Elevated Serum IgG4 and Eosinophils: A Case of Indeterminate Biliary Stricture

Introduction/Objective

Diagnosis of indeterminate biliary stricture is challenging and tissue diagnosis is critical to provide adequate management. We report an unusual case of biliary stricture mimicking extrahepatic cholangiocarcinoma on ERCP.

Methods/Case Report

A 44-year-old male presented with unintentional 30 lb weight loss, scleral icterus, and dark urine for the past 3 weeks. At admission, elevated liver enzymes and bilirubin 12.3 mg/dl were noted. Imaging studies showed dilated intra- and extra-hepatic biliary ducts with abrupt transition and focal wall thickening concerning for cholangiocarcinoma. ERCP revealed frond-like mucosa and neovascularization. Additional lab investigations showed elevated CEA, presence of anti-nuclear and smooth muscle antibodies, and an elevated IgG4 (224.9 mg/dL) raising the differential diagnosis of primary sclerosing cholangitis (SC) and IgG4 sclerosing cholangitis (IgG4-SC), a manifestation of IgG4 related disease (IgG4-RD). An exploratory laparotomy with excision of bile duct stricture, cholecystectomy, and portal lymphadenectomy was performed. Histopathology showed thickened and fibrotic bile duct wall with dense inflammatory infiltrate rich in eosinophils, consistent with eosinophilic cholangitis (EC). There was no evidence of plasma cell infiltration. The gallbladder also exhibited similar changes. Symptoms suggestive of other eosinophilic gastrointestinal disorders were not present. The subsequent review showed persistent eosinophilia (absolute count 1.8 k/mm3). Stool examination was negative for ova/parasite.

Results (if a Case Study enter NA)

NA.

Conclusion

This report highlights that elevated serum IgG4 levels may be a potential overlap in the pathogenesis of EC and IgG4-RD. Eosinophilic cholangitis, a rare benign entity and a mimicker of cholangiocarcinoma, should be included in the differential diagnosis of elevated serum IgG4.

FNA as a Powerful Modality to Detect Granular Cell Tumor in Male Breast: A Report and Review of Literature

Introduction/Objective

Granular cell tumor (GCT) is a benign mesenchymal tumor of Schwannian origin. Granular cell tumor is an uncommon tumor of the breast with a prevalence of 1:1000 to 6.7:1000 of all breast tumors. Most cases are diagnosed on surgical resection. When reported that are most commonly in middle-aged premenopausal women. Diagnosis of GCT on fine needle aspiration (FNA) in male patients is, however, extremely rare. We present here an unusual case of GCT of the breast in a male patient clinically mimicking malignancy.

Methods/Case Report

A 34-year-old male patient presented with a palpable lump in the left breast. An imaging study showed a 0.6 cm hypoechoic mass with microlobulated borders and no internal vascularity suspicious for breast carcinoma (BIRAD-4). Fine needle aspiration (FNA) of the mass was performed. Rapid onsite specimen evaluation was performed and additional passes were performed to collect sample for cell block to perform ancillary studies. FNA revealed clusters of polygonal cells with abundant eosinophilic granular cytoplasm and poorly defined borders. Those cells had round to ovoid nuclei with vesicular chromatin pattern and prominent nucleoli. A differential diagnosis of GCT, apocrine metaplasia, and lesions rich in histiocytes such as granulomatous inflammation, fat necrosis and duct ectasia were considered. Immunohistochemical staining with S100 and CD68 was performed which stained granular cytoplasm in tumor cells of GCT. A review of literature from the past 5 years shows 23 cases of GCT of the breast are reported in the literature and of these only 3 (13%) are reported in males. These tumors ranged from 20-68 years with tumor size ranging from 5- 28 mm. Only 1(4%) cases were preoperatively diagnosed using FNA. No cases of GCT were preoperatively diagnosed on FNA samples from the breast.

Results (if a Case Study enter NA)

N/A.

Conclusion

We show here that a powerful relatively noninvasive and rapid modality like FNA can be effectively utilized to detect very rare benign tumor like GCT in the male breast where imaging studies suspect breast cancer.

Incidental Gastrointestinal Stromal Tumors – What can we learn from them?

Introduction/Objective

Gastrointestinal stromal tumors (GIST), albeit very rare overall, with approximately 5,000 new diagnoses yearly in the US, represent the most common mesenchymal tumor involving the GI tract. particularly the stomach and small bowel. Much progress has been made in the past two decades in terms of classification and targeted therapy of GIST, however, their behavior is still quite challenging and unpredictable, and their prognosis remains guarded.

Methods/Case Report

We reviewed our institutional experience with GIST over the past decade and identified 80 GIST in total, 5 of which were incidental findings, meaning that they were detected as a secondary diagnosis in a specimen that was obtained for a different pathology. All 5 tumors were less than 2 cm in greatest dimension and showed less than 5 mitoses/ 50HPF, which put them into the “no risk of malignant progression category”. As a matter of fact, all five tumors were less than 1 cm (ranging from 0.2-0.7cm), while the mean size overall for GIST is 6 cm, ranging from 0.2-40 cm. They were all c-kit and DOG-1 positive, and 3 out of 5 incidental GIST were diagnosed in association with an adenocarcinoma of the GI tract (gastric or distal esophagus). Three of the 5 incidental GIST were located in the stomach, one in the distal esophagus and one in the sigmoid; unsurprisingly, two gastric and one esophageal GIST were associated with poorly differentiated adenocarcinoma of the stomach or distal esophagus. The mean age at diagnosis in our series was 72.4 yo, while reported mean age for GIST ranges between 60-65yo. All but one of the patients with incidental GIST were males, while there seems to be no gender predilection in GIST in general. The two benign cases associated with incidental, “no risk” GIST were perforated diverticulitis and sleeve gastrectomy for morbid obesity. Review of the stained slides showed no apparent increase of interstitial cells of Cajal in the blocks containing the tumor.

