Assessment of Structural Disconnections In Gliomas: Comparison of Indirect And Direct Approaches

Gliomas are amongst the most common primary brain tumours in adults and are often associated with poor prognosis. Understanding the extent of white matter (WM) which is affected outside the tumoral lesion may be of paramount importance to explain cognitive deficits and the clinical progression of the disease. To this end, we explored both direct (i.e., tractography based) and indirect (i.e., atlas based) approaches to quantifying WM structural disconnections in a cohort of 50 high- and low-grade glioma patients. While these methodologies have recently gained popularity in the context of stroke, to our knowledge this is the first time they are applied in patients with brain tumours. More specifically, in this work we present a quantitative comparison of the disconnection maps provided by the two methodologies by applying well known metrics of spatial similarity, extension and correlation. Given the important role the oedematous tissue plays in the physiopathology of tumours, we performed these analyses both by including and excluding it in the definition of the tumoral lesion. This was done to investigate possible differences determined by this choice.We found that direct and indirect approaches offer two distinct pictures of structural disconnections in patients affected by brain gliomas, presenting key differences in several regions of the brain. Following the outcomes of our analysis, we eventually discuss the strengths and pitfalls of these two approaches when applied in this critical field.

IT IS NOT ALWAYS A CHOLANGIOCARCINOMA: UNUSUAL PERITONEAL CARCINOMATOSIS REVEALING GASTRIC ADENOCARCINOMA

In more than 85% of cases, gastric cancer is discovered at an advanced stage. Malignant biliary obstruction is an uncommon complication of gastric cancer, this case report presents a case of a peritoneal carcinomatosis causing biliary obstruction with radiographic dilatation, mimicking cholangiocarcinoma, and secondary to gastric adenocarcinoma. The imaging investigation had decisive roles in the diagnosis and differential diagnosis of the malignant jaundice predominated by periductal infiltrating cholangiocarcinoma, this pattern of cholangiocarcinoma, is frequently found in perihilar cholangiocarcinoma, it typically shows marked dilatation on imaging of the biliary tree proximal to the tumoral lesion.

A new algorithm of preoperative preparation of patients with focal lesions of the biliopancreatic area complicated by mechanical jaundice

Pancreatoduodenal resection (PDR) represents one of the most demanding procedures which is required in patients with a tumoral lesion at this level. The aim of the present article was to report the results of 272 patients submitted to such surgical procedures. All patients were divided into two groups: the main group, for whom the optimized decompression algorithm was used (n=112) and the control group, for whom preparation for PDR was carried out according to generally accepted standards (n=160). Upon admission to the hospital, the total bilirubin level in the main group was 274.6±5.9 µmol/l while in the control group this level was 270.4±4.6 µmol/l. PDR was performed in 272 of the patients. Whipple’s terminolateral anastomosis was performed in 38/160 (23.7%) of patients in the control group; termino-terminal anastomosis according to Shalimov-Kopchak’s method was imposed in 40/160 (25.0%) patients of the control group. Pancreatojejunoanastomosis with the imposition of a ductomucosal anastomosis was performed in 128 patients in total with 73 cases in the main group and in 55 cases in the control one. Pancreatogastroanastomosis with plunging of the pancreatic stump into the stomach stump was performed in 35 patients in total with 19 patients in the main group and 16 in the control group. Pancreatogastroanastomosis with plunging of the pancreatic stump into the ‘stomach sleeve’ was performed in 32 patients in total with 20 patients in the main group and 12 in the control group. The mortality rate in the main group was 6.3% (7 patients), and in the control group, 11.9% (19 patients). In conclusion, biliary decompression may improve the postoperative outcomes after pancreatic resection. Abbreviations: CEA, carcinoembryonic antigen; CA, cancer antigen; PDR, pancreatoduodenal resection; MRI, magnetic resonance imaging

Physiopathological Aspects of Sellar Epidermoid Cyst Determining Endocrine Disturbances: A Case Report

Epidermoid cysts (ECs) of the central nervous system (CNS) constitute benign circumscribed lesions that are more common in lateral than in midline sites. Epidermoid cysts of the CNS arise more frequently in the cerebellopontine angle, around the pons, near the sella, within the temporal lobe, in the diploe, and in the spinal canal. Most common tumoral lesion of sellar region is pituitary adenoma, and sellar cystic epithelial masses may be difficult to differentiate based only on clinical and imaging findings. Epidermoid cysts are covered by keratinized squamous epithelium and are usually filled with keratin lamellae. The process is, for the most part, maldevelopmental in origin, presumably arising from trapped surface ectodermal elements in association with the developing CNS during the closure of the neural groove or formation of the secondary cerebral vesicles. In the present study, the authors describe a case of sellar epidermoid cyst producing endocrine alterations and visual disturbance in a 35 years woman, and review the physiopathological and diagnostic criteria of this lesion.

