Decidualization of intranodal endometriosis in a postmenopausal woman

Here we describe an unusual case of decidualized endometriosis detected in pelvic lymph nodes. The presence of intranodal ectopic decidua in pregnant women has been described. A few cases of decidualization of endometriotic foci in the pelvic or para-aortic lymph nodes have also been associated with pregnancy. However, decidualized intranodal endometriosis occurring in a postmenopausal woman has not been described. A 52-year-old woman presented with a very large adnexal mass. Menopause occurred at the age of 47, and she had been treated with hormone replacement therapy. She received a total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and para-aortic lymphadenectomy for clear cell carcinoma of the right ovary. Histological examination revealed the presence of ectopic decidua in several pelvic lymph nodes. The deciduas consisted of sheets of loosely cohesive, large, uniform, round cells with abundant eosinophilic cytoplasm. Typical of decidualization of intranodal endometriosis, a few irregularly shaped, inactive endometrial glands lined by single layers of columnar to cuboidal epithelium were present within the decidua. An immunohistochemical study revealed that the decidual cells were positive for CD10, vimentin, estrogen receptor and progesterone receptor, which indicated that progestin-induced decidualization had occurred in the intranodal endometriotic stroma. To the best of our knowledge, this case represents the first report of decidualized intranodal endometriosis occurring in association with hormone replacement therapy in a postmenopausal woman. Misdiagnosis of this condition as a metastatic tumor can be avoided by an awareness of these benign inclusions, supported by immunohistochemical staining results.     

Analysis of clinical outcomes of patients with adenoid cystic carcinoma of Bartholin glands

Adenoid cystic carcinoma of Bartholin glands (BG-ACC) is a rare, slow-growing but a highly aggressive tumor with remarkable capacity for local recurrence and distant metastasis. The purpose of this study was to elucidate our experiences of the diagnosis and treatment of BG-ACC and to analyze the clinical outcomes and prognosis of patients with BG-ACC. A retrospective chart review was performed to assess the demographic information, chief complaints, pathologic features of tumors, primary treatment, and development of local recurrence or distant metastasis, as well as the patient outcome. All patients received surgical excision as the primary treatment, and the diagnosis of BG-ACC was confirmed histopathologically. Three of four patients whose tumors showed pathologic features indicating a high probability of recurrence received adjuvant radiotherapy. These patients did not develop local recurrence, in contrast, one patient who did not receive adjuvant radiotherapy developed local recurrence and distant metastasis on several occasions. All patients who received primary surgical treatment are alive to date. When patients who are more than 40 years of age and who present with symptomatic BG lesions, BG-ACC should be included in the differential diagnosis and biopsy should be performed for histopathologic confirmation. Radical local excision with sufficient negative margins seems to be beneficial for primary treatment. Adjuvant radiotherapy is a reasonable treatment option for patients with high risk factors after surgery or for patients who develop local recurrence.     

Primary ovarian carcinoid tumor showing unusual histology and nuclear accumulation of β-catenin

Carcinoid tumor of the ovary is uncommon. We herein report a very rare case of primary ovarian carcinoid tumor with aggressive histology and an unusual immunophenotype. A 21-year-old woman presented with a palpable abdominal mass. Computed tomographic scan revealed a large, extensively necrotic solid mass in the left ovary. The patient underwent a left salpingo-oophorectomy. Grossly, the left adnexa showed a large, vaguely lobulated ovarian tumor measuring 22×15×13 cm. Histologically, the tumor had a readily identifiable neuroendocrine growth pattern, but some areas showed solid growth pattern associated with mild nuclear pleomorphism and multiple foci of punctate necrosis. Furthermore, mitotic figures were recognized in 8 per 10 high-power fields, and a few foci of large coagulative tumor necrosis were also noted. In addition, the tumor tissue exhibited uniform, strong nuclear β-catenin immunoreactivity, indicating the nuclear accumulation of β-catenin in the individual tumor cells. In summary, we described the first case of primary ovarian carcinoid tumor with loss of neuroendocrine growth pattern, increased mitotic activity and large areas of coagulative tumor necrosis. According to the WHO classification of pulmonary carcinoid tumor, this case may be classified as “atypical” carcinoid. However, currently, no primary ovarian atypical carcinoid exists in the classification system. Due to its rarity, there are no established diagnostic criteria and clinical data on patient outcomes for ovarian carcinoid tumors with aggressive histology. Additional reports are clearly necessary. We also showed for the first time the nuclear accumulation of β-catenin in carcinoid tumor cells, suggestive of a role for β-catenin in the tumorigenesis of ovarian atypical carcinoid tumor or its aggressive histology.     

