Primary mixed large cell neuroendocrine and high grade serous carcinoma of the endometrium.

Endometrial large-cell neuroendocrine carcinoma admixed with a high-grade serous (HGS) adenocarcinoma is extremely rare with only one reported case in the literature. We present the second reported case in a 47-year-old woman who presented with abdominal pain, distension and loss of weight. On examination she had a fixed pelvic mass and vascular left vaginal mass. Imaging confirmed a 13 cm solid cystic rectouterine pelvic mass, omental disease and retroperitoneal lymphadenopathy. She underwent a modified posterior exenteration, partial posterior vaginectomy, omentectomy and Hartmanns procedure with suboptimal debulking. Histopathology revealed a stage 4B mixed carcinoma with large cell neuroendocrine (70%) and HGS carcinoma (30%). Eight cycles of adjuvant cisplatin and paclitaxel were given with a complete radiological and biochemical response after 7 months. Unfortunately, she developed widespread recurrence at 9 month and was offered second line chemotherapy.

Evaluation of pathology review at gynaecological oncology multidisciplinary team meetings: a 5-year prospective analysis of cases with major diagnostic discordance.

Multidisciplinary team meetings (MDTs) play an essential role in the management of patients with newly diagnosed and recurrent cancers, and often include review of pathology specimens that were initially assessed in external departments. Many studies have demonstrated a low but significant rate of diagnostic disagreement following such review but the pathological findings have seldom been detailed. We present a prospective 5-year study of all external cases reviewed at the Western Australian Gynaecological Oncology MDT focusing upon those cases with major diagnostic discordance likely to impact patient management. In total, 1275 cases were reviewed of which 132 (10.4%) were considered discordant including 48 (3.8%) with major discordance. Different interpretation of the presence and/or extent of tumour invasion accounted for a significant proportion of cases and in particular some adenocarcinoma and squamous carcinoma variants were initially reported to show only in situ or minimally invasive disease. Endometrial high-grade serous carcinoma was under-recognised and on occasion reassignment of tumour origin including metastasis to the gynaecological tract was facilitated by additional clinical information and supported by appropriate immunohistochemistry. This study supports the role of pathology review at MDTs and highlights problematic lesions that may merit a low threshold for additional opinion and ancillary studies.

Clinical outcome of atypical endometrial hyperplasia diagnosed on an endometrial biopsy: institutional experience and review of literature.

The aims of this study were: (1) to review the rate of concurrent endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia (AEH); and (2) to determine the features of concurrent endometrial carcinoma and their impact on the subsequent management of AEH. We reviewed a retrospective series of 219 AEHs diagnosed locally in routine practice, over 24 years, and followed by a repeat biopsy or hysterectomy. Another series of 65 cases with a malignant diagnosis on preoperative sampling was included as a control group. Clinicopathologic parameters were obtained. In addition, published data on the risk of malignancy and features of malignant tumors after a diagnosis of AEH were collected and analyzed. This study reported on 2571 patients diagnosed in 31 published studies in addition to the current one. This showed a wide variation in the positive predictive value (PPV) of AEH in detecting endometrial cancer (6% to 63%) with an overall PPV of 37%. This variation is not only based on the differences among studies but also on the degree of atypia [mild/moderate (PPV 13%) or severe (PPV 50%)], the type of subsequent intervention (biopsy vs. hysterectomy), and more importantly the time period of diagnosis (around 20% in studies published before 1990s and up to 40% to 48% in recently published cases). Of the benign outcome cases, nearly 40% to 50% showed AEH with a potential risk of progressing to invasive carcinoma in 25% of cases. Malignant tumors after AEH diagnosis are associated with features of good prognosis with endometrioid morphology, lower grade, and early stage. Although the overall PPV of AEH is 37%, a figure of 40% to 48% is expected in the cases currently diagnosed in routine practice. Providing qualifying criteria for AEH will help identify its different associated risks and therefore should be included in routine pathology reports whenever possible. Unless there is a clinical contraindication, hysterectomy should be performed to treat concurrent carcinoma and to reduce the risk of subsequent carcinoma in nonmalignant cases with residual AEH.

Rare pleural recurrence of typical pulmonary carcinoid tumor 30 years after lobectomy.

A 68-year-old man, who underwent a left lower lobectomy for a typical carcinoid tumor 30 years previously, presented with a 2-year history of left-sided chest pain. A computed tomographic scan, an octreotide scan, and pleural biopsy all showed recurrence of carcinoid tumor in the pleura. He underwent left chest wall resection, and histopathologic examination confirmed the diagnosis of typical carcinoid tumor. A review of the literature indicates that this is only the second reported case of pleural recurrence after previous complete resection of typical pulmonary carcinoid tumor. This case is even more unusual in that the recurrence presented so long after surgery.

Follicular bronchiolitis, an unusual cause of haemoptysis in giant cell arteritis.

The occurrence of follicular bronchiolitis (FB), lymphoid hyperplasia of the bronchus-associated lymphoid tissue, is reported in association with several systemic rheumatic diseases. However, the occurrence of FB in patients with giant cell arteritis (GCA) is not described. A 64-year-old man with long-standing GCA subsequently presented with haemoptysis. A mass in the lower lobe of the left lung was seen on chest x-ray and computed tomography. A wedge resection was performed, and histological examination revealed bronchiectasis, granulation tissue and hyperplasia of peribronchiolar lymphoid aggregates, consistent with FB. FB should be included in the differential diagnosis of haemoptysis in patients with systemic rheumatic diseases.