Isolated left axillary nodal metastasis from endometrial carcinosarcoma: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Non-mammary metastases to the breast and axilla are rare instances, and isolated axillary lymph node metastases are especially rare. We present a rare case of left axillary lymph node metastasis from a primary endometrial carcinosarcoma. CASE PRESENTATION: We report a case of a 73-year-old woman who presented with a left breast tail palpable mass. Sonomammography and breast MRI revealed multiple enlarged left axillary lymph nodes (LN) showing malignant criteria without any suspected malignancy in either breast on imaging. The patient underwent a nodal excisional biopsy that diagnosed axillary lymph node metastasis from a gynecologic origin. Complementary abdominopelvic CT revealed a suspicious endometrial mass that was confirmed on MRI. She underwent D&C and the pathology revealed endometrial carcinosarcoma. CLINICAL DISCUSSION: Accurate detection of extramammary primary sites is crucial as their management and outcome differ significantly from primary breast cancer. To the best of our knowledge, our case could be the first reported case of isolated metastatic axillary LN from uterine carcinosarcoma presenting as the initial symptom without pelvic or abdominal LN involvement. CONCLUSION: For these patients to avoid needless surgical procedures and therapies, a proper diagnosis made by a multidisciplinary team with precise radiologic and pathologic correlation is essential.

Congenital Gastric Teratoma Presenting with Gastrointestinal Bleeding: Case Report and Review of Literature.

BACKGROUND: Gastric teratoma is an extremely rare tumor, representing <1% of all pediatric teratomas, and commonly manifests as a palpable abdominal mass. Upper gastrointestinal tract bleeding in newborns and infants is rare and is mostly caused by a benign lesion. CASE REPORT: We present a 3-month-old boy who presented with recurrent attacks of hematemesis, vomiting, and melena which on work up revealed a gastric teratoma. DISCUSSION/CONCLUSION: Owing to the unique characteristics and the extreme rarity of this entity, accurate preoperative diagnosis has remained elusive.

Metronomic cyclophosphamide and metformin inhibited tumor growth and repopulated tumor-infiltrating lymphocytes in an experimental carcinoma model.

Metformin is a widely used antidiabetic biguanide. Retrospective data demonstrated the association of metformin use with survival benefit in multiple tumor types. Interest in repurposing metformin to treat cancer has not been translated into encouraging clinical benefit. In animal models, metformin activated cytotoxic T cells and exerted an immune-mediated anticancer effect. The current research was conducted to investigate the possible therapeutic benefit of metformin in combination with metronomic cyclophosphamide in an experimental cancer model. Ehrlich ascites carcinoma was injected into the subcutaneous tissue to induce solid tumors in syngeneic mice. Exponential solid tumor growth ensued and was effectively arrested with the administration of a cytotoxic dose of parenteral cyclophosphamide. Alternatively, oral metformin and continuous, low-dose cyclophosphamide significantly inhibited tumor growth relative to untreated mice. The drug combination was well tolerated. Histopathological examination of the tumor showed an increased number of tumor-infiltrating lymphocytes and enhanced expression of granzyme B by this drug combination. The current data suggests a potential role of metformin and metronomic chemotherapy that warrants further investigation.

Pathologic approach to Neonatal cholestasis with a simple scoring system for biliary atresia.

A liver biopsy is essential for the diagnostic workup of persistent neonatal cholestasis (NC). The differential diagnosis of NC is broad, including obstructive and non-obstructive causes. In addition, histologic features of certain disorders may be non-specific in the early course of the disease. To evaluate liver biopsies using a practical histopathologic approach for NC and to define a simple scoring system for biliary atresia (BA) for routine clinical practice. From June 2006 to December 2021, liver biopsy specimens from infants with persistent NC were examined by two independent pathologists. The cases diagnosed as BA were correlated with clinical, radiologic, and laboratory data to calculate the final score. Four hundred and fifty-nine cases were enrolled in the study. They had a mean age of 63.94 ± 20.62 days and were followed for a median time of 58 (1-191) months. They included 162 (35.3%) cases of BA. On multivariate analysis, portal edema, ductular proliferation, cholangiolitis, and bile duct/ductular plugs were the histopathologic predictors of BA. A liver biopsy did perform well with a 95.1% sensitivity, 91.6% specificity, 86% PPV, and 97.1% NPV. At a cutoff of 5 of the scoring system, diagnosis of BA could be done with a sensitivity of 95.1% and a specificity of 100%. We have shown detailed histopathologic features of BA with more depth to infants aged ≤ 6 weeks. We have developed a simple scoring system using a combination of liver biopsy with non-invasive methods to increase the diagnostic accuracy of BA.

