Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

MSH2 c.1022T>C, p.Leu341Pro is a founder pathogenic variation and a major cause of Lynch syndrome in the North of France

Interpretation of missense variants remains a major challenge for genetic diagnosis, even in well-known genes such as the DNA-mismatch repair (MMR) genes involved in Lynch syndrome. We report the characterization of a variant in MSH2: c.1022T>C, which was identified in 20 apparently unrelated families living in the North of France. A total of 150 patients from 20 families were included in this study. Family segregation studies, tumor analyses and functional analyses at both the RNA and protein levels were performed. Founder effect was evaluated by haplotype analysis.We show that MSH2 c.1022T>C is a missense variant (p.Leu341Pro) that affects protein stability. This variant is frequent in the North of France (7.7% of pathogenic variations identified in MMR genes), and is located on an ancestral haplotype. It is associated with a high risk of a broad tumor spectrum including brain and cutaneous cancers. The MSH2 c.1022T>C variant is a pathogenic founder variation associated with a high risk of cancer. These findings have important implications for genetic counseling and management of variant carriers.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Relationships between mucinous gastric carcinoma, MUC2 expression and survival

AIM: To investigate the expression of the four secreted gel-forming mucins (MUC2, MUC5AC, MUC5B and MUC6) in a series of gastric carcinomas, classified according Laurén’s, Mulligan’s, WHO and Goseki’s classifications, with special attention to all the different components (major and minor) present in tumors and to follow up clinical data.

METHODS: Expression of MUC2, MUC5AC, MUC5B and MUC6 was investigated using immunohistochemistry and in situ hybridization.

RESULTS: Expression of secreted gel-forming mucins in gastric carcinoma was particularly complex, each mucin being not restricted to any histopathological type even considering all components (major and minor) present in a given tumor. There was a worst survival in patients with a higher content of mucus (Goseki II or IV) and high positive MUC2 expression.

CONCLUSION: Complexity of mucin gene expression patterns in gastric cancer may reflect a precise state of differentiation at the cell level not recognized in used morphologic classification systems. High expression of MUC2 was nevertheless associated with mucinous subtype of the WHO classification and with group II of Goseki’s classification identified by the major component of a particular tumor. The quantity and quality of mucus were related to survival.

Schwannoma of the sinonasal tract: a clinicopathologic and immunohistochemical study of 5 cases

CONTEXT

Peripheral nerve sheath tumors are soft tissue neoplasms rarely encountered in the nasal cavity and paranasal sinuses.

OBJECTIVE

To describe the clinicopathologic and immunohistochemical features of a series of schwannomas of the sinonasal tract.

DESIGN

Surgical pathology files were searched for the diagnosis "sinonasal schwannoma." All histologic documents and clinical data were reviewed. Immunohistochemistry was performed on paraffin-embedded tissue with antibodies to S100 protein, epithelial membrane antigen, CD34, and MIB-1. RESULSTS: Five cases of sinonasal schwannoma were retrieved; patients included 3 women and 2 men, aged 20 to 56 years. Three cases were located in the ethmoid sinus. Clinical symptoms were nonspecific (nasal obstruction, epistaxis, and anosmia). All tumors were treated with conservative surgical resection. Pathologic examination showed a spindle cell proliferation without encapsulation in all cases. No cytologic atypia was seen, and the mitotic activity was low (<3 mitotic figures/10 high-power fields). Immunohistochemistry showed diffuse positivity with S100 protein and negativity with CD34 and epithelial membrane antigen. MIB-1 staining was low (1%-5% of tumor cell nuclei stained). During the follow-up (median, 6 years), no recurrence or metastasis was observed.

CONCLUSIONS

Schwannoma is a very unusual tumor of the sinonasal tract and is associated with nonspecific symptoms. Histologically, sinonasal schwannomas differ from schwannomas of other locations by their lack of a peripheral capsule and possible ulceration of the epithelial covering. Sinonasal schwannomas are treated with conservative surgical resection and have an excellent prognosis.

[Localized amyloidosis of the cavum]

INTRODUCTION

Amyloidosis is characterized by extracellular deposits of proteins.

OBSERVATION

A 66 year-old patient presented with a pseudo-tumoral amyloidosis of the cavum. Clinical and biological examinations confirmed the localized aspect of the disease and immunohistochemical exploration identified a type AL amyloidosis.

COMMENTS

The disease may be diffuse involving many organs and leading to various clinical manifestations. It can also be localized and take on a pseudo-tumoral aspect. Localised amyloidosis is a rare lesion of the upper aero-digestive tract, predominating in the larynx. Nasopharyngeal involvement is exceptional.

Gastric heterotopia in the nasopharynx

Heterotopic gastrointestinal mucosa is rare in head and neck area. Most cases are described in oral cavity especially in the floor of the mouth. We present herein the case of an 8-month old infant with a tumor-like mass in the cavum which consisted of an heterotopic gastric mucosa. This case is the first described in this localisation. A brief review of the literature and histopathologic differential diagnoses will be study.

