A Rare Case of Ruptured Tailgut Cyst Leading to Carcinomatosis.

Tailgut cysts are congenital cysts arising in the retrorectal space. They are thought to be benign with variable malignancy risks. We report a case with previous surgical intervention decades prior that had undergone a tailgut cyst excision with surgical complications leading to carcinomatosis. An elderly female (70s) presented with tailbone/pelvic pain. She underwent cyst excision that was complicated by an intraoperative rupture. The cyst was pathologically proven to be a tailgut cyst with adenocarcinoma. She presented 13 months postoperatively to the emergency department with worsening abdominal pain. Imaging was concerning for diffuse omental nodules and narrowing of the proximal sigmoid colon. She was not deemed to be a surgical candidate and was transitioned to hospice care, where she passed away shortly afterward. This case report highlights the utility of complete excision of tailgut cysts and possible complications.

Complete Pathologic Response to Neoadjuvant Chemoimmunotherapy and Oxaliplatin-Induced Fever Associated With IL-6 Release in a Patient With Locally Advanced Colon Cancer

Neoadjuvant systemic therapy is a preferred treatment approach for a number of tumor types due to many potential advantages over upfront surgery, including tumor downstaging, early treatment of micrometastatic disease, and providing an in vivo test of tumor biology. For colon cancer, current standard of care is upfront surgery followed by adjuvant systemic therapy in high-risk patients. Concerns about inaccurate radiological staging and tumor progression during preoperative treatment, as well the lack of randomized data demonstrating benefit, are among the reasons for the limited use of neoadjuvant therapy in this disease. Locally advanced colon cancer, defined as primary colon cancer with direct invasion into the adjacent structures or extensive regional lymph node involvement, is not always amenable to pathological complete resection, and when attempted it comes with high incidence of postoperative morbidity and mortality because of the required multivisceral resection. Clinical trials of neoadjuvant chemotherapy for colon cancer to date have been promising with downstaging of disease and higher rates of R0 resection. Here, we report a case of a patient with locally advanced, unresectable, mismatch repair deficient sigmoid colon cancer who was treated with neoadjuvant chemoimmunotherapy followed by surgical resection leading to a complete pathologic response after preoperative systemic chemoimmunotherapy.

A 64-Year-Old Man With Germline BRCA2-Mutated Breast Cancer: Known and Unknown Aspects of Male Breast Cancer.

Male breast cancer is a rather uncommon and understudied disease. It accounts for less than 1% of all breast cancers, but in recent decades its frequency has been on the rise. Clinical trials of breast cancer have traditionally excluded men. Due to the lack of large-scale prospective studies, most published data come from single-institution, small-cohort studies, and treatment recommendations are based on the extrapolation of data from clinical trials enrolling only women. Although to some extent etiology, diagnosis, and treatment characteristics can be similar, male breast cancer exhibits some distinct features. Men tend to be diagnosed with breast cancer at an older age and at a more advanced stage. A better understanding of the biologic features, clinically relevant differences, effective treatments, and outcomes of male breast cancer is crucial to appropriately manage these patients. We present a male breast cancer case with a germline BRCA2 mutation and discuss the epidemiologic, pathologic, and clinical characteristics along with treatment and follow-up recommendations in view of our recent understanding of this disease.

Locally Advanced Gastrointestinal Stromal Tumor in a 33-Year-Old Woman Seeking to Conceive.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract. They commonly present with nonspecific symptoms and thus are often discovered incidentally. They are best identified by CT scan, and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. Several risk stratification classification systems have been developed based on tumor size, mitotic rate, location, and perforation. Traditional chemotherapy and radiation therapy have been very ineffective, making surgery the mainstay of treatment. The discovery of mutations associated with these tumors has revolutionized the treatment approach. Imatinib mesylate, a selective tyrosine kinase receptor inhibitor, used as adjuvant or neoadjuvant therapy, has greatly improved the morbidity and mortality associated with GISTs. As the survival of patients has increased with the long-term use of targeted therapies, quality-of-life issues now have become much more relevant and have come to the forefront of care. We present a young woman who was successfully treated for GIST but now faces associated long-term adverse effects of imatinib, including the challenge of preserving fertility and the potential for childbearing.