Results (if a Case Study enter NA)

NA

Conclusion

In summary, we report a small series of 5 incidental GIST diagnosed over a span of 10 years in our institution. Although a rare tumor overall, with an annual incidence of 10-20 new cases/ million, incidental GIST is even more rare, in our case representing 6.25% out of the total number of cases diagnosed in a decade. Increased awareness of the incidental GIST and closer pathological assessment may throw more light into the pathogenesis of GIST in general.

[CLINICAL CHARACTERISTICS OF DISEASES OF THE ORAL MUCOSA IN PATIENTS WHO HAVE UNDERGONE COVID-19 - WHAT DOES A DENTIST NEED TO KNOW IN A PANDEMIC?]

ization and unification of diseases of the oral mucosa in patients who underwent Covid-19, in order to increase the effectiveness of qualified dental care for this group of people in a pandemic and create conditions for continuous professional development of dentists. 42 patients were attended, who came through Covid-19, aged 36 to 70 years, who applied independently or were referred by doctors of private clinics in the city of Ternopil. The gender distribution of patients was 19 males and 23 females. Clinical examination of patients with acute respiratory viral infection Сovid-19, at the stage of subjective methods, revealed the following complaints: loss of taste was found in 38 people (90%) patients, salivation disorders (dry mouth or hypersalivation) - in 40 people (95%) patients, burning sensation, discomfort and «creeping ants» in the tongue or other anatomical components of the oral mucosa in 29 people (69%) patients. Complaints about the integrity of the oral mucosa and the associated pain were associated with pain in 13 people (31%). Patients diagnosed with Covid-19 were diagnosed with glossodynia 7 individuals, (17%), candidal stomatitis 12 individuals, (28%), herpetic stomatitis 5 individuals, (12%), and chronic recurrent aphthous stomatitis 8 individuals, (19%), desquamative glossitis in 10 people (24%). In some clinical cases, 10 people (24%) observed a combination of nosological units. The obtained results substantiate the development of the necessary algorithm of dental examination of dental data of patients in a pandemic.

3D simulation as a tool for improving the safety culture during remediation work at Andreeva Bay

Andreeva Bay in northwest Russia hosts one of the former coastal technical bases of the Northern Fleet. Currently, this base is designated as the Andreeva Bay branch of Northwest Center for Radioactive Waste Management (SevRAO) and is a site of temporary storage (STS) for spent nuclear fuel (SNF) and other radiological waste generated during the operation and decommissioning of nuclear submarines and ships. According to an integrated expert evaluation, this site is the most dangerous nuclear facility in northwest Russia. Environmental rehabilitation of the site is currently in progress and is supported by strong international collaboration. This paper describes how the optimization principle (ALARA) has been adopted during the planning of remediation work at the Andreeva Bay STS and how Russian-Norwegian collaboration greatly contributed to ensuring the development and maintenance of a high level safety culture during this process. More specifically, this paper describes how integration of a system, specifically designed for improving the radiological safety of workers during the remediation work at Andreeva Bay, was developed in Russia. It also outlines the 3D radiological simulation and virtual reality based systems developed in Norway that have greatly facilitated effective implementation of the ALARA principle, through supporting radiological characterisation, work planning and optimization, decision making, communication between teams and with the authorities and training of field operators.

Apoptosis leads to a degradation of vital components of active nuclear transport and a dissociation of the nuclear lamina

Apoptosis, a physiologically critical process, is characterized by a destruction of the cell after sequential degradation of key cellular components. Here, we set out to explore the fate of the physiologically indispensable nuclear envelope (NE) in this process. The NE mediates the critical nucleocytoplasmic transport through nuclear pore complexes (NPCs). In addition, the NE is involved in gene expression and contributes significantly to the overall structure and mechanical stability of the cell nucleus through the nuclear lamina, which underlies the entire nucleoplasmic face of the NE and thereby interconnects the NPCs, the NE, and the genomic material. Using the nano-imaging and mechanical probing approach atomic force microscopy (AFM) and biochemical methods, we unveiled the fate of the NE during apoptosis. The doomed NE sustains a degradation of both the mediators of the critical selective nucleocytoplasmic transport, namely NPC cytoplasmic filaments and basket, and the nuclear lamina. These observations are paralleled by marked softening and destabilization of the NE and the detection of vesicle-like nuclear fragments. We conclude that destruction of the cell nucleus during apoptosis proceeds in a strategic fashion. Degradation of NPC cytoplasmic filaments and basket shuts down the critical selective nucleocytoplasmic cross-talk. Degradation of the nuclear lamina disrupts the pivotal connection between the NE and the chromatin, breaks up the overall nuclear architecture, and softens the NE, thereby enabling the formation of nuclear fragments at later stages of apoptosis.

The SPASIBA force field as an essential tool for studying the structure and dynamics of saccharides

The SPASIBA force field has been applied to the determination of the structure and dynamical properties of various disaccharides. It has been shown that the experimental properties (structure, dipole moment, conformational relative energies) are satisfactorily predicted. The anomeric and exo-anomeric effects are confidently reproduced without specific terms for the alpha and beta anomers and the type of glycosidic linkages.