Carcinosarcoma of the parotid gland: a case report and review of the literature.

BACKGROUND: Carcinosarcoma of the parotid gland is an extremely rare malignancy comprising of 0.04-0.16% of all salivary gland tumors. This is the first case of an adenoid cystic carcinoma with chondrosarcoma to the best of our knowledge. They consist of distinct carcinomatous and sarcomatous components and may arise de novo or from a preexisting pleomorphic adenoma. CASE PRESENTATION: Herein we present a case of an 80-year-old white female who presented with progressively increasing left facial swelling over 6 weeks. Magnetic Resonance Imagining revealed a mass (3.4 cm) in the parotid gland with a predominant cystic/necrotic component. The cytology was atypical (Milan3) and a total parotidectomy and selective lymph node dissection was done. The resection showed extensive necrosis with high grade sarcomatous (chondrosarcoma) areas. The epithelial component was adenoid cystic carcinoma with perineural invasion. The patient is currently undergoing radiotherapy of the tumor bed and skull base due to propensity of perineural invasion of the adenoid cystic component. The most common carcinomas in carcinosarcomas of salivary glands are adenocarcinoma and squamous cell carcinoma. CONCLUSION: Carcinosarcoma is a high-grade aggressive lesion with a poor prognosis and should be treated aggressively. More studies are needed to understand the origin of these tumors.

Granulomatous myocarditis arising from intravesical Bacillus Calmette-Guérin therapy leading to death diagnosed by postmortem examination: a case report.

BACKGROUND: Intravesical Bacillus Calmette-Guérin (BCG) is used as a standard adjuvant therapy for non-muscle invasive urothelial cancer. Most patients tolerate the treatment well, with mild side effects. Systemic complications are extremely rare, occur due to BCG dissemination and are associated with immunocompromised state and urothelial breach. CASE PRESENTATION: We present a case of a 78-year-old male, a former smoker, with history of non-muscle invasive urothelial carcinoma status post partial resection followed by intravesical BCG therapy. An autopsy was performed due to the sudden nature of his death. Autopsy showed multiple necrotizing granulomas in the brain, atrium, ventricles, lungs, kidneys, and urinary bladder. Stains for acid-fast bacilli and fungi were negative. In addition, bilateral lungs showed evidence of bronchopneumonia secondary to cytomegalovirus. CONCLUSION: Granulomatous myocarditis arising from BCG therapy is extremely rare. Our patient with urothelial cancer treated with BCG developed multiorgan granulomas, most likely due to a hypersensitivity reaction to intravesical BCG. Arrhythmia induced by granulomatous myocarditis was the cause of his death. Although there have been few cases of systemic BCG-osis causing fatal sepsis leading to death, a cardiac cause of death is unique.

A Rare Case of Intraosseous Papillary Hemangioma of the Head and Neck.

Papillary hemangioma is a novel variant of intravascular hemangioma. It is more common in adults and has a male predominance. Most tumors reported so far are solitary and cutaneous. Here we present a rare case of an intraosseous papillary hemangioma involving the frontal bone. Brain imaging in a 69-year-old man with a slowly enlarging swelling on the right frontal area following an accidental fall demonstrated a 4.5 cm × 1.7 cm × 4.2 cm mass originating from the right frontal bone, with a tiny defect on the orbital roof. A malignant process was favored, and the mass was removed. Histopathology revealed a vascular lesion showing intraosseous distribution with foci of extension into the fibrous connective tissue. There were areas of plump endothelial cells with intracytoplasmic hyaline globules arranged in papillary configuration. The lesional cells were immunoreactive with CD34. AE1/AE3, EMA, PR, D2-40, inhibin, and S100 stains were negative. Ki-67 was low. This is the first intraosseous and second noncutaneous papillary hemangioma. Clinically it differs from other cases by the presence of trauma as a preceding event. Since its prognosis is unknown such patients should be monitored for recurrence or malignant transformation.

Does local injection of long acting corticosteroid improve postoperative outcome of hypospadias repair? A randomized controlled trial.

