladder wall calcification and its association with gallbladder malignancy.

RESULTS

The 111 articles which met inclusion criteria identified 340 patients with gallbladder wall calcification. Of the 340 patients, 72 (21 %) were diagnosed with malignancy of the gallbladder. When examining a subgroup of 13 studies (n = 124) without obvious selection bias, the rate of gallbladder malignancy was only 6 % (0-33 %) compared to 1 % (0-4 %) in a matched cohort of patients without gallbladder wall calcification (p = 0.036, relative risk 8.0 (95%CI 1.0-63.0)). Multivariate analysis identified the presence of symptoms typical for gallbladder cancer (odds ratio 83.6, 95%CI 2.3-2979.1, p = 0.015) and the presence of a gallbladder mass (odds ratio 3226.6, 95%CI 17.2-603884.8, p = 0.003) as the only independent prognostic factors for harboring gallbladder malignancy.

CONCLUSIONS

The risk of harboring gallbladder cancer in patients with gallbladder wall calcifications is lower than recently anticipated. The risk factors identified have only limited clinical value, since they are stigmatic for advanced gallbladder cancer. In the absence of better risk stratification and in the presence of a relative low rate of associated malignancy, prophylactic cholecystectomy appears appropriate for otherwise healthy patients; whereas a non-operative approach should be considered in patients with significant co-morbidity.

Precancerous lesions of the biliary tree

The neoplasms of the biliary tree include the carcinomas of the intra- and extrahepatic bile ducts, the gallbladder and the ampulla. Two types of precancerous lesions precede these adenocarcinomas: the flat and non-tumour forming type that is called biliary intraepithelial neoplasia, and the papillary and tumour-forming type that has been named intraductal papillary neoplasm of the bile duct. Rarely also biliary mucinous cystic neoplasm can give rise to invasive biliary adenocarcinomas. This review discusses the pathological, molecular, epidemiological, clinical and prognostic features of the precancerous biliary lesions, separated according to their origin in the bile ducts, the ampulla and the gall bladder.