Abdominal cocoon: a potential pitfall in patients with ovarian carcinoma.

Background. Abdominal cocoon, or sclerosing encapsulating peritonitis, is a rare condition characterized by partial or total encasement of small bowel and mesentery by a thick fibrocollagenous sack that looks like a cocoon. Within the sack, bowel loops are drawn together causing intestinal obstruction.Case presentation. We report on a 57-year-old female patient who developed a very unusual complication of ovarian cancer: abdominal cocoon formation.Conclusions. This report highlights the need for a timely diagnosis of sclerosing encapsulating peritonitis in cancer patients.

Infectious aortitis: a rare cause of chest pain in a child.

Infectious aortitis (IA) is a life-threatening bacterial infection that occurs almost exclusively in adults. Only 1 case of IA had been previously reported in a child. We present a case of IA that occurred in a 6.5-year-old previously healthy girl who was seen in our emergency department because of fever and chest pain of immediate onset. She underwent a thorough evaluation but died of aortic rupture before the correct diagnosis was established. The etiology, clinical presentation, diagnosis, and treatment of IA are discussed.

Chorangiocarcinoma: a case report and review of the literature.

Chorangiocarcinoma is the name designated to a chorangioma with trophoblastic proliferation manifesting increased proliferative activity. Only 3 such cases have been published so far. Other studies challenged this entity by demonstrating that proliferation of the trophoblast around chorangioma is a common phenomenon. We present a case of a unique vascular lesion in a term placenta with a malignant trophoblastic component. Microscopic examination of a well-demarcated placental mass revealed a chorangioma with multiple nodules composed of pleomorphic cells displaying focal multinucleation, large areas of necrosis, and high mitotic activity. Immunohistochemical stains of these cells were strongly positive for pancytokeratin and the beta subunit of human chorionic gonadotropin and focally positive for HSD3B1. There was no invasion of the basement membrane, and no free-floating tumor cells in the intervillous space. No evidence of metastasis was found on follow-up of the mother and newborn. It is concluded that the tumor presented herein, displaying a histologically unequivocal malignant trophoblastic component in a benign chorangioma, is a true chorangiocarcinoma, and should be included within the category of gestational neoplasia as a tumor closely related to choriocarcinoma.

Primary amelanotic melanoma of the vagina.

BACKGROUND: Primary malignant melanoma of the vagina is extremely rare, accounting for 0.3-0.8% of all malignant melanomas. True amelanotic vaginal melanoma showing no melanin on histological examination is exceedingly rare, accounting for only 2% of all vaginal melanomas. CASE REPORT: We describe a 31-year-old female patient who presented with locally advanced amelanotic melanoma of the vagina, with no evidence of metastatic spread on the computerized tomography (CT) scan, but who was subsequently diagnosed as suffering from metastatic disease by positron emission tomography (PET)-CT performed a few weeks following posterior pelvic exenteration. CONCLUSION: Specific immunohistochemical staining with melanoma markers should be performed to confirm or exclude a diagnosis of amelanotic melanoma in all patients presenting with a vaginal mass composed of undifferentiated epithelioid malignant cells. Fluorodeoxyglucose (FDG)-PET-CT should be performed as part of the preoperative evaluation, to identify the presence or absence of metastatic disease in all patients with vaginal melanoma.

Fibroepithelial polyp of the bladder neck in children.

Benign fibroepithelial polyps of the prostatic urethra and bladder are rare congenital lesions most commonly diagnosed in the paediatric population because of diverse urinary symptoms. We report two such cases: one, in a 2-year-old boy who presented with haematuria and voiding difficulties and the other in a 5-year-old boy with acute urinary retention. Imaging and endoscopic studies confirmed the presence of polypoid lesions. Following transurethral resection of these lesions, the diagnosis of a congenital fibroepithelial polyp was rendered by pathologic evaluation. These children are now free of the urinary symptoms and imaging studies are unremarkable 1 and 5 years later. Since these lesions have the potential for recurrence, long-term follow-up is warranted.

Pregnancy-induced vesical decidualized endometriosis simulating a bladder tumor.

Vesical endometriosis accounts for approximately 1% of all discovered cases of endometriosis. We report the first case of a 36-year-old woman with pregnancy-associated decidual changes within bladder endometriosis that are clinically presented as a rapidly growing bladder tumor. Cystoscopy, with subsequent cold cup biopsy and fulguration, revealed a solitary, red-brown, nodular lesion, which turned to be a decidualized endometriosis of the urinary bladder. Delivery and postdelivery follow-up was uneventful and no recurrence was diagnosed.

The "Sentinel Chain": a new concept for prediction of axillary node status in breast cancer patients.

