An unexpected lesion in cerebellopontine angle: hemangiopericytoma.

hemangiopericytoma (hPC) is a rare tumor by definition and intracranial hPC makes up to less than one percent of all the intracranial tumors. It is a dural base tumor and its clinical features and radiological findings are similar to meningiomas. however, cerebellopontine angle hemangipericytoma had only been reported twice and would almost always be misdiagnosed. definite diagnosis is important, as the treatment of hPC is different from meningiomas and acoustic neuromas. we report a case of a young female who presented with atypical symptoms of left cerebellopontine angle mass. A literature review of the nature of the disease, radiological findings, immunohistochemical features and treatment options of the tumor are described.

Nasal type NK/T-cell lymphoma - diagnosis and treatment difficulties.

Primary nasal lymphomas are rare. One of the most common cellular subtypes in the Asian population is natural killer (NK)/T-cell lymphoma (NKTL) with a high association of EBV. We report a case of a 42-year-old female, who presented with a worsening sore throat, odynophagia, dysphagia to solid food due to oropharyngeal ulcers and bilateral nasal blockage and recurrent fever for the past two weeks prior to admission. Physical examination revealed ulcers over the soft palate with nasopharyngeal slough. Computerized Tomography (CT) scan of the neck showed nasopharyngeal abscess with bilateral maxillary ethnoidal sinusitis. The diagnostic and management challenge is discussed.

Mismanagement of cat bite wound: lessons to learn.

Animal inflicted wounds, left untreated may result in chronic bacterial or fungal infection. Clinical features of these infections may overlap leading to a delay in diagnosis and treatment. We report a case of chronic non-healing cat bite wound treated with several antibiotics without improvement. Later patient developed the classical "sporotrichoid spread" and a presumptive diagnosis of sporotrichosis was made. Laboratory investigation for fungal culture and skin biopsy failed to identify the underlying pathogen. A trial of oral antifungal agent resulted in complete recovery of the lesions implicating fungus as the causative pathogen. Physicians should have a high index of suspicion for fungal infections when managing animal inflicted wounds.

Epithelioid sarcoma and concurrent Volkman ischaemic contracture: a case report.

Epithelioid sarcoma is a very infrequent soft tissue sarcoma involving predominantly distal extremities of adolescent and young adult. We hereby report a case of epithelioid sarcoma in a 34-year-old young adult who presented with 1-year history of a painful left upper limb associated subsequently with warm left forearm swelling and a Volkman contracture. He was treated as an inflamed soft tissue condition of the left upper limb. A computed tomography study showed presence of multiple hypodense lesions mainly in the flexor compartment of the left arm as well at the subcutaneous tissue, which measured 1 to 1.7 cm in diameter. Histological examination of the left upper limb mass showed nodular proliferation of epithelioid tumour cells and some with rhabdoid features surrounding a central zone of necrosis and was diagnosed as epithelioid sarcoma. Concurrent presence of epithelioid sarcoma and Volkman ischaemic contracture are rarely seen in clinical practice. The present case highlights the importance of the histology which can be confused with other types of sarcoma or chronic granuloma and even missed at times thereby causing diagnostic problems.

Atypical (symplastic) leiomyoma of the uterus--a case report.

A 30-year-old, nulliparous woman presented with a history of subfertility. On examination she was found to have uterine fibroid of 28 weeks size of gravid uterus and subsequently laporatomy myomectomy was performed. Multilobulated masses, with diameters ranging from 22 mm to 160 mm were found. Cut sections of the lobulated masses showed whitish whorled cut surface. One of the multilobulated masses had a cystic cavity, measuring 60x50x35 mm(3). Light microscopic findings of the mass with the cystic cavity showed a well-circumscribed cellular tumour composed of cells exhibiting moderate nuclear atypia which were enlarged, nuclei with prominent chromatin clumping and were distributed in areas. Some tumour cells showed large nuclear pseudoinclusions, multinucleated or multilobated tumour giant cells, smudging and few enlarged nucleoli. Mitotic activity was 4 MFs per 10 HPFs. Occasional cells with intracytoplasmic inclusions resembling rhabdoid - like features were seen. There were no atypical mitoses or tumour necroses were noted. Diagnosis of atypical leiomyoma or symplastic leiomyoma was made. Atypical or symplastic leiomyomas are rare in the region of Malaysia and the present case discusses its incidence in younger age, its morphological features along with diagnosis and clinical outcome.

