Purpose To summarize the clinical pathological and immunohistochemical characteristics of esophage-al carcinoma with ductal differentiation of esophageal gland,and analyze the somatic mutation characteristics,key driv-ing mutation genes,and significantly mutated genes based on whole exome sequencing.Methods The clinicopatho-logical features of 9 cases of esophageal carcinoma with esophageal duct differentiation were retrospectively analyzed,and the immunohistochemistry EnVision two-step method was used to stain them,and 3 of the samples were subjected to whole exome sequencing and data analysis.Results Among the 9 patients,6 were males and 3 were females.The average age was 68.3 years old(61-80 years old).All 9 cases were located in the middle-lower segment of the e-sophagus.The diameter of the lesion was from 1.5 cm to 3.5 cm.Most areas of the tumor had a double-layer epithelial structure,including the inner layer of luminal epithelium and the outer layer of basal epithelium.Focal areas could be seen with keratinization and mucinous cells.Immunohistochemistry showed that CK7 was positive in the inner epitheli-um,while p63 was positive in the outer basal epithelium.S-100,SOX10 and c-myb were all negative,and p53 was mutated(diffuse strongly positive).The results of whole exome sequencing analysis showed somatic mutation character-istics(796 SNV,37 InDel,482 CNV),key driving mutation genes(12),and significantly mutated genes(TP53).No intraepithelial neoplasia was observed on the surface squamous epithelium of all cases,and no Barrett's esophagus or ectopic gastric mucosa was observed.The average follow-up time was 21.9 months(8 days-51 months),with 8 ca-ses surviving and 1 case dying of severe pulmonary infection 8 days after surgery.Conclusion Esophageal carcinoma with ductal differentiation of esophageal gland is a rare epithelial derived malignant tumor of the esophagus,character-ized by unique morphological,immunohistochemical,and molecular changes.

Objective:To investigate the clinicopathological and molecular genetic characteristics of intracranial mesenchymal tumors with FET::CREB fusion transcript.Methods:The clinical and imaging data of 6 cases of intracranial mesenchymal tumors with FET::CREB fusion from December 2018 to December 2023 were collected at the First Affiliated Hospital of Zhengzhou University. Their histological features, immunophenotype and molecular characteristics were analyzed.Results:Among the 6 patients, 4 were males and 2 were females, and the median age was 20 years. The clinical symptoms were increased intracranial pressure in 5 cases and epilepsy in 1 case. The lesion sites were cerebellum (2 cases), frontal lobe (2 cases), parietal lobe (1 case), and cranioorbital communication (1 case). The radiological features mainly showed solid or cystic components, with obvious annular enhancement on MRI. The histopathological features showed a wide spectrum of morphology, clear boundaries and fibrous pseudocapsule. The tumor cells were arranged in a lamellar or nodular pattern, and some in cord or loose network. The tumor cells were spindle, oval, epithelioid or stellate. The stroma was collagenous or mucin-rich, and accompanied by abundant lymphocytes and plasma cells infiltration. By immunohistochemical staining, desmin, CD99 and EMA were expressed in 6 cases, CD68 in 1 case, MUC4 in 1 case, synaptophysin in 2 cases, and ALK in 1 case. The Ki-67 proliferation index was between 1%-15%. Molecular analysis showed EWSR1::ATF1 fusion in 3 cases, EWSR1::CREB1 fusion in 2 cases, and EWSR1::CREM fusion in 1 case.Conclusions:Intracranial mesenchymal tumors with FET::CREB fusion are relatively rare and typically occur in children and younger adults. These tumors have a broad morphological spectrum and often express desmin, CD99 and EMA. The molecular characteristics are the gene fusions of FET family (mainly EWSR1, FUS) with CREB family transcription factors (ATF1, CREB1 or CREM). It is necessary to distinguish these tumors from meningiomas and solitary fibrous tumors, and the combination of immunohistochemical staining and molecular genetic testing can effectively help identify these tumors.

