Synchronous Parathyroid Carcinoma,Parathyroid Adenoma,and Papillary Thyroid Carcinoma in a Patient with Severe and Long-Standing Hyperparathyroidism

ObjectiveTo describe a patient presenting with the rare constellation of synchronous parathyroid carcinoma, parathyroid adenoma, and papillary thyroid carcinoma.MethodsWe summarize the clinical presentation, diagnostic work-up, surgical management, and pathologic features of our patient and review the pertinent literature.ResultsThe patient was a 59-year-old man who presented with severe clinical manifestations of long-standing primary hyperparathyroidism, a serum calcium concentration of 14.4 mg/dL, and a parathyroid hormone level of 2,023 pg/mL. He was found to have a 3.4-cm parathyroid carcinoma on the left side and a 3.2-cm papillary carcinoma in the right thyroid lobe. In addition, a 917-mg parathyroid adenoma was found on the right side.ConclusionSynchronous parathyroid and thyroid carcinomas are extremely rare. To our knowledge, our patient is the first documented case with a parathyroid adenoma in addition to synchronous parathyroid and thyroid carcinomas. The presence of concurrent parathyroid carcinoma and parathyroid adenoma can cause diagnostic confusion and should be considered in patients presenting with severe hyperparathyroidism. Any concomitant thyroid nodules must be investigated to rule out thyroid carcinoma. (Endocr Pract. 2009;15:463-468)     

Fine needle aspiration of chromophobe renal cell carcinoma

OBJECTIVE: To describe the cytomorphologic findings of chromophobe renal cell carcinoma (CRCC) in order to preoperatively distinguish this rare neoplasm from other primary or secondary tumors arising from the kidney or presenting as retroperitoneal masses. STUDY DESIGN: Clinical data, fine needle aspiration (FNA) and follow-up surgical specimens from 4 patients with CRCC (3 primaries and 1 metastatic to the liver) were reviewed. Electron microscopy was available for 2 histologic specimens. RESULTS: Two tumors (1 primary and 1 metastatic case) were readily identified as CRCC on FNA. The 2 remaining cases were diagnosed as renal cell carcinoma (RCC) consistent with CRCC. All tumors showed aspirates with moderate to high cellularity, with the cells arranged in small clusters and single cells. Neoplastic cells had abundant heterogeneous cytoplasm, a thickened cell membrane, nuclear hyperchromasia, nuclear outline irregularity, significant nuclear size variation, intranuclear inclusions and frequent binucleation. Histology of the 4 renal tumors was characteristic of CRCC, with positivity for Hale's colloidal iron in all cases. Ultrastructurally, characteristic cytoplasmic microvesicles were observed in the 2 cases that we studied. CONCLUSION: In the adequate clinicoradiologic setting, CRCC has distinctive cytologic features that may allow an accurate preoperative FNA diagnosis.     

Detection of Synchronous Cancers by Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography during Primary Staging Workup for Esophageal Squamous Cell Carcinoma in Taiwan

Aim

The aim of this retrospective study was to investigate the ability of fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the detection of synchronous cancers during staging workup for esophageal squamous cell carcinoma.

Materials and Methods

We performed a retrospective chart review of 426 Taiwanese patients with esophageal cancer who received FDG-PET/CT during their primary staging workup between December 2006 and December 2011. We defined synchronous cancers as those occurring within 6 months of the FDG-PET/CT scan. All of the synchronous lesions were confirmed by histology or imaging follow-up. The study patients were followed for at least 18 months or were censored on the date of last follow-up.

Results

Fifty patients were excluded from analysis because of the presence of distant metastases. Of the remaining 376 patients, 359 were diagnosed with squamous cell carcinoma (SCC). We identified 17 patients with synchronous cancers, and all of them had a diagnosis of SCC. Synchronous head and neck cancers were the most frequent (n=13, 76.4%), followed by gastrointestinal cancers (colon cancer, n=2; hepatocellular carcinoma, n=1), and renal cell carcinoma (n=1). FDG-PET/CT successfully detected 15 synchronous cancers (12 head and neck cancers, 2 colon cancers, and 1 renal cell carcinoma). In contrast, conventional workup detected only 9 synchronous cancers (7 head and neck cancers, 1 hepatocellular carcinoma and 1 renal cell carcinoma). The sensitivity of FDG-PET/CT and conventional workup in detecting synchronous cancers were 88.2% and 52.9% respectively.