Identification of different subtypes of breast cancer using tissue microarray.

Breast cancer may be classified into luminal A, luminal B, HER2+/ER-, basal-like and normal-like subtypes based on gene expression profiling or immunohistochemical (IHC) characteristics. The main aim of the present study was to classify breast cancer into molecular subtypes based on immunohistochemistry findings and correlate the subtypes with clinicopathological factors. Two hundred and seventeen primary breast carcinomas tumor tissues were immunostained for ER, PR, HER2, CK5/6, EGFR, CK8/18, p53 and Ki67 using tissue microarray technique. All subtypes were significantly associated with Malay ethnic background (p=0.035) compared to other racial origins. The most common subtypes of breast cancers were luminal A and was significantly associated with low histological grade (p<0.000) and p53 negativity (p=0.003) compared to HER2+/ER-, basal-like and normal-like subtypes with high histological grade (p<0.000) and p53 positivity (p=0.003). Luminal B subtype had the smallest mean tumor size (p=0.009) and also the highest mean number of lymph nodes positive (p=0.032) compared to other subtypes. All markers except EGFR and Ki67 were significantly associated with the subtypes. The most common histological type was infiltrating ductal carcinoma, NOS. Majority of basal-like subtype showed comedo-type necrosis (68.8%) and infiltrative margin (81.3%). Our studies suggest that IHC can be used to identify the different subtypes of breast cancer and all subtypes were significantly associated with race, mean tumor size, mean number of lymph node positive, histological grade and all immunohistochemical markers except EGFR and Ki67.

Enzymatic and microstructural changes in the liver of experimental rats fed with fatty diet and fresh or heated soy oil concurrently.

AIMS: Consumption of heated edible oils may be harmful. The present study aimed to observe the histological changes due to concurrent consumption of soy oil (either fresh or heated) and fatty diet and the changes in the level of alanine transaminase (ALT) and alkaline phosphatase (ALP). MATERIALS AND METHODS: Forty female Spraque-Dawley rats were equally divided into four groups (I to IV). All the rats n groups II, III and IV were ovariectomised. Rats in group I (control) were fed with 2% cholesterol diet, whereas the rats in groups II, III and IV were fed with 2% cholesterol diet fortified with 15% weight/weight (w/w) fresh soy oil (FSO), once heated soy oil (1HSO) and five times heated soy oil (5HSO) respectively, for 16 weeks. Blood was taken for liver enzymes and analysed before and after 16 weeks of study. At the end of the study the animals were sacrificed, and the liver was examined histologically. The specimens were weighed, formalin fixed and the sections were stained with hematoxylin and eosin. RESULTS: Fresh, 1HSO and 5HSO soy oil caused significant increase in serum ALT and ALP compared to their base line values. Fresh, 1HSO and 5HSO soy oil caused microsteatosis, inflammation and necrosis of the liver tissues. However, there was no significant difference in the ALT and ALP enzyme levels amongst the oil fed groups. CONCLUSION: It is concluded that the effect of both fresh and heated soy oil on these parameters was not affected by repeated heating except for the inflammation.

An unexpected case of primary peritoneal carcinoma.

Primary peritoneal carcinoma (PPC) is a rare tumor that is histologically and immunohistochemically indistinguishable from epithelial ovarian carcinoma. The diagnosis is usually made after excluding gross ovarian involvement or the ovarian involvement is only confined to the surface. A 68-year-old lady presented with right iliac fossa pain and increasing CA125. The CT scan showed bilateral pelvic adnexal masses with peritoneal deposits within the right side of abdomen. She was initially diagnosed as carcinomatosis peritonei from the omental cake removed after exploratory surgery. She was managed as advanced ovarian tumor with peritoneal metastasis and was then administered six cycles of chemotherapy. Surgical intervention included debulking surgery consisting of total abdominal hysterectomy, bilateral salpingooophorectomy and omentectomy and also with right hemicolectomy. The histopathological findings were of primary peritoneal serous carcinoma with only minimal involvement of the serosal surface of the right ovarian capsule. No microscopic invasion into underlying ovarian cortex and stroma was observed. Multiple tumor deposits were also seen over the right paratubal and paraovarian tissue, both parametrium as well as serosal surface of the terminal ileum and periappendicular tissue. Immunohistochemically, the malignant cells were positive to CA125, focally positive to CK7 and negative to CD20 and Calretinin. PPC is one of important differential diagnosis which needs to be considered in cases of advanced ovarian tumor, although the former can only be ascertained after excluding the ovarian involvement microscopically.

