Gerlinde Averous

Solid Pseudopapillary Pancreatic Tumor Mimicking a Neuroendocrine Neoplasm on 18F-FDOPA PET/CT

Department of Biophysics and Nuclear Medicine (A.I., I.J.N.), Hautepierre University Hospital, 67098 Strasbourg, France; University of Strasbourg (A.I., I.J.N.), Centre National de la Recherche Scientifique, ICUBE, Unite Mixte de Recherche 7357, 67412 Strasbourg, France; and Departments of Visceral Surgery and Transplantation (P.A., P.B.) and Pathology (G.A.), Hautepierre University Hospital, 67098 Strasbourg, France

Images in SurgeryPancreatic hamartoma

A 61-YEAR-OLD WOMAN was referred to our center for a 24-mm lesion of the pancreatic body. Her past medical history was significant for schizophrenia, hypothyroidism, and breast cancer treated by surgery and adjuvant radiochemotherapy. The pancreatic lesion was incidentally detected by total body computed tomography performed during the periodic follow-up after breast cancer. The physical examination was unremarkable, and her standard blood tests were within normal limits. In particular, her carcinoembryonic antigen, carbohydrate antigen 19-9, 125, and 15-3, chromogranin A, C peptide, and insulin levels were normal. Computed tomography found a relatively well-defined lesion of the pancreatic body with enhancement in the delayed phase without distant metastases. Abdominal magnetic resonance imaging demonstrated a 26-mm lesion showing a heterogeneous and progressive enhancement in the delayed phase (Fig 1). The Wirsung duct was compressed by the tumor and dilated in the distal part of the gland. An endoscopic ultrasound-guided fine needle aspiration revealed fibrotic and hemorrhagic material. The presence of a previous history of malignancy and the radiologic appearance of the lesion indicated operative intervention. A robotic distal pancreatectomy with a splenectomy was performed. The patient recovered uneventfully. At pathology, the firm, solid, encapsulated lesion (27 3 23 3 21 mm) was composed of a disorganized exocrine pancreatic tissue embedded in fibroinflammatory stroma (Fig 2).

Long-term storage and safe retrieval of human papillomavirus DNA using FTA elute cards.

Biobanking or collection and storage of specimens for future research purposes have become an essential tool in many fields of biomedical research and aims to provide a better understanding of disease mechanisms as well as the identification of disease-specific biomarkers that can navigate in complex diseases. In this study, we assessed the use of Flinders Technology Associates (FTA) cards as a long-term storage device for cervical specimens with suspected human papillomavirus (HPV) infections. HPV detection and genotyping results in liquid-based transport media were compared to HPV results from FTA cards. The overall agreement for the presence of any HPV infection between liquid-based medium and FTA cards stored for 1 year at ambient temperature was 100%. Reproducibility analysis of HPV detection and genotyping from FTA cards demonstrated that FTA cards are a reliable medium to store and preserve viral nucleic acids. Biobanking of cervical cells on FTA cards may provide a key resource for epidemiological and retrospective HPV studies.

Unknown Multifocal Ileal Carcinoid Revealed by 18F-FDOPA PET/CT

Department of Biophysics and Nuclear Medicine (A.I., F.H., I.-J.N.), Hautepierre Hospital, University Hospitals of Strasbourg, 67098 Strasbourg, France; ICube (A.I., I.-J.N.), Unite Mixte de Recherche 7357, University of Strasbourg/Centre National de la Recherche Scientifique, and Federation de Medecine Translationnelle de Strasbourg, Faculty of Medicine, 67000 Strasbourg, France; and Departments of Pathology (G.A., J.-P.B.) and Digestive and General Surgery (N.C.-N., E.T., C.B.), Hautepierre Hospital, University Hospitals of Strasbourg, 67098 Strasbourg, France

Successful response to pegylated interferon alpha in a patient with recurrent paraganglioma