PURPOSE: To assess the safety and efficacy of local corticosteroid injection during hypospadias repair. METHODS: Between May 2021 and March 2023 children less than 10 years who were admitted for hypospadias repair were divided by random allocation into two groups. We injected local corticosteroid 2 ml proximal to coronal sulcus in group A while in group B we didn't. All types of hypospadias were included in the study. We excluded patients older than 10 years and those with pre-existing complicated hypospadias (multiple fistulae and multiple surgeries), or bleeding diatheses. Pre-operative, intraoperative and postoperative variables were compared between the two groups. RESULTS: A total of 120 patients (60 in each group) were enrolled in the study. The mean ages and preoperative variables were not significantly different. The site of hypospadias and the type of surgery were comparable in both groups. (Table) There were no significant differences between both groups regarding average blood loss and operative time in each type of surgical repair. There was a significant higher incidence of intraoperative and postoperative penile oedema in group B (P-value < 0.001) while the incidence of skin discolouration was higher in group A. Postoperative complications, described as Clavian classification, were significantly higher in group B. The incidences of superficial skin infection, meatal stenosis, urethral fistula, and recurrence with the need for redo repair were significantly higher in group B (P-value: 0.002, 0.018, 0.032, and 0.001, respectively). CONCLUSION: Local corticosteroid injection during hypospadias repair minimize the penile oedema and decrease the incidence of postoperative functional and cosmetic complications.

The Expression of Stem Cell Marker LGR5 and Its Coexpression with Β-Catenin in Sporadic Colorectal Carcinoma and Adenoma: A Comparative Immunohistochemical Study.

Background: LGR5 is one of the most important stem cell markers for colorectal cancer (CRC), as it potentiates Wnt/Β-catenin signaling. The well-characterized deregulation of Wnt/Β-catenin signaling that occurs during adenoma/carcinoma sequence in CRC renders LGR5 a hopeful therapeutic target. We assessed the immunohistochemical expression of LGR5 and Β-catenin in normal colonic and tumorous lesions with a clinicopathological correlation. Methods: Tissue blocks and clinical data of 50 selected cases were included: 8 from normal mucosa, 12 cases of adenoma, and 30 cases of CRC, where sections were cut and re-examined and the immunohistochemical technique was conducted using anti-LGR5 and anti-Β-catenin to measure the staining density. Results: There was no expression of LGR5 in normal mucosa compared to samples of adenoma and CRC samples. The association analysis showed that CRC specimens were more likely to have strong LGR5 and Β-catenin expressions than the other two groups (p = 0.048 and p < 0.001, respectively). Specimens with high-grade dysplastic adenoma were more likely to express moderate-to-strong expression of LGR5 and Β-catenin (p = 0.013 and p = 0.036, respectively). In contrast, there were no statistically significant associations between LGR5 and Β-catenin expression with grade and stage. Conclusion: These results suggest and support the possible role of LGR5 as a potential marker of cancer stem cells in sporadic colorectal carcinogenesis in addition to a prognostic value for LGR5 and Β-catenin in adenomatous lesions according to immunohistochemical expression density. A potential therapeutic role of LGR5 in CRC is suggested for future studies based on its role in pathogenesis.

Bilateral localized primary parotid gland amyloidosis: A rare entity with literature review.

Amyloidosis of the salivary glands is a rare occurrence. Due to non-specific clinical presentation, the diagnosis can be overlooked. Here we present a case of a localized bilateral parotid glands AL kappa-light chain amyloid deposition without systemic involvement, as well as a literature review. Fine needle aspiration (FNA) of a right parotid lesion was performed with rapid on-site evaluation (ROSE). Slides showed characteristic amyloid staining with Congo red and typical Apple-green birefringence under polarized light microscopy. Amyloid in the head and neck can be misinterpreted as other materials such as colloid, keratin, necrosis, hyaline degeneration especially when the condition is not suspected.

HER2/neu expression status of post BCG recurrent non-muscle-invasive bladder urothelial carcinomas in relation to their primary ones.