76-Year-Old Woman With a Bluish-Purple Lump in her Left Upper Medial Leg.

A woman, aged 76 years, presented with a bluish-purple lump in her mid- to upper medial left thigh. It started initially as a flat rash, and over a 2-month period, it turned into a mass measuring 2.5 cm by 3.1 cm. Work-up, including a PET-CT scan, showed the soft tissue mass on the inner thigh to have a Standardized Uptake Value of 4; there were no other sites of disease. A biopsy of the lesion was performed.

Synchronous Bilateral Lung Cancer With Discordant Histology.

Synchronous multiple primary lung cancer (SMPLC) is a rare occurrence affecting 0.5% to 2% of patients with lung cancer. Synchronous discordant histology with small cell and non-small cell lung carcinoma is an even less common entity. There have been several presentations of synchronous or metachronous multiple primary lung cancers in the literature. However, reports discussing treatment options and prognosis in patients with SMPLC of discordant histology with small cell and non-small cell carcinoma in the same patient are scarce. We report a case of SMPLC presenting with a limited stage left upper lobe small cell lung cancer and an operable right upper lobe non-small cell lung adenocarcinoma. Diagnostic, surgical, and medical treatment options for the patient along with a review of SMPLC topics are presented.

Locally Advanced Rectal Cancer, What is the Standard of Care?

Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one-third of newly diagnosed cases. A comprehensive trimodality approach involving neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy has been the standard of care for medically operable patients with nonmetastatic, locally advanced rectal cancer. Despite a marked reduction in local recurrence rates with good local control, systemic recurrence rates of as high as 35% constitute the leading cause of death in this population. This has led to increasing interest in neoadjuvant systemic therapy before or after neoadjuvant chemoradiation a new approach called total neoadjuvant therapy. This case study will review the current status of clinical stage II or III locally advanced rectal cancer (T3/4, N0, or node-positive) treatment regarding neoadjuvant therapy.

Hereditary vs Familial Pancreatic Cancer: Associated Genetic Syndromes and Clinical Perspective.

Pancreatic ductal adenocarcinoma (PDAC) is a disease marked by high rates of mortality; it is mostly incurable at the time of diagnosis. Only about 7% of patients survive 5 years after diagnosis. Diagnosis at a late stage and rapid progression with minimal response to available treatments are the main reasons for this poor outcome. It is crucial to identify individuals at high risk of developing PDAC so preventive and early detection measures can be employed. Approximately 10% to 15% of PDAC cases have a hereditary or familial basis. In the majority of PDAC cases, no main causative gene has been identified, but several known germline pathogenic mutations have been shown to be related to an increased risk of this cancer. The presence of 2 or more patients with pancreatic cancer within the circle of first-degree relatives, without the presence of a causative germline mutation, is defined as familial pancreatic cancer; this accounts for 4% to 10% of PDAC. Based on the growing evidence supporting the benefit of germline genetic testing in patients with PDAC, both the American Society of Clinical Oncology and the National Comprehensive Cancer Network recently updated their guidelines to include recommendations around genetic testing for patients with pancreatic cancer. However, there is no general consensus on the group of patients and individuals who should be studied and screened. We present a demonstrative case and review the available data on hereditary and familial PDAC.

Pancreatic Neuroendocrine Tumor With Humoral Hypercalcemia and High Tumor PD-L1 Score.

Pancreatic neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms. They can be functioning tumors with secretion of a variety of peptide hormones, or nonfunctioning tumors with metastases to the liver at the time of diagnosis. Well-differentiated tumors tend to be slow-growing and characterized by low tumor mutational burden (TMB) and lower propensity to express PD-L1. Hypercalcemia due to malignancy can occur in about 20% to 30% of patients with cancer. The secretion of parathyroid hormone-related protein (PTH-rP) is among the causes of malignant hypercalcemia and has seldom been associated with hypercalcemia of NETs. Although the therapeutic landscape for neuroendocrine neoplasms has evolved substantially over the past decade, the role of immunotherapy has not yet been completely explored in this group of patients. We present a rare case of a metastatic pancreatic NET with high TMB, high PD-L1 tumor proportion score, and high PTH-rP related hypercalcemia.

