Tumor-stroma ratio as a new prognosticator for pseudomyxoma peritonei: a comprehensive clinicopathological and immunohistochemical study

Background As a rare clinical tumor syndrome with an indolent clinical course and lack of pathognomonic symptoms, pseudomyxoma peritonei (PMP) is usually diagnosed at an advanced stage. In-depth pathological analysis is essential to assess tumor biological behaviors, assist treatment decision, and predict the clinical prognosis of PMP. The tumor-stroma ratio (TSR) is a promising prognostic parameter based on the tumor and stroma. This study explored the relationship between TSR and the pathological characteristics and prognosis of PMP. Methods PMP patients with complete data who underwent cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy were enrolled. The TSR of postoperative pathological images was quantitatively analyzed by Image-Pro Plus. Then the relationship between TSR and the clinicopathological characteristics, immunohistochemical characteristics and prognosis of PMP was analyzed. Results Among the 50 PMP patients included, there were 27 males (54.0%) and 23 females (46.0%), with a median age of 55 (range: 31–76) years. 25 (50.0%) patients were diagnosed with low-grade PMP (LG-PMP), and 25 (50.0%) were diagnosed with high-grade PMP (HG-PMP). There were 4 (8.0%) patients with vascular tumor emboli, 3 (6.0%) patients with nerve invasion, and 5 (10.0%) patients with lymph node metastasis. The immunohistochemical results showed that the Ki67 label index was < 25% in 18 cases (36.0%), 25 - 50% in 18 cases (36.0%) and > 50% in 14 cases (28.0%). The range of TSR was 2 - 24% (median: 8%). The cutoff value of TSR was 10% based on the receiver operating characteristic (ROC) curve and X-Tile analysis. There were 31 (62.0%) cases with TSR < 10% and 19 (38.0%) cases with TSR ≥ 10%. The TSR was closely related to histopathological type (P < 0.001) and Ki67 label index (P < 0.001). Univariate analysis showed that preoperative carcinoembryonic antigen (CEA), preoperative carbohydrate antigen 19–9, pathological type, vascular tumor emboli and TSR influenced the prognosis of PMP patients (P < 0.05). Multivariate analysis showed that preoperative CEA, vascular tumor emboli and the TSR were independent prognostic factors. Conclusions The TSR could be a new independent prognosticator for PMP.

Cerebral Infarction Caused by Direct Cardiac Tumor Emboli Mixed with Thrombus

Cerebral infarction in cancer patients is often caused by thrombosis due to hypercoagulability, and in some cases, caused by direct tumor embolism. We report the case of cerebral infarction due to direct tumor embolism mixed with thrombus. Biopsy of blood clots obtained during thrombectomy is important for diagnosis. If there is a high risk of thrombosis among cancer patients with cerebral infarction, the use of appropriate antithrombotic agents along with maintaining a certain level of platelets should be considered.

Chylous Ascites, Unusual Association with Ductal Pancreatic Adenocarcinoma with Plasmacytoid Morphology: A Case Report and Literature Review

Chylous ascites represents a relatively uncommon condition. In this paper, we present a case of chyloperitoneum associated with pancreatic ductal adenocarcinoma (PDAC) and a review of literature regarding chylous ascites. A 76-year-old male patient was admitted in emergency department with acute abdomen. A pancreatic cancer was suspected. Subtotal spleno-pancreatectomy, for a nodular mass infiltrating the mild and distal portion of the pancreas, was necessary. During surgical intervention in the peritoneal cavity, a moderate quantity of whitish and thick consistency fluid with milk-like appearance was observed to be accumulated. After examination of the fluid, chyloperitoneum was diagnosed. The histologic examination showed a PDAC, with multiple emboli in lymph vessels, with tumor cells with plasmacytoid morphology, diagnosed as lymphangiosis carcinomatosa. The patient died at 3 weeks after surgical intervention. In patients with pancreatic cancer and chylous ascites, suspicion of tumor-related blockage of the lymphatic flow should be suspected. Prognosis of PDAC should be evaluated not only based on the number of lymph node metastases, but also considering the number of lymph vessels with tumor emboli and the architecture of tumor cells. This is the first reported case of a PDAC with plasmacytoid morphology of lymphangiosis carcinomatosa.

