Metastatic prostate adenocarcinoma and high-grade appendiceal mucinous neoplasm mimicking acute appendicitis in a post-radiation therapy patient.

Prostate cancer is the most common visceral malignancy diagnosed in males. Surveillance for post-treatment neoplasms is very crucial. Here we report the first case of recurrent metastatic prostate cancer presenting as acute appendicitis in a background of a high-grade appendiceal mucinous neoplasm. In addition, this case also includes an unusually early presentation of a secondary primary malignancy after radiation therapy. A 70-year-old male with a history of prostate adenocarcinoma status post-proton radiation therapy presented with recurrent poorly differentiated prostate adenocarcinoma with disease progression and extra-prostatic extension. He underwent salvage proton therapy and testosterone replacement therapy. Two years later, the patient presented with right lower quadrant pain. A computed tomography scan showed perforated acute appendicitis with intra-abdominal abscess, which was treated with interval appendectomy. Upon histologic analysis, metastatic prostatic adenocarcinoma was noted in the appendiceal wall and mesoappendix. In addition, an incidental background of high-grade appendiceal mucinous neoplasm was found. Four months later, he presented with persistent abdominal pain, rapid weight loss, fatigue, and fever for 3 months. An abdominal CT scan revealed a 6.1 cm rectal mass. Pathologic analysis diagnosed an aggressive post-radiation spindle cell sarcoma, intermediate to high grade. The patient opted for palliative care. This case shows that a clinical presentation of acute appendicitis in an older patient may sometimes portend a neoplastic rather than infectious etiology. Clinical history and patient epidemiology should always be considered when evaluating an older patient with clinical signs and symptoms of acute appendicitis.

Severe chronic bowel obstruction associated with brown bowel syndrome.

A 61-year-old alcoholic male with history of cholecystectomy presented with a 20-year history of recurrent bowel obstruction and a 30 lb weight loss. After numerous attempts at conservative management, exploratory laparotomy was performed, which showed no mechanical cause. Despite no clear etiology, the obstruction persisted and intensified. A follow-up computed tomography scan revealed a small bowel obstruction with concurrent megacolon. A total abdominal colectomy was performed, with ileostomy. Grossly, there was intestinal dilation up to 15 cm with prominent brown discoloration of bowel wall. No strictures or other fixed obstruction were identified. Microscopic examination revealed prominent lipofuscin-like pigment deposition, involving the muscularis propria, muscularis mucosae, and vascular smooth muscle. Histochemical staining was positive for periodic acid-Schiff and negative for iron and calcium, consistent with lipofuscin. The gross and histologic findings fit with brown bowel syndrome. Brown bowel syndrome is a very rare condition characterized by lipofuscin deposits predominantly within the smooth muscle of the muscularis mucosae and/or muscularis propria that imparts a brown color to the bowel. It is generally thought to be a smooth muscle mitochondrial myopathy due to chronic vitamin E deficiency secondary to fat malabsorption syndromes, resulting in free radicals causing peroxidation of unsaturated membrane lipids with accumulation of lipofuscin. Brown bowel syndrome may be seen in patients with alcohol abuse, maldigestion, chronic bowel inflammation, and intestinal lymphangiectasia. Our patient's severe chronic intestinal pseudo-obstruction, low levels of certain fat-soluble vitamins (A, D, and E), significant weight loss and history of cholecystectomy with alcohol abuse correlates with brown bowel syndrome clinically.

Regional Lymph Node Enlargement in Clinically Severe Cherubism.

Cherubism is a rare benign autosomal dominant disorder characterized by progressive, painless, bilateral enlargement of the mandible and/or maxilla because of bone replacement by fibrotic stromal cells and osteoclast-like cells forming multilocular cysts. The lesions typically stabilize and regress after puberty. We present a 14-year-old male with severe familial cherubism. Bilateral mandibular enlargement began around age 4 and progressed until puberty, affecting his speech and mastication without subsequent involution. Composite mandibulectomy and mandible reconstruction with fibula free flap technique improved functionality and cosmesis. Histology was consistent with the diagnosis of cherubism, showing large areas of bland spindle-cell fibrous tissue and moderately abundant collagen and multiple nodules of giant cell-rich tissue resembling central giant cell granuloma. Regional lymph nodes were sampled due to enlargement, demonstrating hemosiderin-laden macrophages and basophilic laminated concretions localized to the cortical interfollicular space and along the peripheral follicular marginal zone, findings which have not been previously reported.

