Interactive Pathology Tutorial in Neoplastic Hematology Disorders for Medical Hematology-Oncology Fellows.

Hematology-oncology (HO) fellows receive limited instruction in the process of establishing a diagnosis for hematologic neoplasms, and learning neoplastic hematology often occurs in limited encounters. In the current study, we developed a web-based interactive pathology tutorial in neoplastic hematologic disorders for HO fellows to work up simulated cases and establish the diagnosis. An online system ("Pathology Playground") was utilized to load case materials including microscopic images and ancillary studies. Twelve high-yield simulated cases of common leukemias and lymphoma were included. At the beginning of each case, trainees review the clinical history and slide images, and then, they are given the option to request additional pathology work-up. Based on the results, they can enter their diagnostic impression. If the diagnosis is correct, the user is shown a short educational presentation. If the diagnosis is not correct, the user gets notified by the message "Incorrect." The tutorial was integrated in the educational curriculum of our HO fellowship program, and bimonthly teaching sessions were held to review two cases each time. During the sessions, trainees request ancillary studies to complete the diagnostic work-up using the software and interpret the findings. As the case is being worked up by the trainee, the hematopathologists and HO fellowship program director discuss the findings, the appropriate work-up tools, and the implications on management. All of our six HO fellows attended the sessions, and a survey from the trainees showed high ease of use of the system and they viewed it as a very useful educational tool. A pre-test and post-test were administered for one of the sessions, and the result showed improvement in the average from 62 to 73%. Expanding the use of this online interactive tutorial and incorporating additional cases would enhance its value as a learning resource.

Impact of exercise training and diet therapy on the physical fitness, quality of life, and immune response of people living with HIV/AIDS: a randomized controlled trial.

BACKGROUND: Exercise and dietary nutrition are considered crucial in human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) treatment protocols and people living with HIV/AIDS (PLWHA) rehabilitation care. However, there is no well-studied research evaluating the effects of combined interventions on the fitness and immune systems of PLWHA. Therefore, this study aimed to analyze the effects of exercise and dietary intervention on physical fitness, quality of life and immune response in PLWHA. METHODS: This was an experimental study, with a sample of 25 male PLWHA divided into two groups: the intervention group (IG: 12 participants) and the control group (CG: 13 participants). All participants have not had any exercise habits and nutritional supplements in the past six months. The participants in the IG completed 45 min of exercise (60-80% HRmax) 4 times per week for 4 weeks. The exercise was in the form of brisk walking or running. They were also given a nutritional dietary supplement 3 times a day for 4 weeks. The 13 individuals in the CG continued their normal daily life (physical activity and diet). The following parameters were evaluated before and after the intervention: body composition, physical fitness, immune response, quality of life (QoL), stress, dietary behavior, dietary habits, exercise motivation, and physical self-efficacy. RESULTS: The significant changes were observed in burnout of stress variables and physical efficiency index (PEI) of physical fitness in the IG (p =.023). Moreover, in the saliva samples, sal-T levels significantly increased only after the intervention in the IG (p =.012). Additionally, regarding the analysis of the interaction (group × time), there was a significant improvement in the reaction speed (p =.001) and grip strength (left: p =.002, right: p =.030) and a significant difference in physical satisfaction in QoL (p =.001), stress burnout (p =.043), self-confidence in physical efficacy (p =.045), external display (p =.008), and fulfillment (p =.047) in exercise motivation. Moreover, the significant effect of the intervention on emotional eating in dietary behavior was shown in the comparison of the IG before and after intervention (p =.001) and in the comparison of the IG group with the CG after the experiment (p =.013). However, there was no significant effect of time or interaction between the condition and time on body composition. CONCLUSIONS: In conclusion, exercise training and diet therapy caused changes in physical fitness and Sal-T levels, which had positive effects on the health promotion of PLWHA.

Artificial intelligence for diagnosis and Gleason grading of prostate cancer: the PANDA challenge.

Artificial intelligence (AI) has shown promise for diagnosing prostate cancer in biopsies. However, results have been limited to individual studies, lacking validation in multinational settings. Competitions have been shown to be accelerators for medical imaging innovations, but their impact is hindered by lack of reproducibility and independent validation. With this in mind, we organized the PANDA challenge-the largest histopathology competition to date, joined by 1,290 developers-to catalyze development of reproducible AI algorithms for Gleason grading using 10,616 digitized prostate biopsies. We validated that a diverse set of submitted algorithms reached pathologist-level performance on independent cross-continental cohorts, fully blinded to the algorithm developers. On United States and European external validation sets, the algorithms achieved agreements of 0.862 (quadratically weighted κ, 95% confidence interval (CI), 0.840-0.884) and 0.868 (95% CI, 0.835-0.900) with expert uropathologists. Successful generalization across different patient populations, laboratories and reference standards, achieved by a variety of algorithmic approaches, warrants evaluating AI-based Gleason grading in prospective clinical trials.

