Chylous Ascites, Unusual Association with Ductal Pancreatic Adenocarcinoma with Plasmacytoid Morphology: A Case Report and Literature Review.

Chylous ascites represents a relatively uncommon condition. In this paper, we present a case of chyloperitoneum associated with pancreatic ductal adenocarcinoma (PDAC) and a review of literature regarding chylous ascites. A 76-year-old male patient was admitted in emergency department with acute abdomen. A pancreatic cancer was suspected. Subtotal spleno-pancreatectomy, for a nodular mass infiltrating the mild and distal portion of the pancreas, was necessary. During surgical intervention in the peritoneal cavity, a moderate quantity of whitish and thick consistency fluid with milk-like appearance was observed to be accumulated. After examination of the fluid, chyloperitoneum was diagnosed. The histologic examination showed a PDAC, with multiple emboli in lymph vessels, with tumor cells with plasmacytoid morphology, diagnosed as lymphangiosis carcinomatosa. The patient died at 3 weeks after surgical intervention. In patients with pancreatic cancer and chylous ascites, suspicion of tumor-related blockage of the lymphatic flow should be suspected. Prognosis of PDAC should be evaluated not only based on the number of lymph node metastases, but also considering the number of lymph vessels with tumor emboli and the architecture of tumor cells. This is the first reported case of a PDAC with plasmacytoid morphology of lymphangiosis carcinomatosa.

Primary rhabdomyosarcoma: An extremely rare and aggressive variant of male breast cancer.

BACKGROUND: Rhabdomyosarcoma (RMS) of the breast, a mesenchymal neoplasm with skeletal muscle differentiation, is an extremely rare tumour in males, with less than 30 cases published in English-language literature. We report on the first case of a male breast RMS, with an unusual ectomesenchymal/neuroectodermal component. CASE SUMMARY: A 55-year-old, previously healthy male, underwent a radical left mastectomy for an ulcerated tumour mass, occupying the breast and left anterior thoracic wall. The biopsy specimen indicated the presence of a tumour with neural origins, namely a peripheral neuroectodermal tumour (PNET). The surgical specimens identified two components. The rhabdomyosarcomatous component (over 70%) was represented by large pleomorphic cells with positivity for desmin, sarcomeric actin and myogenin. The PNET-like ectomesenchymal component, which was admixed with the RMS cells, and was also revealed during the preoperative biopsy, consisted of small cells which expressed neurofilament, neuron specific enolase and CD99. The microscopic examination, along with the immunohistochemical profile, allowed the diagnosis of an RMS, with unusual ectomesenchymal differentiation. The patient refused the postoperative oncologic therapy and died three months after surgery. CONCLUSION: In patients with RMS of the breast, the PNET-like ectomesenchymal component increases the diagnosis difficulty, especially in biopsy specimens. This differentiation can be immunohistochemically proven and might highlight the possible development of high-grade sarcoma of the breast from remnants of the embryological ectodermal layer.

Cystic low-grade collecting duct renal carcinoma with liver compression - A challenging diagnosis and therapy: A case report.

BACKGROUND: A collecting duct carcinoma is a very rare, malignant renal epithelial tumor. Distant metastases are present in one third of cases at the time of diagnosis. It is known to have a poor prognosis. CASE SUMMARY: A 42-year-old male was sent to our surgery clinic for removal of a 119.2 mm × 108.3 mm encapsulated cystic mass, which was localized in the 8th segment of the right liver lobe. The lesion was first identified on ultrasonography. A computed tomography scan confirmed the presence of a Bosniak type III cystic lesion, which affected the liver and convexity of the right kidney. Surgical intervention involved a right nephrectomy, with removal of the cystic mass. The patient was mobilized on the first postoperative day and was discharged after 7 d. The histological and immunohistochemical examination revealed a low-grade collecting duct renal carcinoma, which is a rare variant of papillary carcinoma, with low malignant potential. The patient did not receive chemotherapy and after 21 mo of follow-up, a radiological examination and laboratory analyses showed normal aspects. No relapse or other complications were reported. CONCLUSION: To manage renal tumors properly, a correct histopathological diagnosis is crucial, as is early diagnosis and correct surgical treatment.