BACKGROUND AND OBJECTIVES: More than half the breast cancer patients with positive sentinel lymph nodes (SLN) do not harbor additional metastases in non-sentinel nodes (NSN). The aim of this study was to identify a subgroup of patients with positive SLNs and negative NSNs, on the basis of tumor involvement patterns in multiple radioactive nodes. METHODS: Between 2000 and 2004, 290 patients with primary invasive breast cancer and clinically negative axillary nodes had a SLN biopsy in our breast unit. Radiotracer was identified intraoperatively in the axilla. All radioactive nodes were removed and radioactivity was measured in each node extracorporeally. Nodes were ranked according to radioactivity, constituting a "Sentinel Chain", and the histopathological status of each node was reported. The different metastatic involvement patterns of the Sentinel Chain were correlated with the metastatic status of the NSNs after axillary dissection. Information was charted in a prospective database. RESULTS: Of 290 patients, 216 (74.5%) had multiple radioactive nodes. Ninety patients (31%) had SLN metastases. Fifty patients had multiple ranked radioactive nodes and positive SLNs. Twenty-five of these patients had a sequential involvement pattern, with tumor-bearing high radioactivity nodes, and uninvolved low-radioactivity nodes. In the 23 of these 25 patients who had axillary dissection, NSN involvement was detected in only one patient (4.3%), whereas in 24 patients with other involvement patterns of the Sentinel Chain, NSN involvement reached 54.2% (p<0.001). CONCLUSION: Tumor-free status of NSN may be predicted using the Sentinel Chain concept in some breast cancer patients with positive SLNs.

Hepatic production of insulin-like growth factors in normal and diseased liver.

BACKGROUND/AIMS: IGF-I levels are reduced in cirrhotic patients. However, it is not known whether this decreased level is the result of reduced hepatic production or modified bioavailability secondary to decreased binding proteins. We determined the hepatic production of IGF-I and IGF-II and their receptors in normal and diseased liver. METHODOLOGY: Twenty-five patients included, 11 controls with normal liver and 14 with either chronic hepatitis or cirrhosis. mRNA for IGF-1, IGF-II and their receptors were measured. Immunohistochemical staining was performed to localize the IGF-producing cells. RESULTS: In 11 normal livers, the IGF-I mRNA levels were 4.95 +/- 1.8; in the 14 diseased livers, the levels were 1.22 +/- 0.69 (p < 0.001). IGF-II mRNA levels were 3.78 +/- 1.45 for the control and 5.11 +/- 2.15 in the diseased livers (NS). IGF-I receptor levels were 1.15 +/- 0.83 in the normal and 0.31 +/- 0.22 in the liver disease group (p < 0.05). There was no statistical difference between the two groups for IGF-II receptor. CONCLUSIONS: Patients with chronic liver disease have a significant reduction in their hepatic production of IGF-I, whereas IGF-II tends to be elevated. Treatment with recombinant IGF-I in patients with metabolic or endocrine complications of cirrhosis might prove useful.

Massive edema of the ovary: a case report and review of the pertinent literature.

BACKGROUND: Massive edema of the ovary is a rare entity affecting mainly young women. It is often misdiagnosed for a malignancy, posing the young patient at risk for over-treatment with resultant loss of hormonal function and fertility. CASE: A 13-year-old premenarchal girl presented with a large solid pelvic mass after recurrent episodes of self-limited abdominal pain. With a working diagnosis of malignant ovarian tumor, an exploratory laparotomy was done in which a twisted ovarian mass was found and excised completely. Pathological examination of the mass revealed massive edema of the ovary with hemorrhagic necrosis. CONCLUSION: After extensive review of the literature, it seems most cases were over-treated, as was ours. This entity should be suspected in women at the fertile age range with solid enlargement of the ovary and definite treatment should be undertaken only after confirmed pathological diagnosis. Conservative treatment is feasible and should be the rule in these cases, where fertility preservation is mandatory.

Menetrier's disease presenting as an acute protein-losing gastroenteropathy in a 27-year-old man with Gaucher disease.

OBJECTIVES: To describe a unique case of a young man with Gaucher disease who was diagnosed with Menetrier's disease. BACKGROUND: After an acute episode of severe gastritis, the patient developed hypoalbuminemia and protein-losing gastroenteropathy, and became unwell. STUDY: Endoscopy revealed an abnormal stomach, with rigid, thickened folds covered with viscous greyish exudates. Superficial biopsies revealed foveolar hyperplasia, acute and severe gastritis with massive inflammatory infiltrate of neutrophils in the lamina propria with pit abscess formation. Tissue cultures for Helicobacter pylori were negative. RESULTS: Snare deep particle biopsy revealed the typical features of Menetrier's disease. Enzyme replacement therapy for Gaucher disease was started. CONCLUSION: This case poses a dilemma because the patient improved spontaneously, and as such is dissimilar to other adults who develop Menetrier's disease because of an infection; it is hoped that he may also not be at risk of the potential malignancies that are correlated with adult Menetrier's disease. The value of enzyme treatment is considered.

Relative expression and localization of the insulin-like growth factor system components in the fetal, child and adult intestine.

