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Ring-Enhancing Lesions• Metastases• Abscess, including pyogenic abscess and abscess caused by at
ypical organisms, such as bacterial pathogens (Mycobacteria, Nocardia, Actinomyces, Rhodococcus, and Listeria); fungal pathogens (zygomycosis, Histoplasma, Coccidioides, Aspergillus, and Cryptococcus); and parasitic pathogens (neurocystircercosis, Echinococcus, and Entamoeba)
• Glioma and other primary CNS neoplasms (eg, lymphoma)• Infarction• Contusion• Demyelination (multiple sclerosis, acute disseminated enceph
alomyelitis)• Resolving hematoma/radionecrosis
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MRI Findings of Cryptococcus
• Dilated Virchow-Robin Space• Hydrocephalus• Miliary leptomeningeal or parenchymal enhanc
ing nodules• Faint leptomeningeal enhancement• Pseudocyst• Cryptococcoma
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2009/11/2 2009/11/20
2010/1/182009/12/18
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PASPAS
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Pathological Diagnosis
• Brain, cerebrum, midbrain and right basal ganglion, stereotactic biopsy, cryptococcosis, HIV-associated
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Cryptococcal Meningoencephalitis
• Most common fungal infection of the central nervous system
• 6% to 8% of AIDS patients
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Pathology of Cryptococcal Meningoencephalitis:Analysis of 27 Patients with Pathogenetic Implications
Lee SC et al, Hum Pathol 1996; 27:839-47.• A pathological analysis in 27 patients in autopsy file at the Albert Eins
tein College of Medicine in New York, from 1966 to 1994
• 13 cases of HIV-associated, male predominance
• Most often in the basal ganglia, midbrain, and superficial cerebral cortex
• Mixed perivascular and parenchymal distribution
• Intracerebral collections of cryptococcal yeasts produced macroscopic “soap-bubble lesion”
• In HIV-associated patients, not associated with a significant inflammatory response
• Large cryptococcomas with numerous organisms were common in HIV-associated patients
• Prominent (or exclusive) encephalitic in AIDS patients
• In some cases, multiple ring-enhancing lesions on radiographs simulating toxoplasmosis
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Immune Reconstitution Syndrome
• Immune reconstitution after HAART in HIV-infected patients may cause undesirable effects, the so-called paradoxical reaction
• As a result of restored immunity, HIV-infected patients receiving HAART may experience atypical clinical manifestations of cryptococcosis, as well as other opportunistic disorders
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Immune Reconstitution Syndrome- Pathogenesis
1. An inflammatory reaction that unmasks active infection,
such as mycobacteria, cytomegalovirus, or cryptococcus
– Unclear pathogenesis
– Increase in the specific lymphocyte response against microbial antigens
2. A paradoxical reaction to latent antigens of inactive
infectious agents. The pathogens are supposed to be dead
or replicate at a very low level .
