Scrotal PNET in an Adult Patient

Scrotal PNET in an Adult Patient TITLE: Scrotal PNET in an Adult Patient: Radiologic-Pathologic Correlation. AUTHORS: M ª Gabriela Tirapu-de-Sagrario, Sandra Baleato-Gonzà ¡lez, Elena Pintos-Martà ­nez and Roberto Garcà ­a-Figueiras KEY WORDS: Neuroectodermal Tumors, Scrotum, Sarcoma, Groin, Inguinal Canal INTRODUCTION We report a, histologically confirmed, rare case of a peripheral primitive neuroectodermal tumor (pPNET) originating from the scrotal sac in an adult patient. This report emphasizes the important role of pathology examination to reach final diagnosis on the basis of immunohistochemistry and electronic microscopy findings. Outcome depends upon the localization and staging of the tumour, age of the patient, histologic classification, extent of surgical resection and time to treatment. CASE REPORT An 84-year-old man was admitted to our hospital with an inguinoscrotal, irreducible, painless mass with a hard consistency, which had progressed over the last six months. There was no presence of urinary or intestinal symptoms. Alpha-Fetoprotein, beta-HCG and LDH values were found to be normal. The patient was subsequently referred to the Urology Departament and he underwent a pelvic MRI. It confirmed a 12x11x19 cm solid mass, which demonstrated central areas of necrosis and subtle amounts of haemorrhage (Figure 1). This mass demonstrated marked and heterogeneous enhancement after intravenous gadolinium administration as well as evidence of internal vascular flow. Both testes showed a normal morphology and signal on T2-weighted sequences (Figure 1). Surgical excision was performed by the Urology Service and they reported that the spermatic cord, femoral vessels and testes were displaced but not infiltrated by the mass (Figure 2A). Despite the fact that a sarcoma was the suggested dia gnosis on imaging, this case exhibited microscopic pathology features of a rare pPNET tumor in an unexpected location. The presence of neurosecretory granules in the electron microscopy (Figure 3) and the EWS-FLI1 traslocation confirmed the diagnosis. DISCUSSION pPNET is an uncommon tumor that belongs to the Ewing’s Sarcoma family of tumors (1-4). It is an aggressive neoplasm, with large size at presentation, which metastasizes rapidly and predominantly affects children and adolescents (1,3,5).The most common locations are: the chest wall, paraspinal area in the chest, abdomen and pelvis (7,8). Ellinger J, et al (1), performed a MEDLINE search identifying renal, bladder, prostate, ureter and seminal cord PNETs, Hari S et al (3) and Kim MS et al (9) also described kidney and retroperitoneum cases and even an uterus case was described by Peres E et al (10) but, to our knowledge, this is the first pPNET case which originated in the scrotal sac, independent of any organ. This tumor is extremely rare in adults and the clinical findings (large painful mass) do not help to distinguish a benign from a malignant tumor (11). At the presentation most of them grow as scrotal masses rather than inguinal masses because they usually originate just b elow the external inguinal ring (12). PNET tumor shows no specific imaging features, but radiological studies are useful to rule out other possible etiologies, to define the location of the tumor and its morphological characteristics as well as its distance extension (1,3,4). In order to diagnose PNET, and differentiate it from other tumors of the Ewing family, we need to demonstrate the expression of some neural markers on the inmunohistochemical stains, including neurofilament, NSE, Leu-7, vimentin, S-100, CD-56, chromogranin and synaptophysin (2). A definitive finding is the EWS-FLI1 traslocation and the presence of neurosecretory granules in electron microscopy (7,8). In conclusion, we present a histologically confirmed case of an extratesticular peripheral scrotal PNET, which possibly originated from a remnant of neuroectodermic cells of the neural crest. In a case like this one, with a huge genital mass, ultrasound and MRI are very useful modalities to assess the location of the mass, its dependency on any other organ and the tumoral internal structure. These will help us to suggest a possible differential diagnosis however the definitive diagnosis requires histopathological and immunohistochemical examination. REFERENCES Ellinger J, Bastian PJ, Hauser S, et al. Primitive Neuroectodermal Tumor: Rare, highly aggressive differential diagnosis in Urologic Malignancies. J Urol 2006; 68(2):257-262 Gurung P,Attar K andPeters J. Primitive neuroectodermal tumorof thespermatic cord. Int J Urol.2010 Jul;17(7):679-80. Hari S,Jain TP,Thulkar S, et al. Imagingfeaturesofperipheral primitive neuroectodermal tumours. Br J Radiol.2008 Dec;81(972):975-83. Javery O,Krajewski K,ORegan K,el al. A to Z of extraskeletal Ewing sarcoma family of tumors in adults: imaging features of primary disease, metastatic patterns, and treatment responses. AJR Am J Roentgenol.2011 Dec;197(6):W1015-22. Ibarburen C, Haberman JJ, Zerhouni EA. Peripheral primitive neuroectodermal tumors. CT and MRI evaluation. Eur J Radiol. 1996 Feb;21(3):225-32. Fontaine C,Schots R,Braeckman J, et al. Long-term survival in an adult metastatic renal peripheral primitive neuroectodermal tumor (PPNET) with multimodality treatment including high-dose chemotherapy. Ann Oncol.1997 Jul;8(7):691-4. Khong P.L, Chan G.C.F, Shek T.W.H, et al. Imaging of Peripheral PNET: Common and uncommon locations. Clinical Radiology. 2002;57:272-277 Hoffer FA, Gianturco LE, Fletcher JA, et al. Percutaneous Biopsy of Peripheral Primitive Neuroectodermal Tumors and Ewing’s Sarcomas for Cytogenetic Analysis. AJR. 1994;162:1141-1142 Kim MS, Kim B, Park CS, et al. Radiologic Findings of Peripheral Primitive Neuroectodermal Tumor Arising in the Retroperitoneum. AJR. 2006; 186:1125-1132. Peres E, Mattoo TK, Poulik J, et al. Primitive Neuroectodermal Tumor (PNET) of the Uterus in a Renal Allograft Patient: A Case Report. Pediatr Blood Cancer. 2005;44:283-285. Lioe TF and Biggart JD. Tumours of the Spermatic Cord and Paratesticular Tissue. A Clinicopathological Study. British Journal of Urology. 1993; 71:600-606 Rodrà ­guez D and Olumi AF. Management of spermatic cord tumors: a rare urologic malignancy. Ther Av Urol. 2012: 4(6): 325-334 FIGURE LEGENDS Figure 1 A) Axial T2 TSE shows a large heterogenous inguinoscrotal mass that displaces the penis (void arrows) but apparently not infiltrates it. B) Axial T1 after intravenous contrast Maximum relative enhancement. It shows central hypoperfusion (black arrows), which is hyperintense on T2 sequences, probably due to necrosis or hemorrhage, and a solid hypervascularized periphery (white arrows). Figure 2 A) Surgical photograph shows the spermatic cord (white arrows), which is displaced but not affected by the large mass. B) A long axis section of the mass. Its observed an heterogenous tumor of mottled appearance with partially embossed, clear brownish areas, which are the solid ones (black asterisks). It also has extensive necrotic and hemorrhagic component (white asterisks). Figure 3 Electronic Microscopy. The presence of neuroendocrine granules (white circles) of various sizes (from 80 to 120 nm) in the cytoplasm of the tumor cells is confirmed. This finding demonstrates the neuroendocrine differentiation of the neuroectodermal tumor.

