Case Report of a Breast Mass with Three Types of Malignant Tumors-Squamous Cell Carcinoma, Invasive Ductal Carcinoma, and Breast Sarcoma.

Breast malignancy comprises malignant tumors originating from epithelial tissue and breast sarcoma arising from mesodermal tissues. Despite heterogeneity in tumors, most malignant tumors of the breast are composed of a single type of tumor. Here, we report a patient with breast tumor consisting of three different types of malignancies-squamous cell carcinoma, invasive ductal carcinoma, and high-grade breast sarcoma.

Esophageal Lichen Planus Is Associated With a Significant Increase in Risk of Squamous Cell Carcinoma.

Esophageal lichen planus (ELP) is a chronic inflammatory process characterized by apoptotic activity of cytotoxic CD8+ T cells on basal keratinocytes as well as regulatory and helper T cells.1-3 Due to chronic inflammation, malignant transformation may be a concern and has been documented in case reports.4,5 We describe the occurrence of esophageal cancer in ELP patients from a large tertiary patient population.

Gastroesophageal Reflux Characteristics and Patterns in Patients with Idiopathic Subglottic Stenosis.

INTRODUCTION: Idiopathic subglottic stenosis represents a spectrum of subglottic disease without a clear underlying cause. Prior studies have implicated a pathogenic role of gastroesophageal reflux disease in idiopathic subglottic stenosis. The aim of this study was to examine the presence and pattern of gastroesophageal reflux in a large cohort of patients with idiopathic subglottic stenosis at a tertiary referral center. METHODS: We performed a retrospective review of patients with idiopathic subglottic stenosis from January 2010 to December 2016 who had undergone combined pH impedance testing. Patients with prior gastric or esophageal surgery were excluded. Data obtained included esophageal acid exposure times, number of reflux events, patient position during reflux events (defined as upright, supine, or mixed), body mass index, and the presence of proton pump inhibitor therapy. RESULTS: 159 patients with the idiopathic subglottic stenosis were identified, of whom 41 had undergone esophageal pH impedance testing. 40 (97.6%) were women, with a mean age of 54.8 (range 31-79) years and BMI of 31.0 (range 17-55). Overall, 19 (46.3%) patients were found to reflux as confirmed by abnormal esophageal acid exposure or abnormal number of reflux events. 15 of the 19 patients with reflux had predominantly upright gastroesophageal reflux disease, whereas 2 had supine and 2 mixed reflux. DISCUSSION: In patients with idiopathic subglottic stenosis who underwent evaluation by combined pH impedance, close to half were found to have gastroesophageal reflux disease. The majority of gastroesophageal reflux occurred while the patients were in the upright position.

Subepithelial esophageal tumors: a single-center review of resected and surveilled lesions.

BACKGROUND AND AIMS: Subepithelial esophageal tumors (SETs) are frequent incidental findings. Although symptomatic tumors are surgically or endoscopically resected, there is no consensus on the management of asymptomatic esophageal leiomyomas. METHODS: Appropriate International Classification of Diseases, Ninth Revision codes followed by medical record review were used to identify patients with SETs from January 1992 to March 2017, with abstraction of basic demographics, surveillance intervals, and mortality. Patients were contacted to complete a phone questionnaire to assess follow-up as well as the validated Brief Esophageal Dysphagia Questionnaire (BEDQ). RESULTS: Eighty-four leiomyomas, 5 leiomyosarcomas, 13 GI stromal tumors (GISTs), and 4 granular cell tumors were found. Among patients with leiomyomas, 58 (69%) were resected and 26 (31%) were followed under surveillance. Resected esophageal leiomyomas were larger than those under surveillance (49.7 mm vs 17.9 mm, P < .003). Esophageal leiomyoma growth during surveillance was only .5 mm over a mean 70-month follow-up (range, 4-288). No malignant transformation was seen, and only 2 patients required subsequent resection. The phone survey was completed by 35 patients and revealed minimal symptom burden, with only 2 patients (15%) under esophageal leiomyoma surveillance reporting symptoms (BEDQ score ≥10) over a mean 96.7-month follow-up. EUS had high diagnostic accuracy with a positive predictive value of 68% and a negative predictive value of 100% for leiomyomas or GISTs compared with surgical pathology. CONCLUSIONS: EUS demonstrated high diagnostic accuracy in resected SETs. Esophageal leiomyomas demonstrate minimal growth or symptomatic progression. Therefore, long-term EUS surveillance of small asymptomatic esophageal leiomyomas may be unnecessary.

