Autopsy & Case Report by Editora Cubo

ISSN 2236-1960

v. 9, n. 2, apr./june 2019

Photomicrograph of the Gamma-Gandy bodies of the spleen showing foci of interstitial fibrosis with iron deposits (H&E, 200X) in a case of sickle cell disease

Hospital UniversitĂĄrio Universidade de SĂŁo Paulo

ISSN 2236-1960 March 2019, volume 9 number 2

Electronic Journal of the Hospital Universitário – Universidade de São Paulo, São Paulo/SP – Brazil President of the University of São Paulo Professor Vahan Agopyan Superintendent of the University Hospital Professor Dr. Paulo Francisco Ramos Margarido

Editorial committee Editor in chief Maria Claudia Nogueira Zerbini, MD, PhD Scientific Editors Aloisio Felipe-Silva, MD, PhD Fernando Peixoto Ferraz de Campos, MD Larry Nichols, MD Alex K Williamson, MD Ameer Hamza, MD Support Team Rubenildo Oliveira da Costa - Head of Library Lucimar da Silva Prado - Editorial assistant Wesley Algarve and Deise Gonçalves dos Santos - Technical support Editora Cubo, desktop publishing Sponsors Programa de Apoio às Publicações Científicas Periódicas da USP Hospital Universitário - University of São Paulo Indexing PubMed Central Lilacs Portal de Revistas da USP PKP IBICT Latindex Diadorin Seminarios.org Directory of Open Access Journals DOAJ

Editorial

The conscientious autopsy Alex K Williamsona,b  How to cite: Williamson AK. The conscientious autopsy. Autops Case Rep [Internet]. 2019;9(2):e2019098. https://doi.org/ 10.4322/acr.2019.098

The competently performed and thoughtfully reported postmortem examination remains a vital component of today’s autopsy practice. The integral role which autopsy plays in documenting diseases and injuries that cause death is well recognized. Of equal importance, however, is that in revealing anatomic pathology (and in some cases microbiologic and biochemical alterations, as well), an autopsy enables morbid anatomy to be correlated with clinical signs and symptoms, thereby enhancing an understanding of the decedent’s ailments. The artful practice of clinical‑pathologic correlation, advanced by Giovanni Battista Morgagni in 1761,1 takes time to master, but becoming skillful at assisting clinicians in understanding a decedent’s medical history or in explaining the cause of a decedent’s symptoms to family members remains one of the most rewarding aspects of autopsy practice. In order to provide meaningful clinical-pathologic correlations, autopsy pathologists should be aware of relevant issues that exist prior to, or arise during, an autopsy, and they should effectively address those issues in a satisfactory manner with the postmortem examination. For example, when pulmonary thromboembolism is identified at autopsy, deep veins of the legs and, if necessary, the arms should be dissected. (N.B. In consented autopsies additional permission(s) for the procedure(s) from next of kin may need to be obtained). Sections of the occluded or empty vessels should be submitted for histology, in addition to sections of pulmonary emboli within vessels.2 Such a thorough evaluation of venous thromboembolism assists in 1) determining the

underlying cause of death (i.e., emboli by definition travel from somewhere, and most but not all pulmonary thromboemboli originate in the legs); 2) identifying a possible etiology of the thrombosis (e.g., potential phlebitis, extrinsic venous compression by tumor); and 3) approximately aging the thrombus and embolus (i.e., “acute”, “subacute”, or “chronic” clots). Complete evaluation and documentation of all relevant issues in such a manner optimizes clinical-pathologic correlation, allows objective medicolegal assessment of relevant issues, and reaffirms the value of autopsy among involved stakeholders. Objectively documenting evidence that can elucidate injury, disease, and/or death, such as in the aforementioned case of venous thromboembolism, is a fundamental purpose of the autopsy and underlies its persistent importance in the medicolegal realm. Indeed, over the past half century hospital autopsy rates have declined around the world,3 while forensic autopsy rates have remained relatively unchanged (at least in the USA).4 The distinction between “hospital” autopsies, in which natural disease processes are evaluated, and “forensic” autopsies, in which injuries as well as natural and non-natural pathologies are investigated, understandably exists to support jurisprudence in various countries. Although forensic pathologists are expected to become adept in performing, reporting, and testifying about autopsies in civil and criminal court proceedings, all pathologists conducting autopsies should recognize that any death may have medicolegal implications and the findings from any autopsy can be drawn into medicolegal proceedings.

Northwell Regional Autopsy Service, Long Island Jewish Medical Center. New Hyde Park, NY, USA. Zucker School of Medicine at Hofstra/Northwell, Department of Pathology. Hempstead, NY, USA.

Autopsy and Case Reports. ISSN 2236-1960. Copyright © 2019. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the article is properly cited.

The conscientious autopsy

In fact, among the various proposed reasons for declining hospital autopsy rates is the misperception among some physicians that autopsies increase the likelihood of malpractice litigation and/or render them culpable in such litigation.5 However, literature from the USA, 6 Germany, 7 and Italy 8 exploring the role of postmortem examinations in cases of medical malpractice revealed that a majority of physicians were exonerated of the charges brought against them in cases where an autopsy had been performed. Moreover, the USA study showed that defendant physicians were acquitted of malpractice in the majority of cases, not only when autopsy findings favored the physician but also when autopsy findings favored the plaintiff initiating the lawsuit. In essence, unfavorable court rulings against defendant physicians involved standard of care issues rather than accuracy of clinical diagnoses in the cases examined by those authors. A poorly performed and/or reported autopsy can be detrimental to physicians, can negatively influence perceptions of the autopsy among healthcare professionals and the public, and does not allow the autopsy’s potential value to be realized. The same review of USA medical malpractice cases discussed above also demonstrated that suboptimal autopsy performance and reporting adversely affected the appeals process in nearly 20% of the examined cases.6 While the legal fate of a particular autopsy may not be known prior to its being completed, pathologists can always control the quality of their autopsy performance and reporting. 9 With the privilege of conducting autopsies and advancing clinical-pathologic correlation comes the responsibility to be consistent, complete, and competent in all facets of autopsy practice.

REFERENCES 1. Ghosh SK. Giovanni Battista Morgagni (1682-1771): father of pathologic anatomy and pioneer of modern medicine. Anat Sci Int. 2017;92(3):305-12. http://dx.doi. org/10.1007/s12565-016-0373-7. PMid:27629485. 2. Gill JR. The medicolegal evaluation of fatal pulmonary thromboembolism. In: Tsokos M, editor. Forensic pathology reviews. Totowa: Humana Press; 2005. p. 285-304. 3. Burton JL, Underwood J. Clinical, educational, and epidemiological value of autopsy. Lancet. 2007;369(9571):1471-80. http://dx.doi.org/10.1016/ S0140-6736(07)60376-6. PMid:17467518. 4. Hoyert DL. The changing profile of autopsied deaths in the United States, 1972-2007. NCHS Data Brief. 2011;(67):18. PMid:22142988. 5. Friederici HH. Turning autopsy liabilities into assets. JAMA. 1983;250(9):1165. http://dx.doi.org/10.1001/ jama.1983.03340090025013. PMid:6876353. 6. Bove KE, Iery C. The role of the autopsy in medical malpractice cases, I: a review of 99 appeals court decisions. Arch Pathol Lab Med. 2002;126(9):1023-31. PMid:12204050. 7. Madea B, Preuss J. Medical malpractice as reflected by the forensic evaluation of 4450 autopsies. Forensic Sci Int. 2009;190(1-3):58-66. http://dx.doi.org/10.1016/j. forsciint.2009.05.013. PMid:19524380. 8. Casali MB, Mobilia F, Del Sordo S, Blandino A, Genovese U. The medical malpractice in Milan-Italy. A retrospective survey on 14 years of judicial autopsies. Forensic Sci Int. 2014;242:38-43. http://dx.doi.org/10.1016/j. forsciint.2014.06.002. PMid:25023215. 9. Williamson AK. Evolving autopsy practice models. In: Hooper JE, Williamson AK, editors. Autopsy in the 21st century: best practices and future directions. Switzerland: Springer Nature; 2018. p. 70-1.

Conflict of interest: None Financial support: None Submitted on: May 24th, 2019 Correspondence Alex K Williamson Department of Pathology - LIJ Medical Center/Northwell 270-05 76th Ave #B68 – New Hyde Park/NY – USA 11040 Phone: +1 718-470-7490 awilliamson@northwell.edu

2-2

Autops Case Rep (São Paulo). 2019;9(2):e2019098

Letter to the Editor

A rare case of abdominal pain Vítor Devezasa , Pedro Amoroso Canãob, Laura Elisabete Barbosaa  How to cite: Devezas V, Canão PA, Barbosa LE. A rare case of abdominal pain. Autops Case Rep [Internet]. 2019;9(2): e2019088. https://doi.org/10.4322/acr.2019.088

DEAR EDITOR We describe herein an unusual cause of recurrent lower abdominal pain of the young male, which is rare and therefore maybe misdiagnosed and scarcely reported. A 23-year-old man with continuous pain in the lower abdominal quadrants (predominantly the left lower quadrant) over the last month, without identifiable maneuvers that cause relief or worsen the pain. He also referred increasing urinary frequency. He denied fever, weight loss, or changes in bowel habits. His past medical history included the diagnosis of a solitary kidney (congenital renal agenesis). The physical examination depicted a soft and depressible abdomen, which was painful on palpation in both lower quadrants, without any mass, swelling, or signs of peritoneal irritation. The ultrasound showed a simple cystic image in the pelvis, adjacent to the left common iliac vessels, with the maximum size of 40 mm. The computed tomography (CT) scan confirmed left renal agenesis (Figure 1), and revealed marked dilation of the left seminal vesicle, with cystic formation at its extremity, measuring 43 × 44 × 47 mm (Figure 1). Thereby the hypothesis of Zinner syndrome (ZS) was raised. With this working diagnosis, the patient was submitted to a laparoscopic excision of the seminal vesicle, which was uneventful. The pathological anatomy report confirmed the presence of a seminal vesicle cyst without malignancy (Figure 2). a b

Acute abdominal pain in the lower quadrants, in males, may be caused by a rare condition as the Zinner syndrome (ZS).1,2 In 1914, A. Zinner 3,4 described the syndrome, which was later named after him. This syndrome is characterized by the association of a triad of Mullerian duct abnormalities, comprising the congenital unilateral renal agenesis, an ipsilateral seminal vesicle cyst, and an ipsilateral ejaculatory duct obstruction. ZS is rare and presents the incidence of 0.00464% in men. 5,6 The ZS description comprises the seminal vesicle cyst with ipsilateral renal agenesis and obstruction of the ejaculatory duct with an ectopic ureter.7,8 According to Maehana et al.,9 to date, just over 200 cases of ZS have been described. It is considered the male counterpart of the Mayer-Rokitansky-Kuster-Hauser syndrome of females. Although the description—and most cases—involve the organs of the same side of the body, four cases have been reported with contralateral renal agenesis.8 This development anomaly is rare and generally asymptomatic. The ZS results from an insult occurring between the 4th and 13th gestational week. 10,11 However, other authors refer the insult (such as mutation of metanephric blastema, or disruption of retinoic acid signaling)4 as occurring before the 7th week of gestation as a preponderant factor.3,4 This anomaly is the result of an incomplete migration of the ureteric bud that fails to fuse with the

Centro Hospitalar Universitário de São João, Department of Surgery. Porto, Portugal. Centro Hospitalar Universitário de São João, Department of Pathology. Porto, Portugal.

A rare case of abdominal pain

Figure 1. abdominopelvic CT. A – axial plane; B – Coronal plane – showing seminal vesicle cyst (arrow); C – axial plane; D – Coronal plane – showing left renal agenesis (asterisk).

Figure 2. A – Gross view of the left seminal vesicle (arrow) and cyst (asterisk); B – Photomicrograph of the cystic wall lined by cuboidal epithelium without atypia and a mild lymphocytic infiltration of the cyst wall consistent with a seminal vesicle cyst (HE, 200x). 2-4

Autops Case Rep (São Paulo). 2019;9(2):e2019088

Devezas V, Canão PA, Barbosa LE

metanephros, which leads to renal agenesis/dysplasia, atresia of the ejaculatory duct, and obstruction and cystic dilatation of the seminal vesicle.10 The symptomatic cases are characterized by perineal pain, painful ejaculation, lower urinary tract symptoms, and other urinary symptoms.9,12 Van den Ouden et al. 13 described dysuria (37%), urinary frequency (33%), perineal pain (29%), epididymitis (27%), and pain after ejaculation (21%) as the main complaints in a series of 52 patients with the diagnosis of ZS. Abdominal pain is a rare symptom of ZS. When present in the suprapubic or lower quadrant, it can be explained by ureterocele or seminal vesicle cyst growth, which elicits an inflammatory reaction in the surrounding viscera.9 The diagnosis of ZS can be incidental, such as in the work-up of infertility.13-15 Malignant transformation in the seminal vesicle cyst is rarely reported.4 The symptoms, when present, start by the second to fourth decade of life (during highest sexual activity), and mostly when cysts exceed 50 mm.3,5,10,16 Our patient is in the third decade of life, and the cyst was 47 mm. He presented mainly with continuous abdominal pain in the lower quadrants and frequent urination. The differential diagnosis of cystic image in the pelvis in males includes: cyst or cystic dilatation of the prostatic utricle, ejaculatory duct cysts (all three in midline), abscess, ectopic ureterocele, prostatic cysts, ejaculatory duct cyst, diverticulosis of the ampulla of the vas deferens, and all cystic pathology of the seminal vesicle (mega vesicles, hydatic cyst, hemorrhage, and hypotonic neuropathy).7,17

or cysts greater than 50 mm, the best approach is laparoscopic (as proposed to our patient) or robotic techniques, with surgical excision of the seminal vesicle cysts.9,12,17 These techniques can relieve the symptoms while preserving fertility and erectile function.17, 18

CONCLUSION We highlight the diagnosis of ZS when a clinician is facing a young male patient with a history of renal agenesis who complains of chronic or recurrent abdominal pain. ZS is a rare condition of abdominal pain, but its correct diagnosis allows the appropriate treatment, which can be minimally invasive surgery in the symptomatic patient or if the cyst is greater than 50 mm. Keywords Kidney Diseases; Seminal Vesicle Secretory Proteins; Congenital Abnormalities; Solitary Kidney; Abdominal Pain.

REFERENCES 1. Ansari P. Acute abdominal pain. MSD Manual; 2017 [cited 2018 Sept 17]. Available from: www.msdmanuals. com 2. Greenberger NJ. Chronic abdominal pain and recurrent abdominal pain. MSD Manual; 2018 [cited 2018 Sept 17]. Available from: www.msdmanuals.com 3. Mehra S, Ranjan R, Garga UC. Zinner syndrome: a rare developmental anomaly of the mesonephric duct diagnosed on magnetic resonance imaging. Radiol Case Rep. 2016;11(4):313-7. http://dx.doi.org/10.1016/j. radcr.2016.04.002. PMid:27920851.

The diagnostic work-up and the differential diagnosis may be aided by several imaging modalities, such as like abdominal or transrectal ultrasonography, which show the cystic nature and evaluate the relationships with pelvic organs. An abdominopelvic CT scan is better to confirm renal agenesis and to define the anatomy of pelvic structures. Magnetic resonance imaging is better than CT in delineating the anomalies, in demonstrating peripheral pelvic structures, and in planning the surgery.12,16,17

4. Ghonge NP, Aggarwal B, Sahu AK. Zinner syndrome: a unique triad of mesonephric duct abnormalities as an unusual cause of urinary symptoms in late adolescence. Indian J Urol. 2010;26(3):444-7. http:// dx.doi.org/10.4103/0970-1591.70592. PMid:21116373.

The treatment of ZS depends on the presence or absence of symptoms as well as the cyst size. In an asymptomatic patient, the treatment can be conservative with follow-up. For symptomatic patients

7. Dagur G, Warren K, Singh N, Khan SA. Detecting diseases of neglected seminal vesicles using imaging modalities: A review of current literature. Int J Reprod Biomed. 2016;14(5):293-302. http://dx.doi.org/10.29252/ ijrm.14.5.293. PMid:27326413.

Autops Case Rep (São Paulo). 2019;9(2):e2019088

5. Fabri TF, Neto CA, Akl MA, Dini FS. Síndrome de Zinner: relato de caso clínico. Revista Urominas. 2018;5(12):48-9. 6. Sheih CP, Hung CS, Wei CF, Lin CY. Cystic dilatations within the pelvis in patients with ipsilateral renal agenesis or dysplasia. J Urol. 1990;144(2 Pt 1):324-7. http://dx.doi. org/10.1016/S0022-5347(17)39444-2. PMid:2197430.

3-4

A rare case of abdominal pain

8. Khanduri S, Katyal G, Sharma H, Goyal A, Singh N, Yadav H. Unique association of multiple seminal vesicle cysts with contralateral renal agenesis: a rara variant of Zinner syndrome. Cureus. 2017;9(7):e1415. http://dx.doi. org/10.7759/cureus.1415. PMid:28875088.

13. Van den Ouden D, Blom JH, Bangma C, de Spiegeleer AH. Diagnosis and management of seminal vesicle cysts associated with ipsilateral renal agenesis: a pooled analysis of 52 cases. Eur Urol. 1998;33(5):433-40. http:// dx.doi.org/10.1159/000019632. PMid:9643661.

9. Maehana T, Fukuta F, Kobayashi K, Hirobe M, Tanaka T, Masumori N. Laparoscopic surgery for seminal vesicle cysts and ureterocele with urination disorder: a case report of Zinner syndrome. J Endourol Case Rep. 2018;4(1):35-8. http://dx.doi.org/10.1089/ cren.2018.0008. PMid:29588919.

14. Pastuszak AW, Font MD, Case JR, Lipshultz LI. An infertile male with dilated seminal vesicles due to functional obstruction. Asian J Androl. 2017;19(2):2567. http://dx.doi.org/10.4103/1008-682X.179858. PMid:27320475.

10. Pavan N, Bucci S, Mazzon G, Bertolotto M, Trombetta C, Liguori G. It’s not always varicocele: a strange case of Zinner syndrome. Can Urol Assoc J. 2015;9(7-8):E535-8. http://dx.doi.org/10.5489/cuaj.2451. PMid:26279734. 11. Kanavaki A, Vidal I, Merlini L, Hanquinet S. Congenital seminal vesicle cyst and ipsilateral renal agenesis (Zinner syndrome): a rare association and its evolution from early childhood to adolescence. European J Pediatr Surg Rep. 2015;3(2):98-102. http://dx.doi. org/10.1055/s-0035-1555605. PMid:26788458. 12. Fiaschetti V, Greco L, Giuricin V, et al. Zinner syndrome diagnosed by magnetic resonance imaging and computed tomography: role of imaging to identify and evaluate the uncommon variation in development of the male genital tract. Radiol Case Rep. 2016;12(1):54-8. http://dx.doi. org/10.1016/j.radcr.2016.10.007. PMid:28228879.

15. Aghaways I, Ahmed S. Endourologic intervention for management of infertility in a man with Zinner syndrome resulting in a natural pregnancy. J Endourol Case Rep. 2016;2(1):71-3. http://dx.doi.org/10.1089/ cren.2016.0010. PMid:27579422. 16. Lin L, Guan J, Jiang X-S, et al. Zinner’s syndrome: clinical features and imaging diagnosis. Asian J Androl. 2018;20(3):316-7. http://dx.doi.org/10.4103/aja. aja_21_17. PMid:28695865. 17. S u n d a r R , S u n d a r G . Z i n n e r s y n d r o m e : a n uncommon cause of painful ejaculation. BMJ Case Rep. 2015;2015(1):bcr2014207618. http://dx.doi. org/10.1136/bcr-2014-207618. PMid:25750220. 18. Benyó M, Berczi C, Jozsa T, Csanadi G, Varga A, Flasko T. Fertility preservation in cases of laparoscopic treatment of seminal vesicle cysts. Cent European J Urol. 2012;65(3):144-5. http://dx.doi.org/10.5173/ ceju.2012.03.art9. PMid:24578951.

Author contributions: Devezas V, Canão PA and Barbosa LE had equally contributed to this article. All authors proofread the final version and approved it for publication. The authors retain an informed consent signed by the patient authorizing the publication of this article, and the manuscript is by the Institutional Ethics Committee. Conflict of interest: None Financial support: None Submitted on: April 7th, 2019 Accepted on: May 14th, 2019 Correspondence Vítor Devezas Department of Surgery - Centro Hospitalar Universitário de São João Alameda Prof. Hernâni Monteiro – Porto – Portugal CEP: 4200-319 Phone: +351 937-427-911/Fax: +351 225-025-766 vitor.devezas7@gmail.com

4-4

Autops Case Rep (São Paulo). 2019;9(2):e2019088

Image in Focus

Gamna-Gandy bodies of the spleen in sickle cell disease Mario Luiz Marques Piubellia, Leticia Campos Clementea, Amaro Nunes Duarte-Netoa How to cite: Piubelli MLM, Clemente LC, Duarte-Neto AN. Gamna-Gandy bodies of the spleen in sickle cell disease. Autops Case Rep [Internet]. 2019;9(2):e2018076. https://doi.org/10.4322/acr.2018.076

Figure 1. A – Gross examination of the atrophic spleen with a light brownish external surface; B, C, and D – Photomicrographs of the spleen; B – shows the foci of interstitial fibrosis with iron deposits (H&E, 200X); C – shows the granulomatous reaction with multinucleated foreign-body cells surrounding the iron deposits (H&E, 400X); D – shows iron pigmentation associated with fibrous tissue (Pearls, 200X). Scale bars: B, C, D = µm.

Gamna-Gandy bodies (GGBs), also called tobacco flecks or siderotic nodules, appear as yellow-brownish and spheroidal foci within the splenic parenchyma, are composed of deposits of iron pigments and calcium salts, a

and are associated with granulomatous inflammatory reactions with multinucleated foreign‑body giant cells and fibrous tissues (Figure 1).1,2 GGBs can vary in size, ranging from 10 to 49 microns in the largest dimension.3

Universidade de São Paulo (USP), Faculty of Medicine, Department of Pathology. São Paulo, SP, Brazil.

Gamna-Gandy bodies of the spleen in sickle cell disease

The first description of GGBs dates back to 1902 when Marini described the siderotic nodules in the spleen. Three years later, the French physician Charles Gandy found these structures in the spleen of a patient with biliary cirrhosis, but the significance of these structures was not elucidated.1,4,5 In 1910, the same finding was described in the lung during the autopsy of a patient who died of endocarditis. At that time, GGBs were associated with a fungal etiology since they microscopically resembled spores. In 1921, the etiology of this pathological finding was better described when Carlos Gamna, an Italian pathologist, found GGBs in the spleen of a patient who died of chronic hemolytic anemia. Gamna observed that the amorphous material was composed of iron and calcium sulfate deposits and was therefore named Splenogranulomatosi siderotica. In 1963, the name “Gamna-Gandy bodies” became established and has been widely used ever since.2 Portal hypertension is one of the pathophysiological mechanisms that explains the formation of these nodules. Patients with increased blood pressure in the splenic circulatory system are likely to have episodes of minimal bleeding in the splenic parenchyma, which is organized as hemosiderin (iron), calcium salts and fibrotic tissue.1,2,6,7 GGBs in the spleen can occur with three main patterns: i) fine granular deposits in the red pulp; ii) iron deposits associated with subcapsular infarcts; and iii) periarterial deposits associated with fibrosis.2 Other histological characteristics of GGBs include blood vessels with proliferation of the tunica media, macrophagic reactions and spheroid fibers. Sickle cell disease (SCD) is another major entity in which GGBs can be found.8 The pathophysiological mechanism of GGBs in SCD is due to chronic episodes of vaso-occlusion and hemolysis in the central arteriole of the white pulp with periarteriolar hemorrhages. Then, mineral elements of the blood will deposit to form GGBs. Piccin and colleagues analyzed the spleen of 17 patients (all African American and mostly male) with diagnoses of SCD and found GGBs in 65% of the patients. The authors determined that the chemical composition of GGBs was carbon (47.1%); oxygen (29.7%); phosphorus (9.0%); iron (7.4%); calcium (6.4%); and potassium (0.4%). 2 The presence of GGBs is not pathognomonic of SCD since GGBs can occur in other diseases and in several other organs (Table 1).1-7,9 2-3

Figure 1 refers to a study of a spleen sampled from the autopsy of a 46-year-old male African American patient with a history of sickle cell anemia, smoking, and alcoholism. The organ weighed 4 g (reference range; 150-250 g) and measured 3.0 cm on the largest dimension. Externally, the capsule was fibrinous. The cut surface of the spleen parenchyma was rugged and had a sandy texture with structural distortion. The patient was admitted to the emergency room with sudden onset dorsalgia and chest pain and died a few minutes after admission. An autopsy was performed, which confirmed death due to a massive pulmonary thromboembolism. The authors retain an autopsy informed consent form. Keywords Anemia, Sickle Cell; Autopsy; Spleen; Splenic Diseases.

Table 1. Conditions associated with Gamna-Gandy bodies Neoplastic Diseases Thymoma Thyroid Follicular Adenoma Pituitary Adenoma CNS Neoplasms Hairy Cell Leukemia Hodgkin and non-Hodgkin Lymphoma Cardiac Myxomas Angiosarcoma Ovary Carcinoma Liver Carcinoma Renal Cell Carcinoma Breast Cancer Gastric Neurinoma Non-neoplastic Diseases

Portal Hypertension Thrombotic Thrombocytopenic Purpura Idiopathic Thrombocytopenic Purpura Hemolytic Anemia Paroxysmal Nocturnal Hemoglobinuria Acquired Hemochromatosis Congestive Splenomegaly Retroperitoneal Lymph Nodes

Autops Case Rep (São Paulo). 2019;9(2):e2018076

Piubelli MLM, Clemente LC, Duarte-Neto AN

REFERENCES

Radiology. 1989;172(3):681-4. http://dx.doi.org/10.1148/ radiology.172.3.2672092. PMid:2672092.

1. Kleinschmidt-DeMasters BK. Gamna-Gandy bodies in surgical neuropathology specimens: observations and a historical note. J Neuropathol Exp Neurol. 2004;63(2):106-12. http://dx.doi.org/10.1093/ jnen/63.2.106. PMid:14989596.

6. Lambertucci JR, Voieta I, Andrade LM. Gamna-Gandy bodies in hepatosplenic schistosomiasis mansoni. Rev Soc Bras Med Trop. 2008;41(3):320-1. http:// dx.doi.org/10.1590/S0037-86822008000300021. PMid:18719819.

2. Piccin A, Rizkalla H, Smith O, et al. Composition and significance of splenic Gamna-Gandy bodies in sickle cell anemia. Hum Pathol. 2012;43(7):1028-36. http://dx.doi. org/10.1016/j.humpath.2011.08.011. PMid:22079355.

7. Dobritz M, Nömayr A, Bautz W, Fellner FA. GamnaGandy bodies of the spleen detected with MR imaging: a case report. Magn Reson Imaging. 2001;19(9):124951. http://dx.doi.org/10.1016/S0730-725X(01)00451-9. PMid:11755737.

3. Tedeschi LG. The Gamna nodule. Hum Pathol. 1971;2(1):182-3. http://dx.doi.org/10.1016/S00468177(71)80030-8. PMid:5095245. 4. Bhatt S, Simon R, Dogra VS. Gamna-Gandy bodies: sonographic features with histopathologic correlation. J Ultrasound Med. 2006;25(12):1625-9. http://dx.doi. org/10.7863/jum.2006.25.12.1625. PMid:17121963. 5. Minami M, Itai Y, Ohtomo K, et al. Siderotic nodules in the spleen: MR imaging of portal hypertension.

8. Pizzi M, Fuligni F, Santoro L, et al. Spleen histology in children with sickle cell disease and hereditary spherocytosis: hints on the disease pathophysiology. Hum Pathol. 2017;60:95-103. http://dx.doi.org/10.1016/j. humpath.2016.09.028. PMid:27771375. 9. Bishop MB, Lansing LS. The spleen: a correlative overview of normal and pathologic anatomy. Hum Pathol. 1982;13(4):334-42. http://dx.doi.org/10.1016/S00468177(82)80223-2. PMid:7076217.

Author contributions: The manuscript was produced, reviewed, and approved by all of the authors collectively. Piubelli MLM and Clemente LC wrote the manuscript under the supervision and guidance of Duarte-Neto AN. Duarte-Neto AN and Piubelli MLM performed the autopsy. Duarte-Neto AN also assisted the autopsy proceedings. Conflict of interest: None Financial support: None Submitted on: January 23rd, 2019 Accepted on: February 25th, 2019 Correspondence Mario Luiz Marques Piubelli Pathology Department - Faculty of Medicine - Universidade de São Paulo (USP) Av. Dr. Arnaldo, 455 – Cerqueira César – São Paulo/SP – Brazil CEP: 01246-903 Phone: +55 (11) 94141-6930 mario.luiz@hc.fm.usp.br

Autops Case Rep (São Paulo). 2019;9(2):e2018076

3-3

Original Article

FOLFIRI as second-line treatment of metastatic biliary tract cancer patients Rafael Caparicaa , Adrien Lengeléb, Winnie Bekoloc, Alain Hendlisza  How to Cite: Caparica R, Lengelé A, Bekolo W, Hendlisz A. FOLFIRI as second-line treatment of metastatic biliary tract cancer patients. Autops Case Rep [Internet]. 2019;9(2):e2019087. https://doi.org/10.4322/acr.2019.087

ABSTRACT The combination of cisplatin and gemcitabine is the standard first-line treatment of metastatic biliary tract cancer (BTC) patients. The benefit of second-line chemotherapy in these patients is controversial. This study aims to evaluate the activity of FOLFIRI (fluorouracil and irinotecan) after failure to the first-line platinum and gemcitabine-based chemotherapy in metastatic BTC patients. We present a single-institution, retrospective cohort study. Patients with locally advanced or metastatic BTC who progressed after at least one line of chemotherapy, consecutively treated at our Institution between 2007 and 2017 were included. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were overall survival (OS), clinical benefit rate (CBR) and safety profile of FOLFIRI. Twelve patients were included in the analysis, with a median follow up of 5 months (95% CI 2.77-7.20). The median number of cycles received was 3 (range 1 to 9). Four grade 3 toxicities were recorded; no grade 4 toxicities and no treatment-related deaths occurred. The median PFS was 1.7 months (95% CI; 0.66-2.67), and median OS was 5 months (95% CI; 2.77-7.20). Two patients presented stable disease, providing a CBR of 17%. We concluded that FOLFIRI presented a favorable toxicity profile and a modest activity in metastatic BTC patients who had progressed to platinum and gemcitabine and may be considered in patients who are able to tolerate additional lines of chemotherapy. Immunotherapy and targeted therapies selected according to the tumoral genomic profile are promising alternatives to improve the outcomes of second-line treatment in BTC. Keywords Biliary Tract Neoplasms; Fluorouracil; Neoplasm Metastasis

INTRODUCTION Biliary tract cancer (BTC) is a rare tumor, with an estimated incidence of 1 to 2 new cases per 100,000 people annually in the United States. 1 In Belgium, around 350 new cases are diagnosed every year, and BTC is responsible for 0.5% of the cancer deaths in males and 0.8% in females.2 Surgery provides the only possibility of curative treatment for BTC patients, although it is feasible in only 20% of the cases because 80% of the patients present with

locally advanced unresectable disease or metastases at diagnosis.3-5 The prognosis of patients with metastatic BTC is dismal, with 5-year survival rates of less than 1%.6 Chemotherapy is the mainstay treatment of metastatic BTC, and its administration aims to promote symptom relief, improve the quality of life and prolong the overall survival of the patients.7 The combination of cisplatin and gemcitabine has been established as the standard first-line treatment of metastatic BTC.8

Institut Jules Bordet and Université Libre de Bruxelles (ULB), Department of Medical Oncology, Brussels, Belgium. Université Libre de Bruxelles (ULB), Brussels, Belgium. c Douala General Hospital, University of Douala, Cameroon. a

FOLFIRI as second-line treatment of metastatic biliary tract cancer patients

However, when disease progression occurs, there is no high-quality data to support the administration of second-line chemotherapy to BTC patients.4,9,10 Indeed, studies evaluating second-line treatments are scarce, and the benefit of chemotherapy over best supportive care in this scenario has never been demonstrated.9,10 Therefore, new strategies are needed to improve these outcomes. Metastatic pancreatic cancer shares some histological and molecular characteristics with BTC.11 The FOLFIRINOX regimen (fluorouracil, irinotecan and oxaliplatin) has robust activity in the first-line treatment of metastatic pancreatic cancer patients, and its superiority over gemcitabine alone has been demonstrated in a phase III study. 12 The results of FOLFIRINOX in pancreatic cancer generated interest in its potential activity also in BTC. Indeed, in a retrospective study with 12 metastatic BTC patients in different lines of treatment, FOLFIRINOX yielded a 41.7% clinical benefit rate (CBR) and a median progressionfree survival (PFS) of 9 weeks.13 Ongoing studies are evaluating FOLFIRINOX in metastatic BTC patients [NCT03291899; NCT03778593; NCT02591030; NCT02456714; NCT01494363]. Notably, FOLFIRINOX is an intensive chemotherapy regimen that comprises 3 cytotoxic drugs administered at 14-day cycles. Thus, the risk of adverse events is relevant and represents a potential concern for the development of this regimen in BTC, especially for frail patients.12 As an alternative, the agents that compose FOLFIRINOX can be combined as doublets (fluorouracil and oxaliplatin [FOLFOX] or fluorouracil and irinotecan [FOLFIRI]) to minimize the risks of adverse events, however more data on the efficacy of FOLFOX and FOLFIRI in BTC is needed.14 The FOLFIRI regimen (fluorouracil and irinotecan) arises as a potentially effective and less toxic alternative of second line-treatment due to the absence of oxaliplatin, which commonly causes hematological toxicities and peripheral neuropathy, the latest being potentially a limiting condition for patients suffering from neuropathy derived from a first-line gemcitabine-cisplatin regimen.14,15 As a consequence, ongoing studies are evaluating FOLFIRI as a second-line treatment in metastatic BTC patients. [NCT03110510; NCT03464968] However, the administration of FOLFIRI after failure to a platinum and gemcitabine-based regimen has been only reported in few retrospective series; therefore more evidence on the activity of FOLFIRI in this setting is needed.10,16-18 The present study aims to assess and describe the activity of FOLFIRI after failure to a first-line platinum and gemcitabine regimen in metastatic BTC patients. 2-9

METHODS Objectives The primary objective of this study is to assess the activity of FOLFIRI in metastatic BTC patients who experienced disease progression after first-line platinum and gemcitabine-based chemotherapy. The primary endpoint is PFS, defined as the time between the first day of the first FOLFIRI cycle and the occurrence of disease progression or death due to any cause, whichever occurred first. The secondary endpoints are overall survival (OS) - defined as the time between the first day of the first FOLFIRI cycle and death due to any cause; CBR - defined as the rate of patients presenting a complete response, a partial response or stable disease (per Response Evaluation Criteria in Solid Tumors [RECIST] criteria version 1.1) at the first imaging assessment performed to evaluate FOLFIRI response; and safety profile – defined as the frequency of grade ≥3 toxicities presented between the first day of the first cycle and 30 days after the last administration of FOLFIRI. Toxicities were classified and graded according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0, which was the latest version available at the time of FOLFIRI administration.

Patient’s Selection This is a single-institution, retrospective cohort study performed at the Medical Oncology Department of Institut Jules Bordet, Brussels, Belgium. Patients with a histologically confirmed diagnosis of BTC of any histological type; with metastatic disease confirmed by imaging exams or locally advanced disease considered not suitable for surgery; who presented disease‑progression as defined per RECIST after at least one line of chemotherapy including platinum and gemcitabine; and consecutively treated at our Institution between 2007 and 2017 were included. A detailed review of electronic records from each patient was performed to extract data for the study. This protocol has been submitted to the local ethics committee of Institut Jules Bordet and received approval before the study initiation. To assess the CBR, we considered the results of the first radiological exam (computerized tomography [CT], magnetic resonance imaging [MRI] or fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computerized tomography [FDG–PET/CT]) Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

Caparica R, Lengelé A, Bekolo W, Hendlisz A

performed after the initiation of FOLFIRI, which was requested according to the treating’s physician discretion. Routinely, imaging exams are performed every 2 to 3 chemotherapy cycles at our Institution to assess treatment response, which is evaluated by RECIST version 1.1. Chemotherapy is administered until the occurrence of disease progression, limiting toxicities or consent withdrawn by the patient, whichever occurs first. The standard FOLFIRI regimen administered at our Institution consists in fluorouracil 400mg/m2 bolus on D1 then 2400 mg/m2 on a 48h protracted infusion D1-2, leucovorin 200 mg/m2 on D1 and irinotecan 180 mg/m2 on D1 every 14 days, with each administration being considered 1 cycle.

Statistical Analysis PFS and OS were calculated with the Kaplan‑Meier method, and median values were reported with their respective 95% confidence intervals (CI). Patients’ characteristics were reported with their respective

median and/or range values when applicable. All the statistical analyses were performed using the R software version 4.4.1.

RESULTS From all the patients with metastatic BTC who were consecutively treated between 2007 and 2017 at our Institution, twelve patients who received at least one cycle of FOLFIRI after progression to first‑line chemotherapy were identified and considered eligible. The median age was 60 years, 75% had an Eastern Cooperative Oncology Group Performance Status (ECOG) ≤1, 100% presented extrahepatic metastases and 92% had only 1 previous line of chemotherapy administered for the treatment of metastatic disease. All patients had received platinum and gemcitabine‑based chemotherapy as the first-line treatment of metastatic disease. Patient’s characteristics are illustrated in Table 1.