Immunohistochemical expression of vascular endothelial growth factor (VEGF) and p53 in breast lesions.

OBJECTIVE: Vascular endothelial growth factor (VEGF) is a leading factor for tumour angiogenesis and p53 protein is the product of a tumor suppressor gene. The main aim of the study was to assess the association of p53 protein with VEGF expression in breast carcinoma. MATERIALS AND METHODS: This was a retrospective study involving 66 invasive breast carcinomas, 66 normal breast tissues and 55 cases of usual ductal hyperplasia (UDH), obtained from the histopathology records. The paraffin blocks were cut and processed by immunohistochemical technique using a monoclonal VEGF and a monoclonal p53 antibody. RESULTS: VEGF positive staining was detected in 12 (18.2%) of the 66 cases of breast carcinoma and only 1 (1.8%) of UDH cases (p=0.004). Expression of p53 was positive in 33 (50%) of the 66 cases of carcinoma; whereas 8 cases of UDH (14.5%) were p53 protein positive (p<0.001). There was statistically significant associations between p53 expression and tumour size (p=0.018) and lymph node status (p=0.046). The VEGF and p53 expressions were negative in all normal breast tissues analyzed. Ten (83.3%) of 33 invasive carcinoma with p53 protein positive were VEGF positive, whereas 2 of 33 patients did not have p53 expression and were VEGF positive (p=0.011). CONCLUSION: The expression of p53 in invasive breast carcinoma had a significant correlation with the tumour size and lymph node metastasis. The evaluation of VEGF expression together with p53 protein may aid clinicians in effective management.

Serum sex hormone levels in pre- and postmenopausal breast cancer patients.

INTRODUCTION: This study was conducted to determine the association between serum sex hormone levels and breast cancer. METHODS: The study was conducted on newly-diagnosed breast cancer patients who had not received any treatment. Controls were women not known to have any breast disease or hormone-related tumours. Serum hormones were divided into quartiles. Logistic regression adjusting for age and race were done to calculate the odds ratio (OR) and 95 percent confidence interval (CI). RESULTS: A total of 207 subjects were recruited; 73 premenopausal (37 cases, 36 controls) and 134 postmenopausal (68 cases and 66 controls) women. In the premenopausal women, only serum testosterone was positively associated with breast cancer (OR 1.72, 95 percent CI 0.40-7.40), but this was not a significant finding (p-value is 0.468). In the postmenopausal women, oestradiol, progesterone and testosterone were positively associated with breast cancer with a highest to lowest quartile OR of 1.48, 2.35 and 4.23 (95 percent CI 0.59-3.69, 1.11-4.95 and 1.52-11.78, respectively). The OR was significant for both progesterone and testosterone (p-values of 0.025 and 0.006, respectively). CONCLUSION: There were no statistically significant findings among the premenopausal cases. In postmenopausal women, serum progesterone and testosterone levels were significantly associated positively with the odds of having breast cancer.

Anaplastic Large Cell Lymphoma Presenting as a Soft

Anaplastic large cell lymphoma (ALCL) is a rare tumour, accounting for approximately 3% of adult non-Hodgkin lymphomas.1 Primary systemic ALCL frequently involves both lymph nodes and extranodal sites. A 44-year-old woman presented with a firm, mobile mass in the left iliac fossa region. Ultrasound findings showed a well defined inhomogenous soft tissue mass, measuring 4x4x2.6cm in the deep subcutaneous region. Histopathological examination revealed that the mass was infiltrated by large lymphoid cells with marked nuclear atypia including kidney-shaped nuclei. These neoplastic cells expressed anaplastic lymphoma kinase (ALK) (both nuclear & cytoplasmic staining), CD30 and EMA but not for T-cell (CD45RO and CD3), and B-cell (CD20 & CD79α) markers. Fluorescence in situ hybridization (FISH) analysis showed a t(2;5)(p23;q35) chromosomal translocation. Subsequently the patient developed shortness of the breath and a thoracic computed tomography (CT) scan showed a mass encasing the right upper lobe bronchus. She also had bilateral axillary lymph nodes, measuring 1 cm in diameter (biopsy was not done). The mediastinum and endobronchial region did not show any abnormalities. She received 6 cycles of CHOP chemotherapy and remained disease free 2 years after diagnosis. ALCL, rarely present as a soft tissue tumour and this disease should be included as a differential diagnosis of any soft tissue mass.

