Hypermetabolic lymphadenopathy following the administration of COVID-19 vaccine and immunotherapy in a lung cancer patient: a case report.

BACKGROUND: Given the current climate of the pandemic, lung cancer patients are especially vulnerable to complications from severe acute respiratory syndrome coronavirus 2 infection. As a high-risk population group, these patients are strongly advised to receive coronavirus disease 2019 vaccination in accordance with Center for Disease Control and Prevention guidelines to minimize morbidity and mortality. In recent years, immunotherapy has taken a preeminent role in the treatment of non-small cell lung cancer with dramatic improvement in overall survival. Reactive lymphadenopathy following the administration of a coronavirus disease 2019 vaccination can confound the radiographic interpretation of positron emission tomography-computed tomography or computed tomography scans from lung cancer patients receiving immunotherapy. CASE PRESENTATION: Here, we present a case of a 61-year-old Caucasian female and former smoker who developed cervical, hilar, supraclavicular, mediastinal, and left retroauricular lymphadenopathy following her coronavirus disease 2019 booster vaccination. At the time, she had been receiving long-term immunotherapy for the treatment of advanced lung adenocarcinoma. Biopsy was pursued owing to concerns of treatment failure and confirmed recurrent malignancy. CONCLUSION: This case report highlights the importance of lymph node biopsies in lung cancer patients who present with contralateral lymphadenopathy following coronavirus disease 2019 vaccination to rule out tumor recurrence in this deserving patient population.

Retropharyngeal abscess- An unusual complication in a COVID-19 patient.

The coronavirus disease 2019 (COVID-19) pandemic has generated many challenges for physicians, including multiple long-term effects that are still being studied. We report a CASE of patient who developed a retropharyngeal abscess post-COVID19 infection. We report a CASE of a female who was diagnosed with COVID19 pneumonia and hospitalized for a week at an outside institute. Approximately 3 weeks post discharge she developed neck pain, dysphagia, voice change and odynophagia for which she went to an outside emergency department. A soft tissue neck CT was performed and was concerning for retropharyngeal abscess. The patient was then transferred to our institution. On arrival, a CT scan of the neck and nasopharyngoscopy were performed and biopsies of the epiglottis and right inferior tonsillar pole were taken. Biopsies of the epiglottis and tonsil showed acute inflammation, spongiosis, edema and marked dilation of the lymphatics. Her clinical course was complicated by persistent infection requiring multiple washouts, hyperglycemia, tube feed intolerance, dysphagia and deconditioning. A multi-disciplinary approach was instituted for appropriate management. This case report highlights the necessity for close follow up after recovery from COVID-19 infection, particularly in patients with multiple comorbidities.

A Rare Case of a Solitary Fibrous Tumor of the Spermatic Cord.

Solitary fibrous tumors (SFTs) are rare mesenchymal tumors, originally identified in the pleura. Even though they have subsequently been described in several extrapleural sites, the incidence of SFTs in the spermatic cord is particularly rare. Here, we report a case of a 27-year-old male that presented with a 3-year history of left scrotal swelling. Computed tomography (CT) and ultrasound demonstrated multiple solid, hypoechoic well-circumscribed masses that were separate from the testis. Surgical excision of the mass led to pathologic diagnosis of a solitary fibrous tumor involving the spermatic cord. Solitary fibrous tumors, although rare, are an important differential diagnosis for urogenital tumors.

Calcifying Pseudoneoplasm of the Neuraxis Involving the Posterior Skull Base: A Case Report and Literature Review.

Calcifying pseudoneoplasm of the neuraxis is an uncommon, nonneoplastic fibro-osseous lesion of the central nervous system. At the time of this report, at least 150 cases have been reported in the literature. Because of the rarity of this lesion, it is often diagnostically challenging for radiologists and pathologists alike. In this article, we present a case of a 44-year-old woman with a 5.8-cm intracranial/skull base calcifying pseudoneoplasm of the neuraxis that was concerning for osteosarcoma on initial frozen section. Permanent sections revealed bone and fibrous stroma, calcifications, and nests of histiocytes with granuloma formation. Scattered, focally dense inflammatory foci and spindled cells outlining abundant large nodules of chondromyxoid matrix were also present. In this case report, we also reviewed recent literature for clinical presentations, radiologic findings, and histologic differential diagnoses. Familiarity with this lesion is important to avoid misdiagnosis leading to unnecessary and potentially harmful treatment.