[Leiomyosarcoma and stromal tumor of the pancreas]

A tumor of the head of pancreas was an incidental finding on US of two patients aged 52 and 61 years presenting with abdominal pain. The tumor was studied by computed tomography, MRI and endoscopic ultrasonography. Surgical biopsy of a liver lesion was performed in one case and partial duodenopancreatectomy was performed in the other case. Histological evaluation, including immunohistochemistry, showed leiomyosarcoma and stromal tumor respectively. Whatever the site of origin, most mesenchymal pancreatic tumors are hypervascular, heterogeneous and have a necrotic center.

Direct microscopic examination of imprints in patients undergoing cardiac valve replacement

BACKGROUND: Bacteriological analysis of cardiac valves might be indicated in patients with suspected endocarditis. METHODS: We report here a prospective study on fifty-three consecutive patients whose native valves were sent to the bacteriological and pathological laboratories, to investigate the performance of direct microscopic examination of imprints and valve culture. RESULTS: On the basis of a histopathological gold standard to classify the inflammatory valve process, the sensitivity, the specificity, the positive and the negative predictive values of direct microscopic examination of imprints and valve culture were 21%, 100%, 100%, 60%, and 21%, 72%, 38%, 52% respectively. This weak threshold of the direct microscopic examination of imprints could be due to antimicrobial therapy prescribed before cardiac surgery and the fact that the patients came from a tertiary hospital receiving patients with a prolonged history of endocarditis. CONCLUSION: Clinical context and histopathology are indispensable when analyzing the imprints and valve culture.

Immunohistochemical detection of Fas and Fas ligand in sarcomatoid renal cell carcinoma

Sarcomatoid renal cell carcinomas (SRC) are rare neoplasms associated with a very poor prognosis. The aim of this study was to evaluate biomarker expression and clinical significance in this uncommon renal cancer. Cytokeratin, epithelial membrane antigen, vimentin, desmin, smooth muscle actin, CD34, S-100 protein, MIB 1, p53, Fas and Fas ligand immunohistochemical expression was investigated in seven renal cell carcinomas with sarcomatoid changes. No significant difference between sarcomatoid and nonsarcomatoid areas was observed with the different biomarkers, excepted for Fas ligand. Fas expression was diffuse in sarcomatoid and nonsarcomatoid areas. However, Fas ligand had a higher expression in sarcomatoid in comparison to nonsarcomatoid areas. Our results showed that Fas and Fas ligand are both expressed in renal cancer. We suggest that the aggressive behavior of sarcomatoid carcinoma may be related to a higher expression of Fas ligand by tumor sarcomatoid cells. These findings may indicate that Fas ligand is a possible therapeutic molecular target for treatment of SRC.

Mucin gene transcripts in benign and borderline mucinous tumours of the ovary: an in situ hybridization study

Mucinous tumours of the ovary are characterized by mucin-secreting cells exhibiting a variable endocervical, intestinal, gastric or pancreatobiliary phenotype as ascertained by microscopy, electron microscopy, histochemistry or immunohistochemistry. The molecular mechanisms underlying the tumourigenesis process are not well understood. The mucin glycoproteins expressed by ovarian mucinous tumours have not been fully characterized, but mucins are known to be implicated in tumour progression in various epithelial neoplasms. The purpose of this study was to evaluate the expression of mucin genes (MUC1, MUC2, MUC3, MUC4, MUC5AC, MUC5B, MUC6) in ovarian mucinous tumour cells, to relate MUC gene expression to the histological diagnosis, and to compare the expression patterns with those observed in normal tissues. The expression of mucin genes was evaluated by in situ hybridization in 21 mucinous tumours (11 adenomas and ten borderline tumours). Heterogeneity of expression correlated with morphological heterogeneity. Intense expression of the MUC5AC gene, suggesting a gastric surface cell phenotype, was demonstrated in 18/21 tumours (86%). Goblet cells expressing the MUC2 gene and columnar cells expressing the MUC3 gene were consistent with an intestinal phenotype, which was observed in 15 tumours (71%) including nine adenomas and six borderline tumours. Major expression of MUC4 and MUC5B consistent with an endocervical phenotype was observed in seven benign (64%) and three borderline (30%) tumours. In all, the MUC profiles suggested gastrointestinal-type cells in 13 cases (62%), gastric-type cells in five cases (24%), and intestinal-type cells in two cases (one benign, one borderline) (9%); the results were inconclusive in one borderline tumour (5%). It is concluded that gastric and, to a lesser degree, intestinal differentiation are early and almost constant events in ovarian mucinous tumourigenesis.

Why do frozen sections have limited value in encapsulated or minimally invasive follicular carcinoma of the thyroid?

