573570
research-article2015
IJSXXX10.1177/1066896915573570International Journal of Surgical PathologyKim et al
Case Report
Gastric Malignant Peripheral Nerve Sheath Tumor: A Case Report
International Journal of Surgical Pathology 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896915573570 ijs.sagepub.com
Eun Young Kim, MD1, Sung Hak Lee, MD1, Han Mo Yoo, MD1, Kyo Young Song, MD, PhD1, and Cho Hyun Park, MD, PhD1
Abstract Gastric malignant peripheral nerve sheath tumors (MPNSTs) are sarcomas arising within a peripheral nerve. Gastric MPNSTs are extremely rare with only a few cases. We herein describe the case of a 48-year-old man with a gastric MPNST for the first time in Korea, which was diagnosed histopathologically after surgery. The patient underwent curative subtotal gastrectomy with D1+ lymph node dissection and Billroth-II reconstruction. The postoperative recovery was uneventful, and he has had no recurrence until now. The ideal adjuvant treatment protocol is yet to be decided due to the relatively limited number of cases of these tumors previously reported. Keywords gastric malignant peripheral nerve sheath tumors, schwannomas, surgery, adjuvant treatment
Introduction Malignant peripheral nerve sheath tumors (MPNSTs) are soft tissue neoplasms that usually arise from peripheral nerves and show variable differentiation toward one of the cellular components of the nerve sheath (Schwann cells, fibroblasts, and perineurial cells).1 MPNSTs include malignant schwannomas, neurofibrosarcomas, or neurogenic sarcomas. MPNSTs are extremely rare with only a few cases reported worldwide. In Korea, to our knowledge, gastric MPNSTs have never been reported. We herein present the case of a 48-year-old man with an exceedingly rare symptomatic gastric MPNST that was diagnosed histopathologically after gastrectomy.
Case Report In January 2014, a 48-year-old man with a 1-month history of melena was admitted to our hospital. He also complained of epigastric discomfort. He did not have any other disease history except for pneumothorax, 10 years ago. On admission, laboratory data revealed a hemoglobin level of 11.6 g/dL because the patient had received several red blood cell transfusions. Gastroduodenoscopy revealed a large distinct protruding mass with a central ulcer at the greater curvature of the gastric mid-body (Figure 1A). On the endoscopic biopsy, the result favored the possibility of neurogenic sarcoma rather than spindle cell carcinoma, gastrointestinal stromal tumor, leiomyosarcoma, and other types of sarcomas. Abdominal computed tomography
(CT) revealed an enhancing mass with large central ulceration at the greater curvature of the stomach mid-body with perigastric fat infiltration. Multiple enlarged perigastric lymph nodes were also noted (Figure 1B). Overall, the most probable clinical diagnosis for the lesion was a neurogenic sarcoma. The patient underwent a curative subtotal gastrectomy with D1+ lymph node dissection and Billroth-II reconstruction. Macroscopically, the elevated lesion was located at the posterior wall of the mid-body and the size was approximately 9.0 × 9.0 cm in diameter (Figure 2). The surface mucosa of the mass was ulcerated and it invaded the serosa but not the adjacent structures. Totally 32 lymph nodes were retrieved but there were not any cancer cells in the lymph nodes. The surgical safety margin (proximal cut margin, 1.5 cm; distal cut margin, 9.0 cm) was negative for tumor cells. Microscopic findings revealed diffuse infiltrative tumor spread throughout the entire wall, and no definite true capsules were histologically detected. The tumor was composed of a variety of bizarre tumor cells. In addition, the tumor consisted of spindle cells, showing a fascicular growth pattern with focal alternating hypercellular 1
The Catholic University of Korea, Seoul, Korea
Corresponding Author: Cho Hyun Park, Division of Gastrointestinal Surgery, Department of Surgery, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Korea. Email: [email protected]
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
2
International Journal of Surgical Pathology
Figure 1. (A) Gastroduodenoscopy revealed a distinctly large protruding mass with central ulcer at the greater curvature of the mid-body. (B) CT revealed a enhancing mass at the greater curvature of the mid-body with perigastric fat infiltration and large central ulceration was seen. Multiple enlarged perigastric lymphadenopathy were also noted.