Nodular Elastosis of the Pancreas.

Elastofibromatous change is a benign process that has been increasingly recognized in the tubular gastrointestinal tract. These changes can present as a colonic polyp or be seen in conjunction with inflammatory changes. Similar lesions have been noted in the liver, apparently associated with vascular injury. We describe a case in which multiple circumscribed nodules of elastofibromatous change within the pancreas had a similar morphology to nodular elastosis of the liver. To our knowledge, this is the first description of such a finding occurring within the pancreas.

Investigation of scanning parameters for thyroid fine needle aspiration cytology specimens: A pilot study.

BACKGROUND: Interest in developing more feasible and affordable applications of virtual microscopy in the field of cytology continues to grow. AIMS: The aim of this study was to investigate the scanning parameters for the thyroid fine needle aspiration (FNA) cytology specimens. SUBJECTS AND METHODS: A total of twelve glass slides from thyroid FNA cytology specimens were digitized at ×40 with 1 micron (µ) interval using seven focal plane (FP) levels (Group 1), five FP levels (Group 2), and three FP levels (Group 3) using iScan Coreo Au scanner (Ventana, AZ, USA) producing 36 virtual images (VI). With an average wash out period of 2 days, three participants diagnosed the preannotated cells of Groups 1, 2, and 3 using BioImagene's Image Viewer (version 3.1) (Ventana, Inc., Tucson, AZ, USA), and the corresponding 12 glass slides (Group 4) using conventional light microscopy. RESULTS: All three raters correctly identified and showed complete agreement on the glass and VI for: 86% of the cases at FP Level 3, 83% of the cases at both the FP Levels 5 and 7. The intra-observer concordance between the glass slides and VI for all three raters was highest (97%) for Level 3 and glass, same (94%) for Level 5 and glass; and Level 7 and glass. The inter-rater reliability was found to be highest for the glass slides, and three FP levels (77%), followed by five FP levels (69.5%), and seven FP levels (69.1%). CONCLUSIONS: This pilot study found that among the three different FP levels, the VI digitized using three FP levels had slightly higher concordance, intra-observer concordance, and inter-rater reliability. Scanning additional levels above three FP levels did not improve concordance. We believe that there is no added benefit of acquiring five FP levels or more especially when considering the file size, and storage costs. Hence, this study reports that FP level three and 1 µ could be the potential scanning parameters for the thyroid FNA cytology specimens.

Transiently Pink-Tinged Serum in a Patient With Multiple Myeloma and Anemia Undergoing Lenalidomide Treatment.

OBJECTIVES: While in vitro hemolysis is a preanalytical interferent, in vivo hemolysis is a pathologic process requiring investigation. We present a case of an anemic patient with multiple myeloma undergoing chemotherapy with lenalidomide who had multiple serum samples drawn before and after chemotherapy treatment. Some of these samples showed hemolysis. This triggered further investigations to differentiate the cause of the hemolysis. METHODS: Various laboratory tests and additional investigations were necessary to establish the root of the hemolytic process. RESULTS: Multiple laboratory tests and a rigorous review of the samples, time of collection, and laboratory results revealed that only samples collected shortly after lenalidomide administration showed hemolysis. This indicates that the chemotherapeutic agent itself was most likely the proximate cause of the in vivo hemolysis in a non-immune-mediated manner. CONCLUSIONS: Upon administration, chemotherapeutic agents, such as lenalidomide, can immediately induce transient hemolysis, which can be visualized as transiently pink-tinged serum samples.

How well do we communicate?: a comparison of intraoperative diagnoses listed in pathology reports and operative notes.