Síndrome da fragilidade e riscos para quedas em idosos da comunidade / Frailty syndrome and risks for falling in the elderly community

RESUMO Objetivo Identificar a prevalência da Síndrome da Fragilidade em idosos e suas relações com o risco para quedas. Método Estudo clínico descritivo, transversal e analítico. Cento e um voluntários com mais de 60 anos, foram submetidos à avaliação audiológica, Dynamic Gait Index - Brazilian brief (DGI), Timed Up and Go(TUG) e Escala de Fragilidade de Edmonton (EFE) que determinaram, respectivamente, os limiares auditivos, síndrome da fragilidade, equilíbrio funcional e dinâmico e risco para quedas. Utilizou-se a distribuição percentual simples, o teste de Wilcoxon e de Correlação Bivariada com coeficiente de Pearson para a análise estatística. Foram adotados limites iguais inferiores a 1,0 e 5,0%. Resultados A EFE identificou 22,8% dos voluntários como frágeis e 22,8% como vulneráveis. O DGI e o TUG classificaram 34,6 e 84,1% de riscos para quedas. Ocorreu correlação significativa entre a EFE e o DGI (p<0,01), a EFE e o TUG (p<0,01) e o DGI e TUG (p<0,01). O coeficiente de Pearson entre EFE e o DGI, entre o EFE e o TUG e DGI e TUG foram -0,26, -0,41 e 0,46 respectivamente. Ocorreu associação entre DGI e TUG e idade (p<0,01). Não houve correlação entre a EFE com sexo e idade. Conclusão A fragilidade e pré-fragilidade foi identificada em uma parcela expressiva dos voluntários, sobretudo nos mais longevos. O equilíbrio funcional e o dinâmico se correlacionaram moderamente com fragilidade, o que demonstrou que a Síndrome da fragilidade aumenta o risco para quedas.

ABSTRACT Purpose To identify the prevalence of Frailty Syndrome in the elderly and the relationship with risk of falling. Methods Descriptive, cross-sectional, and analytical clinical study. One hundred and one volunteers over 60 years old were submitted to audiological evaluation, Dynamic Gait Index - Brazilian brief (DGI), Timed Up and Go (TUG) and Edmonton Fragility Scale (EFE) that verified, respectively, hearing thresholds, frailty syndrome, functional and dynamic balance, and risk of falling. The simple percentual distribution, the Wilcoxon´s test and the Bivariate Correlation with Pearson's coefficient were used for statistical analysis. Limits equal to or less than 1.0 and 5.0% were adopted. Results EFE identified 22.8% of volunteers as fragile and 22.8% as vulnerable. DGI and TUG found 34.6% and 84.1% of at risk for falls, respectively. Significant correlations between EFE and DGI (p <0.01), EFE and TUG (p <0.01), and DGI and TUG (p <0.01) were observed. Pearson's coefficient between EFE and DGI, EFE and TUG, and DGI and TUG were -0.26, -0.41, and 0.46, respectively. An association between DGI and TUG and age (p <0.01) was identified. No correlation between EFE and sex or age was found. Conclusion Frailty and pre-frailty were identified in a significant segment of the volunteers, especially in the oldest subjects. Functional and dynamic balance were moderately correlated with frailty, which demonstrated that frailty syndrome increases the risk of falls.

PSYChosomatic Medicine in ONcologIc and Cardiac Disease (PSYCHONIC) Study-A Retrospective and Prospective Observational Research Protocol.

Psychosocial factors play an important role in non-communicable diseases (NCDs). This observational study is primarily aimed at assessing the relationship of psychological characteristics of patients with the outcomes of different NCDs, and to assess short-term psychotherapy (STP) efficacy in the real world. Methods: One hundred and forty patients with recent acute myocardial infarction, Takotsubo syndrome, or non-metastatic breast cancer and a control group of 140 age and sex-matched healthy subjects, will be enrolled. All subjects will be administered psychometric tests, quality of life tests, a specific body perception questionnaire, a dream questionnaire, and a projective test, the Six Drawing test at baseline and follow-up. All subjects with medical conditions will be asked to freely choose between an ontopsychological STP along with standard medical therapy and, whenever indicated, rehabilitation therapy or medical therapy plus rehabilitation alone. The study endpoints will be to evaluate: the relationship of the psychological characteristics of enrolled subjects with the outcomes of different NCDs, predictors of the choice of psychotherapy, and the efficacy of ontopsychological intervention on psychological and medical outcomes. Conclusion: This study will generate data on distinctive psychological characteristics of patients suffering from different CDs and their relationship with medical outcomes, as well as explore the efficacy of ontopsychological STP in these patients in the real world. (Number of registration: NCT03437642).

