Invasive breast carcinoma with ipsilateral axillary squamous carcinoma of unknown primary: A case report.

INTRODUCTION & IMPORTANCE: Invasive ductal carcinoma is the commonest primary breast carcinoma to metastasize to the axillary nodes. Squamous carcinoma (SCC) of the breast is seen rarely as a primary breast malignancy. Breast SCC with coexistent invasive ductal/lobular carcinoma as a 'collision tumour' is rare. CASE PRESENTATION: A 52-year-old Sri Lankan female presented with a right sided breast lump and ipsilateral cystic axillary mass. She was diagnosed with locally advanced invasive breast carcinoma and underwent neoadjuvant chemotherapy followed by mastectomy and axillary clearance where tumour infiltration of the brachial plexus was observed. Histology revealed two separate carcinomas; an invasive carcinoma of the breast and squamous carcinoma in the axilla. A squamous primary was not found despite evaluation. The patient developed recurrent axillary ulceration due to residual tumour and was transferred for oncological care. CLINICAL DISCUSSION: This patient had a biopsy-proven invasive breast carcinoma with a cystic axillary mass with lymphadenopathy. This was concluded as locally advanced breast cancer. Pathological examination of the specimen indicated the presence of two separate malignancies of the breast and axilla. No evidence of squamous metaplasia or carcinoma of the breast was seen on histology, neither was a squamous primary identified on imaging or endoscopy. Neoadjuvant therapy may have caused resolution of the squamous component. CONCLUSION: The presence of two separate cancers of varied histology in the breast and ipsilateral axilla in close proximity to each other is a rare phenomenon. Clinicians must be cautious not to misinterpret it as evidence of lymphatic spread.

Large epidermoid cyst of the spleen causing massive splenomegaly: A case report.

Splenic cysts are uncommon and are classified as primary cysts or secondary cysts based on the presence or absence of an intact epithelial lining, respectively. Epidermoid cysts have an epithelial lining of stratified squamous epithelium and have been reported in normal and intra-pancreatic accessory spleens. An 18-year-old girl presented with a symptomatic, uncomplicated splenic cyst causing massive splenomegaly and symptoms due to mass effect. Peripheral cytopaenias and lymphoproliferative neoplasm were excluded. Preoperative computed tomography was suggestive of a large splenic cyst causing massive splenomegaly and marked loco-regional pressure effects. Open splenectomy was performed and histology confirmed an epidermoid cyst with no features of malignancy. Splenic epidermoid cysts are a rare cause of massive splenomegaly. Surgical intervention is recommended due to symptoms and the risk of complications.

Tuberculous extensor tenosynovitis of the wrist in a patient with systemic lupus erythematosus mimicking a giant cell tumour: A case report and review of literature.

INTRODUCTION & IMPORTANCE: Extrapulmonary tuberculous involvement of the musculoskeletal system is not common and seen in less than 10 % of all cases. The bidirectional association between tuberculous infection of the musculoskeletal system and rheumatological diseases has been widely recognized and arises both as a result their underlying immunosuppressive state and of drug induced immunosuppression. CASE PRESENTATION: A 45-year-old female on treatment for SLE, in remission, presented with a slow growing mass over the dorsum of the right wrist with functional impairment which was clinically and radiologically compatible with a giant cell tumour. Pathological examination after surgical excision revealed pathognomonic features of tuberculous tenosynovitis. Multidrug antituberculous therapy was commenced. CLINICAL DISCUSSION: Clinical diagnosis of tuberculous tenosynovitis is difficult due to the non-specific clinical symptoms and signs. Laboratory investigations are usually normal except for ESR which may be elevated. Delay in establishing therapy may lead to dissemination of mycobacteria to the surrounding bursae, muscles and soft tissue leading to joint and tendon damage. Detection of mycobacteria through TB culture and microscopy of the specimen has a low sensitivity and therefore treatment should be promptly initiated when typical pathological findings are seen. CONCLUSION: Tuberculous tenosynovitis of the extensor tendons is a rare clinical presentation and must be suspected in cases of chronic and recurrent tendon sheath infection especially in an immunocompromised patient in a TB endemic country. The lack of clinical suspicion, nonspecific findings and mimicry of other conditions can lead to delayed diagnosis and complications.

A giant multi-compartment lipoma of the hand causing median nerve compression: A case report and review of literature.