Complexometric Determination of Water Hardness Essay

Abstract The water hardness for unknown water sample number 40 was determined. From the results of the two complexometric titrations, the water hardness of the unknown sample was calculated to be 250.9 ppm CaCO3, which agrees with the ranges of acceptable water hardness in the city of Phoenix and Tempe Arizona. Introduction When rainfall picks up impurities from the soil, ions of sodium, magnesium, calcium, iron, and other metals are dissolved into the water. These impurities are what cause residues left on glassware from the reaction with the soap used for cleaning. Water hardness is from the metal ions with a +2 charge or higher being dissolved into the rainfall. When reporting water hardness, it is reported in units of mg CaCo3/L of solution, or in ppm due to one mg of solute having one millionth of the mass of a liter of water or dilute aqueous solution. It is reported using only CaCo3 because typically, Calcium is the largest contributor to the water hardness. The purpose of this experiment was to determine the concentration of metal ion impurities in an unknown sample of hard water by performing a complexometric titration with EDTA. The results were then compared to the expected range for municipal water hardness from multiple city websites. Methods All procedures from the CHM 152 Lab, Complexometric Determination of Water Hardness (1) were followed precisely. Unknown water sample #40 was mixed with approximately 20 ml of DI water, 3.0 ml of Ammonia/Ammonium Chloride (NH(aq) Buffer pH=10), and 4 drops of Eriochrome Black T indicator solution. It was then titrated with .004197 M EDTA, which was also made in the lab from 0.7582 g of , added to 500 mL of DI water, that was then standardized with a stock Calcium Ion Solution (CaCO(aq) 1.00g/1.00L) by titration. A total of 3 titration trials were completed to find the average molarity of the EDTA, and the average water hardness of unknown water sample #40. All mass measurements were taken from a AND Balance, serial number 12321601 and all titrations were done using a KIMAX buret, #173. Pipet measurements were taken from a 25mL Bel-Art, and 15mL Bel-Art pipet. The numerical techniques used in this experiment were, stoichiometry with mole ratio for calculating the molarity of the EDTA solution and water hardness and relative average absolute deviation in ppt to show how closely the results from the Standardized EDTA titration of each trial agree with each other. Data Analysis Based on the experiment and calculations, the average calculated concentration of metal ion impurities (water hardness) in unknown sample number 40 from this experiment was 250.9 ppm. From table 1, the average molarity of the titrated was calculated to be 0.004197 M. Table 1 The molarity of the EDTA solution for each trial n was calculated as follows: .0.01000 L CaCO3 SolnTotal EDTA Delivered LÃâ€"1.000 g CaCO31 L CaCO3 SolnÃâ€"1 mol CaCO3100.1 g CaCO3Ãâ€"1 mol Na2EDTA1 mol CaCO3=Molarity of Trial n The Average Molarity of the EDTA solution was calculated as follows: Average Molarity of EDTA Solution =Calculated molarity from each trialNumber of titration trials To determine how closely the results of each trial from the Standard Disodium EDTA titration (Table 1) agreed with each other, a relative average absolute deviation calculation was done. It was calculated as follows: Absolute deviation for trial n= Na2EDTA avg molarity-Total Na2EDTA Trial n absolute deviations3Na2EDTA avg molarityÃâ€"1000=Estimated Prescision (ppt) The results of the above calculation came out to be 14.45 ppt. With the expected range of precision being at most five parts per thousand, it has been observed that the molarity of the standard Disodium EDTA solution includes some obvious error. It seems that the observation of color change when Na2EDTA was titrated to the mixture of CaCO3, DI water, Eriochrome Black T, and ammonia/ammonium chloride was the most error prone. Not knowing when to stop titrating the EDTA solution, would have accounted for a misreading of measurement for the total volume of EDTA solution added to complete the titration, making the final molarity for that trial less than what was expected. Table 2 Based on the molarity results from table 1 and the data from table 2, the average calculated water hardness of unknown water sample 40 was calculated to be 250.9 ppm CaCO3. The water hardness of unknown water sample 40 for each individual trial was calculated as follows: =Total EDTA soln Delivered L0.02500 L CaCO3 solnÃâ€"0.004197 mol EDTA1 L EDTA solnÃâ€"1 mol CaCO31 mol EDTAÃâ€"100.1 g CaCO31 mol CaCO3Ãâ€"1000mg1.0 g Average Water Hardness (ppm)≠¡mg CaCO31 L CaCO3 Interpretation of Results Based on the data, the calculated water hardness of the unknown sample number 40 (250.9 ppm), is within range of the city of Phoenix’s calculated range of 164-291 ppm (2) and the city of Tempe’s calculate range of 150-400 ppm (3). References 1. Complexometric Determination of Water Hardness, Procedures, Mesa Community College CHM152LL website, http://www.physci.mc.maricopa.edu/Chemistry/CHM152/index.html, accessed 9/7/2013. 2. City of Phoenix website. http://phoenix.gov/waterservices/quality/index.html, accessed 9/8/2013. Copyright 2013 3. City of Tempe Az website. https://www.tempe.gov/index.aspx?page=1289#Hardness, accessed 9/8/2013. Copyright

