Breast Implant-Associated Anaplastic Large Cell Lymphoma Presenting in a Postpartum Patient: A Case Report.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare cancer found in women with breast implants, occurring approximately eight years after their placement. Since the initial case report of BIA-ALCL in 1997, over 700 cases have been described worldwide and there is now a registry of cases diagnosed in the United States to help learn more about this disease process and prognosis. The majority of cases have been associated with Allergan's textured implants which have been recalled. As this disease is relatively rare with only 1,130 cases described worldwide, it is important to keep BIA-ALCL in mind in the differential diagnosis of a woman presenting with breast swelling and peri-implant fluid collection in the setting of having a textured implant. Outcomes for women with BIA-ALCL are favorable, as most disease is contained within the peri-implant capsule. Thus, complete surgical resection is often curative. Here, we report the case of a 40-year-old woman with BIA-ALCL who presented with unilateral breast swelling in the peripartum period.

Mucinous Tumor Coexisting With Mesonephric-like Proliferation/Tumor in the Ovary: A Novel Association.

The literature indicates that mesonephric carcinoma (MC) and mesonephric-like adenocarcinoma (MLA) typically lack mucinous and squamous features/differentiation. We report 4 cases of ovarian mucinous tumors (1 mucinous cystadenofibroma and 3 mucinous borderline tumors/atypical proliferative mucinous tumors [MBT/APMT]) co-existing with mesonephric-like lesions which were highlighted by Gata3 and Pax8 expression. All cases contained benign mesonephric-like proliferations (MLP) which focally displayed gastrointestinal-type mucinous metaplasia/differentiation and some were intimately admixed with mucinous glands associated with the mucinous tumor. Metaplastic mucinous epithelium retained expression of Gata3 and Pax8 in some areas while 1 mucinous cystadenofibroma and 1 MBT/APMT were focally positive for Pax8. Along with these mesonephric components, case 1 exhibited features of mesonephric hyperplasia and in 2 cases, 3 and 4, MLA was identified. In case 4, a KRAS c.35G>T (p.Gly12Val) somatic mutation was detected in both the MBT/APMT and the MLA, indicating a clonal origin. This same mutation was also detected in the benign MLP, indicating that it was likely an early genetic event. A CTNNB1 c.98C>T (p.Ser33Phe) somatic mutation, FGFR2 amplification, and CDKN2A/p16 deletion were only detected in the MLA but not in the MBT/APMT. Our result provides evidence to demonstrate the clonal relationship between these morphologically distinct components. Although speculative, we postulate that benign MLPs may give rise to lineage-specific mucinous and mesonephric-like lesions and propose that the MLPs are a new possible origin of some ovarian mucinous tumors. Whether these MLPs arise through transdifferentiation of Müllerian tissue or represent true mesonephric remnants, however, remains largely unknown.

When in Doubt, Cut It Out: Biopsy as Key in Diagnosing Cryptococcal Soft Tissue Infection.

Soft tissue infection is an uncommon presentation of Cryptococcus in the absence of immunosuppression. Most infected patients present with pneumonia or meningitis, often with signs of disseminated disease, which may be fatal. We present a case of an 81-year-old mildly immunocompromised woman with multiple comorbidities, who presented with an extensive soft tissue infection on her right medial thigh. Superficial skin culture grew vancomycin-resistant Enterococcus; however, both initial and subsequent antibacterial therapies failed to resolve the infection. Subsequent biopsy revealed abundant yeasts, and mucicarmine staining confirmed Cryptococcus infection in a patient with no evidence of disseminated disease. Wound debridement and fluconazole for six months resulted in complete resolution of the lesion. In this report, we emphasize the need for tissue biopsy and microbial cultures in diagnosing patients with atypical skin and soft tissue infections who do not respond to appropriate antibiotics.

Invasive Paget's Disease of the Breast: Rash or Recurrence?

Paget's disease of the breast is rare among breast cancers. Secondary Paget's disease of the breast presenting as local recurrence is even rarer, with limited published information on the overall prevalence. In this report, we present a case of secondary Paget's disease of the breast presenting as a pruritic rash and skin changes with normal imaging. This patient's case was unique as her presentation involved invasive Paget's disease of the breast presenting as a local recurrence, with a diffuse rash covering the entirety of the right breast including the nipple-areolar complex, pathology examination showing dermal invasion, and a 20-year time interval between her initial treatment and presentation at our institution. Furthermore, diagnostic mammogram and breast MRI revealed no underlying suspicious findings within the breast tissue. In this case, the patient benefitted from mastectomy with removal of the affected skin, resulting in a clear margin and clinically favorable outcome. The patient did well postoperatively, did not receive any systemic adjuvant treatment, and is now under surveillance. Currently, there is insufficient data on the incidence of diffuse Paget's disease of the breast with dermal invasion. It is important to recognize this atypical presentation to ensure timely diagnosis and treatment of affected patients.

GATA-3 expression in trophoblastic tissues: an immunohistochemical study of 445 cases, including diagnostic utility.