Accuracy of Intraoperative Frozen Section in Detection of Acute Invasive Fungal Rhinosinusitis.

CONTEXT.­: Acute invasive fungal rhinosinusitis (AIFRS) is an aggressive form of fungal sinusitis, which remains a significant cause of morbidity and mortality. Early diagnosis and intervention are keys to improving patient outcomes. Intraoperative consultation has shown promise in facilitating early surgical intervention, but the accuracy of frozen section has not been clarified in this setting. OBJECTIVES.­: To assess the accuracy of frozen-section diagnosis in patients with clinically suspected AIFRS. DESIGN.­: All cases of clinically suspected AIFRS during a 10-year period (2009-2019) were retrospectively reviewed. The frozen-section results were compared with the final permanent sections as well as the tissue fungal culture results, following which the accuracy of frozen section was determined. RESULTS.­: Forty-eight patients with 133 frozen-section evaluations for AIFRS were included in the study. Thirty of 48 patients and 61 of 133 specimens were positive for AIFRS on final pathology. Of 30 positive patients, 27 (90%) had at least 1 specimen diagnosed as positive during intraoperative consultation; among the 61 positive specimens, 54 (88.5%) were diagnosed as positive during intraoperative consultation. Of 72 negative specimens, all were interpreted as negative on frozen section. Thus, frozen sections had a sensitivity of 88.5% (95% CI, 0.78-0.97), specificity of 100% (95% CI, 0.94-1), positive predictive value of 100% (95% CI, 0.92-1), and negative predictive value of 90.6% (95% CI, 0.82-0.97). CONCLUSIONS.­: This study represents the largest series assessing the diagnostic accuracy of frozen section analysis in AIFRS. These findings are useful in frozen section-informed intraoperative decision making.

Histopathologic findings in culture-positive secondary osteomyelitis.

As peripheral vascular disease and diabetes mellitus are increasingly common, chronic wounds are often seen. Bone biopsies, with imaging and microbial cultures, are often obtained to evaluate for osteomyelitis. Because much of the historical literature describing the histology of osteomyelitis pertains to primary osteomyelitis, this study characterizes the histologic findings and provides correlation with culture results in secondary osteomyelitis. The histologic features of bone biopsies were assessed over a 5 year period. Concurrent laboratory and radiographic data were obtained and these data were compared with culture results. This study included 163 cases, of which 104 were culture-positive osteomyelitis. All culture-positive cases had been present longer than 28 days and had at least one of the following histologic features: neutrophilic inflammation, plasmacytic inflammation, or eosinophilic fibrosis. However, none of these findings were restricted to culture-positive cases. Overall, plasmacytic and neutrophilic inflammation provided similar specificity, and positive predictive values for osteomyelitis. Medullary fibrosis gave a sensitivity of 95%, the highest for any single feature, and the combination of fibrosis and neutrophilic inflammation had the greatest specificity of 96%. Additionally, neutrophilic inflammation correlated often with isolation of Staphylococcus aureus, while plasma cell predominance was found more frequently with other infectious agents. This study describes histologic features in secondary osteomyelitis, which may challenge the widespread inclination to equate a neutrophilic inflammation with 'acute osteomyelitis' and 'chronic osteomyelitis' with one rich in plasma cells. We report an early correlation between common histopathologic findings and specific culture isolates, which can be further refined with additional research.

The impact of C4d testing on tissue adequacy in lung transplant surveillance.