The diagnosis of encapsulated or minimally invasive follicular carcinoma of the thyroid requires the proof of vascular or capsular invasion. The aim of the present study was to evaluate the relationship between intraoperative diagnosis (benign, suggestive of carcinoma, or malignant) and the final histopathologic criteria for encapsulated or minimally invasive follicular carcinoma (tumor size, capsular invasion, vascular invasion, and differentiation). This was a retrospective study of 63 cases of encapsulated or minimally invasive carcinomas, with the final histopathologic diagnosis taken as the "gold standard." The sensitivity of frozen sections for the diagnosis of malignant neoplasm was 17%. The median number of vascular invasions was 1, identified with a mean number of 9 paraffin-blocks of the tumor. In most cases, intraoperative frozen sections are unable to establish the proof of malignant neoplasm. Intraoperative study of tumor differentiation is useful to select follicular tumors that require a rapid definitive diagnosis and a completion thyroidectomy within 48 to 72 hours (73% of the cases in our study).

Solitary fibrous tumour of the kidney

Solitary fibrous tumours are relatively rare neoplasms initially described in the pleura. Such lesions are now reported in many extrathoracic sites. To our knowledge, only 8 cases have been reported in the kidney. All these cases were benign. We report a patient with a solitary fibrous tumour of the kidney with infiltration of the wall of the renal vein. Microscopic examination showed proliferation of spindle cells with a prominent vascular haemangiopericytoma-like pattern. Hypercellular areas were admixed with hyalinized collagenous zones. The neoplastic cells stained for vimentin and CD34. CD31 was negative. Biologically, we did not find any arguments for malignancy: the flow cytometric study showed diploid histograms, and immunostaining for p53 was negative.

Inflammatory pseudotumor of the renal pelvis. A report of 2 cases with clinicopathologic and immunohistochemical study

We describe 2 cases of inflammatory pseudotumor of the renal pelvis. Case 1, the male patient, was 37 years old, and case 2, the female patient, was 54 years old. Both patients presented with macroscopic hematuria and flank pain. Computed tomographic (CT) scan and ureterocystoscopy revealed in case 1 a mass in the left renal pelvis and the calyces. In case 2, urography showed a lacuna of the renal pelvis, and CT scan showed an irregular thickening of the renal pelvis. In both cases, the preoperative clinical diagnosis was urothelial carcinoma, and both patients underwent nephrectomy. Microscopic examination revealed in case 1 a tumor of the renal pelvis composed of spindle cells with eosinophilic cytoplasm in a myxoid and vascular stroma with abundant inflammatory infiltrate. In case 2, the tumor was composed of densely basophilic spindle cells in a fascicular pattern intermingled with lymphocytes and plasma cells and involving the lamina propria of the renal pelvis. The spindle cells reacted strongly with antibody to vimentin and focally with antibodies to smooth muscle actin and muscle-specific actin. In the urogenital tract inflammatory pseudotumor involves preferentially the urinary bladder. Rare cases have been reported in the kidney. The 2 cases presented here are unusual due to the location in the renal pelvis, mimicking urothelial carcinoma.

Inflammatory pseudotumor of the renal pelvis. A report of 2 cases with clinicopathologic and immunohistochemical study

We describe 2 cases of inflammatory pseudotumor of the renal pelvis. Case 1, the male patient, was 37 years old, and case 2, the female patient, was 54 years old. Both patients presented with macroscopic hematuria and flank pain. Computed tomographic (CT) scan and ureterocystoscopy revealed in case 1 a mass in the left renal pelvis and the calyces. In case 2, urography showed a lacuna of the renal pelvis, and CT scan showed an irregular thickening of the renal pelvis. In both cases, the preoperative clinical diagnosis was urothelial carcinoma, and both patients underwent nephrectomy. Microscopic examination revealed in case 1 a tumor of the renal pelvis composed of spindle cells with eosinophilic cytoplasm in a myxoid and vascular stroma with abundant inflammatory infiltrate. In case 2, the tumor was composed of densely basophilic spindle cells in a fascicular pattern intermingled with lymphocytes and plasma cells and involving the lamina propria of the renal pelvis. The spindle cells reacted strongly with antibody to vimentin and focally with antibodies to smooth muscle actin and muscle-specific actin. In the urogenital tract inflammatory pseudotumor involves preferentially the urinary bladder. Rare cases have been reported in the kidney. The 2 cases presented here are unusual due to the location in the renal pelvis, mimicking urothelial carcinoma.

[Ovarian mucinous tumor of gastric and intestinal type associated with Peutz-Jeghers syndrome: in situ hybridization study of apomucin gene transcripts]

Occurrence of mucinous tumors is favored by Peutz-Jeghers syndrome (PJS). A case of bilateral ovarian mucinous tumor associated with ovarian mature teratoma occurring in a 22-year-old woman with PJS was reported. Tumor cells included 5 cell types: tall columnar mucinous pale cells with neutral mucins; goblet cells with acidic nonsulfated mucins; non mucinous columnar cells; mucinous cuboidal cells lining small glands; endocrine cells. Expression of the MUC2, MUC3, MUC5AC and MUC6 genes was demonstrated by in situ hybridization according to cell type. Some atypia and numerous mitotic figures were observed in basal glands. Diagnosis was ovarian borderline mucinous tumor with gastric and intestinal phenotype associated with PJS.