and hypocellular areas. The neoplastic cells were mitotically active (up to 12 mitoses per 10 HPFs), with hyperchromatic nuclei and extensive pleomorphism (Figure 3A). Immunohistochemical studies showed that the tumor cells were weakly positive for S-100 (Figure 3B). Moreover, it was possible to rule out synovial sarcoma, fibrosarcoma, leiomyosarcoma, or gastrointestinal stromal tumor, because the results were negative for c-kit (Figure 3C), EMA, CK, bcl-2, CD99, DOG-1, actin, CD34, CD68, or desmin. As a whole, these histopathological and immunohistochemical findings were consistent with a gastric MPNST. The postoperative course of the patient was uneventful and he was discharged on the seventh postoperative day. Recently, he has had no recurrence on additional examination and is doing well.
Discussion
Figure 2. Macroscopically, the elevated lesion was approximately 9.0 × 9.0 cm in diameter and located at the posterior wall of the mid-body.
Malignant peripheral nerve sheath tumors are exceedingly rare with an expected incidence of 0.1/100 000 per year. The incidence of MPNSTs is approximately 5% to 10% of all soft tissue tumors.2 MPNSTs are typically diagnosed in patients between 20 and 50 years of age.3 MPNSTs occur most frequently in the extremities, although there have been a few reports of MPNSTs that originated from the intra-abdominal organs, including the stomach. Because of its limited incidence and recent regulation of MPNST conception, there is a paucity of data in the literature regarding prognostic factors, incidence, and
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
3
Kim et al
Figure 3. The tumor is hypercellular and has a fascicular growth pattern. Microscopic findings showed spindle-shaped tumor cells with frequent mitotic figures (A). Immunohistochemical analysis showed that the tumor cells were focally positive for S-100 protein (B), but lack staining for c-kit (C). Table 1. Literature Review. Author Croker and Greenstein Rădulescu et al5 Bees et al6 Loffeld et al7 Takemura et al8
4
Publication Year
Nation
Symptom and Sign
1979 1995 1997 1998 2012
United Kingdom Romania United Kingdom Netherlands Japan
Abdominal pain; weight loss; anemia Abdominal pain; melena Abdominal pain; tarry stool; vomiting Melena Abdominal pain; melena
long-term outcome in MPNST, especially in stomach. Of the English literature (searched in PubMed), from 1979 until now, there have been only 5 reports of the gastric MPNST.4-8 All the 5 cases presented with upper gastrointestinal bleeding or abdominal pain (Table 1). Our case also corresponded well with the first symptoms of the aforementioned reports. Several cases of gastric schwannomas have been reported in Korea, but there had been no previous cases of malignant schwannoma. In 2008, a pancreatic MPNST was the only case reported to affect intraabdominal organs in Korea.9
MPNSTs display unique clinicopathological characteristics. First, it is extremely difficult to diagnose MPNST. Much of the difficulty in diagnosing MPNST is the lack of specific neural differentiation biomarkers.10 Second, it may occur sporadically or in association with neurofibromatosis type 1 (NF-1). Approximately 25% to 50% of observed MPNSTs occur in patients with NF-1. Most patients with MPNST have a small, truncating mutation in the NF-1 gene that is associated with an 8% to 13% risk of developing MPNST.2 However, in our case, the patient was not associated with neurofibromatosis or mutation in
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
4
International Journal of Surgical Pathology