Purpose To summarize the clinical pathological and immunohistochemical characteristics of esophage-al carcinoma with ductal differentiation of esophageal gland,and analyze the somatic mutation characteristics,key driv-ing mutation genes,and significantly mutated genes based on whole exome sequencing.Methods The clinicopatho-logical features of 9 cases of esophageal carcinoma with esophageal duct differentiation were retrospectively analyzed,and the immunohistochemistry EnVision two-step method was used to stain them,and 3 of the samples were subjected to whole exome sequencing and data analysis.Results Among the 9 patients,6 were males and 3 were females.The average age was 68.3 years old(61-80 years old).All 9 cases were located in the middle-lower segment of the e-sophagus.The diameter of the lesion was from 1.5 cm to 3.5 cm.Most areas of the tumor had a double-layer epithelial structure,including the inner layer of luminal epithelium and the outer layer of basal epithelium.Focal areas could be seen with keratinization and mucinous cells.Immunohistochemistry showed that CK7 was positive in the inner epitheli-um,while p63 was positive in the outer basal epithelium.S-100,SOX10 and c-myb were all negative,and p53 was mutated(diffuse strongly positive).The results of whole exome sequencing analysis showed somatic mutation character-istics(796 SNV,37 InDel,482 CNV),key driving mutation genes(12),and significantly mutated genes(TP53).No intraepithelial neoplasia was observed on the surface squamous epithelium of all cases,and no Barrett's esophagus or ectopic gastric mucosa was observed.The average follow-up time was 21.9 months(8 days-51 months),with 8 ca-ses surviving and 1 case dying of severe pulmonary infection 8 days after surgery.Conclusion Esophageal carcinoma with ductal differentiation of esophageal gland is a rare epithelial derived malignant tumor of the esophagus,character-ized by unique morphological,immunohistochemical,and molecular changes.

Objective:To investigate the clinicopathological and molecular genetic characteristics of intracranial mesenchymal tumors with FET::CREB fusion transcript.Methods:The clinical and imaging data of 6 cases of intracranial mesenchymal tumors with FET::CREB fusion from December 2018 to December 2023 were collected at the First Affiliated Hospital of Zhengzhou University. Their histological features, immunophenotype and molecular characteristics were analyzed.Results:Among the 6 patients, 4 were males and 2 were females, and the median age was 20 years. The clinical symptoms were increased intracranial pressure in 5 cases and epilepsy in 1 case. The lesion sites were cerebellum (2 cases), frontal lobe (2 cases), parietal lobe (1 case), and cranioorbital communication (1 case). The radiological features mainly showed solid or cystic components, with obvious annular enhancement on MRI. The histopathological features showed a wide spectrum of morphology, clear boundaries and fibrous pseudocapsule. The tumor cells were arranged in a lamellar or nodular pattern, and some in cord or loose network. The tumor cells were spindle, oval, epithelioid or stellate. The stroma was collagenous or mucin-rich, and accompanied by abundant lymphocytes and plasma cells infiltration. By immunohistochemical staining, desmin, CD99 and EMA were expressed in 6 cases, CD68 in 1 case, MUC4 in 1 case, synaptophysin in 2 cases, and ALK in 1 case. The Ki-67 proliferation index was between 1%-15%. Molecular analysis showed EWSR1::ATF1 fusion in 3 cases, EWSR1::CREB1 fusion in 2 cases, and EWSR1::CREM fusion in 1 case.Conclusions:Intracranial mesenchymal tumors with FET::CREB fusion are relatively rare and typically occur in children and younger adults. These tumors have a broad morphological spectrum and often express desmin, CD99 and EMA. The molecular characteristics are the gene fusions of FET family (mainly EWSR1, FUS) with CREB family transcription factors (ATF1, CREB1 or CREM). It is necessary to distinguish these tumors from meningiomas and solitary fibrous tumors, and the combination of immunohistochemical staining and molecular genetic testing can effectively help identify these tumors.

Periarticular fracture of the shoulder is a common type of fractures in the elderly. Postoperative adverse events such as internal fixation failure, humeral head ischemic necrosis and upper limb dysfunction occur frequently, which seriously endangers the exercise and health of the elderly. Compared with the fracture with normal bone mass, the osteoporotic periarticular fracture of the shoulder is complicated with slow healing and poor rehabilitation, so the clinical management becomes more difficult. At present, there is no targeted guideline or consensus for this type of fracture in China. In such context, experts from Youth Osteoporosis Group of Chinese Orthopedic Association, Orthopedic Expert Committee of Geriatrics Branch of Chinese Association of Gerontology and Geriatrics, Osteoporosis Group of Youth Committee of Chinese Association of Orthopedic Surgeons and Osteoporosis Committee of Shanghai Association of Chinese Integrative Medicine developed the Chinese expert consensus on the diagnosis and treatment of osteoporotic periarticular fracture of the shoulder in the elderly ( version 2023). Nine recommendations were put forward from the aspects of diagnosis, treatment strategies and rehabilitation of osteoporotic periarticular fracture of the shoulder, hoping to promote the standardized, systematic and personalized diagnosis and treatment concept and improve functional outcomes and quality of life in elderly patients with osteoporotic periarticular fracture of the shoulder.