The epidemiological and clinicopathological characteristics of multifocal/multicentric breast cancer in the Egyptian Delta and its impact on management strategies.

BACKGROUND: Multifocal (MFBC)/multicentric (MCBC) breast cancer is being more recognized due to the improved imaging modalities and the greater orientation with this form of breast cancer, however, optimal surgical treatment, still poses a challenge. The standard surgical treatment is mastectomy, however, breast-conserving surgeries (BCS) may be appropriate in certain situations. METHODS: A total of 464 cases of MF/MCBC out of 4798 cases of breast cancer were retrospectively analyzed from the database of the Oncology Center, Mansoura University (OCMU), between January 2008 and December 2019. RESULTS: Radiologic involvement of multiple quadrants was reported in 27.9% by ultrasonography, 19% by mammography, and 59.1% by magnetic resonance imaging. BCS was performed in 32 cases (6.9%) while 432 cases underwent a mastectomy. Postoperative pathology revealed infiltration of other quadrants grossly in 23.5%, and under the microscope in 63.6% of the examined cases. Mean disease-free and overall survival were 95.5 and 164.6 months, respectively. When compared with MFBC, MCBC showed higher pathologic tumor size (p < 0.001), higher stages (p < 0.001), higher recurrence rates (p = 0.006), and lower DFS (P = 0.009) but with similar OS (P = 0.8). CONCLUSION: Mastectomy is still the primary treatment option for MCBC with higher recurrence rates compared with MFBC. However, BCS for properly selected MFBC is considered oncologically safe, following the same rules of breast conservation for unifocal disease.

Diffusion tensor magnetic resonance imaging in the grading of liver fibrosis associated with congenital ductal plate malformations.

Purpose: Liver biopsy is still the standard method for the diagnosis of ductal plate malformations (DPM). However, it is an invasive tool. Magnetic resonance imaging (MRI) has shown its accuracy in the diagnosis of this pathology. Herein, a study was conducted to elucidate the role of diffusion MRI parameters in predicting the degree of hepatic fibrosis. Material and methods: This prospective study included 29 patients with DPM and 20 healthy controls. Both groups underwent diffusion tensor magnetic resonance imaging (DT-MRI), and its parameters were compared between patients and controls, and then they were correlated with the degree of liver fibrosis in the patient group. Results: All patients with DPM, whatever its type, expressed a significantly lower hepatic apparent diffusion coefficient (ADC) compared to controls. However, fractional anisotropy (FA) showed no significant difference between them. The ADC value of 1.65 × 10-3 mm2/s had sensitivity and specificity of 82.1% and 90%, respectively, in differentiating DPM patients from healthy controls. It was evident that patients with higher fibrosis grades had significantly lower hepatic ADC, indicating a negative correlation between ADC and the grade of hepatic fibrosis; rs = -0.901, p < 0.001. Conclusions: DT-MRI showed good efficacy in the diagnosis of congenital DPM. Moreover, ADC could be applied to monitor the degree of liver fibrosis rather than the invasive liver biopsy. No significant correlation was noted between the FA and the grades of liver fibrosis.

Effect of non-invasive follicular thyroid neoplasm with papillary-like features (NIFTP) terminology on surgical management concepts.