the NF-1 gene. As previously described, it is difficult to diagnose MPNST. Therefore, in our case, to make a diagnosis of MPNST and exclude probable disease, many immunohistochemical stains including S-100, c-kit, EMA, CK, DOG-1, Desmin, Actin, bcl-2, and CD99 were used. Third, another clinicopathological characteristic of MPNST is that they are very aggressive, and the survival is poor. Like other soft tissue sarcomas, MPNSTs recur locally and spread hematogenously.2 Although the ideal adjuvant treatment protocol is yet to be decided due to the relatively limited number of cases of these tumors previously reported, we put together the previous reports. As a result, the treatment choice of MPNST is curative surgical resection with negative margins. Radiation therapy and adjuvant systemic chemotherapy are important in addition to surgery in improving local control. Although improvement in local control have been seen with adjuvant radiation therapy, the only one study out of Milan, Italy, has been able to demonstrate that lack of radiation therapy predicts decreased disease-specific survival.3 Chemotherapy is generally ineffective, although some studies have shown that it may benefit patients with higher-grade tumors or children with unresectable tumors.11-13 Some trials have been achieved, but targeted molecular treatments are not yet available.1 In spite of aggressive surgery and adjuvant therapy, the prognosis for patients with MPNST is still poor,2 with the 5-year survival rates ranging from 35% to 50%.10 In some reports, large tumor size (10 cm) and a lack of S-100 staining were identified as important prognostic factors for the development of distant metastases in patients with localized MPNST.10 In our case, the mass was less than 10 cm and positive for S-100, and we expect to have better prognosis compared with other MPNST cases. However, application of the results is limited because the reports are originated from all MPNSTs, not only stomach. In conclusion, if the tentative diagnosis of a gastric lesion is neurogenic sarcoma before surgery, complete resection to remove all gross diseased tissues and achieving negative margins is important. In addition, careful histopathological and immunohistochemical review is very important to confirm the diagnosis of MPNST.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Thway K, Fisher C. Malignant peripheral nerve sheath tumor: pathology and genetics. Ann Diagn Pathol. 2014;18:109-116. 2. Anghileri M, Miceli R, Fiore M, et al. Malignant peripheral nerve sheath tumors: prognostic factors and survival in a series of patients treated at a single institution. Cancer. 2006;107:1065-1074. 3. Stucky CC, Johnson KN, Gray RJ, et al. Malignant peripheral nerve sheath tumors (MPNST): the Mayo Clinic experience. Ann Surg Oncol. 2012;19:878-885. 4. Croker JR, Greenstein RJ. Malignant schwannoma of the stomach in a patient with von Recklinghausen’s disease. Histopathology. 1979;3:79-85. 5. Rădulescu D, Stoian M, Sârbu M. Gastric malignant schwannoma. Rev Med Chir Soc Med Nat Iasi. 1995;99:221-225. 6. Bees NR, Ng CS, Dicks-Mireaux C, Kiely EM. Gastric malignant schwannoma in a child. Br J Radiol. 1997;70:952-955. 7. Loffeld RJ, Balk TG, Oomen JL, van der Putten AB. Upper gastrointestinal bleeding due to a malignant schwannoma of the stomach. Eur J Gastroenterol Hepatol. 1998;10:159-162. 8. Takemura M, Yoshida K, Takii M, Sakurai K, Kanazawa A. Gastric malignant schwannoma presenting with upper gastrointestinal bleeding: a case report. J Med Case Rep. 2012;6:37. 9. Kwon Y, Lee SE, Hwang DW, Lim CS, Jang JY, Kim SW. Malignant peripheral nerve sheath tumor of the pancreas: a case report. Korean J Hepatobiliary Pancreat Surg. 2008;12:307-311. 10. Zou C, Smith KD, Liu J, et al. Clinical, pathological, and molecular variables predictive of malignant peripheral nerve sheath tumor outcome. Ann Surg. 2009;249:1014-1022. 11. Carli M, Ferrari A, Mattke A, et al. Pediatric malignant peripheral nerve sheath tumor: the Italian and German soft tissue sarcoma cooperative group. J Clin Oncol. 2005;23:8422-8430. 12. Carroll SL, Ratner N. How does the Schwann cell lineage form tumors in NF1? Glia. 2008;56:1590-1605. 13. Ferrari A, Bisogno G, Carli M. Management of childhood malignant peripheral nerve sheath tumor. Paediatr Drugs. 2007;9:239-248.
