PMC6540739_01
The patient's intrahepatic cholangiocarcinoma, which was classified as TNM: cT3, cN1, cM1, and stage IV tumor [according to AJCC/UICC staging criteria ]. (A,B) CT scan demonstrates multiple liver lesions, exemplary shown on two different axial layers. (A) Arrows indicate right-sided cholestasis, caused by a hypodense lesion in liver segments IV/VIII. (B) Asterisk marks a large, lobular-configured tumor mass in liver segment II, that dorsally crosses liver capsule. (C) A representative axial CT scan layer shows multiple bilateral lung noduli, interpreted as pulmonary metastases (indicated by red arrows). A framed image section is displayed as magnified inset in the top left corner of (C). A likely single spleen metastasis and enlargement of retroperitoneal lymph nodes are not shown. (D) The unaffected pancreas neighboring the infiltrated liver is depicted in four serial CT scan layers in coronal plane (consecutively numbered 1-4 from ventral to dorsal). The border between both organs (highlighted by dashed ovals) is not obviously violated by infiltrating tumor tissue, arguing against a primarily pancreatic origin of malignancy. (E,F) Histology from ultrasound-guided liver-biopsy. (E) H&E stain shows infiltrates of an adenocarcinoma with scattered duct formation and a desmoplastic stroma component. (F) High-power field from inset in (E) demonstrates frequent mitoses (indicated by arrow-heads). Immunohistochemistry (not shown) reveals positivity for CK7 and DPC4 and negativity for Hep Par 1, CK20, TTF1, CDX-2, and PSMA, consistent with a tumor of biliopancreatic origin.
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F1
Turkish descent with stage IV intrahepatic cholangiocarcinoma according to the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) staging criteria with distant metastases (e.g., to lungs; Figure 1) was admitted to our emergency room with a clinical and laboratory constellation consistent with sepsis. Figure 1A) with moderate peripherical cholestasis was performed, but demonstrated no clear evidence for cholangitis.
PMC6540739_02
Identification of causative FANCA mutations. (A) Pedigree of the family. Filled and open symbols denote affected and healthy individuals, respectively; an arrow indicates the index patient, diagonal lines indicate deceased status. The mutation status is shown next to each symbol. (B) Agarose gel electrophoresis of FANCA RT-PCR products performed using lymphocyte-derived RNA of the patient's brother (B) who bears the heterozygous c.710-3A>G mutation, and a healthy individual (C), generated using primers F5'-AAGGCATTGTG AGCCTGCAAGA-3' and R5'-ACAGGGCTGTGAGTGAGTATCTGA-3'. The 436-bp wild-type RT-PCR amplicon was amplified in both the patient's brother (B) and the control (C), using exon 8 flanking primers. A second, smaller PCR product of ~350 bp was only obtained in the patient's brother (B), corresponding to skipping of exon 8 (exon 8 contains 83 bp). The 400, 300, and 200 bp reference bands of the molecular marker (M) are indicated.
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F2
Segregation analysis with DNA samples of both healthy parents and his brother revealed the missense variant to be paternally inherited, whereas both the mother and his brother only bear the c.710-3A>G variant (Figure 2A), confirming the compound heterozygosity and an autosomal recessive inheritance. Further, RT-PCR analysis performed with RNA isolated from lymphocytes of the healthy brother as previously described revealed that the c.710-3A>G variant causes skipping of exon 8 (Figure 2B), thus confirming its pathogenicity and allowing the post mortem diagnosis of FA in the index patient.