Enhancing upper tract urothelial carcinoma diagnosis: Utility of cytokeratin 17 and CK20/CD44/p53 immunohistochemical panel.

Upper tract urothelial carcinoma (UTUC) presents diagnostic challenges due to small biopsy specimen size, poor orientation, and technical obstacles that can yield equivocal diagnoses. This uncertainty often mandates repeated biopsies to evaluate the necessity of nephroureterectomy. Prior studies have suggested cytokeratin 17 (CK17) immunostain as an adjunctive tool for diagnosing bladder urothelial neoplasia in both urine cytology and tissue biopsy specimens. We evaluated the utility of CK17 in differentiating UTUC from benign urothelium and its ability to stratify low-grade from high-grade neoplasia. Our study involved a cohort of previously diagnosed cytology (n = 29) and tissue specimens from biopsies and resections (n = 85). We evaluated CK17 staining percentage in cytology and tissue samples and localization patterns in biopsy/resection samples. Our findings showed a statistically significant distinction (p < 0.05) between UTUC and benign tissue specimens based on full thickness localization pattern (odds ratio 8.8 [95% CI 1.53-67.4]). The percentage of CK17 staining failed to significantly differentiate neoplastic from non-neoplastic cases in cytology or tissue samples. Additionally, based on prior research showing the efficacy of CK20/CD44/p53 triple panel in bladder urothelial neoplasia, we utilized tissue microarrays to evaluate if these markers could distinguish UTUC from benign urothelium. We found that CK20/CD44/p53, individually or in combination, could not distinguish urothelial neoplasia from non-neoplasia. Full thickness CK17 urothelial localization by immunohistochemistry was highly reproducible with excellent interobserver agreement and may play a supplementary role in distinguishing upper tract urothelial neoplasia from benign urothelium.

Desmoplakin I/II immunohistochemical staining may be a helpful tool in differentiating cutaneous graft versus host disease from the erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis spectrum disorders.

Cutaneous graft versus host disease (cGVHD) has substantial clinical and histopathologic overlap with erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). This overlap can make it difficult to distinguish these disorders in patients who have received hematopoietic transplants. We sought to evaluate the utility of Dp I/II immunohistochemical stain in differentiating EM/SJS/TEN and cGVHD in a large cohort. Skin biopsy specimens from patients with cGVHD (n = 58) and EM/SJS/TEN (n = 60) were evaluated for Dp I/II expression by immunohistochemistry. We found a statistically significant difference in Dp I/II staining between cGVHD (all grades) and EM/SJS/TEN (mean scores 1.62 and 2.14, respectively; p < 0.005), as well as between Grades 2 + 3 cGVHD and EM/SJS/TEN (mean scores 2.26 and 1.62, respectively; p < 0.005), while we did not find a significant difference between Grade 4 cGVHD and EM/SJS/TEN (mean scores 1.69 and 1.62, respectively; p = 0.71). Dp I/II immunostain may be useful for differentiating EM/SJS/TEN from Grade 2 and Grade 3 cGVHD, especially in clinically ambiguous cases without extracutaneous GVHD.

Malignant Intrarenal/Renal Pelvis Paraganglioma with Co-Occurring SDHB and ATRX Mutations.

Paragangliomas are rare neuroendocrine tumors which originate from embryonic neural crest cells. These tumors may arise from parasympathetic or sympathetic paraganglia, may secrete catecholamines, and can occur in varied anatomic locations, with some locations being less common than others. Hereditary paraganglioma-pheochromocytoma (PGL/PCC) syndromes are characterized by paragangliomas and pheochromocytomas and have been associated with germline heterozygous mutations in MAX, SDHA, SDHAF2, SDHB, SDHC, SDHD, or TMEM127. Herein, we report a case of a middle-aged male who was diagnosed with an intrarenal/renal pelvis paraganglioma after presenting in hypertensive crisis with palpitations, headache, and diaphoresis. He was later found to have extensive metastatic disease, as well as genetic testing that showed biallelic inactivation of SDHB and a co-occurring somatic ATRX mutation. Respectively, these germline and somatic mutations have been associated with increased risk of metastatic spread and clinical aggressiveness. Despite multiple surgical resections and various treatment modalities, the patient eventually elected for palliative care measures and died of disease. Together, the findings seen in this patient are unique and serve as an appropriate catalyst for discussing the unusual locations, interesting genetic profiles, and metastatic risk factors that may be associated with paragangliomas.

Endoscopic, Ultrasonographic, and Histologic Descriptions of Dextranomer/Hyaluronic Acid in a Case of Fecal Incontinence.

OBJECTIVE: To present a case of fecal incontinence treated with dextranomer/hyaluronic acid (Solesta®) injections, which later caused clinical confusion and avoidable interventions. The endoscopic, ultrasonographic, and histologic appearances of dextranomer/hyaluronic acid will also be reported. CASE PRESENTATION: A middle-aged Hispanic male who failed conservative management of his fecal incontinence was injected with dextranomer/hyaluronic acid in an attempt to alleviate symptoms. An unrelated screening colonoscopy was performed soon after, revealing a submucosal rectal lesion. Flexible sigmoidoscopy and endoscopic rectal ultrasound with FNA were scheduled for patient for further evaluation. An unknown foreign material was noted under microscopy and, upon attaining additional history, the gastroenterologist uncovered the patient's recent injections of dextranomer/hyaluronic acid. CONCLUSION: Dextranomer/hyaluronic acid for the treatment of fecal incontinence has become more common in recent years. Though the imaging and histologic appearance of this gel-like material is seen in other areas of medicine, equivalent descriptions are limited in the anorectal region. To curb misdiagnoses and prevent unnecessary interventions, it is important to expound on the endoscopic, imaging, and histopathologic features of this tissue-bulking agent in the setting of fecal incontinence and to encourage communication, proper documentation, and easy accessibility to patient health information by all medical staff.

A peculiar case of asymptomatic spontaneous pneumomediastinum.

OBJECTIVE: To present a case of asymptomatic spontaneous pneumomediastinum and review available evidence-based workup and management. CASE PRESENTATION: A young Caucasian adult male with a history of inhalational drug use was admitted to the internal medicine service for evaluation of dehydration and mild rhabdomyolysis. Patient had been on the run from the police and had spent the last days prior to presentation without food, water, or shelter. On admission, patient had no complaints, except for thirst. It was detected on physical exam and chest x-ray that patient had subcutaneous emphysema and pneumomediastinum. The patient was treated conservatively and discharged after a period of observation. CONCLUSION: Spontaneous pneumomediastinum is benign and seen primarily in young adults. It is more commonly associated with symptoms like chest pain and/or dyspnea, making an asymptomatic case particularly distinctive. The etiologies and precipitating factors are varied and often an apparent cause isn't identified. The diagnostic approach involves chest x-ray and/or computed tomography (CT) chest with further workup being largely unnecessary. The tenants of management include bedrest, analgesics, and supplemental oxygen as needed.