BACKGROUND: Despite the strict diagnostic criteria recently proposed for non-invasive follicular thyroid neoplasm with papillary-like features (NIFTP), its incidence is still unknown. Employing a retrospective analysis of the follicular variant of papillary thyroid carcinoma (FVPTC), we investigated the diagnosis, prevalence and postoperative course of NIFTP. METHODS: We examined retrospectively the records of 112 patients who had undergone thyroid surgery and had a postoperative diagnosis of FVPTC at our hospital from 2010 to 2021. All clinical, radiologic, and pathologic features were evaluated. RESULTS: Only 34 (27.9%) patients met the strict pathologic criteria for NIFTP; 11 cases having been diagnosed as NIFTP initially and 23 after re-evaluation of histopathologic slides. None of the 11 NIFTP patients underwent a 2-stage operation, in contrast to 10 (29.4%) patients initially diagnosed as FVPTC who had a completion thyroidectomy after the initial hemithyroidectomy. The median follow-up was 14.5 (ranging from 0 to 78) months. None of the cases developed a recurrence. CONCLUSION: To avoid unnecessary treatment or the follow-up advised for papillary thyroid carcinoma, clinicians and pathologists should be familiar with the terminology and the corresponding diagnostic criteria for NIFTP and their impact on management.

Intestinal Giardiasis in Children Undergoing Upper Endoscopy for Unexplained Gastrointestinal Symptoms: Implication for Diagnosis.

BACKGROUND: Giardia lamblia is a flagellated protozoan causing diarrheal outbreaks worldwide. Microscopic stool examination is widely used. We conducted this study to explore intestinal giardiasis in children undergoing upper endoscopy for unexplained gastrointestinal symptoms. METHODS: The study included 160 children undergoing upper endoscopy for unexplained gastrointestinal symptoms (patients) and 90 children as controls. We collected stool samples for microscopic examination and ELISA coproantigen detection from all participants. We examined duodenal biopsies for patients. RESULTS: In patients, stool examination revealed Giardia in 23.8% and coproantigen detection was positive in 37.5%. Endoscopic duodenal biopsies revealed Giardia trophozoites in 5% of patients, in addition to various pathological changes. CONCLUSION: Giardiasis was significantly higher (P = 0.001) in children with unexplained gastrointestinal complaints than the controls. Diagnosis by coproantigen detection was superior to microscopic stool examination, with a sensitivity of 90.9%. Duodenal biopsies examination confirmed the infection in fewer cases but added other diagnostic information.

Osseous Metaplasia in Juvenile Polyps: Report of Four Cases and Review of Literature.

Background: There are occasional reports of osseous metaplasia (OM) occurring in gastrointestinal polyps. We report 4 cases occurring in juvenile retention polyps. Case reports: Four juvenile retention polyps presented with rectal bleeding. Microscopically there was osseous metaplasia in addition to the typical surface ulceration and granulation tissue appearance. Discussion/conclusion: Osseous metaplasia was only detected on histopathologic examination of the resected polyps. Although the clinical significance is not established, OM suggests that the polyps have been present for a longer period of time.

Predicting Recurrence of Non-Muscle-Invasive Bladder Cancer: Current Techniques and Future Trends.

Bladder cancer (BC) is the 10th most common cancer globally and has a high mortality rate if not detected early and treated promptly. Non-muscle-invasive BC (NMIBC) is a subclassification of BC associated with high rates of recurrence and progression. Current tools for predicting recurrence and progression on NMIBC use scoring systems based on clinical and histopathological markers. These exclude other potentially useful biomarkers which could provide a more accurate personalized risk assessment. Future trends are likely to use artificial intelligence (AI) to enhance the prediction of recurrence in patients with NMIBC and decrease the use of standard clinical protocols such as cystoscopy and cytology. Here, we provide a comprehensive survey of the most recent studies from the last decade (N = 70 studies), focused on the prediction of patient outcomes in NMIBC, particularly recurrence, using biomarkers such as radiomics, histopathology, clinical, and genomics. The value of individual and combined biomarkers is discussed in detail with the goal of identifying future trends that will lead to the personalized management of NMIBC.

Diffusion tensor imaging of vertebral bone marrow in children with Gaucher's disease type I and III: Pre- and post-therapy.