Table 1. Patient’s characteristics Variable Age (years) Median Range Sex Male Female ECOG 0 1 2 3 Smoking history Current smoker Former smoker Never smoker Histology Adenocarcinoma Others Primary tumor Gallbladder Intrahepatic Extrahepatic

Number (%) 60 (37 - 82) 6 (50%) 6 (50%) 4 (33%) 5 (42%) 1 (08%) 2 (17%) 4 (33%) 1 (08%) 7 (58%) 12 (100%) 0 1 (08%) 9 (75%) 2 (17%)

Variable Staging Metastatic Locally advanced Sites of metastases Hepatic only Extrahepatic Previous biliary drainage Previous surgery to resect primary tumor Previous radiotherapy in the primary tumor Previous radiotherapy in metastases Previous treatment with SIR-spheres Previous chemotherapy lines One Two FOLFIRI cycles Median Range FOLFIRI dose reduction Yes No FOLFIRI cycle delays Yes No Reason for FOLFIRI discontinuation Progressive disease Adverse events

Number (%) 12 (100%) 0 0 12 (100%) 2 (17%) 2 (17%) 0 7 (58%) 1 (08%) 11 (92%) 1 (08%) 3 (1 - 9) 3 (25%) 9 (75%) 2 (17%) 10 (83%) 11 (92%) 1 (08%)

ECOG, Eastern Cooperative Oncology Group performance status scale; SIR-spheres, microspheres impregnated with 90Ytrium, a beta radiating isotope. Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

3-9

FOLFIRI as second-line treatment of metastatic biliary tract cancer patients

Safety Profile

Efficacy

The median number of FOLFIRI cycles received by the patients was 3 (range 1 to 9). In 3 patients (25%), a dose reduction was necessary at any point due to toxicities. Cycle delays occurred in 2 patients (17%), and 1 patient (8%) had to discontinue FOLFIRI due to adverse events. (Table 1).

No loss of follow-up occurred, and all patients were followed until the occurrence of an event (death or progression) at our Institution. The median follow-up since the first day of FOLFIRI administration was 5 months (95% CI 2.77-7.20).

Four grade-3 toxicities were recorded: diarrhea (1), emesis (1), and fatigue (2); no grade-4 toxicities and no treatment-related deaths occurred. (Table 2) Table 2. Adverse events grade ≥3 presented with FOLFIRI Adverse event Anemia Thrombocytopenia Neutropenia Febrile neutropenia Diarrhea Emesis Fatigue Transaminases elevation Bilirubin elevation Creatinine elevation Rash Hand-foot syndrome Mucositis

Number of patients (%)

Grade 3

Grade 4

0 0 0 0 1 (08) 1 (08) 2 (17) 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

Progression-Free Survival (PFS) Eleven patients (92%) discontinued FOLFIRI due to disease progression. All patients included in the analysis presented disease progression confirmed by imaging exams. The median PFS achieved with FOLFIRI was 1.7 months (95% CI; 0.66-2.67). (Figure 1)

Overall Survival (OS) All patients included in the analysis had died before the date of data collection for this study. The median OS from the date of diagnosis of BTC until death was 16 months (95% CI; 9.97-22.06) (Figure 2). The median OS from the first day of FOLFIRI administration until death (median OS with FOLFIRI) was 5 months (95% CI; 2.77-7.20) (Figure 3).

Clinical Benefit Rate At the moment of the first evaluation of treatment response, 10 patients (83%) presented radiological evidence of progressive disease, whereas 2 patients presented stable disease and continued FOLFIRI, providing a CBR of 17%.

Figure 1. Kaplan Meier curve of progression-free survival with FOLFIRI. 4-9

Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

Caparica R, Lengelé A, Bekolo W, Hendlisz A

Figure 2. Kaplan Meier curve of overall survival since the moment of diagnosis of biliary tract cancer.

Figure 3. Kaplan Meier curve of overall survival with FOLFIRI.

DISCUSSION

has limited activity as second-line chemotherapy in metastatic BTC patients.

The population of our study reflects the characteristics of the patients with metastatic BTC reported in other series in terms of age, tumor primary site, and histology, and the OS of 16 months observed is in-line with data reported in the medical literature.19 The administration of FOLFIRI was feasible and presented a manageable toxicity profile, with clinically relevant adverse events being observed in the minority of the patients. The short median PFS and OS and the modest CBR observed in our study suggest that FOLFIRI

The combination of cisplatin and gemcitabine is the standard-of-care first-line treatment of metastatic BTC patients, based on the results of the phase III study ABC-02, which demonstrated an overall survival benefit with cisplatin-gemcitabine compared to gemcitabine alone (median OS 11.7 vs. 8.1 months respectively; hazard ratio [HR] 0.64; 95% CI, 0.52‑0.80; p<0.001). 4,8 Unfortunately, disease progression invariably occurs after first-line chemotherapy, and no second-line treatment has been established as a

Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

5-9

FOLFIRI as second-line treatment of metastatic biliary tract cancer patients

Table 3. Studies reporting outcomes of metastatic biliary tract cancer patients treated with FOLFIRI 1st author year

Regimen

Design

Line

ORR

mPFS

mOS

Feisthammel30 2007

FOLFIRI

Single-arm PHASE II

1st

10%

Brieau16 2015

FOLFIRI

64 b

Retrospective

2nd

11.5%

2.6 m

6.1 m

Moretto17 2013

FOLFIRI

24 b 30 p

Retrospective

38% 2nd

42.9% (CBR)

3.5 m

6.2 m

Sebbagh18 2015

FOLFIRI

Retrospective

2nd

N/A

3.2 m

8.4 m

Mizrahi31 2019

FOLFIRI

Retrospective

2nd and beyond

11%

2.4 m

6.6 m

Caparica 2019

FOLFIRI

Retrospective

2nd and beyond

17% (CBR)

1.7 m

2.8 m (intrahepatic) 5.4 m (intrahepatic) 5.2 m (extrahepatic) 9 m (extrahepatic)

b = biliary; CBR = clinical benefit rate; m = months; mPFS = median progression-free survival; mOS = median overall survival; N = number of patients; ORR = overall response rate; p = pancreatic; N/A = not available.

standard for metastatic BTC patients so far.9,10 Notably, disease progression is generally associated with fatigue, jaundice, weight loss, pain and a decrease in performance status.19 As a consequence of this clinical deterioration that frequently occurs at progression, the administration of second-line treatments is feasible only in a minority of the patients, with best supportive care being recommended in most of the cases.9,10,20,21 The evidence to support the recommendation of second-line chemotherapy in BTC patients is scarce, consisting mainly in retrospective series and phase II studies.9,10 Second-line chemotherapy can be considered in patients who present a good performance status and a low predicted risk of toxicities, although its efficacy is modest.9,10,21 The regimens most frequently administered are those based on fluoropyrimidines and taxanes, which yield response rates of around 10% and median PFS rates of approximately 3 months.9,10 Polychemotherapy regimens are associated with an increased risk of adverse events and do not seem to increase response rates or PFS in comparison to single‑agent chemotherapy.10 Targeted-therapies such as bevacizumab (monoclonal antibody that targets the vascular endothelial growth factor [VEGF]), erlotinib (tyrosine kinase inhibitor that blocks the epithelial growth factor receptor [EGFR]), cetuximab and panitumumab (monoclonal antibodies targeting the EGFR) presented also a modest activity as second-line treatments in BTC patients.22-29 The use of FOLFIRI after failure to first-line chemotherapy has been evaluated in retrospective series, with response rates of around 11% and a median PFS of approximately 3 months (Table 3).16‑18,30,31 In the 6-9

largest of these series, 98 patients who received FOLFIRI after progression on first-line platinum and gemcitabine chemotherapy were evaluated. Sixty‑five out of the 98 patients had response assessments documented in their medical records, with 11% presenting a partial response and 35% presenting stable disease. The median PFS and OS were 2.4 and 6.6 months respectively. 31 In a prospective single‑arm phase II study that evaluated FOLFIRI as the first‑line treatment of 30 patients with unresectable or metastatic BTC, the response rate was 10%, whereas 10% of the patients presented stable disease; the median PFS was 2.8 months for patients with an intrahepatic primary tumor and 5.2 months for those with extrahepatic tumors.30 The results from our study are thus similar to those reported in the literature, supporting the concept that the activity of FOLFIRI in metastatic BTC is at best modest, although a subset of patients may derive benefit from this treatment.9,10 The main challenges in the treatment of metastatic BTC are the small proportion of patients that are eligible to receive a second line treatment when disease‑progression occurs, the absence of effective treatments after the first-line and the lack of biomarkers to predict which patients benefit from treatment. 9,10,19 Promising strategies to overcome these limitations are under evaluation. As an example, immunotherapy is based on the rationale that the activation of the immune system can generate an anti‑tumor immune response. 32 This concept has proven to be effective in several malignancies and is currently being also investigated in metastatic BTC patients. 33 In the preliminary reports of two Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

Caparica R, Lengelé A, Bekolo W, Hendlisz A

phase II studies that enrolled metastatic BTC patients who had received several lines of chemotherapy, the anti‑programmed death-1 receptor antibodies pembrolizumab and nivolumab presented response rates of 5.8% and 17%, respectively. Interestingly, the median duration of response was not reached in both studies, suggesting that patients who respond to immunotherapy may present a long-term benefit with this treatment.34,35 Notably, BTC have a heterogeneous genomic profile, and different abnormalities were found in these tumors, such as mutations/amplifications in the genes of the human epidermal growth factor (HER) family, fibroblast growth factor (FGFR) mutations/rearrangements, isocitrate dehydrogenase (IDH) mutations and hyperexpression or mutations in the genes involved in the mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways. 36 Targetable alterations, meaning those genomic abnormalities for which a potential therapy exists, were found in 68% of the cases in one study with 34 metastatic BTC patients.37 Interestingly, the genomic profile of BTC varies according to the site of origin of the primary tumor: while IDH and FGFR alterations are more frequent in intrahepatic tumors, abnormalities in the genes of the HER family are more common in extrahepatic and gallbladder tumors. 36 The incorporation of tumoral genomic profile as a stratification factor in studies evaluating targeted therapies arises as a promising strategy to optimize the treatment of BTC.37 As an example, the combination of a BRAF inhibitor (dabrafenib) with a mitogen-activated extracellular kinase (MEK) inhibitor (trametinib) yielded a median PFS of 9.2 months in a phase II study that enrolled 33 patients with BRAF mutated metastatic BTC. Partial responses were observed in 14 patients (42%), while stable disease occurred in 15 patients (45%). 38 Although direct comparisons between different studies are precluded, these results are more robust than the ones observed in our study and in the literature with second-line chemotherapy in general.9,10 The potential limitations of the present study need to be considered when interpreting our findings. The retrospective character of our series increases the risks of bias and missing data, limiting the assessment of toxicities and treatment response since all the information was retrieved from the data reported in patient’s medical records. Since most Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

patients who experience progressive disease after first‑line chemotherapy are too debilitated to receive a second‑line treatment, the population included in our study may be composed of selected patients with good prognostic features or with indolent tumors who were eligible to receive additional chemotherapy. The small sample size reduces the robustness of our analyses, and a logistic regression model that was originally pre-planned to seek for potential prognostic or predictive factors could not be performed. All patients were treated at a single tertiary cancer center in Belgium, which possesses high-quality facilities and vast expertise in the management of BTC, a fact that may limit the extrapolation of these results to low‑resource scenarios. However, due to the paucity of studies on the topic, our findings are important to provide additional data on the activity of FOLFIRI after progression to first-line chemotherapy in metastatic BTC patients. In conclusion, FOLFIRI presented a manageable toxicity profile but a modest activity in metastatic BTC patients who had progressed to platinum and gemcitabine chemotherapy and may be considered an option for patients who can tolerate additional lines of chemotherapy. The enrolment of metastatic BTC patients in clinical trials must be encouraged, due to the paucity of effective treatments in this scenario. Immunotherapy and targeted therapies selected according to the tumoral genomic profile arise as promising alternatives to improve the efficacy of second-line treatment in BTC patients.

REFERENCES 1. Vauthey JN, Blumgart LH. Recent advances in the management of cholangiocarcinomas. Semin Liver Dis. 1994;14(2):109-14. http://dx.doi. org/10.1055/s-2007-1007302. PMid:8047893. 2. Belgian Cancer Registry. Cancer incidence in Belgium – Brussels 2008 [online]. Brussel: Kanker Register; 2011 [cited 2019 Apr 19]. Available from: http://www. kankerregister.org/media/docs/StK_publicatie.pdf 3. Bridgewater J, Galle PR, Khan SA, et al. Guidelines for the diagnosis and management of intrahepatic cholangiocarcinoma. J Hepatol. 2014;60(6):126889. http://dx.doi.org/10.1016/j.jhep.2014.01.021. PMid:24681130. 4. Valle JW, Borbath I, Khan SA, Huguet F, Gruenberger T, Arnold D. Biliary cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 7-9

FOLFIRI as second-line treatment of metastatic biliary tract cancer patients

2016;27(Suppl 5):v28-37. http://dx.doi.org/10.1093/ annonc/mdw324. PMid:27664259. 5. Lee SE, Kim KS, Kim WB, et al. Practical guidelines for the surgical treatment of gallbladder cancer. J Korean Med Sci. 2014;29(10):1333-40. http://dx.doi.org/10.3346/ jkms.2014.29.10.1333. PMid:25368485. 6. American Cancer Society. Survival rates for bile duct cancer [online]. 2019 [cited 2019 Apr 5]. https://www. cancer.org/cancer/bile-duct-cancer/detection-diagnosisstaging/survival-by-stage.html 7. Ramírez-Merino N, Aix SP, Cortés-Funes H. Chemotherapy for cholangiocarcinoma: an update. World J Gastrointest Oncol. 2013;5(7):171-6. http://dx.doi.org/10.4251/wjgo. v5.i7.171. PMid:23919111. 8. Valle J, Wasan H, Palmer DH, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med. 2010;362(14):1273-81. http://dx.doi. org/10.1056/NEJMoa0908721. PMid:20375404. 9. Lamarca A, Hubner RA, Ryder WD, Valle JW. Second-line chemotherapy in advanced biliary cancer: a systematic review. Ann Oncol. 2014;25(12):2328-38. http://dx.doi. org/10.1093/annonc/mdu162. PMid:24769639. 10. Fornaro L, Vivaldi C, Cereda S, et al. Second-line chemotherapy in advanced biliary cancer progressed to first-line platinum-gemcitabine combination: a multicenter survey and pooled analysis with published data. J Exp Clin Cancer Res CR. 2015;34(1):156. http://dx.doi. org/10.1186/s13046-015-0267-x. PMid:26693938. 11. Schmuck RB, Carvalho-Fischer CV, Neumann C, Pratschke J, Bahra M. Distal bile duct carcinomas and pancreatic ductal adenocarcinomas: postulating a common tumor entity. Cancer Med. 2016;5(1):88-99. http://dx.doi. org/10.1002/cam4.566. PMid:26645826. 12. Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus Gemcitabine for Metastatic Pancreatic Cancer. N Engl J Med. 2011;364(19):1817-25. http://dx.doi.org/10.1056/ NEJMoa1011923. PMid:21561347. 13. Kus T, Aktas G, Kalender ME, Sevinc A, Camci C. Comparison of FOLFIRINOX Chemotherapy with Other Regimens in Patients with Biliary Tract Cancers: a Retrospective Study. J Gastrointest Cancer. 2017;48(2):170-5. http://dx.doi.org/10.1007/s12029016-9880-y. PMid:27714651. 14. Mohelnikova-Duchonova B, Melichar B, Soucek P. FOLFOX/FOLFIRI pharmacogenetics: the call for a personalized approach in colorectal cancer therapy. World J Gastroenterol. 2014;20(30):10316-30. http://dx.doi. org/10.3748/wjg.v20.i30.10316. PMid:25132748. 15. Alcindor T, Beauger N. Oxaliplatin: a review in the era of molecularly targeted therapy. Curr Oncol. 2011; 18( 1) : 18- 25. http://dx. doi. org/10. 3747/ co.v18i1.708. PMid:21331278. 16. Brieau B, Dahan L, De Rycke Y, et al. Second-line chemotherapy for advanced biliary tract cancer after 8-9

failure of the gemcitabine-platinum combination: A large multicenter study by the Association des GastroEntérologues Oncologues. Cancer. 2015;121(18):3290-7. http://dx.doi.org/10.1002/cncr.29471. PMid:26052689. 17. Moretto R, Raimondo L, De Stefano A, et al. FOLFIRI in patients with locally advanced or metastatic pancreatic or biliary tract carcinoma: a monoinstitutional experience. Anticancer Drugs. 2013;24(9):980-5. http://dx.doi. org/10.1097/CAD.0b013e328364e66b. PMid:23928570. 18. Sebbagh S, Roux J, Dreyer C, et al. Efficacy of a sequential treatment strategy with GEMOX-based followed by FOLFIRI-based chemotherapy in advanced biliary tract cancers. Acta Oncol. 2016;55(9-10):1168-74. http://dx.doi.org/10.1080/0284186X.2016.1191670. PMid:27333436. 19. Rizvi S, Khan SA, Hallemeier CL, Kelley RK, Gores GJ. Cholangiocarcinoma — evolving concepts and therapeutic strategies. Nat Rev Clin Oncol. 2018;15(2):95111. http://dx.doi.org/10.1038/nrclinonc.2017.157. PMid:28994423. 20. Edeline J, Bonnetain F, Phelip JM, et al. Gemox versus surveillance following surgery of localized biliary tract cancer: results of the PRODIGE 12-ACCORD 18 (UNICANCER GI) phase III trial. J Clin Oncol. 2017;35(4 Suppl):225-225. http://dx.doi.org/10.1200/ JCO.2017.35.4_suppl.225. 21. Takahara N, Nakai Y, Isayama H, et al. Second-line chemotherapy in patients with advanced biliary tract cancer. J Clin Oncol. 2018;36(4 Suppl):429-429. http:// dx.doi.org/10.1200/JCO.2018.36.4_suppl.429. 22. Philip PA, Mahoney MR, Allmer C, et al. Phase II study of erlotinib in patients with advanced biliary cancer. J Clin Oncol. 2006;24(19):3069-74. http://dx.doi.org/10.1200/ JCO.2005.05.3579. PMid:16809731. 23. Zhu AX, Meyerhardt JA, Blaszkowsky LS, et al. Efficacy and safety of gemcitabine, oxaliplatin, and bevacizumab in advanced biliary-tract cancers and correlation of changes in 18-fluorodeoxyglucose PET with clinical outcome: a phase 2 study. Lancet Oncol. 2010;11(1):4854. http://dx.doi.org/10.1016/S1470-2045(09)70333-X. PMid:19932054. 24. Guion-Dusserre J-F, Lorgis V, Vincent J, Bengrine L, Ghiringhelli F. FOLFIRI plus bevacizumab as a second-line therapy for metastatic intrahepatic cholangiocarcinoma. World J Gastroenterol. 2015;21(7):2096-101. http:// dx.doi.org/10.3748/wjg.v21.i7.2096. PMid:25717243. 25. Lubner SJ, Mahoney MR, Kolesar JL, et al. Report of a multicenter phase II trial testing a combination of biweekly bevacizumab and daily erlotinib in patients with unresectable biliary cancer: a phase II Consortium study. J Clin Oncol. 2010;28(21):3491-7. http://dx.doi. org/10.1200/JCO.2010.28.4075. PMid:20530271. 26. Iyer RV, Pokuri VK, Groman A, et al. A multicenter phase II study of gemcitabine, capecitabine, and bevacizumab for locally advanced or metastatic biliary tract cancer. Am J Clin Oncol. 2018;41(7):649-55. Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

Caparica R, Lengelé A, Bekolo W, Hendlisz A

http://dx.doi.org/10.1097/COC.0000000000000347. PMid:27849649.

2018; 18( 3) : 212- 9. http://dx. doi. org/10. 1038/ nri.2017.89. PMid:28853444.

27. Bréchon M, Dior M, Dréanic J, et al. Addition of an antiangiogenic thy3yerapy, bevacizumab, to gemcitabine plus oxaliplatin improves survival in advanced biliary tract cancers. Invest New Drugs. 2018;36(1):15662. http://dx.doi.org/10.1007/s10637-017-0492-6. PMid:28762171.

33. Ribas A, Wolchok JD. Cancer immunotherapy using checkpoint blockade. Science. 2018;359(6382):13505. http://dx. doi. org/10. 1126/science. aar4060. PMid:29567705.

28. Gruenberger B, Schueller J, Heubrandtner U, et al. Cetuximab, gemcitabine, and oxaliplatin in patients with unresectable advanced or metastatic biliary tract cancer: a phase 2 study. Lancet Oncol. 2010;11(12):1142-8. http://dx.doi.org/10.1016/S1470-2045(10)70247-3. PMid:21071270. 29. Malka D, Cervera P, Foulon S, et al. Gemcitabine and oxaliplatin with or without cetuximab in advanced biliary-tract cancer (BINGO): a randomised, openlabel, non-comparative phase 2 trial. Lancet Oncol. 2014;15(8):819-28. http://dx.doi.org/10.1016/S14702045(14)70212-8. PMid:24852116. 30. Feisthammel J, Schoppmeyer K, Mössner J, Schulze M, Caca K, Wiedmann M. Irinotecan with 5-FU/FA in advanced biliary tract adenocarcinomas: a multicenter phase II trial. Am J Clin Oncol. 2007;30(3):319-24. http:// dx.doi.org/10.1097/01.coc.0000258124.72884.7a. PMid:17551313. 31. Mizrahi J, Gunchick V, Mody K, et al. FOLFIRI in advanced biliary tract cancers. J Clin Oncol. 2019;37(4 Suppl):451451. http://dx.doi.org/10.1200/JCO.2019.37.4_ suppl.451. 32. Weiden J, Tel J, Figdor CG. Synthetic immune niches for cancer immunotherapy. Nat Rev Immunol.

34. Sakai D, Kanai M, Kobayashi S, et al. Randomized phase III study of Gemcitabine, Cisplatin plus S-1 (GCS) versus Gemcitabine, Cisplatin (GC) for Advanced Biliary Tract Cancer (KHBO1401-MITSUBA). Ann Oncol. 2018;29(Suppl 8):viii205-270. http://dx.doi.org/10.1093/ annonc/mdy282. 35. Kim R, Kim D, Alese O, et al. O-009 – A Phase II multi institutional study of nivolumab in patients with advanced refractory biliary tract cancers (BTC). Ann Oncol. 2018;29(1, Suppl 5):mdy149.008 . . 36. Verlingue L, Hollebecque A, Boige V, Ducreux M, Malka D, Ferté C. Matching genomic molecular aberrations with molecular targeted agents: are biliary tract cancers an ideal playground? Eur J Cancer. 2017;81(81):16173. http://dx.doi.org/10.1016/j.ejca.2017.05.006. PMid:28628842. 37. Verlingue L, Malka D, Allorant A, et al. Precision medicine for patients with advanced biliary tract cancers: an effective strategy within the prospective MOSCATO-01 trial. Eur J Cancer. 2017;87(87):122-30. http://dx.doi. org/10.1016/j.ejca.2017.10.013. PMid:29145038. 38. Wainberg ZA, Lassen UN, Elez E, et al. Efficacy and safety of dabrafenib (D) and trametinib (T) in patients (pts) with BRAF V600E–mutated biliary tract cancer (BTC): A cohort of the ROAR basket trial. J Clin Oncol. 2019;37(4 Suppl):187-187. http://dx.doi.org/10.1200/ JCO.2019.37.4_suppl.187.

Authors’ contributions: All authors participated in the discussion of the rationale to propose the study. WB, AL and RC participated in the data extraction from medical records. RC performed the statistical analysis. All authors participated in the writing of this manuscript and reviewed the final version before submission. This protocol has been submitted to the local ethics committee of Institut Jules Bordet and received approval before the study initiation. Conflict of interest: None Financial support: None Submitted on: April 19th, 2019 Accepted on: May 10th, 2019 Correspondence Rafael Caparica Institut Jules Bordet, Department of Medical Oncology Boulevard de Waterloo, 121, CTSU, 1000 Bruxelles/Belgium Phone: +32 2 5413854 rcaparica@hotmail.com Autops Case Rep (São Paulo). 2019 ;9(2):e2019087

9-9

Article / Autopsy Case Report

Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis Mario Luiz Marques Piubellia, Aloisio Felipe-Silvaa,b, Marcia Yoshie Kanegaec, Fernando Peixoto Ferraz de Camposc How to cite: Piubelli MLM, Felipe-Silva A, Kanegae MY, Campos FPF. Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis. Autops Case Rep [Internet]. 2019;9(2):e2018070. https://doi.org/10.4322/acr.2018.070

ABSTRACT Esophageal infection by Candida spp. is a common opportunistic entity in immunocompromised hosts; however, systemic fungal dissemination due to perforation or transmural necrosis, also known as necrotizing Candida esophagitis (NCE), is rare. We report the case of a 61-year-old male patient with diagnosed ankylosing spondylitis, severe arteriosclerosis, and vasculitis under immunosuppressive therapy who presented NCE with fungal and bacterial septicemia diagnosed at autopsy. Necrotizing esophagitis is a rare manifestation of Candida infection, which may be a final complication in severely ill patients. Unfortunately, it may be underdiagnosed, and we call attention to this devastating complication in patients with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis. Keywords Necrosis; Esophagitis; Candidiasis, Invasive; Mycoses

CASE REPORT A 61-year-old man was referred to the emergency care facility because of symptomatic hypotension diagnosed by the primary care physician. His past medical history included the diagnosis of ankylosing spondylitis over the last 10 years, bilateral cataracts, and a major depressive disorder with progressive and marked weight loss. Over the last 5 months, he complained of pain with necrosis in the extremities (hands and feet). Since then, he had been empirically prescribed prednisone and pentoxifylline by his primary care physician, and started wearing gloves. He lived alone and showed signs of depression since the loss of his parents, and had become progressively

anorectic. Despite this empiric therapeutic attempt, the clinical picture worsened over the following months, with generalized weakness, asthenia, and exertional dyspnea. He had been submitted to amputation of the distal phalanx of the right ring finger and was prescribed ciprofloxacin and clindamycin a couple of days before the hospital admission. He was a smoker (50 pack-years) but denied alcoholism and illicit drugs usage. On admission, the physical examination revealed an emaciated and pale patient with blood pressure of 100/70 mmHg, rhythmic pulse of 80 beats per minute. He was afebrile, eupneic, and had room

Universidade de São Paulo (USP), Faculty of Medicine, Department of Pathology. São Paulo, SP, Brazil. Universidade de São Paulo (USP), Hospital Universitário, Anatomic Pathology Service. São Paulo, SP, Brazil. c Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division. São Paulo, SP, Brazil. a

Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis

air oximetry of 93%, capillary glucose of 94 mg/dL, and a body mass index of 17 kg/m2. The pulmonary examination revealed bilateral diminished breath sounds. The cardiac examination was unremarkable and the abdomen presented signs of moderate ascites. On examination of his back, a grade-4 sacral bedsore was found. Multiple necrotic ulcers in the fingers, feet, pretibial, and around the left knee regions were evident (Figure 1). The laboratory work-up revealed: pancytopenia with hemoglobin of 4.3 g/dL (reference value [RV]; 12.3-15.3 g/dL), leukocytes of 2170/mm3 (RR: 4.4-11.3 × 103/mm3, and platelets of 15.000/mm3 (RV: 150-400 × 103/mm3); an abnormal prothrombin time with the International Normalized Ratio (INR) of 1.59 (RV:1), hypoalbuminemia, and elevated C-reactive protein. The electrolytes, renal function tests, hepatic enzymes, creatine phosphokinase and lactic dehydrogenase, thyroid hormones, iron profile, folic acid dosage were within normal limits. Vitamin B12 was 173 pg/mL (RV: 211-911 pg/mL). Urinalysis

revealed proteinuria, leukocyturia, hematuria, but no casts, and the culture was negative, but it was sampled on antibiotics. Serology was negative for HIV, HCV, and syphilis. However, hepatitis B surface antigen and HBe were positive and so was anti‑HBc and anti-HBe (consistent with chronic hepatitis B in replication phase). Rheumatoid factor, ANA, complement, cryoglobulin, and cold agglutinin were negative. The echocardiogram revealed inferior and lateral left ventricular hypokinesis and signs of pulmonary hypertension. The abdominal ultrasound showed chronic calculous cholecystitis, ascites, and bilateral pleural effusion. Two sets of blood culture were sampled and were negative. Perilesional skin biopsy showed a mild perivascular lymphomononuclear inflammatory infiltrate with capillary fibrinoid necrosis, which was interpreted as small vessel vasculitis (Figure 2). The Grocott special stain was negative for fungi.

Figure 1. Gross examination of the distal right ring-finger after amputation (A) and necrotic skin ulcers; B – Left ring finger; C – Left knee; D – left foot. 2-7

Autops Case Rep (São Paulo). 2019;9(2):e2018070

Piubelli MLM, Felipe-Silva A, Kanegae MY, Campos FPF

Figure 2. Photomicrograph of the skin biopsy showing mild lymphomononuclear pericapillary infiltrate with fibrinoid necrosis close to skin adnexa (H&E, 400X).

Figure 3. Photomicrograph of an area of aspiration pneumonia in the lung showing pseudohyphae of Candida spp. (Grocott, 400X).

With the working diagnosis of small vessel vasculitis of unknown cause, malnutrition, and major depression, the patient was promptly treated with packed red blood cell transfusion, intravenous crystalloids, 60 mg/daily of prednisone (after oral ivermectin) parenteral vitamin B12 supplementation, and the antibiotic regimen was maintained for 10 days. The outcome was unfavorable; the patient worsened his mood disturbance by refusing to eat (but not because of dyspeptic complaints) and to talk to health professionals. After 15 days of hospitalization, there was a marked worsening of the respiratory symptoms with cough and oxygen desaturation. The antibiotic regimen was changed to vancomycin and meropenem, but the patient died soon after.

a vascular pattern and areas of acute inflammatory process, necrosis, and adjacent phlebitis. Special stains for fungi were negative in the skin lesions samples at autopsy. These findings were compatible with a partially treated cutaneous vasculitis.

AUTOPSY FINDINGS After receiving the required consent from the patient’s family member, an autopsy was performed. On external examination, the corpse showed signs of undernourishment with bedsores in the sacral regional, right calcaneus, left lower back and multiple perimalleolar lesions, bilaterally. The right distal ring-finger phalanx had been surgically removed with no apparent signs of infection. The histological examination of the skin lesions showed the presence of chronic ulcerated dermatitis with Autops Case Rep (São Paulo). 2019;9(2):e2018070

We also observed bilateral crystalline opacities and bone deformity in a dorsal spine with hyperextension stiffness. Histological examination of the lumbar joints showed a chronic inflammatory process, signs of old hemorrhage; fibrosis, and adjacent vertebral bone marrow with reactional lymphoplasmacytic infiltrate, which were consistent with the clinical diagnosis of ankylosing spondylitis. There were large and bilateral pleural effusions, and the lungs presented areas of subpleural emphysema and airways filled with mucus. The histological sections taken from the lungs indicated diffuse alveolar damage and some organized foci of aspiration bronchopneumonia, with pseudohyphae and yeasts consistent with Candida spp. (Figure 3). The epicardial surface showed fibrin exudate, and the aorta and coronary arteries exhibited moderate atherosclerosis. The esophagus presented whitish and eroded mucosa with floppy and grayish pseudomembrane on the middle third where the esophageal wall was thickened (Figure 4). The abdomen showed a small amount of peritoneal effusion with fibrin deposits on the parietal peritoneal surface of the large bowel (Figure 5). 3-7

Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis

Figure 4. Gross view of the esophagus showing mucosa with loosely adherent grayish pseudomembranes.

On histological examination, the esophagus showed full thickness necrosis, and diffuse inflammatory infiltrate rich in neutrophils (necrotizing esophagitis) (Figure 6). Bacterial colonies, pseudohyphae, and yeasts consistent with Candida spp were detected on special stains in the esophagus, with invasion extended to the adventitia (Figure 7). Cultures or molecular tests for specific Candida species were not available for autopsy samples. The sections of peritoneum showed acute exudative inflammation with bacterial colonies, pseudohyphae, and yeasts consistent with Candida spp. (Figure 8). The liver and spleen were grossly congested. Upon histology, the liver showed reactive findings related to sepsis, with mild portal infiltration, mild cholangitis, and centrilobular necrosis, while the pancreas showed mild chronic and acute ischemic pancreatitis. An 8.0 mm urinary calculus was found within the right ureter.

Figure 5. Gross aspect of abdominal cavity, showing peritoneal fibrinous exudate on the colonic surface.

According to the autopsy findings, we interpreted the immediate cause of death as being the fungal septicemia due to necrotizing Candida esophagitis (NCE) related to general malnourishment, long-term use of corticotherapy and broad-spectrum antibiotics. The necrotic skin lesions were interpreted as vasculitis of uncertain etiology, possibly related to ankylosing spondylitis.

Figure 6. A – Photomicrograph of the esophagus showing an active ulcer with inflammatory exudate (H&E, 100X); B – Coagulative necrosis of esophageal submucosa and vessels (H&E, 100X). 4-7

Autops Case Rep (São Paulo). 2019;9(2):e2018070

Piubelli MLM, Felipe-Silva A, Kanegae MY, Campos FPF

Figure 7. Photomicrograph of the esophagus showing invasive Candida spp. from mucosal ulcer and submucosa in A (Grocott; 100X) through adventitia; in B (yeasts in left bottom) (Grocott; 200X). barrier and T-cell response, which are fundamental to the protective mechanism.3,6 Among the risk factors for NCE and other esophageal opportunistic infections are the immunodeficiency status (primary or secondary), functional or mechanical gastric obstruction, endocrine disorders, and malnutrition.4,7 In the present case, we considered that the corticotherapy, the recent surgical intervention followed by the broad-spectrum antibiotic usage and starvation, were the main reasons for the emergence of the fungal infection.

Figure 8. Photomicrograph of the peritoneum with exudative inflammation, pseudohyphae, and spores of Candida spp. (Grocott, 400x).

DISCUSSION Severe infections of the esophagus are uncommon in the general population and usually occur in immunocompromised patients. In this setting, the main etiological agents comprise viruses and fungi, such as cytomegalovirus (CMV), herpes virus (HSV) and Candida spp.1 Candida spp. may be present in 20% to 25% of normal esophagus mucosae and the colonization is the primary way of opportunist dissemination.2-5 InÂ addition to the fungal pathogenic factors, the spread is related to the breakdown of the mucosal immune Autops Case Rep (SĂŁo Paulo). 2019;9(2):e2018070

Most cases of esophageal candidiasis occur in the form of superficial esophagitis. Transmural infection, such as NCE is rare, and our case is one of the few reports found in the literature.3,5,8 Clinical features include dysphagia, odynophagia, chest pain, hypotension, and blackened vomiting. 4,7 Complications of NCE, such as perforation, mediastinitis, pneumonia, and tracheoesophageal fistula, may be the initial presentation. However, the cases accompanied by perforation are related to severe neutropenia. 5 More rarely, NCE presents initially with sepsis, which hampers an accurate diagnosis, since the esophagus is not usually investigated as a primary site of infection, and some cases can course asymptomatic, similar to our case. The fungal infection was not detected before death in this patient. Candida yeasts and pseudohyphae were demonstrated in the esophagus, peritoneum, and lungs (aspiration) at autopsy. NoÂ other systemic dissemination sites, including skin lesions, were detected. This insidious presentation in an overall very ill patient certainly has prevented a specific diagnosis and treatment. 5-7

Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis

The diagnosis of NCE is made on endoscopic examination. The differential diagnosis, especially on biopsy samples, with other necrotizing esophagitis such as the black esophagus syndrome, also can be made. A biopsy is usually not required for endoscopic diagnosis but either a biopsy or a brushing may be necessary in guiding therapy.3,4,9,10 When a biopsy is performed, the sections show necrotic debris, transmural coagulative necrosis without epithelium, and frequent submucosal involvement, in addition to yeasts with pseudohyphae.3,9,11,12 However, quite often, the diagnosis is performed at autopsy.3

CONCLUSION

Standard antifungal therapy of NCE is fluconazole and itraconazole with flucytosine or amphotericin B. The latter is usually prescribed in fluconazole‑resistant Candida. Aggressive intervention, such as esophagectomy, should be considered in cases of extensive involvement and in signs of complication.5

1. Baehr PH, McDonald GB. Esophageal infections: risk factors, presentation, diagnosis, and treatment. Gastroenterology. 1994;106(2):509-32. http://dx.doi. org/10.1016/0016-5085(94)90613-0. PMid:7980741.

Candida infection in this case was associated with immunosuppression caused by autoimmune diseases (arthropathy and vasculitis), corticoid therapy, and malnutrition. Moreover, the association between vasculitis and ankylosing spondylitis is a rare underlying cause of death. Apparently, the literature supports this clinical picture in three distinct ways. First is the association between symptomatic aortic valve disease and aortitis large vessel vasculitis with spondyloarthropathies.13 Second is vasculitis related to treatment with biologic agents, particularly anti-tumor necrosis factor drugs. In these cases, cutaneous manifestation predominates in nearly 75% of the patients, especially in the form of purpura; however, ulcers, nodules, and visceral manifestations do occur. The treatment is based in the withdrawal of the drug with improvement in over 90% of cases.14 Finally, there are some case reports of different types of vasculitis in ankylosing spondylitis, including cutaneous, immunoglobulin-A-related retinal and cerebral vasculitis.13,15-19 These rare, sporadic, and localized forms of vasculitis seem to illustrate the third clinical picture in which ankylosing spondylitis could be the underlying cause of leukocytoclastic vasculitis. In the present case, we did not find signs of large vessel vasculitis or thromboangiitis obliterans (Buerger disease) at autopsy. Also, there was no history of any drugs that could explain these findings. 6-7

We interpreted the case as a rare and severe manifestation of cutaneous leukocytoclastic vasculitis in a setting of ankylosing spondylitis, which was complicated with fatal sepsis due to undiagnosed NCE. Medical staff should keep in mind the investigation of esophageal candidiasis in very ill patients despite the lack of local specific clinical symptoms.