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
research-article2015
IJSXXX10.1177/1066896915573570International Journal of Surgical PathologyKim et al
Case Report
Gastric Malignant Peripheral Nerve Sheath Tumor: A Case Report
International Journal of Surgical Pathology 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896915573570 ijs.sagepub.com
Eun Young Kim, MD1, Sung Hak Lee, MD1, Han Mo Yoo, MD1, Kyo Young Song, MD, PhD1, and Cho Hyun Park, MD, PhD1
Abstract Gastric malignant peripheral nerve sheath tumors (MPNSTs) are sarcomas arising within a peripheral nerve. Gastric MPNSTs are extremely rare with only a few cases. We herein describe the case of a 48-year-old man with a gastric MPNST for the first time in Korea, which was diagnosed histopathologically after surgery. The patient underwent curative subtotal gastrectomy with D1+ lymph node dissection and Billroth-II reconstruction. The postoperative recovery was uneventful, and he has had no recurrence until now. The ideal adjuvant treatment protocol is yet to be decided due to the relatively limited number of cases of these tumors previously reported. Keywords gastric malignant peripheral nerve sheath tumors, schwannomas, surgery, adjuvant treatment
Introduction Malignant peripheral nerve sheath tumors (MPNSTs) are soft tissue neoplasms that usually arise from peripheral nerves and show variable differentiation toward one of the cellular components of the nerve sheath (Schwann cells, fibroblasts, and perineurial cells).1 MPNSTs include malignant schwannomas, neurofibrosarcomas, or neurogenic sarcomas. MPNSTs are extremely rare with only a few cases reported worldwide. In Korea, to our knowledge, gastric MPNSTs have never been reported. We herein present the case of a 48-year-old man with an exceedingly rare symptomatic gastric MPNST that was diagnosed histopathologically after gastrectomy.
Case Report In January 2014, a 48-year-old man with a 1-month history of melena was admitted to our hospital. He also complained of epigastric discomfort. He did not have any other disease history except for pneumothorax, 10 years ago. On admission, laboratory data revealed a hemoglobin level of 11.6 g/dL because the patient had received several red blood cell transfusions. Gastroduodenoscopy revealed a large distinct protruding mass with a central ulcer at the greater curvature of the gastric mid-body (Figure 1A). On the endoscopic biopsy, the result favored the possibility of neurogenic sarcoma rather than spindle cell carcinoma, gastrointestinal stromal tumor, leiomyosarcoma, and other types of sarcomas. Abdominal computed tomography
(CT) revealed an enhancing mass with large central ulceration at the greater curvature of the stomach mid-body with perigastric fat infiltration. Multiple enlarged perigastric lymph nodes were also noted (Figure 1B). Overall, the most probable clinical diagnosis for the lesion was a neurogenic sarcoma. The patient underwent a curative subtotal gastrectomy with D1+ lymph node dissection and Billroth-II reconstruction. Macroscopically, the elevated lesion was located at the posterior wall of the mid-body and the size was approximately 9.0 × 9.0 cm in diameter (Figure 2). The surface mucosa of the mass was ulcerated and it invaded the serosa but not the adjacent structures. Totally 32 lymph nodes were retrieved but there were not any cancer cells in the lymph nodes. The surgical safety margin (proximal cut margin, 1.5 cm; distal cut margin, 9.0 cm) was negative for tumor cells. Microscopic findings revealed diffuse infiltrative tumor spread throughout the entire wall, and no definite true capsules were histologically detected. The tumor was composed of a variety of bizarre tumor cells. In addition, the tumor consisted of spindle cells, showing a fascicular growth pattern with focal alternating hypercellular 1
The Catholic University of Korea, Seoul, Korea
Corresponding Author: Cho Hyun Park, Division of Gastrointestinal Surgery, Department of Surgery, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Korea. Email: [email protected]
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
2
International Journal of Surgical Pathology
Figure 1. (A) Gastroduodenoscopy revealed a distinctly large protruding mass with central ulcer at the greater curvature of the mid-body. (B) CT revealed a enhancing mass at the greater curvature of the mid-body with perigastric fat infiltration and large central ulceration was seen. Multiple enlarged perigastric lymphadenopathy were also noted.
