Synchronous Pelvic Schwannoma With Metastatic Prostate Cancer: A Rare Case and Pathology Review.

Schwannomas are benign tumors arising from well-differentiated Schwann cells of peripheral nerves. They are usually found on the limbs, head, and neck. It is uncommon for schwannoma to occur in the pelvis and when it does, it is often diagnosed late. Pelvic schwannoma when diagnosed are often bigger in size (>5 cm) and may present with local symptoms such as constipation and bladder outlet obstruction. We hereby present a patient with concurrent metastatic prostate carcinoma and pelvic schwannoma. The patient is a 57-year-old man initially diagnosed with prostate cancer and was lost to follow-up. One year later, he presented with metastatic prostate disease and bladder outlet obstruction. Further evaluation revealed a concurrent pelvic mass that was increasing in size. The biopsy of this mass was suggestive of schwannoma. It was decided at the multidisciplinary tumor board conference to offer treatment for his metastatic prostate disease and observe the schwannoma. His obstructive symptoms worsened in the face of clinical evidence of regression of his prostatic disease, and it was decided to resect the pelvic mass. The surgery revealed a huge soft tissue mass within the pelvis that was adherent to the bladder, prostate, and rectum. Morphology and immunohistochemistry studies of the pelvic mass confirmed the diagnosis of ancient schwannoma. We hereby highlight the clinical importance of this presentation and the diagnostic and therapeutic dilemma involved in the management of this patient who presented with two pathologic conditions causing similar symptoms but of different prognostic and therapeutic significance.

A Rare Case of Benign Metastasizing Leiomyoma Causing T11 Spinal Cord Compression: A Report and Literature Review.

Diagnosis of uterine smooth muscle tumors depends upon histologic characteristics as both benign and malignant share clinical features such as metastases. A benign metastasizing leiomyoma is a rare benign smooth muscle tumor that metastasizes to extrauterine sites with simultaneous uterine leiomyoma or previously biopsy-proven leiomyoma during myomectomy or hysterectomy. Benign metastasizing leiomyoma metastasizes outside the uterus, predominantly to the lungs and lymph nodes. However, the involvement of other organs, such as the heart, liver, spine, and soft tissue, is also reported. Here, we present a case of a 42-year-old woman with a history of uterine leiomyoma with prior myomectomy and hysterectomy, who presented with worsening back pain and lower extremity weakness and was found to have an acute cord compression, a serious complication caused by mass effect and a medical emergency that requires prompt attention to prevent permanent spinal cord damage. Sacral soft tissue biopsy and T11 spinal bone biopsy both demonstrated leiomyoma with immunostains positive for desmin, smooth muscle actin, and positive estrogen and progesterone receptors. No atypia, necrosis, and mitosis were identified. The patient had hepatic and pulmonary metastasis on imaging. The final diagnosis was benign metastasizing leiomyoma. There is no standard treatment for benign metastasizing leiomyoma. Both surgical and pharmacological approaches are employed. Although most cases are benign, there is a possibility for life-threatening complications. Benign metastasizing leiomyomas can be considered when multiple soft tissue tumors are found in premenopausal women with a history of uterine leiomyomas. Multidisciplinary discussion between oncologists, gynecologists, and relevant specialists is crucial in the optimal evaluation and treatment of benign metastasizing leiomyoma.

Symptomatic Colorectal Cancer Is Associated With Stage IV Diagnosis in Two Disparate Populations.

