Clinicopathologic Features and Genetic Alterations in Mixed-Type Ampullary Carcinoma

Mixed-type ampullary carcinoma is a subtype that combines intestinal-type (I-type) and pancreatobiliary-type (PB-type) lesions, but few studies have examined its clinicopathologic features and genetic alterations. The differences in genetic alterations between mixed type and other subtypes, as well as the genetic differences between I-type and PB-type lesions in the mixed type, remain unclear. In this study, we compared the clinicopathologic features and prognosis of 110 ampullary carcinomas classified by hematoxylin and eosin and immunohistochemical staining as follows: 63 PB-type, 35 I-type, and 12 mixed-type carcinomas. A comparative analysis of genetic mutations by targeted sequencing of 24 genes was also performed in 3 I-type cases, 9 PB-type cases, and I and PB-type lesions of 6 mixed-type cases. The mixed subtype had a poorer prognosis than the other subtypes, and there was also a similar tendency in the adjuvant group (n = 22). A total of 49 genetic mutations were detected in all 18 lesions for which genetic alteration was analyzed. No genetic mutations specific to the mixed type were found, and it was not possible to determine genetically whether the mixed type had originally been I or PB type. However, 5 of 6 cases had mutations common to both I and PB-type lesions, and additional mutations were found only in either I or PB-type lesions. In support of this, the mixed type more frequently exhibited genetic heterogeneity intratumorally than the other subtypes. Mixed-type tumors are histologically, immunohistochemically, and genetically heterogeneous, and this heterogeneity is associated with poor prognosis and may affect treatment resistance.

Clinicopathological characteristics of early gastric cancer with different level of undifferentiated component and nomogram to predict lymph node metastasis

Background

Few studies showed that mixed type early gastric cancer (EGC) relates to higher risk of lymph node metastasis. We aimed to explore the clinicopathological feature of GC according to different proportions of undifferentiated components (PUC) and develop a nomogram to predict status of lymph node metastasis (LNM) in EGC lesions.

Methods

Clinicopathological data of the 4,375 patients who underwent surgically resection for gastric cancer in our center were retrospectively evaluated and finally 626 cases were included. We classified mixed type lesions into five groups (M1:0% < PUC ≤ 20%, M2:20%<PUC ≤ 40%, M3:40%<PUC ≤ 60%, M4:60%<PUC ≤ 80%, M5:80%<PUC < 100%). Lesions with 0% PUC were classified as pure differentiated group (PD) and lesions with 100% PUC were classified as pure undifferentiated group (PUD).

Results

Compared with PD, LNM rate was higher in group M4 and group M5 (p < 0.05 after Bonferroni correction). Differences of tumor size, presence of lymphovascular invasion (LVI), perineural invasion and invasion depth also exist between groups. No statistical difference of LNM rate was found in cases who met the absolute endoscopic submucosal dissection (ESD) indications for EGC patients. Multivariate analysis revealed that tumor size over 2 cm, submucosa invasion to SM2, presence of LVI and PUC level M4 significantly predicted LNM in EGC. With the AUC of 0.899(P < 0.05), the nomogram exhibited a good discrimination. Internal validation by Hosmer-Lemeshow test showed a good fitting effect in model (P > 0.05).

Conclusion

PUC level should be considered as one of the predicting risk factors of LNM in EGC. A nomogram that predicts the risk of LNM in EGC was developed.

Differentiated/undifferentiated mixed type is a prognostic factor for T2/T3 gastric cancer patients

OBJECTIVES

This work aimed to find the association of mixed-type histology and prognosis of T2/T3 GC patients.

METHODS

Eligible T2/T3 gastric cancer patients at our institution were identified. The histological types and risk factors affecting OS were examined. Survival differences were assessed by log-rank tests and Kaplan-Meier curves.

RESULTS

The study identified 972 T2/T3 gastric cancer patients, including 283 differentiated-type patients, 544 undifferentiated-type patients and 145 mixed type. Mixed-type histology was associated with shorter 5-year OS (DT vs UDT vs MT:57.5% vs 44.9% vs 39.6%, P = 0.002). MT histology can be predictive for prognosis of T2/T3 GC patients (HR for OS: 1.386, 95% CI: 1.028-1.868, P = 0.032), and its malignant potential is not inferior to UDT. In the subgroup analysis, MT can potentially be independent risk factor for non-distal GC patients (P = 0.010).