False-negative frozen section of sentinel nodes in early breast cancer (cT1-2N0) patients

Background Sentinel lymph node biopsy (SLNB) is the standard approach for the axillary region in early breast cancer patients with clinically negative nodes. The present study investigated patients with false-negative sentinel nodes in intraoperative frozen sections (FNSN) using real-world data. Methods A case–control study with a 1:3 ratio was conducted. FNSN was determined when sentinel nodes (SNs) were negative in frozen sections but positive for metastasis in formalin-fixed paraffin-embedded (FFPE) sections. The control was defined as having no metastasis of SNs in both frozen and FFPE sections. Results A total of 20 FNSN cases and 60 matched controls from 333 SLNB patients were enrolled between April 1, 2005, and November 31, 2009. The demographics and intrinsic subtypes of breast cancer were similar between the FNSN and control groups. The FNSN patients had larger tumor sizes on preoperative mammography (P = 0.033) and more lymphatic tumor emboli on core biopsy (P < 0.001). Four FNSN patients had metastasis in nonrelevant SNs. Another 16 FNSN patients had benign lymphoid hyperplasia of SNs in frozen sections and metastasis in the same SNs from FFPE sections. Micrometastasis was detected in seven of 16 patients, and metastases in nonrelevant SNs were recognized in two patients. All FNSN patients underwent a second operation with axillary lymph node dissection (ALND). After a median follow-up of 143 months, no FNSN patients developed breast cancer recurrence. The disease-free survival, breast cancer-specific survival, and overall survival in FNSN were not inferior to those in controls. Conclusions Patients with a larger tumor size and more lymphatic tumor emboli have a higher incidence of FNSN. However, the outcomes of FNSN patients after completing ALND were noninferior to those without SN metastasis. ALND provides a correct staging for patients with metastasis in nonsentinel axillary lymph nodes.

Canine Gastric Carcinomas: A Histopathological and Immunohistochemical Study and Similarities with the Human Counterpart

Gastric carcinoma (GC) continues to be one of the leading causes of death in humans and is the most common neoplasm in the stomachs of dogs. In both species, previous studies have demonstrated that the disease is heterogeneous, with genetic and environmental factors playing a quintessential role in disease pathogenesis. Compared to humans, the incidence of gastric carcinoma in dogs is low although, in a small number of breeds, a higher incidence has been reported. In dogs, the etiology and molecular pathways involved remain largely unknown. This retrospective study reviews current signalment data, evaluates the inflammatory component and association with Helicobacter spp. presence in various canine gastric carcinoma histological subtypes, and investigates potential molecular pathways involved in one of the largest study cohorts to date. The benefit of such a comparative study is to highlight the parallel histological features and molecular pathways between dogs and humans.Abstract: Canine gastric carcinoma (CGC) affects both sexes in relatively equal proportions, with a mean age of nine years, and the highest frequency in Staffordshire bull terriers. The most common histological subtype in 149 CGC cases was the undifferentiated carcinoma. CGCs were associated with increased chronic inflammation parameters and a greater chronic inflammatory score when Helicobacter spp. were present. Understanding the molecular pathways of gastric carcinoma is challenging. All markers showed variable expression for each subtype. Expression of the cell cycle regulator 14-3-3σ was positive in undifferentiated, tubular and papillary carcinomas. This demonstrates that 14-3-3σ could serve as an immunohistochemical marker in routine diagnosis and that mucinous, papillary and signet-ring cell (SRC) carcinomas follow a 14-3-3σ independent pathway. p16, another cell cycle regulator, showed increased expression in mucinous and SRC carcinomas. Expression of the adhesion molecules E-cadherin and CD44 appear context-dependent, with switching within tumor emboli potentially playing an important role in tumor cell survival, during invasion and metastasis. Within neoplastic emboli, acinar structures lacked expression of all markers, suggesting an independent molecular pathway that requires further investigation. These findings demonstrate similarities and differences between dogs and humans, albeit further clinicopathological data and molecular analysis are required.