REFERENCES

2. Al-Shawwa B, D’Andrea L, Quintero D. Candida esophageal perforation and esophagopleural fistula: a case report. J Med Case Rep. 2008;2(1):209. http://dx.doi. org/10.1186/1752-1947-2-209. PMid:18559100. 3. Gock M, Schäfer M, Perren A, Demartines N, Clavien PA. Fatal esophageal perforation caused by invasive candidiasis. Ann Thorac Surg. 2005;80(3):1120-2. http://dx.doi.org/10.1016/j.athoracsur.2004.02.147. PMid:16122508. 4. Underwood JA, Williams JW, Keate RF. Clinical findings and risk factors for Candida esophagitis in outpatients. Dis Esophagus. 2003;16(2):66-9. http://dx.doi.org/10.1046/ j.1442-2050.2003.00305.x. PMid:12823199. 5. Gaissert HA, Breuer CK, Weissburg A, Mermel L. Surgical management of necrotizing Candida esophagitis. Ann Thorac Surg. 1999;67(1):231-3. http://dx.doi. org/10.1016/S0003-4975(98)01144-8. PMid:10086557. 6. Gaissert HA, Roper CL, Patterson GA, Grillo HC. Infectious necrotizing esophagitis: outcome after medical and surgical intervention. Ann Thorac Surg. 2003;75(2):3427. http://dx.doi.org/10.1016/S0003-4975(02)04343-6. PMid:12607636. 7. Jones JM. Necrotizing Candida esophagitis: failure of symptoms and roentgenographic findings to reflect severity. JAMA. 1980;244(19):2190-1. http:// dx.doi.org/10.1001/jama.1980.03310190042020. PMid:7420723. 8. Jones JM, Glass NR, Belzer FO. Fatal Candida esophagitis in two diabetics after renal transplantation. Arch Surg. 1982;117(4):499-501. http://dx.doi.org/10.1001/ archsurg.1982.01380280079016. PMid:7039554. 9. Gurvits GE, Shapsis A, Lau N, Gualtieri N, Robilotti JG. Acute esophageal necrosis: a rare syndrome. J Gastroenterol. 2007;42(1):29-38. http://dx.doi. org/10.1007/s00535-006-1974-z. PMid:17322991. Autops Case Rep (São Paulo). 2019;9(2):e2018070

Piubelli MLM, Felipe-Silva A, Kanegae MY, Campos FPF

10. Gurvits GE. Black esophagus: acute esophageal necrosis syndrome. World J Gastroenterol. 2010;16(26):321925. http://dx.doi.org/10.3748/wjg.v16.i26.3219. PMid:20614476. 11. Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev. 2011;24(2):247-80. http://dx.doi.org/10.1128/ CMR.00053-10. PMid:21482725. 12. Kim YH, Choi SY. Black esophagus with concomitant candidiasis developed after diabetic ketoacidosis. World J Gastroenterol. 2007;13(42):5662-3. http://dx.doi. org/10.3748/wjg.v13.i42.5662. PMid:17948944.

15. Gillott TJ, Struthers GR. Cutaneous necrotizing vasculitis, erythema nodosum and ankylosing spondylitis. Rheumatology. 1999;38(4):377-8. http://dx.doi.org/10.1093/rheumatology/38.4.377. PMid:10378721. 16. Kobak S, Yilmaz H, Karaarslan A, Yalcin M. Leukocytoclastic vasculitis in a patient with ankylosing spondylitis. Case Rep Rheumatol. 2014;2014:653837. http://dx.doi. org/10.1155/2014/653837. PMid:24653851. 17. Machet L, Jan V, Ouakil H, Vaillant L, Estève E, Lorette G. Cutaneous leukocytoclastic vasculitis in a case of ankylosing spondylitis. Acta Derm Venereol. 1997;77(4):324. PMid:9228232.

13. Ernst D, Baerlecken NT, Schmidt RE, Witte T. Large vessel vasculitis and spondyloarthritis: coincidence or associated diseases? Scand J Rheumatol. 2014;43(3):2468. http://dx.doi.org/10.3109/03009742.2013.850737. PMid:24438209.

18. Taylan A, Yildiz Y, Sari I, Ozkok G. Vasculitis and long standing ankylosing spondylitis in a patient with familial Mediterranean fever. J Res Med Sci. 2014;19(10):100911. PMid:25538787.

14. Ramos-Casals M, Brito-Zerón P, Muñoz S, et al. Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases. Medicine. 2007;86(4):242-51. http://dx.doi.org/10.1097/MD.0b013e3181441a68. PMid:17632266.

19. Beauvais C, Kaplan G, Mougenot B, Michel C, Marinho E. Cutaneous vasculitis and IgA glomerulonephritis in ankylosing spondylitis. Ann Rheum Dis. 1993;52(1):61‑2. http://dx.doi.org/10.1136/ ard.52.1.61. PMid:8427517.

Author contributions: Piubelli MLM and Felipe-Silva A performed the autopsy. Campos FPF and Kanegae MY were responsible for the patient’s medical care. All authors collectively wrote the manuscript, proofread it and approved it for publication. The authors retain an informed consent signed by the deceased’s next to kin. The manuscript is by the Institutional Ethics Committee. Conflict of interest: None Financial support: None Submitted on: June 19th, 2018 Accepted on: December 24th, 2018 Correspondence Mario Luiz Marques Piubelli Department of Pathology - Faculty of Medicine - Universidade de São Paulo (USP) Avenida Dr. Eneas Carvalho de Aguiar, 155 – Cerqueira Cesar – São Paulo/SP – Brazil CEP: 05403-000 Phone: +55 (11) 94141-6930 marquemario@gmail.com

Autops Case Rep (São Paulo). 2019;9(2):e2018070

7-7

Article / Autopsy Case Report

Interesting post-mortem findings in a H1N1 influenza-positive pneumonia patient Kolady Vijayakumar Vinu Balraama , Avnit Sidhub , Vadlamannati Srinivasb  How to cite: Balraam KVV, Sidhu A, Srinivas V. Interesting post-mortem findings in a H1N1 influenza-positive pneumonia patient. Autops Case Rep [Internet]. 2019;9(2):e2018079. https://doi.org/10.4322/acr.2018.079

ABSTRACT Reports of histopathological findings in a patient infected with H1N1 influenza virus are limited in the literature, although many deaths have occurred because of this viral infection. In an otherwise healthy individual with no underlying co-morbid conditions, this virus passes off as a very mild disease. However, it can be fatal in the presence of underlying risk factors. Here, we present the autopsy findings of a patient who died of H1N1 infection, but who was apparently healthy with no predisposing ailments. The autopsy revealed chronic kidney disease and caseating granulomatous lymphadenitis in addition to the known classical diffuse alveolar damage picture seen in this condition. These underlying co-morbidities may provide greater insight and a better understanding of this infection. Keywords Autopsy; Renal Insufficiency; Granuloma; Influenza A Virus, H1N1 Subtype Key messages: Understanding the pathology of H1N1 influenza will give a better awareness of the novel unrecognized risk factors that will help reduce fatalities in the near future by triaging high-risk patients and preventing life-threatening complications.

INTRODUCTION H1N1 is an influenza virus, which predominantly causes respiratory illness in humans. India reported its first case of H1N1 in July 2009.1 Influenza has been well recognized as a human illness since the Middle Ages.2 Influenza affects the human race in two ways: periodic (the most common) and pandemic (the most dreaded). Pandemics are generally associated with the influenza A virus breeds, which express newer forms of the hemagglutinin (H) molecule.2,3 The interesting aspect of the H1N1 pandemic is that the fatal cases have disproportionately affected young to middle-aged adults, and surprisingly, many of them lacked the known risk factors for a b

life‑threatening complications from influenza infection. The histopathological findings described concerning H1N1 are related exclusively to postmortem studies in the literature.4-8 We present the autopsy findings with their clinicopathological correlation in an H1N1‑positive, healthy, middle-aged male, to further detail the features of this lethal but unique H1N1 influenza virus infection.

CASE REPORT A 43-year-old man, a reformed alcoholic, presented to the hospital with complaints of sudden onset breathlessness and fever of 3 days’ duration.

Armed Forces Medical College. Pune, Maharashtra, India. Command Hospital (Southern Command). Pune, Maharashtra, India.

Interesting post-mortem findings in a H1N1 influenza-positive pneumonia patient

Examination showed the room air arterial oxygen saturation (SpO2) of 80%. All other vital parameters, such as blood pressure and pulse, were within normal limits. A chest x-ray revealed bilateral pneumonitis. After 2 days, with worsening respiratory distress, he was intubated and transferred, on a ventilator, to our tertiary care set-up with a working diagnosis of viral pneumonia, possibly H1N1 related. At our hospital, he continued to be on mechanical ventilation and was given antivirals and antibiotics. On hematological evaluation, he had normal hemoglobin levels. However, he had leukopenia (leukocyte count = 2,700/mm 3). The biochemical evaluation revealed normal liver and renal function (serum bilirubin 0.7 mg/dL; blood urea 37 mg/dL; serum creatinine varied from 0.9 to 1.1 mg/dL during the 4 days of hospitalization). Urinalysis was tested once and was unremarkable. The biochemistry parameters were repeated on a daily basis, and the tests were run on an automated analyzer after running the requisite daily internal quality control tests. However, his health gradually deteriorated, and he was put on inotropic support owing to hypotension. An antemortem nasopharyngeal swab sent to a reference laboratory confirmed positivity for H1N1

virus via real-time polymerase chain reaction (RT-PCR). On day 6 of hospitalization, he suffered cardiac arrest.

AUTOPSY FINDINGS The autopsy, which was performed on the day the patient died (prior to the availability of the RT-PCR results) showed the deceased to be averagely built and well nourished. The thoracic cavity drained two liters of serous pleural effusion bilaterally. Pre‑tracheal and carinal lymph nodes were found to be enlarged, measuring 2 × 1 × 1 cm. However, there was no generalized lymphadenopathy. Both lungs were heavy and boggy; the heart and liver appeared grossly unremarkable; splenomegaly was present; and the kidneys were bilaterally scarred and contracted, measuring 9.5 × 4 × 3 cm (right) and 9 × 4 × 2.5 (left), with partially maintained cortico-medullary differentiation. Cytological analysis of the pleural fluid showed a predominant lymphocyte picture. Histopathological examination of both lungs (Figure 1) showed septal inflammation, congestion, and thickening of alveolar septae. In addition, other features of diffuse alveolar damage (DAD) were seen, which included marked intra-alveolar hemorrhage, reactive hyperplasia of type II pneumocytes, and hyaline

Figure 1. Photomicrograph of the lung. A – A massive intra-alveolar hemorrhage (asterisk) (H&E, 40X); B – Desquamation of bronchiolar epithelium (arrowhead) and necroinflammatory slough in the lumen (H&E, 100X) (asterisk); C – Presence of hyaline membrane (H&E, 400X) (arrows); D – The sloughing off of the bronchial epithelium (H&E, 100X). 2-5

Autops Case Rep (São Paulo). 2019;9(2):e2018079

Balraam KVV, Sidhu A, Srinivas V

membrane formation. Evidence of bronchitis was present focally in the form of epithelial ulceration along with plugging of the lumen with necroinflammatory slough, and submucosal inflammatory infiltrates. No foci of granulomas were found in lung sections. The pre-tracheal and carinal lymph nodes showed caseating epithelioid cell granulomas (Figure 2A and 2B). No acid-fast bacilli or fungal elements could be demonstrated on Ziehl-Neelsen or fungal stains, respectively, and reticulin stain ruled out the sarcoid origin. We found focal myofibril degeneration and interstitial fibrosis in the sections from the heart (Figure 2C and 2D). Microscopic examination of the liver showed areas of centrilobular necrosis, spotty necrosis, and mild periportal lymphocytic inflammation (Figure 3A). Sections from the spleen revealed congestive splenomegaly with red pulp expansion. Sections from both the kidneys showed evidence of renal tissue injury in the form of glomerulosclerosis in many glomeruli (around 50-60%), thyroidization of the renal tubules, and lymphocytic interstitial infiltrate (Figure 3B). The large vessels in the renal parenchyma revealed Monckeberg medial sclerosis.

DISCUSSION Our patient was a middle-aged, apparently healthy male with no known underlying co-morbid conditions, such as obesity, chronic airway diseases, hypertension, smoking, or malignancy, which could have predisposed him for the development of severe, life-threatening H1N1 disease.9 Therefore, the main goal of the autopsy was to identify any antecedent risk factors or cryptic co-morbidities. In a study of 21 patients by Mauad et al., 7 features of DAD were found in 20 of them, of which 6 were associated with necrotizing bronchiolitis, and 5 with extensive hemorrhage. They also discovered viral cytopathic effects in the bronchial and alveolar epithelial cells along with the expression of markers, such as TLR-3, IFN-γ, CD-8, and granzyme. In a study of 15 patients of H1N1 pneumonia in Pune, India, Prasad et al.1 emphasized that the histopathological findings were typically localized to the lungs, which included features of DAD in the form of mononuclear and neutrophilic infiltrates, thickened alveolar septae, intra-alveolar hemorrhage, congested pulmonary vessels, pulmonary edema, hyaline membrane formation, and desquamation of the epithelium of the bronchioles.1,5 The pulmonary pathology findings in our patient are

Figure 2. A and B – Photomicrograph of a carinal lymph node showing caseating granuloma (arrow) with a multinucleate giant cell (arrowhead) (H&E, 100X); C and D – Photomicrograph of the heart showing myofibril degeneration (arrowhead) and fibrosis (arrow) (H&E, 100X and 400X, respectively). Autops Case Rep (São Paulo). 2019;9(2):e2018079

3-5

Interesting post-mortem findings in a H1N1 influenza-positive pneumonia patient

Figure 3. A – Photomicrograph of the liver showing centrilobular necrosis (asterisk) (H&E, 100X); B – Photomicrograph of the kidney showing glomerulosclerosis (arrow) and thyroidization of the tubules (arrowhead) (H&E, 100X). corroborative. However, the only extra‑pulmonary finding reported by Prasad et al. was fatty change along with mild portal triaditis of the liver.1 Bal et al.5 studied a series of nine autopsies of proven H1N1 pneumonia and discovered that apart from lung involvement, the majority of their patients showed centrilobular hemorrhagic necrosis in the liver; and two of them showing changes of acute tubular necrosis in the kidneys. They also found hemophagocytosis in the reticuloendothelial system. We did not find any histopathological evidence of hemophagocytosis in our patient. In a study of 46 patients by Shelke et al.,4 areas of spotty or focal hepatic necrosis and acute tubular necrosis were observed in addition to the classical picture of DAD lungs. As well as spotty necrosis of the liver, we found centrilobular necrosis. We did not 4-5

find any association of chronic kidney disease with H1N1 influenza on a detailed review of the literature; neither have we come across a case of H1N1 influenza being reported along with an underlying caseating granulomatous lymphadenitis. Our case seems to be the first one reported with such an extrapulmonary histopathological feature. H1N1 infection is associated with the classical picture of DAD in the lungs. In our patient, the underlying medical renal disease and caseating granulomatous pathology may have significantly contributed to the progression of the disease, possibly by acting as inciting factors. More studies are required to find out if there is any association at all between the renal pathology and the chronic caseating granulomatous lymphadenitis, as either of these or both may, at some point, have led to immunosuppression. Autops Case Rep (São Paulo). 2019;9(2):e2018079

Balraam KVV, Sidhu A, Srinivas V

H1N1 infection, being superimposed on a case of caseating granulomatous lymphadenitis possibly tuberculosis infection in an Indian setting, leading to a rapidly fatal outcome should be kept in mind in our country. It is suggested that, in India, tuberculosis be considered as a high-risk factor in H1N1-positive patients.

3. Neumann G, Noda T, Kawaoka Y. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature. 2009;459(7249):931-9. http://dx.doi. org/10.1038/nature08157. PMid:19525932.

ACKNOWLEDGEMENTS

5. Bal A, Suri V, Mishra B, et al. Pathology and virology findings in cases of fatal influenza A H1N1 virus infection in 2009-2010. Histopathology. 2012;60(2):326-35. http://dx.doi.org/10.1111/j.1365-2559.2011.04081.x. PMid:22211291.

The authors would like to acknowledge the lab technicians and support staff for their timely effort, sincerity, and dedication towards work. A family member (next of kin) signed the consent declaration for the clinical autopsy. The authors hereby state that the manuscript is in accordance with the institution’s ethics committee policy. REFERENCES

4. Shelke VN, Kolhapure RM, Kadam D, et al. Pathologic study of pandemic influenza A (H1N1) 2009 cases from India. Pathol Int. 2012;62(1):36-42. http://dx.doi.org/10.1111/ j.1440-1827.2011.02751.x. PMid:22192802.

6. Soto-Abraham MV, Soriano-Rosas J, Díaz-Quiñónez A, et al. Pathological changes associated with the 2009 H1N1 virus. N Engl J Med. 2009;361(20):2001-3. http:// dx.doi.org/10.1056/NEJMc0907171. PMid:19907053. 7. Mauad T, Hajjar LA, Callegari GD, et al. Lung pathology in fatal novel human influenza A (H1N1) infection. Am J Respir Crit Care Med. 2010;181(1):729. http://dx.doi.org/10.1164/rccm.200909-1420OC. PMid:19875682.

1. Prasad HB, Puranik SC, Kadam DB, et al. Retrospective analysis of necropsy findings in patients of H1N1 and their correlation to clinical features. J Assoc Physicians India. 2011;59:498-500. PMid:21887906.

8. Gill JR, Sheng Z-M, Ely SF, et al. Pulmonary pathologic findings of fatal 2009 pandemic influenza A/H1N1 viral infections. Arch Pathol Lab Med. 2010;134(2):235-43. PMid:20121613.

2. Taubenberger JK, Morens DM. The pathology of influenza virus infections. Annu Rev Pathol . 2008;3(1):499-522. http://dx.doi.org/10.1146/annurev. pathmechdis.3.121806.154316. PMid:18039138.

9. Harms PW, Schmidt LA, Smith LB, et al. Autopsy findings in eight patients with fatal H1N1 influenza. Am J Clin Pathol. 2010;134(1):27-35. http://dx.doi.org/10.1309/ AJCP35KOZSAVNQZW. PMid:20551263.

Author contributions: Balraam KVV, Sidhu A and Srinivas V equally contributed to the manuscript preparation, and collectively proofread and approved the final version for publishing. Conflict of interest: None Financial support: None Submitted on: July 24th, 2018 Accepted on: February 25th, 2019 Correspondence Kolady Vijayakumar Vinu Balraam Armed Forces Medical College 411040 – Pune/Maharashtra – India Phone: +91 77981-69619 vbalraam@gmail.com

Autops Case Rep (São Paulo). 2019;9(2):e2018079

5-5

Article / Autopsy Case Report

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration Alicia Rodríguez-Velascoa , María del Carmen Rodríguez-Zepedab , Carlos Ortiz-Hidalgoc  How to cite: Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C. Infantile systemic juvenile xanthogranuloma case with massive liver infiltration. Autops Case Rep [Internet]. 2019;9(2):e2018081. https://doi.org/10.4322/acr.2018.081

ABSTRACT Infantile systemic juvenile xanthogranuloma (ISJXG) is an uncommon form of juvenile xanthogranuloma, a non-Langerhans cell proliferation of infancy and early childhood. In a small percentage of patients, the visceral involvement—most commonly to the central nervous system, liver, spleen, or lungs—may be associated with severe morbidity, and eventually fatal outcome. Here we describe the clinical and pathological findings of a 28-day-old girl with ISJXG who died with respiratory distress syndrome. She had few cutaneous lesions but massive liver and spleen infiltration; other affected organs were multiple lymph nodes, thoracic parasympathetic nodule, pleura, pancreas, and kidneys. Additional findings were mild pulmonary hypoplasia and bacteremia. Immunohistochemistry on fixed tissues is the standard for diagnosis. Immunophenotype cells express CD14, CD68, CD163, Factor XIIIa, Stabilin-1, and fascin; S100 was positive in less than 20% of the cases; CD1a and langerin were negative. No consistent cytogenetic or molecular genetic defect has been identified. This case demonstrates that the autopsy is a handy tool, because hepatic infiltration, which was not considered clinically, determined a restrictive respiratory impairment. In our opinion, this was the direct cause of death. Keywords Autopsy; Congenital; Xanthogranuloma, Juvenile; Liver Diseases.

INTRODUCTION Dendritic and histiocytic neoplasms are rare, and together make up less than 1% of neoplasms presenting in the lymph nodes or soft tissues.1 These tumors are usually classified into two main groups based on their derivation from either mesenchymal cells or bone marrow precursors.2,3 They occur less often during the perinatal period, and there is a study suggesting that there has been an increased incidence of spontaneous regression of certain histiocytic lesions in neonates compared to older individuals.4

Infantile systemic juvenile xanthogranuloma (ISJXG), an uncommon non-Langerhans cell proliferation of infancy and early childhood, 5,6 is one of the many clinical variants, with a common histopathology of the juvenile xanthogranuloma (JXG) family disorders namely (i) solitary or multiple dermal; (ii) infantile systemic; (iii) deep (soft tissue, “giant”); (iv) xanthoma disseminatum; (v) papular/generalized eruptive; (vi) benign cephalic histiocytosis; (vii) adult orbital XG; (viii) progressive nodular histiocytosis; and

UMAE, Hospital de Pediatría del Centro Médico Nacional IMSS, Department of Pathology. Ciudad de México, Mexico. UMAE, Hospital de Pediatría del Centro Médico Nacional IMSS Department of Hematology. Ciudad de México, Mexico. c Hospital ABC Medical Center, Department of Surgical Pathology. Ciudad de México, Mexico. a

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

(ix) Erdheim‑Chester disease.5-8 Over the last decade, systemic forms have been increasingly reported.9 Stromal dendritic cells have been proposed (i.e., mesenchymal in origin) as the cells of origin, based on immunoreactivity to fascin and factor XIIIa. Immunohistochemistry, on fixed tissues, is the standard for diagnosis, and a panel of antibodies is required due to a lack of a unique cell marker.5-8 Although the biology of ISJXG is not clear, it often presents spontaneous regression over several years,4 as in the isolated cutaneous form, the reason why the removal of these benign lesions is dissuaded. However, prompt and accurate diagnosis is essential. In a small percentage of patients with visceral involvement— most commonly in the central nervous system (CNS), liver, spleen, or lungs—ISJXG may be associated with severe morbidity. 10-14 Surgery, chemotherapy, and radiotherapy have been used with favorable results.10 However, occasionally fatal outcome may occur.10,15 In a PubMed search, we found five reports of congenital fatal cases of ISJXG. 8,13,15-23 Herein we describe the clinical and pathological findings of a 28-day-old girl with congenital ISJXG who died with respiratory distress syndrome. In our opinion, the massive hepatomegaly caused lung restriction (which could have been present since the late gestation) hampering the pulmonary development, resulting in mild pulmonary hypoplasia. She had few cutaneous lesions but massive liver and spleen infiltration; other affected organs were multiple lymph nodes, the thoracic parasympathetic nodule, the pleura, the pancreas, and the kidneys. Additional findings were hypoplastic lungs and bacteremia.

CASE REPORT This is the case of a 28-day-old girl without a remarkable family history, who was delivered at term after an uneventful pregnancy. She was born with counted bluish palpable nodular lesions from 0.5 to 1 cm, which were initially located on the face. At the age of 21 days, she was presented to a general hospital with irritability and progressive abdominal distention. On admission, she was pale and presented 13 visible and 6 palpable skin nodules located on her face, thorax, and extremities, and massive hepatomegaly and splenomegaly. Blood tests showed mild anemia and thrombocytopenia. 2-14

The abdominal echography revealed multiple nodular lesions throughout the enlarged liver. After 24 hours, the mother decided to take her to a tertiary care hospital, where clinically congenital leukemia was suspected. The anemia and thrombocytopenia worsened, but leukocytes were normal. Serologic studies for HIV, cytomegalovirus, Epstein-Barr virus and Toxoplasma were negative. Serum tumor markers as alpha-fetoprotein, human chorionic gonadotropin, and carcinoembryonic antigen were negative. The platelet count ranged from 4,000 to 18,000/ mm3 (reference range [RR]; 142-424 x 103/mm3), hemoglobin range was 7.5-11.3 g/dL (RR;12.2-18.1 g/dL); peripheral blood leukocyte count range was 4,580-8,520/mm3 (RR; 4.60-10.20 x 10 3/mm 3). Electrolytes showed persistent hyponatremia (sodium range 124-133 mEq/L [RR; 132-144 mEq/L]). However, potassium and renal function tests were within the normal limits. Three days after admission she was suffering from anasarca, and liver function tests showed low serum albumin 1.4 g/dL (RR; 3.50-5.00 g/dL) and notable coagulopathy with an increased Prothrombin Time and a I.N.R of 2.52 (RR; 1); serum aspartate aminotransferase range was 11-325 UI/L (RR; 12-50 UI/L), alanine aminotransferase range was 1.1-55 UI/L (RR; 10-40 UI/L), γ-glutamyl transpeptidase 24.3 UI/L (RR; 10-40 UI/L), total bilirubin range 2.59‑8.75 mg/dL (RR; 0.20-1.00 mg/dL), alkaline phosphatase 38.54 UI/L (RR; 50-136 UI/L), and C-reactive protein 47.72 mg/L (RR;< 5 mg/L). Serum immunoglobulin levels were: IgG 169 mg/dL (RR; 100-360 mg/dL), IgM 14 mg/dL (RR; 26-122 mg/dL), IgA 3 mg/dL (RR; 7-37 mg/dL), and IgE 0.71 (UI/mL, <1.5). Serologic testing for syphilis was negative. A second abdominal ultrasound revealed retroperitoneal lymphadenopathy and ascites, and the kidneys were normal. The clinical course following admission was of rapid deterioration with worsening hepatomegaly, hyperbilirubinemia, abdominal distention, abdominal circumference 43.5 cm (Figure 1A) and ascites, radiological thoracoabdominal images showed bilateral diaphragm elevation (Figure 1B) and intestinal distention. On the fourth day a limited bone marrow aspirate showed no abnormal infiltrate or hemophagocytosis, and an excisional skin biopsy was taken. The patient died on the fifth day with respiratory distress syndrome (respiratory rate 70 breaths per minute), without evidence of hemorrhage. Autops Case Rep (São Paulo). 2019;9(2):e2018081

Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C

PATHOLOGIC FINDINGS Due to the working diagnosis of congenital leukemia, a skin excisional biopsy was received and was evaluated immediately by fine needle aspiration (FNA) (caliber 26), which disclosed large histiocytic-like

cells (Figure 2); therefore, the diagnosis of histiocytosis was suggested. The surgical specimen was studied on formalin-fixed and paraffin-embedded tissue sections. Light microscopic study at low magnification revealed a dense cellular nodule poorly demarcated involving the entire dermis. At higher magnification,

Figure 1. A – Gross examination of the corpse showing marked abdominal distention (abdominal circumference 43.5 cm). Note the skin nodules (arrows) on the upper left extremity and lower right extremity, and genital edema; B – Plain thoraco-abdominal radiograph demonstrating the enlarged liver and diaphragm elevation.

Figure 2. Cytological example obtained by FNA of the skin biopsy. Disclosed monotonous histiocytic type cells. Cytologic features allowed us to suggest the diagnosis of histiocytosis. FNA = fine needle aspiration. (H&E stain), A (100 X), B (400 X). Autops Case Rep (São Paulo). 2019;9(2):e2018081

3-14

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

the predominant cells appeared to be histiocytes, with occasional eosinophils. There were few Touton giant cells (Figure 3), but no cells with foamy cytoplasm, nuclear atypia, or mitotic figures. The diagnosis of JXG was made. Immunohistochemical staining showed that all histiocytes were positive for CD68, CD163, and Factor XIIIa, and negative for S-100, CD1a, and langerin (Figure 4) (CD68/KP-1:700/Biocare, CD163/1:50/BioSb, Factor XIIIa/1:200/Biocare, S-100/1:3800/Dako, CD1a/1:500/Dako, and langerin/1:40/BioSb, respectively). Autopsy permission was restricted to the thoracic and abdominal organs. The infant had generalized edema, an abdominal circumference of 43.5 cm, ascites, and mild jaundice. The postmortem examination revealed intense small bowel distention; the liver weighed 500 g (RR; 121 ±39.2 g); and was extensively infiltrated by irregular micronodular tumor (Figure 5). At the cut surface, the liver gave off a fetid odor. The histology showed that tumor cells consisted of

no plump histiocytes and spindle cell forms, and a few Touton giant cells were present. The tumor obliterated many portal and hepatic veins. In the liver, the tumor was preferentially located within the portal triads, but the biliary epithelium was spared (Figure 6). Macroscopically the spleen was apparently free of tumor, but microscopically there were abundant plump histiocytic cells, positive for CD163, which obliterated the sinusoids (Figure 7). Nodular tumor lesions were also present in the thoracic lymph nodes, pleura (Figure 8), mesenteric lymph nodes, perirectal fat (Figure 9), pancreas (Figure 10), periadrenal, and both kidneys (Figure 11). Multiple bacterial colonies were identified in the hepatic, splenic, and pulmonary vascular spaces (Figure 12), however, blood cultures were not performed. Other relevant findings were pulmonary atelectasis and mild pulmonary hypoplasia (Figure 13). Death was attributed to sepsis and respiratory distress syndrome secondary to pulmonary hypoplasia worsened by severe abdominal distention.

Figure 3. Photomicrographs of the skin biopsy showing dermal expansion for infiltration of histiocytes and occasional Touton giant and eosinophil cells (H&E stain) A (40X), B (100X), C (400 X), and D (400_X). 4-14

Autops Case Rep (São Paulo). 2019;9(2):e2018081

Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C

DISCUSSION The aid of recent advances in immunohistochemistry enabled better classification of dendritic and histiocytic cell neoplasms and improved the knowledge of tumor

biology and histogenesis, which may be helpful in the management of these rare diseases. Dermal and interstitial dendrocytes are responsible for JXG. 2,3 JXG and Langerhans cell histiocytosis (LCH), together in the category of “dendritic cell-related proliferations”,

Figure 4. Photomicrographs of the skin biopsy. Immunohistochemistry was positive for CD68 (A) and Factor XIIIa (C), and negative for CD1a (B) and S-100 (D).

Figure 5. Gross view of the liver showing the parenchyma diffusely infiltrated by the tumor. Autops Case Rep (São Paulo). 2019;9(2):e2018081

5-14

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

Figure 6. Photomicrographs of the liver. A, and C show the portal tract with diffuse infiltration by histiocytes and in B a central vein. The bile ducts are not affected, which is clearly seen with CD163. A (H&E, 100X), B (400X) and C (100X).

Figure 7. Photomicrographs of the spleen. A and B â&#x20AC;&#x201C; High magnification of multisystemic juvenile xanthogranuloma with diffuse infiltration by plump histiocytes, which is strongly positive for CD163. A (H&E, 400X) and B (100X). 6-14

Autops Case Rep (SĂŁo Paulo). 2019;9(2):e2018081

Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C

Figure 8. Gross back view of the cardiopulmonary block showing yellowish pleural nodes in both lungs.

Figure 9. A – Gross view of the mesenteric and perirectal lymph nodes (C). The lymph nodes are infiltrated by foamy macrophages and Touton giant cells (B and D respectively) (H&E, B(40X) and D(400X). Autops Case Rep (São Paulo). 2019;9(2):e2018081

7-14

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

Figure 10. A – Gross view of the pancreas revealed nodular infiltration of the tale. The head of the organ shows a necrotic area surrounded by a hemorrhagic halo; B – Photomicrograph of the pancreas showing substitution of the normal parenchyma by the neoplasm. H&E (40X).

Figure 11. Gross view of the kidney in A and adrenal gland in B. The macroscopic examination shows nodular renal infiltration (asterisks) and periadrenal nodular lesion; C – Photomicrograph of the kidney with neoplastic infiltration (H&E, 100X) and D depicts the peripheral adrenal neoplastic nodule (H&E, 40X). 8-14

Autops Case Rep (São Paulo). 2019;9(2):e2018081

Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C

Figure 12. Photomicrograph of the blood vessels with colonies of bacteria in the A – lung (H&E, 1000X); B – liver (H&E, 1000X); and C – spleen (H&E, 1000X).

Figure 13. Photomicrographs of the lung showing in A – nodular pleural infiltration (H&E, 100X); B – atelectasis (H&E, 40X), and at the periphery of an acinus in this hypoplastic lung (right); C – A radial count (arrow) is below the normal of 4 to 6 for a term infant, confirming the diagnosis of hypoplasia (H&E, 100X). Autops Case Rep (São Paulo). 2019;9(2):e2018081

9-14

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

currently are separated from the macrophage-related proliferations. The reported cases with the coexistence of JXG and LCH suggest their common origin.24,25 Patients with JXG and neurofibromatosis types 1 and 2, as well as a triad with juvenile chronic myelogenous leukemia, has been reported.26 In contrast to other Xanthomatous diseases, JXG is a normolipemic disorder.18,27 The Kiel Pediatric Tumor Registry reported 129 cases of JXG over 36 year (0.52% among 24,600 children), showing the very low frequency of the disease.8 JXG affects mainly children younger than 2 years of age.8,28 In the analysis of Janssen and Harms,8 there were 71.3% of patients younger than 12 months; in contrast, Dehner15 reported a frequency of 45% within the first year. According to various authors, the male to female ratio goes from “1.1:1” to .7:1”.8,26,29 However, when considering only newborns, the ratio of male to female is 1:2.4 (Table 1). Clinically there is a broad spectrum of differential diagnoses, including reactive processes, or benign or malignant tumors. The literature is replete with single-case reports of cutaneous JXG—the most common form of non-LCH of childhood—but JXG may occur at any site of the body, and only 4-5% of children with JXG have the infantile systemic variant of the disease.8,10,15,16,19,20,30,31 A PubMed search revealed very few congenital and lethal ISJXG cases similar to ours (Table 1), with none having more than five affected sites; however, in our case, there were eight affected sites. In ISJXG, the most important morphologic differential diagnosis is with LCH, the most common form of dendritic cell proliferations.1-3 In ISJXG, the skin is involved in only 50% of cases, and the liver is involved in most of these cases, with predominantly portal infiltrate spilling over into the adjacent lobule but sparing the biliary tree, which contrasts with LCH.7 As Fan and Sun30 reported, when JXG has liver involvement, it is a relatively benign disease in its worst form. The location and character of hepatic lesions are important clues to the differential diagnosis, as reported by Favara.32 Other involved sites include: soft tissue, upper aerodigestive tract, CNS, lymph node, bone marrow, kidneys, and lung; other more unusual sites affected are spleen, myocardium, retroperitoneum, pancreas, and adrenal glands.33,34 From the 174 JXG cases reviewed by Denher,15 8 had systemic disease, 2 were diagnosed at birth with hepatosplenomegaly and died of acute hepatic 10-14

failure, but 1 survived after systemic chemotherapy. From 1996 to 2011 there were at last 31 informed cases of the clinical variant ISJXG; in 17 cases the condition was present at birth, 6 of these cases were fatal (35.2%) (Table 1). The reported ISJXG fatal cases of the neonates had a similar clinical presentation to our patient. This supports the concept that ISJXG, complicated by the hepatic infiltration in the neonatal period, is a life-threatening disease caused by hepatic failure, or mainly because severe hepatosplenomegaly induced respiratory failure, as happened in our case. The severe hepatosplenomegaly in our case could have been present since late gestation and compressed the thoracic cavity resulting in mild pulmonary hypoplasia by upward compression the diaphragm—a finding not previously reported in ISJXG. This patient with JXG, which was apparently limited to the skin, must have had a complete physical examination to detect the systemic form, with laboratory and imaging studies if other abnormalities were suspected. Diagnostic studies may include computed tomography or magnetic resonance imaging (MRI), ultrasonography of the abdomen, a radionuclide bone scan, and a detailed ophthalmologic examination. In the instance of neonatal ISJXG where a quick diagnosis is required, FNA cytology made from the surgical biopsies is a useful tool for the initial differential diagnostic procedure and management.21,35,36 In our case, with the working diagnosis of congenital leukemia, the cytology of the skin biopsy allowed the proposed diagnosis of histiocytosis within a few minutes. Clinical presentations include anemia and thrombocytopenia; however, there is little reliable information on their natural history or the treatment of choice. The vast majority of congenital ISJXG cases, even those with visceral involvement, experience disease regression without specific treatment; 4 however, severe morbidity has been reported in some cases, which need supportive interventions and chemotherapy.10,22,28 Treatment protocols recommended for patients with symptoms who have unresectable lesions are those used for LCH. The LCH-III protocol—the most common treatment strategy—was first suggested by Nakatani et al.23 Although most patients with the multisystemic disease are infants and particularly susceptible to the adverse effects of chemotherapy, a prudent approach should emphasize the supportive Autops Case Rep (São Paulo). 2019;9(2):e2018081

Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C

care, reserving chemotherapy or radiation when this treatment is perceived as necessary. Immunophenotypically, cells express CD14, CD68, CD163, Factor XIIIa, Stabilin-1, and fascin;

S100 is a variable positive in less than 20% of the cases; nevertheless, none of these markers are specific for ISJXG, 37 and CD1a and langerin are negative. In our case, CD163 and Factor XIIIa were positive,

Table 1. Reported cases of infantile systemic juvenile xanthogranuloma, detected at birth, with liver affection (n=17), searched in PubMed. Six cases (35.2%) were fatal No. cases

Age at diagnosis

Sex

Sites

Treatment

Outcome

Janssen and Harms8

Birth

Skin, lung, heart, liver, spleen, kidney, small and large intestine, BM

VP16, DX, Ig

DOD, 34 days

Freyer et al.10

Birth

Supportive

Well/2 m

Birth

Skin, soft tissue, lung, liver, retroperitoneum Bone, liver, spleen, adrenal gland

MPD

Well/2 y

Author/year

Haughton et al.12

Birth

Skin, liver

Liver transplantation

ADF/2 y

Chantorn et al.13

2 (twins)

Birth Birth

F F

Skin, liver Skin, liver

PDN PDN

AWD/17 m

Papadakis et al.14

Birth

Skin, liver

VBL, VP16, 6-MP

AWD/7.5 m

Dehner15

Birth

VA, corticosteroids

DOD/2 m

Birth*

CSA, VBL, MPN

ADF/8 y

Birth

Liver, spleen and lung Skin, soft tissue, liver, spleen Liver, spleen, adrenal, intestine and lymph nodes

VA, corticosteroids

DOD/1 m

VP16, DX

Died on day 29 from multiorgan failure and sepsis

Hu et al.16

Birth

Skin, liver, spleen, pancreas, adrenal gland, mesenteric lymph nodes

Azorín et al.17

Birth

Skin, BM, liver

Fan and Sun30

Birth

Liver, spleen, BM, lymph node, lung

PD, VBL, 6-MP and MTX

AWD/20 m

Takeuchi et al.19

Birth

Skin, placental, around portal vein

LCH oriented chemotherapy

ADF/2 y

Santiago et al.20

Birth

Soft tissue, liver, BM

VBL, cytarabine

Died on day 65 with septic shock

Nakatani et al.23

Birth

CNS, hip, liver and spleen

Cytarabine, vincristine, PDN, MTX

ADF/2 y

This case

Birth

Skin, liver, spleen, pancreas, kidneys, lymph nodes, pleura, parasympathetic nodes

Managed symptomatically

Died on day 120 with respiratory distress and septic shock

MPN, VBL, DOD/78th day of life Cytarabine, MTX and RT of the liver

*Previously reported by Freyer et al. J Pediatr 1996;129:227–37; 6-MP = 6-mercaptopurine; ADF = alive disease-free; AWD = alive with disease; BM = bone marrow; CNS = central nervous system; CSA = cyclosporine; DOD = dead of disease; DX = dexamethasone; F = female; Ig = immunoglobulins; LCH = Langerhans cell histiocytosis; M = male; MPN = metilprednisolone; MTX = methrotexate; PDN = prednisone; RT = radiation therapy; VA = Vinca alkaloids; VBL = vinblastine; VP16 = etopsoside. Autops Case Rep (São Paulo). 2019;9(2):e2018081

11-14

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

while S100 and CD1a were negative. No consistent cytogenetic or molecular genetic alterations have been identified.16,17

2. Dalia S, Shao H, Sagatys E, Cualing H, Sokol L. Dendritic cell and histiocytic neoplasms: biology, diagnosis, and treatment. Cancer Control. 2014;21(4):290-300. http://dx.doi.org/10.1177/107327481402100405. PMid:25310210.