INTRODUCTION & IMPORTANCE: Lipomas are slow growing benign soft tissue tumors that arise from mesenchymal preadipocytes. Histologically they are composed of mature adipocytes. They typically have a shawl like distribution in the body, anywhere from the subcutaneous space to bone, but are seen only rarely in the hand. When >5 cm, they are referred to as 'giant lipoma' and can be symptomatic due to neurovascular compression and impaired hand function. CASE PRESENTATION: A 51-year-old forensic analyst presented with a progressively enlarging lump over the thenar eminence and palm of his dominant right hand for 2 years duration. Although initially asymptomatic, he developed progressive numbness over the radial 21/2 fingers and impaired hand function due to its size resulting in occupational impairment. Examination revealed a 5x5cm painless lobulated lump over palm. NCS showed evidence of median nerve compression. MR imaging revealed a giant lipoma involving the thenar and midpalmar space. Enbloc surgical excision was performed and histology was confirmatory. CLINICAL DISCUSSION: Lipomas of the hand could be superficial or deep space. They are slow growing and asymptomatic initially and are brought to attention due to cosmetic concerns, nerve compression or mechanical hand impairment with enlargement. Giant lipomas must be treated with suspicion due to denovo liposarcoma and risk of sarcomatous change. CONCLUSION: Giant multi-compartment lipomas of the hand are rare. Surgical excision is advocated for suspicion of malignancy, nerve compression and functional limitation. Enbloc resection without fragmentation has minimal risk of recurrence and complications.

Air rifle wound to the chest and pellet embolism to the intracranial internal carotid artery with a middle cerebral artery territory infarct: A case report and review of literature.

INTRODUCTION: Traumatic embolization of pellets into the cerebral circulation is a rare complication following gunshot wounds to the neck, chest and abdomen. Foreign bodies enter the circulation from early direct puncture or delayed erosion of an artery or vein or directly through the heart. PRESENTATION OF CASE: A previously well 13-year-old Sri Lankan boy who presented 2 h following an air rifle injury to the lower sternum with chest pain, developed seizures and left hemiparesis. Contrast CT angiogram showed the pellet at the base of the skull at the right carotid canal, with a middle cerebral artery (MCA) thrombus and evidence of MCA infarction. Decompressive craniectomy was performed. Cerebral angiography confirmed complete occlusion of the intracranial internal carotid artery (ICA) by the pellet, without cross circulation from the left ICA. Attempts at endovascular pellet retrieval failed. Open pellet embolectomy was not performed and the patient was managed conservatively. DISCUSSION & CONCLUSION: Air rifle injury to the chest causing pellet embolism from the left ventricle to the right intracranial ICA with associated right MCA thrombus is a rare phenomenon. Missile embolism must be suspected when neurological findings are not in concordance with the site of injury especially in the absence of an exit wound and an inability to locate the pellet in the vicinity of the entry wound. Radiographs, CT and cerebral angiography are indicated to locate the pellet and associated injuries. The decision on surgical embolectomy, endovascular retrieval or expectant management is an individualized decision dependent on many factors.

Recurrent intramedullary endometriosis of the conus medullaris: A case report of diagnostic pitfalls and a review of literature.

INTRODUCTION: Endometriosis is a common gynaecologcial disorder and is characterized by the presence and implantation of endometrial epithelium and glandular stroma in an extrauterine location Intraspinal endometriosis can involve the intramedullary, subarachnoid, intradural-extramedullary, and extradural compartments, including the vertebral bodies. Symptoms due to intraspinal endometriosis will vary depending on the location and degree of compression of neural structures and will fluctuate with the menstrual cycle. PRESENTATION OF CASE: A 20-year-old Sri Lankan female with recurrent catamenial backpain, presented to the neurosurgical clinic with acute cauda equina syndrome. She had a history of cyclical lower back pain and lower limb radiculopathy and had undergone spinal decompression and excision of a haemorrhagic cyst in the conus medullaris on three occasions over the past three years. Clinical, radiological and histological discordance meant that the diagnosis of intraspinal endometriosis was missed previously. She underwent repeat spinal decompression on this occasion with histology confirming an endometrial cyst. DISCUSSION: Intramedullary spinal cord haematomas are rarely encountered in neurosurgery. Vascular or neoplastic causes are common with endometriosis being extremely rare. The lack of clinical suspicion, radiological imaging supporting an alternate diagnosis, along with lack of histological confirmation led to the initial diagnostic dilemma and delays in starting long term endometrial suppression therapy. CONCLUSION: Intraspinal endometriosis is a rare but important differential diagnosis in the evaluation of a female in the reproductive age group with cyclical lower back pain and neurological symptoms. One must have a high degree of suspicion regarding it, in order to prevent protracted morbidity.