Intervenção fonoaudiológica na prevenção de quedas no envelhecimento / Speech therapy´s intervention for falling prevention in aging

RESUMO Objetivo Verificar a eficácia de uma intervenção fonoaudiológica para diminuição do risco de quedas. Método Estudo exploratório e de intervenção em que 148 voluntários socialmente ativos, de ambos os sexos, com média de 68,6(±6,5) anos foram avaliados pelo Dynamic Gait Index (DGI)-Brazilian brief e o Timed Up and Go (TUG). Todos os voluntários, com e sem risco para quedas, foram convidados para o programa de intervenção realizado em cinco semanas consecutivas, com duração de 50 minutos baseados nos exercícios de Cawthorne e Cooksey. Destes, 72 com 68,1(±6,5) anos, com e sem riscos para quedas, que participaram de, pelos menos, três encontros foram reavaliados. Foram utilizados o teste de Wilcoxon, Qui-quadrado, Spearman e Matriz de Correlação, com p≤5,0%. Resultados Inicialmente, 37(25,0%) e 106(71,6%) dos voluntários apresentaram, respectivamente, riscos para quedas no DGI-Brazilian brief e no TUG. Verificou-se correlação negativa do DGI-Brazilian brief (p=0,034) e positiva com o TUG (p=0,0071) com a idade e entre os dois instrumentos (p=0,00000016). Na comparação dos dados iniciais e finais de 72 voluntários averiguou-se correlação positiva no DGI-Brazilian brief e TUG no teste do Qui-quadrado e de Wilkoxon. Foi observado melhor desempenho nestes testes após a intervenção. Conclusão A intervenção foi eficaz, uma vez que diminuiu o risco para quedas e melhorou o desempenho da marcha e equilíbrio funcional e dinâmico.

ABSTRACT Purpose to verify the effectiveness of a Speech Therapy intervention program to decrease the risk of falls in elderly people. Methods Exploratory and intervention study where upon 148 volunteers from community, both genders, with an average of 68.6(± 6.5) years were submitted to the Dynamic Gait Index (DGI)- Brazilian brief and the Timed Up and Go (TUG). Volunteers with or without potential risk for falling were invited to participate in a 50-minutes long intervention program carried out for five consecutive weeks, based on Cawthorne and Cooksey exercises. Seventy-two volunteers 68.1(±6.5) years presented in at least three meeting, were reassessed. The results were analyzed by Wilcoxon, Chi-square, Spearman and Correlation Matrix tests, with p≤5.0%. Results Thirty-seven (25.0%) and 106 (71.6%) participants presented, respectively, risks for falls in the DGI-Brazilian brief and TUG. There was negative correlation between the DGI-Brazilian brief (p=0.034) and positive with the TUG (p=0.0071) with age and both instruments (p=0.00000016). Through the comparison the initial and final data a positive correlation was found for the DGI-Brazilian brief and for TUG in the Chi-square test and by Wilcoxon's. Better performance was observed in both tests after the intervention. Conclusion The intervention was effective in decreasing the risk for falls and improving gait performance, and functional and dynamic balance.

Development and Validation of a Deep Learning Algorithm for Gleason Grading of Prostate Cancer From Biopsy Specimens.