Immunohistochemical expression of GATA-3 is seen predominantly in non-neoplastic bladder and breast epithelium and their respective carcinomas; however, data on expression in normal and lesional trophoblastic tissues are limited. Immunohistochemical staining for GATA-3 was assessed in a range of normal/lesional trophoblastic tissues and tumors in the differential diagnosis (n=445), including nonmolar products of conceptions/second and third trimester placentas/ectopic pregnancies, hydatidiform moles, placental site nodules, normal/exaggerated implantation sites, choriocarcinomas, epithelioid trophoblastic tumors, placental site trophoblastic tumors, atypical smooth muscle tumors (including leiomyosarcoma), and cervical and pulmonary squamous cell carcinomas. The extent of expression (0 to 4+) and intensity (weak to strong) were recorded. All cases with developing trophoblast/non-neoplastic trophoblastic proliferation and 81% of trophoblastic neoplasms were positive. Of all non-neoplastic trophoblast cell types, expression was observed in cytotrophoblast in 89% of cases, syncytiotrophoblast in 50%, intermediate trophoblast in 100%, and villous trophoblastic columns in 100%. Increasing gestational age was associated with a decrease in extent/intensity of expression in non-neoplastic cytotrophoblast and syncytiotrophoblast, whereas intermediate trophoblast maintained diffuse and strong expression from early to late gestation (P<0.0001). Eighty-nine percent of normal/exaggerated implantation sites showed 3+ or 4+ expression, whereas staining in 55% of placental site nodules was 1+ or 2+. Staining for GATA-3 was present in 78% of choriocarcinomas, 95% of epithelioid trophoblastic tumors, and 71% of placental site trophoblastic tumors. Although the number of choriocarcinomas and placental site trophoblastic tumors that showed a spectrum of expression ranging from negative to diffuse was relatively evenly distributed, 81% of epithelioid trophoblastic tumors had 3+ or 4+ staining. None of the atypical smooth muscle tumors and 3% of squamous cell carcinomas were positive, all of which exhibited weak staining. We conclude that GATA-3 is frequently expressed in normal and lesional trophoblastic tissues. It is also differentially expressed in intermediate trophoblast and cytotrophoblast/syncytiotrophoblast, which varies according to time during pregnancy. This study expands the spectrum of neoplasms known to express GATA-3. Thus, recognition of expression in trophoblastic tumors is important, because it can present a diagnostic pitfall in the assessment of suspected metastatic bladder or breast carcinomas involving the gynecologic tract. In the evaluation of diagnostically problematic tumors for which trophoblastic neoplasms are in the differential diagnosis, such as leiomyosarcoma and squamous cell carcinoma, GATA-3 can be included as part of an immunohistochemical panel particularly when other trophoblastic markers are either not available or yield ambiguous results.

Indeterminate cell tumor of the spleen.

Indeterminate cell tumor is an extremely rare neoplasm that mainly occurs in the skin. We report a case of indeterminate cell tumor arising from the spleen, a previously unreported site for indeterminate cell tumor. Histologically, the tumor showed nests, nodules, and sheets of large polygonal cells with mostly oval nuclei; open chromatin; variable nucleoli; and abundant, eosinophilic cytoplasm. Some cells possessed irregularly convoluted nuclei with nuclear grooves and granular cytoplasm, suggestive of Langerhans cells. Immunohistochemically, the tumor cells were diffusely positive for S-100 and CD1a and negative for Langerin. No Birbeck granules were found by electron microscopy. Clinical and radiologic examination showed no other organomegaly or lymphadenopathy. A diagnosis of primary indeterminate cell tumor of the spleen was rendered. To the best of our knowledge, this is the first indeterminate cell tumor reported in the spleen. Biologic insights into dendritic cells in the spleen and the pertinent literature on these entities are reviewed.

Plateau and transpulmonary pressure with elevated intra-abdominal pressure or atelectasis.

BACKGROUND: ARDSnet standards limit plateau pressure (Pplat) to reduce ventilator induced lung injury (VILI). Transpulmonary pressure (Ptp) [Pplat-pleural pressure (Ppl)], not Pplat, is the distending pressure of the lung. Lung distention can be affected by increased intra-abdominal pressure (IAP) and atelectasis. We hypothesized that the changes in distention caused by increases in IAP and atelectasis would be reflected by Ptp but independent of Pplat. METHODS: In Yorkshire pigs, esophageal pressure (Pes) was measured with a balloon catheter as a surrogate for Ppl under two experimental conditions: (1) high IAP group (n=5), where IAP was elevated by CO2 insufflation in 5 mm Hg steps from 0 to 30 mm Hg; and (2) Atelectasis group (n=5), where a double lumen endotracheal tube allowed clamping and degassing of either lung by O2 absorption. Lung collapse was estimated by increases in pulmonary shunt fraction. RESULTS: High IAP: Sequential increments in IAP caused a linear increase in Pplat (r2=0.754, P<0.0001). Ptp did not increase (r2=0.014, P=0.404) with IAP due to the concomitant increase in Pes (r2=0.726, P<0.0001). Partial Lung Collapse: There was no significant difference in Pplat between the atelectatic (21.83+/-0.63 cm H2O) and inflated lung (22.06+/-0.61 cmH2O, P<0.05). Partial lung collapse caused a significant decrease in Pes (11.32+/-1.11 mm Hg) compared with inflation (15.89+/-0.72 mm Hg, P<0.05) resulting in a significant increase in Ptp (inflated=5.97+/-0.72 mm Hg; collapsed=10.55+/-1.53 mm Hg, P<0.05). CONCLUSIONS: Use of Pplat to set ventilation may under-ventilate patients with intra-abdominal hypertension and over-distend the lungs of patients with atelectasis. Thus, Ptp must be used to accurately set mechanical ventilation in the critically ill.