BACKGROUND: Transurethral resection (TUR) followed by adjuvant therapy is still the treatment of choice of Non-Muscle-Invasive Bladder Urothelial Carcinoma (NMIBUC). However, recurrence is one of the most troublesome features of these lesions. Early second resection and adjuvant BCG therapy has been shown to improve the outcome. OBJECTIVE: To evaluate the prognostic value of C-erbB-2 (HER2/neu) expression status in Non-Muscle-Invasive Bladder Urothelial Carcinoma cases, before and after intravesical Bacillus Calmette Guerin (BCG immunotherapy). MATERIALS AND METHODS: HER2/neu expression was studied in 120 (Ta-T1) Non-Muscle-Invasive Urothelial Carcinoma cases. The expression was evaluated and compared to the expression after Bacillus Calmette Guerin (BCG) immunotherapy. RESULTS: HER2/neu expression in low and high grade of the Non- Muscle-Invasive Urothelial Carcinoma was (38%) and (83%) respectively. The difference of the expression rates by tumor grade was statistically significant. In recurring lesions post BCG therapy, C-erbB-2 expression was markedly decreased (31.6%) when compared to its expression before therapy (65%). CONCLUSIONS: The HER2/neu expression increased as the tumor grade rose. The reduction in expression following BCG treatment in Non-Invasive transitional cell carcinoma cases could reflect a reduction of the potential malignancy of the tumor.

Development of High-Grade Sarcoma After Second Dose of Moderna Vaccine.

Coronavirus disease 2019 (COVID-19) is a disease characterized by predominantly respiratory symptoms, which can progress to respiratory failure. Due to the novelty of the vaccines, it is difficult to assess if there are any associated long-term side effects. Here, we present a case of an elderly female who received the Moderna COVID-19 vaccine and developed a high-grade sarcoma at the site of the injection. A 73-year-old female with a past medical history of hypertension, hyperlipidemia, and renal angiomyolipoma status post resection in 2019 presented with worsening right upper arm swelling for the past two weeks. She noticed the swelling two to four days after receiving her second dose of the Moderna vaccine within 1 cm from the prior injection site. Physical examination was remarkable for a 6 cm, circular, mobile, soft mass present in the right upper arm. MRI with and without contrast revealed a 5.2 cm soft tissue mass overlying the triceps region with irregular features concerning for malignancy. Fine needle aspiration revealed pathologic characteristics indicative of high-grade sarcoma. The patient ultimately had resection of the mass four months after the initial visit and was diagnosed as having grade 3, stage IIIA undifferentiated, pleomorphic high-grade sarcoma. Herein, we present a case demonstrating the development of high-grade sarcoma at the injection site in an elderly female patient within days of receiving the second dose of the Moderna COVID-19 vaccine. Currently, it is unclear whether there is a true association between the vaccines and malignancy or inflammatory response exacerbating underlying malignancy. This case highlights the necessity to investigate and be aware of such rare, adverse complications that may be associated with the novel COVID-19 vaccinations to guide physicians in their differential diagnosis.

An assessment of the role of surgical loupe technique in prevention of postthyroidectomy complications: a comparative prospective study.

The magnification technique offered by surgical loupe is a new method that enhances visualization and helps head and neck surgeons with recurrent laryngeal nerve (RLN) and parathyroid glands identification. This study aimed to assess the safety and efficacy of using binocular surgical loupes in thyroidectomy procedures. Material and Methods: Eighty patients with thyroid nodules who underwent thyroidectomy procedure were divided randomly into two comparable groups, group A subjected to thyroidectomy by using binocular magnification loupe, group B underwent conventional thyroidectomy without using magnification. Patients' demographics, operation time, and postoperative morbidities were recorded. All cases had preoperative and postoperative vocal cords assessment by video laryngoscopy. Pathology, laboratory, and radiology investigations were also conducted. Results: Out of 80 patients, there were 58 females and 22 males. Benign thyroid pathology was found in 74 patients and malignant pathology in 6 patients. The mean operating time was 106 min in group A compared to 138.5 min in group B. The mean amount of intraoperative bleeding was 30 ml in group A while 50 ml in group B. There were no cases of the external branch of the superior laryngeal nerve in both groups; there was better identification in group A. There was only one patient who suffered from a temporary RLN injury in group A, while three cases of temporary and one case of permanent RLN injury were recorded in group B. Permanent hypoparathyroidism was diagnosed in only one patient in group B. Conclusion: The utilization of binocular surgical loupe magnification in thyroid surgery is considered a safe and effective maneuver that has the advantages of decreasing the overall operating time and significantly reducing postoperative complications.

Marijuana-Induced Acute Hepatitis: A Case Report.

Marijuana is among the most widely used recreational drugs in the United States. The most common side effects of marijuana include mood changes, impaired memory, impaired body movements, and hallucination. Chronic use of marijuana is associated with transaminitis and hepatomegaly. Reported cases of acute hepatitis secondary to heavy marijuana smoking are very rare.