Interaction of arylsulfatases A and B with maspin: A possible explanation for dysregulation of tumor cell metabolism and invasive potential of colorectal cancer.

BACKGROUND: Although it has been shown that arylsulfatases are lost in colorectal cancer (CRC) cell lines, their exact role in the carcinogenesis and behavior of this cancer was not elucidated. No data about the correlation between serum and immunohistochemical (IHC) level of arylsulfatases (ARSA, ARSB) in patients with CRC were published yet. AIM: To evaluate the possible prognostic value of ARSA and/or ARSB in CRC, at circulating and protein levels. METHODS: The present study included 45 consecutive patients who were prospectively diagnosed with CRC. For IHC stains (protein expression) ARSA, ARSB and maspin expression were quantified. For these markers, cytoplasmic expression was taken into account. For gene expression study, circulating mRNA was isolated from all patients, before surgery. A group of 45 healthy patients without inflammatory or tumor pathologies was used as control group. Reverse transcription and Taqman Gene Expression Array were used for ARSB gene expression. RESULTS: The preoperative circulating RNA level of the ARSB gene was significantly decreased in patients with CRC (RQ < 1), compared with the control group (RQ > 1). A more significant decrease (RQ < 0.5) occurred in ulcero-infiltrative maspin-positive adenocarcinomas, with a higher degree of tumor budding, diagnosed in locally advanced stages (pT3/4). ARSA/maspin immunopositivity indicated a higher risk for lymph node metastasis, while triple positivity for maspin/ARSA/ARSB and ARSB gene expression level < 0.5 were indicators of CRC aggressive behavior, independent of lymph node status. CONCLUSION: The significant independent negative prognostic factors of CRC are the ulcero-infiltrative aspect, high budding degree, triple positivity for maspin, ARSA and ARSB, and low ARSB gene expression.

Laparoscopic gastric plication for the treatment of morbid obesity by using real-time imaging of the stomach pouch.

BACKGROUND: Bariatric surgery is a continuously evolving field. Laparoscopic greater curvature plication is a new investigational procedure used to treat patients with morbid obesity. The demand for this operation from the obese patients is also rising. The problem is that during gastric plication the exact dimensions and volume of the pouch are not known so frequently it is too large or too tight thus compromising the results. The aim of the study was to identify the parameters that can improve the outcomes after this procedure. METHODS: We performed laparoscopic greater curvature plication in 75 obese patients during 2013-2015. The last 25 patients underwent surgery with a modified surgical technique using real-time imaging of the stomach pouch. The inclusion criteria for the 25 patients enrolled in this case series were the usual, body mass index higher than 40 or higher than 35 but with comorbidities along with the option of the patients for laparoscopic gastric plication. The operative technique was enhanced by using a computerized device and special intragastric catheters during the procedure that permitted real-time imaging of the gastric geometry. With this new operative approach we obtained the desired volume of the gastric remnant and we avoided strictures, obstruction or irregular shape of the pouch, problems that otherwise could have compromised the outcomes. RESULTS: We found an increased excess weight loss of 55% at six month and 65% over a 12-month follow-up period with alleviation of comorbidities. There were no major complications (gastric outlet obstructions or leaks) and less minor complications (nausea and vomiting) than in the patients operated with classic gastric plication procedure. CONCLUSIONS: This study shows that in case of laparoscopic gastric plication the use of our modified operative technique has better outcomes than in the classical setting. This is a new operative approach in the bariatric literature which can lead to greater acceptance of gastric plication among bariatric surgeons. The target population is represented by the obese patients who want to obtain similar results to those after gastric bypass and sleeve gastrectomy but are concerned about removing a part of their stomach and the postoperative complications that may occur, especially leaks and nutritional complications. KEY WORDS: Gastric geometry, Laparoscopic gastric plication, Morbid obesity, Real-time imaging.

Paradoxical expression pattern of the epithelial mesenchymal transition-related biomarkers CD44, SLUG, N-cadherin and VSIG1/Glycoprotein A34 in gastrointestinal stromal tumors.

