Endoscopic-Assisted Curettage of Posterior Proximal Tibia Chondroblastoma: A Case Report and Review of Literature.

Chondroblastoma is a benign cartilage-producing bone lesion that characteristically occurs in the epiphyseal region of long bones. The most typical locations are the proximal humerus, proximal femur, distal femur, and proximal tibia. There is no medical treatment for the disease; classically, it must be treated by intralesional curettage and bone grafting. A 15-year-old female patient presented with chronic knee pain with no antecedent history of trauma. Clinical examination showed deep tenderness on maximum flexion and 15 degrees extension lag with full knee flexion. Plain radiographs and knee MRI showed a lesion in the posterior part of the proximal tibia on the midline, highly suggestive of chondroblastoma. CAT-guided biopsy did not show any evidence of malignancy. Intralesional curettage assisted by endoscopic visualization was done using a small incision, and a bone graft substitute reconstructed the defect. Endoscopic-assisted curettage of benign bone lesions can be considered in challenging locations with good results.

Malignant Diffuse-Type Tenosynovial Giant Cell Tumor in the Subcutaneous Tissue of the Midthigh: A Report of a Rare Tumor in an Unusual Location.

Malignant TS-GCT is an extremely rare and aggressive tumor with only few cases published in the literature, due to the small number of cases is not completely understood and is diagnostically challenging. Although surgical treatment is the primary treatment modality, there is no consensus regarding adjuvant treatment. Regardless of mode of treatment, the tumor still caries unfavorable prognosis. In this paper, we reviewed the literature for cases of malignant TS-GCT. We also would like to present an additional case of malignant TS-GCT that was found in an unusual location in subcutaneous tissue of the midthigh.

Pericardial mass: A rare form of cardiac actinomycosis case report.

Actinomycosis is a rare chronic infection caused by a group of anaerobic Gram-positive bacteria which inhabits commonly the oral cavity, colon, and genitourinary tract. Actinomycosis of the thorax is the third most common form. Pericardial actinomycosis is an extremely rare condition. Actinomycosis is characterized by its tendency to mimic malignancy as it can invade surrounding tissue and form a mass. Multiple manifestations should be noted by physicians as a result of the large variety of symptoms and the involvement of multiple organ systems. With proper treatment, it has a good prognosis. We describe a patient with an unusual clinical form of cardiac actinomycosis presenting as an isolated pericardial mass resembling a malignant tumor.

Kidney Transplant Recipient With Multiple Contemporaneous Malignancies Secondary to Muir-Torre Syndrome.

Muir-Torre Syndrome (MTS) is a rare autosomal-dominant genetic condition linked to germline mutations in DNA mismatch repair (MMR) genes, resulting in microsatellite instability. It is considered a variant of Lynch syndrome characterized by the association of at least one sebaceous skin tumor and at least one internal malignancy. In addition, it has been shown that a latent phenotype of MTS might be unmasked in transplant organ recipients and immunosuppressed patients. The diagnosis and treatment of such cases require a multidisciplinary approach. Here, we present a case of a kidney transplant recipient who developed multiple sebaceous carcinomas 16 years after kidney transplantation and daily immunosuppressive medication. The patient then developed multiple contemporaneous internal malignancies in the esophagus and colon with metastases to the lung, thyroid, and lymph nodes, all of which were eventually linked to MTS. To our knowledge, this is the first reported case of MTS in the Arab world and the first reported case of esophageal cancer in relation to MTS in a transplant recipient. Because patients with MTS have a high tendency of developing malignancies, patients with a strong family history of malignancies, any known mutations, or an immunocompromised status should be included in an extensive screening program.

Metastasectomy of Sequential Asynchronous Metastatic Renal Cell Carcinoma to the Pancreas, Thyroid, Skin, Contralateral Kidney, and Lung with Cumulative Survival Beyond 10 Years: A Case Report and Clinicopathologic Review.