Primary B-cell lymphoma of the uterine cervix: Presentation in Pap-test slide and cervical biopsy.

This case involved a 69-year-old female who presented with irritative urinary voiding. Imaging studies showed an 18-cm uterine mass centering on the cervix and extending into the bladder. The Pap test slide demonstrated necrotic background and degenerative changes in single and grouped atypical "small round blue cells" with high nuclear/cytoplasm ratio, scant cytoplasm, and hyperchromatic focally cleaved nuclei with occasional nuclear membrane "snout projections." Cervical biopsies showed similar findings. The tumor cells were positive for CD45, CD20, and PAX-5, and negative with epithelial, neuroendocrine, and muscle markers. A Ki-67 immunostain showed a markedly elevated proliferative index and the MUM1 stain was diffusely positive. Molecular study identified clonal immunoglobulin heavy chain gene rearrangement. Owing to its rarity, cervical lymphoma may sometimes be confused with other types of malignant neoplasms or inflammatory processes. Therefore, it is important to recognize the cytological features of cervical lymphomas and be aware of the potential diagnostic pitfalls for timely diagnosis and therapy. Diagn. Cytopathol. 2017;45:235-238. © 2016 Wiley Periodicals, Inc.

Functioning gangliocytic paraganglioma of the ampulla: clinicopathological correlations and cytologic features.

Gangliocytic paraganglioma (GP) is a rare neuroendocrine tumor almost exclusively found in the ampulla. It is considered nonfunctioning in the literature. We herein report the first case of functioning GP arising in the ampulla. Our patient had a constellation of ampullary neuroendocrine tumor, flushing, diarrhea, weight loss, diabetes mellitus, and cholelithiasis, consistent with effects of serotonin and somatostatin that were overexpressed by the ampullary neuroendocrine tumor. The serum serotonin level was elevated. Immunostaining confirmed somatostatin expression by the epithelioid cells and ganglion-like cells of GP. After surgical resection of the tumor, the patient became euglycemic. However, computed tomography (CT) scan 3 months post-surgery showed regional lymphadenopathy suspicious for residual/recurrent/metastatic disease. In the interim, his flushing and hyperglycemia recurred and worsened. Increased awareness about the functioning potential of GP is important so that the underlying pathophysiologic link is not overlooked and patients are appropriately managed. Moreover, we describe the cytologic features that help make the preoperative diagnosis, and these have not been previously described.

Non-pancreatic retroperitoneal mucinous neoplasms and a discussion of the differential diagnosis.

Retroperitoneal mucinous neoplasms are common and have a wide range of differential diagnoses to consider. It is of utmost importance to maintain a multidisciplinary approach when evaluating these lesions. Clinical history, surgical impression and radiographic studies should be obtained and used in conjunction with morphology and immunohistochemistry to help guide the pathologist to the correct diagnosis. We recently encountered a case of a 51-year-old man who presented with an 11.5 cm left-sided retroperitoneal mucinous neoplasm. This lesion was initially diagnosed as a low-grade mucinous carcinoma of probable pancreatic origin at an outside facility, and he was subsequently treated with chemotherapy. One year later he presented to our institution and underwent retroperitoneal en bloc resection of the 7-cm residual multiloculated mucinous neoplasm. When discussed at tumor board additional medical history was obtained, and review of the patient's chart revealed a remote history of left orchiectomy for a mixed malignant germ cell tumor and metastatic embryonal carcinoma in 2 of 34 retroperitoneal/para-aortic lymph nodes. With no clinical evidence of tumor in the pancreas or extension from it, the predominately para-aortic location of the tumor favors a mucinous carcinoma arising from a rest of mature metastatic/proliferating teratoma that persisted after chemotherapy. This case illustrates the importance of a thorough history, however remote, and correlation with imaging in the development of differential diagnoses, as well as, the need to consider non-pancreaticobiliary sources of retroperitoneal mucinous tumors.

Nuclear protein in testis midline carcinoma with unusual elevation of α-fetoprotein and synaptophysin positivity: a case report and review of the literature.