Cardiac Metastasis from Gastric Adenocarcinoma Mimicking COVID-19 Symptoms

Background Cardiac metastasis with origin of gastric adenocarcinoma is extremely rare. This type of metastasis tends to involve the pericardium through lymphatic seeding. Currently, no reports of solitary tumor emboli to the heart cavity with possible transvenous pathway of seeding has been made. Due to initial dyspnea and accompanying symptoms, cardiac tumor embli may be mistaken with covid-19 infection. Case presentation: A sixty-year-old female with known inoperable diffuse gastric adenocarcinoma receiving chemotherapy from eight months ago, presented to hospital with progressive dyspnea. Other sign and symptoms included chest pain, hypotension, tachycardia and muffled heart sounds. The patients had no fever or other common covid-19 infection symptoms. The RT-PCR for Covid-19 RNA was negative. Initial chest CT-scan showed no sign of infection. A transesophageal echocardiography was performed and revealed a > 6cm vermiform mass free-floating in the right atrium protruding to the tricuspid valve and right ventricle compatible with emboli. By urgent cardiac surgery the mass was removed. The postoperative course was uneventful. The pathology results confirmed a tumor emboli originated from gastric carcinoma. Whole body PET-scan shoed no evidence of other metastasis. Conclusions However cardiac metastasis are extremely rare, in gastric cancer cases with cardiopulmonary manifestation should be considered as a probable differential diagnoses. Regarding to ongoing covid-19 pandemic the present case misdiagnosed with coronavirus infection.

Tumor-stroma Ratio as a New Prognosticator for Pseudomyxoma Peritonei: a Comprehensive Clinicopathological and Immunohistochemical Study

Background: As a rare clinical tumor syndrome, pseudomyxoma peritonei (PMP) is usually diagnosed at an advanced stage. In-depth pathological analysis is essential to assessing tumor biological behaviors, assisting treatment decision, and predicting clinical prognosis of PMP. Tumor-stroma ratio (TSR) is a promising prognostic parameter based on tumor and stroma. This study was to explore the relationship between TSR with pathological characteristics and prognosis of PMP.Methods: PMP patients with complete data who underwent last cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy were collected. The TSR of postoperative pathological images was quantitatively analyzed by Image-Pro Plus. Then the relationship between TSR with clinicopathological characteristics, immunohistochemical characteristics and prognosis of PMP was analyzed.Results: Among the 50 PMP patients included, there were 27 males (54.0%) and 23 females (46.0%), with a median age of 55 (31 - 76) years. The patients with histopathological types of disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA) were both 25 (50.0%), 4 cases (8.0%) with vascular tumor emboli, 3 cases (6.0%) with nerve invasion, and 5 cases (10.0%) with lymph node metastasis. Immunohistochemical results showed that Ki67 label index was < 25% in 18 cases (36.0%) and ≥ 25% in 32 cases (64.0%). The range of TSR was 2% - 24% (median: 8%). The cutoff value of TSR was 10% based on receiver operating characteristic (ROC) curve. There were 31 cases with TSR < 10% while 19 cases with TSR ≥ 10%. It showed that TSR was closely related to histopathological types (P < 0.001) and Ki67 label index (P < 0.001). Univariate analysis showed that preoperative carcinoembryonic antigen (CEA), preoperative carbohydrate antigen (CA) 19-9, pathological types, vascular tumor emboli and TSR influenced prognosis of PMP patients (P < 0.05). Multivariate analysis showed preoperative CEA, vascular tumor emboli and TSR were independent prognostic factors.Conclusion: TSR could be a new independent prognosticator for PMP.