Use of a Retrograde Guidewire to Direct an Antegrade Femoral Nail.

Antegrade intramedullary nailing for the treatment of diaphyseal femur fractures may present challenges in obtaining appropriate positioning of the distal tip of the nail. Known mismatch between the radius of curvature of commonly used nails and the anatomic bow of the femur may result in impingement or perforation of the anterior cortex of the distal femur. Additionally, some unique scenarios may arise that complicate traditional antegrade wire passage. We report our surgical technique and clinical experience using a retrograde guidewire to direct an antegrade femoral nail to aid in obtaining a desired central location of the distal nail tip. [Orthopedics. 2023;46(2):e132-e135.].

Hobnail variant of papillary thyroid carcinoma: an institutional case series and molecular profile.

BACKGROUND: Papillary thyroid carcinoma (PTC) is increasing in incidence while mortality is unchanged. Identifying patients with higher risk of recurrence and death is essential. Case series identify the hobnail variant of PTC (HVPTC), which is characterized by micropapillary architecture, apocrine features, and loss of cellular polarity. Herein, we describe the clinical course, pathologic features, and mutational profile of patients at our institution with HVPTC. METHODS: A query into the surgical pathologic database (2009-2012) was performed, and clinicopathologic data were collected on all patients carrying the diagnosis of HVPTC. BRAF(V600E) testing was performed on paraffin-embedded blocks using SNaPshot mutational analysis. RESULTS: Twelve patients with HVPTC were identified, with an average age of 54.1±18.8 years. Seven patients (63.6%) were AJCC Stage III or IV at presentation. Tumors were large (3.7±2.0 cm), some were multifocal (33.3%), and frequently with extrathyroidal extension (58.3%), lymphovascular invasion (41.7%), and lymph node metastasis (75%). Forty percent of the patients had concomitant tall cell features (TCF), and two had small foci of undifferentiated (anaplastic) thyroid carcinoma (ATC). Eighty percent of tumors undergoing mutational analysis had the BRAF(V600E) mutation, and the remaining 20% harbored a RET/PTC1 gene rearrangement. No other known thyroid cancer mutations were identified on SNaPshot analysis. At median follow-up of 26 months, four patients had recurrent or persistent disease, one of whom died from the disease one year after surgery. CONCLUSIONS: The hobnail variant of PTC has an aggressive behavior, with a high incidence of infiltrative tumors and metastatic disease. Strikingly, all tumors in our series harbored a PTC-associated genetic abnormality, either a BRAF(V600E) mutation (80%) or a RET/PTC1 rearrangement (20%). This histologic variant warrants further study, and patients with this diagnosis should be observed closely for recurrence.

Basal cell carcinoma with osteosarcomatous component.

Sarcomatoid carcinoma or carcinosarcomas of the skin are rare. Basal cell carcinoma (BCC) with osteosarcomatous differentiation is the second most common sarcomatoid carcinoma of the skin, following squamous cell carcinoma with heterologous mesenchymal differentiation. There are only 11 cases of BCC with osteosarcomatous component reported in the literature, with limited documented molecular analyses. The authors report the clinical and histological features of 2 cases with molecular analyses for recurrent mutations in 17 cancer genes. In both cases, the epithelial or BCC component was positive for BerEP4 and high-molecular weight cytokeratin, whereas the sarcomatous component was negative for both markers. Mutational analyses revealed TP53 mutation in 1 case with p53 expression noted in both components. The other case was negative for both p53 expression and TP53 mutation.

Apocrine-eccrine carcinomas: molecular and immunohistochemical analyses.

Apocrine-eccrine carcinomas are rare and associated with poor prognosis. Currently there is no uniform treatment guideline. Chemotherapeutic drugs that selectively target cancer-promoting pathways may complement conventional therapeutic approaches. However, studies on genetic alterations and EGFR and Her2 status of apocrine-eccrine carcinomas are few in number. In addition, hormonal studies have not been comprehensive and performed only on certain subsets of apocrine-eccrine carcinomas. To investigate whether apocrine-eccrine carcinomas express hormonal receptors or possess activation of oncogenic pathways that can be targeted by available chemotherapeutic agent we performed immunohistochemistry for AR, PR, ER, EGFR, and HER2 expression; fluorescence in situ hybridization (FISH) for EGFR and ERBB2 gene amplification; and molecular analyses for recurrent mutations in 15 cancer genes including AKT-1, EGFR, PIK3CA, and TP53 on 54 cases of apocrine-eccrine carcinomas. They include 10 apocrine carcinomas, 7 eccrine carcinomas, 9 aggressive digital papillary adenocarcinomas, 10 hidradenocarcinomas, 11 porocarcinomas, 1 adenoid cystic carcinoma, 4 malignant chondroid syringomas, 1 malignant spiradenoma, and 1 malignant cylindroma. AR, ER, PR, EGFR and HER2 expression was seen in 36% (19/53), 27% (14/51), 16% (8/51), 85% (44/52) and 12% (6/52), respectively. Polysomy or trisomy of EGFR was detected by FISH in 30% (14/46). Mutations of AKT-1, PIK3CA, and TP53 were detected in 1, 3, and 7 cases, respectively (11/47, 23%). Additional investigation regarding the potential treatment of rare cases of apocrine-eccrine carcinomas with PI3K/Akt/mTOR pathway inhibitors, currently in clinical testing, may be of clinical interest.