The River of Earth

The River of Earth The novel River Of Earth by James Still is a story about life in e Appalachia just before The Great Depression. The story provides a very clear description of the problems and challenges the mountain people faced after the settlement of their land. Even though the novel is shadowed by other writings of the time period dealing with poor southern life, it is still considered a great neglected masterpiece. The story is about a family that considers awkward. They struggle to put enough food on the table for the entire family, most of the time the mother barely eats.They live in a small smoke house that is very cramped and cluttered because of the number of people living in it. The Father is waiting for the coal mines to open so he can work, while the mother takes care of the kids, the family does not complain; they feel blessed for what they have . The father is very proud and doesn’t turn anyone away when they need help. In the book he allowed a group of miners to take most of his beans from the garden to help keep their families feed .The mother is a very strongwilled woman. She never lets anything bring her down; when the family begins to have trouble with food she suggests that they begin growing a garden and providing for themselves. The kids are smart and goodwilled from what they are taught by their parents. They display good moral values in their characters. The garden is a source of life for the family in the book. This is so because as times get harder they grow together and the garden also becomes more and heartier.They begin to have more food for their dinners, this helps the family keep their spirits up and continue to hope for good blessings to be brought to the family such as the mines opening. As the family grows stronger they begin to add to their source of food. Instead of eating only soup and vegetables and potatoes, they add begin to eat meat. They own a guinea Chicken which starts to lay a large amount of eggs they let hatch and raise. The kids are not embarrassed about what they eat, they seem happy for what they have.The father makes the children go to school because he feels that everyone should learn the basics of academics such as reading and writing to help them survive is the world. At first they are scared and don’t want to go because they have never been and feel they are too young. As they continue to grow they start to show improvements and gain confidence in their ability to perform in the classroom. They fear for the teacher being run off because the older kids don’t like him and some of the parents don’t appreciate his teaching methods.The main character and his sister hope he stays so they will continue to learn. The main character is sent by his father to stay with his grandmother. This is where you learn that the strong heart runs in the family. This is true because she is a seventy-eight year old woman and will still patch out two acres of corn and make enou gh bread for the winter to do what she can to keep her family feed. In her old age she hasn’t kept the best health. Some days she is too sick to get out of the bed. The main character takes care of her he cooks all the meals for her and helps her start to feel better.Living with her he hears stories of his father and how he is an honest man. Also his grandmother tells him about his grandfather and all the great things he would do. Living with his grandmother is a great experience for the main character because she brings him history of his family and teaches him many things on how to live a content life. Also being away from home helps himself grow as a person. It teaches to stick up for himself and make his own decisions without the influence of others. When the main character returns to his family he learns that the baby had died from croup.Also the family moves to a farm they rented in Flaxpatch on Little Angus. Here they plant crops and farm together as a family. The fath er has returned from the mines and decides he wishes to move back because he heard they would stay open through the winter. They go and he works there for a while and earns decent money, enough to support his family. During the winter the main characters grandmother dies. It’s a sad moment for the entire family. This is so because she was such a strong figure in the book even with her bad health.After the winter the father decides to stop mining and move the family to a place where he can find a different job or stat a farm. In the end the main character imagines his grandmother talking to him about his baby sibling crying. This story gives great detail to a life lived by the mountain families of the Appalachia. It puts you in the shoes of a young boy who is growing up in the hard time period just before The Great Depression. James Still does a great job of capturing the culture of the time period. Unfortunately, this book will always remain a neglected masterpiece.