PURPOSE: To assess diffusion tensor imaging (DTI) of the vertebral bone marrow (BM) in children with Gaucher's disease (GD) types I and III before and after therapy. METHODS: Prospective study was conducted upon 25 children with GD type I (n = 17) and III (n = 8) and 13 age and sex-matched controls underwent DTI of vertebral BM. Mean diffusivity (MD) and fractional anisotropy (FA) of vertebral BM was calculated and correlated with genotyping, chitotriosidase, hemoglobin (HB) and, platelet count. RESULTS: There was a statistically significant difference in MD and FA of BM between patients and controls (P = 0.001 and 0.02). The area under the curve (AUC) of MD and FA used to differentiate untreated patients from controls was 0.902 and 0.68 with sensitivity, specificity, and, accuracy 92%, 84.6%, and, 89.5% respectively. There was a significant difference in MD and FA of BM between untreated and treated patients (P = 0.001 and 0.02). AUC of MD and FA used to differentiate untreated from treated patients was 0.93 and 0.649 with sensitivity, specificity, and accuracy of 92%, 80%, and 86% respectively. There was a significant difference in MD and FA (P = 0.03, 0.001 respectively) of BM in GD with homozygous L444P mutation (n = 9) and other mutations (n = 14). Chiotriptase, HB and platelet count of patients was correlated with MD (r = -0.36, 0.42, -0.41) and FA (r = -0.47, -0.37, -0.46) respectively. CONCLUSION: DTI of vertebral BM can help in diagnosis and monitoring patients with GD after therapy and correlated with genotyping, and hematological biomarkers of GD.

Diffusion tensor imaging of the spleen in prediction and grading of esophageal varices in cirrhotic children with portal hypertension.

PURPOSE: To assess diffusion tensor imaging (DTI) of spleen in prediction and grading of esophageal varices (OV) in cirrhotic children. METHODS: This prospective study was conducted upon 30 children with cirrhotic children with OV and 10 age-gender matched controls that underwent DTI of abdomen. Mean diffusivity (MD) and fractional anisotropy (FA) of spleen were calculated and matched with the grading of OV at endoscopy and laboratory biomarkers of portal hypertension. RESULTS: Mean ADC of spleen in patient was significantly different (p = 0.001) from that of controls by both reviewers respectively. The cutoff ADC measurement of the spleen used for prediction of OV was ≥ 0.75 and ≥ 0.76 × 10-3mm2/s with AUC was 0.993 and 0.997 for both reviewers respectively. The FA of the spleen in patient was different (p = 0.01) from of controls of both reviewers respectively. Cutoff FA of spleen used for prediction of OV was ≤ 0.35 and ≤ 0.36 for both observers respectively. ADC and FA of spleen was correlated with platelets count (r = - 0.713, 0.392; p = 0.001, 0.012) and prothrombin time (r = 0.518, - 0.380; p = 0.001, 0.016). CONCLUSION: DTI metrics of spleen can predict and grade OV and correlated with laboratory biomarkers of portal hypertension.

Cognitive impairment in children with chronic Hepatitis C Virus: Case control study.

Hepatitis C virus (HCV) infection is the most common cause of chronic liver disease of infectious etiology in children. This study aims to compare cognitive impairment, and psychological status of treatment-naïve HCV children with control group. Treatment-naïve children with HCV and an equal control group of children of matched age and gender were recruited. Assessment included measures of children's cognitive functioning, behavior, depression and anxiety as well as laboratory investigations and liver biopsy. Overall 102 children of both genders were recruited; the majority was from rural areas and from middle social class. Their age ranged from 7 to 17 years old. Only 6.9% reported positive family history of Psychiatric disorders while 35.3% reported current Psychiatric disorder. The most frequent diagnosis in the sample was depression (16.7%). Depression scores correlated negatively with liver biopsy activity (p = 0.024) and positively with WBCS (p = 0.0024). Anxiety scores correlated positively with WBCS (p = 0.017). Verbal IQ, performance IQ and total IQ correlated with the social class and with the liver biopsy activity. Also it was found that higher depression scores can predict lower verbal IQ. Depression, social class and liver Inflammation are predictors of cognitive impairment in children with HCV.

Histopathologic ─ Endoscopic Concordance of Pediatric Duodenal Biopsy; How to Be Improved?

OBJECTIVE: Few studies have correlated pediatric endoscopic and histologic impressions of duodenal biopsies. Method: This is a retrospective study on children undergoing upper gastrointestinal endoscopy over a period of 11 years. We investigated concordance between the gross endoscopic and histopathologic characteristics of pediatric duodenal biopsies. Results: Of 1793 children enrolled in the study, duodenal pathology was observed in 72.3%. The gross endoscopic findings showed a low sensitivity of 38.9%, specificity of 99.2%, PPV of 99.2%, and NPV of 38.3%. Concordance between the gross endoscopic and histopathologic analysis was 55.6%. Conclusion: This study showed a higher rate of pediatric duodenal pathologies than gross assessment. This emphasizes the value for acquiring routine duodenal biopsies from grossly normal mucosa.