BACKGROUND: The insulin-like growth factors (IGFs) are important in the development and maintenance of the gastrointestinal tract. OBJECTIVES: To compare the expression of IGFs and their receptors in the stomach and duodenum of the fetus, the child and the adult. To identify the cells mainly responsible for the production of the members of the IGF system. METHODS: Tissue was obtained from fetus after abortion and from children and adults during diagnostic endoscopy and biopsy. The expression of the IGFs and their receptors was estimated by an RNAse protection assay and sections were stained with antisera to the components of IGF system. RESULTS: The tissues from the stomach and the duodenum expressed the two IGFs and their receptors at all stages of life. The fetal IGF receptors I and II, were approximately ten times higher than in the child and IGF-II was five times higher. Immunohistochemical staining showed the components of the IGF system to be localized to the gastric glands and to the basotlateral border of the gastric epithelial cells. In the duodenum, they were concentrated at the apical portion of the epithelial tissue. They could also be identified in ganglion cells and nerves. CONCLUSIONS: The IGFs and their receptors in the stomach and duodenum are expressed in all age groups and mostly are highest in the fetus. The IGF system proteins were located in the gastric glands and epithelium and in the apical portion of the villous epithelium of the duodenum.

Toll-like receptor 9 signaling mediates the anti-inflammatory effects of probiotics in murine experimental colitis.

BACKGROUND & AIMS: We tested whether the attenuation of experimental colitis by live probiotic bacteria is due to their immunostimulatory DNA, whether toll-like receptor (TLR) signaling is required, and whether nonviable probiotics are effective. METHODS: Methylated and unmethylated genomic DNA isolated from probiotics (VSL-3), DNAse-treated probiotics and Escherichia coli (DH5 alpha) genomic DNA were administered intragastrically (i.g.) or subcutaneously (s.c.) to mice prior to the induction of colitis. Viable or gamma-irradiated probiotics were administered i.g. to wild-type mice and mice deficient in different TLR or in the adaptor protein MyD88, 10 days prior to administration of dextran sodium sulfate (DSS) to their drinking water and for 7 days thereafter. RESULTS: Intragastric and s.c. administration of probiotic and E. coli DNA ameliorated the severity of DSS-induced colitis, whereas methylated probiotic DNA, calf thymus DNA, and DNase-treated probiotics had no effect. The colitis severity was attenuated to the same extent by i.g. delivery of nonviable gamma-irradiated or viable probiotics. Mice deficient in MyD88 did not respond to gamma-irradiated probiotics. The severity of DSS-induced colitis in TLR2 and TLR4 deficient mice was significantly decreased by i.g. administration of gamma-irradiated probiotics, whereas, in TLR9-deficient mice, gamma-irradiated probiotics had no effect. CONCLUSIONS: The protective effects of probiotics are mediated by their own DNA rather than by their metabolites or ability to colonize the colon. TLR9 signaling is essential in mediating the anti-inflammatory effect of probiotics, and live microorganisms are not required to attenuate experimental colitis because nonviable probiotics are equally effective.

Amyloidosis and gastric bleeding in a patient with Gaucher disease.

GOALS: To describe the clinical course of a patient with Gaucher disease who subsequently developed amyloidosis. BACKGROUND: We present a case of a splenectomized patient with Gaucher disease who developed portal hypertension secondary to an enlarged, cirrhotic-like liver, and recurrent life-threatening upper gastrointestinal bleeding. STUDY: Despite repeated diagnostic biopsies, amyloidosis was only ascertained after death. RESULTS: Albeit very rare, there are four other similar cases in the literature, but unlike these previous reports of concurrence of Gaucher disease and amyloidosis, in this patient the gastrointestinal symptoms were life-threatening but there was no evidence of gammopathy or renal disease. Also, this is the first patient who was treated with enzyme replacement therapy for 5 years prior to manifestation of amyloidosis. CONCLUSIONS: Coexistence of apparently unrelated diseases with Gaucher disease demands a greater awareness of abnormalities at the biochemical and/or molecular level to adequately manage patients with Gaucher disease, regardless of concurrent enzyme replacement therapy.

Multiple hypoechoic hepatic lesions in a patient with Gaucher disease.

The most common symptoms of Gaucher disease include hepatosplenomegaly and anemia and thrombocytopenia due to hypersplenism. We describe the case of a patient with Gaucher disease who had cachexia, massive hepatomegaly, and multiple focal hepatic lesions. The clinical and radiologic findings suggested malignancy. A biopsy specimen was taken from a hepatic lesion and revealed infiltration by Gaucher cells. We discuss our findings in light of the putative increased incidence of hematologic malignancies in patients with Gaucher disease.

Post-chemotherapy microscopic residual prostate rhabdomyosarcoma: long-term conservative follow-up.

In spite of advances in the treatment of childhood bladder and prostate rhabdomyosarcoma (RMS), the ability to detect minimal residual disease correlates imperfectly with the ultimate outcome. We report the long-term follow-up of a child with microscopic residual RMS after chemotherapy. The correct interpretation of the histologic findings spared the child unnecessary additional therapy and raises enigmatic questions about the biology of minimal residual disease.