BACKGROUND One-third of renal cell carcinoma cases present with an initial metastasis to various organs, emphasizing the tumor's unpredictable behavior. Prognosis is poor once metastasis is discovered. Multiple-organ involvement with metastatic lesions has a particularly dismal survival rate. Surgical resection alone of metastatic masses can extend patient survival with reasonable quality of life. CASE REPORT Here, we present the case of a healthy 46-year-old woman who initially presented with an incidental localized clear cell renal cell carcinoma. During the follow-up period, she presented with sequential asynchronous metastasis to the pancreas, thyroid, skin, contralateral kidney, and lung. She has no family history of malignancy. Her physical examination and laboratory investigations were normal even upon presentation of most of her metastatic organs. The first metastasis was in her sixth year of follow-up. She underwent consecutive metastasectomy of all the organs described above, excluding the lung. She eventually was started on sunitinib after non-resectable lung nodules were discovered. Her survival is now over 10 years since her first metastasectomy, with good performance status. CONCLUSIONS Metastasis to a single organ has a poor prognosis and dramatically affects survival. Nevertheless, our patient had multiple consecutive examples of metachronous metastasis, yet she has survived for over a decade since the occurrence of metastasis. Our case offers more information to fill the gaps in understanding the favorable role of surgical resection in advanced renal cell carcinoma metastasis.

Colonic mucinous adenocarcinoma with secondary in the breast: A case report and literature review.

INTRODUCTION: Secondary breast metastasis from the colonic origin is a rare phenomenon in the literature, and an estimation of an increase in the incidence has been reported in the literature to reach approximately 7%. PRESENTATION OF CASE: We report a case of a 56-year-old male with constipation who underwent extended right hemicolectomy after confirmation of adenocarcinoma of the right colon. The patient was diagnosed with multiple metastases over 5 years and endured numerous resections of the costal margins, ribs, diaphragm, liver wedges, abdominal wall, and the small bowel. Eventually, the patient's right breast mass measured about 2.1 cm on ultrasonography and revealed metastatic adenocarcinoma of the same colonic origin. The patient started on palliative chemotherapy and was deceased after 11 months. DISCUSSION: Comparing this case to the 56 similar cases, we found our case with an almost average time to metastasize but unfortunately with aggressive metastatic behavior to various organs. Nevertheless, the triple assessment of the breast by physical examination, radiological, and pathological studies assisted in diagnosis and early establishment of the treatment. Currently, there is no definitive guideline for the management of secondary breast metastasis from the colonic origin. We estimated the average survival rate as 6.1 months, and it was reported to reach an average of 8-10 months in the literature. CONCLUSION: During the surveillance program of colorectal cancer, a full-body examination is warranted. Secondary breast cancer metastasis from colorectal origin behaves aggressively and a multidisciplinary approach is essential for the establishment of personalized treatment.

Early Stage Anaplastic Sarcomatoid Carcinoma of The Pancreas, A Case Report.

BACKGROUND Anaplastic sarcomatoid carcinoma of the pancreas (ASCP) is a rare variant of pancreatic malignancies. It is a high-grade epithelial carcinoma predominated with spindle cells. CASE REPORT We report a case of a 65-year-old patient who presented with early stage, ampullary mass indicating malignancy, and who subsequently underwent pancreatoduodenectomy. Histopathology and immunohistochemistry were confirmatory for anaplastic, grade IV sarcomatoid adenocarcinoma arising from the head of the pancreas. CONCLUSIONS To our knowledge, this is a rare presentation with few cases reported in the literature.

Carcinosarcoma of the Gallbladder with Chondrosarcomatous Differentiation and Intracytoplasmic Eosinophilic Hyaline Globules (Thanatosomes): A Report of a Case and Review of the Literature.

A 52-year-old woman presented with abdominal pain and vomiting. Computed tomography (CT) scan of the abdomen revealed a huge exophytic gallbladder mass displacing or invading the surrounding structures. The patient underwent radical cholecystectomy, transverse colectomy, distal gastrectomy, and liver bed resection. Histologically, the tumor showed both carcinomatous and sarcomatous components, with prominent chondrosarcomatous differentiation. In addition, several malignant cells showed intracytoplasmic eosinophilic hyaline globules (Thanatosomes). The tumor showed metastatic deposits to the omentum, the liver, and the peripancreatic lymph nodes. We report this unusual case and present a review of all cases of carcinosarcoma of the gallbladder with chondrosarcomatous differentiation.

