Perineal nerve block versus periprostatic block for patients undergoing transperineal prostate biopsy (APROPOS): a prospective, multicentre, randomised controlled study.

Background: We aimed to investigate perineal nerve block versus periprostatic block in pain control for men undergoing a transperineal prostate biopsy. Methods: In this prospective, randomised, blinded and parallel-group trial, men in six Chinese hospitals with suspected prostate cancer were randomly assigned (1:1) at the point of local anaesthesia to receive a perineal nerve block or periprostatic block and followed by a transperineal prostate biopsy. Centres used their usual biopsy procedure. Operators who performed anaesthesia were trained in both techniques before the trial and were masked to the randomised allocation until the time of anaesthesia and were not involved in the subsequent biopsy procedure and any assessment or analysis. Other investigators and the patients were masked until trial completion. The primary outcome was the level of the worst pain experienced during the prostate biopsy procedure. Secondary outcomes included pain (post-biopsy at 1, 6 and 24 h), changes in blood pressure, heart rate and breathing rate during the biopsy procedure, external manifestations of pain during biopsy, anaesthesia satisfaction, the detection rate of PCa and clinically significant PCa. This trial is registered on ClinicalTrials.gov, NCT04501055. Findings: Between August 13, 2020, and July 20, 2022, 192 men were randomly assigned to perineal nerve block or periprostatic block, 96 per study group. Perineal nerve block was superior for the relief of pain during the biopsy procedure (mean 2.80 for perineal nerve block and 3.98 for periprostatic block; adjusted difference in means -1.17, P < 0.001). Although the perineal nerve block had a lower mean pain score at 1 h post-biopsy compared with the periprostatic block (0.23 vs 0.43, P = 0.042), they were equivalent at 6 h (0.16 vs 0.25, P = 0.389) and 24 h (0.10 vs 0.26, P = 0.184) respectively. For the change in vital signs during biopsy procedure, perineal nerve block was significantly superior to periprostatic block in terms of maximum value of systolic blood pressure, maximum value of mean arterial pressure and maximum value of heart rate. There are no statistical differences in average value of systolic blood pressure, average value of mean, average value of heart rate, diastolic blood pressure and breathing rate. Perineal nerve block was also superior to periprostatic block in external manifestations of pain (1.88 vs 3.00, P < 0.001) and anaesthesia satisfaction (8.93 vs 11.90, P < 0.001). Equivalence was shown for the detection rate of PCa (31.25% for perineal nerve block and 29.17% for periprostatic block, P = 0.753) or csPCa (23.96% for perineal nerve block and 20.83% for periprostatic block, P = 0.604). 33 (34.8%) of 96 patients in the perineal nerve block group and 40 (41.67%) of 96 patients in the periprostatic block group had at least one complication. Interpretation: Perineal nerve block was superior to periprostatic block in pain control for men undergoing a transperineal prostate biopsy. Funding: Grant 2019YFC0119100 from the National Key Research and Development Program of China.

No-touch endoscopic full-thickness resection technique for gastric gastrointestinal stromal tumors.

BACKGROUND : There remain concerns regarding the technical feasibility of endoscopic resection for large gastrointestinal stromal tumors (GISTs), mainly relating to the risk of tumor rupture and the adequacy of the resection margins. This study aimed to evaluate the feasibility and therapeutic outcomes of the newly developed no-touch endoscopic full-thickness resection (NT-EFTR) technique for GISTs. METHODS : In this retrospective study, 92 patients with gastric GISTs undergoing NT-EFTR were included. Clinicopathological, endoscopic, and follow-up data were collected and analyzed. RESULTS : The median tumor size was 2.5 cm and en bloc resection was achieved in all patients with negative surgical margins. The median time of the NT-EFTR procedure was 59.5 minutes. Large tumors (> 3.0 cm), extraluminal tumor growth pattern, and large gastric defects were significant contributors to long operative times. Patients were discharged within 4 days postoperatively. During follow-up, all patients were free from local recurrence and distant metastasis. CONCLUSIONS : NT-EFTR was a feasible method for the resection of gastric GISTs and can be expected to achieve complete radical resection. Large tumors with extraluminal growth and large gastric defects impact procedural difficulty.