CONCLUSION

This study reported that mixed histology could be regarded as a potential prognostic factor for T2/T3 gastric cancer patients, especially for those with non-distal cancer. MT patients have higher incidence of metastasis and recurrence and had poorer prognosis than those with pure histological type. It is necessary for MT patients to have preoperative pathological examination for accurate histologic classification, so as to make the comprehensive treatment strategies..

MUC1, CK20, and CDX2 immunohistochemical markers can sub-classify periampullary carcinomas into pancreaticobiliary, intestinal, and mixed subtypes

Introduction

Pancreaticobiliary subtype of Periampullary carcinoma (PAC) has a poor prognosis in comparison to the intestinal subtype. We assessed the potential of cytokeratins and mucin markers to classify the sub-types of periampullary tumors and compared them with the survival data to identify markers that may predict prognosis.

Methodology

PAC tumor tissues were obtained from 94 patients undergoing Whipples Pancreaticoduodenectomy. Paraffin-embedded tissues were immunostained with cytokeratins CK7, CK20), mucins (MUC1, MUC2, MUC5Ac), and CDX2 antibodies. The survival status of patients was obtained as follow-up up to 5-years of surgery. The Receiver Operating Character Curve (ROC) analysis was used for detecting sensitivity and specificity. The survival data were analyzed using the Kaplan-Meier survival curve.

Results

Tumors were initially categorized on the basis of histological classification as pancreaticobiliary (n = 46), intestinal (n = 35) and indeterminate (n = 13). Further, using immunohistochemical markers (MUC1, CK20, and CDX2), we gave systematic classification of IHC-PB (n = 51), IHC-Int (n = 30) and IHC-Mixed (n = 13). The interobserver analysis showed good agreement between histologic and IHC type with a kappa value of 0.554. Combined expression of CK20, MUC1 and CDX2 accurately classify the mixed type of tumor. Overall survival rate and duration were 74.4% and 44.95 ± 2.29 months. Survival analysis for subtypes reveal, pancreaticobiliary tumors have low survival (27.9 ± 1.63 months) than mixed type (35.5 ± 0.45 months) and intestinal-type (52.92 ± 2.18 months). Among these, intestinal-type have better survival. Only TNM Stage III (tumor staging as per American Joint Committee on Cancer classification) and perineural invasion have been associated with predicting poor survival in PAC patients.

Conclusion

Our results suggest that the combined expression of MUC1, CK20 and CDX2 could serve as markers to diagnose histological inconclusive specimens as mixed subtype tumors.

Papillary Endothelial Hyperplasia of Scalp with Bone Erosion: A Case Report with Review of Literature

Papillary endothelial hyperplasia (PEH) is a reactive pseudoneoplastic proliferation of endothelial cells. They are typically well-circumscribed, indolent lesions and curable by complete excision. Description: We present a four-year-old girl with post traumatic scalp swelling, clinically considered to be a capillary hemangioma. Computed tomography revealed a 3.3 × 1.5 cm scalp mass with erosion of outer table and diploic space of the occipital calvarial bone, suggesting a vascular or soft tissue tumor. Histologically it was a PEH within a hemangioma. Literature Review: PEH presenting as a scalp swelling with bone erosion has only been reported thrice in the literature. Conclusion: Scalp PEH with skull bone defect can affect the pediatric age group. Bone erosion is not stage dependent; it can occur in the early stages.

Mixed type total anomalous pulmonary venous connection: Early results and midterm outcomes of surgical correction

BACKGROUND AND AIM OF THE STUDY

The morphological heterogeneity of anomalous pulmonary venous drainage in mixed type total anomalous pulmonary venous connection (TAPVC) has important implications in preoperative diagnosis and surgical repair resulting in high mortality in these patients.

