A Case of Unilateral Proptosis Secondary to Prostatic Metastasis.

Prostate cancer metastases involving the orbit and/or paranasal sinuses represent a rare oncological presentation. Patients can have a myriad of symptoms such as proptosis, periorbital swelling, blurry vision, rhinorrhea, epistaxis, anosmia, or others depending on the structures involved. The differential diagnosis of paranasal sinus masses on imaging studies is broad and can include inflammatory, congenital, or neoplastic masses; leading to the requirement of biopsy for definitive diagnosis. Tissue sample is usually obtained via an endoscopic approach. The prognosis of such a presentation is not well described in the literature, but it is usually guarded due to the advanced stage of the disease and generally a poorly differentiated primary tumor. Treatments usually aim to reduce the burden of disease and debulk the tumor mass for palliative purposes. We present a case of a 71-year-old male presenting with unilateral proptosis and periorbital swelling secondary to prostatic metastasis.

Renal actinomycosis presenting as uro-cutaneous fistula.

Renal actinomycosis is a rare clinical entity. Diagnosis is usually made after resection. A 36-year-old male presented with uro-cutaneous fistula and left xanthogranulomatous pyelonephritis. He was offered left open radical nephrectomy. Intra-operatively, there was "woody" inflammation of the left kidney fistulizing to the splenic flexure of the colon. We successfully resected it and a segment of the colon that had fistulized. His tissue cultures grew Actinomyces odontolyticus. Post-operatively, he received 6 weeks of intravenous beta-lactam antibiotic. He recovered well without any complications. In conclusion, renal actinomycosis can be challenging to diagnose, operate and eradicate. Perioperative considerations are presented for successful management.

A thyroid gland with over 30 foci of papillary thyroid carcinoma with activating BRAF V600E mutation.

Multifocal papillary thyroid carcinoma (PTC) is common and the number of tumor foci rarely exceeds ten. The mechanism of multifocal disease is debated, with the two main hypotheses consisting of either intrathyroidal metastatic spread from a single tumor or independent multicentric tumorigenesis from distinct progenitor cells. We report the case of a 46-year-old woman who underwent total thyroidectomy and left central neck lymph node dissection after fine-needle aspiration of bilateral thyroid nodules that yielded cytological findings consistent with PTC. Final pathology of the surgical specimen showed an isthmic dominant 1.5 cm classical PTC and over 30 foci of microcarcinoma, which displayed decreasing density with increasing distance from the central lesion. Furthermore, all malignant tumors and lymph nodes harbored the activating BRAF V600E mutation. The present case highlights various pathological features that support a mechanism of intraglandular spread, namely a strategic isthmic location of the primary tumor, radial pattern of distribution and extensive number of small malignant foci and BRAF mutational homogeneity. Learning points: Multifocal papillary thyroid carcinoma (PTC) is commonly seen in clinical practice, but the number of malignant foci is usually limited to ten or less. There is no clear consensus in the literature as to whether multifocal PTC arises from a single or multiple distinct tumor progenitor cells. Strategic location of the dominant tumor in the thyroid isthmus may favor intraglandular dissemination of malignant cells by means of the extensive lymphatic network. An important pathological finding that may be suggestive of intrathyroidal metastatic spread is a central pattern of distribution with a reduction in the density of satellite lesions with increasing distance from the dominant focus. PTCs originating from the isthmus with intraglandular metastatic dissemination behave more aggressively. As such, a more aggressive treatment course may be warranted, particularly with regard to the extent of surgery.

A recurrent hydatid cyst of the thigh diagnosed 13 years after initial presentation.

This case presents a hydatid cyst of the thigh in a 57-year-old patient born and raised in rural Montenegro. He presented with a painful erythematous mass on the lateral aspect of the right thigh at the site of a previous cystic mass resection 13 years earlier. Complete surgical resection was conducted, histopathology revealed laminated membranes and polymerase chain reaction was positive for Echinococcus granulosus. Primary musculoskeletal hydatidosis is a rare entity and diagnosis is challenging. Any cystic lesion in a patient from an endemic area should raise the possibility of echinococcosis, regardless of anatomic location. The key aspects of diagnosis, albendazole treatment and surgical management are discussed.

Inverted urothelial carcinoma: a series of 12 cases with a wide morphologic spectrum overlapping with the large nested variant.