Atypical presentation of SARS-CoV-2 infection: A case report.

BACKGROUND: The first case of pneumonia subsequently attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred in Wuhan, Hubei Province on December 8, 2019. The symptoms included fever, coughing, and breathing difficulties. A few patients with this infection may only have atypical symptoms, which could lead to a misdiagnosis and subsequently further facilitate the spread of the virus. CASE SUMMARY: A 74-year-old female patient complained of severe diarrhea. She did not have fever, coughing, or breathing difficulties. A physical examination revealed no obvious positive signs. The patient had been hypertensive for more than 10 years. Her blood pressure was well controlled. On January 9, 2020, the patient's son visited a colleague who was later confirmed positive for SARS-CoV-2 and his first close contact with our patient was on January 17. The patient was first diagnosed with gastrointestinal dysfunction. However, considering her indirect contact with a SARS-CoV-2-infected individual, we suggested that an atypical pneumonia virus infection should be ruled out. A computed tomography scan was performed on January 26, and showed ground-glass nodules scattered along the two lungs, suggestive of viral pneumonia. Given the clinical characteristics, epidemiological history, and examination, the patient was diagnosed with coronavirus disease-2019 (COVID-19). CONCLUSION: Our patient had atypical symptoms of COVID-19. Careful acquisition of an epidemiological history is necessary to make a correct diagnosis and strategize a treatment plan.

Genome-wide association study identifies SIAH3 locus influencing the rate of ventricular enlargement in non-demented elders.

Ventricular enlargement occurs in several neurodegenerative and psychiatric diseases. A large genome-wide association study (GWAS) has identified seven loci associated with ventricular volume. The rate of ventricular enlargement increased in the progression of disease from normal cognition to dementia. Here, we aimed to use the rate of ventricular enlargement as an endophenotype for the development and progression of neurodegenerative diseases to discover more common genetic variants. We performed a GWAS of the rate of ventricular enlargement using 507 nondemented non-Hispanic white participants from the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort. Linear regression model was used to identify the association of the rate of ventricular enlargement with single nucleotide polymorphisms (SNPs) in PLINK software. The associations of genome-wide significant SNPs with other four phenotypes were further discussed. Two SNPs (rs11620312, P = 4.04×10-8; rs79174114, P = 4.28×10-8) within SIAH3 gene in linkage disequilibrium (LD) reached genome-wide significance for association with increased rate of ventricular enlargement. Some intergenic SNPs and SNPs within NKAIN2, TBC1D2, GALNT18, ABCC1 and SRCIN1 genes were identified as potential candidates. SIAH3 rs11620312-C carriers were associated with poor cognition and brain hypometabolism longitudinally. Our findings indicated that SIAH3 gene may have potential influence on the pathogenesis of neurodegenerative diseases.

Clinicopathologic and neuroradiologic studies of papillary glioneuronal tumors.

BACKGROUND: Papillary glioneuronal tumor (PGNT) is a rare, recently described distinct low-grade brain neoplasm. This study was performed to characterize the clinicopathologic and neuroradiologic features of PGNTs. METHODS: We reviewed the medical records of 16 patients with PGNT who underwent surgery, including 11 males and five females (median age 27 years). The clinical, neuroradiologic, histopathologic, and immunohistochemical findings were documented. RESULTS: Headache was the principal presentation. Neuroimaging showed contrast-enhancing, cystic-solid or cystic masses with a mural nodule, mostly involved the frontal or parietal lobes. Histologically, the tumors were characterized by glial fibrillary acidic protein (GFAP)-positive small cuboidal cells lining hyalinized vascular pseudopapillae and synaptophysin and/or NeuN-positive interpapillary neuronal elements. Other findings included small angiomatous areas in ten, small islands of neuropil and rosettes in seven, and microvascular proliferation and/or nuclear atypia in six. Mitoses or necrosis were absent. All lacked isocitrate dehydrogenase 1 (IDH1) R132H protein expression. Low expression of p53 was observed in three cases. Ki67 labeling index ranged from less than 1 to 3 %. All but one was totally resected. Median follow-up was 65 months, and one patient had tumor recurrence. CONCLUSIONS: PGNTs display distinct clinicopathologic and imaging characteristics and indicate a favorable prognosis. However, recurrences sometimes occur. Immunohistochemistry facilitates the appropriate diagnosis of these tumors. Complete resection of the tumor is important for a favorable outcome.