CONCLUSIONS

3. Dalia S, Jaglal M, Chervenick P, Cualing H, Sokol L. Clinicopathologic characteristics and outcomes of histiocytic and dendritic cell neoplasms: the Moffitt Cancer Center experience over the last twenty five years. Cancers. 2014;6(4):2275-95. http://dx.doi.org/10.3390/ cancers6042275. PMid:25405526.

Infantile systemic forms of JXG have different presentation, response to the treatment and outcome. Incidence rates are about 0.1 case/1,000.000 of children younger than 15 years old. Although this report has the inherent limitation of a case report, it presents the importance of the autopsy examination, which can still influence medical practice and show several problems that were clinically undetected. In this case, the disseminated neoplasms could have been diagnosed earlier, because, in neonatal patients in whom JXG is considered, systemic forms could be underestimated, as in this case. For new patients with cutaneous JXG who have other symptoms, clinicians must be alert to refer the patient to a tertiary care center where tests, including (at the very least) MRI of the brain and ultrasonography of the abdomen, can be undertaken to enable accurate diagnosis. Adjuvant chemotherapy could have changed the course of the disease in our case. Although JXG is the most common benign type of histiocytosis in infants, the ISJXG variant is a very rare and distinctive clinicopathologic entity, generating a challenging group of patients. More than 70% of the patients are younger than 1 year. ISJXG must be distinguished principally from LCH. The clinical findings are attributable to sites of disease and can be severe. No published case has eight affected sites of the body, as in our case. The most common sites of disease beyond subcutaneous soft tissue are liver, spleen (or both), lung, and CNS. Exceptionally, liver, spleen, or lung involvement cause serious consequences, and the gold standard for diagnosis is the biopsy. The respiratory distress and bacteremia, as in our case, may be the cause of death in most cases.

REFERENCES 1. Chang LK, Weiss LM. Other histiocytic and dendritic cell neoplasms. In: Jaffe ES, Harris NL, Vardiman JW, Campo E, Arber DA, editors. Hematopathology. Philadelphia: Saunders Elsevier; 2011. p. 835-6. http:// dx.doi.org/10.1016/B978-0-7216-0040-6.00053-8. 12-14

4. Isaacs H Jr. Fetal and neonatal histiocytoses. Pediatr Blood Cancer. 2006;47(2):123-9. http://dx.doi.org/10.1002/ pbc.20725. PMid:16416419. 5. Chu AC. The confusing state of the histiocytosis. Br J Dermatol. 2000;143(3):475-6. PMid:10971316. 6. Zelger BWH, Sidoroff A, Orchard G, Cerio R. NonLangerhans cell histiocytosis: a new unifying concept. Am J Dermatopathol. 1996;18(5):490-504. http:// dx.doi.org/10.1097/00000372-199610000-00008. PMid:8902096. 7. Jaffe R, Fletcher CDM, Burgdorf W. Disseminated juvenile xanthogranuloma. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., editors. WHO Classification of tumours of haematopoietic and lymphoid tissues. 4th ed. Lyon: International Agency for Research on Cancer; 2008. p. 366-7. 8. Janssen D, Harms D. Juvenile xanthogranuloma in childhood and adolescence: a clinicopathologic study of 129 patients from the Kiel Pediatric Tumor Registry. Am J Surg Pathol. 2005;29(1):21-8. http:// dx.doi.org/10.1097/01.pas.0000147395.01229.06. PMid:15613853. 9. PubMed Help [Internet]. Bethesda: National Center for Biotechnology Information; 2005 [cited 2015 Apr 23]. Available from: http://www.ncbi.nlm.nih.gov/books/ NBK3827/ 10. Freyer DR, Kennedy R, Bostrom BC, Kohut G, Dehner LP. Juvenile xanthogranuloma: forms of systemic disease and their clinical implications. J Pediatr. 1996;129(2):22737. http://dx.doi.org/10.1016/S0022-3476(96)70247-0. PMid:8765620. 11. Unuvar E, Devecioglu O, Akcay A, et al. Successful therapy of systemic xanthogranuloma in a child. J Pediatr Hematol Oncol. 2007;29(6):425-7. http://dx.doi.org/10.1097/ MPH.0b013e318064515e. PMid:17551409. 12. Haughton AM, Horii KA, Shao L, Daniel J, Nopper AJ. Disseminated juvenile xanthogranulomatosis in a newborn resulting in liver transplantation. J Am Acad Dermatol. 2008;58(2, Suppl):S12-5. http://dx.doi. org/10.1016/j.jaad.2007.09.012. PMid:18191690. 13. Chantorn R, Wisuthsarewong W, Aanpreung P, Sanpakit K, Manonukul J. Severe congenital systemic Autops Case Rep (São Paulo). 2019;9(2):e2018081

Rodríguez-Velasco A, Rodríguez-Zepeda MC, Ortiz-Hidalgo C

juvenile xanthogranuloma in monozygotic twins. Pediatr Dermatol. 2008;25(4):470-3. http://dx.doi.org/10.1111/ j.1525-1470.2008.00752.x. PMid:18789091. 14. Papadakis V, Volonaki E, Katsibardi K, et al. A rare case of neonatal systemic xanthogranulomatosis with severe hepatic disease and metachronous skin involvement. J Pediatr Hematol Oncol. 2012;34(3):2268. http://dx.doi.org/10.1097/MPH.0b013e3182203086. PMid:22031119. 15. Dehner LP. Juvenile xanthogranulomas in the first two decades of life: a clinicopathologic study of 174 cases with cutaneous and extracutaneous manifestations. Am J Surg Pathol. 2003;27(5):579-93. PMid:12717244. 16. Hu WK, Gilliam AC, Wiersma SR, Dahms BB. Fatal congenital systemic juvenile xanthogranuloma with liver failure. Pediatr Dev Pathol. 2004;7(1):71-6. http://dx.doi. org/10.1007/s10024-003-4040-3. PMid:15255037. 17. Azorín D, Torrelo A, Lassaletta A, et al. Systemic juvenile xanthogranuloma with fatal outcome. Pediatr Dermatol. 2009;26(6):709-12. http://dx.doi.org/10.1111/j.15251470.2009.01018.x. PMid:20199446. 18. Kolivras A, Theunis A, Saint-Aubain N, et al. Congenital disseminated juvenile xanthogranuloma with unusual skin presentation and renal involvement. J Cutan Pathol. 2009;36(6):684-8. http://dx.doi.org/10.1111/j.16000560.2008.01101.x. PMid:19515049. 19. Takeuchi M, Nakayama M, Nakano A, Kitajima H, Sawada A. Congenital systemic juvenile xanthogranuloma with placental lesion. Pediatr Int. 2009;51(6):833-6. http://dx.doi.org/10.1111/j.1442-200X.2009.02932.x. PMid:20158626. 20. Santiago J, Martinez-Garcia E, Giron J, Salcedo C, Perez-Gallardo A. Prophylactic recombinant factor VIIa administration to an infant with congenital systemic juvenile xanthogranuloma. Paediatr Anaesth. 2006;16(9):974-6. http://dx.doi.org/10.1111/j.14609592.2006.02009.x. PMid:16918661. 21. Barroca H, Farinha NJ, Lobo A, Monteiro J, Lopes JM. Deep-seated congenital juvenile xanthogranuloma: report of a case with emphasis on cytologic features. Acta Cytol. 2007;51(3):473-6. http://dx.doi.org/10.1159/000325771. PMid:17536559. 22. Hu WK, Gilliam AC, Wiersma SR, Dahms BB. Fatal congenital systemic juvenile xanthogranuloma with liver failure. Pediatr Dev Pathol. 2004;7(1):71-6. http://dx.doi. org/10.1007/s10024-003-4040-3. PMid:15255037. 23. Nakatani T, Morimoto A, Kato R, et al. Successful treatment of congenital systemic juvenile xanthogranuloma with Langerhans cell histiocytosis-based chemotherapy. J Pediatr Hematol Oncol. 2004;26(6):371-4. http:// dx.doi.org/10.1097/00043426-200406000-00007. PMid:15167350. Autops Case Rep (São Paulo). 2019;9(2):e2018081

24. Yu H, Kong J, Gu Y, Ling B, Xi Z, Yao Z. A child with coexistent juvenile xanthogranuloma and Langerhans cell histiocytosis. J Am Acad Dermatol. 2010;62(2):32932. http://dx.doi.org/10.1016/j.jaad.2009.02.028. PMid:19969387. 25. Bains A, Parham DM. Langerhans cell histiocytosis preceding the development of juvenile xanthogranuloma: A case and review of recent developments. Pediatr Dev Pathol. 2011;14(6):480-4. http://dx.doi.org/10.2350/1012-0950-CR.1. PMid:21793710. 26. Allen C, McClain K. Juvenile xanthogranuloma [Internet]. 2015 [ cited 2015 Apr 23 ]. Available from: https:// histiocytesociety.org/document.doc?id=48 27. Zaremba J, Zaczkiewicz A, Placek W. Eruptive xanthomas. Postepy Dermatol Alergol. 2013;30(6):399-402. http:// dx.doi.org/10.5114/pdia.2013.39439. PMid:24494004. 28. Sonoda T, Hashimoto H, Enjoji M. Juvenile xanthogranuloma: clinicopathologic analysis and immunohistochemical study of 57 patients. Cancer. 1985;56(9):2280-6. http://dx.doi. org/10.1002/1097-0142(19851101)56:9<2280::AIDCNCR2820560923>3.0.CO;2-L. PMid:3931900. 29. N a s c i m e n t o A G . A c l i n i c o p a t h o l o g i c a n d immunohistochemical comparative study of cutaneous and intramuscular forms of juvenile xanthogranuloma. Am J Surg Pathol. 1997;21(6):645-52. http:// dx.doi.org/10.1097/00000478-199706000-00003. PMid:9199641. 30. Fan R, Sun J. Neonatal systemic juvenile xanthogranuloma with ominous presentations and successful treatment. Clin Med Insights Oncol. 2011;5:157-61. http://dx.doi. org/10.4137/CMO.S6686. PMid:21695102. 31. C h a n t r a n u w a t C . S y s t e m i c f o r m o f j u v e n i l e xanthogranuloma: Report of a case with liver and bone marrow involvement. Pediatr Dev Pathol. 2004;7(6):6468. http://dx.doi.org/10.1007/s10024-004-1012-1. PMid:15630537. 32. Favara BE. Histopathology of the liver in histiocytosis syndromes. Pediatr Pathol Lab Med. 1996;16(3):41333. http://dx.doi.org/10.1080/15513819609168681. PMid:9025843. 33. Chang MW. Update on juvenile xanthogranuloma: unusual cutaneous and systemic variants. Semin Cutan Med Surg. 1999;18(3):195-205. http://dx.doi. org/10.1016/S1085-5629(99)80017-0. PMid:10468039. 34. Jaffe R. Liver involvement in the histiocytic disorders of childhood. Pediatr Dev Pathol. 2004;7(3):21425. http://dx.doi.org/10.1007/s10024-003-9876-z. PMid:15022067. 35. Grenko RT, Sickel JZ, Abendroth CS, Cilley RE. Cytologic features of deep juvenile xanthogranuloma. Diagn Cytopathol. 1996;15(4):329-33. http://dx.doi. org/10.1002/(SICI)1097-0339(199611)15:4<329::AIDDC15>3.0.CO;2-Q. PMid:8982590. 13-14

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

36. Gutiérrez Martín A, Pérez Barrios A, Vaillo Vinagre A, De Agustín De Agustín P. Neonatal juvenile xanthogranuloma: report of a case with fine needle aspiration cytologic findings in a soft tissue mass. Acta Cytol. 2000;44(3):3858. PMid:10833996.

37. Amouri M, Gouiaa N, Chaaben H, et al. Disseminated juvenile xanthogranuloma expressing protein S100. Ann Dermatol Venereol. 2012;139(2):128-31. http://dx.doi.org/10.1016/j.annder.2011.10.408. PMid:22325752.

Author contributions: Rodríguez-Velasco A performed the autopsy and wrote the article, Ortiz-Hidalgo C contributed with the immunohistochemistry and with the final Pathological report. Rodríguez-Zepeda MC was the hematologist who saw the patient. All authors proofread the final version and approved for publication. The authors retain a signed informed consent for the restricted autopsy and the manuscript is by the Institutional Ethics Committee. Conflict of interest: None Financial support: None Submitted on: February 6th, 2019 Accepted on: March 4th, 2019 Correspondence Alicia Rodríguez-Velasco Department of Pathology - UMAE Hospital de Pediatría del Centro Médico Nacional IMSS Av. Cuauhtémoc, 330, Col. Doctores – Ciudad de México – Mexico C.P. 06720 Cuauhtémoc Phone: +52 (55) 54535759 alirove0101@gmail.com

14-14

Autops Case Rep (São Paulo). 2019;9(2):e2018081

Article / Autopsy Case Report

Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature Massimiliano Guerrieroa , Arnaldo Carboneb , Francesco Colasurdoc, Valerio Pellegrinid, Anna Maria Pollioa How to cite: Guerriero M, Carbone A, Colasurdo F, Pellegrini V, Pollio AM. Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature. Autops Case Rep [Internet]. 2019;9(2):e2019089. https://doi.org/10.4322/acr.2019.089

ABSTRACT Liver metastases are commonly found in advanced cancer patients; however, acute liver failure secondary to diffuse liver infiltration is rare. Small cell lung carcinoma accounts for 15% of lung carcinomas. We describe the ninth case of small cell lung carcinoma massively metastatic to the liver, reported in the scientific literature, with sudden clinical onset and death after a few days. An autopsy was performed to understand the cause of death. Keywords Small Cell Lung Carcinoma, Hepatomegaly, Acute Liver Failure, Liver Metastasis

INTRODUCTION Small cell lung carcinoma (SCLC) is an aggressive neuroendocrine neoplasia, which is strongly related to smoking attitude, characterized by rapid growth and very poor overall survival, usually diagnosed as a central tumor.1 It accounts for 13-15% of all lung cancers and represents the sixth most common cause of death for malignant tumours.2 Histological evaluation is mandatory. According to the World Health Organization (WHO), morphology and immunohistochemistry should be performed for the final diagnosis.3 The lack of specific symptoms at early tumor stages and the lack of screening methods continue to be the main obstacles for the early detection of this disease. Most patients are diagnosed with advanced disease— often with a metastatic dissemination (extensive

stage [ES]).4 Because of the highly progressed disease states, clinical courses are usually too short to identify the causes, resulting in multi-organ failure. We describe the unusual case of an occult SCLC with clinical onset for jaundice and fulminant progression up to death within a few days. The particularities of the case are also its incidental diagnosis at autopsy, clinical onset with non-obstructive jaundice liver disease, and the rapid progression towards death. To date 35 cases (in 25 papers) of SCLCs with diffuse liver metastases and fulminant liver failure have been described in the medical literature, but in 9 cases the clinical onset was sudden and without warning, followed by a quick death. We will carry out a critical review of all published cases.

A. Cardelli Regional Hospital, Regional Health Authority of Molise (ASReM), Department of Pathology. Campobasso, Italy. Universita Cattolica del S. Cuore, Institute of Pathology. Rome, Italy. c Independent scholar. Campobasso, Italy. d University of Molise, Department of Medicine and Health Sciences. Campobasso, Italy. a

Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature

CASE REPORT A 78-year-old male, who was a heavy smoker, presented at the Emergency Department with recently appeared jaundice (sclera and skin) and lower limbs edema. Past medical history included chronic obstructive pulmonary disease and hypertensive heart disease. He had no history of hepatitis, alcohol abuse, or drug allergy. On admission, the physical examination revealed a globose abdomen with marked hepatomegaly, respiratory examination was consistent with chronic bronchitis with mild dyspnea and shortness of breath. An abdominal and thoracic computed tomography was performed and showed a lesion in the lower lobe of the right lung highly suspicious of malignancy, and marked hepatomegaly not otherwise specified. Due to severe renal, cardiac, and hepatic conditions, the patient was hospitalized in intensive care. The patient developed hepatic encephalopathy and later went into a coma. He died with acute liver failure (ALF) and multi-organ failure only 7 days after admission.

AUTOPSY PRESENTATION The Autopsy Revealed Unexpected Findings The liver (Figure 1) extended from the right to the left hipochondrium. The liver’s dimensions had increased so much that it could be measured from the costal arch of 14 cm on the right and 6 cm on the left. The liver weighed 4.25 kg (Reference range [RR]; 1.5 kg) and the cut surface was entirely occupied by small yellowish-white nodules of varying sizes (average size of 0.3-0.4 cm). Moderate ascitic fluid (approx. 400 mL) was present. There was evidence of bilateral pulmonary edema, and lower limbs edema. In the right lower pulmonary lobe (Figure 2) there was a yellowishwhite nodule of 5.5 cm, which involved bronchial branches. There were bilateral lymphadenopathies; the ipsilateral major lymph node measured 1.9 cm. The left ventricle hypertrophy (wall thickness of the left ventricle of 2.3 cm) was compatible with hypertensive heart disease. No brain lesions were identified and the other organs did not show remarkable changes. 2-8

Figure 1. Gross view the liver. A – the outer surface is completely covered by small nodular lesions; B – multiple cross-sections showing the hepatic parenchyma completely occupied by yellowish-white nodules, with an average diameter of 3-4 mm.

Figure 2. Gross view of lung tumor. A whitish 5.5 cm nodule was found in the right lower lobe, with peribronchial growth. Autops Case Rep (São Paulo). 2019;9(2):e2019089

Guerriero M, Carbone A, Colasurdo F, Pellegrini V, Pollio AM

The Tissues Were Fixed in 10% Neutral Formalin and Embedded in Paraffin T h e p u l m o n a r y l e s i o n (F i g u r e 3 ) w a s a n undifferentiated lymphocytic-like neoplasm, mainly of small cells, with nuclear characteristics (salt and pepper chromatin), which allowed the diagnosis of small cell carcinoma. The immunohistochemical findings confirmed a small cell carcinoma; in fact, these tumor

cells were strongly and diffusely positive for cytokeratin cocktail MNF116, CD56, and TTF-1, and faintly positive for synaptophysin and chromogranin A. Three Ipsilateral Peribronchial Lymph Nodes Revealed SLCL Metastases The liver was enlarged due to massive SLCL infiltration, which was also responsible by the cholestasis (Figures 4 and 5).

Figure 3. Photomicrographs of the lung neoplasm (A – H&E, 40X; B – H&E, 200X). The lesion histology consisted of small, rounded to oval, tumor cells, diffusely overlapped with diffused growth, with granular chromatin, nucleolus absent.

Figure 4. Photomicrographs of liver infiltrated by small cell lungs carcinoma (A – H&E, 40X; B – H&E, 100X; C – H&E, 200X; D – H&E, 40X). The liver was massively infiltrated by the lung neoplasm; only thin cords of hepatocytes remained. Autops Case Rep (São Paulo). 2019;9(2):e2019089

3-8

Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature

Figure 5. Photomicrographs of liver infiltrated by small cell lung carcinoma. A – the rare waves of residual hepatocytes are evident (Hep Par 1 immunohistochemical stain, 200X); B – the extensive aggregates of neoplastic cells that destroy the hepatic structure are evident (CD56 immunohistochemical stain 200X); C – faint positivitity for Chromogranin (200X); D – faint positivitity for Synaptophysin (400X).

No signs of portal hypertension was found. The spleen was small (weighed 70g, mean RR; 112g), and was histologically normal. The Remaining Organs Were Free of Neoplastic Infiltration Based on the gross and microscopic features and the clinical picture, the cause of the patient’s death might therefore be placed as: “ALF and multi-organic damage associated with the hepato-renal syndrome in SCLC with massive hepatic infiltration.”

DISCUSSION Most studies regarding fulminant hepatic failure in metastatic liver SCLC have been published as case reports. To our knowledge, in 25 scientific papers a total of 35 cases of hepatic failure due to metastatic SCLC were reported (see Table 1). 4-8

An autopsy was performed in 24 of the 35 published cases.5-29 Apart from our case, only 10 others have been described with sudden onset and death within a few days. In 8 of these 10 cases, an autopsy was performed. In this type of case, performing an autopsy is of paramount importance to understand the causes of death. Let us consider these eight cases and compare them with ours. The lung tumors (when measured) in these cases were large, from a minimum of 14 mm29 to a maximum of 48 mm;26 in our case it measured 55 mm and was the largest ever described, yet it remained clinically silent. In the other 35 reported cases, the liver weight ranged between 1.4 and 8.2 kg;21,27 in our case, the liver weighed 4.25 kg. In the other cases, death occurred after a minimum of 1 hour22 from the time of arrival in the hospital to Autops Case Rep (São Paulo). 2019;9(2):e2019089

Guerriero M, Carbone A, Colasurdo F, Pellegrini V, Pollio AM

Table 1. Summary of previously reported cases and the index case of acute hepatic failure due to metastatic SCLC Authors Watson5

Spechler et al.6

Time from admission to death

Autopsy

Age y

Sex

Pulmonary lesion size

Liver weight kg

Clinical onset

14 d

Yes

3.7

14 d

Yes

4.76

tracheo-bronchial lymph nodes. porta hepatis and supra-pancreatic nodes

Yes

2.4

Pleural effusion, bone marrow

Few days

Yes

4.16

Mediastinal lymph nodes, pleurae, pericardium, retroperitoneal lymph-nodes

Other metastases Hilar, tracheo-bronchial lymph-nodes, bone marrow

Yes

large

hilar lymph nodes, spleen

Yes

20 mm

Yes

extensive

Pleural

Harrison et al.7

Yes

50 mm

4.3

Wesbey

10 d

Yes

–

Yes

–

Some months

20 mm

Small

Yes

5.1

Mediastinal lymph node

20 mm

Yes

–

5.2

Ihara et al.

20 d

Yes

small

Kovalev et al.13

small

Pleural effusion

Sheriff

McGuire et al.10

Galus11 12

–

Athanasakis et al.

50 mm

20 d

Rajvanshi et al.15

Yes

small

3.4

10 d

Alexopoulou et al.

Kaira et al.

>182 d

–

Hwang et al.18

15 d

Ill-defined mass

Mediastinal nodes enlargement

Gilbert et al.19

Yes

32 mm

5.2

Lung, bone, lymph nodes, spinal soft tissue

Richecoeur et al.20

20 mm

hepatomegaly

Miyaaki et al.21

Yes

small

3.55

Vaideeswar et al.

Yes

40 mm

1.4

Hilar lymph nodal/bone marrow metastases

Sato et al.23

Yes

3,57

Yes

2.7

Ke et al.24

10 d

–

Mediastinal lymphadenopathy

13 d

15 mm

–

Mishima et al.25 Maglantay et al.

Fodor et al.27

Mitselou et al.28

Lungs, kidneys, adrenals, spleen, vertebrae NA

Yes

48 mm

2.98

7 hours

Yes

10 mm

6.5

Lymph nodes, iliac crest bone marrow, synchronous prostate adenocarcinoma

Few days

Yes

25 mm

8.2

Lymph node

Arif et al.

10 d

14 mm

This study

Yes

55 mm

4.25

Three ipsilateral peribronchial lymph nodes

D = days; E = enlarged; EM = extensive metastases; F = female; H = hepatomegaly; M = male; ME = moderately enlarged; NA = not available; S = sudden; SCLC = small cell lung carcinoma; y = year. Autops Case Rep (São Paulo). 2019;9(2):e2019089

5-8

Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature

a maximum of 14 days5 (average of 7.1 days); in our case death occurred 7 days after hospitalization. The liver is the most common site for metastatic tumor deposits with evidence of hepatic metastases reported in 36% of all patients who died from cancer.30 Despite this, liver dysfunction may not be evident. Fulminant hepatic failure (FHF; also known as ALF) secondary to a metastatic tumor is rare. In some cases, tumors may replace up to 90% of the liver without any manifestation of jaundice. However drowsiness and abdominal pain have been reported. Small cell lung cancer is so highly invasive that hepatic metastasis is common, but a rapid progression to ALF is extremely rare. In most patients with ALF secondary to malignant infiltration of the liver, the prognosis is terrible.

2. Howlader N, Noone AM, Krapcho M, et al. SEER cancer statistics review, 1975-2010. Bethesda: National Cancer Institute; 2013. 3. Travis WD, Brambilla E, Nicholson AG, et al. The 2015 World Health Organization classification of lung tumors: impact of genetic, clinical and radiologic advances since the 2004 classification. J Thorac Oncol. 2015;10(9):124360. http://dx.doi.org/10.1097/JTO.0000000000000630. PMid:26291008. 4. Dearing MP, Steinberg SM, Phelps R, et al. Outcome of patients with small-cell lung cancer: effect of changes in staging procedures and imaging technology on prognostic factors over 14 years. J Clin Oncol. 1990;8(6):10429. http://dx.doi.org/10.1200/JCO.1990.8.6.1042. PMid:2161447. 5. Watson AJ. Diffuse intra-sinusoidal metastatic carcinoma of the liver. J Pathol Bacteriol. 1955;69(1-2):207-17. http:// dx.doi.org/10.1002/path.1700690128. PMid:13243188.

In cases of very rapid progression from the time of clinical onset, the cause of hepatomegaly may be unknown at the time of the patient’s death.

6. Spechler SJ, Esposito AL, Koff RS, Hong WK. Lactic acidosis in oat cell carcinoma with extensive hepatic metastases. Arch Intern Med. 1978;138(11):1663-4. http:// dx.doi.org/10.1001/archinte.1978.03630360045020. PMid:214048.

CONCLUSION

7. Harrison HB, Middleton HM 3rd, Crosby JH, Dasher MN Jr. Fulminant hepatic failure: an unusual presentation of metastatic liver disease. Gastroenterology. 1981;80(4):8205. http://dx.doi.org/10.1016/0016-5085(81)90147-5. PMid:7202952.

Each case of ALF of undetermined etiology must be evaluated with a high index of suspicion. The aggressiveness of SCLC is well documented and, in many cases, metastatic lesions are diagnosed prior to the discovery of the primary tumor. In hepatomegaly, imaging is often non-diagnostic. In order to suggest which therapies to follow, liver biopsy must be considered in indeterminate cases. Diffuse liver metastasis must be considered when imaging modalities show hepatomegaly in patients with FHF, especially when viral hepatitis and drug reactions are excluded. It is therefore of paramount importance for the clinician to take hepatomegaly into consideration in the investigation of distant metastases of unknown primary origin. The role of the autopsy in this type of case is fundamental.

REFERENCES 1. Früh M, De Ruysscher D, Popat S, Crinò L, Peters S, Felip E. Small-cell lung cancer (SCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24(Suppl 6):vi99-105. http://dx.doi. org/10.1093/annonc/mdt178. PMid:23813929. 6-8

8. Wesbey G. Lactic acidosis in oat cell carcinoma with extensive hepatic metastases. Arch Intern Med. 1981;141(6):816-7. http://dx.doi.org/10.1001/ archinte.1981.00340060124034. PMid:6263203. 9. Sheriff DS. Lactic acidosis and small cell carcinoma of the lung. Postgrad Med J. 1986;62(726):297-8. http://dx.doi. org/10.1136/pgmj.62.726.297. PMid:3012499. 10. McGuire BM, Cherwitz DL, Rabe KM, Ho SB. Small-cell carcinoma of the lung manifesting as acute hepatic failure. Mayo Clin Proc. 1997;72(2):133-9. http://dx.doi. org/10.4065/72.2.133. PMid:9033546. 11. Galus M. Liver failure due to metastatic small-cell carcinoma of the lung. Mayo Clin Proc. 1997;72(8):791. http://dx.doi.org/10.1016/S0025-6196(11)63603-3. PMid:9276611. 12. Ihara N, Yashiro N, Kinoshita T, et al. Diffuse intrasinusoidal liver metastasis of small cell lung cancer causing fulminant hepatic failure: CT findings-a case report. Radiat Med. 2001;19(5):275-7. PMid:11724260. 13. Kovalev Y, Lurie M, Naschitz JE, Yeshurun D, Zuckerman E. Metastatic small cell carcinoma presenting as acute hepatic failure. Am J Gastroenterol. 2001;96(12):34713. http://dx.doi.org/10.1111/j.1572-0241.2001.05366.x. PMid:11774994. Autops Case Rep (São Paulo). 2019;9(2):e2019089

Guerriero M, Carbone A, Colasurdo F, Pellegrini V, Pollio AM

14. Athanasakis E, Mouloudi E, Prinianakis G, Kostaki M, Tzardi M, Georgopoulos D. Metastatic liver disease and fulminant hepatic failure: presentation of a case and review of the literature. Eur J Gastroenterol Hepatol. 2003;15(11):123540. http://dx.doi.org/10.1097/00042737-20031100000014. PMid:14560159. 15. Rajvanshi P, Kowdley KV, Hirota WK, Meyers JB, Keeffe EB. Fulminant hepatic failure secondary to neoplastic infiltration of the liver. J Clin Gastroenterol. 2005;39(4):339-43. http://dx.doi.org/10.1097/01. mcg.0000155123.97418.06. PMid:15758630. 16. Alexopoulou A, Koskinas J, Deutsch M, Delladetsima J, Kountouras D, Dourakis SP. Acute liver failure as the initial manifestation of hepatic infiltration by a solid tumor: report of 5 cases and review of the literature. Tumori. 2006;92(4):354-7. http://dx.doi. org/10.1177/030089160609200417. PMid:17036530. 17. Kaira K, Takise A, Watanabe R, Mori M. Fulminant hepatic failure resulting from small-cell lung cancer and dramatic response of chemotherapy. World J Gastroenterol. 2006;12(15):2466-8. http://dx.doi.org/10.3748/wjg.v12. i15.2466. PMid:16688847. 18. Hwang YT, Shin JW, Lee JH, et al. A case of fulminant hepatic failure secondary to hepatic metastasis of small cell lung carcinoma. Korean J Hepatol. 2007;13(4):56570. http://dx.doi.org/10.3350/kjhep.2007.13.4.565. PMid:18159155. 19. Gilbert J, Rutledge H, Koch A. Diffuse malignant infiltration of the liver manifesting as a case of acute liver failure. Nat Clin Pract Gastroenterol Hepatol. 2008;5(7):405-8. http:// dx.doi.org/10.1038/ncpgasthep1154. PMid:18521114. 20. Richecoeur M, Massoure M-P, Le Coadou G, Lipovac AS, Bronstein J-A, Delluc C. Acute hepatic failure as the presenting manifestation of a metastatic lung carcinoma to liver. Rev Med Interne. 2009;30(10):911-3. http://dx.doi. org/10.1016/j.revmed.2009.01.016. PMid:19328604. 21. Miyaaki H, Ichikawa T, Taura N, et al. Diffuse liver metastasis of small cell lung cancer causing marked hepatomegaly and fulminant hepatic failure. Intern Med. 2010;49(14):1383-6. http://dx.doi.org/10.2169/ internalmedicine.49.3296. PMid:20647652.

22. Vaideeswar P, Munot S, Rojekar A, Deodhar K. Hepatic diffuse intra-sinusoidal metastases of pulmonary small-cell carcinoma. J Postgrad Med. 2012;58(3):230-1. http:// dx.doi.org/10.4103/0022-3859.101654. PMid:23023366. 23. Sato K, Takeyama Y, Tanaka T, Fukui Y, Gonda H, Suzuki R. Fulminant hepatic failure and hepatomegaly caused by diffuse liver metastases from small cell lung carcinoma: 2 autopsy cases. Respir Investig. 2013;51(2):98102. http://dx.doi.org/10.1016/j.resinv.2012.12.004. PMid:23790738. 24. Ke E, Gomez JD, Tang K, Sriram KB. Metastatic small-cell lung cancer presenting as fulminant hepatic failure. BMJ Case Rep. 2013;2013(1):bcr2012007865. http://dx.doi. org/10.1136/bcr-2012-007865. PMid:23616311. 25. Mishima S, Nozaki Y, Mikami S, et al. Diffuse liver metastasis of small-cell lung cancer presenting as acute liver failure and diagnosed by transjugular liver biopsy: a rare case in whom nodular lesions were detected by enhanced CT examination. Case Rep Gastroenterol. 2015;9(1):81-7. http://dx.doi.org/10.1159/000381140. PMid:25969674. 26. Maglantay R, Qin J, Lanjewar S, et al. Metastatic small cell carcinoma of the lung: an unusual cause of acute fulminant hepatic failure. Fed Pract. 2016;33(Suppl 5):30S4S. PMid:30766221. 27. Fodor D, Gurzu S, Contac AO, Jung I. Giant hepatic metastasis in a patient with coin-like small cell lung carcinoma incidentally diagnosed at autopsy: a case report. Medicine. 2017;96(11):e6366. http://dx.doi.org/10.1097/ MD.0000000000006366. PMid:28296775. 28. Mitselou A, Papadatos SS, Tsoultsidou S, et al. Giant metastatic liver tumor of unknown primary origin: thoracic autopsy solves the mystery. Acta Med. 2017;60(4):1636. http://dx.doi.org/10.14712/18059694.2018.14. PMid:29716684. 29. Arif H, Suchniak-Mussari K, Beg M, Morrissey S. Unusual acute liver failure from small cell carcinoma of the lung. Clin Exp Hepatol. 2018;4(4):275-7. http://dx.doi. org/10.5114/ceh.2018.80130. PMid:30603677. 30. Rowbotham D, Wendon J, Williams R. Acute liver failure secondary to hepatic infiltration: a single centre experience of 18 cases. Gut. 1998;42(4):576-80. http://dx.doi. org/10.1136/gut.42.4.576. PMid:9616324.

Author contributions: Guerriero M, Carbone A, Colasurdo F, Pellegrini V and Pollio AM equally contributed for the concepcion of the manuscript. All authors collectively proofread and approved the manuscript for publication. The authors retain a signed informed consent of the relatives for the case publication. Conflict of interest: None Financial support: None Autops Case Rep (São Paulo). 2019;9(2):e2019089

7-8

Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature

Submitted on: May 5th, 2019 Accepted on: May 23rd, 2019 Correspondence Massimiliano Guerriero Department of Pathology - Regional Health Authority of Molise (ASReM) - Antonio Cardelli Regional Hospital Contrada Tappino s.n.c. Campobasso/CB â&#x20AC;&#x201C; Italy 86100 Phone: +39 (0874) 409-205 ilguerrierochecorre@gmail.com

8-8

Autops Case Rep (SĂŁo Paulo). 2019;9(2):e2019089

Article / Autopsy Case Report

Sigmoid gallstone ileus: a challenging diagnosis Renuka Maleniea , Lisa Leoneb, MGF Gillilandb How to cite: Malenie R, Leone L, Gilliland MGF. Sigmoid gallstone ileus: a challenging diagnosis. Autopsy Case Rep [Internet]. 2019 9(2):e2019102. https://doi.org/10.4322/acr.2019.102

ABSTRACT Gallstone ileus is a rare (1%–4%) complication of gallstone disease. Gallstones entering the gastrointestinal tract by penetration may cause obstruction at any point along their course through the tract; however, they have a predilection to obstruct the smaller-caliber lumen of the small intestine (80.1%) or stomach (14.2%). The condition is seen more commonly in the elderly who often have significant co-morbidities. Gallstone ileus causing large bowel obstruction is rare. We report the case of a 95-year-old woman who presented with a history of abdominal pain without fever, nausea, vomiting, or diarrhea. Computed tomography of the abdomen and pelvis with oral contrast revealed a high-density structure within the lumen of the distal sigmoid colon, initially suspected to be a foreign body. Medical management failed and surgical intervention was not possible. Autopsy revealed peritonitis and a rupture of the sigmoid colon at the site of a cylindrical stone found impacted in an area of fibrotic narrowing with multiple diverticula. A necrotic, thick-walled gallbladder had an irregular stone in its lumen that was a fracture match with the stone in the sigmoid. Adhesions, but no discrete fistula, were identified between the gallbladder and the adjacent transverse colon. The immediate cause of death was peritonitis caused by colonic perforation by the gallstone impacted at an area of diverticular narrowing. To our knowledge, such autopsy findings have not been previously reported. Keywords Autopsy; Gallstones; Colon, Sigmoid; Diverticulosis; Intestinal Perforation

CASE REPORT The patient was a 95-year-old African American female living in a nursing home who complained of abdominal pain for about 6 days. The patient had a past medical history of hypertension, dementia, chronic obstructive pulmonary disease, chronic kidney disease, and gastroesophageal reflux disease. She had worsening pain and requested to be taken to the hospital, which was unusual for her. She was brought to the local emergency department (ED). A computed tomography (CT) scan done in the ED showed a 3.4 × 3.5 cm curvilinear structure with high-density

a b

wall within the lumen of the distal sigmoid colon, suspect foreign body. There was moderate bowel wall thickening proximal to this level compatible with colitis. There were scattered colonic diverticula. Pneumobilia without significant bile duct dilatation. The gall bladder was not clearly delineated.” The CT image is shown in Figure 1 with a stone in the sigmoid colon and a stone in the gallbladder with pneumobilia. Aggressive bowel cleansing was initiated in an unsuccessful attempt to pass the foreign body, suspected to be a gallstone. The patient had increased

East Carolina University Brody School of Medicine, Department of Pathology and Laboratory Medicine. Greenville, North Carolina, USA. East Carolina University Brody School of Medicine, Department of Clinical/Forensic Pathology. Greenville, North Carolina, USA.