Importance: For prostate cancer, Gleason grading of the biopsy specimen plays a pivotal role in determining case management. However, Gleason grading is associated with substantial interobserver variability, resulting in a need for decision support tools to improve the reproducibility of Gleason grading in routine clinical practice. Objective: To evaluate the ability of a deep learning system (DLS) to grade diagnostic prostate biopsy specimens. Design, Setting, and Participants: The DLS was evaluated using 752 deidentified digitized images of formalin-fixed paraffin-embedded prostate needle core biopsy specimens obtained from 3 institutions in the United States, including 1 institution not used for DLS development. To obtain the Gleason grade group (GG), each specimen was first reviewed by 2 expert urologic subspecialists from a multi-institutional panel of 6 individuals (years of experience: mean, 25 years; range, 18-34 years). A third subspecialist reviewed discordant cases to arrive at a majority opinion. To reduce diagnostic uncertainty, all subspecialists had access to an immunohistochemical-stained section and 3 histologic sections for every biopsied specimen. Their review was conducted from December 2018 to June 2019. Main Outcomes and Measures: The frequency of the exact agreement of the DLS with the majority opinion of the subspecialists in categorizing each tumor-containing specimen as 1 of 5 categories: nontumor, GG1, GG2, GG3, or GG4-5. For comparison, the rate of agreement of 19 general pathologists' opinions with the subspecialists' majority opinions was also evaluated. Results: For grading tumor-containing biopsy specimens in the validation set (n = 498), the rate of agreement with subspecialists was significantly higher for the DLS (71.7%; 95% CI, 67.9%-75.3%) than for general pathologists (58.0%; 95% CI, 54.5%-61.4%) (P < .001). In subanalyses of biopsy specimens from an external validation set (n = 322), the Gleason grading performance of the DLS remained similar. For distinguishing nontumor from tumor-containing biopsy specimens (n = 752), the rate of agreement with subspecialists was 94.3% (95% CI, 92.4%-95.9%) for the DLS and similar at 94.7% (95% CI, 92.8%-96.3%) for general pathologists (P = .58). Conclusions and Relevance: In this study, the DLS showed higher proficiency than general pathologists at Gleason grading prostate needle core biopsy specimens and generalized to an independent institution. Future research is necessary to evaluate the potential utility of using the DLS as a decision support tool in clinical workflows and to improve the quality of prostate cancer grading for therapy decisions.

Thrombocytopenia with multiple splenic lesions - histiocytic sarcoma of the spleen without splenomegaly: A case report.

BACKGROUND: Histiocytic sarcoma (HS) of the spleen is reported to be a rare and lethal disease. The clinicopathological features of splenic HS have not been well described. The objective of this paper is to describe the diagnosis and treatment of a case of this rare disease and provide a review of the literature. CASE SUMMARY: In this article, we discuss the case of a 40-year-old Hispanic female who presented with progressive thrombocytopenia and multiple hypoechoic lesions in the spleen without splenomegaly. Positron emission tomography-computed tomography showed increased activity in cervical lymph nodes, as well as multiple bone and splenic lesions with positive uptake. Two bone marrow biopsies and fine-needle aspiration of the cervical lymph node were inconclusive. Laparoscopic splenectomy was performed, and gross examination showed a 110.1 g spleen with multiple rubbery, nodular lesions within the subcapsular sinus and splenic parenchyma. The microscopic findings showed multinodular histiocyte proliferation with atypia and multilobulated nuclei, which were positive for CD163, CD4, and CD68 by immunohistochemical analysis. The final pathologic diagnosis was difficult and was found to be low-grade HS of the spleen, after consultations with two renowned hematopathology institutions. At the patient's five-month follow-up visit, her bone marrow metastasis had progressed. She is waiting to be enrolled in a clinical trial. CONCLUSION: Pathologic diagnosis of splenic HS can be challenging. Low-grade differentiation may be associated with a slow progressive disease.

NUT (Nuclear Protein in Testis) Carcinoma: A Report of Two Cases With Different Histopathologic Features.

NUT (nuclear protein in testis) carcinoma (NC) is an aggressive carcinoma characterized by rearrangements of the NUT gene on chromosome 15q14. Histologically, it is a poorly differentiated carcinoma composed of monotonous, medium-sized, round cells with scant amphophilic or eosinophilic cytoplasm. Foci of abrupt keratinization are often seen. In this report, we compare the morphology of 2 cases of NC. The first case shows characteristic features of uniform, round epithelioid cells admixed with foci of abrupt keratinization. The second case demonstrates nests of epithelioid-polygonal cells that appear to be loosely cribriform within a mucoid stroma. Although considered rare, the actual incidence of NC may be underestimated, as it is likely that many go undiagnosed because the morphology deviates from what is typical. Our report demonstrates that NC should always be considered in any case of an undifferentiated carcinoma and should not be excluded if typical histologic and immunohistochemical features of squamous differentiation are lacking.

NK cell enteropathy: a case report with 10 years of indolent clinical behaviour.