Conclusion

The most frequent synchronous lesions in patients with esophageal SCC were head and neck cancers in Taiwan. Our data indicate that FDG-PET/CT is superior to conventional workup in the detection of synchronous tumors during primary staging for esophageal squamous cell carcinoma.     

Primary cytodiagnosis of synchronous small-cell cancer and squamous-cell carcinoma of the respiratory tract

Report is made of the first primary cytodiagnosis of a synchronous small-cell cancer of the lung and squamous-cell carcinoma of the larynx, which were histologically confirmed. Sputum cytology should be used in the detection and surveillance of multiple primary malignancies of the respiratory tract, which have been observed with increasing frequency.     

Papillary carcinoma of the common bile duct. Diagnosis by bile drainage cytology

A 54-year-old man with clinical and radiologic findings suggestive of pancreatic carcinoma had cytologic examination of bile drainage fluid specimens prepared by membrane filtration and cytocentrifugation. Examination showed clumps of malignant cells with features most consistent with a well-differentiated papillary neoplasm of bile duct origin, rather than a primary pancreatic carcinoma. Partial pancreatoduodenectomy with resection of the proximal common bile duct confirmed the presence of a small, well-differentiated but invasive papillary bile duct carcinoma. Pancreatic carcinoma and papillary carcinoma of the bile duct are anatomically and biologically different lesions that should be distinguished, when possible, by cytologic examination. In this case, surgical treatment was planned on the assumption that cytologic examination could distinguish a papillary carcinoma of the bile duct from the clinically suspected pancreatic adenocarcinoma.     

Sputum cytology of metastatic carcinoma of the lung.

The cytopathology of 47 cases of metastatic carcinoma of the lung and of 28 cases of recurrent or metastatic bronchogenic carcinoma is reviewed. The diagnostic yield was better for recurrent than for metastatic carcinoma but overall was comparable to that of primary bronchogenic carcinomas. The metastatic tumors were located in all areas of the lung and included single as well as multiple lesions. The positive yield did not differ significantly in relation to any of the pathologic features but was somewhat higher if the metastases were large and centrally located. A definite differentiation of the metastatic tumors, usually adenocarcinomas, from new primary bronchogenic carcinomas is often possible particularly if the cytopathology can be compared with that of the primary lesion. Specific cytologic features include the relative lack of cohesion and the formation of columns in metastatic breast carcinomas, the formation of larger cohesive well circumscribed nodules composed of tall columnar cells in metastatic colon carcinomas, clear cell features in some metastatic adenocarcinomas of the kidney, and the small cell size and uniform, regular nuclear features in the often cytologically well differentiated metastatic carcinomas of the prostate.     

Metastatic Renal Cell Carcinoma to the Thyroid Gland

ObjectiveTo examine the presentation, diagnosis, and appropriate management of renal clear cell carcinoma metastasis to the thyroid gland.MethodsWe describe a clinical case of solitary thyroid metastasis from renal clear cell carcinoma and present a comprehensive review of the related English-language literature. Common patterns of presentation and generalized overall management recommendations are evaluated and summarized.ResultsEight years after nephrectomy for renal carcinoma at age 61 years, a man presented with a thyroid mass. Cytology and histopathologic surgical findings were consistent with a solitary metastasis most compatible with metastatic clear cell carcinoma from his previous renal carcinoma. After left thyroid lobectomy and isthmusectomy, the patient remains disease-free 5 years later. Although uncommon, nearly 150 cases of clinically recognized metastatic renal cell carcinoma to the thyroid have been reported in the English-language literature. Metastatic disease from the kidney to the thyroid gland can occur more than 20 years after nephrectomy with the average time interval being 7.5 years. Obtaining a full clinical history in any patient who presents with a thyroid nodule is essential to allow consideration of possible metastatic disease from previous primary tumor. Metastatic disease to the thyroid gland can be correctly diagnosed preoperatively. If metastatic renal cancer is limited to the thyroid gland only, prompt, appropriate surgical intervention can be curative.ConclusionMetastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of renal cell carcinoma. (Endocr Pract. 2008;14:1040-1046)     

Cytology of primary pulmonary mucoepidermoid and adenoid cystic carcinoma. A report of four cases