Nuclear protein in testis (NUT) midline carcinoma (NMC) is a rare cancer that displays a characteristic chromosomal rearrangement of BRD4-NUT t(15;19)(q14;q13.1). Despite occasional dramatic responses to radiation and chemotherapy, NMC usually behaves aggressively and becomes rapidly progressive. Immunohistochemical staining is usually limited to p63, cytokeratins, and monoclonal NUT antibody. Here, we report a NMC case in a 36-year-old man with elevated serum α-fetoprotein (AFP), synaptophysin positivity, and a 9.0 cm mass involving the right lung and mediastinum. Tumor cells demonstrated BRD4-NUT fusion on fluorescence in situ hybridization. To our knowledge, only one other case with elevated serum AFP and one case with synaptophysin positivity have been described. This diagnosis will undoubtedly grow more common as informed physicians become more aware of the disease and begin testing for NMC. Further study is needed to establish the prevalence of NMC and to elucidate the significance of elevated AFP and synaptophysin positivity in this rare tumor.

Cytoplasmic vacuoles: clue in the fine-needle aspiration diagnosis of melanoma.

For the fine-needle aspiration (FNA) diagnosis of melanoma recognition of characteristic morphologic features is key. In our practice we noted that cytoplasmic vacuoles in Romanowsky-stained FNA smears of melanoma appeared to be a frequent finding. To investigate this premise, we examined 36 consecutive melanoma FNA cases that had both adequate Papanicolaou-stained and Romanowsky-stained smears in an effort to determine the prevalence, and thereby, the potential diagnostic utility of cytoplasmic vacuoles in the diagnosis of melanoma compared to established cytomorphologic parameters of melanoma. We found pigment in 21 cases (58%) and plasmacytoid cells in 28 cases (78%), and in all 36 cases (100%) we found bi/multinucleation, intranuclear cytoplasmic inclusions and prominent nucleoli. Cytoplasmic vacuoles were present in 30 cases (83%) and were found in air-dried Romanowsky-stained smears only. These findings suggest that in FNA smears of melanoma cytoplasmic vacuoles in Romanowsky-stained smears have prevalence and potential diagnostic utility that are comparable to widely recognized cytomorphologic features of melanoma. Numerous articles have focused on the cytomorphologic criteria for the FNA diagnosis of melanoma, but few have noted the presence of cytoplasmic vacuoles in FNA smears of melanoma, and rare reports suggest this finding to be a useful clue to the FNA diagnosis of melanoma. This report appears to be the first to focus on the prevalence and potential diagnostic utility of cytoplasmic vacuoles in FNA samples of melanoma.

Cytopathology of the pancreatobiliary tract-the agony, and sometimes, the ease of it.

Pancreatic cytopathology is recognized as a rapid, reliable, safe and cost-beneficial modality of investigation of pancreatic mass lesions. Optimal cytodiagnosis depends on multiple factors including sample quality, and expertise of the cytopathologist and endoscopist. This article discusses key cytologic features of specific tumor types, specimen handling, differential diagnoses and pitfalls.

Cytopathologic diagnosis of liver mass lesions.

The liver is a common site for metastatic malignancies, particularly from the gastrointestinal tract. It also may be involved by primary neoplasms, both benign and malignant. Cytopathologic examination of mass lesions of the liver with pertinent use of ancillary studies is a useful method of establishing a correct diagnosis for patient management. The authors reviewed the literature for articles pertaining to cytologic characteristics of specific tumor types, utility of immunohistochemical markers and pertinent molecular studies, differential diagnoses and pitfalls.

Parotid dermoid cyst: a case report.

A dermoid cyst arising in the parotid is rare and usually represents the rare first branchial cleft type II anomaly, which can have morphology similar to a dermoid cyst. This study reports the case of a 20-year-old woman who presented with a parotid mass, which on histologic review was consistent with a dermoid cyst. This appears to be the first case report of a parotid dermoid cyst with focus on the gross and histopathologic findings and to be presented in a histopathology focused journal. The discussion includes the clinical presentation, imaging findings, gross pathology, histologic features, and differential diagnosis of parotid dermoid cysts. Although there was no prior fine needle aspiration (FNA) of the lesion in this case, parotid masses are commonly subject to FNA prior to excision. Therefore, a brief review of the FNA findings in dermoid cysts is also included.

Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers.

Cytology of gastro-intestinal (GI) tract lesions can be used successfully to diagnose neoplastic and non-neoplastic conditions, especially when combined with biopsies. Cytologic evaluation is widely accepted as a cost-effective method that allows rapid interpretation and triaging of material. Technical advances over the years have allowed simultaneous visualization of abnormal tissue and procurement of needle aspirates, brushings and biopsies from mucosal and deeper seated lesions. Successful cytologic examination of the GI tract is highly dependent on the skill of the endoscopist, specimen preparation, the expertise of the pathologist, and the recognition of the limitations of cytology. This article reviews the key cytologic features of important GI tract lesions, differential diagnoses, and pitfalls, and addresses the advantages and limitations of different collection techniques.

