Immune checkpoint inhibitors (ICIs) in the recent times have transformed the landscape of the management of many solid tumors. Unfortunately, many immune-related adverse effects are associated with ICIs, which lead to a negative outcome in cancer treatment. We present a case of a 63-year-old female with metastatic adenocarcinoma of unknown origin, who developed celiac disease during the course of treatment with pembrolizumab. Association of celiac disease with this form of immunotherapy has never been documented before.
Undifferentiated/dedifferentiated endometrial carcinoma is an uncommon malignant neoplasm of the endometrium that can present as a diagnostic challenge, especially in a metastatic setting. We present a case of a 70‐year‐old woman with a prior endometrial biopsy diagnosed as endometrioid carcinoma, FIGO Grade 2. Chest computerized tomography showed moderate to severe centrilobular emphysema with a 3 mm nodule in the right upper lobe and posterior mediastinal lymphadenopathy. Fine needle aspiration smears of the mediastinal lymph node showed predominantly single and loosely cohesive tumor cells with scant basophilic cytoplasm, prominent nuclear streaking, and molding. Inconspicuous nucleoli and mitotic figures were present. Immunohistochemical (IHC) stains showed the tumor cells were positive for CD56 and synaptophysin but negative for AE1/AE3, CAM5.2, CK7, CK20, TTF‐1, INSM1, chromogranin, CD99, HMB45, SOX10, EBV‐LMP1, and desmin. Flow cytometry was negative for lymphoma. Based on the overall cytologic findings and significant smoking history, a small cell carcinoma could not be excluded. Similar morphologic findings were identified on the corresponding lymph node biopsy. Because of the history of endometrial carcinoma, additional IHC stains (PAX 8, ER, and EMA) were done but were negative. However, the mismatch repair proteins revealed loss of MLH1 and PMS2 with retained MSH2 and MSH6 nuclear expression. Hence, a metastatic undifferentiated component of a dedifferentiated carcinoma from the patients' endometrial primary was favored and subsequently confirmed on the hysterectomy specimen.
Introduction/Objective Osteoporosis often complicates the management of vertebral conditions, including spinal stenosis and vertebral fractures in the geriatric population. In addition to pharmacologic pain management; surgical interventions are employed if the pain is not adequately managed. The surgical interventions include vertebroplasty and kyphoplasty. These procedures involve the introduction of a cement polymer, Polymethylmethacrylate (PMMA), into the vertebral body. Cement leakage is a reported complication more commonly seen in vertebroplasty (30-75%) compared to kyphoplasty (8-33%). This occurs due to distant leakage of cement into the venous plexus or retrograde migration into the aorta which leads to pulmonary cement emboli (PCE). PCE are usually asymptomatic; few patients are symptomatic; seen in 0.9% for vertebroplasty and 0.4% for kyphoplasty. PMMA has a prothrombotic effect, contributing to the thrombosis of the pulmonary vessels. Symptoms typically arise weeks to months after the procedure. In addition, it has been reported that rarely PCE can present with ARDS especially in patients with interstitial lung abnormalities. Methods We present a case of an 80-year-old female with a history of hypertension, diabetes mellitus and osteoporosis who underwent a kyphoplasty procedure with use of PMMA for spinal stenosis. Her post-operative course was complicated by multiple surgical revisions. She was noted to have pulmonary cement emboli five months post kyphoplasty and developed significant shortness of breath eight months post procedure. She ultimately developed cardio-pulmonary failure and was found to have bilateral pulmonary emboli and cement emboli at autopsy. Microscopic examination of the cement emboli documented round to oval vacuole-like cavities within and around blood vessels consistent with PMMA. Conclusion The histo-pathologic findings of cement emboli are not well documented in human beings compared to animal models. We attempt to highlight the gross and microscopic findings of PMMA cement emboli which is essential in the clinical-histo-pathologic correlation and characterization of pulmonary emboli at autopsy.
Immunocompromised patients, especially organ transplant recipients, are at risk for opportunistic infections. Cryptococcus , a ubiquitous environmental fungus, can cause potentially fatal infection in such hosts. While it can involve any organ in the human body, respiratory and central nervous systems are commonly affected. We present a case of disseminated cryptococcal infection in a liver transplant recipient in whom the initial presentation was bilateral axillary lymphadenopathy, a relatively rare clinical manifestation. Rapid diagnosis and targeted antimicrobial therapy are paramount for favorable clinical outcomes, particularly in this patient population.
Introduction/Objective Gastrointestinal stromal tumors (GISTs) are rare with an approximate prevalence of 2%. Though rare, they are the most common mesenchymal neoplasm of the gastrointestinal tract. They commonly occur in the stomach (50-60%), small intestine (20-30%), large intestine and esophagus (<10%). GISTs arising in the appendix are very rare, with less than 20 cases reported in the English literature to date. The clinical presentation varies from appendicitis-like symptoms to incidental findings on imaging, during surgery for other diseases or at autopsy. The differential diagnosis of GIST from other stromal tumors is often difficult on hematoxylin and eosin (H&E) examination alone. The use of immunohistochemistry (IHC) plays a key role in confirming the diagnosis. GISTs can be graded based on a four-tier risk stratification system, including high, intermediate, low and very low risk, taking size tumor and mitotic activity into consideration. Most of the previously reported cases of primary appendiceal GIST were low or very low risk but one case of malignant GIST arising in the appendix has been reported. Methods We present the case of a 65-year-old male with a slightly thickened appendix and fluid in the distal aspect incidentally found on computer tomography (CT) scan for diverticulitis workup. An appendectomy with adequate was performed. The gross specimen revealed a 0.2-0.4 cm thick wall with no gross perforations or masses. Histologically, the tumor measured 0.8 cm and was composed of spindle cells with no nuclear atypia and absent to low mitotic activity. The IHC profile of the tumor was positive for CD117, DOG1 and CD34. A diagnosis of Gastrointestinal stromal tumor, low grade was rendered. Conclusion We endeavor to highlight the importance of considering GIST in the differential diagnosis in patients with nonspecific symptoms and/or atypical image findings of the appendix especially in ruling out a possible malignant GIST.
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