Intrathyroidal parathyroid carcinoma: a case report with clinical and histological findings

Aims

To analyse the histo-morphology of cases of medullomyoblastoma and identifying its divergent differentiation.

Methods

A retrospective review of all cases reported as medulloblastoma between the period of Jan 2000 to Dec 2006 was carried out on Hematoxylin and eosin (H & E) stained slides. The cases were screened on light microscopy for primitive neuroectodermal component of a medulloblastoma accompanied by areas of "myoid" differentiation, identified on the basis of presence of strap cells (indicating a clear skeletal muscle differentiation) and/or large anaplastic cells with vescicular nuclei and moderate to abundant amount of eosinophilic cytoplasm. All these cases were subjected to a panel of immunohistochemical stains, including Desmin, GFAP, NFP, HMB45, SMA, S100, CK and EMA. Ultrastructral analysis was done on tissue obtained from paraffin blocks in 2 cases.

Results

Male predominance (M:F = 5:1) was noted with an incidence of five percent of all cases of medulloblastoma (6 out of 120 cases) over a period of 6 years. Primitive neuroectodermal areas were accompanied with areas of "myoid" differentiation, 5 cases showing strap cells. Two cases with epithelial and cartilaginous differentiation were seen. Three cases showed focal melanocytic differentiation, identified only on HMB45 immunostaining. Four cases showed glial differentiation. Neuronal differentiation again was very focally seen in two cases, of which one was identified only by NFP immunostain. Seventh case is included in the study, however it is not considered to calculate incidence as it occurred beyond the period of 6 years of records search.

Conclusion

Medullomyoblastoma is a rare childhood tumor of cerebellum. Majority of cases reveal divergent differentiation, which are identified with the help of panel of immunostains indicating multi-potential nature of primitive neuroectodermal cells.     

Purulent pericarditis,an uncommon entity in modern practice: a case report

We report an 82-year-old female with pneumococcal pneumonia. Antimicrobial therapy was started in an early stage of the disease. On the 10th day of admission she developed peripheral pitting oedema with elevated jugular venous pressure and a drop in blood pressure. Her electrocardiogram showed sinus tachycardia and concave upward ST-segment elevation in almost all leads. A transthoracic two-dimensional echocardiogram revealed a large circumferential pericardial effusion, with diastolic collapse of the right atrium and a mitral inflow pattern that suggested cardiac tamponade. Emergency pericardiocentesis was performed, releasing 600 cc of thick green purulent material, followed by good haemodynamic recovery. The haemodynamic state, pneumonic infiltrate and inflammatory parameters responded gradually to antimicrobial therapy and the patient recovered and was discharged after six weeks. We conclude that even susceptible strains of Streptococcus pneumonia in a patient with no predisposing factors may still cause purulent pericarditis, even in the era of adequate antibiotic therapy.     

An unusual presentation of filariasis: a case report

BACKGROUND: Filariasis and its consequences are a major health problem in tropical countries, including the Indian subcontinent. Despite its high incidence, it is unusual to find microfilaria in fine needle aspiration cytology (FNAC) smears. We present a case of subcutaneous firm to cystic swelling, aspiration of which revealed a large number of microfilaria. CASE: A 30-year-old man presented with a chain of intermittent, firm swellings in both arms. FNAC of the swellings revealed a large number of 4 microfilariae with associated giant cell reaction and inflammatory cell-like eosinophils. CONCLUSION: Besides the documented usual mode of presentation of filarial infection, it can present in an atypical manner, so careful examination of aspirates from the subcutaneous swellings, especially in filariasis endemic zones, is very important.     

Solitary fibrous tumor: report of a case with an unusual presentation as a spindle cell parotid neoplasm

BACKGROUND: Initially described as a pleural tumor, solitaryfibrous tumor of the parotid gland (SFT) is rare and has been reported at a wide range ofanatomic sites. Although cases of SFT arising in the parotid gland have been previously described, a review of the literature failed to reveal cytology-based reports of this entity. CASE: A 42-year-old man presented with a right parotid mass that had gradually enlarged over 3 years. He was otherwise asymptomatic. Fine needle aspiration biopsy of the mass showed a hypercellular smear composed of spindle cells in both clusters and isolated forms, with ovoid nuclei, evenly distributed chromatin, inconspicuous nucleoli and scant to moderate cytoplasm with focally wispy, collagenous, intercellular material. The background was hemorrhagic, without chondromyxoid matrix or inflammatory cells. There was no evidence of a myoepithelial component. A diagnosis of spindle cell neoplasm was rendered. Histologic examination of the total parotidectomy specimen revealed a SFT arising in the parotid gland. The diagnosis was supported by immunohistochemical studies. CONCLUSION: SFT is a well-circumscribed neoplasm composed of short, spindled, plump cells with scanty cytoplasm growing in a haphazard or "patternless" pattern. Tumor cells are intimately admixed with collagenous stroma. Hemangiopericytomalike vessels are frequently seen. Although SFT rarely occurs in the salivary gland and a definitive diagnosis based on cytologic preparations alone is difficult, the diagnosis of SFT can be considered when cytologic examination reveals a hypercellular smear composed of isolated, cohesive clusters of spindled, fibroblastlike cells associated with a collagenous component in ahemorrhagic background. The preoperative magnetic esonance image findings of a highly vascular neoplasm support the diagnosis.     