Utility of TRPS-1 immunohistochemistry in diagnosis of metastatic breast carcinoma in cytology specimens.

INTRODUCTION: At present, GATA binding protein 3 (GATA-3) is the most frequently used diagnostic immunohistochemical (IHC) marker for breast carcinoma (BC). However, it is not specific and has very low sensitivity for triple-negative BC (TNBC). SRY-box transcription factor 10 (SOX-10) and trichorhinophalangeal syndrome type 1 (TRPS-1) have been suggested for inclusion in the diagnostic workup of TNBC. TRPS-1 has not been established in cytology specimens as a diagnostic IHC marker for metastatic BC (MBC). Hence, in the present study we evaluated the utility of TRPS-1 in diagnosing MBC in cytology specimens. MATERIALS AND METHODS: MBC cases diagnosed on cytology specimens from January to October 2020 were included in the present study. Only cases with hormonal status available and ≥20 tumor cells on cell blocks were included in the study. The cell blocks were assessed for TRPS-1, GATA-3, and SOX-10 IHC marker positivity (intensity and percentage of tumor cells). The results were correlated with the specimen type (fine needle aspiration [FNA] versus body fluid) and various BC prognostic subgroups. RESULTS: We analyzed 61 cases, including 33 body fluid and 28 FNA (13 lymph node, 10 bone, 2 liver, 2 soft tissue, and 1 lung) specimens. TRPS-1 had 97.2% positivity in ER/PR+ (estrogen receptor/progesterone receptor-positive) MBC compared with GATA-3, which had 100% positivity in the same group. TRPS-1 showed high positivity in 35 of 37 cases (94.6%) and intermediate positivity in 1 (2.6%) and was negative/low positive in 1 case (2.7%). In contrast, GATA-3 showed high positivity for all 37 cases (100%). SOX-10 showed positivity in only 1 of 37 cases (2.7%), with intermediate positivity. In the HER2+ (human epidermal growth factor receptor 2-positive) group, TRPS-1 showed high positivity in 5 of 7 cases (71.4%), intermediate positivity in 1 case (14.3%), and negativity in 1 case (14.3%). However, GATA-3 showed high positivity in 6 of 7 cases (85.7%) and negative/low positivity in 1 case (14.3%). SOX-10 was negative in all 7 cases. In TNBC, TRPS-1 showed high positivity in 16 of 17 cases (94%) and intermediate positivity in 1 (5.9%), and GATA-3 showed high positivity in 9 (53%), intermediate positivity in 2 (11.8%), and low positive/negative in 6 of the 17 cases (35.3%). TRPS-1 expression was significantly higher than GATA-3 expression for the number of positive cases (P = 0.07), mean percentage of positive tumor cells (P = 0.005), and intensity of reactivity (P = 0.005). SOX-10 expression was present in only 5 of 17 cases (29%), with a mean percentage of positivity in the tumor cells of 26.5% and intensity of 0.8. No differences were found in the IHC results between the different specimen types (FNA versus fluid) in any group. CONCLUSIONS: TRPS-1 is a highly sensitive new diagnostic IHC marker for breast carcinoma, with a similar positivity rate in ER/PR+ and HER2+ BC compared with GATA-3 and a higher positivity rate than GATA-3 and SOX-10 in TNBC in cytology specimens. In particular, when only a few clusters of tumor cells are present on the cell block, TRPS-1 can be highly useful, because its mean percentage of positive tumor cells and intensity are higher than those of other IHC markers.

Computational portraits of the tumoral microenvironment in human breast cancer.