Pheochromocytoma (PHEO) and extra-adrenal paraganglioma (PGL) are neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla and the autonomic nervous system, respectively. These neoplasms are malignant in approximately 20% of cases (malignant PHEO and PGL and MPPs) (Baudin et al. 2014). Prospective trials are ongoing including the FIRSTMAPPP (First International Randomized Study in Malignant Progressive Pheochromocytoma and Paraganglioma) trial. Here, we describe a patient with recurrent PGL who showed significant response (based on anatomical and functional imaging) to one year of medical treatment with pegylated interferon alpha. The patient, a 52-year-old male, had a history of isolated, secreting, left retroperitoneal PGL located in the lateroaortic region, close to the renal pedicle. In 2005, the patient had undergone a surgical resection that led to complete removal of a well-delineated, partially hemorrhagic tumor (60 × 50 × 30 mm) with no evidence of necrosis. Histopathology revealed clustered oval or fusiform acidophilic cells with variable shapes and nuclear sizes. There was no evidence of lymphatic or vascular invasion. On immunohistochemistry, cells were negative for the keratin antigen KL1 and positive for the epithelial membrane antigen, vimentin, synaptophysin and chromogranin. The mitotic index was <2 mitotic figures per 10 high-power fields (HPF) and the percentage of Ki67-positive cells was 13.5%. The Pheochromocytoma of the Adrenal Gland Scale Score (PASS) was unavailable. Three months after surgery, both plasma and urinary normetanephrine (NMN) concentrations were within the reference range. No abnormal findings were evident on 2-deoxy-2[fluorine-18]fluoro-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT). The screening for germline mutations in SDHB/C/D and VHL genes was negative. The patient was asymptomatic, and biochemical monitoring yielded negative results until 2013, when the patient experienced symptom recurrence associated with an increase of urinary NMN. FDG PET/CT revealed a hypermetabolic uptake located close to the left renal pedicle with no evidence of systemic spread. The patient underwent surgery, and the pathological examination revealed the presence of two tumoral masses (50 × 40 × 20 mm and 17 × 13 × 19 mm in size) that exhibited tumor necrosis, lymphovascular invasion, extracapsular spread and peritumoral adipose tissue invasion. The presence of a poorly differentiated PGL was suspected, and microscopic resection was considered incomplete (R1). Immunostaining revealed that cells were positive for chromogranin expression. The mitotic index was 3 mitoses per 10 HPF, and the percentage of Ki67-positive cells was 15%. The PASS score was 8. Three months after surgery, urinary NMN were again in the reference range. Because of the aggressive biological features of tumor recurrence, the screening for germline mutations was extended to other PGL susceptibility genes (i.e. MAX, FH and SDHAF2). Again, the results were negative. Immunohistochemical studies conducted on tumor samples obtained in 2005 and 2013 were positive for SDHA and SDHB and negative for SDHD expression, suggesting that the succinate dehydrogenase (SDH) enzymatic complex inactivation was unlikely in both tumor tissues. Histology and immunohistochemistry did not reveal an important T and/or B cells infiltrate. Finally, immunohistochemistry for HIF1-alpha yielded negative results. After approximately one year, the patient became symptomatic again and laboratory tests showed significantly increased urinary NMN concentrations. Contrast-enhanced CT identified an isolated 17-mm lesion in close contact with the surgical clips of the left renal pedicle (suggestive of local relapse). FDG PET/CT confirmed the pathological nature of that nodule and allowed the detection of two additional hypermetabolic lesions suggestive of metastases, in the left lumbar

Adrenal Metastasis of a Poorly Differentiated Adenocarcinoma Mimicking a Pheochromocytoma on 18F-FDOPA PET/CT.

We report the surprising intense uptake of F-FDOPA in a right adrenal metastasis of a poorly differentiated metastatic adenocarcinoma of unknown primary mimicking a pheochromocytoma in a hemodialyzed patient with the typical Menards triad and increased serum catecholamines. Our observation emphasizes that F-FDOPA is not a specific radiotracer for pheochromocytoma and paraganglioma investigation, although it is currently and successfully used in this clinical setting. Moreover, we underline that kidney failure may be responsible for abnormally high serum catecholamines values even in subjects without pheochromocytoma, leading to erroneous diagnostic conclusions particularly in patients with adrenal masses.

Real case of primitive embryonal duodenal carcinoma in a young man

We report here the case of a young man suffering from a rare germ cell tumour. The patient was a 25-year-old man who was referred to our centre for asthenia, stinging epigastric pain, and an iron deficiency anaemia. Gastroscopy revealed a circumferential vegetating lesion on the second portion of the duodenum. The lesion was indurated at the third portion of the duodenum, responsible for a tight stenosis. A computerized tomography-scan of the chest, abdomen and pelvis, and a pancreatic MRI showed a circumferential lesion with a bi-ductal dilatation (i.e., of the common bile duct and Wirsung’s duct) without metastatic localisation. The patient underwent a pancreaticoduodenectomy with lymph node dissection including all cellular adipose tissues of the hepatic pedicle from the hepatic common artery and of the retroportal lamina. Histological findings were suggestive of a duodenal embryonal carcinoma with pancreatic infiltration. This is the second published case highlighting the duodenal primitive localisation of an embryonal carcinoma with pancreatic infiltration.