Fine needle aspiration cytology and diagnostic pitfalls in Warthin's tumor with necrotizing granulomatous inflammation and facial nerve paralysis: a case report.

BACKGROUND: Warthin's tumor can be associated with various secondary changes that challenge both clinical and cytologic diagnosis. CASE: A 44-year-old man presented with a Warthin's tumor (WT) that was associated with multiple secondary changes. The right parotid mass was present and mostly asymptomatic for 6 years, but during the 7th year, there was pain and ipsilateral facial nerve dysfunction following abrupt increase in size of the mass. Fine needle aspiration (FNA) yielded murky, brown, viscous fluid, and the residual mass was also aspirated. Cytologic examination showed acute, chronic and granulomatous inflammation and rare squamous cells in a background of finely granular necrotic debris. Oncocytes were not identified. Histologic examination of the excised mass revealed a WT with extensive necrotizing granulomatous inflammation, with acute and chronic inflammation, fibrosis and squamous metaplasia. Microorganisms were not identified by culture or by special stains of the FNA cell block and histologic sections. CONCLUSION: The secondary changes observed in this case probably relate to spontaneous infarction of the WT. Awareness of the secondary changes that can occur in WT will help prevent misdiagnosis, which could result in inappropriate therapy, including unnecessary radical surgery.

Clinical significance of atypical glandular cells in conventional pap smears in a large, high-risk U.S. west coast minority population.

OBJECTIVE: To determine the incidence of clinically significant lesions on subsequent histologic follow-up in high-risk, predominantly minority patients with atypical glandular cells (AGC). STUDY DESIGN: A retrospective study was done on conventional Pap smears diagnosed as AGC of endocervical origin (AGC-EC), AGC of endometrial origin (AGC-EM) and AGC not otherwise specified (AGC-NOS) between January 1, 2003, and December 31, 2005. Histologic diagnoses were correlated with cytologic diagnoses. RESULT: Confirmed AGC cases were divided into 4 categories: 187 AGC-NOS, 169 AGC-EC, 68 AGC and atypical squamous cells of undetermined significance (ASCUS) and 36 AGC-EM. A total of 105 patients (22.8%) had significant precancerous (cervical intraepithelial neoplasia [CIN] 2/3, adenocarcinoma in situ [AIS]) or malignant (carcinoma) histologic outcomes. CIN 2/3 was the most common significant histologic outcome in women with AGC and ASCUS and patients <35 years with AGC. Endometrial neoplasia was the most common significant outcome in women with AGC-NOS and AGC-EM Pap results and in AGC patients > or =35. In women with AGC-EC Pap results, glandular cervical neoplasia occurred in 8.3% and CIN 2/3 in 5.9% offollow-up biopsies. CONCLUSION: AGC subtype and age significantly affect the probability of precancerous and malignant follow-up findings and anatomic site of neoplastic lesions. Access to newer screening technologies such as high-risk HPVDNA testing and liquid-based cytology will likely benefit such high-risk populations.

Breast fine-needle aspiration samples reported as "proliferative breast lesion": clinical utility of the subcategory "proliferative breast lesion with atypia".

BACKGROUND: The fine-needle aspiration (FNA) diagnosis of proliferative breast lesion is an indeterminate category. The aim of this correlative study was to determine whether a subcategory of "proliferative breast lesion with atypia" was achievable and whether this subcategory has management utility. METHODS: Breast FNA cases from 2000 through 2005 diagnosed as proliferative breast lesion and proliferative breast lesion with atypia were retrieved. Both cytologic and surgical slides of these cases were reviewed blindly. A cytologic diagnosis of proliferative breast lesion (without atypia) or proliferative breast lesion with atypia was used if the findings of the proliferative breast lesion did not fit a more specific category. RESULTS: Of the 3934 breast FNAs performed on palpable breast masses from January 2000 to December 2005 at the LAC + USC Medical Center, 317 (8.1%) were diagnosed cytologically as proliferative breast lesion with atypia, without atypia or without mention of atypia. There was subsequent histopathology on 201 of these cases. After the cytologic smears were reviewed, 29 cases were excluded from this study. Of the 172 remaining cases, 21 (12.2%) were found to be malignant and the remaining 151 (87.8%) were found to be benign on histology. Of the malignant cases, 90% had an FNA diagnosis of proliferative breast lesion with atypia; of the benign cases, 78% were interpreted as proliferative breast lesion without atypia. CONCLUSIONS: Proliferative breast lesion with atypia was clinically significant because it was associated with a significantly increased likelihood of malignancy compared with proliferative breast lesion without atypia. Most of the malignancies had hypocellularity or low nuclear grade on the FNA smears. Fibroadenoma accounted for most of the benign lesions in both proliferative breast lesion and proliferative breast lesion with atypia.