and hypocellular areas. The neoplastic cells were mitotically active (up to 12 mitoses per 10 HPFs), with hyperchromatic nuclei and extensive pleomorphism (Figure 3A). Immunohistochemical studies showed that the tumor cells were weakly positive for S-100 (Figure 3B). Moreover, it was possible to rule out synovial sarcoma, fibrosarcoma, leiomyosarcoma, or gastrointestinal stromal tumor, because the results were negative for c-kit (Figure 3C), EMA, CK, bcl-2, CD99, DOG-1, actin, CD34, CD68, or desmin. As a whole, these histopathological and immunohistochemical findings were consistent with a gastric MPNST. The postoperative course of the patient was uneventful and he was discharged on the seventh postoperative day. Recently, he has had no recurrence on additional examination and is doing well.
Discussion
Figure 2. Macroscopically, the elevated lesion was approximately 9.0 × 9.0 cm in diameter and located at the posterior wall of the mid-body.
Malignant peripheral nerve sheath tumors are exceedingly rare with an expected incidence of 0.1/100 000 per year. The incidence of MPNSTs is approximately 5% to 10% of all soft tissue tumors.2 MPNSTs are typically diagnosed in patients between 20 and 50 years of age.3 MPNSTs occur most frequently in the extremities, although there have been a few reports of MPNSTs that originated from the intra-abdominal organs, including the stomach. Because of its limited incidence and recent regulation of MPNST conception, there is a paucity of data in the literature regarding prognostic factors, incidence, and
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
3
Kim et al
Figure 3. The tumor is hypercellular and has a fascicular growth pattern. Microscopic findings showed spindle-shaped tumor cells with frequent mitotic figures (A). Immunohistochemical analysis showed that the tumor cells were focally positive for S-100 protein (B), but lack staining for c-kit (C). Table 1. Literature Review. Author Croker and Greenstein Rădulescu et al5 Bees et al6 Loffeld et al7 Takemura et al8
4
Publication Year
Nation
Symptom and Sign
1979 1995 1997 1998 2012
United Kingdom Romania United Kingdom Netherlands Japan
Abdominal pain; weight loss; anemia Abdominal pain; melena Abdominal pain; tarry stool; vomiting Melena Abdominal pain; melena
long-term outcome in MPNST, especially in stomach. Of the English literature (searched in PubMed), from 1979 until now, there have been only 5 reports of the gastric MPNST.4-8 All the 5 cases presented with upper gastrointestinal bleeding or abdominal pain (Table 1). Our case also corresponded well with the first symptoms of the aforementioned reports. Several cases of gastric schwannomas have been reported in Korea, but there had been no previous cases of malignant schwannoma. In 2008, a pancreatic MPNST was the only case reported to affect intraabdominal organs in Korea.9
MPNSTs display unique clinicopathological characteristics. First, it is extremely difficult to diagnose MPNST. Much of the difficulty in diagnosing MPNST is the lack of specific neural differentiation biomarkers.10 Second, it may occur sporadically or in association with neurofibromatosis type 1 (NF-1). Approximately 25% to 50% of observed MPNSTs occur in patients with NF-1. Most patients with MPNST have a small, truncating mutation in the NF-1 gene that is associated with an 8% to 13% risk of developing MPNST.2 However, in our case, the patient was not associated with neurofibromatosis or mutation in
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
4
International Journal of Surgical Pathology