Effects of Starting a Gastroenterology Fellowship Training Program on Quality Measures of Colonoscopy.

OBJECTIVES: Adenoma detection rate (ADR) is the most established indicator of the quality of screening colonoscopy. The effect of gastroenterology (GI) fellows on the quality of screening colonoscopies has been evaluated previously; however, the effect of starting a new GI fellowship program on the quality of screening colonoscopies has not been studied. The aim of our study was to assess the effects of starting a GI fellowship program and the participation of fellows in screening colonoscopies on ADR and other measures of quality. METHODS: This was a retrospective, cross-sectional study of all screening colonoscopies performed 20 months before and 20 months after starting the GI fellowship at our medical center (November 2010-February 2014). Colonoscopy procedure notes and pathology records were reviewed for each patient. Data from the two periods were compared using either the Fisher exact test or the two-sample t test. RESULTS: A total of 2127 complete colonoscopies were included in the analysis. The mean age of patients was 58.8 ± 6.6 years. Of the 2127 colonoscopies, GI fellows were involved in 385 (18%), whereas 1742 (82%) were performed solely by GI attendings (attending physicians). Multivariate analysis using relative risk (RR) of regression was done. The after starting the GI fellowship period was significantly associated with an increase in ADR (RR 1.19, 95% confidence interval 1.10-1.30, P < 0.001) and advanced adenoma detection rate (RR 1.17, 95% confidence interval 1.00-1.38, P < 0.001) compared with the before starting the GI fellowship period. In the after starting the GI fellowship period, the polyp detection rate and ADR for colonoscopies performed by the attending physicians with the fellows were significantly higher than colonoscopies performed solely by the same attendings (58.4% vs 44.5%, P = 0.001, 42.0% vs 32.9%, P = 0.017, respectively). CONCLUSIONS: Starting a GI fellowship program significantly increased the polyp detection rate, ADR, and advanced ADR.

Primary central nervous system amelanotic melanoma in a Hispanic male: Case report.

BACKGROUND: Primary melanotic neoplasms of the central nervous system (CNS) are uncommon; amelanotic melanomas in this region are extremely rare. Very few cases of amelanotic variation of primary melanoma in the CNS were reported on. General guidelines or recommendations to establish this diagnosis do not exist. CASE REPORT: A sixty-year-old male Hispanic patient presented with a 7-day history of numbness and dizziness. Initial laboratory work-up and physical examination were inconclusive. Cerebral radiological imaging showed a left frontal lesion. Further work-up after clinical deterioration revealed an increase in the lesion size consistent with hemorrhage and changes in T1WI. Biopsy and immunochemistry demonstrated the presence of amelanotic melanoma in the CNS without evidence of another primary lesion. CONCLUSIONS: Primary amelanotic melanoma of the CNS represents a challenge, clinically and diagnostically. Magnetic resonance imaging can be helpful in early stages. Final diagnosis is established with immunohistochemical testing. Physicians should be aware of the existence of this rare manifestation and difficulties faced while building this diagnosis.

Comparison of adeno-associated virus serotypes and delivery methods for cardiac gene transfer.

Cardiac gene transfer is a potentially useful strategy for cardiovascular diseases. The adeno-associated virus (AAV) is a common vector to obtain transgene expression in the heart. Initial studies conducted in rodents used indirect intracoronary delivery for cardiac gene transfer. More recently AAV vectors with so-called cardiac tropism have enabled significant cardiac transgene expression following intravenous injection. However, a direct comparison of intravenous versus intracoronary delivery with rigorous quantification of cardiac transgene expression has not been conducted. In the present study we tested the hypothesis that intracoronary AAV delivery would be superior to intravenous delivery vis-à-vis cardiac transgene expression. We compared intravenous and intracoronary delivery of AAV5, AAV6, and AAV9 (5×10(11) genome copies per mouse). Using enhanced green fluorescent protein as a reporter, we quantified transgene expression by fluorescence intensity and Western blotting. Quantitative polymerase chain reaction (PCR) was also performed to assess vector DNA copies, employing primers against common sequences on AAV5, AAV6, and AAV9. Intracoronary delivery resulted in 2.6- to 28-fold higher transgene protein expression in the heart 3 weeks after AAV injection compared to intravenous delivery depending on AAV serotype. The highest level of cardiac gene expression was achieved following intracoronary delivery of AAV9. Intracoronary delivery of AAV9 is a preferred method for cardiac gene transfer.