METHODS

A retrospective review of 14 patients with mixed type TAPVC undergoing biventricular repair between January 2012 and December 2019 was conducted. A descriptive analysis was done, highlighting the anatomic variation, diagnostic and surgical approach, and surgical outcomes in these patients.

RESULTS

The most common anatomic pattern was "3 by 1" (79%) followed by "2 by 2" (21%). The correct diagnosis by transthoracic echocardiography was made in 10 (71%) of the 14 patients. In contrast, preoperative computed tomographic (CT) angiography was performed in 10 patients and correct diagnosis was obtained in 8 (80%) of them. Pulmonary venous obstruction was seen in one patient before surgery. The in-hospital mortality was 14% (2/14). Four patients had pulmonary hypertensive crisis in the postoperative period. The average follow-up was 54 ± 27 months (range: 17-98 months) after surgical repair, and all surviving patients were asymptomatic. There was no late death. No clinically apparent sequelae were seen in six patients in whom isolated left superior pulmonary vein drainage was left uncorrected.

CONCLUSION

An accurate diagnosis of anatomic pattern in mixed type TAPVC can be difficult to establish in all the patients before surgery. Detailed intraoperative assessment, individualized surgical approach, and aggressive perioperative management may reduce surgical mortality. Operative survivors have good midterm outcome.

Clinical characteristics and survival outcomes of ascending, descending and mixed types of nasopharyngeal carcinoma in the non-endemic areas of china: A propensity score matching analysis

Purpose

To compare the clinical characteristics and survival outcomes of patients with ascending type (type A), descending type (type D), and mixed type (type AD) of nasopharyngeal carcinoma (NPC) in non‐endemic areas.

Materials and methods

The cohort included 628 patients diagnosed with type A, type D, and type AD of NPC between January 2009 and December 2014. Type A was defined as T_3‐4 N_0‐1, type D as T_0‐1 N_2‐3, and type AD as T_3‐4 N_2‐3. Propensity score matching (PSM) was performed to balance clinical factors and match patients. Kaplan‐Meier methods and Cox proportional hazards models were used to evaluate the impact of different NPC types on survival outcomes.

Results

There were 145 patients with type A, 194 with type D, and 289 with type AD. However, after PSM, there were only 130 patients with each type. Compared with patients with type A, those with type D had lower 5‐year disease‐specific survival (96.9% vs 91.5%) and distant metastasis‐free survival (92.3% vs 77.7%) and higher local relapse‐free survival (88.5% vs 96.9%) (p < 0.05 for all). Patients with type AD may have an increased risk of disease progression (progression‐free survival, 56.9% vs 74.6% and 66.2%) and death (overall survival [OS], 76.9% vs 85.4% and 85.4%) (p < 0.05 for all) compared to patients with the other two types of tumors.

We further analyzed the metastasis trend. Similar metastasis patterns were observed in types AD and D, and types AD and A had similar recurrence trends. The mortality rate of patients with types AD and D in the first 3 years after metastasis was remarkably higher than that of patients with type A.

Conclusions

In non‐endemic areas of China, metastases and recurrence patterns differed across tumor types. Type AD has the worst OS, and the clinical process is more radical. Type D has a lower recurrence rate, higher metastasis, and disease‐related mortality rates, and poorer prognosis after metastasis than type A.

A 17-year-old woman with a solitary, mixed squamous cell and glandular papilloma of the bronchus

A 17-year-old woman was referred to our hospital due to cough on exertion and right chest pain over the previous two months, together with bloody sputum over the previous week. Chest X-ray demonstrated a nodule measuring 3 cm in diameter in the right middle lung field. On repeated bronchoscopy, the tumour was recognized as a rapidly growing intra-bronchial protruded tumour at the orifice of the right B8. Based on a tentative diagnosis of lung cancer, right lower lobectomy was performed. She was diagnosed with mixed squamous cell and glandular papilloma of the bronchus without smoking history and human papillomavirus infection. Solitary endobronchial papillomas are rare but should be considered a differential diagnosis for solitary lung nodule with the potential to develop into carcinoma.

