An unusual cause of shoulder pain: osteochondroma of ventral scapula (a case report).

Osteochondromas mainly affect the metaphysis of long bones such as femur, humerus, and tibia. It is unusual in flat bones such as scapula. Osteochondroma of ventral surface of scapula is one of the rare cause of shoulder pain and difficult to diagnose in first place. We report the case of an 18-year old girl, presenting progressive right shoulder pain for two years. Physical examination showed an imbalance of the shoulders, a winging of the right scapula, and a snapping of the shoulder on mobilization. Radiographic evaluation showed a pedunculated bony structure extruding from the scapula. Computed tomography (CT) scanner and magnetic resonance imaging (MRI) revealed a bony exostosis along the medial border on the ventral surface of the right scapula. The patient had an excision of the exostosis. Histologic examination confirmed that the specimen was an osteochondroma with no signs of malignant transformation. The shoulder was immobilized for two weeks. The patient has regained full function of her shoulder, six weeks postoperatively.

OBJECTIVE MULTI-STATION CLINICAL EVALUATION IN PATHOLOGICAL ANATOMY. CRITICAL ANALYSIS AND PERCEPTION.

BACKGROUND: Multi-station objective clinical evaluation (MSOCE) is an equitable and genuine formative and normative assessment tool that is deemed relevant to its effectiveness, reliability and validity in clinical evaluation. However, no experience with its application in pathological anatomy has been published. AIM: To carry out a critical analysis and a perceptual study of the MSOCE in pathological anatomy in medical students. METHODS: This was a cross-sectional, multicenter prospective study in which we developed and tested a MSOCE on 32 medical students of the 1st year of the second cycle of medical studies. Docimological analysis of the 12 stations and the 28 questions of the different stations was done by the file "AnItem.xls". RESULTS: The mean total score obtained at the MSOCE was 36.2/50 (range : 29 to 41). The majority of stations were of acceptable difficulty (92%) and of poor discrimination (92%). The majority of questions were easy (57%) with poor discrimination (75% of the total questions). One question on 28 was "ideal", 4%. The MSOCE had a large heterogeneity (average Cronbach alpha of 0.29), and discriminated well between the average students (platykurtic, left-spread, negatively asymmetric distribution curve). The perception analysis showed that 27 students (84%) were satisfied with the OMSCE and thought that it was close to the reality of the clinical training. CONCLUSION: The OMSCE tested was easy and discriminated mostly between average students. It was well perceived by the students and close to the reality of the clinical training. Ongoing analysis will further improve the quality of MSOCE.

An Immunoscore System Based On CD3+ And CD8+ Infiltrating Lymphocytes Densities To Predict The Outcome Of Patients With Colorectal Adenocarcinoma.

PURPOSE: The aim of this study was to evaluate the Immunoscore (IS) methodology as a prognostic marker of colorectal adenocarcinoma in Tunisian population. Tumor blocks were retrospectively collected from 106 patients with sporadic colorectal cancer. METHODS: Immunohistochemical staining and images analysis software were used to quantify the density of CD3+ and CD8+ tumor-infiltrating lymphocytes in the center of the tumor and invasive margin. RESULTS: The density of CD3+ and CD8+ was significantly associated with 5-year overall survival (P=0.001 and P=0.00098, respectively) and 5-year disease-free survival (P=0.0006 and P=0.0056, respectively). The earlier stage and the absence of vascular emboli showed a significant association with IS analysis. Cox multivariate regression analysis revealed that Immunoscore (from I0 to I4) was more significantly correlated with overall survival (P=0.00011) and disease-free survival (P=0.0008) than Tumor-Node-Metastasis (TNM) staging (P=0.057 and P=0.039, respectively). Patients with low IS were associated with inferior disease-free survival and overall survival, contrary to patients with high IS. CONCLUSION: This is the first study which evaluated the prognostic value of IS methodology in colorectal cancer in African and Arabic population. The IS methodology carries out in this study allows to estimate the risk of relapse in patients with colorectal cancer. Overall, our results support the implementation of the consensus Immunoscore as a new component for the classification of cancer, designated TNM-Immune.

Primary signet-ring cell carcinoma of the urinary bladder: A report of two cases.