the NF-1 gene. As previously described, it is difficult to diagnose MPNST. Therefore, in our case, to make a diagnosis of MPNST and exclude probable disease, many immunohistochemical stains including S-100, c-kit, EMA, CK, DOG-1, Desmin, Actin, bcl-2, and CD99 were used. Third, another clinicopathological characteristic of MPNST is that they are very aggressive, and the survival is poor. Like other soft tissue sarcomas, MPNSTs recur locally and spread hematogenously.2 Although the ideal adjuvant treatment protocol is yet to be decided due to the relatively limited number of cases of these tumors previously reported, we put together the previous reports. As a result, the treatment choice of MPNST is curative surgical resection with negative margins. Radiation therapy and adjuvant systemic chemotherapy are important in addition to surgery in improving local control. Although improvement in local control have been seen with adjuvant radiation therapy, the only one study out of Milan, Italy, has been able to demonstrate that lack of radiation therapy predicts decreased disease-specific survival.3 Chemotherapy is generally ineffective, although some studies have shown that it may benefit patients with higher-grade tumors or children with unresectable tumors.11-13 Some trials have been achieved, but targeted molecular treatments are not yet available.1 In spite of aggressive surgery and adjuvant therapy, the prognosis for patients with MPNST is still poor,2 with the 5-year survival rates ranging from 35% to 50%.10 In some reports, large tumor size (10 cm) and a lack of S-100 staining were identified as important prognostic factors for the development of distant metastases in patients with localized MPNST.10 In our case, the mass was less than 10 cm and positive for S-100, and we expect to have better prognosis compared with other MPNST cases. However, application of the results is limited because the reports are originated from all MPNSTs, not only stomach. In conclusion, if the tentative diagnosis of a gastric lesion is neurogenic sarcoma before surgery, complete resection to remove all gross diseased tissues and achieving negative margins is important. In addition, careful histopathological and immunohistochemical review is very important to confirm the diagnosis of MPNST.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Thway K, Fisher C. Malignant peripheral nerve sheath tumor: pathology and genetics. Ann Diagn Pathol. 2014;18:109-116. 2. Anghileri M, Miceli R, Fiore M, et al. Malignant peripheral nerve sheath tumors: prognostic factors and survival in a series of patients treated at a single institution. Cancer. 2006;107:1065-1074. 3. Stucky CC, Johnson KN, Gray RJ, et al. Malignant peripheral nerve sheath tumors (MPNST): the Mayo Clinic experience. Ann Surg Oncol. 2012;19:878-885. 4. Croker JR, Greenstein RJ. Malignant schwannoma of the stomach in a patient with von Recklinghausen’s disease. Histopathology. 1979;3:79-85. 5. Rădulescu D, Stoian M, Sârbu M. Gastric malignant schwannoma. Rev Med Chir Soc Med Nat Iasi. 1995;99:221-225. 6. Bees NR, Ng CS, Dicks-Mireaux C, Kiely EM. Gastric malignant schwannoma in a child. Br J Radiol. 1997;70:952-955. 7. Loffeld RJ, Balk TG, Oomen JL, van der Putten AB. Upper gastrointestinal bleeding due to a malignant schwannoma of the stomach. Eur J Gastroenterol Hepatol. 1998;10:159-162. 8. Takemura M, Yoshida K, Takii M, Sakurai K, Kanazawa A. Gastric malignant schwannoma presenting with upper gastrointestinal bleeding: a case report. J Med Case Rep. 2012;6:37. 9. Kwon Y, Lee SE, Hwang DW, Lim CS, Jang JY, Kim SW. Malignant peripheral nerve sheath tumor of the pancreas: a case report. Korean J Hepatobiliary Pancreat Surg. 2008;12:307-311. 10. Zou C, Smith KD, Liu J, et al. Clinical, pathological, and molecular variables predictive of malignant peripheral nerve sheath tumor outcome. Ann Surg. 2009;249:1014-1022. 11. Carli M, Ferrari A, Mattke A, et al. Pediatric malignant peripheral nerve sheath tumor: the Italian and German soft tissue sarcoma cooperative group. J Clin Oncol. 2005;23:8422-8430. 12. Carroll SL, Ratner N. How does the Schwann cell lineage form tumors in NF1? Glia. 2008;56:1590-1605. 13. Ferrari A, Bisogno G, Carli M. Management of childhood malignant peripheral nerve sheath tumor. Paediatr Drugs. 2007;9:239-248.
Downloaded from ijs.sagepub.com at CMU Libraries - library.cmich.edu on September 15, 2015