A spinal tumor showing mixed features of ependymoma and hemangioblastoma: a case report and literature review.

We report an intramedullary spinal tumor consisting of an ependymoma and a hemangioblastoma (HB). A 37-year-old woman presented with progressive bilateral lower limb sensory and motor deficits. Magnetic resonance imaging showed a single intramedullary mass in the thoracic cord (T4-T6 level). Clinically, the patient had no von Hippel-Lindau disease and neurofibromatosis type 2. Metastatic carcinomas including renal cell carcinoma were altogether negative. Complete surgical resection was performed. Histologically, the tumor consisted of a mixed ependymoma and HB. Tumor cells of ependymoma displayed a rather uniform appearance with round to oval nuclei having salt-and-pepper-like chromatin, forming perivascular pseudorosette structures with radially arranged, tapering cell processes extending to intratumoral blood vessels. Stromal cells of HB had vacuolated or homogeneously eosinophilic cytoplasm and variable sized hyperchromatic nuclei within a background of capillaries. Immunohistochemically, tumor cells of ependymoma were strongly positive for glial fibrillary acidic protein (GFAP), focally positive for epithelial membrane antigen (EMA) and D2-40 in a dot-like or ring-like pattern. Stromal cells of HB showed immunoreactivity for S100, vimentin, inhibin-α, D2-40, EMA and cytokeratins (CK: AE1/AE3, CK19). A review of the literature, in conjunction with the present case, shows that ependymomas and HBs may have a close relationship with each other.

Dysembryoplastic neuroepithelial tumor-like neoplasm of the septum pellucidum: review of 2 cases with chromosome 1p/19q and IDH1 analysis.

Dysembryoplastic neuroepithelial tumor (DNT)-like neoplasms of the septum pellucidum are extremely rare. We reviewed 2 cases of DNT-like neoplasm of the septum pellucidum and specifically studied the immunohistochemical features and chromosomes 1p and 19q deletions. One case was a 26-year-old woman who complained of aggravated headache for 2 weeks. The other case was a 31-year-old female presenting with double vision for a month. Histological examinations showed that the lesions were composed of uniform oligodendrocytelike cells (OLCs) with obvious floating neurons in a mucin-rich background. Immunohistochemical studies revealed that both tumors were diffusely positive for Synaptophysin and Olig2. Sporadic neurons were clearly positive for NeuN. Loss of chromosome 1p/19q and isocitrate dehydrogenase 1(IDH1) mutations were not identified in both cases. It might indicate that these OLCs of DNT-like neoplasms were genetically different from glial tumors, although they showed close morphological similarities.

Rosette-forming glioneuronal tumor of the septum pellucidum with extension to the supratentorial ventricles: rare case with genetic analysis.

In the original description, rosette-forming glioneuronal tumors (RGNTs) were restricted to the fourth ventricle and/or posterior fossa. Here, we first report an unusual case of RGNT centered in the septum pellucidum and associated with multiple masses occupying the wall of the bilateral lateral ventricles and the third ventricle. No mass was found in the fourth ventricle. Histological and immunohistochemical examination revealed that the tumor presented biphasic differentiation characterized by predominantly neurocytic rosettes and pilocytic astrocytoma-like components with obvious microvascular proliferation. Chromosome 1p/19q deletions and isocitrate dehydrogenase 1 and 2 (IDH1/2) mutations were not identified. Because this case exhibited a worrisome growth pattern, further studies and long-term follow-up are needed to determine the true nature of these tumors.

Embryonal tumor with abundant neuropil and true rosettes (ETANTR) with a focal amplification at chromosome 19q13.42 locus: further evidence of two new instances in China.