Presence of Leishmania sp. and Dirofilaria immitis in Cutaneous Canine Transmissible Venereal Tumor

Background: Canine Transmissible Venereal Tumor (CTVT) is a neoplasm transmitted by implantation of its cells into genital and extragenital organs, while Heartworm and Visceral Leishmaniasis are zoonosis transmitted by hematophagous insects that are often underdiagnosed in asymptomatic animals. Coinfection by the agents of these parasitosis is well documented, however, the association of both diseases with the CTVT is still unusual. Thus, it was aimed to report a case of incidental identification of microfilariae of D. immitis and amastigotes forms of Leishmania sp. in cutaneous CTVT by cytology in an asymptomatic dog for the parasitosis.Case: A 6-year-old, male, mongrel, sexually intact dog from the city of Patos, Paraiba, Brazil, was presented with a cutaneous circumscribed tumoral lesion in a region adjacent to the right olecranon, with an ulcerated surface of reddish color, having areas of necrosis inside and larvae (myiasis), draining bloody secretion. The material was collected for cytological analysis, which proved to be Canine Transmissible Venereal Tumor (CTVT) with the presence of amastigote forms of Leishmania sp. and microfilariae of D. immitis among neoplastic cells. Blood count, serum urea, creatinine and albumin, ALT, AST, FA, CK, Na+, K+, Ca++, CK-MB, Troponin I (cTnI), Snap 4Dx Plus (Idexx®), Snap Leishmania (Idexx®), and Knott's test were performed, plus chest radiography, blood pressure measurements and electrocardiogram (ECG). The alterations found corresponded to normochromic normocytic anemia, thrombocytopenia, hypoalbuminemia, microfilariae in the Knott test, increase of CK, CK-MB and cTnI, positivity for Erlichia sp., Anaplasma sp., Leishmania sp. and Dirofilaria immitis. Furthermore cardiomegaly on radiographs and sinus arrhythmia associated with atrioventricular block (AVB) of the first degree on the ECG. Euthanasia was performed after necropsy, in which adult worms were observed in the right heart chambers.Discussion: The coexistence of neoplastic diseases and infectious microorganisms is often detected only incidentally in asymptomatic animals and complementary tests are important tools to support clinical suspicions, as was observed in the present case. The fact that the animal is not neutered, be in full sexual activity and have unrestricted life habit, favored his involvement by CTVT due to greater contact with other whole canines. Coinfection by Dirofilaria sp. and Leishmania sp., identified in this case, has already been confirmed in several countries, suggesting the presence of distinct vectors in the same geographical area and the imminent exposure of humans to these agents. Despite the studies evidencing the systemic infection by the two parasites, there are no reports of mutual parasitism by the pathogens mentioned in canine neoplasms, especially in the cutaneous extragenital form of the CTVT, making the present case uncommon. The cytological examination was fundamental not only to show that the cutaneous lesion was a CTVT, but also to have evidenced the parasites Leishmania sp. and Dirofilaria immitis, whose infections remained hidden. The changes present in hematology are commonly present in the diseases diagnosed in this case, and elevation of CK, CK-MB and cTnI denote damage to cardiomyocytes due to the action of both parasites. Cardiomegaly on radiographs and 1st degree AVB on the ECG also correspond to secondary changes in the presence of worms in the animal's cardiovascular system. Thus, the presence of a dog autochthonously infected by parasites with a zoonotic potential reveals the susceptibility of other animals and humans in the region to infections.

