Durable partial response to pembrolizumab, lenvatinib, and letrozole in a case of recurrent uterine carcinosarcoma with ESR1 gene amplification.

•ESR1 gene amplification occurs in 7% of uterine carcinosarcoma.•The presence of ESR1 gene amplification in recurrent uterine carcinosarcoma may be targeted by aromatase inhibitors.•ESR1 gene amplification may be identified through immunohistochemical staining for estrogen receptor followed by fluorescence in situ hybridization or tumor targeted gene sequencing.

Identification of Glandular (Acinar)/Tubule Formation in Invasive Carcinoma of the Breast: A Study to Determine Concordance Using the World Health Organization Definition.

CONTEXT.­: The Nottingham Grading System (NGS) developed by Elston and Ellis is used to grade invasive breast cancer (IBC). Glandular (acinar)/tubule formation is a component of NGS. OBJECTIVE.­: To investigate the ability of pathologists to identify individual structures that should be classified as glandular (acinar)/tubule formation. DESIGN.­: A total of 58 hematoxylin-eosin photographic images of IBC with 1 structure circled were classified as tubules (41 cases) or nontubules (17 cases) by Professor Ellis. Images were sent as a PowerPoint (Microsoft) file to breast pathologists, who were provided with the World Health Organization definition of a tubule and asked to determine if a circled structure represented a tubule. RESULTS.­: Among 35 pathologists, the κ statistic for assessing agreement in evaluating the 58 images was 0.324 (95% CI, 0.314-0.335). The median concordance rate between a participating pathologist and Professor Ellis was 94.1% for evaluating 17 nontubule cases and 53.7% for 41 tubule cases. A total of 41% of the tubule cases were classified correctly by less than 50% of pathologists. Structures classified as tubules by Professor Ellis but often not recognized as tubules by pathologists included glands with complex architecture, mucinous carcinoma, and the "inverted tubule" pattern of micropapillary carcinoma. A total of 80% of participants reported that they did not have clarity on what represented a tubule. CONCLUSIONS.­: We identified structures that should be included as tubules but that were not readily identified by pathologists. Greater concordance for identification of tubules might be obtained by providing more detailed images and descriptions of the types of structures included as tubules.

Falla hepatica fulminante: forma atipica de presentacion de insuficiencia cardiaca / Fulminant hepatic failure: atypical form of cardiac failure presentation

La insuficiencia cardíaca puede presentar como manifestación clínica la enfermedad hepática congestiva. En el shock cardiogénico puede aparecer falla hepática aguda por isquemia hepática. Presentamos una paciente que con antecedentes de insuficiencia cardíaca crónica ingresa a nuestro servicio por presentar mal estado general asociado a deterioro progresivo del hepatograma, del tiempo de protrombina y de la función renal. Las serologías virales y los autoanticuerpos fueron negativos. No tenía antecedentes de contacto con hepatotóxicos. En su evolución presentó encefalopatía sin evidencias iniciales de shock. Al cuarto día de internación presenta shock cardiogénico, con manifestaciones del laboratorio compatibles con isquemia y congestión hepáticas. La paciente fallece 24 horas después. La histología demostró cambios compatibles con isquemia hepática. Se han descripto varios casos de hepatopatías crónicas sin causa evidente que resultaron ser manifestaciones secundarias a enfermedades cardiológicas, especialmente pericarditis constrictiva o miocarditis restrictivas. En este caso la paciente presentó falla hepática aguda sin evidencia inicial de mayor deterioro de su cardiopatía previa. Con este caso queremos destacar la importancia de las causas cardiológicas como probables etiologías de hepatopatías sin causa aparente.