Different Versions of the Birth of Dionysus

In Greek mythology, there are often different and conflicting versions of mythological events. The story of the birth of Dionysus is no different, and Dionysus complicates matters by having different names. Here are two versions of the birth of Dionysus and one of the related birth of Zagreus: From a union between Persephone and Zeus in serpent form sprang the horned god Zagreus. Jealous Hera persuaded the Titans to attack the infant god as he looked into a mirror. Not only did they tear him to pieces, but the Titans ate him --all but his heart which Athena rescued. From this organ, the rest of the god was resurrected. Semele is impregnated by drinking a preparation made from the heart of Dionysus who had been torn to pieces by the Titans. [Pseudo-Hyginus, Fabulae 167]Most familiar is the story of Semeles impregnation by Zeus but failure to live long enough to give birth to the child. To save the fetus, Zeus sewed him inside himself and gave birth through his leg when the time came.(ll. 940-942) And Semele, daughter of Cadmus was joined with him in love and bare him a splendid son, joyous Dionysus, -- a mortal woman an immortal son. And now they both are gods. Hesiod, Theogony (trans. Evelyn-White) Homeric Hymn1 to Dionysus ((LACUNA))(ll. 1-9) For some say, at Dracanum; and some, on windy Icarus; and some, in Naxos, O Heaven-born, Insewn; and others by the deep-eddying river Alpheus that pregnant Semele bare you to Zeus the thunder-lover. And others yet, lord, say you were born in Thebes; but all these lie. The Father of men and gods gave you birth remote from men and secretly from white-armed Hera. There is a certain Nysa, a mountain most high and richly grown with woods, far off in Phoenice, near the streams of Aegyptus.((LACUNA))(ll. 10-12) ...and men will lay up for her many offerings in her shrines. And as these things are three, so shall mortals ever sacrifice perfect hecatombs to you at your feasts each three years.(ll. 13-16) The Son of Cronos spoke and nodded with his dark brows. And the divine locks of the king flowed forward from his immortal head, and he made great Olympus reel. So spake wise Zeus and ordained it with a nod.(ll. 17-21) Be favourable, O Insewn, Inspirer of frenzied women! we singers sing of you as we begin and as we end a strain, and none forgetting you may call holy song to mind. And so, farewell, Dionysus, Insewn, with your mother Semele whom men call Thyone.Source: The Homeric Hymns I. To Dionysus [3.4.3] But Zeus loved Semele and bedded with her unknown to Hera. Now Zeus had agreed to do for her whatever she asked, and deceived by Hera she asked that he would come to her as he came when he was wooing Hera. Unable to refuse, Zeus came to her bridal chamber in a chariot, with lightning and thunderings, and launched a thunderbolt. But Semele expired of fright, and Zeus, snatching the sixth-month abortive child from the fire, sewed it in his thigh. On the death of Semele, the other daughters of Cadmus spread a report that Semele had bedded with a mortal man, and had falsely accused Zeus and that therefore she had been blasted by thunder. But at the proper time, Zeus undid the stitches and gave birth to Dionysus, and entrusted him to Hermes. And he conveyed him to Ino and Athamas, and persuaded them to rear him as a girl.- Apollodorus 3.4.3