AIMS: Natural killer (NK) cell enteropathy is a recently described clinically indolent condition characterised by atypical NK cell infiltrates in the gastrointestinal mucosa that mimics malignant lymphoma. We report a case that highlights the indolent clinical behaviour by documenting absence of clinical progression over 10 years. METHODS AND RESULTS: We report the case of a 69-year old female who had clinically long-standing abdominal pain and recurrent mucosal ulcerations associated with atypical NK cell infiltrates. The clinical, morphologic and immunophenotypical findings in this case were diagnostic of NK cell enteropathy. Review of the patient's prior biopsies demonstrated that this persisted without clinical progression for 10 years, confirming the clinical indolent course. CONCLUSION: Recognition of NK cell enteropathy is important to avoid over-diagnosing this benign condition as an aggressive lymphoma.

Low Grade Lymphoma Mimicking Metastatic Urothelial Carcinoma: When Do We Need Further Histologic Staging?

Introduction. Patients with urothelial carcinoma of the bladder often present with metastases to regional lymph nodes, with lymphadenopathy on physical examination or radiographic imaging. Case Presentation. We present the case of a 73-year-old Caucasian man with presumed metastatic urothelial carcinoma of the bladder to regional pelvic and retroperitoneal lymph nodes. He underwent systemic chemotherapy for treatment of urothelial carcinoma and was discovered on restaging to have findings suggestive of disease progression but ultimately was found to have a concurrent secondary malignancy. Conclusion. Our case suggests that in patients with urothelial carcinoma, the concurrent presentation of regional lymphadenopathy may not be metastatic urothelial carcinoma and may warrant further investigation.

Eficácia de programa de prevenção de quedas em idosos / Efficacy in Falls Prevention Programs for the Elderly / Efectividad del programa de prevención de caídas en ancianos

Introdução:O envelhecimento dos sistemas envolvidos no equilíbrio corporal pode causar eventos de quedas e piorar a qualidade de vida de idosos. Objetivo: verificar a eficácia de um programa de prevenção a quedas em idosos socialmente ativos. Método: 60 idosos foram submetidos à Avaliação da Mobilidade Orientada pelo Desempenho (Performance Oriented Mobility Assessment ­ POMA) e à Escala de eficácia de quedas ­ Internacional ­ Brasil (Falls Efficacy Scale International ­ FES I-Brasil)l que avaliam, respectivamente, a tendência e o medo de quedas. Aqueles com escores alterados participaram de um programa de intervenção durante oito semanas consecutivas e foram reavaliados. Resultados: Na avaliação do equilíbrio orientado, 70,0% dos idosos apresentaram risco moderado, 5,0 % risco alto e 25,0% risco baixo para queda, ocorrendo associação siginificante e inversamente proporcional com a idade. No término do programa, verificou-se associação entre os resultados iniciais e finais nos testes, visto que ocorreu a redução total do risco alto e elevação do risco baixo para 68,0%. Verificou-se a diminuição com a preocupação com quedas frente à associação significante entre o medo de quedas inicial e a reavaliação. Conclusão: A proposta se mostrou eficaz uma vez que diminuiu o risco de quedas melhorando, consequentemente, o equilíbrio corporal dos voluntários da pesquisa. Promoveu, ainda, a redução com a preocupação de futuras quedas, principalmente nos idosos mais longevos.

Introduction: The aging of systems involved in body balance can cause fall episodes and worsen life quality in the elderly. Objective: To verify the efficacy of a fall prevention program in socially active elderly. Method: 60 elderly were submitted to a Performance Oriented Mobility Assessment and to the Falls Efficacy Scale International FES I-Brasil that evaluate, respectively, the tendency and the fear of falling. Those with altered scores participated in an intervention program during eight consecutive weeks and were reevaluated. Results: In the oriented balance evaluation, 70.0% of the elderly presented moderate risk, 5.0% high risk and 25.0% for low fall risk, resulting in a significant relationship to age. At the end of the program it was confirmed the relationship between initial outcomes and final tests, noticing there was a total reduction of high risk and an increase of low risk to 68.0%. The reduction of falling fear was confirmed in view of the significant relationship between the initial fall fears and the reevaluation. Conclusion: The proposal was effective once the falling fears diminished, improving, consequently, body balance with those who volunteered in the research. It even promoted the reduction of future falling concerns, especially with older seniors.

