Cytologic features of chordoid meningioma. A case report

BACKGROUND: Chordoid meningioma is a rare subtype of meningioma characterized by myxoid matrices deposited among epithelioid or vacuolated tumor cells and infiltrates of inflammatory cells, and its cytologic features have rarely been reported. CASE: A 57-year-old man with a history of headache and visual disturbance presented with a tumor in the suprasellar region. Intraoperative touch smear cytology of the tumor disclosed a cord-like arrangement of polygonal tumor cells occasionally containing intranuclear inclusions. Furthermore, periodic acid-Schiff-positive, mucinous matrices were deposited among the tumor cells. Also, infiltrates of lymphocytes and plasma cells were noted. Histologic, immunohistochemical and ultrastructural examination confirmed the diagnosis of chordoid meningioma. CONCLUSION: Intraoperative smear cytology in a case of chordoid meningioma showed distinctive cytologic features suggestive of the histologic patterns. The cytologic features, together with a histologic examination, are useful for its diagnosis.     

Problems in assessing multiple cutaneous melanoma. A review on the accuracy of a population based cancer registry

Databases with information on malignant tumors are of great value for epidemiologic studies. From the Regional South Swedish Tumour Registry, which is of documented high quality, 24 patients out of 8008 with reported melanoma diagnosis 1973–2003 were reported as having multiple (≥3) primary, invasive cutaneous malignant melanomas (CMM). Of the 76 tumours identified in these patients, 7 (9%) were found not to be invasive melanomas. Additional cases could be put into question since the lesions could be interpreted as epidermotropic metastases, a diagnosis which can be difficult to establish reliably by microscopic examination. Among the 24 patients we could also identify 8 (10%) additional lesions representing invasive CMM, not included in the Tumour Registry database. Thorough information concerning an earlier melanoma diagnosis and its site of presentation is needed from the clinician and the pathologist for optimal assessment of the histology and the prognostication of the patient, as well as proper reporting to a tumour registry. Identifying multiple primary malignant melanomas is also of special importance for counselling patients belonging to families with hereditary disease. In this study it is shown that diagnosing and reporting multiple malignant melanomas can be problematic due to insufficient communication and to the rare and deceptive capability of cutaneous metastases to imitate primary tumours.     

Cutaneous squamous cell carcinoma metastatic to chronic lymphocytic leukaemia: diagnostic potential of fine needle aspiration cytology

OBJECTIVE: The phenomenon of cancer-to-cancer metastasis of cutaneous squamous cell carcinoma (SCC) and chronic lymphocytic leukaemia (CLL)/small lymphocytic lymphoma (SLL) is a rare event and only occasionally documented in the medical literature. METHODS: Two patients with SCC of the skin that were previously treated for CLL are presented. Both had palpable lymph nodes in the neck and fine needle aspiration cytology (FNAC) was performed to evaluate the pathological process. In addition, the literature on cutaneous SCC metastatic to CLL/SLL with special emphasis on the role of FNAC in this specific clinical situation was reviewed. RESULTS: On examination of the FNAC smear, cancer-to-cancer metastasis of cutaneous SCC to lymph node replaced by CLL was found. In one of the patients, light microscopy examination of the smear was complemented by immunostaining of atypical cells with cytokeratin antibodies and immunophenotyping of lymphoid cells by flow cytometry. In addition to our two patients, nine cases of cutaneous SCC metastatic to CLL/SLL have been reported in the literature, and in only one was the diagnosis made by FNAC. CONCLUSION: FNAC supported by ancillary immunocytological techniques could also be used in diagnosis of specific clinical situations such as cancer-to-cancer metastasis of the tandem of SCC-CLL/SLL.     

Upper gastrointestinal Kaposi's sarcoma in patients positive for HIV antibody without cutaneous disease

Six patients with antibodies to the human immunodeficiency virus (HIV) and with persistent gastrointestinal symptoms of HIV infection but without cutaneous lesions of Kaposi''s sarcoma underwent endoscopy. Four also underwent barium meal examination. In all six cases small lesions were seen in the stomach at endoscopy, and histological examination of biopsy specimens taken from the lesions confirmed the diagnosis of Kaposi''s sarcoma. The barium meal examinations were reported as normal in three patients and showed oesophageal candidiasis in the fourth.These findings suggest that Kaposi''s sarcoma of the upper gastrointestinal tract is common in patients positive for HIV antibody, even those without cutaneous lesions. Endoscopy, with biopsy of suspicious lesions, is necessary to make the diagnosis and is recommended in all HIV antibody positive patients with persistent upper gastrointestinal symptoms.     

