Clinical diagnostic dilemma: Oral verruciform xanthoma

Verruciform xanthoma is a specific but not so common, papillary growth typically occurring on the oral mucosa of middle-aged persons. It is a unique entity and has found to be incident in 0.025-0.05% of all cases reported as per the literature study. One such case of 75 days duration was successfully managed with complete local surgical excision. The surgical site was monitored for one year postoperatively with no signs of recurrence or other postoperative complications. Clinical perspective, histopathological highlights and differential interpretation is discussed in this article with an in-depth review of the literature. It is important to consider this rare entity in the differential diagnosis of lesions involving oral mucosa as its clinical and histological features overlap with several other lesions.

The BRAFV600E Mutation Is Not a Risk Factor for More Aggressive Tumor Behavior in Radiogenic and Sporadic Papillary Thyroid Carcinoma at a Young Age

Histopathological changes in the fusion oncogene-driven papillary thyroid carcinomas (PTCs) from children and adolescents exposed to Chernobyl fallout have been extensively studied. However, characteristics of the radiogenic BRAFV600E-positive PTCs, whose proportion is growing with time, are not well described yet. We analyzed the relationship between the BRAFV600E status (determined immunohistochemically with the VE1 antibody) and the clinicopathological features of 247 radiogenic and 138 sporadic PTCs from young Ukrainian patients aged ≤28 years. The frequency of BRAFV600E was increasing with patient age, consistently remaining lower in radiogenic PTCs. In both etiopathogenic groups, the BRAFV600E-positive PTCs more frequently had a dominant papillary growth pattern, smaller tumor size, higher Ki67 labeling index, and a frequency of the major indicators of tumor invasiveness that is lower than or equal to that of the BRAFV600E-negative tumors. Comparison of the BRAFV600E-positive PTCs across the groups found a virtual absence of differences. In contrast, the BRAFV600E-negative radiogenic PTCs displayed less frequent dominant papillary and more frequent solid growth patterns, lower Ki67 labeling index, and higher invasiveness than the BRAFV600E-negative sporadic tumors. Thus, BRAFV600E is not associated with a more aggressive course of PTC in young patients regardless of etiology. The major clinicopathological differences between the radiogenic and sporadic PTCs are observed among the BRAFV600E-negative tumors.

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.

The Morphological Spectrum of Papillary Renal Cell Carcinoma and Prevalence of Provisional/Emerging Renal Tumor Entities with Papillary Growth

Renal cell carcinoma (RCC) represents a heterogeneous disease, encompassing an increasing number of tumor subtypes. Post-2016, the World Health Organization (WHO) classification recognized that the spectrum of papillary renal cell carcinoma is evolving and has long surpassed the dichotomic simplistic “type 1 versus type 2” classification. The differential diagnosis of pRCC includes several new provisional/emerging entities with papillary growth. Type 2 tumors have been cleared out of several confounding entities, now regarded as independent tumors with specific clinical and molecular backgrounds. In this work we describe the prevalence and characteristics of emerging papillary tumor entities in two renal tumor cohorts (one consisting of consecutive papillary tumors from a single institute, the other consisting of consultation cases from several centers). After a review of 154 consecutive pRCC cases, 58% remained type 1 pRCC, and 34% type 2 pRCC. Papillary renal neoplasm with reversed polarity (1.3%), biphasic hyalinizing psammomatous RCC (1.3%), and biphasic squamoid/alveolar RCC (4.5%) were rare. Among 281 consultation cases, 121 (43%) tumors had a dominant papillary growth (most frequently MiT family translocation RCCs, mucinous tubular and spindle cell carcinoma and clear cell papillary RCC). Our data confirm that the spectrum of RCCs with papillary growth represents a major diagnostical challenge, frequently requiring a second expert opinion. Papillary renal neoplasm with reversed polarity, biphasic hyalinizing psammomatous RCC, and biphasic squamoid/alveolar RCC are rarely sent out for a second opinion, but correct classification and knowledge of these variants will improve our understanding of the clinical behavior of renal tumors with papillary growth.

Upregulation of Fatty Acid Transporters is Associated With Tumor Progression in Non-Muscle-Invasive Bladder Cancer

As patients with non-muscle-invasive bladder cancer (NMIBC) show a high degree of heterogeneity in tumor recurrence or progression, many clinicians demand a detailed risk stratification. Although modified fatty acid metabolism in cancer cells is reported to reflect malignant phenotypes such as metastasis, the impact of fatty acid transporters on NMIBC has never been investigated. This study examined the clinicopathologic implications of fatty acid transporters such as fatty acid transport protein 4 (FATP4), cluster of differentiation 36/fatty acid translocase (CD36/FAT), and long chain acyl CoA synthetase 1 (ACSL1) in 286 NMIBC cases. This study revealed that FATP4, CD36, and ACSL1 were overexpressed in 123 (43.0%), 43 (15.0%), and 35 (12.2%) NMIBC cases, respectively. High FATP4 in tumor cells was associated with high grade (p = 0.004) and high stage (p = 0.039). High CD36 was related to high grade (p < 0.001), high stage (p = 0.002), and non-papillary growth type (p = 0.004). High ACSL1 showed an association with high grade (p < 0.001), high stage (p = 0.01), non-papillary growth type (p = 0.002), and metastasis (p = 0.033). High FATP4 was an independent factor predicting short overall survival (OS) (hazard ratio = 3.32; 95% confidence interval, 1.07–10.31; p = 0.038). In conclusion, upregulation of FATP4, CD36, and ACSL1 might promote the NMIBC progression and could be exploited in clinical risk stratification and targeted therapy.