INTRODUCTION: Primitive bladder adenocarcinomas account for about 2% of urinary bladder tumors. Primary signet-ring cell carcinoma is a rare variant of bladder adenocarcinoma. It is characterized by a late diagnosis and a poor prognosis. The aim of the study was to discuss the clinical, pathological and evolutive features of this rare entity. Clinical Observations: We report two patients a 53-year-old man and a 70-year-old woman. The main reason for consultation was right back pain, mictional burn and total hematuria. Abdominal ultrasound showed a thickened bladder wall measuring 8 mm in thickness. Ultrasonography revealed a budding intravesical lesion with a calculation of the lower left ureter measuring 5mm of great diameter. Cystoscopy showed an atypical tissular lesion frayed whitish and solid in the cut. Pelvic MRI performed in women showed a cervix ill-limited tissue mass invading the anterior vaginal wall. A transurethral resection of the bladder tumor was performed in one case and a biopsy of the bladder lesion for the other case. The immunohistochemical study showed positive tumoral cells to CK7. The diagnosis of signet ring cell adenocarcinoma of the bladder was established. CONCLUSION: Signet ring cell adenocarcinoma of the bladder is an aggressive tumor of rapid development and poor prognosis. Its management is multidisciplinary and involves surgery. Adjuvant chemotherapy should be discussed even if consensual attitude has not been set.

Accuracy of fine-needle aspiration cytology of head and neck masses.

BACKGROUND: Head and neck masses are a common presentation in daily practice and can be challenging to both clinicians and cytopathologists. Fine needle aspiration cytology (FNAC) is a widely used method for the diagnosis of head and neck masses. The aim of the study was to assess our institutional experience of the accuracy of FNAC in the diagnosis of head and neck masses. METHODS: A total of 1262 FNACs were conducted from January 2013 to December 2016 and subdivided into benign and malignant categories. The thyroid and salivary glands FNACs were classified according to the Bethesda System for Reporting Thyroid cytopathology and to the Milan System for Reporting Salivary Gland Cytopathology respectively. The measures of diagnostic accuracy of FNAC were determined taking histology as a gold standard. RESULTS: A total of 7 false negative (FN) and 6 false positive (FP) FNACs were identified. Overall sensitivity and specificity of FNAC for a malignant diagnosis were 92% and 94.4%, respectively. Accuracy of FNACs of head and neck masses was 93.5% for all sites. The salivary gland group had the highest rate of FN (2.8%). All FP were reported in the thyroid group. These cases were cytologically classified suspicious for malignancy (n = 3) and papillary carcinoma (n = 3) and proved to be lymphocytic thyroiditis on final histology. Among the most common locations, cytology of lymph nodes provided the best sensitivity (98.2%). Salivary glands as well as lymph nodes had the best specificity (100%). CONCLUSION: FNAC of head and neck masses has a high accuracy allowing a correct therapeutic management. However, this accuracy depends on the anatomic location of the mass.

Prognostic values of detecting MSI phenotypes in colorectal carcinoma by immunohistochemical method compared to molecular investigation.

BACKGROUND: The identification essentially of hMSH2 and/or hMLH1 alterations has clinical implications for recognition and prognosis of MSI phenotypes cases. In this study, we tried to identify instability by immunohistochemical expression pattern analysis, compared the results with molecular investigation and shown their usefulness as predictive factors for determination of Microsatellite Instability in patients with colorectal carcinomas in routinely. METHODS: Forty seven colorectal cancers and their adjacent colonic mucosa were selected retrospectively for this study. We first studied the potential value of molecular investigation to identify microsatellite instability in which a NCI panel (or Bethesda panel) of five microsatellite was analyzed (Bat-25, Bat-26, D2S123, D5S346 and D17S250). Secondary, we evaluated the immunohistochemical assessment of hMLH1, hMSH2, hMSH6 and PMS2 proteins in tumor and adjacent normal colorectal mucosa tissues. RESULTS: Fourteen cases were scored as MSI and the remaining MSS. Moreover, we found loss of expression for hMLH1, hMSH2, hMSH6 and PMS2 respectively in 9, 10, 6 and 9 of cases. The MSI patients were less than 45 years old, have right localization and mucinous histological type. We found an association between MSH2, age (P=0.03) and staging (P=0.02). MLH1 is associated only with age (P=0.02) while MSH6 with tumor grade (P=0.01). CONCLUSIONS: We found an association between MSI molecular investigation and MMR immunohistochemical expression which may allow one to specifically identify MSI phenotype of patients with colorectal carcinomas. Furthermore, immunohistochemical analysis of MMR protein can be used in routinely for detection of microsatellite instability without occurs to molecular investigation.