Successful Surgical Management of a Rare Case of Mixed Type of Total Anomalous Pulmonary Venous Connection in a Very Low Birth Weight Preterm Child Using a Novel Surgical Technique

We report a rare case of combined supra- and infracardiac type of total anomalous pulmonary venous connection (mixed-type TAPVC) in a 26-day-old low birth weight (1.9 kg) infant who was admitted with respiratory distress. The child underwent successful surgical repair using a novel surgical technique and is doing well at one year follow-up.

A 30-year experience with mixed-type total anomalous pulmonary venous connection: a word of caution

BACKGROUND

Patients with total anomalous pulmonary venous connection can be problematic, particularly those with mixed-type pathology. We aimed to describe a cohort of patients with mixed-type anomalous drainage, highlighting the treatment challenges, and identifying risk factors for poor outcome.

METHODS

We reviewed the clinical records of patients who underwent repair for mixed-type total anomalous pulmonary venous connection between 1986 and 2015.

RESULTS

A total of 19 patients were identified. The median age and weight of patients at surgery were 18 days (with a range from 1 to 185) and 3.4 kg (with a range from 1.9 to 6.5), respectively. Venous anatomy included a combination of duplicate supracardiac (four), supracardiac and cardiac (11), and supracardiac and infracardiac (four) drainage. Out of 19 patients, six (32%) died within 30 days or the initial hospital stay; two additional patients died from progressive pulmonary vein stenosis at 72 and 201 days, respectively, resulting in 42% mortality within the 1st year. Follow-up data were available for 8/11 long-term survivors. The median follow-up period was 7.3 years (with a range from 1.8 to 15.7). Only one patient underwent re-intervention for recurrent pulmonary vein stenosis. For surgical mortality, no statistically significant risk factors were identified, although the risk trended to be higher (p⩽0.1) with lower age and weight, an infracardiac component, and prolonged cardiopulmonary bypass. For 1-year mortality, the risk became significant (p⩽0.05) with a lower weight (p=0.01), an infracardiac component (p=0.03), and prolonged cardiopulmonary bypass (p=0.04).

CONCLUSION

The surgical and 1-year mortality in patients with mixed-type total anomalous pulmonary venous connection is high. On the other hand, among patients who survive past the 1st year, most have good outcomes without subsequent sequelae.

Prevalence of Pseudoexfoliation Syndrome in Turkish Patients with Senile Cataract

PURPOSE

To investigate the prevalence of pseudoexfoliation syndrome (PEX) among Turkish patients with senile cataract.

MATERIALS AND METHODS

Records of 352 eyes of 352 patients who underwent cataract surgery were analyzed in this retrospective study. The presence of PEX, type of cataract, intraocular pressure (IOP), glaucoma, age-related macular degeneration, and systemic diseases (coronary artery disease, hypertension, diabetes mellitus) were recorded.

RESULTS

The overall prevalence of PEX syndrome was detected to be 11%. The mean age of PEX patients was significantly higher than without PEX (74.4 ± 7.2 years and 69.3 ± 11.4 years, respectively, p = 0.004). The most common cataract type in the PEX patients was mixed-type cataract determined in 51.2% of patients. IOP was significantly higher in eyes with PEX than in eyes without it (16.1 ± 4.5 mmHg and 14.7 ± 3.8 mmHg, respectively; p = 0.03). Moreover, the prevalence of age-related macular degeneration was found to be significantly higher, and prevalence of glaucoma slightly higher in PEX patients than without PEX.

CONCLUSION

Pseudoexfoliation syndrome is a common condition in Turkish people. PEX is associated with mixed type of cataract, age-related macular degeneration, and elevated IOP. Therefore, PEX patients should be checked for concomitant diseases.

Characteristics of Mixed Type Basal Cell Carcinoma in Comparison to Other BCC Subtypes

Background:

There are limited data exploring the characteristics of mixed type basal cell carcinoma (BCC).

Objectives:

To explore different characteristics of mixed type BCC.

Design:

Cross sectional study.

Materials and Methods:

825 patients with BCC enrolled in this study.