Sigmoid gallstone ileus: a challenging diagnosis

slightly grossly enlarged with mild left ventricular hypertrophy. The coronary arteries had right dominant distribution with 10% atherosclerotic narrowing of the left main artery, the left anterior descending and circumflex arteries, and the right main artery. The fossa ovalis measured 1.8 cm, and the foramen ovale was closed. The myocardium was red-brown with no focal lesions and the free walls measured 0.6 cm and 1.5 cm, right and left, respectively. The interventricular septum measured 1.7 cm. The circumferences of the cardiac valves were: tricuspid 12.4 cm (RR; 12–13 cm), pulmonic 10.1 cm (RR; 8.5–9 cm), mitral 9.8 cm (RR; 10–10.5 cm), and aortic 7.8 cm (RR; 8–8.5 cm) cm. The intimal surface of the aorta was not roughened by atherosclerotic plaque. The remainder of the vascular system was unremarkable.

Figure 1. Abdominal computed tomography from the emergency room showing a stone in the gallbladder with pneumobilia – A; and another stone in the sigmoid colon – B.

pain after an enema. By the third hospital day, she was hypotensive and septic with increasing abdominal pain. Surgical intervention or colonoscopy was no longer considered possible. The family agreed to comfort care. The patient died on the third hospital day.

AUTOPSY FINDINGS The patient’s body weighed 68.0 kilograms and measured 157.0 centimeters in length (body mass index 27.68 kg/m2). The autopsy was performed in the conventional manner. On opening the thoracic cavity, the right and left pleural cavities each contained 50 mL of serous fluid. The pleural surfaces were pale pink at the anterior surface, and red-maroon on the posterior surface with moderate black pigmentation. The lungs were subcrepitant to palpation and soft on section. The cut surfaces were red-maroon and edematous. The distal airways were clear. The pulmonary vessels were unremarkable. The pericardial cavity contained no significant accumulation of fluid. The heart weighed 370 g (reference range [RR] for height 139–316 g) and was 2-6

The peritoneal cavity contained 200–250 mL of brown-gray opaque fluid with yellow fibrin strands. Bowel contents (resembling corn and celery) were identified in the fluid. Dense adhesions were found between the perforated gallbladder and the transverse colon, but no discrete perforation or fistula of the transverse colon was identified. The esophagus had no significant abnormalities. The stomach contained 150 mL of green-yellow liquid. The gastric mucosa and the small bowel mucosa were unremarkable. The sigmoid colon revealed an acute perforation measuring 4.0 × 2.4 cm and a cylindrical stone measuring 4.5 × 2.9 × 2.9 cm in the bowel lumen (Figure 2A). The external surface of the stone was yellow-black and had smooth to slightly irregular circular fractured ends (Figure 2B). These fractured ends had concentric rings; the outer dark ring measured 0.4 cm, a yellow ring measured 0.7 cm, and a black to yellow center measured 1.7 × 1.5 cm (Figure 3B), which resembled one surface of the stone in the gallbladder. The walls of the sigmoid colon around the perforation were tan and edematous, and multiple diverticula were identified. The appendix was present. The liver weighed 1011 g (RR; 1540- 2030g); the capsule was gray-green, with a firm consistency on palpation and sectioning. The hepatic architecture appeared unremarkable. The gallbladder had a 4.0 × 4.0 cm artifactual perforation through a black and thickened wall. The lumen of the gallbladder contained a black-yellow, irregular 3.6 × 3.1 × 3.0 cm Autops Case Rep (São Paulo). 2019 Apr-Jun;9(2):e2019102

Malenie R, Leone L, Gilliland MGF

Figure 2. A – Gross view of the impacted stone in the sigmoid colon; B – Cylindrical surface of the stone from the sigmoid colon.

Figure 3. Gross view of the stones. A – Stone from the gallbladder; B – Fracture surface of the stone; C – Entire stone.

Autops Case Rep (São Paulo). 2019 Apr-Jun;9(2):e2019102

3-6

Sigmoid gallstone ileus: a challenging diagnosis

gallstone that appeared to be two stones fused to each other (Figure 3A). One component of the stone was cylindrical and the other was a more irregular oval, pale cap. The cylindrical stone had a fracture surface with concentric rings from an outer dark ring to a yellow ring to a black-to-yellow center. The black-to‑yellow center measured 1.7 × 1.5 cm, a yellow ring measured 0.7 cm, and an outer black ring measured 0.4 cm, which corresponds to the dimensions of the stone from the sigmoid. The complete stone is depicted in Figure 3C. Both kidneys were normal in size and weight. The capsules stripped with moderate difficulty. The kidney surfaces were pink-red, granular, and appeared lobulated. The kidneys were soft on section, and the cortices measured 0.4 cm. The cut surfaces had moderately increased peripelvic fat but were otherwise unremarkable. The brain weighed 1080 g (RR; 1200–1600 g). The brain—including the proximal-most spinal cord and the dura—was examined after fixation. Grossly, the brain appeared to have moderate cerebral atrophy. All tissues were fixed in buffered 10% formalin and processed to paraffin blocks in the conventional manner. Tissue sections were made, stained with hematoxylin and eosin and examined microscopically. Microscopic examination of the gallbladder showed a thickened and fibrotic wall with dense infiltration by chronic inflammatory cells composed of lymphocytes and plasma cells. Sections from the sigmoid colon revealed denuded and autolyzed mucosal lining and features suggestive of acute colitis. No evidence of collagenous colitis was identified. The diverticula in the sigmoid colon, which were identified on gross examination, were confirmed histologically. Microscopic examination of the heart revealed significant amyloid deposition not found in other postcranial organs. Sections from the lungs revealed centrilobular emphysema, respiratory bronchiolar fibrosis, and fibrointimal thickening in the pulmonary arteries. Congestion and edema were seen in two of the three sections. The third section had marked atelectasis. The liver was moderately autolyzed with loss of lobular architecture. There was mild portal triaditis. Sections from the kidneys showed some glomeruli 4-6

to be globally sclerotic but otherwise unremarkable. Moderate arterio- and arteriolosclerosis was present. Microscopic examination of the brain revealed findings that were diagnostic of Alzheimer disease and were consistent with intermediate to advanced stage disease. Histopathologic findings accounted for clinically discernible dementia, intermediate to severe stage. Only mild amyloid angiopathy was seen in the brain with a moderate number of amyloid plaques in the cerebral cortex and white matter different from the amyloid deposition in the heart. Terminal, global hypoxic-ischemic change was identified. Patchy, less than 10% stenotic atherosclerosis was present. No other degenerative, inflammatory, infectious, or vascular disease processes were identified which would account for the patient’s dementia.

DISCUSSION Gallstone ileus is a rare complication of gallstone disease. It is more common in patients over 65 (the average age was 72 years). 1 Gallstones can erode through the wall of the gallbladder and penetrate the gastrointestinal tract where they may cause obstruction at any point along their course through the tract. They have a predilection to obstruct the smaller-caliber lumen of the small intestine (80.1%) or stomach (14.2%). Gallstones causing large bowel obstruction is rare (4.1%) and even more rarely can cause colonic perforation. 2 Obstruction occurs when a single large stone or multiple small stones pass through a cholecystocolonic fistula. When a large stone measuring greater than 2.0 cm in diameter enters the colon through a cholecystocolonic fistula it impacts distally and can cause mechanical obstruction. 3 Impaction usually occurs at a site of pathological narrowing, which may be a result of diverticular disease 4,5 or pelvic irradiation. 6 The presence of neoplasms, or intestinal strictures such as those secondary to Crohn disease, can also decrease the lumen size and may cause the gallstone to impact at the narrowing site. Our patient had a much larger stone and had severe diverticular disease with narrowed sigmoid colon, which predisposed her to impaction. Ischemia may develop at the site of gallstone impaction, due to the pressure generated against the bowel wall causing proximal distention. Necrosis and perforation followed by peritonitis may occur. Autops Case Rep (São Paulo). 2019 Apr-Jun;9(2):e2019102

Malenie R, Leone L, Gilliland MGF

Patients typically present with abdominal pain due to acute cholecystitis followed by inflammation that leads to adhesions between the gallbladder and the hepatic flexure. The inflammation can progress to the development of a fistulous connection. 3 This was clearly appreciated in our patient during autopsy although only adhesions remained where the fistula that had allowed the stone to penetrate the colon had been. The stone was found more distally in the transverse colon. Symptoms of gallstone ileus can be vague and insidious; therefore, a high index of clinical suspicion is required. The Rigler triad of pneumobilia, dilated small bowel with paucity of air in the large bowel, and an opacity (gallstone) is seen on plain abdominal x-rays in less than 50% of cases.7 A CT scan is considered to be the gold standard for confirming the clinical diagnosis of gallstone ileus. It has a sensitivity of 93% and a specificity of 100%.8 Gallstone ileus is seen in elderly patients with other co-morbid conditions; therefore, surgery has a high risk of morbidity and mortality. A conservative management strategy can be an acceptable option, which includes colonic lavage/enema/cleansing; this was tried in our patient. Spontaneous passage of the gallstone was awaited as this has been reported in the literature.9-12 Surgery is the treatment of choice but it can be replaced by less invasive techniques, including colonoscopy, which can relieve the obstruction by fragmentation of the stone using lithotripsy. 7,13,14 Laparoscopic enterolithotomy also has been used to circumvent surgery.13 These techniques are limited by the availability of local expertise and are dependent on the size and composition of the impacted stone. In our patient, conservative management was adopted and multiple aggressive bowel cleansing attempts were made with no success in passing the gallstone. The patient experienced increased pain after an enema. By the third hospital day, she was hypotensive and septic with increasing abdominal pain. Surgical intervention or colonoscopy were not considered possible due to her age and other co-morbidities. The family agreed to comfort care and the patient passed away quietly. The immediate cause of death was peritonitis due to the perforated sigmoid colon caused by a large gallstone impacted in the narrowed sigmoid colon, which was the â&#x20AC;&#x153;perfect Autops Case Rep (SĂŁo Paulo). 2019 Apr-Jun;9(2):e2019102

storm,â&#x20AC;? resulting from chronic cholecystitis and cholelithiasis, and severe diverticular disease. A PubMed search yielded very few cases of colonic perforation caused by gallstones. All these cases underwent the Hartmann procedure.2 To the best of our knowledge, no autopsy case of colonic perforation at an impacted gallstone has so far been reported.

CONCLUSION Gallstone ileus is such a rare complication of gallstone disease that it is not usually considered by the physician. However, delayed or missed diagnosis may have a fatal outcome. Therefore, a high index of clinical suspicion for gallstone ileus should prompt a CT scan to demonstrate a fistulous communication, intraluminal gallstone in the bowel, pneumobilia, and any other co-existing pathology contributing to the impaction and perforation of the gallstone. Gallstone ileus is a condition seen in older populations, usually with other co-morbid conditions; surgical management is associated with a high risk of morbidity and mortality. Non-surgical treatment has been suggested, including endoscopic removal and lithotripsy. In our case, the age and associated medical conditions of the patient helped the family to decide on comfort care and eventually autopsy, which confirmed the diagnosis. Early diagnosis and prompt management can prevent fatal outcomes in elderly patients who present late and have other comorbidities.

ACKNOWLEDGEMENTS The authors acknowledge the assistance of Brian Kuszyk, MD, Affiliate Professor and Chair of Clinical Radiology, Brody School of Medicine, in obtaining the appropriate CT image and identifying the points of relevance. REFERENCES 1. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-6. PMid:8198337. 2. Halleran DR, Halleran DR. Colonic perforation by a large gallstone: A rare case report. Int J Surg Case 5-6

Sigmoid gallstone ileus: a challenging diagnosis

Rep. 2014;5(12):1295-8. http://dx.doi.org/10.1016/j. ijscr.2014.11.058. PMid:25498567.

dx.doi.org/10.1097/00000658-194205000-00002. PMid:17858013.

3. Osman N, Subar D, Loh MY, Goscimski A. Gallstone ileus of the sigmoid colon: An unusual cause of large-bowel obstruction. HPB Surg. 2010;2010:153740. http://dx.doi. org/10.1155/2010/153740. PMid:20585361.

10. Tan YM, Wong WK, Ooi LLPJ. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Med J. 2004;45(2):69-72. PMid:14985844.

4. Brown C. Colonic obstruction due to a gallstone. Br J Clin Pract. 1972;26(4):175-7. PMid:5036487.

11. Dumonceau JM, Delhaye M, Cremer M. Extracorporeal shock-wave lithotripsy for gallstone ileus. Gastrointest Endosc. 1996;44(6):759. http://dx.doi.org/10.1016/ S0016-5107(96)70073-1. PMid:8979079.

5. Buetow GW, Glaubitz JP, Crampton RS. Recurrent gallstone ileus. Surgery. 1963;54:716-24. PMid:14083576. 6. Ishikura H, Sakata A, Kimura S, et al. Gallstone ileus of the colon. Surgery. 2005;138(3):540-2. http://dx.doi. org/10.1016/j.surg.2004.03.013. PMid:16213911. 7. Athwal TS, Howard N, Belfield J, Gur U. Large bowel obstruction due to impaction of a gallstone. BMJ Case Rep. 2012;2012(feb07 1):bcr1120115100. http://dx.doi. org/10.1136/bcr.11.2011.5100. PMid:22665402. 8. Yu CY, Lin CC, Shyu RY, et al. Value of CT in the diagnosis and management of gallstone ileus. World J Gastroenterol. 2005;11(14):2142-7. http://dx.doi. org/10.3748/wjg.v11.i14.2142. PMid:15810081. 9. Foss HL, Summers JD. Intestinal obstruction from gallstones. Ann Surg. 1942;115(5):721-35. http://

12. Salemans PB, Vles GF, Fransen S, Vliegen R, Sosef MN. Gallstone ileus of the colon: Leave no stone unturned. Case Rep Surg. 2013;2013:359871. http://dx.doi. org/10.1155/2013/359871. PMid:23970992. 13. Zielinski MD, Ferreira LE, Baron TH. Successful endoscopic treatment of colonic gallstone ileus using electrohydraulic lithotripsy. World J Gastroenterol. 2010;16(12):15336. http://dx.doi.org/10.3748/wjg.v16.i12.1533. PMid:20333797. 14. Bourke MJ, Scheider DM, Haber GB. Electrohydraulic lithotripsy of a gallstone causing gallstone ileus. Gastrointest Endosc. 1997;45(6):521-3. http://dx.doi. org/10.1016/S0016-5107(97)70186-X. PMid:9199914.

Authors’ contributions: Malenie R collected the data wrote the manuscript and together with Leone L. and Gilliland MGF performed the autopsy and edited the paper. Leone L, provided the images. All authors collectively proofread the manuscript and approved for publication. Consent was obtained from the family for an unrestricted autopsy. Conflict of interest: None Financial support: None Submitted on: March 1st, 2019 Accepted on: March 21st, 2019 Correspondence Renuka Malenie East Carolina University Brody School of Medicine – Department of Pathology and Laboratory Medicine 600 Moye Blvd – Greenville/North Carolina – USA Zip Code: 27834-4300 Phone: 252-847-4495 malenier15@ecu.edu

6-6

Autops Case Rep (São Paulo). 2019 Apr-Jun;9(2):e2019102

Article / Clinical Case Report

JAK2-mutated acute myeloid leukemia: comparison of next‑generation sequencing (NGS) and single nucleotide polymorphism array (SNPa) findings between two cases Thiago Rodrigo de Noronhaa , Miguel Mitne-Netob, , Maria de Lourdes Chauffaillea,b  How to cite: Noronha TR, Mitne-Neto M, Chauffaille ML. JAK2-mutated acute myeloid leukemia: comparison of next‑generation sequencing (NGS) and single nucleotide polymorphism array (SNPa) findings between two cases. Autops Case Rep [Internet]. 2019;9(2):e2018084. https://doi.org/10.4322/acr.2018.084

ABSTRACT JAK2 mutations are rare in de novo acute myeloid leukemia (AML), and JAK2-mutated acute myeloid leukemia (AML) patients usually have a previous history of myeloproliferative neoplasms (MPNs). Current advances in laboratory techniques, such as single nucleotide polymorphism array (SNPa) and next-generation sequencing (NGS), have facilitated new insight into the molecular basis of hematologic diseases. Herein, we present two cases of JAK2-mutated AML in which both SNPa and NGS methods added valuable information. Both cases had leukemogenic collaboration, namely, copy-neutral loss of heterozygosity (CN-LOH), detected on chromosome 9. One of the cases exhibited both JAK2 and IDH2 mutations, most likely having originated as an MPN with leukemic transformation, while the other case was classified as a de novo AML with JAK2, CEBPA, and FLT3 mutations. Keywords Cytogenetics; Leukemia, Myeloid, Acute; Polymorphism, Single Nucleotide; Sequence Analysis, DNA

INTRODUCTION Myeloproliferative neoplasms (MPNs) are clonal disorders of hematopoietic stem cells with increased proliferation of myeloid cells and effective maturation, leading to peripheral blood leukocytosis and excess erythrocytes or platelets. 1 According to the World Health Organization (WHO) 2016 revision of the classification of myeloid neoplasms and acute leukemia, MPNs are subdivided into (i) chronic myeloid leukemia (BCR-ABL1–positive); (ii) chronic neutrophilic leukemia; (iii) polycythemia vera; (iv) primary myelofibrosis; (v) essential thrombocythemia; (vi) chronic eosinophilic leukemia; and (vii) unclassifiable myeloproliferative neoplasm. 2 The final evolution of MPNs involves

progression to fibrosis or leukemic transformation. Acute myeloid leukemia (AML) following MPNs is characterized by 20% or more blasts being present in the bone marrow (BM) or peripheral blood (PB). 3 MPN patients who develop AML have a poor prognosis, with a median survival of fewer than 6 months. 4 Leukemic transformation occurs in 1%, 4% and 20% of patients with essential thrombocythemia (ET), polycythemia vera (PV) and primary myelofibrosis (PM), respectively, over a 10-year period.5 Mutations in JAK2 have been identified in the majority of patients with PV, ET, and PM, underscoring

Federal University of São Paulo, Division of Hematology. São Paulo, SP, Brazil. Fleury Group, Research and Development. São Paulo, SP, Brazil.

JAK2-mutated acute myeloid leukemia: comparison of next-generation sequencing (NGS) and single nucleotide polymorphism array (SNPa) findings between two cases

the importance of constitutive activation of JAK2 signaling caused by mutations.6 Genetic studies of paired samples before and after AML transformation suggest that there are at least two distinct routes for leukemic transformation. Patients who exhibit the JAK2 mutation in MPNs progress to AML, suggesting that this mutation might be associated with the acquisition of additional genetic alterations. In contrast, patients who harbor the JAK2 mutation in their MPNs have no evidence of the mutation in leukemic blasts post-MPN AML.6,7 It is important to highlight that, despite the cooccurrence of JAK2 mutations with other genetic alterations, JAK2 mutations have rarely been reported in de novo AML (<5%).8,9 Cytogenetic and molecular cytogenetic techniques combined may provide a comprehensive analysis of chromosomal aberrations. Advances in laboratory techniques, such as single nucleotide polymorphism array (SNPa), a molecular cytogenetic method, and high‑throughput sequencing, have facilitated new insight into the molecular basis of hematologic diseases. SNPa is a sensitive technique used to perform high‑resolution genome-wide DNA copy number analysis and to detect copy-neutral loss of heterozygosity (CN-LOH). Next-generation sequencing (NGS) is capable of detecting single nucleotide variants (SNVs) or small insertions and deletions that have recently been shown as important molecular phenomena in AML.10 To substantiate this idea, we describe two JAK2-mutated AML cases for which both SNPa and NGS added valuable information.

METHODS Patients The patients described in this report were seen for follow up at the Hospital São Paulo of the Federal University of São Paulo, São Paulo, Brazil. The Ethics Committee of the institution approved the study, and written informed consent was obtained from all patients (CAAE 00547512.5.0000.5505).

Conventional Cytogenetics Karyotypes were made from BM samples using standard methods, and aberrations were described according to the International System for Human Cytogenetic Nomenclature (ISCN) 2016.11 2-7

Single Nucleotide Polymorphism Array SNPa was performed on total BM (cases 1 and 2) and buccal cells (only case 1) samples. Two hundred and fifty nanograms of DNA were extracted and digested, amplified, purified, fragmented, labeled and hybridized using the Affymetrix CytoScan HD Array. CEL files were created using the GeneChip System 3000 7G according to the manufacturer’s instructions. CEL files were analyzed using Chromosome Analysis Suite v3.0 (ChAS) software. Regions of copy number variations (CNVs) larger than 1 Mb and CN-LOH larger than 10 Mb identified by the ChAS Software or detected by visual inspection, regardless of gene content, are considered true aberrations, with the exception of those known to be normal genomic variants (present in the Genomic Variants Database [http://projects.tcag.ca/variation]) or identified in constitutional (buccal cells) SNPa analysis.10 Aberrations identified by SNPa were described according to the ISCN 2016.

Next-Generation Sequencing Total BM was used for DNA extraction. A 19-gene panel was screened using the Ion AmpliSeq AML Research Panel (Thermo Fisher). Reads were mapped to th e H G1 9 re fe re n ce h u ma n g e n o m e , a n d alignment results were analyzed using CLC Genomics Workbench software. 10 FLT3-ITD was tested in addition to the gene panel by PCR and capillary electrophoresis using the following primers: forward 5’−6FAM- tgcctattcctaactgactcatc-3’ and reverse 5’‑ tctttgttgctgtccttccac-3’.

CASE REPORTS Case 1: A 66-year-old female patient was referred to the Hematology service for investigation of polyglobulia (hemoglobin 17.0 g/dL and hematocrit 53.4%) associated with weight loss (18 kg over the last six months). However, admission lab tests showed hemoglobin of 9.4 g/dL, hematocrit of 33.4%, WBC count of 47.8 × 109/L (with 22% blasts) and platelet counts of 119.0 × 109/L. Bone marrow aspirate smear revealed 20% of blasts, and multiparametric flow cytometry immunophenotyping was compatible with AML (Positive: CD45 moderate, CD34, HLA-DR, Autops Case Rep (São Paulo). 2019;9(2):e2018084

Noronha TR, Mitne-Neto M, Chauffaille ML

CD117, CD33 heterogeneous, CD13 heterogeneous, CD11b partial, CD64 partial heterogeneous, CD36 partial, CD7 partial. Negative: CD14, CD65, CD41, CD2, CD4, CD56, CD19, CD10). The bone marrow karyotype is as follows: 48,XX,+8,+21[11]/46,XX[1]. SNPa results are as follows: arr[hg19] (8)x2-3; arr[hg19] (21)x2-3; arr[hg19] 9p24.3p13.3(192128_35098008) hmz (Figure 1). NGS analysis revealed IDH2 R140Q and JAK2 V617F mutations. The patient was on chronic osteomyelitis treatment prior to initiating chemotherapy and died one month after admission due to infection. Case 2: A 77-year-old female patient was admitted to hematology service with complaints of fatigue and easy bruising. Lab tests on admission showed hemoglobin of 10.3 g/dL, WBC count of 99.9 × 109/L (with 45% blasts) and platelet counts of 23.0 × 109/L. Bone marrow aspirate, showing 40% blasts and multiparametric flow cytometry immunophenotyping, was compatible with AML (Positive: CD34, CD117, CD13, CD45 moderate, CD33, HLA-DR, CD64, CD7. Negative: CD11b, CD10, CD19, CD15, CD36, CD14, CD65, CD2, CD56). The bone marrow karyotype did not present metaphases. SNPa results are as follows: arr[hg19] 8q23.1q24.12(107621735_119398978)×1; arr[hg19] 9p24.3p13.1(192128_40087758) hmz; arr[hg19] 11p15.5p11.2(198509_47404314) hmz

(mosaic) (Figure 2). NGS results revealed mutations in FLT3-ITD, CEBPA E309_T310insE and JAK2 V617F. The patient was on conventional chemotherapy treatment and died three months after admission due to infection.

DISCUSSION The two cases presented herein were classified as AML, one of which had a previous history of polyglobulia and weight loss (case 1), while the other had become recently symptomatic (case 2). Based on the clinical history, one may interpret the first case as leukemic transformation of a myeloproliferative neoplasm and the second as de novo AML. Which tests could confirm the above-mentioned hypotheses: Conventional cytogenetics (karyotype), molecular cytogenetics (SNPa) or molecular tests (NGS)? Cytogenetic abnormalities identified by karyotype allow the detection of clonal abnormalities, classifying cases into favorable, intermediate or unfavorable prognosis. Karyotype remains one of the most powerful predictors of outcome in AML.12 However, approximately 50% of AML cases present a normal karyotype or present noninformative results, requiring other tests to better characterize the disease.10

Figure 1. Genomic alterations detected by SNPa (Affymetrix CytoScan HD array) in case 1. a – Mosaic gain of one entire chromosome 8 (CN: 2.57). b – Red box showing CN-LOH in 9p24.3p13.3. The JAK2 gene is located in this region. c – Mosaic gain of chromosome 21 (CN: 2.54). Autops Case Rep (São Paulo). 2019;9(2):e2018084

3-7

JAK2-mutated acute myeloid leukemia: comparison of next-generation sequencing (NGS) and single nucleotide polymorphism array (SNPa) findings between two cases

Figure 2. Genomic alterations detected by SNPa (Affymetrix CytoScan HD array) in case 2. a – Red box showing deletion in 8q23.1q24.12 (CN: 1.00). b – Red box showing CN-LOH in 9p24.3p13.1. The JAK2 gene is located in this region. c – Red box showing mosaic CN-LOH in 11p15.5p11.2.

Table 1. Technique comparison for identifying genetic abnormalities Technique

Characteristics Resolution

Gain and Loss

Translocation

CN-LOH

SNVs/INDELs

Karyotype

5Mb

Yes

SNPa

<1Mb

Yes

NGS

1Bp

Yes*

Yes

SNPa: Affymetrix CytoScan™ HD. NGS: Ion AmpliSeq™ AML Research Panel. *SNVs (Single Nucleotide Variants) / INDELs (Insertions and Deletions <50 base pairs).

Our first case presented a hyperdiploid karyotype, (trisomies 8 and 21), an aberration observed in 0.7% of AMLs,13 allowing no additional clarification to the posed question. However, it allowed the classification of this case as intermediate risk by the European Leukemia Net genetic classification,14 although this is a conceptually a high-risk disease as it fits into the “AML with myelodysplasia-related changes” (post-MPN AML). For case 2, the karyotype was noninformative, and in this condition, risk stratification could not be correctly interpreted. SNPa is a complementary tool to karyotype, and may be applied for the evaluation of chromosomal losses, gains and CN-LOH. Combining SNPa with karyotype increases the detection rate of abnormalities 4-7

in 28%.15 Advances in high-throughput sequencing techniques have facilitated new insights into the molecular basis of AML. 12,16 Indeed, each test has distinct performances characteristics, with variability in the detection rate being defined by the type of genomic alteration (Table 1). SNPa confirmed the karyotype results in case 1 and added new information in both cases: CN-LOH on chromosome 9 (cases 1 and 2), CN-LOH on chromosome 11 (case 2) and partial deletion of chromosome 8 (case 2). CN-LOH indicates that an individual possesses two identical copies of one chromosome or chromosome region, i.e., this abnormality represents an important mechanism by which point mutations and other micro lesions can be Autops Case Rep (São Paulo). 2019;9(2):e2018084

Noronha TR, Mitne-Neto M, Chauffaille ML

established in a homozygous state.17 JAK2 and FLT3 mutations share a common mechanism that confers augmented reactive oxygen species, which induce DNA damage, resulting in homologous recombination events that initiate CN-LOH.18 NGS identified mutations in both cases, two in case 1 and three in case 2. The JAK2 V617F mutation was identified in both cases. Case 1 presented 72.5% allelic frequency, and case 2 exhibited 94.3% allelic frequency. These values are compatible with a CN-LOH on chromosome 9 detected by SNPa, where the JAK2 is gene located. In MPNs, the high JAK2 V617F allele burden in PV represents a risk factor for progression to myelofibrosis. In contrast, high JAK2 V617F allele burden is not significantly related to leukemic transformation.19 The JAK2 mutation constitutively activates the JAK/STAT signaling pathway, but the prognostic implications of this alteration remain unclear.20 Regarding the other mutations, IDH2 (case 1) is involved in DNA methylation, and the relationship of this mutation with prognosis is still uncertain.21 However, some groups have identified the IDH2 mutation in a subset of patients with MPN who underwent leukemic transformation.22,23 In addition, combined expression of JAK2 V617F and IDH2 R140Q induces MPN progression, alters stem/progenitor cell function and impairs differentiation in mice.24 The CEBPA mutation is involved in the development of myeloid progenitors into differentiated neutrophils. Previous studies suggest that monoallelic mutations in CEBPA are prognostically neutral, whereas biallelic mutations in trans are associated with a favorable prognosis in cytogenetically normal AML.25 FLT3-ITD constitutively activate tyrosine kinase by interfering with the autoinhibitory function of the juxtamembrane domain, leading to enhanced RAS, MAPK, and STAT5 signaling. Mutations in this gene are associated with worse prognosis.25 JAK2 mutations are rare in de novo AML, and AML patients with JAK2 mutations usually have a history of an antecedent MPN. The most common mutations observed in de novo AML, including NPM1, DNMT3A, and FLT3, are largely absent from AMLs that occur following an MPN.6 Despite the infrequent incidence of JAK2 mutation in AML, mutated JAK2 could be therapeutically targeted in some cases with JAK2 mutations.8 Autops Case Rep (São Paulo). 2019;9(2):e2018084

SNPa and NGS added valuable information to these analyses, as both cases exhibited leukemogenic collaboration of the detected mutations: one had JAK2 and IDH2 mutations, being most likely an MPN with leukemic transformation, while the other could be a de novo AML with JAK2, CEBPA, and FLT3 mutations. In summary, the present work supports the use of both SNPa and NGS as important tools for patients with AML, offering insights into the molecular pathogenesis and indicating that different mutation combinations and cytogenetic results could further stratify prognosis. The authors retain an informed consent signed by the patients, and this manuscript is in accordance with the Institutional Ethics Committee.

REFERENCES 1. Chauffaille MLLF. Myeloproliferative neoplasms: a review of diagnostic criteria and clinical aspects. Rev Bras Hematol Hemoter. 2010;32(4):308-16. http://dx.doi. org/10.1590/S1516-84842010005000091. 2. Arber DA, Orazi A, Hasserjian R, et al. The 2016 revision to the World Health Organization classi fi cation of myeloid neoplasms and acute leukemia. Blood. 2016;127(20):2391-405. http://dx.doi.org/10.1182/ blood-2016-03-643544. PMid:27069254. 3. Mesa RA, Verstovsek S, Cervantes F, et al. Primary myelofibrosis (PMF), post polycythemia vera myelofibrosis (post-PV MF), post essential thrombocythemia myelofibrosis (post-ET MF), blast phase PMF (PMF-BP): Consensus on terminology by the international working group for myelofibrosis research and treatment (IWGMRT). Leuk Res. 2007;31(6):737-40. http://dx.doi. org/10.1016/j.leukres.2006.12.002. PMid:17210175. 4. Mesa RA, Li CY, Ketterling RP, Schroeder GS, Knudson RA, Tefferi A. Leukemic transformation in myelofibrosis with myeloid metaplasia: A single-institution experience with 91 cases. Blood. 2005;105(3):973-7. http://dx.doi. org/10.1182/blood-2004-07-2864. PMid:15388582. 5. Abdulkarim K, Girodon F, Johansson P, et al. AML transformation in 56 patients with Ph–MPD in two well defined populations. Eur J Haematol. 2009;82(2):106-11. http://dx.doi.org/10.1111/j.1600-0609.2008.01163.x. PMid:19134023. 6. Rampal R, Ahn J, Abdel-Wahab O, et al. Genomic and functional analysis of leukemic transformation of myeloproliferative neoplasms. Proc Natl Acad Sci USA. 2014;111(50):E5401-10. http://dx.doi.org/10.1073/ pnas.1407792111. PMid:25516983. 5-7

JAK2-mutated acute myeloid leukemia: comparison of next-generation sequencing (NGS) and single nucleotide polymorphism array (SNPa) findings between two cases

7. Heaney ML, Soriano G. Acute myeloid leukemia following a myeloproliferative neoplasm: Clinical characteristics, genetic features and effects of therapy. Curr Hematol Malig Rep. 2013;8(2):116-22. http://dx.doi.org/10.1007/ s11899-013-0154-5. PMid:23572311. 8. Lee JW, Kim YG, Soung YH, et al. The JAK2 V617F mutation in de novo acute myelogenous leukemias. Oncogene. 2006;25(9):1434-6. http://dx.doi. org/10.1038/sj.onc.1209163. PMid:16247455. 9. Hidalgo-López JE, Kanagal-Shamanna R, Medeiros LJ, et al. Morphologic and molecular characteristics of de novo AML with JAK2 V617F mutation. J Natl Compr Canc Netw. 2017;15(6):790-6. http://dx.doi. org/10.6004/jnccn.2017.0106. PMid:28596259. 10. Noronha T, Mitne-Neto M, Chauffaille M. Mutational profiling of acute myeloid leukemia with normal cytogenetics in Brazilian patients: The value of nextgeneration sequencing for genomic classification. J Investig Med. 2017;65(8):1155-8. http://dx.doi. org/10.1136/jim-2017-000566. PMid:28923882. 11. Pinheiro RF, Chauffaille M. Comparison of I-FISH and G-banding for the detection of chromosomal abnormalities during the evolution of myelodysplastic syndrome. Braz J Med Biol Res. 2009;42(11):42-5. http:// dx.doi.org/10.1590/S0100-879X2009001100018. PMid:19855907. 12. Papaemmanuil E, Gerstung M, Bullinger L, et al. Genomic Classification and Prognosis in Acute Myeloid Leukemia. N Engl J Med. 2016;374(23):2209-21. http:// dx.doi.org/10.1056/NEJMoa1516192. PMid:27276561. 13. Cortes JE, Kantarjian H, O’Brien S, et al. Clinical and prognostic significance of trisomy 21 in adult patients with acute myelogenous leukemia and myelodysplastic syndromes. Leukemia. 1995;9(1):115-7. PMid:7845005. 14. Döhner H, Estey E, Grimwade D, et al. Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood. 2017;129(4):424-47. http://dx.doi.org/10.1182/ blood-2016-08-733196. PMid:27895058. 15. Noronha TR, Rohr S, Chauffaille M. Identifying the similarities and differences between single nucleotide polymorphism array (SNPa) analysis and karyotyping in acute myeloid leukemia and myelodysplastic syndromes. Rev Bras Hematol Hemoter. 2015;37(1):4854. http://dx.doi.org/10.1016/j.bjhh.2014.09.011. PMid:25638768. 16. Ley TJ, Miller C, Ding L, et al. Genomic and epigenomic landscapes of adult de novo acute myeloid leukemia.

6-7

N Engl J Med. 2013;368(22):2059-74. http://dx.doi. org/10.1056/NEJMoa1301689. PMid:23634996. 17. Noronha T, Chauffaille M. Multiple long runs of homozygosity detected by SNP array: offspring of consanguineous parents and his siblings. Adv Cytol Pathol. 2018;3(3):56-9. 18. Gaymes TJ, Mohamedali A, Eiliazadeh AL, Darling D, Mufti GJ. FLT3 and JAK2 mutations in acute myeloid leukemia promote interchromosomal homologous recombination and the potential for copy neutral loss of heterozygosity. Cancer Res. 2017;77(7):1697-708. http://dx.doi.org/10.1158/0008-5472.CAN-16-1678. PMid:28108507. 19. Passamonti F, Rumi E, Pietra D, et al. A prospective study of 338 patients with polycythemia vera: The impact of JAK2 (V617F) allele burden and leukocytosis on fibrotic or leukemic disease transformation and vascular complications. Leukemia. 2010;24(9):1574-9. http:// dx.doi.org/10.1038/leu.2010.148. PMid:20631743. 20. Lee HJ, Daver N, Kantarjian HM, Verstovsek S, Ravandi F. The role of JAK pathway dysregulation in the pathogenesis and treatment of acute myeloid leukemia. Clin Cancer Res. 2013;19(2):327-35. http://dx.doi.org/10.1158/1078-0432.CCR-12-2087. PMid:23209034. 21. Im AP, Sehgal AR, Carroll MP, et al. DNMT3A and IDH mutations in acute myeloid leukemia and other myeloid malignancies: associations with prognosis and potential treatment strategies. Leukemia. 2014;28(9):1774-83. http://dx.doi.org/10.1038/ leu.2014.124. PMid:24699305. 22. Tefferi A, Jimma T, Sulai NH, et al. IDH mutations in primary myelofibrosis predict leukemic transformation and shortened survival: clinical evidence for leukemogenic collaboration with JAK2V617F. Leukemia. 2012;26(3):475-80. http://dx.doi.org/10.1038/ leu.2011.253. PMid:21912393. 23. Green A, Beer P. Somatic Mutations of IDH1 and IDH2 in the Leukemic Transformation of Myeloproliferative Neoplasms. N Engl J Med. 2010;362(4):369-70. http:// dx.doi.org/10.1056/NEJMc0910063. PMid:20107228. 24. McKenney AS, Lau AN, Somasundara AVH, et al. JAK2/ IDH-mutant–driven myeloproliferative neoplasm is sensitive to combined targeted inhibition. J Clin Invest. 2018;128(2):789-804. http://dx.doi.org/10.1172/ JCI94516. PMid:29355841. 25. Meyer SC, Levine RL. Translational implications of somatic genomics in acute myeloid leukaemia. Lancet Oncol. 2014;15(9):e382-94. http://dx.doi.org/10.1016/ S1470-2045(14)70008-7. PMid:25079101.

