Sister Mary Joseph's Nodule as a Cutaneous Expression of Metastatic Pancreatic Adenocarcinoma.

A Sister Mary Joseph's nodule (SMJN) is characterized by a palpable umbilical nodule and is often a clinical indicator of the metastasis of an advanced abdominal or pelvic malignancy. Observing the cutaneous manifestation of an abdomino-pelvic malignancy is a relatively rare phenomenon due to the appearance of visible changes in the later stages of the disease. With the pancreas being a less common primary tumor site for SMJN, this case report describes a 57-year-old male diagnosed with metastatic pancreatic adenocarcinoma with a SMJN. With a history of alcohol use disorder and alcohol pancreatitis, this patient presented to the Emergency Department with worsening abdominal pain and vomiting. A computed tomography (CT) scan with intravenous (IV) contrast revealed a mass in the patient's rectum and a lobulated mass traversing the anterior abdominal wall, which extended into the umbilicus. A physical exam revealed the presence of an umbilical lesion. A biopsy of the umbilical lesion revealed metastatic adenocarcinoma that favored pancreaticobiliary origin. The results of the umbilical biopsy and CT imaging established the diagnosis of SMJN secondary to pancreatic cancer metastasis to the umbilicus.

Detection of human cytomegalovirus in normal and neoplastic breast epithelium.

INTRODUCTION: Human cytomegalovirus (HCMV) establishes a persistent life-long infection, and can cause severe pathology in the fetus and the immunocompromised host1. Breast milk is the primary route of transmission in humans worldwide, and breast epithelium is thus a likely site of persistent infection and/or reactivation, though this phenomenon has not previously been demonstrated. Increasing evidence indicates HCMV infection can modulate signaling pathways associated with oncogenesis. We hypothesized that persistent HCMV infection occurs in normal adult breast epithelium and that persistent viral expression might be associated with normal and neoplastic ductal epithelium. METHODS: Surgical biopsy specimens of normal breast (n = 38) breast carcinoma (n = 39) and paired normal breast from breast cancer patients (n = 21) were obtained. Specimens were evaluated by immunohistochemistry, in situ hybridization, PCR and DNA sequencing for evidence of HCMV antigens and nucleic acids. RESULTS: We detected HCMV expression specifically in glandular epithelium in 17/27 (63%) of normal adult breast cases evaluated. In contrast, HCMV expression was evident in the neoplastic epithelium of 31/32 (97%) patients with ductal carcinoma in situ (DCIS) and infiltrating ductal carcinoma (IDC) cases evaluated (p = 0.0009). CONCLUSIONS: These findings are the first to demonstrate that persistent HCMV infection occurs in breast epithelium in a significant percentage of normal adult females. HCMV expression was also evident in neoplastic breast epithelium in a high percentage of normal and neoplastic breast tissues obtained from breast cancer patients, raising the possibility that viral infection may be involved in the neoplastic process.

Testicular lesions other than germ cell tumours: feasibility of testis-sparing surgery.

OBJECTIVE: To review all non-germ-cell testicular lesions presenting at our institution and to determine the feasibility of testis-sparing surgery for these patients. PATIENTS AND METHODS: All surgery for testicular masses between June 1995 and June 2005 were reviewed retrospectively. Patients with atrophy, germ cell tumours, infection or torsion were excluded. The study comprised men who had radical orchidectomy for suspected germ-cell tumour but had other final pathology, and those where testis-sparing surgery was attempted for a presumed benign lesion. RESULTS: Thirteen patients with lesions appropriate for the study were identified; all but one had a palpable lesion. The lesions could be categorized as inflammatory (three hyalinized fibrosis, two sarcoidosis, one chronic inflammation), cystic (one epidermoid cyst, one unilocular cyst), benign neoplasms (two adenomatoid tumours, one Leydig cell tumour, one capillary haemangioma) or malignant neoplasms (one lymphoma). Based on the preoperative impression, testis-sparing surgery was attempted in eight of the lesions and was successful in six where it was attempted. In the other five, testis-sparing surgery was not attempted because the preoperative impression was that of a germ cell tumour. Testis-sparing surgery was successful in only six of the 13 patients with these lesions. CONCLUSION: Testis-sparing surgery might be possible if there is significant suspicion of a benign lesion. If frozen-section analysis is equivocal, a radical orchidectomy is required. Testis-sparing surgery was feasible in highly selected cases.