Extra-salivary gland presentations of adenoid cystic carcinoma: a report of three cases.

Adenoid cystic carcinoma (ACC) is a malignant neoplasm most commonly originating in salivary glands of the head and neck area. When ACC presents outside of these locations, the diagnosis may become more challenging. We describe three cases of ACC presenting in extra-salivary gland sites. Two cases were metastatic; in case 1 the initial presentation was widespread bony metastasis of unknown primary origin. The other metastatic case (case 2) was from a patient presenting with a pleural effusion and a history of previously treated metastatic pulmonary ACC. The pleural effusion cytology was unusual in that exfoliated ACC cells were present in the effusion itself, a rare occurrence. Case 3 was a primary bronchial ACC. In conclusion, ACC can present in various body sites and cytologists must consider this neoplasm when presented with a basaloid carcinoma of uncertain origin.

Fine-needle aspiration diagnosis of Hodgkin lymphoma using current WHO classification--re-evaluation of cases from 1999-2004 with new proposals.

With the advent of modern therapy, the differences in prognoses and treatment regimens among different subtypes of Hodgkin lymphoma (HL) have largely vanished. Stage and the presence of systemic symptoms are much more important than histologic subtypes as predictive factors. The current (2001) WHO classification markedly de-emphasizes spatial relationships as critical to the diagnosis of lymphoma and emphasizes cell morphology, immunophenotype, genetic features, and clinical information to define the disease states. This classification, thus, greatly enhances the capability of fine-needle aspiration (FNA) to accurately diagnose HL. We searched all the FNA cases in our institute in years 1999 through 2004 and found 42 cases, for which 13 were primarily diagnosed (31.0%), 2 were recurrent (4.8%), 5 were highly suspicious (11.9%), and 22 were suspicious (52.3%) for HL. On follow-up tissue biopsy, all the primarily diagnosed, recurrent, and highly suspicious cases were confirmed to be HL (100% agreement). For the 22 suspicious cases, 13 were HL (59.1%), 5 were other lymphomas (22.8%), 1 was lymphoma unclassifiable (4.5%), and 3 were reactive processes (13.6%). The effect of immunostains on the diagnosis of HL was examined, and its importance was emphasized. Analysis of demographic data and the distribution of HL subtypes demonstrate that the study sample is representative of the general HL patient population. On the basis of these results, we propose: (1) If the FNA diagnosis of HL is confirmed both by morphology and immunostains, no further tissue confirmation, subclassification and grading is necessary, and appropriate treatment regimens should follow. (2) The nodular lymphocyte predominant HL and classical HL can be differentiated by adequate immunostaining. (3) If a definitive diagnosis cannot be achieved by FNA, a second FNA or a tissue biopsy should be recommended.

Fine-needle aspiration of a pleomorphic lipoma of the head and neck: a case report.

Pleomorphic lipoma is a rare soft-tissue tumor, most commonly seen in the head and neck regions of middle-aged men. Fine-needle aspiration (FNA) of these lesions can present a diagnostic challenge. Its large, hyperchromatic cells and multinucleated forms (floret cells) can easily be mistaken for a malignancy. A patient with a round, well-circumscribed, painless, soft, subcutaneous posterior neck mass for 6 yr presented to our FNA clinic. Aspiration of the mass showed a hypocellular specimen with atypical large and floret cells with fragments of mature fibroadipose tissue in the background. Based on the clinical and cytomorphological findings, a diagnosis of pleomorphic lipoma was suggested, and it was confirmed on excision. This case highlights the need to be aware of unusual benign lesions that may arise in the head and neck region. Knowledge of these benign lesions will help in making the correct cytological diagnosis when these lesions are sampled by FNA.