Gastric Mucormycosis Masquerading as Gastric Malignancy.

Mucormycosis is an opportunistic fungal infection usually seen in immunocompromised patients. We report a case of gastric mucormycosis in an immune-competent lady that mimicked a gastric malignancy, presenting a diagnostic challenge. A high index of suspicion is required for the diagnosis and successful treatment of this potentially life-threatening condition.

The diagnostic and therapeutic challenges in the management of a double giant parathyroid adenoma.

Primary hyperparathyroidism is a common endocrine disorder of the parathyroid gland. It is mostly seen as a single gland adenoma in up to 85% of the cases with the excess production of parathyroid hormone. Double adenomas although reported are very rare and double giant parathyroid adenomas are even rarer. We possibly report the second case in the literature of primary hyperparathyroidism caused by double giant parathyroid adenomas, presenting with severe symptomatic hypercalcemia and review the diagnostic and therapeutic challenges in its management. The presentation with severe hypercalcemia and the presence of atypia in one of the adenomas added to its uniqueness. A combination of the neck ultrasound and a parathyroid scintigraphy should be used for preoperative localization and selection of the right surgical approach for patients undergoing parathyroidectomy. The parathyroid scintigraphic protocols keep getting refined; it is hence vitally important and practical to adapt the diagnostic algorithms in accordance with local availability and expertise.

Metastatic Follicular Carcinoma Thyroid Masquerading as a Primary Jaw Tumor.

Metastatic tumours of the oral cavity are rare constituting approximately one percent of all oral malignancies. These tumors are clinically significant as their appearance may be the first indication of an undiscovered malignancy at a distant primary site or the first evidence of dissemination from a known primary tumor. Thyroid cancer metastasizing to the jaw bones is a rare occurrence and very few cases have been described in literature. We present an additional case which in fact masqueraded as a primary jaw tumor. Metastasis to jaw bones is generally associated with poor prognosis with a majority of the patients dying within 6 months of diagnosis. Thyroid cancers however seem to be an exception to this, resectable solitary jaw bone metastasis from differentiated thyroid cancers is associated with a much better prognosis and therefore should be considered for metastatectomy.

Nodular Fasciitis of the Orofacial Region: An Uncommon Differential.

Nodular fasciitis is a benign proliferative spindle-cell lesion that presents as a rapidly growing mass arising from the subcutaneous fascia, leading it to be erroneously diagnosed as a sarcoma. These lesions commonly present in individuals in their third to fifth decades of life with no definite gender predilection. They are frequently located on the extremities and the trunk and infrequently in the head and neck region. Lesions in the orofacial region are uncommon. We describe an interesting case of orofacial nodular fasciitis in a 21-year-old boy that essentially summarises the clinical features and management of this pseudosarcomatous reactive proliferative lesion. Clinicians and more so maxillofacial surgeons need to be aware of the distinctions between nodular fasciitis and its malignant mimic (sarcomas) in order to limit overtreatment and the resultant treatment-related morbidities.

A Rare Case of Multiloculated Cervical Thymic Cyst Masquerading as Tuberculous Adenitis.

Cervical thymic cysts are among the rarest cysts found in the neck. They usually occur during infancy and childhood, and they are extremely rare in adults. They may be found at any level of the pathway of normal thymic descent, from the angle of the mandible to the superior mediastinum. Being uncommon, they are rarely included in the clinical diagnosis of lateral neck masses and are commonly misdiagnosed as branchial cysts, lymphatic malformations, epidermoid cysts, dermoid cysts, lymphadenitis or neoplastic masses. The diagnosis of cervical thymic cyst is rarely made preoperatively and histopathological examination of the excised specimen is the only definitive means of diagnosis in a majority of the reported cases. We report the clinical presentation and therapeutic management of a rare case of multiloculated cervical thymic cyst in a 24-year-old adult which masqueraded as a tuberculous lympadenitis along with a review of literature.

A Rare Case of a Recurrent Giant Solitary Fibrous Tumor of the Ciliary Body of the Orbit.