In the United States, individuals of Black/African Ancestry (AA) have a higher incidence and mortality from colorectal cancer (CRC) compared to individuals of White/European Ancestry (EA). In order to develop an approach towards disentangling the complex effects of associated race and socioeconomic factors on CRC outcome, we have conducted a manual chart review of sporadic CRC pathological diagnoses (total n = 334) at an urban public hospital (UH) and a suburban university hospital (SH). There were significant differences between the SH and UH CRC patients with respect to Black/AA race (4.2% vs. 89.1%, p < 0.0001) and Medicaid/Self-pay insurance status (14.9% vs. 85.0%, p < 0.0001). While a higher proportion of newly diagnosed CRC patients presented with metastatic stage 4 CRC at the UH (21%) than the SH (12.5%), only the presence of symptoms was significantly associated with stage 4 CRC (odds ratio, OR 7.94, 95% confidence interval, CI 1.83- 34.54, p = 0.0057) in a multivariable generalized linear model (GLM). The proportion of asymptomatic CRC patients was ~20% at both institutions, suggesting that the UH has contributed to reducing CRC disparities. Initiation of CRC screening at the recommended age at both institutions could reduce the proportion of CRC patients presenting with metastatic spread.

Immune-Related Gene Expression and Cytokine Secretion Is Reduced Among African American Colon Cancer Patients.

Background: Colorectal cancer is the third most deadly cancer among African Americans (AA). When compared to Caucasian Americans (CA), AA present with more advanced disease and lower survival rates. Here, we investigated if differences in tumor immunology could be contributive to disparities observed between these populations. Methods: We examined gene expression of tumor and non-tumor adjacent tissues from AA and CA by whole transcriptome sequencing, and generated scores for immune cell populations by NanoString. In addition, we utilized "The Cancer Genome Atlas" (TCGA) database from AA and CA as a validation cohort. Finally, we measured the secretion of cytokines characteristic of effector T helper cell (Th) subsets by ELISA using plasma from each AA and CA participant. Results: Colon tumors from AA patients showed significant fold-change increase in gene expression when compared to CA for FOXP3 (6.22 vs. 3.22), IL1B (103 vs. 11.4) and IL8 (220 vs. 28.9) (p < 0.05). In contrast, among CA we observed statistically higher gene expression of markers associated with antitumor activity such as GZMB (Granzyme B), IFNG and the immunotherapy targets PDL1 (CD274) and CTLA4 (p < 0.05). TCGA data validated our observed higher gene expression of GZMB and PDL1 in CA patients when compared to AA. Notably, our observations on immune cell populations show that AA tumors have significantly higher number of exhausted CD8+ cells (p < 0.01), mast cells (p < 0.02) and increased T regulatory cells when compared to CA. AA colon cancer patients differed from CA in cytokine production patterns in plasma (i.e., reduced IL-12). Conclusions: Our study demonstrates significant differences of the immunological profiles of colon tumors from AA compared to CA that suggest a deficiency of appropriate immune defense mechanisms in terms of gene expression, recruitment of immune cells and systemic secretion of cytokines. As such, these immune differences could be mitigated through population-specific therapeutic approaches.

Pneumoperitoneum without Intestinal Perforation in a Neonate: Case Report and Literature Review.

Pneumoperitoneum in a preterm neonate usually indicates perforation of the intestine and is considered a surgical emergency. However, there are cases of pneumoperitoneum with no evidence of rupture of the intestine reported in the literature. We report a case of pneumoperitoneum with no intestinal perforation in a preterm neonate with respiratory distress syndrome who was on high frequency oscillatory ventilation (HFOV). He developed bilateral pulmonary interstitial emphysema with localized cystic lesion, likely localized pulmonary interstitial emphysema, and recurrent pneumothoraces. He was treated with dexamethasone to wean from the ventilator. Pneumoperitoneum developed in association with left sided pneumothorax following mechanical ventilation and cardiopulmonary resuscitation. Pneumoperitoneum resolved after the pneumothorax was resolved with chest tube drainage. He died from acute cardiorespiratory failure. At autopsy, there was no evidence of intestinal perforation. This case highlights the fact that pneumoperitoneum can develop secondary to pneumothorax and does not always indicate intestinal perforation or require exploratory laparotomy.

Perception of low-titer group A plasma and potential barriers to using this product: A blood center's experience serving community and academic hospitals.