Fine needle aspiration cytology diagnosis of cutaneous leishmaniasis in a 6-month-old child: a case report.

BACKGROUND: Skin biopsy and scrape smear examination are the two most commonly employed investigatory techniques in the diagnosis of cutaneous leishmaniasis. Although cases Leishmania lymphadenitis are reliably diagnosed with fine needle aspiration (FNA) cytology, it has not attained popularity in the diagnosis of cutaneous leishmaniasis, and only a few reports are available. CASE: A 6-month-old Kuwaiti child presented with a skin lesion on her left forearm of five months' duration. Both scrape smears and FNA were performed from the lesion. FNA cytology smears showed a rich population of inflammatory cells predominating in lymphocytes and histiocytes and epithelioid cell granulomas. The amastigote forms of Leishmania were noted on the smears. The scrape smears were nondiagnostic. CONCLUSION: FNA cytology can be reliably used in the diagnosis of cutaneous leishmaniasis, especially in dry lesions, where scrape smears are likely to be nondiagnostic.     

Pulmonary metastases from intracranial meningioma diagnosed by aspiration biopsy cytology

A case of rare extracranial metastasis from a recurrent intracranial meningioma is described. Incidentally discovered asymptomatic pulmonary metastases were diagnosed as meningioma by transthoracic fine needle aspiration (FNA) biopsy. The aspirate contained spindle-shaped tumor cells and other forms that seemed to correspond to the fibroblastic, syncytial and angioblastic areas seen in the histologic sections of the primary tumor. Cytomorphologically, metastatic meningioma appears to be sufficiently distinctive to permit its cytologic differentiation from other spindle-cell tumors. Although meningiomas metastasize rarely, this diagnosis should be considered in the interpretation of a transthoracic FNA biopsy of a pulmonary nodule or nodules in a patient with a history of recurrent intracranial meningioma, especially when the aspirate mainly consists of spindle-shaped neoplastic cells.     

Intracranial Meningioma with Ophthalmoplegia in a Rhesus Macaque (Macaca mulatta)

A 21-y-old female rhesus macaque presented with signs of internal and external ophthamoplegia, including anisocoria and ptosis. Ophthalmoplegia is the paralysis or weakness of one or more intraocular or extraocular muscles that control the movement of eye; this condition can be caused by neurologic or muscle disorders. The macaque was euthanized due to progression of clinical symptoms, and postmortem gross examination revealed a mass at the base of the brain attached to the meninges. Histopathologic examination led to the diagnosis of intracranial meningioma. Here we describe a case of intracranial meningioma with internal and external ophthalmoplegia in a rhesus macaque (Macaca mulatta).Meningioma is a tumor that develops in the meninges, including the dura mater, arachnoid mater, and pia mater, all of which surround the brain and spinal cord. In humans, meningioma is the most frequently encountered primary intracranial neoplasia and accounts for approximately 35% of all reported primary brain tumors in the United States.^5,7 Clinical manifestations are dependent on the size and location of the tumor.^3,23 To our knowledge, only 3 cases of naturally occurring meningioma in nonhuman primates have been reported; these cases affected 2 baboons and 1 collared brown lemur.^17,19,21 The meningiomas of 2 of these previous cases were described only briefly as part of a disease survey of neoplasia in 100 free-ranging baboons and a captive prosimian population.^17,21 The third report focused on the pathologic features of the meningioma described with no mention of the clinical signs in the baboon, although its location was similar to that of the case we describe here.¹⁹In the current case report, we describe the clinical manifestations, postmortem examination, and diagnosis of an intracranial meningioma in a rhesus macaque (Macaca mulatta).     

Primary pneumococcal peritonitis

A case of primary pneumococcal peritonitis in a girl of 9 is presented. The diagnosis was made at laparotomy and confirmed by immediate bacteriological examination. The condition is extremely rare and accounts for 1 in 5 of all cases of primary peritonitis in children.     

Malignant pericardial effusion and cardiac tamponade

Cardiac tamponade due to malignant effusion, though rarely the initial manifestation of malignancy, is usually secondary to adenocarcinoma of the lung. Two cases are reported. One patient presented with cardiac tamponade; the other had diffuse cutaneous involvement of the left neck and shoulder two months before he presented with cardiac tamponade. Cytologic examination of both fluids revealed adenocarcinoma. Ultrastructural examination showed poorly differentiated adenocarcinoma in the first patient and bronchioloalveolar carcinoma in the second; carcinoembryonic antigen levels in the fluids were 9.4 ng/mL and over 60 ng/mL, respectively. The computed tomographic (CT) scans of both patients revealed mediastinal fullness with no lung involvement. Even in the absence of a pulmonary mass, lung carcinoma may be the likely primary in patients with malignant pericardial effusions.     