Prognostic value of venous invasion in resected T3 pancreatic adenocarcinoma: Depth of invasion matters

Background. Incomplete evaluation of venous invasion has led to conflicting results regarding the prognosis of patients undergoing pancreatectomy with a synchronous venous resection. This study evaluates the prognostic value associated with the presence and the depth of venous invasion in T3 pancreatic adenocarcinoma. Methods. This study evaluated retrospectively 181 consecutive pancreatoduodenectomies performed for T3N0M0 and T3N1M0 pancreatic adenocarcinomas (stages IIA and IIB) from January 2006 to December 2014. Univariate and multivariate Cox analyses were performed to assess survival prognostic factors. Results. Pancreatoduodenectomies with a segmental venous resection was performed on 91 patients, while 90 other patients had a standard pancreatoduodenectomies without venous resection. Pathologic venous invasion was detected in 68 (74%) of the 91 venous resection patients. Depth of venous invasion was into the adventitia (n = 25), media (n = 28), and intima (n = 15). The overall survival rates at 1, 3, 5, and 10 years were 75%, 33%, 21%, and 6%, respectively. There were no differences in survival between patients undergoing standard pancreatoduodenectomies and pancreatoduodenectomies with venous resection (27 vs 22 months; P = .28) or between patients with and without venous invasion (20 vs 27 months; P = .08). In multivariate analysis, depth of venous invasion into the intima (hazard ratio, 2.25; 95% confidence interval, 1.16–4.34; P = .0001) and adjuvant chemotherapy (hazard ratio, 0.16; 95% confidence interval, 0.09–0.43; P ≤ .0001) were identified as independent prognostic factors of overall survival. Conclusion. Depth of venous invasion into the intima indicates poor survival in pancreatic T3 adenocarcinoma. Preoperative identification of this factor could be helpful for better selection of patients for curative operation.

Endometrioid Carcinoma of the Ovary

Ovarian epithelial tumor is a complex disease involving several subgroups. Ovarian endometrioid carcinoma (OEC) ranks second in terms of incidence, occurs in perimenopausal women and is generally diagnosed at early stage. Low grade carcinoma arises from endometriotic cysts, with an early loss of ARID1A. PTEN and KRAS mutations are also frequent in low grade ECO, although there is no data supporting the involvement of NRAS. Conversely, high grade OEC is associated with atypical endometriosis and is characterized by genetic instability and TP53 and CCNE mutations.

Reporting reactive cellular changes on smears among women who undergo cervical cancer screening: results of a cohort study after seven years of follow-up

OBJECTIVE To identify whether women presenting with reactive cellular changes (RCC) on their cervical smear face an increased risk for developing high grade cervical intraepithelial neoplasia (CIN2-3) or cancer as compared with women with an entirely normal smear. STUDY DESIGN French data from the association in charge of organized cervical cancer screening in Bas-Rhin administrative region were used to establish a cohort of 96,215 women presenting with a smear classified as entirely normal or with RCC during the year 2001. The Kaplan-Meyer method was used to calculate the probabilities of CIN2-3 and cancer at seven years of follow-up. Univariate and multivariate survival analyses were performed using Cox proportional hazard models. RESULTS Among the 95,559 women included in the final analysis, 32.2% presented a smear with RCC. After seven years of follow-up, 441 women developed a CIN2-3 and 35 a cancer. Probability of CIN2-3 was increased in the RCC group as compared with the group of women with a normal smear (0.7% versus 0.5%, p=0.002). Multivariate analyses showed that, compared with a normal cervical smear, RCC were associated with a significant 37% increased risk of CIN2-3 (HR=1.37 CI95 [1.13-1.66]). However, the risk of cancer was not significantly increased (HR=1.11 CI95 [0.55-2.23]). CONCLUSION This study showed that, at seven years, women with RCC on their cervical smear face an increased risk of CIN2-3 but no significant increased risk of cancer. The distinction between entirely normal and RCC cervical smears should therefore not lead to specific clinical management.