Maximum standard uptake value of mediastinal lymph nodes on integrated FDG-PET-CT predicts pathology in patients with non-small cell lung cancer.

BACKGROUND: Positron emission tomography (PET) scans often help direct biopsies of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), but the maximum standard uptake value (maxSUV) of individual nodes has not been evaluated. METHODS: This is a prospective study of consecutive patients with NSCLC, all of whom underwent integrated fluorodeoxyglucose-positron emission-computed tomography (FDG-PET-CT) and had biopsy or resection of their mediastinal lymph nodes. RESULTS: There were 397 patients. One-hundred and forty-three patients had N2 disease and 1,252 N2 nodes were pathologically examined. The median maxSUV of the nodes that had metastatic disease were the following: for the 2R node, 10.4 (range, 0-18.6); for 4R, 8.6 (range, 0-18.3); for 5, 8.9 (range, 0-26.3); for 6, 7.6 (range, 0-19.6); for 7, 7.7 (range, 0-14); for 8 and 9, 5.4 (range, 0-8.9). The median maxSUV for all of the N2 nodes that were benign was 0 (range, 0-18.8) (p < 0.05 for all stations except for nodes 8 and 9). When a maxSUV of 5.3 is used the accuracy of integrated FDG-PET-CT for each N2 nodal station is maximized and is at least 92% for each. CONCLUSIONS: The maxSUV of individual mediastinal lymph nodes is a predictor of malignancy. There is overlap between false and true positives. Definitive biopsies are required to prove cancer irrespective of the maxSUV value. However, when a maxSUV of 5.3 is used instead of the traditional value of 2.5, the accuracy for FDG-PET-CT for each N2 nodal station increases to at least 92%.

High prevalence of human cytomegalovirus in prostatic intraepithelial neoplasia and prostatic carcinoma.

PURPOSE: Recent epidemiological data indicate that a history of increased exposure to sexually transmitted diseases is associated with an increased risk of prostate cancer. Human cytomegalovirus (HCMV) is a member of the herpesvirus family, is sexually transmitted in adults and can persistently infect prostatic epithelium in non-immunocompromised hosts. Based on increased awareness of the oncogenic potential of this virus, we decided to reexplore the issue of whether HCMV might be involved in prostate cancer pathogenesis. MATERIALS AND METHODS: Paraffin embedded biopsy specimens from 22 randomly selected patients with prostatic intraepithelial neoplasia (PIN) lesions and prostatic carcinoma were analyzed by immunohistochemistry, in situ hybridization, polymerase chain reaction and DNA sequencing to detect HCMV nucleic acids and determine whether HCMV gene products were specifically associated with neoplastic cells. RESULTS: We detected HCMV proteins and/or nucleic acids in all 22 of the 22 preneoplastic and neoplastic prostate lesions evaluated. HCMV proteins were specifically and often highly expressed in basal cell hyperplasia and PIN lesions, and to a lesser degree in carcinoma cells. RESULTS: To our knowledge these data demonstrate for the first time the specific localization of HCMV nucleic acids and proteins in a high percent of PIN and prostate carcinoma lesions, and raise the possibility that HCMV might contribute to the natural history of prostatic cancer.

Infiltration of Helicobacter pylori in the gastric mucosa.

It is our hypothesis that if Helicobacter pylori could be demonstrated conclusively to have transgressed the mucosal surface into the lamina propria, this would help explain how H pylori recruits inflammatory cells. We report our immunohistochemical and electron microscopic findings that demonstrate that H pylori can be detected in the lamina propria of the stomach, offering evidence of its invasive potential. We stained 67 endoscopic gastric biopsy specimens with Warthin-Starry silver and immunoperoxidase stains for H pylori. In addition, transmission electron microscopy was performed on 1 case. The presence of surface H pylori was associated significantly with active (P < .0001) and chronic (P < .0001) inflammation. H pylori could not be identified in the lamina propria using the Warthin-Starry silver stain alone. Immunoreactivity for H pylori in the lamina propria was detected in 20 (30%) of 67 gastric biopsy specimens. Transmission electron microscopy confirmed the immunohistochemical findings. H pylori can infiltrate the lamina propria of the gastric mucosa, thereby proving morphologic evidence of its invasive capability.