The current series presents 12 cases of invasive urothelial carcinoma (UC) with inverted growth pattern that fulfill the architectural criteria of the recently described "large nested" variant of UC, but which display a wider spectrum of morphologic and cytologic changes. All cases had an associated component of usual invasive UC, and 10 had an associated surface papillary component. Although many areas within the tumors were indistinguishable from a noninvasive endophytic growth pattern, at least some had an irregular ragged contour, and all showed haphazard arrangement with variable amount of intervening stroma at least focally. Inflammatory stromal reaction was noted in 11 cases, and desmoplasia and retraction artifact were present in 8 cases each. Although major areas showed mild atypia, many tumors showed marked hyperchromasia, prominent nucleoli, marked irregular nuclear membranes, and brisk mitotic activity. Final pathological stage on cystectomy specimens was T2 in 4 cases, T3 in 2 cases, and T4 in 3 cases. In 3 cases, lymph node metastases were documented histologically. Review of the literature shows that the "large nested," "inverted," "endophytic," and "inverted papilloma-like" variants of invasive UC are interrelated entities and should probably be considered as one variant with a wide spectrum of cytoarchitectural features. They should also be separated from the "nested" variant with which they rarely coexist and which shows different characteristics at the morphologic level.

Primary effusion lymphoma with central nervous system involvement in an HIV-negative homosexual male.

Primary effusion lymphoma (PEL) is a rare form of non-Hodgkin lymphoma that presents with body cavity effusions. It occurs chiefly in immunodeficient HIV-positive patients. The tumor cells generally express gene sequences of human herpesvirus-8 (HHV-8) and Epstein-Barr virus (EBV). Tumor cells of HIV-negative patients usually express HHV-8 gene sequences, but rarely those of EBV. We report a novel case of PEL in an HIV-negative homosexual male whose tumor cells expressed both HHV-8 and EBV gene sequences and who developed evidence of central nervous system involvement.

Follicular variant of papillary thyroid cancer: encapsulated, nonencapsulated, and diffuse: distinct biologic and clinical entities.

OBJECTIVE: To examine genotypic and clinical differences between encapsulated, nonencapsulated, and diffuse follicular variant of papillary thyroid carcinoma (EFVPTC, NFVPTC, and diffuse FVPTC, respectively), to characterize the entities and identify predictors of their behavior. DESIGN: Retrospective medical chart review and molecular analysis. SETTING: Referral center of a university hospital. PATIENTS: The pathologic characteristics of 484 consecutive patients with differentiated thyroid cancer who underwent surgery by the 3 members of the New York University Endocrine Surgery Associates from January 1, 2007, to August 1, 2010, were reviewed. Forty-five patients with FVPTC and in whom at least 1 central compartment lymph node was removed were included. MAIN OUTCOME MEASURES: Patients with FVPTC were compared in terms of age, sex, tumor size, encapsulation, extrathyroid extension, vascular invasion, central nodal metastases, and the presence or absence of mutations in BRAF, H-RAS 12/13, K-RAS 12/13, N-RAS 12/13, H-RAS 61, K-RAS 61, N-RAS 61, and RET/PTC1. RESULTS: No patient with EFVPTC had central lymph node metastasis, and in this group, 1 patient (4.5%) had a BRAF V600E mutation and 2 patients (9%) had RAS mutations. Of the patients with NFVPTC, none had central lymph node metastasis (P > .99) and 2 (11%) had a BRAF V600E mutation (P = .59). Of the patients with diffuse FVPTC, all had central lymph node metastasis (P < .001), and 2 (50%) had a BRAF V600E mutation (P = .06). CONCLUSIONS: FVPTC consists of several distinct subtypes. Diffuse FVPTC seems to present and behave in a more aggressive fashion. It has a higher rate of central nodal metastasis and BRAF V600E mutation in comparison with EFVPTC and NFVPTC. Both EFVPTC and NFVPTC behave in a similar fashion. The diffuse infiltrative pattern and not just presence or absence of encapsulation seems to determine the tumor phenotype. Understanding the different subtypes of FVPTC will help guide appropriate treatment strategies.

Extranodal Rosai-Dorfman disease arising in the right atrium: a case report with literature review.

Rosai-Dorfman disease is a rare, benign histiocytic proliferative disorder that commonly affects the lymph nodes. Although extranodal involvement has been reported in diverse sites, manifestation in the cardiovascular system is extremely uncommon. Specifically, the involvement of the heart by Rosai-Dorfman disease is an extraordinarily infrequent event. Here, the authors present a case of Rosai-Dorfman disease arising in the right atrium in a symptomatic 61-year-old man who initially presented with pleuritic chest pain and was found to have a large, lobulated, and circumscribed right atrial mass. The lesion exhibited an exuberant histiocytic and chronic fibroinflammatory process with focal emperipolesis within histiocytes. Immunohistochemical studies demonstrated strong S100 positivity in CD68+ CD1a- histiocytes. Although rare, Rosai-Dorfman disease should be considered in the differential diagnosis of a right atrial mass.