Solitary fibrous tumors (SFTs) are uncommon spindle-cell tumors of mesenchymal origin initially described in the pleura and subsequently in other extra-pleural sites. These tumors are categorized as tumors of 'intermediate malignancy' under the World Health Organization classification of soft tissue tumors. SFT was virtually non-existent or misdiagnosed until its characteristic features, particularly the strong and diffuse immuno-reactivity to CD 34 were described. Extra-pleural manifestations of SFT, particularly in the head and neck region are rare. Although a number of isolated case reports of orbital SFTs have been described ever since its initial description in 1994, cases of recurrent SFTs have been very few. Recurrences of these tumors following surgery are considered unusual and metastasis exceptional. We describe clinical presentation and the management challenges of recurrent giant orbital SFT in a 15-year old girl along with a brief review of literature.

Role of fluorine-18-fluorodeoxyglucose positron emission tomography-computed tomography in management of pulmonary mucoepidermoid carcinomas and review of literature.

Pulmonary mucoepidermoid carcinoma (PMEC) is a rare tumor of bronchial gland origin with a striking resemblance to MEC of the salivary glands. The World Health Organization classifies PMECs as "salivary gland type" tumors along with pulmonary adenoid cystic carcinomas and epimyoepithelial lung carcinomas. Their description in literature is largely limited to a few case series/case reports. Further, the experience of imaging in these tumors with fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography ( (18)F-FDG PET-CT) is also limited and evolving largely due to rarity of PMEC. We recently managed an interesting case of a PMEC and reviewed the literature surrounding this rare tumor with an emphasis on the role of (18)F-FDG PET-CT in its management. An (18)F-FDG PET-CT appears to be a useful imaging modality for predicting the tumor grade of patients with PMECs; further, there is emerging data to suggest the role of (18)F-FDG PET-CT for predicting the long-term prognosis of patients with PMEC.

Malignant chondroid syringoma of the pinna.

Chondroid syringoma (CS) represents the cutaneous counterpart of mixed tumor (pleomorphic adenoma) of salivary glands. The malignant counterpart of CS, termed as "malignant CS" is a malignant eccrine neoplasm which lacks distinctive clinical features, often delaying initial diagnosis. Unlike its benign counterpart which often localizes in the head and neck region, malignant CS most often encountered in the trunk and the extremities. We report a rare case of an aggressive malignant CS of the left pinna with cervical lymph node metastasis. Our patient, to the best of our knowledge, possibly is the first case of malignant CS of the pinna and the fourth to arise in the head and neck region. The diagnostic challenges with an added emphasis on the role of positron emission tomography-computed tomography in aiding the management of this rare tumor are discussed.

Diagnostic dilemma involving a mass in the parapharyngeal space: A metastatic breast carcinoma masquerading as a malignant salivary gland tumor.

Parapharyngeal space (PPS) tumors are rare and account for about 0.5% of all head and neck neoplasms. Most PPS tumors are benign (up to 80%) while the remaining 20% are malignant. These tumors are either primaries; most commonly arising from salivary glands or metastatic tumors or due to direct extension of tumors from the adjacent sites. Distant metastasis from breast cancers more commonly involves the lungs, bones, brain and liver. Metastasis to the PPS from a primary breast carcinoma is rare, with only one case reported in literature. We, to the best of our knowledge report the second case of a carcinoma breast metastasizing to the PPS and further discuss the diagnostic and therapeutic challenges involved in its management. A fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan apart from explicitly defining the extent of the PPS tumor, majorly influenced the therapeutic decision making process by ruling out other sites of metastasis.

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in the detection of primary pulmonary angiosarcomas.

Angiosarcoma is a malignant vascular tumor that originates from the mesenchymal cells which have undergone angioblastic differentiation. Pulmonary angiosarcomas are invariably (>90%) metastatic tumors form primaries of the skin, bone, liver, breast, or heart. Primary pulmonary angiosarcomas are exceedingly rare, with just about 20 cases being reported in the literature. We report an additional case with a brief review of the literature of a primary pulmonary angiosarcoma in a 26-year-old lady who presented with intractable hemoptysis. In addition, we highlight the potential of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography as an important diagnostic tool in the evaluation of this tumor and thus contribute to the existing sparse literature on this fascinating yet devastating disease.

Multiple synchronous verrucous carcinomas of the scalp in the background of generalized verruca vulgaris.

Verrucous carcinoma (VC) is a clinicopathologic entity which is defined as a locally aggressive, clinically exophytic, slow-growing, well-differentiated, squamous cell carcinoma with negligible metastatic potential. The cutaneous form of VC is typically known to arise from the palmoplantar and the genitocrural areas. Involvement of the scalp is extremely rare. Multiple synchronous involvement of the scalp by VC along with associated generalized verruca vulgaris has possibly never been reported before. We present this unique report of VC in a 38-year-old male patient with emphasis on its atypical clinical presentation and the resultant challenges in management. Interestingly, the tumor cells of our patient were confirmed to be positive for human papillomavirus infection by polymerase chain reaction and by p16 immunohistochemistry.