Objective:To study the clinicopathological features and prognosis of nodal lymphoplasmacytic lymphoma/Waldenstrom′s macroglobulinemia (n-LPL/WM).Methods:A total of 19 cases of n-LPL/WM were collected from May 2009 to January 2020 at First Affiliated Hospital of Zhengzhou University. The clinicopathologic features, immunophenotype, Ig gene rearrangement (BIOMED-2), MYD88 L265P mutation status (by Sanger sequencing) and follow-up data (by telephone) were analyzed.Results:There were 15 males and 4 females with a median age of 61 years (range 43 to 82 years). There were 14 WM and five LPL. The most common symptoms were weakness, fatigue (9/19) and B symptoms (11/19). Majority of the patients (16/18) presented with systemic multiple lymphadenopathies. Eighteen patients presented at advanced stages (Ⅲ/Ⅳ stage). Serum M protein status was IgM (15 cases), IgG (1 case), IgA (1 case) and no-secretory type (2 cases). Seventeen patients had bone marrow involvement. Morphologically, all 19 cases were divided into two groups: typical group (9 cases) or atypical group (10 cases). In the typical group, the structures of the lymph nodes were preserved; the neoplastic cells were predominantly plasmacytoid lymphocytes or mixed small lymphocytes, plasmacytoid lymphocytes and plasma cells, without proliferation of FDC network and follicular implantation. In the atypical group, the tumor showed effaced nodal architecture (5 cases), mainly proliferation of small lymphocytes (6 cases), FDC proliferation and/or follicular implantation (6 cases), marginal zone B cell differentiation (4 cases) and diffuse amyloidosis (1 case). Hemosiderin deposition (19 cases), infiltration of fatty tissue (19 cases) and interstitial sclerosis (9 cases) were commonly seen in both groups. Immunohistochemically, the neoplastic B cells expressed CD20 and CD79α, and the neoplastic plasma cells were positive for CD38, CD138 and MUM-1; eight cases showed light chain restriction; of the seven detected cases, five expressed IgM and the other two expressed IgG and IgA respectively; four cases expressed CD23 weakly, Ki-67 index was 10%-30%. MYD88 L265P mutation was seen in 18/18 cases. There was no significant difference in clinicopathologic features and prognosis between the two groups ( P>0.05). The median follow-up time was 61 months, 11 patients were alive, while eight died; the 5-year survival rate was 21.1%. Conclusions:n-LPL/WM is rare, but patients usually present in advanced stages. It is easily confused with other small B-cell lymphomas with plasma cell differentiation, especially basing on morphologic features alone; thus the accurate diagnosis of n-LPL/WM requires a combination of clinical features, serum M protein, immunohistochemistry, bone marrow morphology,flow cytometry and MYD88 L265P mutation status etc. The prognosis of n-LPL/WM may be not very good, and further studies with more cases are needed.

Objective:Unidentified filling objects (UFO) can cause adverse results including infections, overfilling, asymmetry, foreign body granulomas, dislocation or psychological panic. To remove UFO accurately, it is important to locate and identify the injected substances preoperatively. This study investigated the viability of using MRI to correctly locate and identify injected substances by relating MRI to gross and pathological microscopic examination.Methods:Eighty-two facial UFO patients from 2013 to 2017 were studied by the experts of the Department of Image, Xinhua Hospital of Dalian University. Five of the patients were male and seventy-seven were female. The age ranged from 17 to 58 years with average 29.4 years. They came to our hospital for removal of UFO after they had facial injective fillers in the illegal medial offices. The injected sites involved in the forehead, temple, malar, cheek, nose, nasolabial folds, and chin. All the patients＇ faces were examined with MRI preoperatively, using T1W, T2W and fat-suppressed sequences. Based on the guides of MRI, UFOs were removed with their capsules by open approach. Samples were recorded with digital pictures and then were fixed in 10% formalin solution for microscopic examination of HE stained slices.Results:Based on MRI, gross and microscopic examination, UFO were classified into 3 types, gel-like fillers, solid particles, and growth factors. Gel-like fillers appeared strongly hyperintense on T2 W and STIR sequences and hypointense on T1 W sequences. Grossly, they looked like gruel covered by altered soft tissue. Under the light microscope, many pieces of blue-stained material were dispersed in subcutaneous tissue infiltrated with a large number of mononuclear cells and foreign-body giant cells. Solid particles had low to intermediate signal intensity on T1 W and T2 W images. Grossly, they were like sand merging in soft tissue. The biopsy showed crowed bubbles surrounded by tissue filled with a large number of mononuclear cells and foreign-body giant cells. For growth factors affected tissue, it was hard to differentiate between normal and abnormal on MRI. The affected tissue appeared as somehow hypointense on T1 W sequences and hyperintense on T2 W fat suppressed sequences. During the operation, the affected region was easy bleeding and full of fibrofatty tissue. Under the microscope, there were increased small blood vessels and collagens.Conclusions:Based on MRI, gross and microscopic examination, UFO can be classified into 3 types, gel-like fillers, solid particles, and growth factors. MRI is very important for doctors to assess the patient＇s conditions and make the plan of operation. MRI is also useful for doctors to locate UFO and understand the relationship between UFO and their nearby organs.