Assessment of Diffusion Tensor Imaging Parameters of Hepatic Parenchyma for Differentiation of Biliary Atresia from Alagille Syndrome.

OBJECTIVE: To assess diffusion tensor imaging (DTI) parameters of the hepatic parenchyma for the differentiation of biliary atresia (BA) from Alagille syndrome (ALGS). MATERIALS AND METHODS: This study included 32 infants with BA and 12 infants with ALGS groups who had undergone DTI. Fractional anisotropy (FA) and mean diffusivity (MD) of the liver were calculated twice by two separate readers and hepatic tissue was biopsied. Statistical analyses were performed to determine the mean values of the two groups. The optimum cut-off values for DTI differentiation of BA and ALGS were calculated by receiver operating characteristic (ROC) analysis. RESULTS: The mean hepatic MD of BA (1.56 ± 0.20 and 1.63 ± 0.2 × 10-3 mm²/s) was significantly lower than that of ALGS (1.84 ± 0.04 and 1.79 ± 0.03 × 10-3 mm²/s) for both readers (r = 0.8, p = 0.001). Hepatic MD values of 1.77 and 1.79 × 10-3 mm²/s as a threshold for differentiating BA from ALGS showed accuracies of 82 and 79% and area under the curves (AUCs) of 0.90 and 0.91 for both readers, respectively. The mean hepatic FA of BA (0.34 ± 0.04 and 0.36 ± 0.04) was significantly higher (p = 0.01, 0.02) than that of ALGS (0.30 ± 0.06 and 0.31 ± 0.05) for both readers (r = 0.80, p = 0.001). FA values of 0.30 and 0.28 as a threshold for differentiating BA from ALGS showed accuracies of 75% and 82% and AUCs of 0.69 and 0.68 for both readers, respectively. CONCLUSION: Hepatic DTI parameters are promising quantitative imaging parameters for the detection of hepatic parenchymal changes in BA and ALGS and may be an additional noninvasive imaging tool for the differentiation of BA from ALGS.

Role of P53, E-cadherin and BRAF as predictors of regional nodal recurrence for papillary thyroid cancer.

BACKGROUND: Regional nodal recurrence (RNR) in patients diagnosed with papillary thyroid carcinoma (PTC) has increased. Variable immunohistochemical (IHC) markers have been studied for predicting the likelihood of PTC for recurrence. We aimed to clarify the IHC expression of p53, Ecadherin and BRAF as potential markers of RNR in PTC. METHOD: 145 (73 study group and 72 control group) patients with PTC were analyzed retrospectively between January 2010 and June 2017. Further classification to a specific histological variant was done, and IHC expression of p53, Ecadherin and BRAF was analyzed both in the primary tumor and in nodal recurrence. RESULTS: Regarding the risk of RNR, we found certain clinicopathologic features as elder age ≥55 years, tumor size >1 cm, presence of microscopic extrathyroid extension, presence of lymphovascular emboli, and conventional papillary subtype. Furthermore, IHC results for negative E-cadherin, and positive P53 and BRAF are significant risk factors, while radioactive iodine (RAI) adjuvant therapy decrease recurrence risk. CONCLUSION: We found several risk factors for RNR in PTC diagnosed patients, all of which are easily achievable in clinical settings. In this regard, we suggested that patients with specific clinicopathologic and immunohistochemical features have strict follow up for early detection of RNR as it has a great impact on their survival.

Assessment of Liver and Spleen in Children With Gaucher Disease Type 1 With Chemical Shift Imaging.