Autops Case Rep (São Paulo). 2019;9(2):e2018084

Noronha TR, Mitne-Neto M, Chauffaille ML

Author contributions: Noronha TR wrote the manuscript and performed and analyzed NGS and SNPa tests. Mitne-Neto M wrote the manuscript and analyzed NGS and SNPa tests. Chauffaille ML coordinated the work, wrote the manuscript, and analyzed the karyotype, NGS and SNPa tests. All authors collectively proofread and approved the final version of the manuscript for publication. Conflict of interest: None Financial support: NGS and SNPa procedures were supported by Fleury Group Submitted on: November 23th, 2018 Accepted on: February 27th, 2019 Correspondence Thiago Rodrigo de Noronha Disciplina de Hematologia - Universidade Federal de São Paulo (UNIFESP) Rua Doutor Diogo de Faria, 824, 5º andar – Vila Clementino – São Paulo/SP – Brazil CEP: 04037-002 Phone: +55 (11) 5576-2670 thinoronha@yahoo.com.br

Autops Case Rep (São Paulo). 2019;9(2):e2018084

7-7

Article / Clinical Case Report

Plasma cell cheilitis: the diagnosis of a disorder mimicking lip cancer Harim Tavares dos Santosa , John Lennon Silva Cunhab , Lucas Alves Mota Santanaa , Cleverson Luciano Trentoa , Antônio Carlos Marquettia , Ricardo Luiz Cavalcanti de Albuquerque-Júniorb , Sílvia Ferreira de Sousac  How to cite: Santos HT, Cunha JLS, Santana LAM et al. Plasma cell cheilitis: the diagnosis of a disorder mimicking lip cancer. Autops Case Rep [Internet]. 2019;9(2):e2018075. https://doi.org/10.4322/acr.2018.075

ABSTRACT Plasma cell cheilitis (PCC) is an inflammatory disorder of unknown etiology that affects the lip. It is characterized histologically by a dense infiltrate of plasma cells with a variety of clinical features. The response to different therapeutic modalities is controversial, especially regarding the effectiveness of corticosteroids. We present a case of a 56-year-old Caucasian man with a painful ulcerated and crusted area in the lower lip, resembling a squamous cell carcinoma or actinic cheilitis. Topical corticosteroid was used for one week, which resulted in partial regression and motivated a biopsy. The histological examination provided the diagnosis of PCC. The patient has been disease-free for six months. We also provide a discussion on the criteria of differential diagnosis and management of this rare condition. Keywords Cheilitis; Lip; Lip diseases; Plasma cell.

INTRODUCTION Plasma cell cheilitis (PCC) is a rare site-specific type of plasma cell mucositis reported in older adults, with higher prevalence in men.1,2 The lesion is presented as circumscribed erosive or erythematous plaques or patches on the labial mucosa, predominantly on the lower lip.1,3,4 Histopathologically, PCC consists of a proliferation of mature plasma cells distributed as a dense band-like subepithelial infiltrate.2,5,6 Additionally, the epithelium may present dyskeratosis, intercellular edema, erosion or ulceration, hyperkeratosis, and vacuolar degeneration in the conjunctival-epithelial junction. 2,7 When these clinical and microscopic findings are located intraorally, they are called plasma cell mucositis.8-11 Different therapeutic approaches

have been performed, but the outcomes remain paradoxical.5 We present a case of PCC clinically similar to lip squamous cell carcinoma or actinic cheilitis, but responsive to topical corticosteroid.

CASE REPORT A 56-year-old Caucasian male farmer sought the Oral Diagnosis Clinic complaining of a pricking pain in the lower lip where he had an unhealed wound for about six years. His medical history included hypertension and diabetes and there was no history of drinking or smoking. However, the patient reported being exposed daily to the sun without UV protection.

Federal University of Sergipe (UFS), Department of Dentistry, Biological Sciences and Health Center. Aracaju, SE, Brazil. Tiradentes University, Laboratory of Morphology and Experimental Pathology, Institute of Technology and Research. Aracaju, SE, Brazil. c Federal University of Minas Gerais (UFMG), Oral Surgery and Pathology Department, School of Dentistry. Belo Horizonte, MG, Brazil. a

Plasma cell cheilitis: the diagnosis of a disorder mimicking lip cancer

The examination showed a 3-cm ulcerated and crusted area on the lower lip (Figures 1A and 1B). There were no clinical changes in the intraoral examination. The clinical findings and the patient’s occupation led to the diagnosis of lip squamous cell carcinoma or actinic cheilitis. An incisional biopsy could not be performed at the first appointment due to the patient’s high blood pressure (200/120 mmHg). The topical use of

0.1% triamcinolone acetonide cream was prescribed until the next appointment. After seven days, the patient returned to the clinic with significant clinical improvement. The incisional biopsy was performed under local anesthesia and the tissue specimen was sent to histopathological analysis. The tissue sections showed parakeratotic stratum corneum with ulcerated areas, showing in the lamina propria a dense sheet-like infiltrate predominantly of mature plasma cells, some

Figure 1. Clinical aspect of lips. A – Absence of upper lip changes; B – Well-marked ulcerated and crusted area on the lower lip.

Figure 2. Photomicrograph of the biopsy specimen. A – Hyperplastic and parakeratinized stratified squamous epithelium with dense infiltrate of plasma cells in the lamina propria (Hematoxylin-eosin, 20X); B – Presence of a band‑like infiltrate of plasma cells. (Hematoxylin-eosin, 100X); C – Monomorphic mature plasma cells. (Hematoxylin‑eosin, 400X); D – Presence of Russel body (arrow) (Hematoxylin-eosin, 200X). 2-6

Autops Case Rep (São Paulo). 2019;9(2):e2018075

Santos HT, Cunha JLS, Santana LAM et al.

lymphocytes, few eosinophils, and sparse Russell bodies (Figures 2A-D). The plasma cells infiltrated the entire connective tissue up to the minor salivary glands. It is worth noting the absence of cellular atypia, pleomorphic figures, and mitotic activity. Immunohistochemistry to kappa and lambda immunoglobulin light chains showed polyclonal plasma cells, with a predominance of lambda (Figures 3A and 3B). Considering the clinical and histopathological findings and a negative serological test for syphilis, PCC was diagnosed. The topical corticosteroid was suspended after 10 days of use. Lip balm cream and sunscreen were prescribed and the lesion completely regressed 35 days after the biopsy (Figure 4). There was no recurrence after six months of follow-up and the administration of lip balm and sunscreen was maintained.

DISCUSSION Plasma cell cheilitis (PCC) is a type of mucositis enriched with plasma cells. Plasma cell mucositis was first described in 1952 by Zoon 12 and it has been identified in distinct anatomical areas and in other mucosae such as glans and vulva. 8 Plasmacytosis circumorificialis and plasmacytosis mucosae are other terms used in the literature.13 Although PCC is mentioned in the literature as a rare disorder, the data on its incidence is scarce. The PCC affects more commonly the lower lip of men, with the peak of incidence in the elderly. 1,2 The clinical features are characterized by erosive, ulcerative, fissured, bleeding, crusting, and erythematous plaques or patches on the labial mucosa,4,5,14 usually accompanied by the symptom of

Figure 3. Photomicrograph of the biopsy specimen. Plasma cells showing positivity for both lambda (A) and kappa (B) (Immunohistochemistry, 200X).

Figure 4. Clinical aspect of lower lip during follow-up. A, B – Complete regression of ulcerated and bleeding area 35 days after the biopsy. Autops Case Rep (São Paulo). 2019;9(2):e2018075

3-6

Plasma cell cheilitis: the diagnosis of a disorder mimicking lip cancer

pricking.2 The clinical evaluation of PCC frequently leads to an initial misdiagnosis, which requires biopsy and additional investigations.11 The clinical differential diagnoses are actinic cheilitis, allergic contact cheilitis, exfoliative cheilitis, granulomatous cheilitis, lichen planus, and lip squamous cell carcinoma.5 Considering that PCC is rarely considered a differential diagnosis in the clinical routine, our provisional clinical diagnosis (actinic cheilitis or lip squamous cell carcinoma) was based on the most frequent ones for the clinical features of the patient. The histological diagnosis is based on the identification of a sheet-like infiltration of monomorphic mature plasma cells without anaplasia or prominent nucleoli, and Russel bodies are found occasionally.2,5,6 The clinicopathologic features of the current case were consistent with PCC. The etiology of PCC remains unknown. One theory speculates that inflammatory cells such as T cells and macrophages affect the growth and differentiation of B cells.4,5,15,16 Another theory holds that PCC might be a response to exogenous factors such as trauma and solar damage.2,6 We assume that solar damage might have triggered PCC, considering our patient is a farmer who is constantly exposed to the sun without UV protection. In addition, neoplastic plasma cell disorders are composed mainly of monoclonal cells, whereas inflammatory ones consist of polyclonal cells.17 Therefore, considering that oral plasma cell mucositis is composed of polyclonal plasma cells,12 PCC might be considered a benign inflammatory condition. A predominance of kappa immunoglobulin light chain was mentioned in nine out of 13 cases evaluated previously,2 which contrasts with the higher levels of lambda positivity of cells in the present case. Considering the histological character of PCC diagnosis,14 the microscopic differential diagnosis may include a variety of lesions such as allergic contact cheilitis, secondary syphilis (mucous patches - erosions or ulcers with an erythematous margin), actinic cheilitis, squamous cell carcinoma, cheilitis granulomatosa, and plasmacytoma. 7,8,18 These lesions may be excluded depending on the histomorphology. Allergic contact cheilitis shows inflammatory infiltrates mainly consisting of lymphocytes, Langerhans cells, macrophages, and eosinophils rather than plasma cells.19 Our case showed a consistent infiltrate of mature plasma cells and the patient did not report allergies or sensitivities to a specific substance. The histopathological features of 4-6

syphilis are inflammatory infiltrates containing plasma cells, lymphocytes, and macrophages, usually with a perivascular distribution. 20 The present case was not marked by a perivascular location of plasma cells and a serological screening ruled out syphilis. Actinic cheilitis is represented by hyperkeratosis with epithelial hyperplasia or atrophy, acanthosis, solar elastosis, chronic inflammatory infiltrate, vasodilatation, and it may present dysplasia,21-23 which were not detected in our case. Lip squamous cell carcinoma shows variable degrees of squamous differentiation featured by the invasion of the underlying stroma,24 which was not observed in our findings. Cheilitis granulomatosa shows noncaseating granulomatous inflammation,25 which was not found in the present case. Plasmacytoma is a rare malignant neoplasm that usually affects the mandible when occurring in the oral cavity, 26 and it is characterized by the proliferation of atypical monoclonal plasma cells.20 Our biopsy specimen did not show cellular atypia, pleomorphic figures, and mitotic activity, and the cells were polyclonal, thus ruling out the diagnosis of plasmacytoma. Different therapeutic approaches to PCC have been proposed, such as surgical excision, radiation therapy, electrocauterization, cryotherapy, topical application of fusidic acid, systemic and topical corticosteroids, administration of systemic griseofulvin, and immunomodulatory agents.1,5,8,18,27-32 Nevertheless, the outcome with topical corticosteroid therapy varies from poor15 to successful1. Such sliding response to topical corticosteroid may be explained by epithelial width, as distinct results of topical corticosteroid treatment between atrophic, mild acanthotic, and marked acanthotic variants have been reported. 8,33 Our patient presented clinical improvement with topical steroid treatment. Thus, we assume that the presence of ulcerative lesions increased the effectiveness of topical corticosteroid treatment. In addition, it is worth emphasizing that disorders featured by plasma cell mucositis, considered as benign entities, have a favorable prognosis. 11 The absence of recurrence in the present case contributes to this concept. Moreover, to the best of our knowledge, PCC has a benign clinical behavior, as the development of malignant neoplasia from PCC has not been reported yet. In summary, PCC is an uncommon disorder in the clinical routine, which may present some similar Autops Case Rep (São Paulo). 2019;9(2):e2018075

Santos HT, Cunha JLS, Santana LAM et al.

clinical and histopathological findings with different conditions. Biopsy is required to confirm the diagnosis. Clinicians and pathologists should consider PCC when evaluating lesions on the lip, and corticosteroid treatment should be considered when detecting such condition.

11. Solomon LW, Wein RO, Rosenwald I, Laver N. Plasma cell mucositis of the oral cavity: report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(6):853-60. http://dx.doi.org/10.1016/j. tripleo.2008.08.016. PMid:18926737.

REFERENCES

13. Senol M, Özcan A, Aydın NE, Hazneci E, Turan N. Intertriginous plasmacytosis with plasmoacanthoma: report of a typical case and review of the literature. Int J Dermatol. 2008;47(3):265-8. http://dx.doi.org/10.1111/ j.1365-4632.2008.03385.x. PMid:18289329.

1. Tamaki K, Osada A, Tsukamoto K, Ohtake N, Furue M. Treatment of plasma cell cheilitis with griseofulvin. J Am Acad Dermatol. 1994;30(5):789-90. http://dx.doi. org/10.1016/S0190-9622(08)81515-0. PMid:8176022. 2. Lee JY, Kim KH, Hahm JE, et al. Plasma cell cheilitis: a clinicopathological and immunohistochemical study of 13 cases. Ann Dermatol. 2017;29(5):536-42. http://dx.doi. org/10.5021/ad.2017.29.5.536. PMid:28966508. 3. Baughman RD, Berger P, Pringle WM. Plasma cell cheilitis. Arch Dermatol. 1974;110(5):725-6. http:// dx.doi.org/10.1001/archderm.1974.01630110023003. PMid:4422015. 4. Rocha N, Mota F, Horta M, Lima O, Massa A, Sanches M. Plasma cell cheilitis. J Eur Acad Dermatol Venereol. 2004;18(1):96-8. http://dx.doi.org/10.1111/j.14683083.2004.00791.x. PMid:14678543. 5. Yang JH, Lee UH, Jang SJ, Choi JC. Plasma cell cheilitis treated with intralesional injection of corticosteroids. J Dermatol. 2005;32(12):987-90. http:// dx.doi.org/10.1111/j.1346-8138.2005.tb00887.x. PMid:16471463. 6. da Cunha Filho RR, Tochetto LB, Tochetto BB, de Almeida HL Jr, Lorencette NA, Netto JF. “Angular” plasma cell cheilitis. Dermatol Online J. 2014;20(3):12. PMid:24656273. 7. Fujimura Y, Natsuga K, Abe R, Morita Y, Nomura T, Shimizu H. Plasma cell cheilitis extending beyond vermillion border. J Dermatol. 2015;42(9):935-6. http:// dx.doi.org/10.1111/1346-8138.12985. PMid:26076584. 8. White JW Jr, Olsen KD, Banks PM. Plasma cell orificial mucositis: report of a case and review of the literature. Arch Dermatol. 1986;122(11):1321-4. http:// dx.doi.org/10.1001/archderm.1986.01660230113023. PMid:3777979. 9. Noorily AD. Plasma cell orificial mucositis. Otolaryngol Head Neck Surg. 1997;116(3):416-7. http://dx.doi. org/10.1016/S0194-5998(97)70287-0. PMid:9121804. 10. Smith ME, Crighton AJ, Chisholm DM, Mountain RE. Plasma cell mucositis: a review and case report. J Oral Pathol Med. 1999;28(4):183-6. http:// dx.doi.org/10.1111/j.1600-0714.1999.tb02021.x. PMid:10235373. Autops Case Rep (São Paulo). 2019;9(2):e2018075

12. Zoon JJ. Chronic benign circumscript plasmocytic balanoposthitis. Dermatologica. 1952;105(1):1-7. http:// dx.doi.org/10.1159/000256880. PMid:12979576.

14. Farrier JN, Perkins CS. Plasma cell cheilitis. Br J Oral Maxillofac Surg. 2008;46(8):679-80. http://dx.doi. org/10.1016/j.bjoms.2008.03.009. PMid:18439733. 15. Aiba S, Tagami H. Immunoglobulin-producing cells in plasma cell orificial mucositis. J Cutan Pathol. 1989;16(4):207-10. http://dx.doi.org/10.1111/j.1600-0560.1989.tb00042.x. PMid:2677069. 16. Rogers RS 3rd, Bekic M. Diseases of the lips. Semin Cutan Med Surg. 1997;16(4):328-36. http://dx.doi.org/10.1016/ S1085-5629(97)80025-9. PMid:9421227. 17. Gonzalez-Perez LM, Borrero-Martin JJ. An elderly man with a gingival mass that spontaneously regressed. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;121(4):34852. http://dx.doi.org/10.1016/j.oooo.2015.08.014. PMid:26482192. 18. Román CC, Yuste CM, González MA, González AP, López G. Plasma cell gingivitis. Cutis. 2002;69(1):41-5. PMid:11829177. 19. So JK, Hamstra A, Calame A, Hamann CR, Jacob SE. Another great imitator: allergic contact dermatitis differential diagnosis, clues to diagnosis, histopathology, and treatment. Curr Treat Options Allergy. 2015;2(4):33348. http://dx.doi.org/10.1007/s40521-015-0064-y. 20. Bharti R, Smith DR. Mucous membrane plasmacytosis: a case report and review of the literature. Dermatol Online J. 2003;9(5):15. PMid:14996388. 21. Girard KR, Hoffman BL. Actinic cheilitis: report of a case. Oral Surg Oral Med Oral Pathol. 1980;50(1):214. http://dx.doi.org/10.1016/0030-4220(80)90325-4. PMid:6930597. 22. Main JH, Pavone M. Actinic cheilitis and carcinoma of the lip. J Can Dent Assoc. 1994;60(2):113-6. PMid:8111655. 23. Cavalcante AS, Anbinder AL, Carvalho YR. Actinic cheilitis: clinical and histological features. J Oral Maxillofac Surg. 2008;66(3):498-503. http://dx.doi.org/10.1016/j. joms.2006.09.016. PMid:18280383. 24. Cabral LAG, Carvalho LF, Salgado JA, Brandão AA, Almeida JD. Gingival squamous cell carcinoma: a case 5-6

Plasma cell cheilitis: the diagnosis of a disorder mimicking lip cancer

report. J Oral Maxillofac Res. 2010;1(3):e6. http://dx.doi. org/10.5037/jomr.2010.1306. PMid:24421976.

http://dx.doi.org/10.1111/j.1365-2230.2008.02765.x. PMid:18795938.

25. Critchlow WA, Chang D. Cheilitis granulomatosa: a review. Head Neck Pathol. 2014;8(2):209-13. http://dx.doi. org/10.1007/s12105-013-0488-2. PMid:24057987.

30. Jin SP, Cho KH, Huh CH. Plasma cell cheilitis, successfully treated with topical 0.03% tacrolimus ointment. J Dermatolog Treat. 2010;21(3):130-2. http://dx.doi. org/10.3109/09546630903200620. PMid:19707925.

26. Pisano JJ, Coupland R, Chen SY, Miller AS. Plasmacytoma of the oral cavity and jaws: a clinicopathologic study of 13 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(2):265-71. http://dx.doi.org/10.1016/ S1079-2104(97)90015-9. PMid:9117760. 27. Choi JW, Choi M, Cho KH. Successful treatment of plasma cell cheilitis with topical calcineurin inhibitors. J Dermatol. 2009;36(12):669-71. http://dx.doi.org/10.1111/j.13468138.2009.00733.x. PMid:19958456. 28. Mahler V, Hornstein OP, Kiesewetter F. Plasma cell gingivitis: treatment with 2% fusidic acid. J Am Acad Dermatol. 1996;34(1):145-6. http://dx.doi.org/10.1016/ S0190-9622(96)90865-8. PMid:8543685. 29. Tseng JT, Cheng CJ, Lee WR, Wang KH. Plasma-cell cheilitis: successful treatment with intralesional injections of corticosteroids. Clin Exp Dermatol. 2009;34(2):174-7.

31. Hanami Y, Motoki Y, Yamamoto T. Successful treatment of plasma cell cheilitis with topical tacrolimus: report of two cases. Dermatol Online J. 2011;17(2):6. PMid:21382289. 32. Yoshimura K, Nakano S, Tsuruta D, Ohata C, Hashimoto T. Successful treatment with 308-nm monochromatic excimer light and subsequent tacrolimus 0.03% ointment in refractory plasma cell cheilitis. J Dermatol. 2013;40(6):471-4. http://dx.doi.org/10.1111/13468138.12152. PMid:23621817. 33. Jones SK, Kennedy CT. Response of plasma cell orificial mucositis to topically applied steroids. Arch Dermatol. 1988;124(12):1871-2. http://dx.doi.org/10.1001/ archderm.1988.01670120077023. PMid:3190265.

Author contributions: Trento CL and Marquetti AC treated the patient and performed the surgical procedure. Albuquerque-Júnior RLC and de Sousa SF performed the microscopic analysis. Santos HT, Cunha JLS, and Santana LAM reviewed the literature and wrote the manuscript. All authors approved and proofread the final document. The authors retain an informed consent form signed by the patient for image and data publication and the paper is in accordance with the Institutional Ethics Committee. Conflict of interest: None Financial support: None Submitted on: November 25th, 2019 Accepted on: January 31st, 2019 Correspondence Sílvia Ferreira de Sousa Universidade Federal de Minas Gerais, Oral Surgery and Pathology Department – School of Dentistry – (UFMG) Avenida Antônio Carlos, 6627, Pampulha – Belo Horizonte/MG – Brazil CEP: 31270-901 Phone: +55 (31) 3409-2477 silviafsousa@ufmg.br

6-6

Autops Case Rep (São Paulo). 2019;9(2):e2018075

Article / Clinical Case Report

Cystic lesion of pectoralis minor muscle: learning from mistakes Javier García-Tiradoa , Marta Allué-Cabañuzb , Nadia Muñoz-Gonzáleza , María Jesús Viso-Sorianoc , Isabel Marquina-Ibáñezc  How to cite: García-Tirado J, Allué-Cabañuz M, Muñoz-González N, Viso-Soriano MJ, Marquina-Ibáñez I. Cystic lesion of pectoralis minor muscle: learning from mistakes. Autops Case Rep [Internet]. 2019;9(2):e20180780. https://doi.org/10.4322/acr.2018.078

ABSTRACT Hydatidosis is a frequent infestation in large endemic areas, caused by helminths. Primary localization within the muscle or bone tissues is rare. We report the case of a 52-year-old woman with a cystic lesion located in the right pectoralis minor muscle, who was initially diagnosed with cystic lymphangioma by imaging examination. She was submitted for surgical treatment; in block resection of the tumor along with the involved muscle was performed. The histopathological diagnosis was of hydatid cyst. The contribution of the ancillary lab tests is analyzed for a precise preoperative diagnostic approach. This case well illustrates that the most likely is not always what it appears to be. Facing of a cystic lesion in the lungs, liver or muscle, clinicians should always think on hydatid disease, particularly in endemic areas. Keywords Echinococcosis; Lymphangioma, Cyst; Muscular Disease; Thoracic Wall.

INTRODUCTION Hydatidosis is a frequent infestation in large endemic areas, caused by helminths. The involvement

the contribution of the ancillary tests to the diagnostic approach.

of the muscular or bone tissues is rare. Hydatidosis is a zoonosis caused by the larval form of the genus Echinococcus. The infestation occurs in humans after the ingestion of the eggs excreted with the feces by the definitive hosts such as dogs and foxes. Hydatidosis involves the liver and the lungs primarily, since they are capillary filters.1 Musculoskeletal hydatidosis occurs in only 1-4% of the cases.1 As far as we know, this is the first case report showing the involvement of the pectoralis minor muscle. We present a clinical case of hydatid disease of the pectoralis muscle, accompanied by a discussion on

CASE REPORT A 52-year-old woman sought the medical facility complaining of a painful tumor in the right pectoral region over the last 8 months. The patient lived in the rural area but had no contact with livestock or domestic animals. During the last 5 months, she reported two episodes of bulging mass over the right frontal chest region accompanied by inflammatory signs that subsided within 1-2 weeks. Her past medical history was unremarkable. Her blood tests were normal. However, the thoracic computed tomography (CT)

Miguel Servet University Hospital, Thoracic Surgery Department. Zaragoza, Spain. Lozano Blesa University Clinical Hospital, General Surgery Department. Zaragoza, Spain. c Miguel Servet University Hospital, Department of Pathology. Zaragoza, Spain. a

Cystic lesion of pectoralis minor muscle: learning from mistakes

depicted a 60 mm bilobed and cystic lesion in the right pectoralis minor muscle, which compressed the right subclavian vein at the exit of the costoclavicular space. These findings were consistent with cystic lymphangioma or intramuscular myxoma (Figure 1). The magnetic resonance imaging (MRI) of the shoulder confirmed a soft-tissue tumor affecting the pectoralis minor, which measured 6.3x4.4x1.6 cm. The mass was delimited by the muscular aponeurosis, preserved the brachial plexus; and cranially reached the coracoid process. The lesion showed a thin and well-defined margin except for its posterior and cranial margin, showed hyperintense signal in T2 weighted images, and no contrast enhancement was observed. These findings were consistent with a vascular malformation of lymphatic origin (cystic lymphangioma) (Figure 2). Given the nature of these findings and their potential vascular injury, the surgical resection was performed through a right infraclavicular incision. The exeresis of the tumor also involved the right pectoralis minor muscle. Intraoperatively, an intramuscular tumor of 6 cm was found, lined by a fibrous capsule. The cranial tumor part was in close contact with the coracoid process, and with the subclavian-axillary axis, which required careful dissection to avoid a vascular injury. During the resection, the tumor capsule was violated with

drainage of a caseous content but was immediately sutured. The gross examination revealed an irregular lobed cystic and encapsulated tumor of 6.5x4x2.5 cm, which at the cut surface showed a light-yellowish center. The histopathology revealed a fibrous capsule admixed with inflammatory infiltrate. The center of the lesion showed abundant proteinaceous debris, and a thick, acellular layer fragmented and collapsed towards the lumen (Figure 3). No germ layer was identified with nucleated cells, daughter vesicles or a scolex. The final pathologic diagnosis was a hydatid cyst with pericystic layer and cuticle, with free surgical margins. The postoperative period was uneventful. After the diagnostic confirmation, a serological study was performed and was positive for Echinococcus granulosus. No involvement was found in other sites in a postoperative body CT scan. The patient was treated with oral albendazole, 800 mg/day, two cycles of 28 days, separated by a rest period of 14 days. Currently, the patient is asymptomatic, without any functional sequelae.

DISCUSSION Hydatid disease is a parasitic infestation caused by a tapeworm of the genus Echinococcus.1 The main endemic areas are the Mediterranean countries, the Middle East, southern Africa, the southern

Figure 1. Thoracic CT – Axial plane showing a bilobed cystic lesion within the pectoralis minor muscle, which bulges the muscle contour from its insertion into the coracoid process (A) and compresses the right subclavian vein to the outlet of the costoclavicular space (B). 2-5

Autops Case Rep (São Paulo). 2019;9(2):e20180780

García-Tirado J, Allué-Cabañuz M, Muñoz-González N, Viso-Soriano MJ, Marquina-Ibáñez I

Figure 2. MRI T2 weighted images of the pectoral region showing a cystic tumor of 6.3 cm within the pectoralis minor muscle (A and B: axial plane; C and D: coronal plane). The lobed cyst (D) presented a density with a very high signal in T2 weighted images (A and B).

Figure 3. Photomicrograph of the lesion. A – Panoramic view of the encapsulated cystic lesion containing a hydatid cyst cuticle (H&E, low power), B – Cystic wall composed of fibrous tissue and inflammatory infiltrate. Inside, hydatid membranes (H&E, 4X). C and D – Wall of the hydatid membranes. (H&E, 10X and 20X respectively). Autops Case Rep (São Paulo). 2019;9(2):e20180780

3-5

Cystic lesion of pectoralis minor muscle: learning from mistakes

part of South America, New Zealand, Australia, and Iceland. 2 The most frequent clinical forms of hydatidosis are pulmonary (15%) and hepatic (65%). The musculoskeletal condition is uncommon (1%–4%),1 what renders few data on this involvement.3 Daali et al.3 published a series comprising 15 cases with muscular involvement, mostly affecting the diaphragm or the psoas muscles, without synchronous hepatic or pulmonary involvement. However, the involvement of these visceral organs should be discarded during the diagnostic process, because of its frequency. Imaging exams are fundamental to the diagnosis and include some typical patterns as the unilocular cyst, the multivesicular lesion (highly characteristic), and the atypical complex or solid lesion.4,5 The multivesicular lesion is formed by the grouping of multiple daughter vesicles within the original cyst is characteristic but not pathognomonic, though.4,6 When the cysts are not viable, they do not produce fluid; 5 the case presented corresponded to a non-viable hydatid cyst. In some cases, an inflammatory reaction may produce changes that resemble an atypical complex or solid lesion, challenging the differential diagnosis. The MRI is considered the imaging exam of choice, because of the higher sensitivity and specificity.5,6 Immunological tests have been shown to be useful for the diagnosis of visceral hydatid disease.7 Cystic echinococcosis is one of the few parasitic infections in which the basis for laboratory diagnosis is primarily serology.8 Indirect hemagglutination test and enzyme‑linked immunosorbent assay are the most widely used methods for detection of anti-Echinococcus antibodies (IgG). Nonetheless, no standard, highly sensitive, and specific serologic test exists for cystic echinococcosis antibody detection. 9 Furthermore, in the cases of osteomuscular involvement, the sensitivity of these tests is decreased. 10 According to Rigano et al. 11 the decrease in the sensitivity may be due to inadequate activation of T-helper-2 lymphocytes, with the consequent reduction in the peripheral expression of immunoglobulins. In our case, the lack of the diagnosis suspicion was responsible for not testing the serologic exam. However, once the diagnosis was established, the serological study was performed, which was positive. Treatment-wise, surgery is the best option, always performed with a large margin of safety due to the 4-5

high risk of relapse, regardless of the site of the lesion. Depending on the location and the relationship with vital structures, this will determine the prognosis.10 Nevertheless, minimally invasive approaches are currently being considered, as the laparoscopy and the PAIR (puncture, aspiration, injection, and reaspiration).12 Some authors consider the preoperative treatment with benzimidazole derivatives to be fundamental, and likewise for 3 more months postoperatively.3 In our case, the preoperative pharmacological treatment was not considered due to the lack of diagnostic suspicion. The accidental cyst injury during the surgical procedure did not cause any harm due to the absence of viability of the parasite. The convenience of preoperative treatment, together with the risk of rupture of the cyst during surgery with the implications that it entails, highlights the importance of considering the diagnosis of hydatid cyst in the differential diagnosis of this type of lesion for an optimal preoperative study and appropriate therapeutic management (especially in endemic regions).

REFERENCES 1. Merkle EM, Schulte M, Vogel J, et al. Musculosketal involvement in cystic echinococcosis: report of eight cases and review of the literature. AJR Am J Roentgenol. 1997;168(6):1531-4. http://dx.doi.org/10.2214/ ajr.168.6.9168719. PMid:9168719. 2. Ito A, Budke CM. The echinococcoses in Asia: the present situation. Acta Trop. 2017;176:11-21. http://dx.doi. org/10.1016/j.actatropica.2017.07.013. PMid:28728830. 3. Daali M, Hssaida R. L’hydatidose musculaire: 15 cases. Presse Med. 2000;21(29):1166-9. PMid:10906934. 4. Martin J, Marco V, Zidan A, Marco C. Hydatid disease of the soft tissues of the lower limb: findings in three cases. Skeletal Radiol. 1993;22(7):511-4. http://dx.doi. org/10.1007/BF00209098. PMid:8272887. 5. Marzouki A, Naam A, Abdulrazak S, Soumaré B, Lahrach K, Boutayeb F. Musculoskeletal Echinococcus infection as a rare first presentation of hydatid disease: case report. Patient Saf Surg. 2017;11(21):15. http://dx.doi.org/10.1186/s13037-017-0136-y. PMid:28725269. 6. Vasilevska V, Zafirovski G, Kirjas N, et al. Imaging diagnosis of musculoskeletal hydatid disease. Prilozi. 2007;28(2):199-209. PMid:18356790. Autops Case Rep (São Paulo). 2019;9(2):e20180780

García-Tirado J, Allué-Cabañuz M, Muñoz-González N, Viso-Soriano MJ, Marquina-Ibáñez I

7. Torcal J, Navarro-Zorraquino M, Lozano R, et al. Immune response and in vivo production of cytokines in patients with liver hydatidosis. Clin Exp Immunol. 1996;106(2):31722. http://dx.doi.org/10.1046/j.1365-2249.1996.d01843.x. PMid:8918579. 8. Brunetti E, Kern P, Vuitton DA. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop. 2010;114(1):1-16. http://dx.doi.org/10.1016/j.actatropica.2009.11.001. PMid:19931502. 9. Brunetti E. Echinococcosis Hydatid Cyst Workup. Laboratory Studies. New York: Medscape, LLC; 2018 [cited 2019 Dec 27]. Available from: https://emedicine. medscape.com/article/216432-workup

10. Torcal J, García-Álvarez F, Salinas JC, et al. Hidatidosis muscular primaria. Cir Esp. 2002;72(3):147-51. http:// dx.doi.org/10.1016/S0009-739X(02)72029-0. 11. Rigano R, Profumo E, Ioppolo S, Notargiacomo S, Teggi A, Siracusano A. Cytokine patterns in seropositive and seronegative patients with Echinococcus granulosus infection. Immunol Lett. 1998;64(1):5-8. http://dx.doi. org/10.1016/S0165-2478(98)00072-8. PMid:9865595. 12. Chen X, Cen C, Xie H, Zhou L, Wen H, Zheng S. The comparison of 2 new promising weapons for the treatment of hydatid cyst disease: PAIR and laparoscopic therapy. Surg Laparosc Endosc Percutan Tech. 2015;25(4):35862. http://dx.doi.org/10.1097/SLE.0000000000000177. PMid:26241297.

Author contributions: García-Tirado J, Allué-Cabañuz M, Muñoz-González N, Viso-Soriano MJ, and Marquina‑Ibáñez I, planned the article; García-Tirado J, Allué-Cabañuz M, Muñoz-González N and Viso-Soriano MJ wrote the article. All authors collectively proofread and approved the manuscript’s final version for publication. The authors retain an informed consent document signed by the patient, and the manuscript is in accordance with the requirements of the institutional ethics committee. Conflict of interest: None Financial support: None Submitted on: January 16th, 2019 Accepted on: February 13th, 2019 Correspondence: Javier García-Tirado Pº de la Sagrada, 27, casa 31 – 50120 Monzalbarba – Zaragoza – Spain Phone: +34 615660334 fco854@separ.es; jgarciatirado.cto@gmail.com

Autops Case Rep (São Paulo). 2019;9(2):e20180780

5-5

Article / Clinical Case Report

Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case Miao Tiana , Karen E Matsukumaa  How to cite: Tian M, Matsukuma KE. Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case. Autops Case Rep [Internet]. 2019;9(2):e2018082. https://doi.org/10.4322/acr.2018.082

ABSTRACT Cholesterol crystal embolism is a rare and easily overlooked cause of colonic ischemia. The gastrointestinal tract is the third most common organ system affected by cholesterol emboli, second only to kidney and skin. Here we present a catastrophic case of gastrointestinal cholesterol crystal embolism leading to extensive post-operative bowel infarction and ultimately death. For a practicing pathologist, careful attention to the vessels of any ischemic bowel and recognition of the subtle but distinct angular imprint of cholesterol crystals facilitates prompt identification of the atheroemboli. In some cases, early identification may help mitigate further tissue damage. In more acute and severe cases, identification of the cholesterol crystal emboli may be important primarily for documentation of procedural complications. Keywords Cholesterol; Embolism; Gastrointestinal Tract; Ischemia.

CASE REPORT A 62-year-old man underwent bilateral common femoral endarterectomy and aortobifemoral bypass for severe claudication secondary to extensive atherosclerosis. On postoperative day 1, he developed melena and hematochezia. Emergency colonoscopy demonstrated severe ischemia of the proximal colon and severe circumferential ischemic proctitis. Due to severe hypoxia, hypotension, and lactic acidosis, exploratory laparotomy was performed on postoperative day 2. Necrosis of the distal ileum and cecum was identified, and these segments were subsequently resected. Dusky areas in the remainder of the small bowel and colon were left intact, pending future operative evaluation. On the following day, the patient developed multi-organ failure, and a second-look exploratory laparotomy was performed. Diffuse small bowel and ascending colon necrosis a

was identified, and these segments were resected. Intraoperatively, the patient became acidotic and hyperkalemic, and upon transport to the intensive care unit, the patient expired.

PATHOLOGIC RESULTS Gross examination of the small bowel and colon resections revealed dusky serosa and dark red to grey mucosa with attenuated folds (Figure 1). On the histologic sections, extensive mucosal and focal submucosal necrosis was present throughout the bowel (Figure 2). In the submucosa, numerous thin, needle-shaped clefts were noted in congested arterioles. Fibrin thrombi were also seen in some of the arterioles (Figure 2A). Additionally, focal areas of

University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine. Sacramento, CA, USA.

Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case

viable mucosa were noted on histologic sections. These areas were notable for absence of the aforementioned vascular changes.

Figure 1. Ascending colon showing dusky mucosa with necrosis, hemorrhage, and attenuated folding (formalin‑fixed specimen).