Results:

Among 825 patients, 512 (62%) were male. Three hundred and fifty five (43%) presented with nodular subtype, 267 (32.4%) with mixed subtype, 25 with superficial and the 178 remaining presented with other subtypes. Four hundred and eighty three (58.6%) of the lesions were on the face, 243 (29.5%) on scalp, 52 (6.3%) on ears, 20 (2.4%) on neck, 15 (1.8%) on trunk and 12 (1.4%) on extremities. Anatomic distribution of mixed type was as follows: 137 on face, (51.4%), 100 (37.3%) on scalp, 19 (7%) on ear, 6 (2.1%) on neck, 4 (1.5%) extremity and 1 (0.7%) on trunk, which the difference from non mixed types was statistically significant (P = 0.002). The mean diameter of the mixed types and non mixed type BCCs were significantly different (2.7 ± 2.1 cm vs. 2.2 ± 1.6 cm; P = 0.01. The prevalence of necrosis in mixed type BCC was two times higher than non mixed type BCCs (OR = 2.3, CI 95% 1.3-3.9, P = 0.001). The most frequent combined subtypes were nodular-infiltrative (P < 0.001).

Conclusion:

Mixed type BCC has differences with other BCC subtypes in anatomical distribution and tumor diameter. Indeed, mixed type BCCs are frequently composed of aggressive subtypes than nonaggressive subtypes.

Hemorrhage and ischemia in different hemispheres in a child with moyamoya disease: Case report and review of literature

Hemorrhagic type of moyamoya disease (MMD) is extremely rare in children. Ischemia following hemorrhage is very rare in MMD. There are only 11 reports of mixed-type of MMD, with the patient having both hemorrhage and ischemia in the same hemisphere at the time of presentation, or at different time periods. The ischemia is usually secondary to a precipitating cause. However, there are no reports of a child presenting with both ischemia and hemorrhage in different hemispheres. We present a previously unreported phenomenon of MMD, presenting as hemorrhage and ischemia in opposite hemispheres and review the relevant literature.

Mixed Type of Malignant Mesothelioma in an Aged Male ICR Mouse

Multiple whitish nodules in the thoracic cavity at the site of the thymus were observed in a 101-week-old male ICR mouse. In a histopathological examination, the neoplastic cells were predominantly fusiform in shape and proliferated in sarcomatoid growth patterns. Some neoplastic cells showed epithelial growth patterns, such as the ductal structures. Mitotic figures were frequently seen, and small necrotic foci and invasion to adjacent thoracic organs were noted. In Alcian blue staining, bluish materials were observed between fusiform-shaped cells and in some of the lumens of the ductal structures. In immunohistochemistry, both fusiform-shaped and ductal structure-forming cells were positive for vimentin and weakly positive to positive for cytokeratin. Based on the aforementioned findings, the thoracic nodules were diagnosed as a mixed type of malignant mesothelioma. This case was thought to be rare because of the very low occurrence of spontaneous mesothelioma in mice.

Association of G>A transition in exon-1 of alpha crystallin gene in age-related cataracts

Aim

To identify the presence of a known or novel mutation/SNP in Exon-1 (ex-1) of alpha crystallin (CRYAA) gene in different types of age-related cataract (ARC) patients.

Materials and Methods

Single strand Conformation Polymorphism (SSCP) analysis was carried for the detection of single nucleotide polymorphism (SNP) in ex-1 of alpha crystallin (CRYAA) gene which was confirmed by sequencing.

Results

The SSCP analysis of ex-1 of CRYAA gene revealed mobility shift in patients and controls, which was due to G>A transition at 6^th position in exon-1 of CRYAA gene. All the three genotypes, GG, AA and GA, were detected in patients and controls indicating that G>A substitution is polymorphic. The analysis showed significant risk for heterozygotes (GA) as compared to pooled frequencies of homozygotes (GG + AA), which was 1.81 times for all the types of cataracts in general and 2.5 times for Nuclear Cataract and twice for Cortical Cataract.

Conclusion

The GA heterozygotes were at higher risk for developing NC and CC types of cataracts, where as the GG homozygotes for MT and AA homozygotes for PSC types were at risk. To our knowledge, an association of G>A transition found in ex-1 of CRYAA gene with ARC, with differential risk of genotypes for individual type of cataracts has not been reported previously.