An immunohistochemical study of retinoblastoma gene product in normal, premalignant and malignant tissues of the uterine cervix.

The retinoblastoma gene was the first tumour suppressor gene identified that was altered not only in retinoblastomas but has been described in a wide variety of human neoplasms. The retinoblastoma gene encodes a nuclear phosphoprotein that in its hypophosphorylated state plays an important role in regulating the cell cycle, thus preventing from tumour formation. Expression of retinoblastoma gene protein product (pRB) was investigated in 118 formalin-fixed, paraffin-embedded cervical tissues by immunohistochemistry using commercially available antibody directed against RB protein. Ten normal ectocervical epithelium, 16 cervical intraepithelial neoplasia (CIN) I, 13 CIN II, 14 CIN III, 53 invasive squamous cell carcinoma, 11 adenocarcinoma and 1 small cell carcinoma were selected for this study. The proportions of pRB-positive cells as well as the extent of pRB expression in ectocervical squamous epithelium were assessed and compared among the lesions. The pRB expression was observed in 100% of normal ectocervical epithelium (n=10), 100% of CIN lesions (n=43) and 98.5% of invasive carcinoma of the uterine cervix (n=65) and were statistically significant when CIN or CIN/invasive were compared to normal cases (P < 0.01, P < 0.05 respectively). While in invasive squamous cell carcinoma (SCC), 81.8% (9/11) pRB-positive cells were found in much higher percentages in well differentiated SCC compared to 64.3% (18/28) of moderately differentiated cases and only 7.1% (1/14) of poorly differentiated SCC (P < 0.01, respectively). The results of this study suggest that loss of RB protein expression is rare in carcinoma of the uterine cervix and this protein may be important in the pathogenesis of cervical carcinoma.

Detection of human papillomavirus using in situ hybridization technique in vulvo-vaginal warts.

Human papillomavirus (HPV) is the commonest sexually transmitted viral infection and one of its manifestations is genital warts or condyloma acuminata. Eight cases of vulvo-vaginal warts were diagnosed between January 1992 and December 1993. There were 4 Malays, 2 Chinese and 2 Indians. The patients' age ranged from 22 to 43 years (mean 27.9 years). Formalin-fixed, paraffin-embedded tissues were studied by histology and in situ hybridization using biotinylated probes to detect the HPV deoxyribonucleic acid (DNA) of types 6, 11, 16, 18, 31 and 33. All vulvar and vaginal lesions showed typical histopathological features of condylomatous changes. HPV 6 and HPV 11 were detected in 100% (8/8) and 87.5% (7/8) of all cases, respectively. HPVs 16, 18, 31 and 33 were not found. The positive cells were mainly in the upper layers of the squamous epithelium. The hybridization data indicated that the HPV found in this study one of the same types as found in other studies.

Prebiopsy localization of nonpalpable breast lesions.

Radiologically guided localization procedures are indicated pre-operatively when breast lesions are nonpalpable. The results of 42 percutaneous hookwire localizations over a period of 3 years are described. Of the total, 7 (17%) were found to be malignant. Biopsy was indicated by mammographically detected mass in 48%, by microcalcifications in 40% and by microcalcifications with an associated mass in 12%.

Bilateral pure gonadoblastoma in a 46 XY individual--a case report.

We report here a rare case of bilateral pure gonadoblastoma which accounts for only 0.2% of all ovarian tumours seen at Universiti Kebangsaan Malaysia from 1980 to 1987. This tumour occurred in an 18 year old Chinese "female" who presented with primary amenorrhoea. Examination showed a phenotypic female with poorly developed external gentalia. Exploratory laparotomy revealed a hypoplastic uterus, rudimentary fallopian tubes and streak gonads. Histological examination of the gonads showed a mixed tumour comprising large germ cells and smaller sex cord derivatives arranged in characteristic nests or islands containing hyaline material.