DISCUSSION Needle-shaped clefts are the characteristic imprint of cholesterol crystals. The cholesterol itself is no longer present, as it dissolves during tissue processing (due to serial incubations in ethanol and xylene). When the needle-shaped clefts are present in small blood vessels in association with histologic features of tissue ischemia, the findings are diagnostic of cholesterol crystal embolism (CCE). 1-3 Fibrin thrombi develop secondarily as a result of obstructed blood flow.1,3 C C E a ls o re fe rre d to a s a th e ro e m b o l i s m or cholesterol embolization syndrome is a rare manifestation of the atherosclerotic disease.4 It occurs when an atherosclerotic plaque in the aorta or other major artery ruptures and releases cholesterol crystals and atheroma debris into the bloodstream. The crystals embolize to small and medium-sized arteries and arterioles, resulting in end-organ damage.1 The location of the disrupted atherosclerotic plaque

Figure 2. Photomicrograph of the ascending colon. A – Cholesterol crystal clefts (arrow) in an arteriole located in the submucosa of the cecum. Note the fibrin thrombus associated with the cholesterol crystal cleft. Mucosal necrosis is present; B – Cholesterol crystal clefts (arrows) in arterioles of varying sizes within the superficial and mid layers of the submucosa. (All images digitally scanned at 40X). 2-5

Autops Case Rep (São Paulo). 2019;9(2):e2018082

Tian M, Matsukuma KE

determines the pattern of end-organ damage and thus its clinical manifestations. CCE can occur upon spontaneous rupture of an atherosclerotic plaque, after iatrogenic mechanical trauma (e.g., vascular surgery, angiography, or angioplasty), or as a side effect of medications targeting the coagulation system (e.g., anticoagulants, or thrombolytics).5 The incidence of CCE is estimated to be less than 0.5% based on studies of unselected autopsy populations. 6 However, it has been reported to be 1.4% after coronary catheterization.7 The risk factors for cholesterol crystal formation are primarily those of atherosclerosis (e.g., smoking, hypercholesterolemia, hypertension, and obesity), while the risk factors for cholesterol crystal embolization include atherosclerosis, vascular manipulation, anticoagulation, and thrombolytic therapy.5,8 The gastrointestinal tract is the third most frequent organ system affected (13.4%), following kidney (31.5%) and skin (15.5%). 6 Within the alimentary tract, the colon is the most common site of involvement (42.3%), followed by small intestine (33%), stomach (12.3%), rectum (9.2%), and esophagus (1.5%).9 CCE may also involve the pancreas, liver, and gallbladder. 10,11 CCE involving the digestive tract often presents as abdominal pain, diarrhea, and gastrointestinal bleeding. 5,8,12 Because the clinical presentation is not specific, the disease can masquerade as other conditions (e.g., infection, tumor, inflammatory bowel disease). CCE can present as either a chronic indolent disease that resolves over time or an acute catastrophic multi-organ disorder with poor prognosis.5 Although histologic evaluation is the gold standard for diagnosis, the co-occurrence of 3 clinical findings: (1) history of known risk factors for CCE (e.g., vascular surgery, anticoagulation), (2) acute onset renal failure with creatinine elevation of greater than 50% of baseline, and (3) signs of cutaneous vascular compromise (e.g., livedo reticularis, purples toes) or funduscopic evidence of retinal atheroemboli, has proved to be relatively specific for disseminated CCE.13 Thus, non-invasive procedures such as funduscopic examination can be useful. No specific treatment for CCE exists; however, early and aggressive supportive therapy (e.g., use of blood pressure lowering agents - in the context of cardiac failure, hemodialysis, nutritional support, discontinuation of inciting medications) can Autops Case Rep (São Paulo). 2019;9(2):e2018082

improve prognosis. 13 Nonetheless, overall mortality rates are still as high as 80%.14 In the present case, the patient had multiple atherosclerotic plaques (identified by imaging) along the entire abdominal aorta, placing him at risk for multi-organ CCE. Indeed, besides the extensive gastrointestinal tract involvement, acute renal and liver failure emerged after aortobifemoral bypass. Although an autopsy was not performed, the widespread aortic atherosclerosis, diffuse bowel infarction, and acute renal and liver dysfunction point to multi-organ CCE as the ultimate cause of his demise. Nonetheless, since no post-surgical angiography studies were performed, we cannot entirely exclude the possibility that vasoconstriction of large arteries contributed to the vascular compromise, as has been described previously.15 It is also worth noting that the patient’s abdominal aorta clamp time (35 minutes) and blood loss (1.5 L) would be considered moderate16 and would not be expected to be the primary cause of the patient’s massive vascular compromise. From a histologic standpoint, the differential diagnosis of colonic ischemia includes infection (e.g., cytomegalovirus, E. coli O157:H7), vasculitis, mesenteric ischemia due to prolonged aortic clamping, mesenteric thrombosis, radiation-induced vasculopathy, mesenteric myointimal hyperplasia,17 and enterocolic lymphocytic phlebitis, 18 none of which were observed in this case. Additionally, a thrombus overlying an atheromatous plaque can become loose and occlude downstream large caliber arteries (thromboembolism).3,4,19 Thromboembolism is distinguished from CCE in that it usually involves a single target organ and the emboli are predominantly composed of fibrin, whereas CCE is characterized by multiple cholesterol crystal emboli in small arterioles. Of note, some studies report the presence of CCE in small vessels mostly less than 200 µm in diameter,2,20 whereas in the current case the size of the affected arterioles ranged from 50 to 950 µm in diameter, similar to the findings of Flory.1

CONCLUSION CCE is a type of vasculopathy that occurs when an atherosclerotic plaque ruptures and releases cholesterol crystals and atheroma debris into downstream arterioles. Although the digestive tract is a commonly affected 3-5

Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case

site, CCE is a relatively uncommon cause of colonic ischemia overall and as such must be kept in mind in the differential diagnosis of ischemia, particularly in the setting of a recent vascular procedure and/or certain patient-specific risk factors (atherosclerosis, smoking, hypercholesterolemia, hypertension, obesity). Unfortunately, due to the relatively non-specific symptoms, a high degree of clinical suspicion is necessary for establishing a timely diagnosis. For the pathologist, attention to the character and content of the vessels is critical for identification. If not viewed carefully, cholesterol clefts may be overlooked as artefactual fractioning of vessel lumina rather than an indication of a potentially widespread and morbid pathologic process.

9. Moolenaar W, Lamers CB. Cholesterol crystal embolisation to the alimentary tract. Gut. 1996;38(2):196-200. http:// dx.doi.org/10.1136/gut.38.2.196. PMid:8801196. 10. Konstantinidis IT, Warshaw AL, Deshpande V, et al. Cholesterol crystal embolization presenting as either solid or cystic pancreatic lesion. J Surg Oncol. 2010;102(6):7068. http://dx.doi.org/10.1002/jso.21521. PMid:20976733. 11. Moolenaar W, Lamers CB. Cholesterol crystal embolization to liver, gallbladder, and pancreas. Dig Dis Sci. 1996;41(9):1819-22. http://dx.doi.org/10.1007/ BF02088752. PMid:8794801. 12. Moolenaar W, Lamers CB. Cholesterol crystal embolization and the digestive system. Scand J Gastroenterol Suppl. 1991;188(Suppl 188):69-72. http://dx.doi. org/10.3109/00365529109111232. PMid:1775943.

REFERENCES

13. Belenfant X, Meyrier A, Jacquot C. Supportive treatment improves survival in multivisceral cholesterol crystal embolism. Am J Kidney Dis. 1999;33(5):840-50. http://dx.doi.org/10.1016/S0272-6386(99)70415-4. PMid:10213638.

1. Flory CM. Arterial occlusions produced by emboli from eroded aortic atheromatous plaques. Am J Pathol. 1945;21(3):549-65. PMid:19970827.

14. Ghanem F, Vodnala D, K Kalavakunta J, et al. Cholesterol crystal embolization following plaque rupture: a systemic disease with unusual features. J Biomed Res. 2017;31(2):82-94. PMid:28808190.

2. Kassirer JP. Atheroembolic renal disease. N Engl J Med. 1969;280(15):812-8. http://dx.doi.org/10.1056/ NEJM196904102801506. PMid:4887250. 3. Eliot RS, Kanjuh VI, Edwards JE. Atheromatous embolism. Circulation. 1964;30(4):611-8. http://dx.doi. org/10.1161/01.CIR.30.4.611. PMid:14211824. 4. Saric M, Kronzon I. Aortic atherosclerosis and embolic events. Curr Cardiol Rep. 2012;14(3):342-9. http://dx.doi. org/10.1007/s11886-012-0261-2. PMid:22437371. 5. Ben-Horin S, Bardan E, Barshack I, Zaks N, Livneh A. Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism. Am J Gastroenterol. 2003;98(7):1471-9. http://dx.doi.org/10.1111/j.15720241.2003.07532.x. PMid:12873565. 6. Moolenaar W, Lamers CB. Cholesterol crystal embolization in the Netherlands. Arch Intern Med. 1996;156(6):653-7. http://dx.doi.org/10.1001/ archinte.1996.00440060081009. PMid:8629877. 7. Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. 2003;42(2):211-6. http://dx.doi.org/10.1016/S07351097(03)00579-5. PMid:12875753. 8. Fries C, Roos M, Gaspert A, et al. Atheroembolic disease: a frequently missed diagnosis: results of a 12-year matched-pair autopsy study. Medicine. 2010;89(2):12632. http://dx.doi.org/10.1097/MD.0b013e3181d5eb39. PMid:20517183. 4-5

15. Imanaka K, Kyo S, Ban S. Possible close relationship between non-occlusive mesenteric ischemia and cholesterol crystal embolism after cardiovascular surgery. Eur J Cardiothorac Surg. 2002;22(6):1032-4. http://dx.doi.org/10.1016/S1010-7940(02)00590-0. PMid:12467838. 16. Bruls S, Quaniers J, Tromme P, Lavigne JP, Van Damme H, Defraigne JO. Comparison of laparoscopic and open aortobifemoral bypass in the treatment of aortoiliac disease: results of a contemporary series (2003-2009). Acta Chir Belg. 2012;112(1):51-8. http://dx.doi.org/10. 1080/00015458.2012.11680795. PMid:22442910. 17. Yantiss RK, Cui I, Panarelli NC, Jessurun J. Idiopathic myointimal hyperplasia of mesenteric veins: an uncommon cause of ischemic colitis with distinct mucosal features. Am J Surg Pathol. 2017;41(12):1657-65. http://dx.doi. org/10.1097/PAS.0000000000000905. PMid:28817406. 18. Louie CY, DiMaio MA, Charville GW, Berry GJ, Longacre TA. Gastrointestinal Tract Vasculopathy: Clinicopathology and Description of a Possible “New Entity” With Protean Features. Am J Surg Pathol. 2018;42(7):86676. http://dx.doi.org/10.1097/PAS.0000000000001060. PMid:29624512. 19. Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol. 2000;35(3):545-54. http://dx.doi.org/10.1016/S07351097(99)00604-X. PMid:10716454. 20. Quinones A, Saric M. The cholesterol emboli syndrome in atherosclerosis. Curr Atheroscler Rep. 2013;15(4):315. http://dx.doi.org/10.1007/s11883-013-0315-y. PMid:23423524. Autops Case Rep (São Paulo). 2019;9(2):e2018082

Tian M, Matsukuma KE

Author contributions: Tian M made the figures. Matsukuma KE and Tian M wrote the manuscript and developed the discussion. All authors collectively proofread the manuscript and approved it for publication. The manuscript is in accordance with our institutional ethical research committee. Conflict of interest: None Financial support: None Submitted on: February 1st, 2019 Accepted on: March 11th, 2019 Correspondence Karen E Matsukuma Department of Pathology and Laboratory Medicine - Davis Medical Center- University of California 4400 V Street – Sacramento/CA – USA PO Box: 95817 Phone: +1 (91) 6734-2529 kmatsukuma@ucdavis.edu

Autops Case Rep (São Paulo). 2019;9(2):e2018082

5-5

Article / Clinical Case Report

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule José Cândido Caldeira Xavier-Júniora,b , Deolino João Camilo-Júniora, Sebastião Conrado-Netoc,d, Ana Cláudia Severo de Castro Lippee, Neivio José Mattara How to cite: Xavier-Júnior JCC, Camilo-Júnior DJ, Conrado-Neto S, Lippe ACSC, Mattar NJ. Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule. Autops Case Rep [Internet]. 2019;9(2):e2018083. https://doi.org/10.4322/acr.2018.083

ABSTRACT Heterotopic ossification has been described in papillary thyroid carcinoma in association with high incidence of extrathyroidal invasion, multifocality, lymph node metastasis, and older age. Nevertheless, it has not been described as a specific subtype of papillary thyroid carcinoma, because of its rarity. We described the case of an 80-year-old female patient, with familial history of papillary thyroid carcinoma. In the annual screening examination, she was diagnosed with thyroid nodules. The patient was submitted to a thyroidectomy because the fine needle aspiration cytology was positive for malignancy according to the Bethesda classification. The surgical specimen analyses showed a multifocal papillary carcinoma with one major lesion in the left lobe measuring 0.9 cm, and two small lesions (0.4 cm and 0.2 cm) in the right lobe. Only the biggest lesion in the right lobe had the osteoid matrix with rare osteoclasts and fat metaplasia with progenitor cells. There was perineural invasion, but vascular invasion was not identified. The margins were free and there was no extrathyroidal extension. In the left lobe there was an oncocytic nodule and a lipomatous follicular nodule. In recent years there has been a significant increase in the diagnosis of thyroid cancer, mainly because of the finding of microcarcinomas as a result of many requests for cervical image exams. Future studies may define (i) whether papillary thyroid carcinoma with heterotopic ossification is a true histological variant; (ii) the causes of that alteration; and (iii) eventual follow-up implications. Keywords Thyroid Gland; Thyroid Neoplasms; Ossification, Heterotopic; Carcinoma, Papillary

INTRODUCTION Over the last 20 years, there has been a significant increase in the diagnosis of thyroid cancer, mainly due to the discovery of microcarcinomas1 as a result

of excessive requests for cervical image exams. 2 Among the different subtypes of thyroid cancer, papillary thyroid carcinoma (PTC) is the most frequent.

Pathology Institute of Araçatuba. Araçatuba, SP, Brazil. Catholic Salesian Auxilium University Center (UNISALESIANO), School of Medicine. Araçatuba, SP, Brazil. c Paulista State University, Oral Oncology Center. Araçatuba, SP, Brazil. d Hospital Santa Casa de Misericórdia de Araçatuba. Araçatuba, SP, Brazil. e Tomoson. Araçatuba, SP, Brazil. a

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule

There are many variants of PTC, but PTC with intratumoral heterotopic ossification (IHO) has not been defined as a singular one.3 The main risk factor for the development of thyroid cancer is previous radiant exposure.2,3 In the latest estimate (2016) from the Brazilian Cancer National Institute (INCA – Instituto Nacional do Cancer José Alencar Gomes da Silva) approximately 7,000 new cases of thyroid cancer were expected, and it was the eighth most frequent malignant neoplasia among women.2 We describe a multifocal PTC with IHO and extramedullary hematopoiesis (EMH) associated with a lipomatous colloid nodule in a patient with multinodular goiter. We believe that collectively all these 4 findings in a single case wasn’t described in the English language, based on literature research on PUBMED using the uniterms “papillary thyroid carcinoma” and/or “heterotopic ossification” and/or “extramedullary hematopoiesis” and/or “lipomatous thyroid nodule”.

CASE REPORT An 80-year-old female patient sought medical care because she was incidentally found to have a thyroid nodule during an annual screening exam. Both of her sons had been previously been diagnosed with papillary thyroid carcinoma. The patient’s thyroid hormone levels were normal: TSH: 3.1 Um/L (0.3-4.0 mU/L); freeT4: 1.04 (0.7-1.8 ng/dL). The cervical ultrasound revealed a multinodular goiter with coarse calcification in the right lobe. In the left lobe, two well-defined nodules (one with 7.2 mm and the other with 11.9 mm), and one irregular outline lesion measuring 9.9 mm, which did not fit all the benign criteria, were found. The results of the fine needle aspiration of the irregular lesion in the left lobe revealed it to be malignant and consistent with papillary carcinoma (category VI of the Bethesda system).4 The aspiration sample provided a hypercellular smear with widely oncocytic changes. It was also identified nuclear grooves and rare pseudo nuclear inclusions (Figure 1). No colloid was present in this sample.

Figure 1. Photomicrograph of the fine needle aspiration smear. Nuclear grooves and a pseudo inclusion (arrow) (H&E, 1,000X). 2-8

Autops Case Rep (São Paulo). 2019;9(2):e2018083

Xavier-Júnior JCC, Camilo-Júnior DJ, Conrado-Neto S, Lippe ACSC, Mattar NJ

Figure 2. Photomicrograph of the surgical specimen. A – Low power view of papillary thyroid carcinoma in the left thyroid lobe (H&E,40X); B – Panoramic view of the smaller lesion in the right lobe with a papillary architecture of a microcarcinoma of PTC (H&E, 100X). Patient subsequently underwent thyroidectomy. During surgery no suspicious cervical lymph nodes were identified. At gross analyses, the surgical specimen weighed 17 g. The right lobe measured 4.3 × 2.0 × 1.5 cm, the isthmus 3.0 × 1.5 × 0.8 cm, and the left lobe 4.5 × 2.0 × 1.5 cm. There was a multifocal PTC (Figures 2 to 4) with one major lesion in the left lobe measuring 0.9 cm, and two small lesions in the right lobe measuring 0.4 cm and 0.2 cm. Only the largest lesion in the right lobe showed IHO with EMH. All lesions showed nuclear features of PTC, and a predominant follicular pattern with areas of classical subtype. The IHO was characterized by an osteoid matrix (Figure 4A) with rare osteoclasts (Figure 4B) and EMH was characterized by fat metaplasia with progenitor cells Autops Case Rep (São Paulo). 2019;9(2):e2018083

Figure 3. High magnification photomicrograph of the surgical specimen. Note the pseudo inclusion (H&E,1000X). 3-8

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule

Figure 4. Photomicrographs of the surgical specimen. A – Panoramic view of the 0.4 cm lesion in the right lobe (H&E, 40X); B – Intratumoral heterotopic ossification. Note the osteoclast (H&E, 400X); C – Progenitor bone marrow cells (H&E, 400X). 4-8

Autops Case Rep (São Paulo). 2019;9(2):e2018083

Xavier-Júnior JCC, Camilo-Júnior DJ, Conrado-Neto S, Lippe ACSC, Mattar NJ

(Figure 4C). IHO was identified in both right lobe nodules while EMH was present in only the larger (0.4 cm) nodule.

DISCUSSION

There was perineural invasion (Figure 5), but vascular invasion was absent. The margins were free of neoplasia and there was no extrathyroidal extension. In the left lobe there was a lipomatous follicular nodule (Figure 6). The lipomatous follicular nodule can be described as a non-capsulated follicular proliferation among mature adipose cells. In this setting, there was good correlation among the ultrasound and the histological analyses.

Heterotopic ossification has been described in up to 20% of papillary thyroid carcinomas 5-7 and is associated with a high incidence of extrathyroidal extension,6,7 multifocality, lymph node metastasis,7 and older age,6; however, it does not seem to influence the survival rate.5 In our case, the patient was 80 years old and the tumor was multifocal, but there was neither extrathyroidal extension nor lymph node metastasis.

The patient’s outcome was uneventful and she was referred to the nuclear medicine service because of the multifocality and the perineural invasion.

The cervical ultrasound examination lacks a pathognomonic finding of malignancy in thyroid nodules.8 The finding of coarse calcification is frequently associated with benign nodules in multinodular goiter.8

Figure 5. A, B – Photomicrograph of the surgical specimen showing the neoplastic follicles surrounding the nerves in two different areas (H&E, 200X). Autops Case Rep (São Paulo). 2019;9(2):e2018083

5-8

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule

Figure 6. Photomicrograph of the surgical specimen showing the follicular lipomatous nodule. A – H&E, 40X; B – H&E,100X. Nevertheless, our patient presented IHO with EMH in association with malignancy. Therefore, coarse calcification can be associated with IOH and EMH as described. IOH and EMH can be present in malignant and benign thyroid nodules.9,10 A possible explanation for IHO in thyroid nodules is increased bone morphogenetic proteins (BMP)—a group of proteins associated with ectopic bone formation inducing local ossification.5,9 Na et al.6 described an activin-receptor-like kinase (ALK) 1 expression associated with PTC with bone formation compared with normal thyroid tissue and PTC without bone formation. Another possible hypothesis is the role of ALK1 as a cellular receptor for BMP, inducing osteogenesis.6 6-8

Extramedullary hematopoiesis is defined by the presence of immature hematopoietic cells in sites other than bone marrow, which is extremely rare in the thyroid gland. 11 There are some theories considering EMH as a possible result of heterotopic bone formation arising in long-standing dystrophic calcifications.12 Our case is the first case describing multifocal PTC with IHO, EMH, and a follicular lipomatous nodule in a single patient. Follicular lipomatous nodule or adenolipoma is defined as by the presence of thyroid follicles intermingled with mature adipose tissue.3,12 Usually, it is an incidental finding.13 In our case, since there was no fibrous capsule, it was called a follicular nodule Autops Case Rep (São Paulo). 2019;9(2):e2018083

Xavier-Júnior JCC, Camilo-Júnior DJ, Conrado-Neto S, Lippe ACSC, Mattar NJ

with adipose metaplasia. Lipoadenomas are related to Cowden syndrome and previous radiation exposure,3 which were not present in this case. Besides that, a fat component can be found in benign and malignant thyroid lesions.12,14 The last WHO classification of endocrine tumors did not describe the PTC with IHO as a specific category,3 probably because it is a rare phenomenon without well-known prognostic significance. Since IHO and EMH are rarely described and are underestimated, future studies might define (i) if it is a true histological variant of PTC; (ii) the underlying mechanism and pathogenesis of this entity; and (iii) the management and prognostic implications.

REFERENCES 1. American Joint Committee on Cancer (AJCC). American Joint Committee on Cancer staging manual. 8th ed. Chicago: Springer; 2017. 2. Instituto Nacional do Câncer José de Alencar Gomes da Silva (INCA). Estimate/2016: cancer incidence in Brazil. Rio de Janeiro; 2015. Portuguese. 3. Lloyd RV, Osamura RY, Kloppel G, et al, editors. WHO classification of tumours of endocrine organs. 4th ed. Lyon: IARC; 2017. 4. Ali SZ, Cibas ES. The Bethesda system for thyroid cytopathology. New York: Springer; 2009. 5. Bai Y, Zhou G, Nakamura M, et al. Survival impact of psammoma body, stromal calcification and bone formation in papillary thyroid carcinoma. Mod Pathol. 2009;22(7):887-94. http://dx.doi.org/10.1038/ modpathol.2009.38. PMid:19305382. 6. Na KY, Kim HS, Lee SK, et al. Papillary thyroid carcinoma with bone formation. Pathol Res Pract. 2013;209(1):14-

8. http://dx.doi.org/10.1016/j.prp.2012.10.001. PMid:23177617. 7. Takeda M, Mikami T, Numata CY, Okamoto M, Okayasu I. Papillary thyroid carcinoma with heterotopic ossification is a special subtype with extensive progression. Am J Clin Pathol. 2013;139(5):587-98. http://dx.doi.org/10.1309/ AJCPQZQN50HKIAHA. PMid:23596110. 8. Anil G, Hegde A, Chong FH. Thyroid nodules: risk stratification for malignancy with ultrasound and guided biopsy. Cancer Imaging. 2011;11:209-23. PMid:22203727. 9. Aurora N, Hashmi I, Misra S, Aydin N. A rare presentation: a case report of osseous metaplasia and mature bone formation in a follicular adenoma of the thyroid. Int J Surg Case Rep. 2017;37:83-6. http://dx.doi.org/10.1016/j. ijscr.2017.06.031. PMid:28648877. 10. Pontikides N, Botsios D, Kariki E, Vassiliadis K, Krassas GE. Extramedullary hematopoiesis in a thyroid nodule with extensive bone metaplasia and mature bone formation. Thyroid. 2003;13(9):877-80. http://dx.doi. org/10.1089/105072503322401087. PMid:14588103. 11. Been LC, Ogden L, Traweek ST. Extramedullary hematopoiesis involving the thyroid: fine-needle aspiration features and literature review. J Am Soc Cytopathol. 2016;5(3):133-8. http://dx.doi.org/10.1016/j. jasc.2015.10.002. 12. Gnepp DR, Ogorzalek JM, Heffess CS. Fat-containing lesions of the thyroid gland. Am J Surg Pathol. 1989;13(7):60512. http://dx.doi.org/10.1097/00000478-19890700000009. PMid:2660611. 13. Kitagawa W, Kameyama K, Tamai S, et al. Adenolipoma of the thyroid gland: report of a case. Surg Today. 2004;34(7):593-6. http://dx.doi.org/10.1007/s00595004-2772-y. PMid:15221553. 14. Guarda V, Pickhard A, Boxberg M, Specht K, Buchberger AMS. Liposarcoma of the thyroid: a case report with a review of the literature. Eur Thyroid J. 2018;7(2):102-8. http://dx.doi.org/10.1159/000486333. PMid:29594062.

Author contributions: Xavier-Júnior JCC was the pathologist in charge of the histological report and wrote the manuscript. Camilo-Júnior DJ reviewed the manuscript and the pathological analysis. Conrado-Neto S was the head and neck surgeon. Lippe ACSC and Mattar NJ reviewed the manuscript. The authors retain an informed consent signed by the patient authorizing the use of data and images in this case report. Conflict of interest: None Financial support: None Submitted on: January 14th, 2019 Accepted on: March 12th, 2019

Autops Case Rep (São Paulo). 2019;9(2):e2018083

7-8

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule

Correspondence José Cândido Caldeira Xavier-Júnior Pathology Institute of Araçatuba Rua Floriano Peixoto, 808 – Vila Mendonça – Araçatuba/SP – Brazil CEP: 16015-000 Phone: +55 (18) 3623-6326 josecandidojr@yahoo.com.br

8-8

Autops Case Rep (São Paulo). 2019;9(2):e2018083

Article / Clinical Case Report

Not everything is as it seems: a rare form of metastatic breast cancer Mariana Rochaa , Daniela Azevedoa , António Teiraa , Miguel Barbosaa How to cite: Rocha M, Azevedo D, Teira A, Barbosa M. Not everything is as it seems: a rare form of metastatic breast cancer. Autops Case Rep [Internet]. 2019; 9(2):e2018085. https://doi.org/10.4322/acr.2018.085

Abstract Breast cancer is the most prevalent cancer and the leading cause of cancer-related death among females worldwide. Despite all therapeutic advances, metastatic breast cancer is still associated with a median overall survival of 3 years. Alongside this condition, bladder metastases of solid neoplasms are rarely observed. In this setting, the secondary bladder tumors with an origin in breast cancer occur in 2.5% of cases in some series. The authors report the case of a 68-year-old female with stage IV breast cancer (bone metastasis) treated with anastrozole, who presented with peripheral edema and renal failure with a creatinine clearance of 12.5 mL/min. After hospital admission, the patient was diagnosed with new liver lesions and bladder involvement with bilateral hydronephrosis. She was submitted to bilateral percutaneous nephrostomies with improvement in renal function. There was a high suspicion of primary bladder tumor in this patient who was a previous smoker, with a family history of high-grade bladder carcinoma (her mother). Liver and transurethral biopsies were performed, and histological examination was consistent with breast cancer metastases. The patient started treatment with capecitabine and denosumab, remaining clinically stable after 3 months of treatment. This case report underlines the diagnostic challenges of bladder metastases in a patient with multiple risk factors for bladder cancer and without evident clinical symptoms. Even though this is a rare entity, the close surveillance of metastatic breast cancer is important in order to allow early detection of new metastatic sites and their treatment to preserve the quality of life in these patients. Keywords: Breast Neoplasms; Hydronephrosis; Urinary Bladder Neoplasms

INTRODUCTION In 2018, worldwide, breast cancer presented an estimated age-standardized incidence and mortality of 46.3 and 13.0 per 100,000 inhabitants, respectively.1 Breast cancer is the most prevalent cancer and the leading cause of cancer-related death in females across the globe. Despite all the recent therapeutic advances, metastatic breast cancer is still associated with poor prognosis with a median overall survival of 3 years, and a 5-year survival rate of approximately 25%.2 Metastatic disease at the time of the initial diagnosis is not common in breast cancer, with an estimated prevalence of 6%.3 The different breast a

cancer subtypes have been associated with different patterns of metastatic disease. The most frequent locations of breast cancer metastatic disease are the bone, liver, and lung.4,5 In this clinical case, we present a rare form of presentation of metastatic breast cancer.

CASE REPORT A 68-year-old female patient sought the emergency room complaining of a 4-day history of back pain radiating to the flank, which she associated

Centro Hospitalar Trás-os-Montes e Alto Douro, Medical Oncology Department. Vila Real, Portugal.

Not everything is as it seems: a rare form of metastatic breast cancer

with physical effort. Her past medical history included the diagnosis of rheumatoid arthritis, congestive heart failure with preserved ventricular function, and smoking (40 pack/years). She had undergone a mammogram every 2 years integrated into the national breast cancer screening scheme. Her living brother was diagnosed with Hodgkin lymphoma, and her mother, who had high-grade bladder urothelial carcinoma, had died at the age of 86. The diagnostic work-up included a spine computed tomography (CT) scan that showed diffuse morphologic and structural changes involving the posterior bodies and arches of the sacroiliac vertebrae with lithic lesions and discrete cortical erosions consistent with metastases. The thoracic, abdominal, and pelvic CT scan showed pleural effusion plus cervical and axillary adenopathy. The pleural effusion was consistent with transudate by biochemical analysis. The histological examination of the biopsied cervical lymph node was consistent with metastasis of breast cancer with positivity for CK7, CK19, CK20, E-cadherin, and estrogen receptors, but negativity for progesterone receptors and c-ErbB2. The ultrasound and mammography failed to show the primary breast cancer lesion. The patient was started on anastrozole and denosumab, and the disease remained stable for 17 months. By that time, she had started presenting peripheral edema and asthenia, but no concomitant urinary complaints such as dysuria, hematuria, or decreased urinary output. The analytic evaluation showed renal failure with creatinine clearance of 12.5 mL/min, hypocalcemia, and elevation of the tumoral marker Ca15.3 of 93 U/mL (previously 61 U/mL; reference range <30 U/mL). The physical

examination was normal except for the presence of lower limbs edema without other significant changes. The urinary tract ultrasound showed a vesical mass with 5 × 1.5cm and signs of invasion of both orifices of the ureters with consequent bilateral hydronephrosis. She was submitted to bilateral percutaneous nephrostomies with improvement in the renal function. The pelvic CT scan revealed a 5 cm lesion in the bladder floor (making it difficult to establish a cleavage plane with the vaginal dome), and multiple hepatic nodules consistent with metastases (Figure 1). Due to the suspicion of bladder urothelial carcinoma, a liver biopsy and transurethral resection (RTU-V) of the bladder lesion were performed. During the RTU-V, both orifices of the ureters were not found due to the tumor invasion, and the lesion was partially resected. Histologic analysis of the liver biopsy was consistent with breast cancer metastasis with diffuse marking to CK7, estrogen, and progesterone receptors; and negative for CK20, CDX-2, TTF-1, c-ErbB2, and uroplakin III. Histologic analysis of the bladder biopsy showed tissue with the representation of mucosa, submucosa, and muscular tunica with neoplastic infiltration. The immunohistochemical study was characterized by the diffuse expression for CK7, estrogen receptors, and GATA3; and negative for CK20, p40 and uroplakin III, consistent with metastatic involvement of primary breast cancer (Figures 2 and 3). The patient started treatment with capecitabine and denosumab, and remains clinically stable after 3 months of treatment with a decrease of the tumoral marker Ca15.3 to 72 (previously 93).

Figure 1. Computed tomography scan. A – Infiltrative lesion of the bladder floor, making it difficult to establish a cleavage plane with the vaginal dome, and infiltrating both orifices of the ureters. B – Bilateral hydronephrosis. 2-6

Autops Case Rep (São Paulo). 2019;9(2):e2018085

Rocha M, Azevedo D, Teira A, Barbosa M

Figure 2. Photomicrographs of the biopsy specimen. A – Preserved urothelial mucosa (on the right) and mucosa involved by the neoplasm (on the left), with extensive involvement of the chorion by sheets or small nests of bulky neoplastic cells (H&E, 10X). B – Intense and diffuse expression of cytokeratin 7 by the neoplastic cell population on the left (10X). C – Intense and diffuse expression of GATA3 by the neoplastic cell population on the left (10X). D – Intense and diffuse expression of the estrogen receptors by the neoplastic cell population, and the absence of the ER expression by the residual surface urothelium (10X).

Figure 3. Immunohistochemical photomicrographs of negative staining for uroplakin III in a collection of neoplastic cells. A – Liver biopsy. B – Bladder biopsy.

DISCUSSION Occult breast cancer is extremely rare, accounting for 0.2% to 0.9% of all breast cancer cases.6,7 It presents without a detectable primary cancer lesion whether on Autops Case Rep (São Paulo). 2019;9(2):e2018085

a physical examination or an imaging examination such as ultrasound and mammograph. The initial symptoms of this entity include axillary lymph node metastasis, distant metastasis, nipple discharge, nipple dermatitis, papillary dermal edema, eczema, and skin retraction.8 3-6

Not everything is as it seems: a rare form of metastatic breast cancer

The low incidence of occult breast cancer poses a diagnostic and therapeutic challenge even with the increasing availability of investigative techniques, such as mammography, ultrasound, and magnetic resonance imaging (MRI).9,10 MRI and mammography can be used to detect non-occult breast cancer, but they are not sensitive for the diagnosis of occult breast cancer cases.11 However, immunohistochemical staining of tumor tissue using breast-cancer-specific glycoprotein monoclonal antibodies is widely used for the diagnostic and prognostic evaluation of breast cancer.12 Particularly in this case, immunohistochemistry of the cervical lymph node biopsy pointed to breast origin, except for the expression of CK20, which may be an error. However, the lymph node biopsy could not be re-evaluated because it was processed in another laboratory. Bladder secondary tumors from solid cancer are a rare entity. The retrospective study of Bates and Baithun13 revealed that secondary tumors comprised 2.3% of surgical and 20% of postmortem cases in a series comprising 6,289 bladder tumors with the estimated prevalence of bladder secondary tumors of 4.5%. Most of the cases of bladder secondary tumors had their origin in adjacent organs as a direct invasion. The most common primary sites are the female genital tract, the prostate, and the lower gastrointestinal tract. Lymphatic or hematogenous metastatic spread to the bladder from distant primary tumors does occur but is much less common. In this setting, primary tumors of the stomach, skin, and lung are the most common places of origin of these distant metastases.13 A recent systematic review conducted by Sanguedolce et al.14 reported 54 cases of breast cancer with bladder metastasis. A retrospective study with 282 cases of secondary solid bladder tumors showed a prevalence of 2.5% of breast cancer metastasis. 13 Also, the analyses by Abrams et al.15 found the incidence of 3.6% of secondary tumors of the bladder in a series of 1,000 autopsies of malignant epithelial neoplasms, and 4 cases (2.4%) of secondary bladder involvement with the origin in breast carcinoma. On the other hand, a study comprising 43 autopsies on patients with primary carcinoma of the breast did not find any case of bladder involvement.16 The metastatic involvement of the bladder may present a broad spectrum of symptoms; namely dysuria, urgency, lower abdominal or flank pain, and 4-6

gross or microscopic haematuria.17,18 Less frequently, patients may be asymptomatic. The acute renal failure due to ureteral obstruction with hydronephrosis is a rare complication due to metastatic breast cancer.19,20 Winston et al. 21 conducted a retrospective review of 57 CT scans of patients with metastatic lobular breast cancer and identified 6 patients (11%) with hydronephrosis as a complication caused by inﬁltration of the retroperitoneum. In this specific case, the patient presented with peripheral edema and asthenia, secondary to renal failure due to hydronephrosis caused by a vesical mass. Further study showed hepatic nodules as well. Both the vesical mass and a hepatic nodule were biopsied, and both biopsies were consistent with the diagnosis of breast cancer metastasis, as was evident in the immunohistochemical analysis: CK7, estrogen, and progesterone receptors; and negative for CK20, CDX-2, TTF-1, c-ErbB2, and uroplakin III for the hepatic biopsy and diffuse expression for CK7, estrogen receptors, and GATA3; and negative for CK20, p40, and uroplakin III for the vesical biopsy. The absence of simultaneous staining for CK7 and CK20, which is typical in 65% cases of urothelial carcinomas, positive staining for estrogen receptors and negative staining for uroplakin III confirmed the diagnosis of liver and bladder metastasis of breast cancer. The treatment of metastatic breast cancer may comprise a combination of chemotherapy and hormonal treatment depending on the intrinsic characteristics of the tumor and its clinical features. The transurethral resection of the lesion may improve symptomatology and allow catheterization of the ureters. However, in some cases, percutaneous nephrostomy is needed, as it was in our case report. Radiotherapy has its role as a hemostatic measure and as a local disease control. The patients with bladder metastases usually have other metastatic sites and tend to have a poor prognosis.22 Our case exemplifies a rare form of metastatic breast cancer. The presence of risk factors, such as smoking tobacco, a family history of bladder cancer along with a failure of imaging study, and a lack of clinical symptoms, challenged the diagnosis of our case. It is essential for clinicians to be aware of urinary symptoms in breast cancer patients, as well as the early recognition of disease progression, and the necessity of rapid institution of measures to preserve the quality of life in these patients. Autops Case Rep (São Paulo). 2019;9(2):e2018085

Rocha M, Azevedo D, Teira A, Barbosa M

REFERENCES 1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. http://dx.doi.org/10.3322/caac.21492. PMid:30207593. 2. Cardoso F, Spence D, Mertz S, et al. Global analysis of advanced/metastatic breast cancer: Decade report (2005-2015). Breast. 2018;39:131-8. http://dx.doi. org/10.1016/j.breast.2018.03.002. PMid:29679849. 3. Khodari W, Sedrati A, Naisse I, Bosc R, Belkacemi Y. Impact of loco-regional treatment on metastatic breast cancer outcome: a review. Crit Rev Oncol Hematol. 2013;87(1):69-79. http://dx.doi.org/10.1016/j. critrevonc.2012.12.005. PMid:23369750. 4. Gerratana L, Fanotto V, Bonotto M, et al. Pattern of metastasis and outcome in patients with breast cancer. Clin Exp Metastasis. 2015;32(2):125-33. http://dx.doi. org/10.1007/s10585-015-9697-2. PMid:25630269.