BACKGROUND: Surveillance transbronchial biopsies are routinely used to assess lung allograft rejection. While the criteria for diagnosing acute cellular rejection have been well-established, the morphological findings associated with antibody mediated rejection are variable. To increase the sensitivity for antibody mediated rejection, a portion of a biopsy can be used for C4d immunofluorescence testing, along with histologic findings and donor specific antibodies. When the number of alveolar pieces in a biopsy is small, the relative utility of sending one piece for C4d testing is unclear. METHODS: Pathology reports of 1400 surveillance transbronchial lung biopsies from 2008 to 2017 were reviewed to obtain the number of pieces of alveolar parenchyma in each case. Based on a standard definition of adequacy as five pieces of well-expanded alveolar parenchyma, reports with five fragments were grouped as "adequate", four pieces as a "marginal" sample, and three or less were considered an "inadequate" sample. RESULTS: Of the 1400 biopsies, 653 specimens had 5 or more pieces of alveolar parenchyma.747 specimens were submitted with less than 5 pieces and 290 of those were considered marginal. In all marginal cases, a piece was withheld for C4d immunofluorescence testing. CONCLUSIONS: About 21% of specimens would have the recommended 5 pieces of alveolar parenchyma if not for the withholding of pieces for C4d IF testing. Over the span of 10 years, 290 such cases were recorded at our institution. Given this nontrivial impact, it is unclear if C4d immunofluorescence testing should be performed on surveillance transbronchial biopsies when the number of pieces in the specimen is marginal.

Pulmonary Alveolar Microlithiasis: An Isolated Case in a Hispanic Male.

Pulmonary alveolar microlithiasis (PAM) is an uncommon hereditary lung disease characterized by widespread deposition of calcium phosphate microliths within the alveolar spaces. It is considered an autosomal recessive disease with a mutation in a gene encoding a sodium phosphate cotransporter. The imaging findings in the early phase of disease can be mistaken for miliary tuberculosis or sarcoidosis. However, the classic radiologic findings in the later phases of disease show numerous opacities causing a "snowstorm" appearance to the lungs that corresponds with widespread deposition of microliths throughout the lung parenchyma. Although the disease often progresses over a slow time course, there are no effective therapies, and bilateral lung transplantation is recommended when there are increasing oxygen requirements or evidence of pulmonary hypertension.

Cholangiolytic Changes in Statin-Induced Liver Injury.

Atorvastatin is a commonly used oral cholesterol-lowering agent. Side effects associated with statin therapy include arthralgia, myalgia, dyspepsia, weakness, and headache. Prospective and retrospective studies of drug-induced liver injury have identified statin-induced hepatotoxicity, with atorvastatin being the most commonly cited. Associated liver function test elevations have varied from hepatocellular to cholestatic/mixed pattern. We report a case of a 58-year-old woman that illustrates unusual histologic findings associated with a mixed pattern of statin-induced liver injury. While being treated with atorvastatin, the patient exhibited repeated bouts of abdominal pain over a year associated with biliary tree dilation, variably attributed to postcholecystectomy dilation and stenosis of the ampulla of Vater. Following sphincterotomy, the patient's bilirubin normalized but the other liver function tests remained elevated. Liver biopsy revealed portal and lobular inflammation with cholangiolysis. The patient's liver function tests normalized following cessation of atorvastatin therapy.

Trends in Thyroid Fine-Needle Aspiration Cytology Practices: Results From a College of American Pathologists 2016 Practice Survey.