BACKGROUND: Mucoepidermoid and adenoid cystic carcinomas are very rare primary pulmonary neoplasms that can be classified under the broader heading of salivary gland-like neoplasms (SGN). Both entities need to be considered in the cytologic differential diagnosis of lung tumors. We reviewed cytologic findings in primary pulmonary neoplasms diagnosed at our institution during the time period 1981 to the present along with outside consultation cases. CASES: Three cases of primary mucoepidermoid carcinoma and one case of primary adenoid cystic carcinoma of the lung were diagnosed based on cytology during the period examined. Patient ages were 16, 25, 47 and 78 years, respectively. The mucoepidermoid cytology specimens were composed of three cell types, mucinous, squamous and intermediate cells, at times associated with extracellular mucin. The adenoid cystic carcinoma consisted of small, uniform cells with dark nuclei, scant cytoplasm and associated, acellular balls of basement membrane material. CONCLUSION: The differential diagnosis for primary pulmonary neoplasms needs to include the rare SGN. Cytologic features of adenoid cystic carcinoma are diagnostic; those of mucoepidermoid carcinoma are at least suggestive.     

Primary malignant melanoma of the duodenum without visible melanin pigment: a mimicker of lymphoma or carcinoma

ABSTRACT: Primary malignant melanoma of the duodenum is an unusual oncologic entity. Patients usually present the similar clinical symptoms like other common tumors in this site. And there are no specific radiological features either. The cases with only little melanin pigment or without notable melanin pigment are very misleading, especially in small biopsies or frozen sections. Definite diagnosis depends on both careful histologic examination and the use of proper immunohistochemical stains. Moreover, detailed history and thorough investigation should be made to exclude the preexistence or coexistence of a primary lesion elsewhere. Herein we report the case of a 60-year-old male patient with primary malignant melanoma of the duodenum, which was misdiagnosed as lymphoma or undifferentiated carcinoma in frozen consultation. The patient had achieved disease-free survival for more than 46 months without any evidence of recurrence after surgery. Virtual slides The virtual slides for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1221457317710561.     

Rheumatoid nodule and combined pulmonary carcinoma: topographic correlations; a case report and review of the literature

An association between rheumatoid arthritis (RA) and malignancies has been ascertained and patients with RA appear to be at higher risk of lymphoma and lung cancer. The higher risk of the latter malignancy may be related to rheumatoid interstitial lung disease and immunosuppressive therapies. Herein we illustrate the case of a 59-year-old male smoker affected by RA and treated with cortisone, methotrexate and TNF-α antagonists, who underwent right lower lobectomy for a nodular lesion. On microscopic examination, the lesion consisted of two distinct areas: a central area of fibrinoid necrosis, bordered by histiocytes in a palisaded arrangement, lymphocytes and a 0.4 cm thick peripheral area constituted by a combined small cell anaplastic carcinoma, adenocarcinoma and squamous cell carcinoma. The combination of three histotypes is very rare in such a small tumour. In our case, it may be hypothesized that synchronous, heterogeneous mutations occurred in different type of committed cells or in stem cells, due to the production of cytokines by RA nodule histiocytes and lymphocytes, which are contiguous to the carcinomatous area. Since few studies have evaluated the topographic correlation between tumors and rheumatoid lung lesions, further morphological and molecular studies are needed to clarify this association and the pathogenetic relationship between RA and cancer of the lung.     

Primary papillary serous carcinoma of the peritoneum: report of a case with diagnosis by fine needle aspiration and immunocytochemistry

BACKGROUND: Primary papillary serous carcinoma (PPSC) of the peritoneum is a rare neoplasm, histologically indistinguishable from papillary serous carcinoma of the ovary, which diffusely involves the peritoneum but spares or minimally invades the ovaries. To the best of our knowledge, the preoperative and the fine needle aspiration diagnosis of this disorder have not been reported before. CASE: A woman developed an extensive peritoneal neoplasm 4 years after hysterectomy and bilateral salpingo-oophorectomy for benign disease. Fine needle aspiration of the tumor was performed, and the cytologic and immunocytochemical findings were consistent with papillary serous carcinoma. A diagnosis of PPSC of the peritoneum was rendered because review of all slides from previous surgical specimens showed no evidence of carcinoma and no other primary tumors were found elsewhere. CONCLUSION: Fine needle aspiration cytology coupled with immunocytochemical and clinical data allows an unequivocal preoperative diagnosis of papillary serous carcinoma (primary peritoneal or with an ovarian origin). The sole limitation to establish a primary peritoneal origin before surgery is the requirement to histologically study the ovaries. Based on this fact, the preoperative fine needle aspiration cytology diagnosis of PSCP should be restricted to oophorectomized patients.     