Total patellectomy with extensor mechanism reconstruction following pathological fracture due to patellar Ewing's sarcoma.

A young patient presented with a progressive right knee pain and swelling that was worse on ambulation. Following appropriate investigations, he was confirmed having Ewing's sarcoma of the right patella. Two cycles of chemotherapy were initiated before he sustained a fall and a resultant pathological patellar fracture. He finally underwent a total right patellectomy and extensor mechanism reconstruction using Achilles tendon allograft in an attempt to eradicate the disease and salvage his knee extensor mechanism. At 1-year follow-up, no disease recurrence was observed, and the patient had a full range of motion but with slight weakness of the extensor mechanism.

Anaplastic Carcinoma Arising in a Mucinous Cystic Neoplasm Masquerading as Pancreatic Pseudocyst.

Mucinous cystic neoplasms (MCN) of the pancreas can vary from benign to premalignant and malignant. Preoperative diagnosis is essential to offer the patient appropriate treatment. Occasionally these cases may harbor anaplastic carcinoma while clinically masquerade as a pseudocyst. Here in, we report an unusual case of a 37-year old female presented with recurrent abdominal pain that was suspected clinically and by imaging studies to have a pseudocyst. EUS-FNA with internal drainage of the cyst was performed. Cytological evaluation of the cyst fluid showed numerous inflammatory cells composed mainly of many neutrophils admixed with macrophages reminiscent of the usual pseudocyst content but there were scattered rare dyscohesive malignant cells which were highly pleomorphic with multinucleation. Immunostains on the cell block showed immunoreactivity of these cells including the multinucleated cells for Cam 5.2 and AE1/AE3 and focally for Ber-Ep4, Moc -31, and CA19-9. The subsequent resection confirmed the presence of anaplastic (undifferentiated) carcinoma (AC) arising in a MCN of the pancreas. Diagn. Cytopathol. 2016;44:538-542. © 2016 Wiley Periodicals, Inc.

Fine-Needle Aspiration Followed by Core-Needle Biopsy in the Same Setting: Modifying Our Approach.

Fine-needle aspiration biopsy (FNAB) is a well-established initial diagnostic tool. However, in some instances limitations and shortcomings arise, making it insufficient for determining a specific diagnosis. Consequently, patients have to undergo another diagnostic procedure. The second procedure is either repeat FNAB, core-needle or open biopsy, and can be inconvenient and costly. In some centers, the FNAB is immediately followed by core-needle biopsy (CNB) in the same setting after assuring adequacy on the initial FNAB utilizing rapid on-site specimen evaluation (ROSE). It is argued that implementing such an approach will eventually have additional critical advantages that include the following: (a) it is more convenient to patients to have both procedures in one visit, (b) the tissue procured by both procedures will be more adequate, enabling cytopathologists to reach an accurate diagnosis, and (c) it is ultimately a cost-effective approach if we take into consideration the avoidance of a potential second more invasive diagnostic procedure. Since we are living in an era of patient-centered medicine coupled with cost-cutting strategies, we present here a brief review of the topic with analysis of this alternative approach, review of the pertinent literature and shed light on a few scenarios that justify this approach.

Significance, cytomorphology of decoy cells in polyomavirus-associated nephropathy: Review of clinical, histopathological, and virological correlates with commentary.