– Opportunistic agent can not be identified by cultures, but only revealed on special histological specimen
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Immune Reconstitution Cryptococcosis
• HAART era: significant clinical and laboratory changes of HIV-related cryptococcosis• Rapid immune recovery following HAART: varied presentations of AIDS-related opportunism• A retrospective cohort analysis of 84 patients with AIDS-related cryptococcal meningitis: 18 out of 59 (30.5%) patients who started HAART following treatment developed IRIS• Risk factors for the development of IRIS following cryptococcal infection: Early initiation of antiretroviral therapy Fungemia A low initial CD4 count
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Case 2
• Name: 陳 XX• Age: 52 years old• Gender: Female• Chart Number: 03449864• G2P2, NSD• Menopause without hormone therapy (HT)
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Clinical Course 1/8
• Irregular vaginal spotting that had lasted for 2 months on July 1, 2005
• Pelvic examination: a cul-de-sac induration was noted
• Transvaginal ultrasonography revealed a normal uterus and adnexa
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Uterus-sagittal view
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Uterus-transverse view
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• Histological analysis of the cervical biopsy suggested adenomyomatous polyp suspected originate from prior endometriosis
• She was referred for pelvic MRI examination• Focal bulging space taking lesion at posterior lip
of lower body of uterus and extended to cervix, with slightly heterogeneous enhancement
Clinical Course 3/8
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Clinical Course 4/8
• Pelvic examination revealed vaginal recurrent adenomatous polyp, r/o sarcoma on June 1, 2007
• Transvaginal ultrasonography revealed two small cervical mass
• Pelvic MRI was arranged again and showed soft tissue at posterior aspect of lower uterus and cervix with slightly heterogeneous enhancement
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Uterus-sagittal view
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Uterus-transverse view
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Ultrasound Findings
Uterus: Position: AVF
size: 56.8 x 37.1 x 40.6 mm
endometrium: thickness 3.6 mm
two small masses were seen in the cervix on scan
mass: (1) 17.5 x 15.5 mm
(2) 16.7 x 10.9 mm
Blood Flow:
S/D: 2.56; RI: 0.61; PI: 1.06
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Clinical Course 5/8
• Vaginal polypoid excision was performed• Pathology report revealed adenofibroma
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Clinical Course 6/8
• 3rd pelvic MRI was performed• R/O endometriosis or true mass lesion with subs
erosa is located at uterus,cervix or vagina• Laparotomy was performed under the impressio
n of persistent recurrent adenofibroma
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Clinical Course 7/8
• During operation, a normal-sized uterus with severe pelvic adhesion were found, then total hysterectomy with bilateral salpingoophorectomy was performed
• A well-defined protruding whitish nodule around 4 x 3 cm. at the posterior lip of cervix
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Clinical Course 7/8
• 4th pelvic MRI was performed due to vaginal polypoid tumor recurrent
• Soft tissue mass about 3.3x3.8x4.5cm from residues vagina stump, compatible with recurrent adenofibroma
Adenosarcoma- Diagnostic Criteria - Clement and Scully
1. characteristic relationship between the sarcomatous component and at least some of the glands, with formation of periglandular cuffs and intraglandular protrusions of cellular stroma2. noninvasive glands lined by benign-appearing mullerian epithelia of various types showing mild to marked nuclear atypia3. an average of >=2 mitosis/10 HPF in the stromal component4. more than mild nuclear atypia of the stromal cells
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Mullerian AdenosarcomaA Clinicopathologic and Immunohistochemical Study
of 55 Cases- Challenging the Existence of adenofibroma Gallardo A et al, Am J Surg Pathol 2009; 33:278-88
• Local recurrence of typical adenofibromas with myometrial and vascular invasion has been described
• Forty-eight uterine tumors (37 of the corpus and 11 of the cervix), 4 ovarian tumors, and 1 each tumors of the vagina, fallopian tube, and peritoneum in this series
– ? whether or not adenofibroma exists as a tumor entity
• No evidence that there exist histopathologic criteria that will reliably distinguish adenofibroma from adenosarcoma
• Some tumors currently classified as adenofibromas, on the basis of their low mitotic count and lack of significant nuclear atypia, are, in fact, well-differentiated adenosarcomas
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Mullerian adenosarcoma of vagina arising in persistent endometriosis: Report of a case and
review of the literature Liu L et al, Gynecol Oncol 2003; 90:486-90
• There are only two prior case reports in the English literature of a primary mullerian adenosarcoma arising in vaginal endometriosis
• Persistent extrauterine endometriosis even after surgical and hormonal treatment may undergo malignant transformation of the stroma into an adenosarcoma
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Pathological Diagnosis
• Recurrent adeofibroma, cervicovaginal region, with sarcomatous transformation
• ? Adenosarcoma– Low-grade sarcoma – High recurrence rate: 25-40%– Recurrence sites: typically in pelvis or vagina– Distant metastasis: 5%