The dysplastic nevus: recognition and management

The recognition of atypical or dysplastic nevomelanocytic nevi potentially provides clinicians with another means of identifying individuals at increased risk for cutaneous malignant melanoma. However, a great deal of controversy still surrounds these lesions, their significance, and the clinical and histologic criteria needed for their diagnosis at present. In general, dysplastic nevi tend to be asymmetrical and larger (greater than 5 mm) than ordinary acquired nevi, have a macular component, irregular and ill-defined borders, and haphazard (variegate) coloration. A clinical diagnosis of dysplastic nevi must be confirmed by histopathology, since not all clinically atypical nevi are dysplastic. While precise histopathologic criteria for dysplastic nevi are lacking, most authorities agree that an abnormal nevomelanocytic proliferative pattern as manifested by increased numbers of basilar melanocytes and/or abnormal junctional nevomelanocytic nesting in the setting of lentiginous epidermal hyperplasia, variable degrees of nevomelanocytic nuclear atypia, and a lymphocytic host response are consistent with a histologic diagnosis of dysplastic nevi. Current data for individuals with dysplastic nevi and a family history of cutaneous malignant melanoma (at least two family members with cutaneous malignant melanoma) indicate a relative risk for cutaneous malignant melanoma about 148 times that of the general population. In comparison, cutaneous malignant melanoma risk seems lower for individuals with familial dysplastic nevi (but without familial cutaneous malignant melanoma) and "sporadic" dysplastic nevi. With respect to progression to melanoma, probably the vast majority of dysplastic nevi remain stable or possibly regress. Management of individuals with histologically confirmed dysplastic nevi involves periodic skin examinations. Regional overview and life-size photography are helpful in following these patients. Patients should also be instructed in the examination of their own skin. While a definite relationship between sun exposure and dysplastic nevi remains unproved, the use of sunscreens and avoidance of unnecessary sun exposure are advised. Examination of family members for atypical melanocytic lesions is also recommended.     

Fine needle aspiration cytology of metastatic scalp nodules

OBJECTIVE: To analyze cases of palpable cutaneous/ subcutaneous scalp nodules and evaluate the clinical features and role of fine needle aspiration cytology (FNAC) in their diagnosis. STUDY DESIGN: A total of 1,022 cases of metastatic malignancies at various sites were analyzed over a period of two years. FNAC was performed as a routine outpatient procedure for palpable lesions and under ultrasound or computed tomographic guidance for nonpalpable, internal sites. Histologic correlation was done when possible. RESULTS: Eighteen cases were found to be metastatic scalp nodules. The scalp as a metastatic site constituted 1.76% of all metastatic sites, 7.72% of extranodal sites, and 15.3% of extranodal and extrahepatic sites. Of the 18 cases, 7 (38.9%) had primaries in the head and neck region (thyroid, 3; orbit, 1; tonsil, 1; tongue, 1; and parathyroid, 1). Cutaneous/subcutaneous metastasis was encountered in 58 patients, and the 18 cases of scalp metastasis constituted 31.03% of all cutaneous sites. CONCLUSION: Careful examination of the skin on the entire body, with particular attention to the scalp, should be done when a primary internal malignancy or recurrence is suspected. FNAC is a very helpful and cost-effective modality in determining the nature of such lesions.     

Fine needle aspiration cytology of dermatofibrosarcoma protuberans presenting as a breast mass. A case report

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon cutaneous soft tissue neoplasm with a tendency to recur but rarely metastasize. It occurs at almost any site but usually in the trunk and extremities. DFSP mimicking a primary breast lesion has not been reported before. CASE: A 30-year-old female presented with an eight-month history of a breast mass that was aspirated, revealing a spindle cell neoplasm. The diagnosis of DFSP was made on excisional biopsy. CONCLUSION: The diagnosis of DFSP may be problematic, especially when it presents clinically as a primary breast lesion.     