Squamous cell carcinoma of the skin

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the subtypes of squamous cell carcinoma of the skin. 2. Identify factors that affect recurrence and/or metastasis. 3. Develop a surgical management plan for treating high-risk squamous cell carcinoma of the skin. In treating squamous cell carcinoma of the skin, a key concept in proper management is understanding why certain tumors are more prone to both recurrence and metastasis. When developing a surgical management plan, an understanding of "high risk" is essential. This article concentrates on identifying those tumor subtypes and factors that may serve as predictors of high-risk status as well as on providing management suggestions.     

Primary intracranial epidermoid carcinoma

The cytologic findings in the cerebrospinal fluid in a case of primary intracranial epidermoid carcinoma are presented. The presence of a few squamous cells showing hyaline cytoplasm compatible with keratinization suggested the possible nature of the tomographically observed lesion. These tumors may arise in congenital epidermoid cysts at the base of the brain. Because of their location and meningeal spread, such tumors may cause severe symptoms and death despite a minute size, as illustrated by this case.     

Small cell undifferentiated carcinoma of the parotid gland. Cytologic, histologic, immunohistochemical and ultrastructural features of a neuroendocrine variant

A case of primary small cell undifferentiated carcinoma (SCUC) of the parotid gland, diagnosed initially by fine needle aspiration (FNA) cytology and confirmed by histology, immunohistochemistry and transmission electron microscopy (TEM), is presented. The FNA cytologic features that enabled an accurate diagnosis of this rare salivary gland tumor included nuclear granularity and markedly angular nuclear molding of numerous small cells that were usually present as large syncytia in an inflammatory background. Numerous mitotic figures were also present in this vascular lesion. These features were also evident in the surgical specimens. Immunohistochemistry demonstrated neuron-specific enolase positivity while TEM demonstrated intracytoplasmic neurosecretory granules in this case, indicating a neuroendocrine derivation for this neoplasm instead of the more usual origin of salivary gland SCUCs in ductal epithelial or myoepithelial tissue.     

Expression of the serine protease, matriptase, in breast ductal carcinoma of Chinese women: correlation with clinicopathological parameters

Matriptase is a serine protease expressed by cells of surface epithelial origin, including epithelial breast tumor cells. Matriptase cleaves and activates proteins implicated in the progression of cancer and represents a potential prognostic and therapeutic target. The aim of this study was to examine matriptase expression in breast tumors of Chinese women and to identify its clinicopathological correlations. Immunohistochemical analysis of matriptase was performed in tissue microarrays of 251 breast tumors including 30 fibroadenomas, 59 ductal carcinomas in situ (DCIS), 38 grade I invasive ductal carcinomas (IDC), 79 grade II IDC, and 45 grade III IDC. The matriptase scores were significantly higher in the tumors than their non-tumor counterparts (178+/-12 for fibroadenoma; 275+/-11 for DCIS; 299+/-10 for grade I IDC; 251+/-10 for grade II IDC; and 314+/-11 for grade III IDC). In cases of IDC, matriptase scores were significantly correlated with tumor staging and nodal staging. Our findings demonstrate that matriptase is over-expressed in breast ductal carcinoma of Chinese women. It therefore may be a good biomarker for diagnosis and treatment of malignant breast tumors.     

Fine needle aspiration biopsy of three cases of squamous cell carcinoma presenting as a thyroid mass: cytological findings and differential diagnosis

M. Rosa and K. Toronczyk Fine needle aspiration biopsy of three cases of squamous cell carcinoma presenting as a thyroid mass: cytological findings and differential diagnosis Objective: Primary squamous cell carcinomas of the thyroid gland are extremely rare, comprising about 1% of thyroid malignancies. Although squamous cell carcinomas are readily identified as such on aspiration cytology in the majority of cases, the differentiation of primary versus metastatic tumour might not always be easy. Herein, we report three cases of squamous cell carcinomas involving the thyroid gland. Methods: Fine needle aspiration cytology (FNAC) was performed in three patients with a thyroid mass using standard guidelines. Smears were stained with Diff‐Quik and Papanicolaou stains. Results: Two patients were male and one was female, aged 59, 45 and 35 years, respectively. In all three patients a thyroid mass was present. FNAC smears in all cases showed cytological features of squamous cell carcinoma including keratinization and necrosis. After clinical and cytological correlation, one case appeared to be primary, one case metastatic, and in the third case no additional clinical information or biopsy follow‐up was available for further characterization. Conclusions: Because primary squamous cell carcinoma of the thyroid is a rare finding, metastatic squamous cell carcinoma should always be excluded first. Metastatic disease usually presents in the setting of widespread malignancy, therefore a dedicated clinical and radiological investigation is necessary in these cases. In both clinical scenarios the patient’s prognosis is poor.     

