Recurrent intraductal papillary neoplasm of the bile duct due to intraductal dissemination: a case report and literature review

Background Intraductal papillary neoplasm of the bile duct (IPNB) is a subtype of biliary tumor. The 5-year survival rate of patients with IPNB who underwent curative resection is 81%. However, IPNB is known to often recur in other parts of the bile duct. Nevertheless, its mechanism remains poorly understood. Herein, we report the case of a patient with recurrent IPNB, which was considered to be attributed to intraductal dissemination in the common bile duct at 12 months after curative resection. We also made a review of the existing literature. Case presentation A 69-year-old man was referred to our hospital for the evaluation and dilation of an intrahepatic bile duct (IHBD) mass. Computed tomography (CT) findings confirmed a mass in the left hepatic duct. Left trisectionectomy, extrahepatic bile duct resection with biliary reconstruction, and regional lymph node dissection were performed. Intraoperative examination of the resection margin at the common bile duct and posterior segmental branch of the hepatic duct was negative for the presence of malignant cells. Histologically, the tumor showed intraductal papillary growth of the mucinous epithelium and was diagnosed as non-invasive IPNB. It had a papillary structure with atypical epithelial cells lined up along the neoplastic fibrovascular stalks. Immunohistochemically, this was as a gastric-type lesion. At 12 postoperative months, CT revealed a 1.5-cm mass in the lower remnant common bile duct. We performed subtotal stomach-preserving pancreaticoduodenectomy. The tumor exhibited papillary growth and was microscopically and immunohistochemically similar to the first tumor. At approximately 16 months after the patient’s second discharge, CT showed an abdominal mass at the superior mesenteric plexus, which was diagnosed as recurrent IPNB. Chemotherapy is ongoing, and the patient is still alive. In this case, as described in many previous reports, IPNB recurred below the primary lesion in the bile duct. Conclusion Based on our review of previous reports on IPNB recurrence, intraductal dissemination was considered one of the mechanisms underlying recurrence after multicentric development. Considering the high frequency and oncological conversion of recurrence in IPNB, regular follow-up examination is essential to achieve better prognosis in patients with recurrent IPNB.

Classic Ciliated Muconodular Papillary Tumor of the Lung With Braf Mutation: The New We Should Know

Background Ciliated muconodular papillary tumor (CMPT) was initially recognized as three typical types of cells (ciliated cells, mucinous cells and basal cells) and two typical structures (papillary and tubular). It is found that the proportion of various cells is different and papillary structure is not necessary. So some scholars propose that CMPT is a proximal-type bronchiolar adenoma (BA) which expands the concept of CMPT. At the same time they propose revising the terminology. These morphological variations bring great challenges to the diagnosis. Case presentation: Multiple small nodules in bilateral lungs were found in 79-year old female patient. A frozen examination was performed. Grossly, there were jelly-like nodules with clear boundaries, and the maximum diameter was about 4mm. Microscopically, glandular ducts, papillary and even micropapillary structures were seen. The cavities were lined by columnar cell and mucous cells. In a low-power field the conspicuous mucin pool was observed, as well as floating tumor cells in the mucin pool. So atypical adenomatous hyperplasia of the lung was reported in intraoperative rapid diagnosis, and the surgeon performed a lobectomy for the patient. In typical HE, this tumor was made up of three kinds of cells in different proportions, including ciliated columnar cells, mucous cells, and basal cells which were confirmed by CK5/6 and P63 immunohistochemistry staining. Immunohistochemical analysis reveals thyroid transcription factor1 (TTF-1) and CK7 expression by ciliated columnar epithelial cells, basal cells, and nonciliated columnar and cuboidal epithelial cells, but not mucous cells. All the cells do not express CK20. BRAF V600E protein express in the tumor. At the same time, the tumor harbores the BRAF gene mutation, while EGFR, KRAS, ALK, HER-2, RET, ROS-1, PIK3CA and NRAS mutation are negative.Conclusion We report a classic CMPT. The tumor has BRAF mutation and BRAF protein expression. Classic lesions are easy to identify, while for morphological variant cases, the key to the diagnosis of the disease is the diversity of cell components and the presence of basal cells.