Breast cancer is the most diagnosed cancer in humans. In recent years, myxoid and proportionated stroma have been described as clinically significant in many cancer subtypes. Here computational portraits of tumor-associated stromata were created from a machine learning (ML) classifier using QuPath to evaluate proportionated stromal area (PSA), myxoid stromal ratio (MSR), and immune stroma proportion (ISP) from whole slide images (WSI). The ML classifier was validated in independent training (n = 40) and validation (n = 109) cohorts finding MSR, PSA, and ISP to be associated with tumor stage, lymph node status, Nottingham grade, stromal differentiation (SD), tumor size, estrogen receptor (ER), progesterone receptor (PR), and receptor tyrosine-protein kinase erbB-2 (HER-2). Overall, MSR correlated better with the clinicopathologic profile than PSA and ISP. High MSR was found to be associated with high tumor stage, low ISP, and high Nottingham histologic score. As a computational biomarker, high MSR was more likely to be associated with luminal B like, Her-2 enriched, and triple-negative biomarker status when compared to luminal A like. The supervised ML superpixel approach demonstrated here can be performed by a trained pathologist to provide a faster and more uniformed approach to the analysis to the tumoral microenvironment (TME). The TME may be relevant for clinical decision-making, determining chemotherapeutic efficacy, and guiding a more overall precision-based breast cancer care.

Adult-Onset Still's Disease with Dermatopathic Lymphadenitis Clinicopathologic Features: A Rare Case Report and Review of the Literature.

Adult-onset Still's disease (AOSD) is an inflammatory disorder characterized by fever, arthritis, and a transient skin rash. It is a rare condition characterized by inflammatory multisystem changes of unknown cause. A 35-year-old woman was admitted to rheumatology department of tertiary care hospital complaining of painful wrist and skin rash as well as fever, generalized lymphadenopathy, weight loss, and fatigue. The early diagnosis of AOSD was confirmed by clinical history, examination, and laboratory tests, as well as a confirmatory skin biopsy with typical histopathological features, namely, upper epidermal dyskeratosis and dermal inflammatory neutrophilic infiltration. The patient's condition was treated with steroids and NSAIDs, to which she responded well, and on follow-up, her symptoms regressed along with improvement in biochemical parameters. The authors suggest that skin biopsy and confirmation of histopathological diagnosis of AOSD are useful in the diagnosis and proper management of AOSD patients in cases with clinical suspicion of AOSD.

Urothelial Papilloma of the Urinary Bladder: A Case Report and Literature Review of a Rare Entity.

Urothelial papilloma is a rare benign neoplasm composed of a delicate fibrovascular core covered by normal urothelium. In this report, we present a case of an incidentally detected endovesical papillary growth in ultrasound scan (USS) during a routine check-up, suggestive of bladder tumor which was also suggested by CT urography. The tumor was initially managed with transurethral resection and immediate intravesical instillation of mitomycine C 40 mg. The histopathologic assessment of the specimen concluded that the growth was "urothelial papilloma with no atypia or malignancy." Although papilloma is unequivocally benign, it can recur; recurrences can be multiple and can occur years after the initial diagnosis occasionally with progression to carcinoma, hence long-term surveillance is essential. Our case was followed up for a year with no signs of recurrence or progression and long-term surveillance will be done annually.

The role of cytology as an effective tool in management of omental and peritoneal lesions: Experience of a large health care system.

BACKGROUND: The aim of this study is to assess the efficacy of cytology in omental or peritoneal lesions. METHODS: A retrospective review of the pathology database for cytology cases of peritoneal or omental nodules over a 3-year period (2016-2018) was conducted. The cases consisted of either FNA only (FO); FNA and Core biopsy (FCB) or Touch prep and core biopsy (TCB). Cases were further divided based on the prior history of carcinoma. Concordance rates of cytologic diagnosis with histologic diagnosis were studied. RESULTS: Out of 104 cytology cases reviewed, 60 (57.7%) had prior history of cancer (PHC) and 44 (42.3%) had no prior history of cancer (NPHC). Of the cases with PHC, 43(71.66%) were recurrence, 10 (16.66%) were second cancer, and 7 (11.66%) were non-neoplastic lesions. Of the cases with NPHC, 38 (86.4%) had a second cancer diagnosis, while 6 (13.6%) were non-neoplastic. For FO only cases, 11 of 35 (31.4%) had follow up and 9 of 11 (81.8%) were concordant. For FCB cases, 6 out of 39 (15.4%) had follow up and 6 (100%) were concordant. For TCB cases, 9 out of 30 (30%) had follow up and 9 (100%) were concordant. A definite diagnosis was reached in 30/35, 39/39, and 29/30 cases in FO, FCB, and TCB, respectively. CONCLUSION: In summary, cytologic evaluation of omental lesions is an effective tool in providing accurate diagnosis and guiding further management. Also, the results based on our study show that the combined techniques are superior at reaching a definitive diagnosis.