Inflammatory Pseudotumor of the Pancreas Mimicking a Pancreatic Neoplasm

A 78-year-old woman was admitted to our hospital with a pancreatic tumor, incidentally discovered in an abdominal ultrasound exam. She was asymptomatic and without any previous personal pathological condition. The computed tomography (CT) and the magnetic resonance imaging (MRI) scan showed a mass lesion of 4 cm in diameter, located in the pancreatic body, conditioning the invasion of the splenic vein. The patient was admitted to surgery. During the laparotomy, we found a tumoral lesion highly suspicious of pancreatic neoplasia located in the transition of the head/body of the pancreas, with an invasion of the portal vein and several peri-regional lymph nodes. We performed biopsies of the pancreatic mass and lymphadenectomy of the peri-regional pancreatic lymph nodes. Histological analysis found an inflammatory pseudotumor of the head/body of the pancreas, without signals of malign epithelial neoplasm and also without criteria for immunoglobulin G4-related disease. During the follow-up, a PET/CT and MRI confirmed that the pancreatic lesion had disappeared without any treatment. Inflammatory pseudotumor of the pancreas is a rare entity not fully understood. Despite this, the administration of corticosteroids and immunosuppressive therapy could be taken into consideration as the disease carries a risk.

Primary mucosa-associated lymphoid tissue (MALT) lymphoma of the lacrimal drainage system in two pediatric patients

Primary non-Hodgkin lymphoma (NHL) of lacrimal drainage system (LDS) is quite rare in children, but it is important to expedite early diagnosis in an effort to alter possible life-threatening disease since they are usually misdiagnosed as chronic dacryocystitis. In the literature, there are few examples of tumors of LDS in children. The authors herein report two pediatric cases of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) originating from lacrimal sac in an attempt to increase the knowledge about the clinical course of NHL of LDS. Considerable care must be taken since tumors of lacrimal drainage can mimic dacryocystitis clinically and macroscopically. Two patients both attended with painless swelling in the left lacrimal sac region and epiphora of the left eye. Orbital magnetic resonance imaging showed a tumoral lesion in the left lacrimal sac region and histopathological examination of excisional biopsy specimen demonstrated MALT lymphoma in both patients. The treatment regimen comprises lacrimal sac excision within the tumor, canalicular dacryocystorhinostomy (DCR) with bicanalicular silicone intubation (BSI) combined with chemotherapy and regional radiotherapy in one case, whereas the second case received only radiotherapy after canalicular DCR with BSI. Both of them maintained clinical remission along follow-up.

Fatal Course of Abdominal Neonatal Intestinal Fibrosarcoma

Infantile fibrosarcoma (IFS) is a rare nonrhabdomyosarcoma soft tissue tumor and accounts for less than 1% of childhood cancers. Forty per cent are present at birth and only 10% of IFS occurs in the abdomen. Our case of neonatal fibrosarcoma presented as a distal small bowel stenosis complicated with meconium peritonitis. The diagnosis was by histology of the surgical resection. The diagnosis of IFS is challenging as there are no specific features of IFS on imaging. Any unexpected solid lesion should raise the suspicion of complicated bowel tumoral lesion. If a neoplastic lesion is suspected extensive, surgery may be postponed until the final diagnosis is made.

Pediatric patient with diagnosis of extra osseous Ewing’s sarcoma of the tongue: case report

ABSTRACT Ewing’s sarcoma is a malignant tumor that arises mainly from bone tissue, so that its extra-osseous presentation is not very common and even more unusual, in the soft tissues of the oral cavity. The objective of this case was to describe the clinical characteristics of an extra-osseous Ewing’s Sarcoma of the tongue in a pediatric patient. An 11-year-old male school patient, who attended an oral medicine consultation referring a volume increase in the tongue. Intraorally, a tumoral lesion was observed on the left lateral edge of the tongue, indurated, with the same color of the mucosa with ulcerated areas, well defined edges and symptomatic on palpation, with an approximate size of 2.5 cm. A cervical and maxillofacial MRI was indicated, observing a partially delimited hyperintense and non-infiltrating lesion in the described area. An incisional biopsy was performed with histopathological diagnosis of malignant neoplasm of blue round cells, theCD99 marker was found to be positive in the immunohistochemical study and was key to the definitive diagnosis of this tumor. A thoraco-abdomino-pelvic tomography was requested by the Pediatric Oncology service, as well as biopsy and aspiration of bone marrow, in which no neoplastic infiltrations were evidenced. After four cycles of chemotherapy, total removal of the lesion was performed with a consecutive histopathological study of the surgical piece, indicating free edges of the lesion. Ewing’s sarcoma is a tumor with aggressive behavior, so this case represents a finding of clinical and epidemiological relevance, both due to its extra-osseous appearance and its unusual behavior.