12. Montagna E, Bagnardi V, Rotmensz N, et al. Immunohistochemically defined subtypes and outcome in occult breast carcinoma with axillary presentation. Breast Cancer Res Treat. 2011;129(3):867-75. http://dx.doi. org/10.1007/s10549-011-1697-6. PMid:21822638. 13. Bates AW, Baithun SI. Secondary neoplasms of the bladder are histological mimics of nontransitional cell primary tumours: clinicopathological and histological features of 282 cases. Histopathology. 2000;36(1):32-40. http://dx.doi.org/10.1046/j.1365-2559.2000.00797.x. PMid:10632749. 14. Sanguedolce F, Landriscina M, Ambrosi A, et al. Bladder metastases from breast cancer: managing the unexpected. a systematic review. Urol Int. 2018;101(2):125-31. http:// dx.doi.org/10.1159/000481576. PMid:29055945. 15. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer. 1950;3(1):74-85. http://dx.doi.org/10.1002/10970142(1950)3:1<74::AID-CNCR2820030111>3.0.CO;2-7. PMid:15405683.

5. Redig AJ, McAllister SS. Breast cancer as a systemic disease: a view of metastasis. J Intern Med. 2013;274(2):113-26. http://dx.doi.org/10.1111/joim.12084. PMid:23844915.

16. Saphir O, Parker ML. Metastasis of primary carcinoma of the breast. With special reference to spleen, adrenal glands and ovaries. Arch Surg. 1941;42(6):1003-18. http:// dx.doi.org/10.1001/archsurg.1941.01210120038004.

6. Baron PL, Moore MP, Kinne DW, Candela FC, Osborne MP, Petrek JA. Occult breast cancer presenting with axillary metastases. Updated management. Arch Surg. 1990;125(2):210-4. http://dx.doi.org/10.1001/ archsurg.1990.01410140088014. PMid:2302061.

17. Schneidau T, Stroumbakis N, Choudhury M, Eshgi M, Mallouh C. Metastatic breast cancer to the bladder: a case report. Int Urol Nephrol. 1995;27(3):297-300. http:// dx.doi.org/10.1007/BF02564765. PMid:7591593.

7. He M, Liu H, Jiang Y. A case report of male occult breast cancer first manifesting as axillary lymph node metastasis with part of metastatic mucinous carcinoma. Medicine. 2015;94(25):e1038. http://dx.doi.org/10.1097/ MD.0000000000001038. PMid:26107674. 8. Ahmed I, Dharmarajan K, Tiersten A, et al. A unique presentation of occult primary breast cancer with a review of the literature. Case Rep Oncol Med. 2015;2015:102963. http://dx.doi.org/10.1155/2015/102963. PMid:25866689. 9. Abbruzzese JL, Abbruzzese MC, Lenzi R, Hess KR, Raber MN. Analysis of a diagnostic strategy for patients with suspected tumors of unknown origin. J Clin Oncol. 1995;13(8):2094-103. http://dx.doi.org/10.1200/ JCO.1995.13.8.2094. PMid:7636553. 10. Galimberti V, Bassani G, Monti S, et al. Clinical experience with axillary presentation breast cancer. Breast Cancer Res Treat. 2004;88(1):43-7. http://dx.doi.org/10.1007/ s10549-004-9453-9. PMid:15538044. 11. Ping S, Ming WH, Bin SH, et al. Comparison of clinical characteristics between occult and non-occult breast cancer. J BUON. 2014;19(3):662-6. PMid:25261649. Autops Case Rep (São Paulo). 2019;9(2):e2018085

18. Berger Y, Nissenblatt M, Salwitz J, Lega B. Bladder involvement in metastatic breast carcinoma. J Urol. 1992;147(1):137-9. http://dx.doi.org/10.1016/S00225347(17)37161-6. PMid:1729507. 19. Vulcano E, Montesano M, Battista C, et al. Urinary complications from breast cancer metastasis: case report and review of the literature. G Chir. 2010;31(5):243-5. PMid:20615369. 20. Modi PR, Rizvi J, Shah KG. Breast carcinoma metastasizing to the urinary bladder and retroperitoneum presenting as acute renal failure. Indian J Urol. 2011;27(1):1356. http://dx.doi.org/10.4103/0970-1591.78421. PMid:21716877. 21. Winston CB, Hadar O, Teitcher JB, et al. Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT. AJR Am J Roentgenol. 2000;175(3):795-800. http://dx.doi.org/10.2214/ ajr.175.3.1750795. PMid:10954469. 22. Xiao GQ, Chow J, Unger PD. Metastatic tumors to the urinary bladder: clinicopathologic study of 11 cases. Int J Surg Pathol. 2012;20(4):342-8. http://dx.doi. org/10.1177/1066896911428736. PMid:22134629. 5-6

Not everything is as it seems: a rare form of metastatic breast cancer

Author contributions: Rocha M drafted the manuscript. Azevedo D, Teira A, and Barbosa M reviewed the manuscript. All authors collectively proofread and approved the manuscript’s final version to be published. The authors retain an informed consent signed by the patient, and the manuscript is in accordance with the Institutional Ethics Committee. Conflict of interest: None Financial support: None Submitted on: December 11th, 2018 Accepted on: March 16th, 2019 Correspondence Mariana Rocha Centro Hospitalar Trás-os-Montes e Alto Douro - Medical Oncology Department Avenida Noruega Lordelo – Vila Real – Portugal CP: 5000-508 m_rocha_s@hotmail.com

6-6

Autops Case Rep (São Paulo). 2019;9(2):e2018085

Article / Clinical Case Report

Bilateral mandibular buccal bifurcation cyst: a case report emphasizing the role of imaging examination in the diagnosis Cristhian Reynaldo Gomez Bautistaa , Noala Vicensoto Moreira Milhana , Milagros Del Valle El Abras Ankhaa , Renata Falchete do Pradoa , Ana Sueli Rodrigues Cavalcantea , Sergio Lúcio Pereira de Castro Lopesb , Ana Lia Anbindera  How to cite: Bautista CRG, Milhan NVM, Ankha MVA et al. Bilateral mandibular buccal bifurcation cyst: a case report emphasizing the role of imaging examination in the diagnosis. Autops Case Rep [Internet]. 2019;9(2):e2018073. https://doi. org/10.4322/acr.2018.073

ABSTRACT A mandibular buccal bifurcation cyst is an inflammatory cyst that usually occurs on the buccal aspect of the permanent mandibular first molar of children. This lesion is diagnosed by an association of radiographic, clinical, and histological features. We report a bilateral case of mandibular buccal bifurcation cyst and discuss the main findings of this entity. A 7-year-old girl presented pain and delayed dental eruption in the posterior mandibular region. A cone beam computed tomography was performed and revealed hypodense lesions involving the crown and root of the mandibular first molars, with expansion of the buccal cortical and lingual tilting of the molar roots. A biopsy was carried out, and the common features of an inflammatory odontogenic cyst were histologically observed. The final diagnosis was bilateral mandibular buccal bifurcation cyst. Clinicians need to be aware of this diagnostic possibility in cases of mandibular cysts in children— especially when bilateral—to perform the correct treatment, which should not involve the extraction of the affected tooth. Keywords Cysts; Jaw Cysts; Odontogenic Cysts.

INTRODUCTION Mandibular buccal bifurcation cyst (MBBC) is an inflammatory odontogenic cyst that develops on the buccal aspect of the first or second permanent mandibular molar of children.1 Stoneman and Worth described MBBC 36 years ago as a “mandibular

infected buccal cyst.” 2 Since then, this lesion has also been described as juvenile paradental cyst, 3 mandibular buccal bifurcation cyst,1,4 inflammatory lateral periodontal cyst,5 and inflammatory paradental cyst.6

São Paulo State University (UNESP), Institute of Science and Technology, Department of Biosciences and Oral Diagnosis. São José dos Campos, SP, Brazil. b São Paulo State University (UNESP), Institute of Science and Technology, Department of Diagnosis and Surgery. São José dos Campos, SP, Brazil. a

Bilateral mandibular buccal bifurcation cyst: a case report emphasizing the role of imaging examination in the diagnosis

The World Health Organization classifies MBBC and paradental cyst as inflammatory collateral cysts.1 Both originate from inflammation in pericoronal tissue and seem to present the same etiology. However, a criterion has been used to distinguish each cyst: the paradental cyst is observed in the lower third molars, while the MBBC occurs in the buccal aspect of the mandibular first and second molars.1,7 In spite of this, many cases of MBBC are found in the literature with the nomenclature of paradental cyst.6 MBBC is commonly misinterpreted due to the variety of names for the same lesion and the histological or clinical similarities with other entities. The aims of this paper are to report a well-documented case of a MBBC and discuss the main clinical, histological, and image findings of this lesion, in order to make clinicians aware of the most common features and treatments for this entity.

CASE REPORT A 7-year-old female patient presented with pain and delayed mandibular molar eruption. Clinically, right and left mandibular buccal swelling of about 2–3 cm in diameter was observed. The local mucosa was more whitish than the surrounding one. The left first molar was not clinically erupted, while partial

eruption of the right first molar was evident. Both regions were resistant to palpation. Cone beam computed tomography (CBCT) was requested to establish the vestibular-lingual extension of the lesion, the relationship with the teeth, and the lamina dura maintenance. The images showed hypodense lesions involving the crowns and roots of the first mandibular molars. Basilar cortical resorption of the mandible was present on the right side. The evident expansion of the buccal cortical bone and the tilting of the molar roots toward the lingual cortex were observed (Figures 1 and 2). These findings, as well as the relationship of the lesion with adjacent structures, were also analyzed in a three-dimensional volume rendering reconstruction (Figure 3). With the hypothesis of an odontogenic cyst, an excisional biopsy of the right side and ulectomy of the left side were performed. The histological analysis revealed cystic lesions partially lined by non-keratinized stratified epithelium, predominantly presenting a few layers of cells. Epithelial hyperplasia, exocytosis, and spongiosis were observed in some areas. The cyst wall, especially of the right side, had intense chronic subepithelial inflammation, which was mainly composed of lymphocytes and plasma cells (Figure 4). Based on the clinical, microscopic, radiographic, and CBCT images, the diagnosis was bilateral MBBC.

Figure 1. A – Axial view, demonstrating: (a) expansion and thinning of the buccal cortical bone of the posterior mandibular regions caused by the hypodense cystic lesions; (b) displacement of the permanent mandibular first molars to lingual side, with tilting of their coronary portions toward the buccal direction and of their apexes toward the lingual plate; L = left side. B – Coronal view showing the same findings described previously: (a) bulging of the buccal cortex; and (b) roots tilted toward the lingual cortex. 2-7

Autops Case Rep (São Paulo). 2019;9(2):e2018073

Bautista CRG, Milhan NVM, Ankha MVA et al.

Figure 2. A – Central panoramic view in which a hypodense lesion may be observed bilaterally in the regions of permanent mandibular first molars. B and C – Transverse view of the right and left sides, respectively, in which buccal expansion of the cortical bone as well as the tilting of the teeth may be seen.

Figure 3. Three-dimensional reconstructions in bone protocol of the right (A) and left (B) mandibular regions, emphasizing the findings and the relation of the lesion to the adjacent structures. Autops Case Rep (São Paulo). 2019;9(2):e2018073

3-7

Bilateral mandibular buccal bifurcation cyst: a case report emphasizing the role of imaging examination in the diagnosis

Figure 4. Photomicrograph of the lesion showing non-keratinized stratified epithelium with few layers of cells, exocytosis, and spongiosis covering the cyst wall that presented moderate chronic inflammation mainly composed of lymphocytes and plasma cells (H&E).

DISCUSSION The etiology of MBBC is not clear, but it has been suggested that the cystic epithelium may arise from reduced enamel epithelium, cell rests of Malassez, remnants of the dental lamina or crevicular epithelium.6 Some authors discarded the Malassez remnants origin once MBBC is not equally distributed around the root surface.8 Besides the origin of the cystic epithelium, the reason for the inflammatory process has also been discussed. The inflammation may be induced by food impaction in an opening pericoronal pocket (pericoronitis). The obstruction causes fluid accumulation within the blocked pocket, which leads to cystic expansion by osmosis.9 Additionally, enamel projection into the furcation area of the tooth has been mentioned as an MBBC predisposing factor.10,11 Ramos et al. 12 reviewed the English language literature and found 16 manuscripts describing cases of MBBC, with a total of 56 cysts. In fact, the real epidemiology of MBBC is very difficult to evaluate, since different names are used for the same entity; 4-7

for example, cases of inflammatory collateral cysts in the first or second molars have also been described as paradental cysts.13-15 Besides the variety of names, MBBC shares histological, clinical, and image features with other lesions.7 The similar appearance of many cysts may lead to an incorrect diagnosis and inappropriate treatment. The careful analysis of imaging exams is an important aid in the recognition and distinction of cystic lesions. Although cysts usually present as well-defined radiolucent/hypodense lesions, different lesions may exhibit peculiar imaging features. MBBC presents as a U-shaped radiolucent lesion that overlaps the roots. The space of the periodontal ligament and lamina dura remains unchanged. Tilted apexes toward the lingual cortical bone, the prominence of lingual cusps (due to inclination), an intact lower border of the mandible, expansion of the buccal cortical bone, a periosteal reaction, and displacement of adjacent non-erupted teeth also have been commonly observed.1,4,16 Considering all these image features, the achievement of a three‑dimensional analysis—as in the present case—is an important tool. Autops Case Rep (São Paulo). 2019;9(2):e2018073

Bautista CRG, Milhan NVM, Ankha MVA et al.

Clinically, MBBC usually presents an increase in the probing depth on the buccal gingiva. Other features, such as pain, swelling, and localized abscess, also may be seen. The clinical and radiographic characteristics of the present case are consistent with the previously published literature.16,17

analyzed 44 MBBC, of which 6 were associated with non‑erupted teeth. In 25% of the cases, a second subclinical contralateral MBBC was observed in the radiographic examination and confirmed at the time of surgery. Thus, when there is a hypothesis of MBBC, the clinicians must carefully evaluate the contralateral side.

Histologically, MBBC is lined by non-keratinized stratified epithelium with a fibrous cyst wall presenting intense chronic inflammation. 6,7,12,18,19 However, the diagnosis of this cyst cannot be ascertained only with the histopathological characteristics, if they are not specific. These features are common to all inflammatory cysts, which is a fact that strongly emphasizes the importance of the correct imaging interpretation.6,7

The treatment of MBBC has changed significantly over the years. Initially, it was treated with enucleation and extraction of the involved tooth.2,23 Currently, the treatment of choice has been enucleation without the extraction of the involved tooth. Recently, Levarek et al.24 successfully used a bone graft as an adjuvant treatment after the enucleation and curettage of the cyst. Conservative treatment characterized by daily irrigation of the buccal pocket with a saline solution until the complete resolution of the lesion was reported,16 as well as cases of self-resolution.16,18,25 The potential self-resolving nature of MBBC has been suggested as this lesion is not observed in adults or in the maxilla.17 A previous study conjectured that periodontal probing may induce a small opening in the cyst, causing a condition of “micromarsupialization,” which permits depressurizing and cyst healing.16

The dentigerous cyst, the lateral radicular cyst, and the periodontal pocket have been mentioned as possible differential diagnoses of MBBC.7 The circumferential dentigerous cyst, which is characterized by the complete circumscription of the tooth, 20 may be a differential diagnosis of MBBC.12 The cemento‑enamel junction connects the cyst to the tooth, and it may occur in the first or second molars,21 as MBBC, interfering with their eruption. Moreover, the histologic exam of a dentigerous cyst may show the presence of inflammation, hyperplasia, and leukocyte exocytosis,7,22 similar to that observed in MBBC. In these cases, computed tomography may be an important aid, because through the different sections it is possible to observe the buccal expansion and the lingual tilting of the apexes, which are typical features of the MBBC. A lateral radicular cyst is an inflammatory radicular lesion that shares histological features with other inflammatory cysts, including MBBC. However, a lateral radicular cyst is associated with a non-vital tooth, and a simple pulp vitality test may discard this hypothesis. A “paradental cyst” mimicking a periodontal pocket was described by Pelka et al.14 in a tooth showing a probing depth of 15 mm on the buccal aspect. However, this probing depth is not expected in a recently erupted molar of a child.14 In this kind of situation, the hypotheses of MBBC should be considered. Bilateral cases of MBBC, as in this report, have been observed less frequently than unilateral cases.6,12 It is important to emphasize that in the current report, one cyst was related to a non-erupted tooth. In a retrospective study, Pompura et al. 17 Autops Case Rep (São Paulo). 2019;9(2):e2018073

In summary, the diagnosis of MBBC should be ascertained based on the correlation of clinical, imaging, and histopathological exams. Clinicians must recognize this entity and be aware of this diagnostic possibility in lesions occurring in the mandibular molars (especially bilateral) of children. The CBCT aspects were very useful in this case due to the vestibular and lingual inclinations of the teeth.

REFERENCES 1. El-Naggar AK, Chan JKC, Grandis JR, Takata T, Slootweg PJ. WHO classification of head and neck tumours. 4th ed. Lyon: IARC; 2017. p. 232-33: Odontogenic cysts of inflammatory origin. English. 2. Stoneman DW, Worth HM. The mandibular infected buccal cyst--molar area. Dent Radiogr Photogr. 1983;56(1):1-14. PMid:6574040. 3. Borgonovo AE, Rigaldo F, Censi R, Conti G, Re D. Large buccal bifurcation cyst in a child: a case report and literature review. Eur J Paediatr Dent. 2014;15(2, Suppl):237-40. PMid:25101512. 4. Shear M, Speight P. Cyst of the oral and maxillofacial regions. 4th ed. Oxford: Sheffield; 2007. p. 143-49: Inflammatory paradental cysts. English. http://dx.doi. org/10.1002/9780470759769. 5-7

Bilateral mandibular buccal bifurcation cyst: a case report emphasizing the role of imaging examination in the diagnosis

5. Main DM. Epithelial jaw cysts: 10 years of the WHO classification. J Oral Pathol. 1985;14(1):1-7. http:// dx.doi.org/10.1111/j.1600-0714.1985.tb00459.x. PMid:3918149. 6. Philipsen HP, Reichart PA, Ogawa I, Suei Y, Takata T. The inflammatory paradental cyst: a critical review of 342 cases from a literature survey, including 17 new cases from the author’s files. J Oral Pathol Med. 2004;33(3):147-55. http://dx.doi.org/10.1111/j.09042512.2004.00139.x. PMid:15128056. 7. Chrcanovic BR, Reis BM, Freire-Maia B. Paradental (mandibular inflammatory buccal) cyst. Head Neck Pathol. 2011;5(2):159-64. http://dx.doi.org/10.1007/s12105010-0233-z. PMid:21161456. 8. Ackermann G, Cohen MA, Altini M. The paradental cyst: a clinicopathologic study of 50 cases. Oral Surg Oral Med Oral Pathol. 1987;64(3):308-12. http://dx.doi. org/10.1016/0030-4220(87)90010-7. PMid:3477747. 9. Colgan CM, Henry J, Napier SS, Cowan CG. Paradental cysts: a role for food impaction in the pathogenesis? A review of cases from Northern Ireland. Br J Oral Maxillofac Surg. 2002;40(2):163-8. http://dx.doi.org/10.1054/ bjom.2001.0750. PMid:12180213. 10. Craig GT. The paradental cyst. A specific inflammatory odontogenic cyst. Br Dent J. 1976;141(1):9-14. http:// dx.doi.org/10.1038/sj.bdj.4803781. PMid:1065342. 11. Fowler CB, Brannon RB. The paradental cyst: a clinicopathologic study of six new cases and review of the literature. J Oral Maxillofac Surg. 1989;47(3):2438. http://dx.doi.org/10.1016/0278-2391(89)90226-7. PMid:2646404. 12. Ramos LM, Vargas PA, Coletta RD, Almeida OP, Lopes MA. Bilateral buccal bifurcation cyst: case report and literature review. Head Neck Pathol. 2012;6(4):4559. http://dx.doi.org/10.1007/s12105-012-0342-y. PMid:22392410.

15. Naclério-Homem MG, Deboni MCZ, Simões WA, Traina AA, Chin V. Paradental cyst: case report and review of the literature. J Clin Pediatr Dent. 2004;29(1):83-6. http://dx.doi.org/10.17796/jcpd.29.1.j7ul1jw240x08335. PMid:15554410. 16. David LA, Sandor GK, Stoneman DW. The buccal bifurcation cyst: in non-surgical treatment an option? J Can Dent Assoc. 1998;64(10):712-6. PMid:9854359. 17. Pompura JR, Sandor GK, Stoneman DW. The buccal bifurcation cyst: a prospective study of treatment outcomes in 44 sites. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(2):215-21. http://dx.doi. org/10.1016/S1079-2104(97)90008-1. PMid:9117753. 18. Zadik Y, Yitschaky O, Neuman T, Nitzan DW. On the self-resolution nature of the buccal bifurcation cyst. J Oral Maxillofac Surg. 2011;69(7):e282-4. http://dx.doi. org/10.1016/j.joms.2011.02.124. PMid:21571416. 19. Fabbri A, Grossi GB, Borgonovo AE, Speroni S. Paradental cyst of the first molar: a report of two cases. J Indian Soc Pedod Prev Dent. 2010;28(2):116-20. http://dx.doi. org/10.4103/0970-4388.66753. PMid:20660980. 20. Thoma KH. The circumferential dentigerous cyst. Oral Surg Oral Med Oral Pathol. 1964;18(3):368-71. http://dx.doi. org/10.1016/0030-4220(64)90090-8. PMid:14178914. 21. Shibata Y, Asaumi J, Yanagi Y, et al. Radiographic examination of dentigerous cysts in the transitional dentition. Dentomaxillofac Radiol. 2004;33(1):1720. http://dx.doi.org/10.1259/dmfr/24148363. PMid:15140817. 22. Huang G, Moore L, Logan RM, Gue S. Histological analysis of 41 dentigerous cysts in a paediatric population. J Oral Pathol Med. 2019;48(1):74-8. http://dx.doi.org/10.1111/ jop.12776. PMid:30175860. 23. Fantasia JE. Lateral periodontal cyst. An analysis of forty-six cases. Oral Surg Oral Med Oral Pathol. 1979;48(3):23743. http://dx.doi.org/10.1016/0030-4220(79)90010-0. PMid:289928.

13. Lacaita MG, Capodiferro S, Favia G, Santarelli A, Muzio LL. Infected paradental cysts in children: a clinicopathological study of 15 cases. Br J Oral Maxillofac Surg. 2006;44(2):112-5. http://dx.doi.org/10.1016/j. bjoms.2005.03.011. PMid:16203063.

24. Levarek RE, Wiltz MJ, Kelsch RD, Kraut RA. Surgical management of the buccal bifurcation cyst: bone grafting as a treatment adjunct to enucleation and curettage. J Oral Maxillofac Surg. 2014;72(10):1966-73. http://dx.doi. org/10.1016/j.joms.2014.04.028. PMid:25234530.

14. Pelka M, van Waes H. Paradental cyst mimicking a periodontal pocket: case report of a conservative treatment approach. Int J Oral Maxillofac Surg. 2010;39(5):5146. http://dx.doi.org/10.1016/j.ijom.2009.11.005. PMid:20005075.

25. Corona-Rodriguez J, Torres-Labardini R, Velasco-Tizcareño M, Mora-Rincones O. Bilateral buccal bifurcation cyst: case report and literature review. J Oral Maxillofac Surg. 2011;69(6):1694-6. http://dx.doi.org/10.1016/j. joms.2010.07.030. PMid:21211889.

Authors’ contributions: Bautista CRG and Milhan NVM wrote the manuscript. Ankha MVA and Cavalcante ASR performed the surgical procedure. Lopes SLPC performed and interpreted the imaging examination. Prado RF and Anbinder AL performed the histopathological examination. All authors proofread and approved the manuscript for publication. 6-7

Autops Case Rep (São Paulo). 2019;9(2):e2018073

Bautista CRG, Milhan NVM, Ankha MVA et al.

The authors retain an informed consent signed by the patient’s mother authorizing the publication of the clinical data and images. The manuscript is in accordance with the Institutional Ethics Committee. Conflict of Interest: None Financial Support: Bautista CRG and Ankha MVA received a scholarship financed by CAPES – Coordination for the Improvement of Higher Education Personnel. Submitted on: December 5th, 2018 Approved on: January 31st, 2019 Correspondence Ana Lia Anbinder Av. Engenheiro Francisco José Longo, 777 – São José dos Campos/SP – Brazil CEP: 12245-000 Phone: +55 (12) 3947-9358 ana.anbinder@unesp.br

Autops Case Rep (São Paulo). 2019;9(2):e2018073

7-7

Article / Clinical Case Report

Monostotic craniofacial fibrous dysplasia: report of two cases with interesting histology Vikram Singha , Kirti Guptaa , Pravin Salunkeb  How to cite: Singh V, Gupta K, Salunke P. Monostotic craniofacial fibrous dysplasia: report of two cases with interesting histology. 2019;9(2):e2018092. https://doi.org/10.4322/acr.2018.092

ABSTRACT Fibrous dysplasia (FD) is a relatively rare osseous disease of unknown etiology, wherein the normal bone is replaced by collagen-rich tissue, comprising of fibroblasts and variably abundant immature woven bone. Clinically, it may involve a single bone or multiple bones. It commonly arises in the jaw bone, skull, rib, and proximal femur. Those arising in the skull and the jaw are together termed “craniofacial fibrous dysplasia.” The differential diagnosis at this location includes meningioma and metastatic carcinoma. In this report, we highlight two diagnostically challenging cases presenting with orbital swelling and headache as the main complaints. Our first case was misinterpreted as meningioma on intraoperative squash smear, and paraffin sections revealed characteristic features of FD. The second case highlights the morphological feature of non-specific cystic degeneration occurring in FD. Radiographs in such cases show cystic swelling, which is indicative of a secondary aneurysmal bone cyst. Keywords: Fibrous Dysplasia, Monostotic; Meningioma; Bone Cysts, Aneurysmal.

INTRODUCTION Fibrous dysplasia (FD) is a benign intramedullary fibro-osseous lesion, which is regarded as a bone developmental anomaly characterized by replacement of normal bone and its marrow by variably abundant immature woven bone. 1,2 Clinically, it may involve single bone (monostotic disease) or multiple bones (polyostotic disease).3 It commonly arises in the jaw bone, skull, rib, and proximal femur. Those arising in the skull and jaw are together termed “craniofacial fibrous dysplasia.”3 The associated clinical symptoms depend upon the affected bone or bones.4

In this report, we highlight the two diagnostically challenging cases presenting with orbital swelling and the history of headache. Our first case was misinterpreted as meningioma on intraoperative squash smear and paraffin sections revealed characteristic features of FD. The second case highlights the rare morphological feature of cystic degeneration occurring in FD. Radiographs in such case show cystic swelling, which is indicative of a secondary aneurysmal bone cyst.5 Cortical destruction with soft tissue extension is usually indicative of malignant transformation and thus needs a thorough histological assessment.6

Postgraduate Institute of Medical Education and Research (PGIMER), Departments of Histopathology. Chandigarh, India. Postgraduate Institute of Medical Education and Research (PGIMER), Departments of Neurosurgery. Chandigarh, India.

Monostotic craniofacial fibrous dysplasia: report of two cases with interesting histology

CASE REPORT Case #1 A 35-year-old female presented with left fronto-orbital swelling of 10 years’ duration. She had progressive deterioration of vision in the left eye for 1.5 years, and could barely perceive hand movements close to face. The proptosis increased over the last month. The left eye was displaced inferiorly and medially. No endocrine abnormalities were detected. Radiology revealed a lesion involving the orbital roof, the frontal bone, and the sphenoid wing (Figures 1A and 1B). The patient was operated on through a twin-piece craniotomy. Intraoperatively, the lesion was found to be of variable consistency with fibrous, fleshy, and cystic areas. The morphological features at the time of the intraoperative frozen section suggested a meningioma (Figures 2A and 2B). However, the paraffin sections revealed a cellular lesion characterized by sheets of fibroblastic cells on a low magnification, which closely resembled a meningioma (Figure 2C). Intimately admixed within these fibroblast-rich islands were small trabeculae of irregularly shaped immature woven bone devoid of osteoblastic riming, which were noted on a higher magnification (Figure 2D). The central portion in some of these small trabeculae revealed calcification

that mimicked psammoma bodies of meningioma, which perhaps are a diagnostic pitfall. Mitosis was extremely rare. Postoperatively the patient improved cosmetically, and her vision improved marginally. The histological features are characteristic as encountered in craniofacial FD.

Case #2 A 16-year-old male presented with a history of headache and swelling over the right supraorbital region of 25 days’ duration. There was no history of diplopia, nystagmus, or blurred vision. On examination, there was a fixed, non-tender, hard, bony bulge present over the right supraorbital region. Computed tomography showed a bony expansion and the presence of multiloculated cystic swelling in the orbital part of the right frontal bone, suggestive of an aneurysmal bone cyst (Figures 3A and 3B). With the working diagnosis of a right supra-orbital aneurysmal bone cyst, a right fronto temporoparietal craniotomy with right orbital roof and lateral wall removal were performed. Sections examined from the excised part of the frontal bone showed a normal cortical bone at the periphery, while a lesional tissue was identified in the center (Figure 4A). This center lesion revealed numerous irregular-shaped trabeculae of immature woven bone without osteoblastic rimming (Figures 4B and 4C). Large areas of cystic degeneration were also identified (Figure 4D).

Figure 1. Radiological findings of case #1. A – Brain axial magnetic resonance image after injection of medium contrast showing heterogeneous enhancing of an orbital mass displacing the globe anteriorly and inferolaterally; B – Axial brain computed tomography image showing expansive lytic bony lesion involving the superior and lateral walls of the orbit. 2-6

Autops Case Rep (São Paulo). 2019; 9(2):e2018092

Singh V, Gupta K, Salunke P

Figure 2. Photomicrographs of the surgical specimen. A – Intra-operative squash smear demonstrating trabeculae of woven bone resembling psammoma bodies of meningioma (H&E; 20X); B – Frozen section demonstrating fibroblastic islands with interspersed trabeculae of woven bone interpreted as meningioma; C – Low magnification depicting fibroblast-rich islands interrupted by osseous tissue closely mimicking meningioma (H&E; 10X); D – Irregularly shaped trabeculae of woven bone constituting the osseous element on high magnification. Calcification is seen within some of the trabeculae (arrow) resembling psammoma bodies of meningioma (H&E; 40X).

Figure 3. Radiological findings of case study #2. A – Brain axial computed tomography image showing a bony expansion of the right greater wing of the sphenoid and lateral wall of orbit; B – Post gadolinium magnetic resonance imaging showing expansion of the orbital roof and lateral wall with a lesion partially enhanced after the contrast injection, expanding into the orbital cavity and the sub-frontal region. R: right; F: Front. Autops Case Rep (São Paulo). 2019; 9(2):e2018092

3-6

Monostotic craniofacial fibrous dysplasia: report of two cases with interesting histology

Figure 4. Photomicrograph showing histological findings of case study #2. A – Scanner view magnification showing three distinct areas within the lesion (H&E; 2X); B – Irregularly shaped trabeculae of woven bone constituting the osseous element (H&E; 20X); C – Bone trabeculae are devoid of osteoblastic rimming, on high magnification (H&E; 40X); D – Large areas of cystic degeneration are evident (H&E; 20X).

There were no features to suggest an aneurysmal bone cyst, such as blood-filled cystic spaces separated by a spindle cell and multinucleated giant cells. Based on the histomorphological features, diagnosis of fibrous dysplasia with secondary cystic change was made. Postoperatively, the patient presented a cosmetic improvement and has been symptom-free for the year following surgery.

DISCUSSION FD is a developmental tumor-like condition and still remains as a clinicopathologic challenge for many reasons. This is because it may present with clinical and radiographic features that border with other benign fibro-osseous lesions of the skeleton, and occasionally it may be confused with certain elusive types of malignancies.7 4-6

The radiological presence of cortical destruction is a harbinger of malignant transformation in patients with FD. This is particularly noted in patients with craniognathic disease who undergo radiotherapy of the affected area. Osteosarcoma accounts for more than half of all the malignant neoplasms in FD, followed by fibrosarcoma and chondrosarcoma, secondary angiosarcomas, and a malignant fibrous histiocytoma.8,9 Secondary cystic degeneration within FD rarely occurs, and is radiologically interpreted as a secondary aneurysmal bone cyst.5 Intraosseous sphenoid wing meningioma can closely mimic FD both clinically and radiologically.10 The microscopy at a low magnification closely mimics a meningioma and is easy to misdiagnose; however, the characteristic features of meningioma—such as a whorling pattern, a syncytial arrangement, and bland nuclear features—are typically absent. The Autops Case Rep (São Paulo). 2019; 9(2):e2018092

Singh V, Gupta K, Salunke P

key morphological features of FD include trabeculae of immature woven bone without osteoblastic rimming, which sometimes closely mimics whorls and psammoma bodies of meningioma.10 The metastatic carcinoma is another close differential at this site. However, the epithelial nature of neoplastic cells encountered in a metastatic carcinoma is the distinguishing factor. Non-epithelial-lined cysts occasionally occur in association with various benign and malignant bone lesions; including FD, giant cell tumor, chondroblastoma, ossifying fibroma, benign osteoblastoma, cemento-osseous dysplasia, and osteosarcoma. These cysts vary in nature; some are aneurysmal bone cysts, while others include simple bone cysts or non-specific cystic degenerations. Non-specific cystic degeneration within FD have been occasionally described in earlier reports.11 In the second case study, FD with non-specific cystic degeneration presented as a rapidly growing scalp mass and mimicked an aneurysmal bone cyst on radiology. Complete surgical resection is recommended for patients with rapidly expanding FD or with lesions that encroach on the orbit as noticed in case study #1. The growth of FD often tends to stabilize, and occasionally stops when skeletal maturity is attained; hence, surgical intervention in children and adolescents with more extensive lesions should be delayed as long as possible. Radiation therapy is contraindicated owing to the increased risk of malignant transformation. Long-term clinical and radiographic follow-up is recommended in patients with FD.12

CONCLUSION FD presenting as fronto-orbital swelling requires careful evaluation by an experienced team of clinicians, radiologists, and pathologists to ensure that it is not overtreated as a malignancy, or misdiagnosed as an aneurysmal bone cyst or meningioma.

REFERENCES 1. Waldron CA, Giansanti JS. Benign fibro-osseous lesions of the jaws: a clinical-radiologic-histologic review of sixtyfive cases. II. Benign fibro-osseous lesions of periodontal Autops Case Rep (São Paulo). 2019; 9(2):e2018092

ligament origin. Oral Surg Oral Med Oral Pathol. 1973;35(3):340-50. http://dx.doi.org/10.1016/00304220(73)90072-8. PMid:4510606. 2. Waldron CA, Giansanti JS, Browand BC. Sclerotic cemental masses of the jaws (so-called chronic sclerosing osteomyelitis, sclerosing osteitis, multiple enostosis, and gigantiformcementoma. Oral Surg Oral Med Oral Pathol. 1975;39(4):590-604. http://dx.doi.org/10.1016/00304220(75)90201-7. PMid:1054467. 3. Alawi F. benign fibro-osseous diseases of the maxillofacial bones. a review and differential diagnosis. Am J Clin Pathol. 2002;118(1, Suppl):S50-70. PMid:14569813. 4. Feller L, Wood NH, Khammissa RA, Lemmer J, Raubenheimer EJ. The nature of fibrous dysplasia. Head Face Med. 2009;5(1):22-7. http://dx.doi. org/10.1186/1746-160X-5-22. PMid:19895712. 5. Lee HS, Koh YC, Roh HG, Park HK, Kim SY. Secondary aneurysmal bone cyst in a craniofacial fibrous dysplasia: case report. Brain Tumor Res Treat. 2018;6(2):8691. http://dx.doi.org/10.14791/btrt.2018.6.e15. PMid:30381923. 6. Muthusamy S, Subhawong T, Conway SA, Temple HT. Locally aggressive fibrous dysplasia mimicking malignancy: a report of four cases and review of the literature. Clin Orthop Relat Res. 2015;473(2):742-50. http://dx.doi. org/10.1007/s11999-014-3926-x. PMid:25212962. 7. Ippolito E, Bray EW, Corsi A, et al. Natural history and treatment of fibrous dysplasia of bone: a multicenter clinicopathologic study promoted by the European Pediatric Orthopaedic Society. J Pediatr Orthop B. 2003;12(3):155-77. PMid:12703030. 8. Doganavsargil B, Argin M, Kececi B, Sezak M, Sanli UA, Oztop F. Secondary osteosarcoma arising in fibrous dysplasia, case report. Arch Orthop Trauma Surg. 2009;129(4):439-44. http://dx.doi.org/10.1007/s00402008-0669-8. PMid:18560851. 9. DeMers Riddle NM, Yamauchi H, Caracciolo JT, et al. Chondrosarcoma arising in fibrous dysplasia: a case report and review of the current literature. Pathol Lab Med Int. 2009;1:1-6. http://dx.doi.org/10.2147/PLMI.S5930. 10. Shaftel SS, Alameddine RM, Oh SR, et al. Intraosseous meningioma masquerading as fibrous dysplasia. Diagn Pathol: Open Access. 2016;1(1):104. 11. Nadaf A, Radhika M, Paremala K, Srinath N. Monostostic fibrous dysplasia with nonspecific cystic degeneration: a case report and review of literature. J Oral Maxillofac Pathol. 2013;17(2):274-80. http://dx.doi.org/10.4103/0973029X.119765. PMid:24250093. 12. Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg. 1993;51(8):828-35. http://dx.doi. org/10.1016/S0278-2391(10)80097-7. PMid:8336219. 5-6

Monostotic craniofacial fibrous dysplasia: report of two cases with interesting histology

Author contributions: Singh V and Gupta K were the pathologists that conceptualized and prepared the manuscript. Salunke P was the treating surgeon. All authors collectively proofread the manuscript and approved it for publication. The authors retain an informed consent signed by the patients and the manuscript is approved by the Institutional Ethics Committee. Conflict of interest: None Financial support: None Submitted on: January 26th, 2019 Accepted on: March 31st, 2019 Correspondence Kirti Gupta Department of Histopathology - Postgraduate Institute of Medical Education and Research (PGIMER) Sector 12, Chandigarh, India CEP: 160012 Phone: +91 (172) 2755105 / Fax: 0172-2744401 kirtigupta10@yahoo.co.in

6-6

Autops Case Rep (SĂŁo Paulo). 2019; ďťż9(2):e2018092