Recently, the term "embryonal tumor with multilayered rosettes" (ETMR), including embryonal tumor with abundant neuropil and true rosettes (ETANTR) and ependymoblastoma (EBL) as a distinct tumor entity, has become an important topic of discussion for neuropathologists since the discovery of a unique genomic alteration in 2009. Here, we contribute two new East Asian instances of ETANTR in a 29-month-old boy who underwent subtotal resection of a large tumor in the bilateral parieto-occipital lobes and a 4-year-old boy who underwent subtotal resection of the right midpontine neoplasm. Both tumors showed a typical histopathological pattern of hypercellular clusters of undifferentiated small cells and ependymoblastic rosettes admixed with paucicellular neuropil-like zones indicative for ETANTR. Rare Homer-Wright neuroblastic rosettes and papillary pseudorosettes, as well as enlarged lumina with mucinous material, were also observed. Immunohistological studies revealed that tumor cells in hypercellular and paucicellular zones were diffusely positive for microtubule-associated protein 2; ependymoblastic rosette cells stained with epithelial membrane antigen at the luminal membrane and exhibiting strong immunoreactivity with p53 protein. ß-Catenin and Nestin were frequently detected in the hypercellular zones as well as in the ependymoblastic rosettes. Fluorescence in situ hypribization analysis revealed that both cases contained a unique focal amplification at the 19q13.42 chromosome locus and chromosome 2 polysomy. A new WHO classification of tumors of the CNS should be considered for these neoplasms with unique focal amplification at the 19q13.42 chromosome locus, based on the clinicopathological and molecular features of ETANTR that are distinct and reproducibly recognizable.

Pigmented pleomorphic xanthoastrocytoma: a rare variant and literature review.

A 16-year-old male teenager presented with seizure and loss of consciousness for 20 min. Magnetic resonance imaging demonstrated a mass occupying the right medial temporal lobe. Histological examination revealed a non-pigmented area with spindle-shaped and large xanthomatous pleomorphic cells and a pigmented region with pigmented neoplastic cells with fascicular arrangement. Immunohistochemical studies showed the tumor was positive for GFAP and low index of Ki-67. Considering the patient's history, clinical data and pathological findings, we rendered a rare variant named pigmented pleomorphic xanthoastrocytoma.

Metastasis of renal cell carcinoma to a haemangioblastoma of the medulla oblongata in von Hippel-Lindau syndrome.

We describe a patient with von Hippel-Lindau (VHL) syndrome with metastasis of renal cell carcinoma (RCC) to a haemangioblastoma (HAB) of the medulla oblongata. Histological examination revealed cells with clear cytoplasm arranged in alveolar or tubular patterns in most fields of view. In a small area, the tumor showed abundant thin-walled vessels and clear cells. Immunohistochemically, staining for cytokeratin, epithelial membrane antigen and CD10 was typically positive in the tumor portion that contained RCC but not in the HAB. The HAB was immunopositive for inhibin-alpha and CD34. Detailed histological analysis and immunohistochemistry should allow differentiation of HAB and RCC.

Rosette-forming glioneuronal tumor: report of an unusual case with intraventricular dissemination.

A rosette-forming glioneuronal tumor (RGNT) was encountered in a 16-year-old Chinese girl. She experienced seizures with loss of consciousness for 1 month prior to diagnosis. A brain MRI revealed multifocal masses occupying all of the ventricular system associated with marked hydrocephalus. A biopsy was performed on the right lateral ventricle using a neuroendoscope and the patient was given postoperative radiotherapy. She was followed for 7 months, and there was no radiological or clinical evidence of tumor progression. Histological examination demonstrated two regions characterized by predominant neurocytic rosettes and scant low grade astrocytoma. No histological anaplasia was present. Immunohistological studies showed that the small round tumor cells forming rosettes were strongly positive for Olig2. A chromosome 1p/19q co-deletion was not detected by FISH analysis. While the pathological features of our case closely resembled those reported in the original description, the diffuse intraventricular growth pattern of the tumor was different from previous examples. Further long-term follow-up studies are required to assess the biological behavior and clinical outcome of the RGNT entity.