Challenging of frozen diagnoses of small sclerosing pneumocytoma

AimsAn increasing number of small pulmonary nodules are being screened by CT, and an intraoperative diagnosis is necessary for preventing excessive treatment. However, there is limited literature on the frozen diagnosis of small sclerosing pneumocytomas (SPs). In particular, tumours smaller than 1 cm are challenging for pathologists performing intraoperative frozen diagnosis.MethodsIn total, 230 cases of SP were surgically resected between January 2015 and March 2019 at Shanghai Chest Hospital, and of them, 76 cases were smaller than 1 cm. The histology and clinical information of these 76 cases (33.0%, 76/230) were reviewed retrospectively, 54 cases of which were diagnosed intraoperatively, and the pitfalls were summarised. All diagnoses were confirmed on permanent sections and immunohistochemical sections.ResultsHistologically, 78.9% (60/76) of the small SP was dominated by one growth pattern, and solid and papillary growth pattern were the most commonly misdiagnosed circumstances. The rate of intraoperative misdiagnosis of these SP smaller than 1 cm was 11.1% (6/54).ConclusionsThe main reason for misdiagnosis was failure to recognise the dual cell populations and the cellular atypia. Diagnostic clues include the gross morphology, the presence of dual-cell populations and a hypercellular papillary core, foam cell accumulation in glandular spaces and haemorrhage and haemosiderin on the periphery. In spite of awareness of pitfalls some cases may still be essentially impossible to diagnose on frozen section.

Progression to invasive cancer after snare polypectomy of intracholecystic papillary neoplasms during gallbladder stone removal by percutaneous transhepatic choledochoscopy: a case report

Background Intracholecystic papillary neoplasms (ICPNs) of the gallbladder are rare, preinvasive lesions characterized by an intracholecystic papillary growth that may be associated with invasive adenocarcinoma. The natural history of ICPN is unknown. Here, we report a case of ICPN, highlighting its natural course. Case presentation A 79-year-old woman presented to the emergency department with perforated cholecystitis. After percutaneous transhepatic gallbladder drainage, due to the presence of surgical risk factors, we opted to perform gallstone removal through percutaneous transhepatic cholangioscopy instead of cholecystectomy. ICPN, which was accidentally detected after the removal of the gallbladder stones, was also endoscopically removed. After 4 years, the patient came back to the hospital with a large gallbladder mass. After cholecystectomy, pathological examination revealed ICPN with invasive adenocarcinoma. Conclusion The current case showed endoscopic findings of ICPN and its natural progression, particularly its clinicopathological features and outcomes.

Etiology and Management of Inflammatory Papillary Hyperplasia in Completely Edentulous Patients - A Review

Oral mucosa of complete denture wearing patients is subjected to varying amount of stresses as compared to patient having natural teeth. This can leads to different type of oral mucosal lesions like denture stomatitis, epulis fissuratum, angular cheilitis, traumatic ulcers, inflammatory papillary hyperplasia (IPH) etc. IPH is a type of chronic inflammatory proliferative lesion characterized by numerous small, wart like edematous red papillary growth most commonly seen in deepest part of the palate. Review of literature suggest denture associated widely distributed etiology for IPH like over accentuation of palatal relief and vacuum chamber in upper denture, old ill fitting dentures, poor denture hygiene, continuous denture wearing habit, faulty occlusion, skidding of instable denture etc. Treatment for IPH varies with the severity of the condition and may range from conservative to surgical depending on clinical presentation. Conservative approach include discontinuing use of ill fitting denture, correction of faulty prostheses, improving the oral and denture hygiene and antifungal drugs. However, the surgical approach is used when the lesion is more aggressive and this include supraperiosteal excision, resesctive surgery, cryotherapy, and electrosurgery, blade-loop surgery, fulguration, and mucoabrasion or laser surgery. As a method of prevention patient should be advised to avoid continuous day and night wearing of denture. Additionally, avoid providing excessive relief in the palatal region, as these areas become site for bacterial and fungal colonization. Patients should be well motivated for proper care and maintenance of denture hygiene and also for the importance of periodic dental visits and follow-ups.

Misdiagnosed mesonephric adenocarcinoma in the cervix: a case report and review of the literature

Background Mesonephric adenocarcinoma (MNAC) in the female reproductive system is a rare tumour caused by remnants of the mesonephric duct, mainly located in the cervix. Because of the rarity of the disease and few reports to date, no specific clinical features have been identified. Its diagnosis is challenging because MNAC may exhibit multiple morphological patterns, complicating differential diagnosis. Case presentation We report a 57-year-old female with cervical MNAC who was misdiagnosed with squamous cell carcinoma by biopsy. Histological study revealed a solid, glandular and papillary tumour. The pattern of papillary growth exhibited a vascular axis, and the morphology was similar to that of high-grade squamous intraepithelial lesions. Based on immunohistochemistry, the tumour cells were negative for CK5/6, P40 and Vimentin; GATA-binding protein 3 (GATA3), CD10, AE1/AE3, CK7 and P16 were diffusely positive; calretinin was focally positive; and oestrogen receptor (ER), progesterone receptor (PR), thyroid transcription factor-1 (TTF1) and p53 were negative. The patient received neoadjuvant chemotherapy, surgery and adjuvant chemotherapy and had no evidence of disease as of 10 months after the operation. The clinical manifestations, pathological features, treatment and prognosis of MNAC were summarized by reviewing the existing literature. Conclusions When tumours with papillary and squamous epithelial growth patterns are detected by biopsy, it is necessary to apply immunohistochemistry analysis to avoid misdiagnosis.