Clinicopathological characteristics and outcomes of eosinophilic cystitis: A retrospective study.

BACKGROUND: Eosinophilic cystitis (EC) is a rare inflammatory urinary bladder disorder whose etiology, pathogenesis, and treatment are unknown. The work aims to evaluate the clinical manifestations, cystoscopic characteristics, pathological features, treatment, and clinical outcome of EC patients. MATERIALS AND METHODS: The clinical records and histopathology material of 22 patients diagnosed as EC during ten years were reviewed and analyzed for patient's age, sex, clinical data, cystoscopic features, biopsy procedures, treatment plan, follow-up, and prognosis. Frequencies, normality tests, descriptive statistics, and correlations were run. RESULTS: The mean age of patients was 46.5 + 17 years, 12 females and 10 males. Regarding the patient's complaints, dysuria was the most frequent main symptom, followed by hematuria. On cystoscopic examination, bladder mass was seen in 54.5% of patients. Six patients (27.3%) were associated with different allergic diseases; however peripheral eosinophilia was shown in two patients (9.1%). All cases revealed predominance of eosinophilic infiltration on microscopic examination. The most commonly used medications were corticosteroids for 72.7% of patients with tapering dose giving a significant improvement with a recorded recurrence in one patient after 12 months from the first lesion. CONCLUSIONS: No specific clinical presentation for EC patients and histopathology is the standard diagnostic tool. Medical treatment including corticosteroids was the first line with good prognosis, although recurrence remains a possibility which emphasizes the importance of patients' follow-up.

Human Leukocyte Antigen (HLA) class I and II datasets for sudanese.

Sudan is located in the heart of Africa and surrounded by eight countries with people of different ethnic origins. Historical records show that the population of the Sudan is a mixture of Arabic, West Asian Arabic and sub-Saharan African elements. The present survey provides data on allele lineages, and haplotype frequencies of Human Leukocyte Antigen (HLA) class I (HLA-A and HLA-B) and class II (HLA-DR and -HLA-DQ) loci in 11 Sudanese populations. The sampled individuals are all local transplant donors who provided informed consent for HLA analyses on their blood samples and were registered at National Cancer Institute, University of Gezira, Wad Medani. The HLA class I and II data reported here can be subjected for future analyses of genetic structure and health in Sudan. These include as reference datasets for identifying the association between HLA and diseases and for designing donor recruitment strategies.

Increased COX-2 Immunostaining in Urothelial Carcinoma of the Urinary Bladder Is Associated with Invasiveness and Poor Prognosis.

BACKGROUND: Urothelial carcinoma of the urinary bladder (UCB) is the commonest bladder tumor. Cyclooxygenase-2 (COX-2) mediates angiogenesis, cell survival/proliferation, and apoptosis. This study investigates the relation of COX-2 immunostaining in UCB to clinicopathological parameters in Saudi Arabia. METHODS: The study population includes 123 UCB and 25 urothelial mucosae adjacent to UCB. UCB samples were collected before any local or systemic therapy. Tissue microarrays were designed and constructed, and TMA blocks were sliced for further immunohistochemical staining. Immunohistochemical staining was done using a mouse anti-human COX-2 monoclonal antibody. A cutoff point of 10% was chosen as the threshold to determine low and high COX-2 immunostaining. RESULTS: COX-2 immunostaining is higher in UCB than in the adjacent urothelium (p = 0.033). High COX-2 immunostaining is associated with high-grade UCB (p = 0.013), distant metastasis (p = 0.031), lymphovascular invasion (p = 0.008), positive muscle invasion (p = 0.017), pT2 and above (p = 0.003), and high anatomical stages (stage II and above). High COX-2 immunostaining is an independent predictor of higher tumor grade (p < 0.001), muscle invasion (p = 0.015), advanced pathological T (p = 0.014), lymphovascular invasion (p = 0.011), and distant metastasis (p = 0.039). High COX-2 immunostaining is associated with lower overall survival rate (p = 0.019). CONCLUSION: COX-2 immunostaining is associated with the invasiveness of UCB which may be used as an independent prognostic marker. COX-2 may be a significant molecule in the initiation and progression of UCB. Molecular and clinical investigations are required to explore the molecular downstream of COX-2 in UCB and effectiveness of COX-2 inhibitors as adjuvant therapy along with traditional chemotherapy.