Molecular diagnostics of cancer predisposition: hereditary non-polyposis colorectal carcinoma and mismatch repair defects

Hereditary non-polyposis colorectal carcinoma accounts for 5–13% of all colorectal carcinomas and is inherited in a dominant fashion. Two different forms can be distinguished. Type I is restricted to colorectal cancers, whereas type II patients acquire acolorectal, endometrial, gastric, small intestinal and transitional carcinomas of the upper urinary tract. Germline mutations in the human mismatch repair genes (hMSH2, hMSH6, hMLH1, hPMS2) account for the majority of hereditary non-polyposis colorectal carcinoma. As a result of the mismatch repair deficiency, replication errors are not repaired, resulting in a mutator phenotype. Simple repetitive sequences (microsatellites) are especially prone to replication errors and analysis of their stability combined with immunohistochemical analysis of mismatch repair protein expression provides a rapid diagnostic strategy. For patients either (1) fulfilling the Amsterdam criteria for HNPCC, (2) with synchronous or metachronous hereditary non-polyposis colorectal carcinoma-related tumors, (3) with hereditary non-polyposis colorectal carcinoma-related tumors before the age of 45 and/or (4) with right sided CRC and mucinous, solid, or cribriform growth patterns, screening for mismatch repair deficiencies should be performed. The identification of colorectal cancers displaying a mutator phenotype has implications for both treatment and prognosis.     

Endometrial carcinoma with pleural metastasis: A case report

BACKGROUND: There have been a limited number of studies giving the incidence of pleural metastasis from female genital tract tumors. CASE: An unusual case occurred of recurrent pleural malignant effusion associated with disseminated serous papillary endometrial adenocarcinoma (EC). A total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, appendectomy and omentectomy was performed. Treatment of the pleural malignant effusion consisted of thoracotomy with partial decortication, systemic chemotherapy and radiotherapy. The patient died of circulatory failure 8 months after the primary diagnosis. CONCLUSION: Although the pleura is a rare site of widespread EC, one should recognize the possibility of pleural spread from female genital tract neoplasms presenting with associated symptoms. Cytopathologic examination of the pleural effusion and the finding ofcarcinoma cells mandate an investigation for the primary site of the neoplasm by a multidisciplinary group.     

Giant basal cell carcinoma of the forehead: a case report

Giant basal cell carcinoma (GBCC) is defined as a tumor 5cm or greater in diameter. They present less than 1% of all basal cell carcinomas. We present a case of an 85-year-old male patient with a giant ulcerating tumor of the left forehead (measuring 7x6 cm). Under local anesthesia tumor was surgically excised. No involvement of the underlying periostal or bone structure was noted. Pathohystological exam revealed the giant basal cell carcinoma, with free surgical margins. Giant basal cell carcinomas are rare tumors and are usually result of a long duration and patient neglect. In comparison to the ordinary basal cell carcinoma these tumors have a higher metastatic potential. Surgical resection with negative surgical margin is the best possible treatment option.     

Cytology of metastatic neuroendocrine (Merkel-cell) carcinoma in pleural fluid. A case report

A case of Merkel-cell (neuroendocrine) carcinoma of the skin with extensive metastases, including pleural effusion, occurring over 20 years after primary resection and treatment, is reported. The histologic appearance of the primary neoplasm was identical to that seen in the biopsy specimens of the metastatic carcinoma involving the great toe and inguinal lymph nodes and to that of the residual neoplasm tissue found at necropsy. Electron microscopic examination of a lymph node metastasis demonstrated cytoplasmic microfilaments and numerous dense-core, peripheral, neurosecretory granules, as previously described in Merkel-cell carcinoma. Cytologic examination of a pleural fluid specimen demonstrated numerous small malignant cells closely resembling the cells seen in the histopathologic sections from the surgical and necropsy tissues involved by metastatic carcinoma. This is the first report of the cytologic findings in a patient with Merkel-cell carcinoma metastatic to the pleural cavity.