AIM: To evaluate the immunohistochemical (IHC) expression of five biomarkers, commonly involved in epithelial mesenchymal/mesenchymal epithelial transition (EMT/MET), in gastrointestinal stromal tumors (GISTs). METHODS: In 80 consecutive GISTs the IHC examinations were performed using the EMT-related antibodies E-cadherin, N-cadherin, SLUG, V-set and immunoglobulin domain containing 1 (VSIG1) and CD44. RESULTS: The positivity rate was 88.75% for SLUG, 83.75% for VSIG1, 36.25% for CD44 and 10% for N-cadherin. No correlation was noted between the examined markers and clinicopathological parameters. Nuclear positivity for SLUG and VSIG1 was observed in all cases with distant metastasis. The extra-gastrointestinal stromal tumors (e-GISTs) expressed nuclear positivity for VSIG1 and SLUG, with infrequent positivity for N-cadherin and CD44. The low overall survival was mainly dependent on VSIG1 negativity (P = 0.01) and nuclear positivity for SLUG and/or CD44. CONCLUSION: GIST aggressivity may be induced by nuclear up-regulation of SLUG and loss or cytoplasm-to-nuclear translocation of VSIG1. SLUG and VSIG1 may act as activated nuclear transcription factors. The CD44, but not N-cadherin, might also have an independent prognostic value in these tumors. The role of the EMT/MET-related transcription factors in the evolution of GISTs, should be revisited with a larger dataset. This is the first study exploring the IHC pattern of VSIG1 in GISTs.

Gastric Burkitt lymphoma: A case report and literature review.

RATIONALE: Burkitt lymphoma (BL) is an endemic tumor in Africa but rare sporadic cases are diagnosed in Europe. PATIENT CONCERNS: A 60-year-old woman was hospitalized with fulminant hematemesis and a history of recurring melena. DIAGNOSES: The upper gastrointestinal endoscopy revealed a tumor of the antrum. INTERVENTIONS: Emergency gastrectomy was performed. OUTCOMES: Gross findings revealed an ulcerated tumor with elevated margins and several perigastric and extragastric lymph nodes. Histological examination showed proliferation of atypical lymphocytes with a Ki67 index of 100%; they were marked by CD20, CD79a, bcl-6, and CD10 and were negative for CD3, CD5, CD23, TdT, bcl-2, and Cyclin D1. The tumor cells crossed the serosa and presented invasion of the lymph nodes. The patient died 10 days after surgery due to bronchopneumonia and acute renal failure. LESSONS: In our department, only one gastric BL was diagnosed in a 61 consecutive lymphomas of the gastrointestinal tract (1.64%). Less than 200 reports about gastric-BL have been published to date. This case highlights the difficulty of diagnosis of rare variants of aggressive gastric lymphomas in medium-income countries without screening programmes.

First Case Report of a Sporadic Adrenocortical Carcinoma With Gastric Metastasis and a Synchronous Gastrointestinal Stromal Tumor of the Stomach.

Adrenocortical carcinoma is a rare tumor with high aggresivity that can associate systemic metastases. A 71-year-old man was hospitalized for gastric cancer. The abdominal computed tomography also revealed a tumor above the right kidney. Total gastrectomy and right adrenalectomy were performed. The encapsulated tumor of the adrenal gland weighed 560 grams and presented diffuse tumor architecture under microscope, with capsular, sinusoidal, and vascular invasion. The large tumor cells had a polygonal shape, with slight basophilic, eosinophilic, or vacuolated cytoplasm, pleomorphic nuclei, and a high mitotic rate. In the stomach, the protruded tumor was covered by normal mucosa; under microscope, the tumor cells were observed only in the submucosal layer. In primary adrenal tumor and gastric metastasis the tumor cells were marked by vimentin, inhibin, synaptophysin, neuron-specific enolase, and calretinin. Based on these criteria, the diagnosis of adrenocortical carcinoma (ACC) with gastric metastasis and no lymph node metastases was established. A synchronous 10 × 10-mm-sized gastrointestinal stromal tumor (GIST) of the stomach, without mitoses, was also identified. So far, as we know, this is the 15th case of ever reported synchronous/metachronous sporadic ACCs; the ACC-related gastric metastases either synchronous ACC and GIST, has not been reported in the literature previously.