As a non-physiological way of ventilation, mechanical ventilation has a great effect on the respiratory mechanics. The biggest problem of artificial airway is that it brings extra airway resistance to the respiratory tract. For different parts of the lung, positive pressure ventilation could cause different mechanic states. We can find the formation and influencing factors of transpulmonary pressure, transchest wall pressure, trans-lung-chest pressure, trans-diaphragmatic pressure, trans-pulmonary-diaphragmatic pressure, intrapleural pressure, plateau pressure and driving pressure, by analyzing the mechanic state in a unit area of the chest or diaphragm position in the way of basic mechanics. It is obviously different in the pulmonary pressure gradient caused by inspiratory driving between in spontaneous breathing and in mechanical ventilation. The pressure is transmitted from the periphery to the center in spontaneous breathing in physiological state, playing a traction role for lung tissue. The pressure is transmitted from the center to the periphery in positive pressure ventilation without spontaneous breathing, playing a pushing role for lung tissue. It can be divided into two stages in positive pressure ventilation with spontaneous breathing. The first stage is from inspiratory trigger effort to trigger sensitivity. It is similar to spontaneous inspiration in physiological state. The pressure gradient in this stage is from the peripheral to center. But the period is very short. The second stage is the positive pressure ventilation progress after the trigger sensitivity. The pressure gradient is caused by the pulling of the patient's spontaneous inhalation and the pushing of the positive pressure ventilation of the ventilator. There is a certain complementarity in the distribution and transmission of pressure, especially for non-physiological positive pressure ventilation. Therefore, through these basic mechanical analysis, clinical medical staff can better understand the impact of mechanical ventilation on respiratory mechanics.

Objective:To study the clinicopathologic and genetic features of Waldeyer′s ring peripheral T-cell lymphoma with follicular helper T cell immunophenotypes (wPTCL-TFH), with comparison to the nodal peripheral T-cell lymphoma with TFH immunophenotypes (nPTCL-TFH) and angioimmunoblastic T-cell lymphoma (AITL), as to know this rare tumor better.Methods:The clinical data, histopathology features, EBV positivity, T cell clonality and IDH2 R172 gene mutation in 8 cases of wPTCL-TFH were collected at the First Affiliated Hospital of Zhengzhou University from December 2015 to April 2019, and analyzed by immunohistochemistry, in situ hybridization, TCR gene rearrangement (BIOMED-2) and Sanger sequencing.Follow-up data were obtained by telephone. Results:There were 6 males and 2 females with a median age of 62.5 years (age ranging from 30 to 75 years). All patients had neither fever nor skin manifestations, but were all found mucosa thickened or mass of waldeyer′s ring with multiple lymph nodes enlarged by PET-CT/CT scans. Five of the 7 patients were at advanced stages (Ⅲ/Ⅳ stage). Microscopically, the mucosa was infiltrated diffusely and characteristically by numerous small-medium sized lymphocytes, lacking polymorphous inflammatory background and extra-follicular expansion of follicular dendritic cell networks (FDC networks). The clear T cells presented in 5 cases. Ulcers on mucosal surfaces (6 cases) and local-extensive loss of intramucosal glands (7 cases) were commonly noted. Granulomas composed of epithelioid histiocytes were observed in 2 cases. Immunohistochemically, all the tumor cells expressed CD4 and at least 2 types of follicular helper of T cell (TFH) markers: PD-1 (8/8), bcl-6 (8/8), CXCL13 (7/8) and CD10 (1/8). Most of the cases (6 cases) expressed CD30. EBV positive appeared in 4 cases. All 8 cases were T cell monoclonal. IDH2 R172 were wild-type in 6 cases. One patient died at the follow-up time on 18 months; the other 7 survived (the follow-up time varied from 3 to 10 months). Conclusions:wPTCL-TFH is rare, and its clinicopathological features are similar to nPTCL-TFH which may be the manifestation of the same disease at different stage, and partly overlapped with AITL. The differential diagnosis from PTCL-NOS is necessary and comprehensive analyses of clinical, morphological, immunohistochemical and genetic features can help make a correct diagnosis.

TSCI have dyskinesia and sensory disturbance that can cause various life-threaten complications. The patients with traumatic spinal cord injury (TSCI), seriously affecting the quality of life of patients. Based on the epidemiology of TSCI and domestic and foreign literatures as well as expert investigations, this expert consensus reviews the definition, injury classification, rehabilitation assessment, rehabilitation strategies and rehabilitation measures of TSCI so as to provide early standardized rehabilitation treatment methods for TSCI.