[Immunohistochemical analysis of mismatch repair proteins in colorectal adenomas]. / Analyse immunohistochimique des protéins de réparation de I'ADN dans les adénomes colorectaux.

BACKGROUND: The deficiency of mismatch repair system is one of the main pathways in colorectal cancer. This system consists mainly of four proteins: MLH1, MSH2, MSH6 and PMS2. Colorectal cancer develops in the majority of cases from precancerous lesions called adenomas. Only few studies have reported on the deficiencies of these proteins in adenomas. AIM: In this study we used immunohistochemistry staining in colorectal adenomas to assay functional status of MLH1, MSH2, MSH6, and PMS2 proteins. METHODS: 102 adenomas from 93 patients were collected in our institution during six years (2007-2012). The immunohistochemical technique was performed with 4 antibodies: MLH1, MSH2, MSH6 and PMS2. The loss of expression was retained if adenomatous cells were not stained with positive internal control. Staining was considered as abnormal if nucleus of adenomatous cells showed low nuclear staining and / or heterogeneous one, while positive internal control had normal staining. RESULTS: Loss of expression of MSH2 and MSH6 in adenomatous cells was found in only 1 case which was a tubular adenoma 3mm high-grade dysplasia. Abnormal staining of the adenomatous cells was noted in 23 cases (22.5%) for MSH2 and in 8 cases (7.8%) for MSH6. No cases showed loss of expression of MLH1 and PMS2. Abnormal expression of MSH2 and MSH6 was not correlated with sex of patients, the location of the adenoma, its grade of dysplasia and its histological type. CONCLUSIONS: Loss of Mismatch repair proteins expression is a rare event in adenomas. However, the abnormal expression levels are higher in our study compared to those reported in the literature. This could reflect a higher rate of microsatellite instability in our patients. Multicenter and larger studies with molecular biology techniques are needed.

Parent-adolescent relationships and social adjustment: the case of a collectivistic culture.

This study examined how parent-adolescent relationships are related to adolescent loneliness, interpersonal difficulties and school adjustment among Israeli Arabs. Two hundred and thirty-one 11th graders (103 boys and 128 girls) and their homeroom teachers participated. Four groups of adolescents were identified according to parenting practice profiles: Adolescents in the harsh parenting group reported the highest levels of loneliness, those in the distant and mixed groups reported midway levels of loneliness, and those in the warm group showed the lowest degree of loneliness and the lowest levels of interpersonal problems. Overall, boys reported higher levels of peer-related loneliness and lower levels of affinity for aloneness than girls. Gender interacted significantly with parenting group, with girls in the harsh parenting group exhibiting greater parent-related loneliness and affinity for loneliness, while boys exhibited more peer-related loneliness. The important role that parents play in their children's social adjustment is discussed in relation to gender and culture.

[An exceptional hepatic tumor]. / Une tumeur hépatique exceptionnelle.

BACKGROUND: Hepatic localization of non Hodgkin's lymphoma is generally secondary. Primary localizations are rare. AIM: To report a rare case of primary hepatic lymphoma particular by its association with dermatopolymyositis. OBSERVATION: A 55-year-old woman with a past medical history of dermatopolymyositis diagnosed one year before presented with abdominal pain and fever. Laboratory tests showed pancytopenia. Radiologic examination revealed multiple hepatic masses. Surgical biopsy revealed a large B cell hepatic lymphoma. No other localizations were found so the diagnosis of primary hepatic lymphoma was retained. The patient died after a few days due to a severe sepsis. CONCLUSION: Primary hepatic lymphoma is a rare tumor with a bad prognosis. Its diagnosis is based on histologic examination. Treatment of these tumors remains non consensual.

[Prostatic stromal sarcoma]. / Sarcome stromal de la prostate.