CONTEXT.­: The College of American Pathologists periodically surveys laboratories to determine changes in cytopathology practices. We report the results of a 2016 survey concerning thyroid fine-needle aspiration (FNA). OBJECTIVE.­: To provide a cross-sectional survey of thyroid cytology practices in 2016. DESIGN.­: In 2016, a survey was sent to 2013 laboratories participating in the College of American Pathologists Non-Gynecologic Cytology Education Program (NGC-A) requesting data from 2015-2016 on several topics relating to thyroid FNA. RESULTS.­: A total of 878 laboratories (43.6% of 2013) replied to the survey. Radiologists performed the most thyroid FNA procedures in most laboratories (70%; 529 of 756), followed by endocrinologists (18.7%; 141 of 756), and most of these were performed under ultrasound guidance (92.1%; 699 of 759). A total of 32.6% of respondents (251 of 769) provided feedback on unsatisfactory rates for nonpathology providers who performed FNA. Intraprocedural adequacy assessment was primarily performed by attending pathologists (77.4%; 490 of 633) or cytotechnologists (28.4%; 180 of 633). Most laboratories used the Bethesda System for Reporting Thyroid Cytopathology (89.8%; 701 of 781) and performed molecular testing based on clinician request (68.1%; 184 of 270) rather than FNA diagnosis. Correlation of thyroid excisions with prior cytology results most often occurred retrospectively (38.4%; 283 of 737) and was used for pathologist interpretive quality assurance purposes. CONCLUSIONS.­: These survey results offer a snapshot of national thyroid FNA cytology practices in 2016 and indicate that standardized cytology terminology is commonly used; pathologists perform most immediate adequacy assessments for thyroid FNA; laboratories use correlation statistics to evaluate pathologists' performance; and molecular tests are increasingly requested for indeterminate interpretations, but reflex molecular testing is rare.

A Biphasic Pleural Tumor with Features of an Epithelioid and Small Cell Mesothelioma: Morphologic and Molecular Findings.

Malignant mesotheliomas are generally classified into epithelioid, sarcomatoid, desmoplastic, and biphasic types with rare reports of a small cell form. These small cell variants display some morphologic overlap with desmoplastic small round cell tumors (DSRCTs) which generally occur within the abdominal cavity of young males and are defined by a characteristic t(11;22)(p13;q12) translocation. However, there are rare reports of DSRCTs lacking this translocation. We present a 78-year-old man with a pleura-based biphasic neoplasm with features of both epithelioid mesothelioma and a small cell blastema-like neoplasm. The epithelioid portion showed IHC reactivity for pan cytokeratin, CK5/6, D2-40, and calretinin and the small cell portion marked with CD99, pan cytokeratin, WT1, FLI1, S100, CD200, MyoD1, and CD15. Fluorescence in situ hybridization testing for the t(11;22)(p13;q12) translocation disclosed loss of the EWSR1 gene in 94% of tumor cell nuclei, but there was no evidence of the classic translocation. Array based-comparative genomic hybridization (a-CGH) confirmed the tumor had numerous chromosome copy number losses, including 11p15.5-p11.12 and 22q12.1-q13.33, with loss of the EWSR1 and WT1 gene regions. Herein, we report novel complex CGH findings in a biphasic tumor and review the molecular genetic alterations in both mesothelioma and DSRCTs.

Cryptic insertion of 3'FOXO1 into inverted chromosome arm 2q in the presence of two normal chromosome 13s and 13 small interstitial duplications in a patient with alveolar rhabdomyosarcoma.

Alveolar rhabdomyosarcoma (ARMS) is a pediatric soft tissue neoplasm with a characteristic translocation, t(2;13)(q35;q14), which is detected in 70-80% of cases. This well-described translocation produces the gene fusion product PAX3-FOXO1. Cryptic rearrangements of this fusion have never before been reported in ARMS. Here we describe a patient with ARMS that showed, by fluorescence in situ hybridization and G-banded chromosomes, a cryptic insertion of 3'FOXO1 into inverted chromosome 2q. The inversion breakpoints were depicted by array comparative genomic hybridization as two small interstitial duplications, one of which involved the PAX3 gene. In addition, the array comparative genomic hybridization results revealed 1q gain, 16q loss, and 11 more small duplications, with one of them involving the FOXO1 gene. Although the pathogenesis in classic ARMS cases is thought to be driven by the 5'PAX3-3'FOXO1 fusion on derivative chromosome 13, here we report a novel cryptic insertion of 3'FOXO1 resulting in a pathogenic fusion with 5'PAX3 on inverted chromosome 2q.