BACKGROUND: To alleviate the shortage of AB plasma, an alternative plasma product, low-titer group A plasma (LTGAP), is now available. The product is indicated for emergency transfusions when the patient's blood group has not been identified. The product's defining anti-B titers vary across institutions, and at our blood center we define <1:100 as low-titer. METHODS: We created two surveys and emailed them to hospital blood bank managers, supervisors, and medical directors who currently use LTGAP and those that have not ordered it. We calculated the amount of LTGAP that met our <1:100 cutoff. We searched our inventory database to obtain sales of LTGAP, AB, and all other types of plasma in 2014. RESULTS: We learned from the surveys that the product is safe and being used as indicated for only life or limb-threatening emergencies until patient's blood group is known and specific products can be provided. Most common reasons for not using LTGAP were lack of need in non-trauma hospitals and limiting capabilities in blood bank software. Although sales of LTGAP increased by ~5% by end of the first year since introduction, sales of AB plasma remained relatively steady. CONCLUSION: LTGAP appears to be a safe alternative to group AB plasma for emergency indications. By reviewing our percentage of group A plasma units that meet our low-titer cutoff and the current interest for the product, we can reduce the amount of units we titer each day by ~30% and can readjust that amount if there is increased interest. Besides lack of familiarity and limitations in computer software to incorporate LTGAP, the steady demand for AB plasma can potentially be attributed to trauma centers ordering more AB plasma than needed and potentially wasting it in nonurgent cases to avoid outdating the product and lack of institutional guidelines on when to switch from AB to type-specific plasma resulting in excess AB plasma being transfused.

Cokeromyces recurvatus identified in lung biopsy: case report of a non-pathogenic fungus, highlighting its potential histologic mimics.

We report a case of aspiration in a patient with gastric outlet obstruction due to pancreatic adenocarcinoma, in which three large yeasts were identified on tissue biopsy of the lung infiltrate. The histologic sections of the yeasts showed densely eosinophilic, round to oval, thick-walled structures with frayed borders and intra-cystic bluish inclusions. There was a background of mixed neutrophilic and eosinophilic infiltrate along with focal tissue necrosis. Our initial differential diagnoses included the usual large yeasts such as Cryptococcus, Coccidioides, and Blastomyces. Immunohistochemistry revealed reactivity to the Blastomyces antibody. Mycology studies eventually identified the organism as Cokeromyces recurvatus. Anti-fungal treatment was withheld with spontaneous resolution of the infiltrates. This case demonstrates the importance of using culture to speciate organisms identified on tissue, separating pathogens from non-pathogens and non-living artifacts in order for appropriate management.

Comparison of GeneXpert PCR to BD GeneOhm for detecting C. difficile toxin gene in GDH positive toxin negative samples.

The need for rapid diagnosis of Clostridium difficile (C. difficile) associated infection in a clinical microbiology laboratory has provided the stimulus for new diagnostic tests and testing protocols. A two-test algorithm has been proposed using assays such as Quik Chek Complete, which detects both C. difficile glutamate dehydrogenase (GDH) and C. difficile toxins A and B, followed by reflex testing of samples having inconclusive results (GDH positive and toxin negative) with PCR for identification of toxin gene specific DNA. The goal of this study was to compare the outcome and efficiency of PCR assays, BD GeneOhm and GeneXpert, for detecting C. difficile toxin B gene in samples that have tested indeterminate for C. difficile by the Quik Chek Complete test. Over a three-month period, a total of 41 cases tested indeterminate by Quik Chek Complete test and were retested by the aforementioned PCR assays. Out of the 41 samples, 36 had matching results in both assays; 19 negative samples and 17 positive samples. In terms of efficiency, GeneXpert was user-friendly and had a turnaround time (TAT) of 45 minutes with two-minute specimen processing compared to BD GeneOhm which had a TAT of 75 to 90 minutes.