Mediastinal parathyroid carcinoma: a case report

A 72 year-old woman with primary hyperparathyroidism was operated for parathyroid crisis. PTH serum level was 808 pg/mL. During the operation, only two superior parathyroid glands were found. One was normal, and hypertrophy was revealed in the other. After the surgical procedure, PTH serum level was 726.5 pg/mL. Helical computer tomography examination showed a heterogeneous mass in the anterior mediastinum. The tumour was removed via a sternotomy approach. Histopathological examination revealed parathyroid carcinoma. PTH level dropped to 5.74 pg/mL. Cytofluorometric examination revealed diploidy (DI = 1) in both the hypertrophic and the unchanged upper glands, whereas parathyroid cancer was aneuploid. After the initial operation, the woman was discharged from the hospital on the 27th postoperative day. One year after surgical procedures, she is well. She has to take calcium.     

Fine needle aspiration of urethral recurrence of urothelial carcinoma after radical cystectomy presenting as a perineal mass: a case report

BACKGROUND: Recurrence of urothelial (transitional cell) carcinoma in the urethra after cystectomy for invasive urothelial carcinoma is relatively uncommon. It is also uncommon for the recurring urethral tumor to present as a painful perineal mass. Fine needle aspiration (FNA) can be used to evaluate such perineal lesions and confirm tumor recurrence. CASE: A 5-cm-diameter mass was found in the perineum of a 63-year-old man 1 year after radical cystoprostatectomy for invasive urothelial carcinoma of the urinary bladder. The mass was detected on pelvic computed tomographic scanning. FNA cytology showed numerous urothelial carcinoma cells of high grade displaying squamous cell differentiation mimicking the histopathologic findings of the primary tumor found on cystectomy. Diagnosis of recurrent urothelial carcinoma was rendered. The FNA in this case spared the patient an open biopsy. CONCLUSION: Mass lesions arising in the perineum of patients who underwent cystectomy for urothelial carcinoma should raise the suspicion of urothelial carcinoma recurrence. Evaluation of perineal masses for recurrence of urothelial carcinoma can be made on FNA without the need for open biopsy.     

Cytology of secondary vulvar Paget's disease of urothelial origin: a case report

BACKGROUND: Primary cutaneous Paget's disease of the vulva is an intraepithelial adenocarcinoma most likely arising from a cutaneous stem cell with sweat gland epithelial differentiation or can be of sweat gland origin. Primary vulvar Paget's disease, however, can be mimicked by an internal noncutaneous neoplasm htat has extended to secondarily involve the vulva. Most commonly, this is due to an anal or rectal adenocarcinoma or a urothelial carcinoma. These malignancies may be detected in a vaginal or vulvar cytologic smear. CASE: An 81-year-old woman with a past history of urothelial carcinoma in situ of the bladder presented severalyears subsequent to treatment for bladder cancer with extensive vulvar and vaginal disease, clinically interpreted as primary vulvar Paget's disease involving the vagina. Vaginal cytology showed a high grade malignancy. The patient subsequently underwent radical (total deep) vulvectomy and vaginal excision. Subsequent investigation of her bladder showed recurrent urothelial carcinoma in situ with extensive spread to the vagina and vulva, simulating primary cutaneous vulvar Paget's disease. CONCLUSION: It is important to recognize secondary vulvar Paget's disease, although uncommon, because of the difference in therapy for primary and secondary vulvar Paget's disease. Certain cytologic characteristics in a vaginal or vulvar smear in a patient with suspected vulvar Paget's disease may aid in distinguishing them.     

Paranuclear blue inclusions of small cell carcinoma of the stomach: report of a case with cytologic presentation in peritoneal washings

BACKGROUND: Primary gastric small cell carcinoma is a rare but important entity. We describe a case that we diagnosed by peritoneal washing cytology. CASE: A 70-year-old male presented with upper abdominal discomfort and underwent endoscopic evaluation. Gastric endoscopy revealed a diffuse, infiltrating tumor from the body to the antrum. Total gastrectomy with lymph node dissection and intraoperative peritoneal washing cytology were carried out. Peritoneal washing cytology showed the presence of many undifferentiated malignant small cells with a necrotic background. The tumor cells were small and round, with naked, hyperchromatic nuclei and finely granular chromatin. Some tumor cells contained paranuclear blue inclusions (PBls) in the cytoplasm. The tumor cells were positive for neuron-specific enolase and synaptophysin on immunocyto-chemistry. Carcinoembryonic antigen, alpha-fetoprotein (AFP) and leukocyte common antigen were negative. Pathologic diagnosis after the operation was moderately to poorly differentiated adenocarcinoma and small cell carcinoma containing AFP-positive cells. CONCLUSION: The prognosis of primary gastric small cell carcinoma is usually poor. Our patient died of multiple liver metastases and peritonitis carcinomatosa 69 days after surgery. When a gastric small cell carcinoma is suspected in peritoneal washings, immunocytochemical demonstration of neuroendocrine differentiation is required to arrive at the final diagnosis.     

Metaplastic carcinoma of the breast in an HIV-positive patient: a case report

BACKGROUND: Metaplastic carcinoma of the breast is a rare neoplasm that causes diagnostic difficulty on fine needle aspiration smears. Breast carcinoma in HIV-infected patients occurs at a relatively early age, with increased bilateral disease, unusual histology, and early metastatic spread with a poor outcome. CASE: A case of metaplastic carcinoma of the breast arose in a 36-year-old woman who was seropositive for HIV. In the absence of a sarcomatous component and presence of obvious ductal differentiation on aspirates, a diagnosis of high grade infiltrating duct carcinoma, not otherwise specified, was made on fine needle aspiration cytology (FNAC). CONCLUSION: This case underlines the limitations of FNAC in the diagnosis of metaplastic carcinoma of the breast. It also shows that it is imperative to maintain a high index of suspicion for rare pathologies in immunocompromised patients.