Not Your Everyday Duodenal Ulcer: Massive Gastrointestinal Bleed Secondary to Extramedullary Plasma Cell Myeloma.

The differential for gastrointestinal (GI) bleeding is broad, ranging from peptic ulcers and Helicobacter pylori infection to variceal hemorrhage and neoplasms. The rarer causes of GI bleeds are frequently overlooked and as such can ultimately be more dangerous. Extramedullary multiple myeloma, an atypical plasma cell dyscrasia arising outside of the bone marrow, involves the GI tract in <5% of cases and often presents with nonspecific symptoms. We describe a rare case of such GI involvement of a plasma cell tumor, with subsequent transmural duodenal ulceration involving the gastroduodenal artery, ultimately resulting in a fatal GI bleed.

Incidental Pathologic Findings in Young Men with Gynecomastia.

BACKGROUND: Pathologic examination of young adult gynecomastia tissue is controversial given the low incidence of breast carcinoma in this population. The authors examined the pathologic findings in a large cohort of adolescents with gynecomastia to evaluate the need for routine tissue analysis in this population. METHODS: A retrospective review of men who underwent unilateral or bilateral mastectomy for gynecomastia at a single institution between February of 2007 and November of 2019 identified demographics, medical history, surgical characteristics, and pathologic findings. Descriptive statistics were performed. RESULTS: A total of 268 male patients were included. Mean age was 16.6 years. Mean body mass index was 27.8 kg/m2, and 42.5 percent of the sample was obese. The majority (83.2 percent) underwent bilateral subcutaneous mastectomy. There were no abnormal histopathologic findings in 95.1 percent. Among the 13 patients with abnormalities, eight (3 percent) had nonproliferative changes, two (0.8 percent) had proliferative changes without atypia, two (0.8 percent) had atypical ductal hyperplasia, and one (0.4 percent) had both bilateral atypical ductal hyperplasia and unilateral ductal carcinoma in situ. No patients had invasive carcinoma. The three patients with atypical ductal hyperplasia and/or ductal carcinoma in situ were obese but had no other breast cancer or gynecomastia risk factors. CONCLUSIONS: Findings conferring potentially increased risk of developing breast cancer were identified in three male adolescents (1.2 percent). Incidence of these findings is similar between male adolescents and similarly aged female adolescents undergoing breast reduction surgery. Although worrisome pathology results are rare, too little is known about the natural history of atypical proliferation and ductal carcinoma in situ in young men to recommend against routine analysis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Incidental Pathologic Findings in Young Adult Reduction Mammaplasty.

BACKGROUND: This study aims to characterize incidental microscopic findings in this population to determine whether there is a benefit to routine histopathologic examination of breast tissue in young women. METHODS: A retrospective review of young women who underwent reduction mammaplasty between June of 2010 and May of 2018 was performed at a single institution to identify demographics, age at the time of surgery, breast cancer risk factors, and pathologic data. Histologic reevaluation was performed when diagnostic clarification was needed. Descriptive, univariate, and multivariable statistical analyses were performed. RESULTS: A total of 798 young women were included. At the time of surgery, the mean patient age was 17.5 ± 2.0 years, the mean body mass index was 28.7 ± 5.7 kg/m2, and the mean resection weight was 685 ± 339 g/breast. The majority of patients were reported to have pathologically normal tissue [n = 704 (88.2 percent)]. Of the 94 patients (11.8 percent) with abnormal findings, 21 (2.6 percent) had benign nonproliferative changes, 64 (8.0 percent) had proliferative lesions without atypia, nine (1.1 percent) had proliferative lesions with atypia, and a single patient (0.1 percent) had a borderline phyllodes tumor. Univariate and multivariate analyses revealed that age at menarche younger than 12 years was significantly associated with increased incidence of proliferative lesions. CONCLUSIONS: Over 10 percent of young women with reduction mammaplasty have histopathologic findings. Although this study demonstrated an overall low incidence of atypical lesions, because early identification offers potential for improved surveillance, the authors continue to advocate for routine pathologic evaluation, particularly for women with early menarche. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Immunophenotypic dysplasia and aberrant T-cell antigen expression in acute myeloid leukaemia with complex karyotype and TP53 mutations.

AIMS: Cytogenetic and molecular aberrations are the strongest factors in determining outcome in acute myeloid leukaemia (AML). AML with complex karyotype confers a particularly poor prognosis and is associated with morphologic dysplasia. Flow cytometric immunophenotyping (FCI) has been investigated in defining dysplasia within myelodysplastic syndromes, but little is known about immunophenotypic dysplasia in AML and correlation with genetic abnormalities. This study aimed to explore differences in antigen expression by FCI in AML with complex karyotype (AML-CK) and AML with complex karyotype and TP53 mutations (AML-TP53) compared with AML with normal karyotype (AML-NK). METHODS: Twenty-five cases of AML-CK, 13 of which had abnormalities of TP53, were compared with 83 cases of AML-NK using FCI. RESULTS: Our findings demonstrated brighter expression of CD34 with decreased CD33 and aberrant expression of CD5 in blasts of AML-CK, while AML-TP53 blasts exhibited brighter expression of CD13. Granulocytes in AML-CK exhibited brighter expression of CD5, CD7, CD10 and CD14, with brighter CD3 also seen in AML-TP53. CONCLUSIONS: Our results suggest that immunophenotypic dysplasia correlates with complex karyotype and TP53 mutation, including increased expression of T-cell antigens.

Down-regulation of soluble fms-like tyrosine kinase 1 expression in invasive placentation.

PURPOSE: To confirm reduced expression of soluble fms-like tyrosine kinase 1 (sFlt-1) in accreta/increta. METHODS: Formalin-fixed tissue sections from 11 peripartum hysterectomies with invasive placentation and 5 controls were stained for sFlt-1. Stain intensity was scored in selected 100× microscopic fields. We compared sFlt-1 expression in invasive areas among cases, non-invasive areas among cases and areas from control placentas. RESULTS: Chorionic villi displayed significantly decreased sFlt-1 expression in invasive areas of cases compared to control placentas (p = 0.003), as well as in non-invasive areas of cases compared to control placentas (p = 0.01). There was no difference in sFlt-1 expression between invasive and non-invasive areas among cases. CONCLUSIONS: Expression of sFlt-1 is diminished in villous trophoblasts from patients with placenta increta or percreta. Local depth of invasion was not associated with sFlt-1 expression, suggesting a more global abnormality across the implantation site rather than localized to areas of histologic invasion.