Human polyomaviruses (PyV) are ubiquitous, remaining predominantly inactive hence asymptomatic in the healthy, immunocompetent population. BK and JC PyV potentially infect pan-urinary tract epithelial cells. With reactivation, PyV disrupt cell cycling mechanisms, facilitating viral replication leading to cell necrosis, exfoliation, and, infrequently, carcinogenesis. Exfoliated PyV-infected cells pose diagnostic pitfalls, hence they are termed "decoy cells" as they may mimic high-grade urothelial carcinoma cells. BK polyomavirus-associated-nephropathy (BKVAN) is an inflammatory disease causing interstitial fibrosis with tubular atrophy in renal transplant recipients, increasing risk of graft loss. BKVAN is confirmed by renal biopsy, and managed by immunosuppression modulation. As voided urine may provide pan-reno-urinary tract sampling, cytopathology may serve a critical diagnostic purpose coupled with decoy cell quantification and indirect BK PyV load gauging. Thus, identification of decoy cells and differentiation from high-grade urothelial carcinoma cells, and degenerated, benign urothelial cells, is clinically essential. PyV virology and pathobiology in the context of renal transplantation, immuno-suppression and BKVAN, and, decoy cell cytomorphology and cytopreparation with commentary are highlighted. Decoy cell overall characteristics: variable degeneration; cytomegaly; comet-like shapes; angular cytoplasmic extensions; eccentric, polar nuclear placements; moderate anisocytosis; typically single cells with high N:C ratios. Cytoplasmic features: moderate-abundance; granular, blue-gray monochromatism. Nuclear features: karyomegaly; haphazardly-scattered chromatin densities; smudged, homogeneous, basophilic ground glass masses displacing chromatin alongside inner periphery of regular, symmetrical nuclear envelopes. Background features: granular cellular debris; inflammatory cells; intact and lyzed erythrocytes. Decoy cells lack coarse chromatin as in high-grade urothelial carcinoma cells. Benign urothelial cells exhibit low N:C ratios with fine chromatin distribution and euchromasia.

Strongyloides stercoralis infection in kidney transplant recipients.

Strongyloides stercoralis is an uncommon infection in Saudi Arabia. It can establish latency and cause an autoinfection in humans that lasts for years. The infection can get reactivated during immunosuppression and can result in a life-threatening Strongyloides hyperinfection syndrome. We present three cases of renal transplant recipients who developed Strongyloides infection following transplantation. A bronchoalveolar lavage specimen, a duodenal biopsy and/or a stool specimen from these patients revealed evidence of S. stercoralis larvae. The first two patients received kidneys from the same deceased donor, a native of Bangladesh, an area that is highly endemic for S. stercoralis. The data suggest that the first two cases might be donor derived. High-risk donors and recipients should be screened for Strongyloides infection to initiate treatment before transplantation thus reducing morbidity and mortality.

Pathologic basis of antibody-mediated organ transplant rejection: from pathogenesis to diagnosis.

PURPOSE OF REVIEW: Although antibody-mediated rejection of clinical organ transplants has been recognized more than a half-century ago, our understanding of its pathological/clinical phenotypes has dramatically increased over the past decade. This review highlights the pathological/clinical spectrum of ABMR and discusses its microscopic pathology in relationship with pathogenesis. RECENT FINDINGS: Newly recognized pathological manifestations of ABMR are: (1) C4d-negative active ABMR, which cannot be definitely diagnosed by current diagnostic systems and often remains underdetected. Novel molecular diagnostic tests can fill this diagnostic gap but these new tests are yet to be prepared for routine application; (2) antibody-mediated vascular rejection, which is misclassified by the current Banff Classification, is therefore inadequately treated and has a high risk for transplant failure; and (3) subclinical (insidious) microvascular inflammation, which can be with or without complement activation, predicts progression to chronic rejection, transplant dysfunction, and failure. SUMMARY: A major progress has been made in understanding of ABMR of clinical transplants in the last 5 years. New pathology types of ABMR are not appropriately classified and updates to the Banff diagnostic criteria are required. Better diagnosis would help develop effective antiantibody treatment strategies and improve long-term outcomes for patients.

Thymoma and thymic carcinoma arising in a thymolipoma: report of a unique case.

Thymic carcinoma arising within a thymolipoma has not been reported previously. The authors present a unique case of thymoma and undifferentiated thymic carcinoma arising within a thymolipoma in a 36-year-old woman. The bulk of the resected mass was composed of benign fatty tissue admixed with foci of unremarkable thymic tissue; however, it also harbored a central solid mass showing undifferentiated thymic carcinoma associated with a type B2 thymoma. The carcinoma cells were positive for cytokeratin AE1/AE3, cytokeratin 19, and cytokeratin 8/18. They were negative for vimentin, cytokeratin 7, cytokeratin 20, CD5, epithelial membrane antigen, CD30, placental alkaline phosphatase, carcinoembryonic antigen, CD99, leukocyte common antigen, Epstein-Barr virus, inhibin alpha, and protein gene product 9.5. Rare tumor cells showed positive staining for chromogranin and synaptophysin.