Dumbbell Shaped Schwannoma of the Lateral Chest Wall masquandering as a soft tissue sarcoma.

Schwannomas are benign, slow growing nerve sheath tumours of Schwann cell origin. They predominantly are known to involve the head, neck and the flexor surfaces of the extremities, retroperitoneum and the posterior spinal roots. The chest wall is a relatively uncommon location for a schwannoma, the vast majority of which are intra-thoracic, which are usually located in the posterior mediastinum and bulge into the thoracic cavity. Schwannomas arising from the lateral chest wall are relatively uncommon (<5 %). Dumbbell shaped schwannomas of the lateral chest wall i.e. with an intra-thoracic and extra-thoracic component, is extraordinarily rare and to the best of our knowledge only one case has been reported prior. We report possibly the second case of a dumbbell shaped lateral chest wall schwannoma in a 33-year-old female patient which masquandered as a case of soft tissue sarcoma.

Palliative thyroidectomy in the setting of a metastatic renal cell carcinoma.

A secondary neoplasm of the thyroid gland is a distinctly uncommon cause of thyroid enlargement. These tumors mimic primary thyroid gland tumors and often lead to diagnostic difficulties. We report an interesting case of secondary thyroid tumor coexisting with a micropapillary carcinoma in an elderly male patient following a radical nephrectomy done 15 years prior for a renal cell carcinoma (RCC). Interestingly, the previously described coincidental association of thyroid and pancreatic metastases in a metastatic RCC was also noted in our patient as was demonstrated in the positron emission tomography-computed tomography which was done as part of the metastatic workup. This association needs to be further explored as also the role of palliative thyroidectomy in the setting of a metastatic RCC. The possibility of metastatic RCC should be kept as a differential during the course of the evaluation of clear cell renal tumor of the thyroid gland.

A large extra cranial cystic trigeminal schwannoma of the parapharyngeal space - exploring the right approach.

Tumors of the parapharyngeal space (PPS) are uncommon, comprising less than 1 % of all head and neck neoplasm's. Neurogenic lesions are the most common tumors of the poststyloid PPS accounting for nearly 25-30 % of all the PPS lesions. Schwannomas are uncommon nerve sheath tumors that may originate from any peripheral, cranial or autonomic nerve of the body, about one-third of them are known to arise in the head and neck region. Trigeminal schwannomas are known to arise from the root, ganglion, or intracranial portion of the three peripheral divisions of the nerve - ophthalmic (CN V1), maxillary (CN V2) and mandibular (CN V3). Schwannomas involving the mandibular division of the trigeminal nerve and localizing exclusively in the parapharyngeal space (PPS) is extremely rare and a surgical approach to such tumors has not been well established. The management of a PPS schwannoma is thus a clinical challenge, an adequate preoperative imaging with the identification of the possible nerve of origin allows for making informed decisions regarding the various approaches of management.

Primary plasma cell leukaemia with unusual presentations: a case series.

We present here three cases of plasma cell dyscrasias; first case presenting as primary plasma cell leukemia showing unusual morphology and aberrant expression of myeloid markers; the second case presenting as plasma cell leukaemia with atypical plasma cells in peripheral blood and the third case presenting as myelomatous pleural effusion after treatment for myeloma.

The aesthetic and oncological challenges in the management of an atypical nodular hidradenoma of the pinna.

Nodular hidradenomas are benign adenomatous tumours of sweat gland origin, which commonly arise from the skin of the head, neck and extremities. Some of these benign appearing lesions exhibit aggressive clinical behaviour with rapid growth, pigmentation and ulceration. These tumors are designated as "atypical nodular hidradenomas" and are known to histologically possess some focal atypical features i.e. nuclear pleomorphism, focal necrosis or prominent mitotic activity. Nodular hidradenomas involving the pinna are rare and to the best of our knowledge there have been no prior reports in the English language literature. We describe a unique case of a 45-year-old woman with an atypical nodular hidradenoma of the left pinna and discuss the aesthetic and the oncological issues pertaining to the reconstruction of the pinna.