The Diagnostic Value of Multi-Modal Ultrasound on the Ovarian Serous Surface Papillary Borderline Tumor

Background: Compared with epithelial ovarian cancer, borderline ovarian tumor has earlier onset age and better prognosis. Ovarian serous surface papillary borderline tumor (SSPBT) is a special subtype of ovarian serous borderline tumor, which is rare in clinic. It is easy to be misdiagnosed as malignant before operation. SSPBT usually occurs in women of childbearing age. The operation of preserving fertility can have a higher pregnancy rate. Therefore, preoperative ultrasound for qualitative diagnosis of SSPBT is of great significance in the selection of surgical methods and treatment. There are few reports on the imaging of SSPBT, and the multimodal ultrasound features of SSPBT combined with conventional ultrasound, two-dimensional and three-dimensional contrast-enhanced ultrasound have not been reported. The purpose of this article is to explore the multimodal ultrasonic characteristics of ovarian SSPBT, combining its clinical and pathological features.Result: The conventional ultrasound of ovarian SSPBT was characterized by large patchy substantial masses wrapped around the ovary.Large flaky dense fine anechoic areas could be seen in the parenchyma,accompanied by speckle strong echo with different degrees.Peritoneal implants were observed in 3 cases(60%)and ascites were found in 4 cases(80%).On further contrast-enhanced ultrasonography,with reference to the myometrium,the tumor on 2D-CEUS showed synchronous or delayed eccentric and inhomogeneous enhancement,and subsided earlier than the uterine wall.The tortuously running tumor trophoblast vessels from the periovarian of the affected side could be further observed clearly and stereospecially on 3D-CEUS.Angiographic rising time(RT),time to peak(TTP),peak intensity(PI),area under the curve(AUC)and half time of descending peak intensity(HT)were significantly different from those of the myometrium(P<0.05).The speckled strong echo observed by conventional ultrasound was correlated with the sand body of the fiber stalk axis in the papillary structure under pathological microscope,while the tortuosity and dilation of microvessels in the fibrous connective tissue axis was the pathological basis of their CEUS perfusion.Conclusion: There are characteristic manifestations of ovarian SSPBT on multimodal ultrasound,which are closely related to the pathological structure.Multimodal ultrasound has important reference value in the diagnosis of ovarian SSPBT.

The solid subtype, according to the IASLC/ATS/ERS classification of lung adenocarcinoma, as a predictive marker for PD-L1 expression

Background: PD-L1 expression in tumor cells can predict the efficacy of PD-1/PD-L1 inhibitors and prognosis in patients. However, the correlation between the PD-L1 expression and the novel lung adenocarcinoma classification are obscure. Methods: 126 lung adenocarcinoma cases were reviewed in the Third Affiliated Hospital of Soochow University from Jan. to Dec. 2019. PD-L1 (DAKO 22C3) was used to test the PD-L1 expression in lung cancer tissue. Result: TPS was used to interpret the PD-L1 expression. The negative, low positive and high positive of PD-L1 were 72 cases (57.14%), 39 cases (30.95%) and 15 cases (11.90%). PD-L1 TPS in solid structure was significantly higher than that in acinar structure, lepidic structure and papillary structure (P<0.001, respectively). The results of c2 test showed the PD-L1 expression had the significant difference with gender (P = 0.005), age (P = 0.030), smoking history (P = 0.024), lymph node metastasis (P <0.001), TNM stage (P = 0.001), acinar structure (P = 0.003) and solid structure (P < 0.001). Multi-factor linear regression results suggested that solid structure, TNM stage and smoking history were associated with PD-L1 expression (P < 0.05). The solid structure showed more capability to PD-L1 expression (β = 0.428). Conclusion: PD-L1 expression was heterogeneity in lung adenocarcinoma. The solid structure, TNM stage and smoking history were correlation to up-regulation of PD-L1 expression, and solid structure was the most importance factor.

Clinicopathological and Genomic Analysis of a Chinese ccRCC Patient with Multiple Morphologies and Rapid Progression : A Case Report

