Comparison of Tissue Mismatch Repair Protein Deficiency between Early- and Advanced-Stage Endometrial Cancer.

OBJECTIVE: ESGO/ESTRO/ESP guidelines recommend that DNA mismatch repair (MMR) proteins or microsatellite instability tests should be performed in all cases of endometrial cancer. This study aims to clarify the relationship of MMR protein deficiency (dMMR) between early and advanced stages of endometrial cancer. Secondary objective is to identify dMMR affecting factors in endometrial cancer. METHODS: This cross-sectional study was conducted on endometrial cancer patients who underwent surgery at HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, between May 2013 and April 2021. Patients with endometrial cancer whose tumor tissue was available for analysis were identified. The expression of MMR proteins was assessed by immunohistochemistry, including MLH1, MSH2, MSH6, and PMS2. Then, the pathological specimens were reviewed. RESULTS: A total of 207 patients with endometrial cancer were assessed for data analysis. MMR deficiency was observed in 92 cases (44.4%). We found patients with dMMR in both the early and advanced stages of endometrial cancer-68/155 cases (43.9%) and 24/52 cases (46.2%), respectively (P = 0.774).  Statistically significant differences were found only in myometrial invasion (adjusted prevalence odds ratio 2.35, 95% CI 1.21 to 4.57, P = 0.012). CONCLUSION: Our study showed no difference in tissue dMMR between early- and advanced-stage endometrial cancer. The dMMR was not associated with improved outcomes in patients with endometrial cancer. Even though ESGO/ESTRO/ESP guidelines recommend the performance of MMR IHC or MSI tests in all endometrial cancer cases, we can select the appropriate patients those categorized as "advanced stage" or "recurrent"-who may gain the most benefits from the immunotherapy modality of treatment.

Lacrimal sac lymphoma: a case report.

Primary lymphoma originating from the lacrimal drainage system is a rare disease. Such lymphomas are mostly B-cell in origin and present nonspecific symptoms. The treatment of malignant lymphoma of the lacrimal drainage system is slightly different. We present the case of a 71-year-old woman with a painless mass below the medial canthus. Computed tomography (CT) scan of the orbit revealed a mass invading the right lacrimal sac. An incision biopsy was obtained, and the pathologic findings suggested a diagnosis of primary diffuse large B-cell lymphoma of the lacrimal sac. The patient was treated with chemotherapy and intrathecal methotrexate. After completing eight cycles of chemotherapy, the patient was followed up by a CT scan, which revealed nearly total resolution of an ill-defined enhancing mass. At the time of this case report writing, the patient is in complete remission at six months with no other complications.

Intrahepatic Sarcomatous Cholangiocarcinoma: Case Report and Review of the Literature.

The authors report a case of a patient with intrahepatic sarcomatous cholangiocarcinoma. A 45-year-old Thai man presented with a 3-month history of right upper abdominal pain. CT scan revealed hepatomegaly with a 6.5 cm hypovascular soft tissue density mass in the right lobe and showed mild delayed enhancement. On exploratory laparotomy, the tumor adherent to right diaphragm was found. We performed right hepatectomy, partial resection of right diaphragm, and cholecystectomy. The immunohistological results suggested "sarcomatous intrahepatic cholangiocarcinoma." The tumor was recurrent in 5 months after operation and unresectable. Therefore, the treatment in this patient was supportive care. He died 11 months after his initial presentation. The literature reviews showed that intrahepatic sarcomatous cholangiocarcinoma is aggressive malignant with poor prognosis. Early detection, radical resection, and careful follow-up would be the treatment for the favorable prognosis.

Cytomegalovirus Colitis in an End-Stage Renal Disease Patient Presenting with Lower Gastrointestinal Bleeding.

The authors report a case of cytomegalovirus colitis which is one of uncommon causes of lower gastrointestinal bleeding in a patient with end-stage renal disease receiving hemodialysis. Our patient presented with recurrent episodes of massive hematochezia within 2 months. He had the underlying end-stage renal disease, ischemic heart disease, cerebrovascular disease, hypertension and gout. Colonoscopy revealed multiple clean base ulcers at rectum and sigmoid colon. An active bleeding lesion was rectal ulcer with non bleeding visible vessel which was successfully treated with hemoclipping. The diagnosis of cytomegalovirus colitis was confirmed by pathology from colonic tissues which showed compatible patterns of cytopathic change. Human immunodeficiency virus serology was negative. He was treated with with ganciclovir intravenously for 1 week after the pathological finding was reported. To our knowledge, cytomegalovirus infection should be considered as causative pathogen of colitis and colonic ulcers in end-stage renal disease patients.

Clinical course of IgG4-related hypophysitis presenting with focal seizure and relapsing lymphocytic hypophysitis.

BACKGROUND: This is the first case report of focal seizure as a manifestation of Immunoglobulin G4 (IgG4)-related hypophysitis. IgG4-related hypophysitis is a novel category of hypophysitis. The clinical presentations, imaging studies and initial pathology studies can mimic lymphocytic hypophysitis. Here we report additional clinical clues in differentiating these two conditions. CASE PRESENTATION: A 43-year-old Thai male presented with focal seizure, headache, and anterior pituitary hypofunction. His MRI study showed typical hypophysitis lesion with abnormal cerebral parenchymal signal intensity at right frontal lobe. The pituitary biopsied was obtained and the patient was initially diagnosed with lymphocytic hypophysitis. Following initial low-dose steroid therapy, his seizure and headache resolved but his anterior pituitary hormones remained deficient. However, during steroid tapering, he developed new onset acute visual loss. Upon rigorous pathologic review, his diagnosis of IgG4-related hypophysitis with suspected CNS involvement was established. He was subsequently treated with high-dose steroid and rapidly regained his sight. CONCLUSION: This case report highlights the important distinguishing features of IgG4-related hypophysitis from lymphocytic hypophysitis. These include the relapsing clinical course of hypophysitis after steroid decrement and concomitant pachymeningitis particularly in middle-aged to elderly Asian male who presented with hypophysitis. With appropriate dosage of steroids, medical treatment is usually sufficient to control the disease and surgical interventions are usually not required.

The specimen handling of GI mucosal biopsy: a simple and effective quality improvement initiative.

OBJECTIVE: Histologic diagnostic foci on GI mucosal biopsy may be patchy. Therefore, slides with good orientation of mucosal tissue in a perpendicular plane and demonstrating an entire layer of mucosa will increase the diagnostic yield. Department of Pathology Faculty of Medicine Siriraj Hospital has launched the two steps quality improvement program and a parallel research aiming to demonstrate the importance of tissue orientation of GI biopsy. MATERIAL AND METHOD: Step 1: quality improvement was introduced at the pathology laboratory. Embedding technicians were trained to embed tissue in perpendicular plane. Step 2: quality improvement at endoscopy unit, endoscopic nurses were trained to spread the biopsy tissues on a mesh with upward mucosal surface before fixing them into formalin. Three sets of 50 consecutive cases of GI mucosal biopsy were retrieved from before, after step 1, and after step 2. The number of high quality slides, diagnostic discrepancy, and diagnostic confidence of the pathologists were compared between the three sets. RESULTS: High quality slides were significantly increased from 23 (46%) before quality improvement to 30 (60%) after step 1, and 37 (74%) after step 2 (p-value = 0.017). Diagnostic discrepancy was decreased while diagnostic confidence was increased after quality improvement. CONCLUSION: The quality of GI mucosal biopsy slides were significantly improved after a simple and feasible program indicating that both educating and training of medical personnel for tissue procurement and tissue processing are crucial. Higher quality of slide can lead to more accurate diagnosis and fewer laboratory resources used.