PURPOSE: The aim of this study was to assess of liver and spleen in children with Gaucher disease type 1 with chemical shift imaging. METHODS: Retrospective analysis was conducted on 36 untreated children with Gaucher disease type 1 and 15 age- and sex-matched control children who underwent chemical shift imaging of the abdomen. The hepatic and splenic fat fraction was calculated. The Pediatric Gaucher Severity Scoring System, hematologic parameters, and enzyme assay of the disease were calculated and correlated with hepatic and splenic fat fraction. RESULTS: The mean hepatic fat fraction in Gaucher disease was 14.1 ± 3.1 (95% confidence interval [CI], 12.9-15.2) was significantly higher (P = 0.001) than that of control subjects 5.2 ± 0.9 (95% CI, 4.7-5.7). The mean splenic fat fraction in Gaucher disease was 11.2 ± 2.9 (95% CI, 11.2 ± 2.9), and that of control was 4.5 ± 0.9 (95% CI, 4.02-5.2). The thresholds of hepatic and splenic fat fraction used to differentiate patients from control subjects were 0.47 and 0.39 with areas under the curve of 0.947 and 0.999, respectively. The hepatic and splenic fat fraction is correlated with the Pediatric Gaucher Severity Scoring System (r = -0.523, -0.602), hemoglobin concentration (r = -0.491, -0.505), platelet count (r = -0.593, -0.24), ß-glucosidase (r = 0.519, 0.549), and chitotriosidase (r = -0.03, 0.267), respectively. CONCLUSIONS: Hepatic and splenic fat fraction is a promising quantitative imaging parameter for detection and quantification of hepatic and splenic infiltration in children with Gaucher disease and correlated with clinical scoring, hematologic parameters, and enzyme assay of the disease.

Multi-parametric MR imaging using apparent diffusion coefficient and fat fraction in quantification of bone marrow in pediatrics with Gaucher disease.

PURPOSE: To assess multi-parametric MR imaging with apparent diffusion coefficient (ADC) and fat fraction (FF) in detection and quantification of bone marrow involvement in pediatric patients with Gaucher disease. MATERIAL AND METHODS: This study was conducted upon 29 pediatric patients with Gaucher disease and 13 age and sex matched controls that underwent diffusion-weighted MR imaging and dual-echo gradient recalled echo imaging. The ADC and FF of the bone marrow were calculated. RESULTS: There was significant difference in ADC (P = 0.001) and FF (P = 0.001) of bone marrow between patients and controls. The cutoff ADC and FF differentiate patients from controls were 0.47 × 10-3 mm2/s and 0.36 with area under the curve of 0.947 and 0.885 and accuracy of 86.5% and 83.8% respectively. There was significant difference in ADC (P = 0.001) and FF (P = 0.001) between untreated (n = 17) and treated (n = 12) patients. The cutoff ADC and FF differentiate untreated from treated patients were 0.39 × 10-3 mm2/s and 0.27 with area under curve of 0.886 and 0.851 and accuracy of 88% and 84% respectively. CONCLUSION: Multi-parametric MR imaging using ADC and FF are quantitative imaging parameters that can be used for detection and quantification of vertebral bone marrow involvement in pediatric patients with Gaucher disease.

Assessment of the liver and spleen in children with Gaucher disease type I with diffusion-weighted MR imaging.

PURPOSE: To assess hepatic and splenic apparent diffusion coefficient (ADC) in children with Gaucher disease type I with diffusion-weighted MR imaging and to correlate hepatic and splenic ADC with parameters of disease severity. SUBJECTS AND METHODS: Prospective study was conducted upon 25 children (11 treated and 14 untreated) with Gaucher disease and 12 age and sex matched control children. They underwent diffusion-weighted MR imaging of abdomen. Hepatic and splenic ADC and volume were calculated. RESULTS: There was statistically difference in hepatic and splenic apparent diffusion coefficient (P=0.001) between patients and controls. The cutoff ADC of liver and spleen used to differentiate patients from controls were 0.47 and 0.39×10-3mm2 with area and curve of 0.947 and 0.886 respectively. There was significant difference in hepatic and splenic ADC between untreated and treated patients (P=0.003 and 0.001). Hepatic ADC correlated with splenic volume (r=-0.721), hepatic volume (r=-0.555) and chitotriosidase (r=-0.413). Splenic ADC correlated with splenic volume (r=-0.652), hepatic volume (r=-0.544) and chitotriosidase (r=-0.355). CONCLUSION: Hepatic and splenic ADC can detect hepatic and splenic infiltration in Gaucher disease and correlated with some parameters of disease severity.