Prostatic sarcoma is a very rare tumour arising from the specialized stroma of the prostatic parenchyma. The clinical and histological features and biological behaviour of this entity are poorly elucidated at the present time. The authors report a case of prostatic stromal sarcoma in a 47-year-old man presenting with complete bladder retention. The initial diagnosis was that of benign prostatic hyperplasia and the patient was treated by suprapubic prostatectomy with no other complementary treatment. Histological examination demonstrated primary neuroectodermal tumour (PNET). The patient was subsequently lost to follow-up and was only reviewed 22 months later in a context of haematuria. Digital rectal examination revealed a large, soft prostate with an estimated weight of 83 grams on ultrasound. Transurethral resection was performed and histological examination of the resection material and review of the slides of the primary tumour showed identical microscopic and immunohistochemical features, corresponding to stromal sarcoma. The patient was treated by local and regional radiotherapy (60 Grays). With a follow-up of 36 months, he presents urinary symptoms with no signs of local extension or metastasis.

[A particular hepatocellular carcinoma combining the ordinary and the fibrolamellar variant]. / Un carcinome hepatocellulaire particulier associant la forme classique et la forme fibrolamellaire.

Fibrolamellar carcinoma (FLC) of the liver is a rare variant of hepatocellular carcinoma (HCC) occurring on non cirrhotic liver. Since its first description by Hugh Edmondson in 1956, 200 cases of FLC have been reported in the literature, but only some cases describe the association of the ordinary HCC with the FLC within the same lesion. We report in this study the case of a 14-year-old female patient with a hepatic mass whose radiological aspect evoked a nodular and focal hyperplasia. Histologically, this tumor was composed of area of FLC mixed with ordinary HCC. Staining for cytokeratine 7 was positive in the FL component and negative in the ordinary HCC component.

[Prognostic value of clinicopathologic factors in superficial bladder tumors: a retrospective analysis]. / Valeur pronostique des facteurs clinicopathologiques dans les tumeurs superficielles de la vessie: Etude rétrospective à propos de 59 cas.

OBJECTIVE: To study, through a series of superficial bladder tumors, the prognostic factors of recurrence and tumoral progression. MATERIALS AND METHODS: This is a retrospective study of a series of 59 urothelial tumors of the bladder at stage pTa or pT1. The following parameters were considered: age, sex, treatment, stage and grade. The chi square test was used in search of a correlation between the different parameters and the course (recurrence and progress) of the disease. A multivariate analysis was undertaken by integrating factors correlated with the course. RESULTS: Thirty two tumors (54 %) had recured versus 27 (46%) without recurrence. Eight tumors (25 %) progressed in grade and 4 (12,5 %) had become infiltrative. Age beyond 65 years, tumoral size > 3 cm and multifocality were predictive factors of recurrence with a relative risks of 2,36, 3,28 and 3,88 respectively. In a multivariate analysis, these factors remained significant with adjusted relatif risks respectively of 1,36, 1,6 and 1,7.

[Retroperitoneal Castleman disease]. / Maladie de Castleman rétropéritonéale.

Castleman disease or angiofollicular lymph node hyperplasia is a rare disease of unknown cause with polymorphic clinical features that raises many diagnostic and therapeutic problems. The unifocal, localized, pseudoneoplastic form, first described in 1956, has a good prognosis, but the multifocal form has a more aggressive course. Three histological types have been identified: hyaline vascular, plasma cell and mixed. The authors present a case of hyaline vascular unifocal Castleman disease. A retroperitoneal mass was discovered incidentally during follow-up ultrasound examination in a 38-year-old woman treated for recurrent renal stones. On CT examination, a solid mass measuring 9 x 8 x 6 cm raised a problem of differential diagnosis with other retroperitoneal masses. CT-guided biopsy was inconclusive and the diagnosis was finally established by tumour excision and histological examination. The immediate and subsequent postoperative course was uneventful.

[Jaccoud arthropathy and pyrophosphate arthropathy: a rare association]. / Arthropathie de Jaccoud et chondrocalcinose articulaire: une association rare.

Jaccoud's arthropathy (JA) is a chronic deformity affecting hands and feet, which are voluntarily correctable by the patients. JA was usually reported in association with rheumatic fever and systemic lupus erythematosus. We describe an exceptional association between a pyrophosphate arthropathy and JA of the hands. It is a 48-year-old woman, having a 13 years history of polyarthritis involving shoulders, elbows, hips and knees, and 4 years after, a progressive unlar deviation of the fingers of the hands. Calcium pyrophosphate dihydrate crystals were identified in the synovial knee biopsy. Hands x-rays as RMI don't identify erosions and confirmed the JA.