OBJECTIVES: To compare surgeons' interpretations of intraoperative diagnoses with those rendered by the pathologist. METHODS: Consecutive intraoperative diagnoses over a nine-month period were retrospectively reviewed. For each case, operative notes were obtained from the hospital information system. The intraoperative diagnoses listed in the final pathology reports were compared with those dictated by the surgeon. Discrepancies were stratified by potential clinical impact: category A, overall correct diagnosis with minor unimportant differences; category B, discrepant diagnosis with both either benign or malignant; and category C, intraoperative diagnoses differing between benign and malignant. The method of communication of each discrepant intraoperative diagnoses (in person vs telephone) was also examined. RESULTS: There was no record of the intraoperative diagnoses in 20% of operative notes. Comparison of intraoperative diagnoses was possible in 1,131 cases. Category A errors were noted in 94 (8.3%) cases, B in 11 (1%), and C in 4 (0.3%). The most frequent means of communication in A and B cases was the telephone, with more C cases being relayed in person. CONCLUSIONS: A subset of verbally reported intraoperative diagnoses is misinterpreted by surgeons. While rare events, miscommunication can lead to inappropriate intraoperative management. Communicating diagnoses by phone may increase the risk of perception errors.

Urothelial cell intracytoplasmic inclusions after treatment of promyelocytic leukemia with arsenic trioxide.

Intramitochondrial inclusions containing arsenite that occur within urothelial cells have been previously described in mice exposed to high concentrations of arsenic but not in rats. In epidemiology studies, similar urothelial cell inclusions have also been observed in the urine of humans exposed to high concentrations of arsenic in the drinking water; however, these inclusions were mistakenly identified as micronuclei. To further examine the urothelial cell inclusions that occur in inorganic arsenic-exposed humans, we evaluated two patients with a history of acute promyelocytic leukemia treated for disease relapse with a combination of all-trans retinoic acid and arsenic trioxide. Posttreatment examination of the patients' urine cytology specimens by light and electron microscopy demonstrated cytoplasmic inclusions in exfoliated superficial urothelial cells similar to those seen in mice. The inclusions were present in decreasing quantities at 3 and 7 months after completion of treatment. No comparable inclusions were detected in exfoliated urothelial cells in urine from six individuals not treated with arsenic trioxide. Based on the results of the examination by light and electron microscopy, we have determined that urothelial cell inclusions in the urine of humans previously identified as micronuclei are instead intracytoplasmic inclusions similar to those found in arsenic-treated mice.

Cytomegalovirus reactivation and colitis after left ventricular assist device placement.

We describe two patients who developed gastrointestinal bleeding due to cytomegalovirus (CMV) colitis after placement of a HeartMate II left ventricular assist device (LVAD). We aim to raise awareness of CMV colitis as a possible cause of gastrointestinal bleeding after LVAD placement and discuss potential mechanisms for CMV reactivation and areas for future research.

Optimal z-axis scanning parameters for gynecologic cytology specimens.

BACKGROUND: The use of virtual microscopy (VM) in clinical cytology has been limited due to the inability to focus through three dimensional (3D) cell clusters with a single focal plane (2D images). Limited information exists regarding the optimal scanning parameters for 3D scanning. AIMS: The purpose of this study was to determine the optimal number of the focal plane levels and the optimal scanning interval to digitize gynecological (GYN) specimens prepared on SurePath™ glass slides while maintaining a manageable file size. SUBJECTS AND METHODS: The iScanCoreo Au scanner (Ventana, AZ, USA) was used to digitize 192 SurePath™ glass slides at three focal plane levels at 1 µ interval. The digitized virtual images (VI) were annotated using BioImagene's Image Viewer. Five participants interpreted the VI and recorded the focal plane level at which they felt confident and later interpreted the corresponding glass slide specimens using light microscopy (LM). The participants completed a survey about their experiences. Inter-rater agreement and concordance between the VI and the glass slide specimens were evaluated. RESULTS: This study determined an overall high intra-rater diagnostic concordance between glass and VI (89-97%), however, the inter-rater agreement for all cases was higher for LM (94%) compared with VM (82%). Survey results indicate participants found low grade dysplasia and koilocytes easy to diagnose using three focal plane levels, the image enhancement tool was useful and focusing through the cells helped with interpretation; however, the participants found VI with hyperchromatic crowded groups challenging to interpret. Participants reported they prefer using LM over VM. This study supports using three focal plane levels and 1 µ interval to expand the use of VM in GYN cytology. CONCLUSION: Future improvements in technology and appropriate training should make this format a more preferable and practical option in clinical cytology.