[The value of diffusion MR imaging in judging pathological changes of brain multiple sclerosis].

OBJECTIVE: To analyze the findings of MR diffusion weighted imaging (DWI) and diffusion tensor Imaging (DTI) in patients with multiple sclerosis (MS), and to explore their role in reflecting the pathological changes of MR lesions. METHODS: DWI and DTI were performed on 41 MS cases and 25 sub-acute brain infarct cases which used as control group. The appearances of ADC maps, EADC maps and FA maps in patients of both groups were analyzed. Quantitative analysis of the values of ADC, EADC and FA in the center and periphery of the lesions of acute MS, chronic MS and sub-acute brain infarct was carried out separately. RESULT: In DWI, the small chronic lesions were iso-intensity, and the large acute MS lesions and the sub-acute-infarct lesions had a high signal intensity to various degrees. In the EADC map, only in 13 cases with acute MS around the peripheral zone of the lesions there was a high signal intensity, and all other cases, including the cases with chronic MS and brain infarct had no high signal lesions. The ADC values of chronic and infarct lesions were similar (P > 0.05), both of them had the highest ADC value which were higher than the signal intensity in the center (both P < 0.05) and the periphery (both P < 0.05) of the MS lesions. The FA values in the infarct lesions were the lowest, much more lower than that in the chronic MS lesions (P < 0.05). The FA value in the center of acute MS lesions was lower than that in the peripheral zone (P < 0.05), and higher than the FA value both in the chronic MS and infarct lesions (P < 0.05). The lowest ADC value outside the peripheral zone of acute MS lesions and the highest EADC value were found. CONCLUSION: The significance of DWI high signal in the diagnosis and differential diagnosis of MS is not reliable, so the patient's history and the findings found in the routine MRI must be conjugated when an imaging diagnosis is made. The EADC map is more accurate than ADC map for showing the diffusion restriction of water molecular in the MS lesions. The degree of increase of the ADC value and the degree of decease of the FA value are proportional to the degree of severity of the pathological changes of the MS lesions.

[Value of magnetization transfer imaging in judging microchanges lesions in normal-appearing white matter of multiple sclerosis].

OBJECTIVE: To explore the value of magnetization transfer imaging (MTI) in judging microscopic lesions in normal-appearing white matter of multiple sclerosis (MS). METHODS: Forty-one patients with brain MS, 17 males and 24 females, aged 13 approximately 65, and 21 healthy people, 8 males and 13 females, aged 18 approximately 57, used as controls underwent magnetic resonance imaging (MRI) using 3D-spoiled grass (3D-SPGR) series, to scan the whole brain with saturated pulses on and off respectively. The signal values were measured directly in the pictures of these 2 series. The formula MTR = (M(0)-MS)/M(0) x 100% was used, where M0 represents the signal value of region of interest with the saturated pulses off, and Ms represents signal value of region of interest with the saturated pulses on, to calculate the MTR value. With reference to T(2)WI imaging, the MTR values of 17 regions of interest (ROI) in the normal-appearing brain white matter, including the white matter of pons, bilateral cerebellar peduncles, knees of internal capsules, splenium and genu of corpus callosum, and the white matter by the anterior horn and posterior horn of lateral ventricle, body of lateral ventricle, and deep in the frontal and parietal lobes, were measured. The average MTR value of the 17 ROI was used to represent the MTR value of the whole normal-appearing brain and used to make comparison with that of the healthy samples statistically. RESULTS: Compared with those of the healthy samples, the average MTR values of each ROI of the MS patients were lower at different degrees. The difference in the MTR values of the white matter of splenium of corpus callosum, and by lateral ventricle and deep in parietal lobe were especially bigger. The MTR value of the whole brain white matter in the healthy persons ranged from 22.76% to 25.42%, with an average value of 23.97%, both significantly higher than those of the MS patients (19.45% to 24.15%, and 22.44% respectively, both P < 0.05). CONCLUSION: MTI can be used to detect the microchange of normal appearing white matter in MS. MTR is a sensitive indicator to reflect the damage of structure of tissues.