SOX11 and TP53 add prognostic information to MIPI in a homogenously treated cohort of mantle cell lymphoma – a Nordic Lymphoma Group study

Mantle cell lymphoma (MCL) is an aggressive B cell lymphoma, where survival has been remarkably improved by use of protocols including high dose cytarabine, rituximab and autologous stem cell transplantation, such as the Nordic MCL2/3 protocols. In 2008, a MCL international prognostic index (MIPI) was created to enable stratification of the clinical diverse MCL patients into three risk groups. So far, use of the MIPI in clinical routine has been limited, as it has been shown that it inadequately separates low and intermediate risk group patients. To improve outcome and minimize treatment‐related morbidity, additional parameters need to be evaluated to enable risk‐adapted treatment selection. We have investigated the individual prognostic role of the MIPI and molecular markers including SOX11, TP53 (p53), MKI67 (Ki‐67) and CCND1 (cyclin D1). Furthermore, we explored the possibility of creating an improved prognostic tool by combining the MIPI with information on molecular markers. SOX11 was shown to significantly add prognostic information to the MIPI, but in multivariate analysis TP53 was the only significant independent molecular marker. Based on these findings, we propose that TP53 and SOX11 should routinely be assessed and that a combined TP53/MIPI score may be used to guide treatment decisions.     

The Impact of Stressor Patterns on Clinical Features in Patients With Tako‐tsubo Cardiomyopathy: Experiences of Two Tertiary Cardiovascular Centers

Background:

Tako‐tsubo cardiomyopathy (TTC) is typically triggered by an acute emotional or physical stress event. The aim of this study was to investigate the impact of stressor patterns on clinical features, laboratory parameters, and electrocardiographic and echocardiographic findings in patients with TTC.

Hypothesis:

Clinical features are different according to stressor patterns.

Methods:

Of 137 patients enrolled from the TTC registry database, 14 patients had emotional triggers (E group), 96 had physical triggers (P group), and 27 had no triggers (N group).

Results:

Most clinical presentations and in‐hospital courses were similar among the groups. However, the E group had a higher prevalence of chest pain (P = 0.006) and palpitation (P = 0.006), whereas the P group had a higher prevalence of cardiogenic shock (P = 0.040), than other groups. The P group had a significantly higher heart rate (P = 0.001); higher high‐sensitivity C‐reactive protein (P = 0.006), creatine kinase MB fraction (P = 0.045), and N terminal‐probrain natriuretic peptide (P = 0.036) levels; higher left ventricular end‐diastolic pressure (P = 0.019) and left ventricular end‐systolic diameter (P = 0.002); but lower left ventricular ejection fraction (P = 0.018). The E group had lesser prevalence of apical ballooning pattern (P = 0.038) than other groups. The P group required more frequent use of inotropics (P = 0.041) and diuretics (P = 0.047) and had significantly longer intensive care unit (P = 0.014) and in‐hospital stays (P = 0.001).

Conclusions:

The clinical features of TTC are different according to preceding stressor patterns. The TTC group with preceding physical stressors was less likely to have preserved cardiovascular reserve and more likely to require hemodynamic support than other groups. The overall prognosis of TTC is excellent, regardless of triggering stressors. Clin. Cardiol. 2011 DOI: 10.1002/clc.22053 The authors have no funding, financial relationships, or conflicts of interest to disclose.