Introducción: El envejecimiento de los sistemas involucrados en el equilibrio del cuerpo, puede provocar episodios de caídas y empeorar la calidad de vida en los ancianos. Objetivo: Verificar la eficacia de un programa de prevención de caídas en ancianos socialmente activos. Métodos: 60 ancianos fueron sometidos a la Evaluación del Desempeño de la Mobilidad y la Eficacia de Caidas en la Escala Internacional. (Performance Oriented Mobility Assessment e Falls Efficacy Scale International), para evaluar, respectivamente, la tendencia y el miedo a caerse. Aquellas personas con puntuación alterada participaron en un programa de intervención durante ocho semanas consecutivas y fueron reevaluados. Resultados: En la evaluación del equilibrio orientado, el 70,0% de los sujetos presentaron riesgo moderado de caerse, 5,0% alto y de un bajo riesgo de 25,0%. En los extremos del programa, hubo una relación entre los resultados de las pruebas iniciales y finales, así como la reducción total de alto riesgo y un bajo riesgo que alcanzó 68,0%. Se confirmó una disminución del miedo de caerse frente a la relación significativa entre el miedo inicial y la revaluación. Conclusión: La propuesta mostró ser eficaz una vez que disminuyó el riesgo de caídas, mejorando, consecuentemente, el equilibrio corporal de los voluntarios en la investigación.También promovió la reducción con la preocupación de futuras caída, sobre todo en los más ancianos.

Fiber-Optic Confocal Laser Endomicroscopy of Small Renal Masses: Toward Real-Time Optical Diagnostic Biopsy.

PURPOSE: The incidental detection of small renal masses is increasing. However, not all require aggressive treatments as up to 20% are benign and the majority of malignant tumors harbor indolent features. Improved preoperative diagnostics are needed to differentiate tumors requiring aggressive treatment from those more suitable for surveillance. We evaluated and compared confocal laser endomicroscopy with standard histopathology in ex vivo human kidney tumors as proof of principle towards diagnostic optical biopsy. MATERIALS AND METHODS: Patients with a solitary small renal mass scheduled for partial or radical nephrectomy were enrolled in study. Two kidneys were infused with fluorescein via intraoperative intravenous injection and 18 tumors were bathed ex vivo in dilute fluorescein prior to confocal imaging. A 2.6 mm confocal laser endomicroscopy probe was used to image tumors and surrounding parenchyma from external and en face surfaces after specimen bisection. Confocal laser endomicroscopy images were compared to standard hematoxylin and eosin analysis of corresponding areas. RESULTS: Ex vivo confocal laser endomicroscopy imaging revealed normal renal structures that correlated well with histology findings. Tumor tissue was readily distinguishable from normal parenchyma, demonstrating features unique to benign and malignant tumor subtypes. Topical fluorescein administration provided more consistent confocal laser endomicroscopy imaging than the intravenous route. Additionally, en face tumor imaging was superior to external imaging. CONCLUSIONS: We report what is to our knowledge the first feasibility study using confocal laser endomicroscopy to evaluate small renal masses ex vivo and provide a preliminary atlas of images from various renal neoplasms with corresponding histology. These findings serve as an initial and promising step toward real-time diagnostic optical biopsy of small renal masses.

Primary Pulmonary Synovial Sarcoma during Pregnancy: A Diagnostic and Therapeutic Dilemma.

Synovial sarcoma is a rare soft tissue sarcoma that typically arises in the extremities of young adults. We report a case of a 26-year-old pregnant woman with biopsy-proven primary synovial sarcoma of the lung that was treated with chemotherapy with radiographic response. This is only the third documented case of primary pulmonary synovial sarcoma occurring during pregnancy and the first case where chemotherapy was given.

Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia.

PURPOSE: We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS: We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS: We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS: In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

The Role of KRAS Mutational Analysis to Determine the Site of Origin of Metastatic Carcinoma to the Lung: A Case Report.

Metastatic carcinomas involving the lung are a common specimen encountered in surgical pathology. These metastases may have different morphologic, and architectural patterns and may mimic primary pulmonary adenocarcinoma, especially the intra-alveolar (lepidic) pattern of spread which may simulate a primary pulmonary bronchioloalveolar carcinoma (adenocarcinoma in situ). We present the case of a metastatic pancreatic adenocarcinoma that morphologically mimicked bronchioloalveolar carcinoma of the lung in that the tumor had an exclusive intra-alveolar pattern of spread and had an immunophenotype that was noninformative as to the site of origin (cytokeratin 7+, cytokeratin 20-, TTF-1-). In this case, we used KRAS gene mutation analysis to support that the lung carcinoma represented a metastatic pancreatic carcinoma as they both possessed identical codon 12 KRAS mutations. We show that this method may be a useful way to prove site of origin of metastatic carcinoma-particularly if standard morphologic or immunohistochemical analysis is not definitive.