Background: Renal cell carcinoma (RCC) with sarcomatoid differentiation and multiple metastases is highly aggressive RCC with poor prognosis. However, there are not sufficient report on the genetic alterations and tumor immune microenviroment (TIME) of RCC with complex pathological morphology and aggressive behavior.Case presentation: A rare Chinese RCC case with complex pathological morphology and multiple subcutaneous and soft tissue metastases was reported. The clinical manifestations, histomorphology, immunophenotype and follow-up data were collected and analyzed. We performed target region sequencing and immunohistochemistry staining in different morphological regions of the primary tumor and the peritoneal metastasis. Microscopically, this primary tumor was composed of three different histological variations, including ccRCC like region, eosinophilic papillary structure and sarcomatoid differentiation. The peritoneal metastasis partially showed rhabdoid differentiation. IHC staining didn’t display positivity for characteristic markers. IHC for inflammatory cells showed that CD8+T cells and tumor associated neutrophils (TANs) were significantly increased in the sarcomatous areas and peritoneal metastatic tumor. Genomic analysis indicated that VHL mutations were present in all types of pathological regions and peritoneal metastatic tumor. Therefore, the pathological diagnosis of high-grade ccRCC with sarcomatoid differentiation was established. Additionally, we also found SETD2, TP53 and PDGFRA mutations were observed in sarcomatoid tumor area, whereas BRCA2, ATR, CYLD, YAP1 and COL5A3 mutations were specifically detected in peritoneal metastases. These findings are rather striking because some genes e.g., ATR serine/threonine kinase (ATR) and Hippo signaling (YAP1), PI3K-Akt signaling (PDGFRA) and T cell receptor signaling (COL5A3) were previously reported to be very rare in ccRCC patients.Conclusions: Using next-generation sequencing and TIME analysis, multiple low-frequency mutant genes including PDGFRA, ATR, YAP1 and COL5A3 and increased CD8+ T cells and neutrophils were detected in this rare Chinese ccRCC. These findings potentially provide new evidence and molecular markers for accurately assessing the biological behavior of ccRCC.

A Mouse Model for Studying Stem Cell Effects on Regeneration of Hair Follicle Outer Root Sheaths

ObjectiveStem cells hold promise for treating hair loss. Here an in vitro mouse model was developed using outer root sheaths (ORSs) isolated from hair follicles for studying stem cell-mediated dermal papillary regeneration.MethodsUnder sterile conditions, structurally intact ORSs were isolated from hair follicles of 3-day-old Kunming mice and incubated in growth medium. Samples were collected daily for 5 days. Stem cell distribution, proliferation, differentiation, and migration were monitored during regeneration.ResultsCell proliferation began at the glass membrane periphery then spread gradually toward the membrane center, with the presence of CD34 and CD200 positive stem cells involved in repair initiation. Next, CD34 positive stem cells migrated down the glass membrane, where some participated in ORS formation, while other CD34 cells and CD200 positive cells migrated to hair follicle centers. Within the hair follicle matrix, stem cells divided, grew, differentiated and caused outward expansion of the glass membrane to form a dermal papillary structure containing alpha-smooth muscle actin. Neutrophils attracted to the wound site phagocytosed bacterial and cell debris to protect regenerating tissue from infection.ConclusionIsolated hair follicle ORSs can regenerate new dermal papillary structures in vitro. Stem cells and neutrophils play important roles in the regeneration process.

Fatal hemothorax caused by pleural mesothelioma in a lion

ABSTRACT: Mesothelioma is considered a malignant neoplasm caused by the proliferation of mesothelial cells mostly from the pleura, peritoneum and pericardium. Here we described a case of fatal hemothorax caused by pleural mesothelioma in a lion by means of necropsy, histopathology and immunohistochemistry. Gross inspection of the thoracic cavity showed hemothorax with about 4 liters of blood. Microscopically, numerous, randomly distributed, soft, red-pink, irregular masses with up to 1cm in diameter were observed in both visceral and parietal pleurae. Microscopically, a papillary structure pattern was observed in the thoracic masses, composed mainly by one layer of cubic mesothelial cells, which presented eosinophilic cytoplasm, central nucleus and evident nucleolus, supported by a low cellular fibrovascularstroma. Neoplastic cells were positive for both cytokeratin and vimentin by immunohistochemistry. This seems to be the first report of fatal hemothorax caused by pleural mesothelioma in a lion.

The Bionic Anti-Adhesion Study of the Clay on Caterpillar Surface

With analysis of the phenomenon that clay adsorb to the caterpillar surface, a new idea focused on improvement in the surface topography of caterpillar to decrease adhesion of clay is presented on the basis of inspiration from the biological hydrophobic phenomenon and perspective of bionics. The surface topography with papillary structure of caterpillar surface is designed on the basis of Lotus-leaf-likes surface with analysis of its microstructure in accordance with similarity principle. The new structure could effectively prevent clay from adhering to caterpillar surface. A model of the new structure is also built.