Fine needle aspiration cytology of parapharyngeal meningioma

A unique case of parapharyngeal meningioma identified on a tomographic scan and diagnosed preoperatively by fine needle aspiration (FNA) cytology is reported. The FNA smear showed the spindle-shaped cells in concentric whorls and scattered psammoma bodies that are characteristic of meningioma. The FNA diagnosis was subsequently confirmed on the excised specimen. The preoperative cytologic diagnosis was very helpful in planning the surgical removal of the tumor by a team of otolaryngologists and neurosurgeons.     

Subcutaneous endometriosis diagnosed by fine needle aspiration cytology

The fine needle aspiration cytology (FNAC) of two patients manifesting cutaneous/subcutaneous endometriosis is presented. Endometrial tissue sampled by the aspiration technique manifested different cytologic characteristics as compared to those of endometrial tissue obtained by standard exfoliative methods. A primary difference was the appearance of the endometrial cells in syncytial clusters in the aspirate, in contrast to the three-dimensional clusters seen in exfoliated material. These cases emphasize the need to include endometriosis in the differential diagnosis of palpable lesions of the abdominal wall, especially in women with healed surgical scars, and the role of FNAC in diagnosing such lesions.     

Fine needle aspiration cytology of primary pulmonary meningioma associated with minute meningotheliallike nodules. Report of a case with histologic,immunohistochemical and ultrastructural studies

BACKGROUND: Pulmonary meningioma is an unusual tumor located in the lung. Minute pulmonary meningotheliallike nodules are also uncommon tumor-like lesions found at the pleuropulmonary level as solitary or multiple nodules. The association of both entities is described in a recent report. CASE: A 58-year-old, male smoker without pathology underwent radiologic study before a surgical procedure. A peripheral nodule was found in the left lower lobe of the lung with benign characteristics. Fine needle aspiration cytology was performed under computed tomography guidance. Cytologic examination showed features of transitional meningioma and other lesions near the tumor. Minute pulmonary meningotheliallike nodules were also present. CONCLUSION: A diagnosis of meningioma should be considered when there is a combination of scanty material, whorls composed of concentrically arranged cells and isolated cells with intranuclear inclusions. The simultaneous presence of meningioma and meningotheliallike nodules corroborates the unifying hypothesis of their common origin and the nature of these rare pulmonary lesions.     

Extradural spinal meningioma as a source of plasmacytoid cells. A case report

BACKGROUND: Meningiomas, tumors that often affect middle-aged and elderly people, occasionally arise in the spine, typically at the thoracic level. The cytologic findings in meningiomas include whorls and syncytial clusters of bland-looking cells with scattered, psammomatous calcifications and intranudclear cytoplasmic inclusions. However, in many cases, not all these findings are seen, and in rare cases, unusual cytomorphologic features are observed. CASE: A case of spinal meningioma was located in the extradural compartment and composed predominantly of singly scattered cells with a plasmacytoid appearance, demonstrated on fine needle aspiration biopsy smear preparations. The cell block showed more typical features of meningioma, and the diagnosis was supported by the results of immunohistochemical staining. CONCLUSION: The diagnosis of spinal meningioma is readily made by employing magnetic resonance imaging. The diagnosis can be difficult to confirm pathologically when atypical histologic findings are present, as in this case, with prominent plasmacytoid features. Sections from the cell block and immunohistochemical stains as well as clinical and radiologic findings were extremely helpful in arriving at the final diagnosis.     

Primary cardiac lymphoma initially diagnosed by routine cytology. Case report and literature review

A case of primary cardiac lymphoma initially diagnosed by routine cytologic examination of pericardial fluid is presented. In a 64-year-old woman woman who originally presented with chest pain and heart block, the initial clinical impression was ischemic heart disease. However, coronary angiography failed to reveal significant disease. An echocardiogram demonstrated pericardial fluid, which was drained. A small amount was sent for cytologic examination, and the diagnosis of malignant lymphoma, large cell type, was made. Subsequent radiologic examinations revealed an intracardiac mass involving the atrioventricular canal; surgical biopsy confirmed the diagnosis of a large cell lymphoma. While primary malignant lymphoma of the heart is rare, this case highlights the efficacy of routine cytologic examination of an effusion fluid (often drained therapeutically) in establishing the correct diagnosis.     

Mandibuloacral dysplasia: a report of two Egyptian cases

Mandibuloacral dysplasia (MAD) is a rare disorder. Only 35 patients, coming from 22 families, have been reported worldwide. We report on two Egyptian unrelated girls with MAD. The first patient presented at the age of 5 years with acral defect and partial alopecia. The second patient presented at the age of 17 years with progressive micrognathia and loss of subcutaneous fat from the limbs. Physical examination detected the craniofacial, skeletal and cutaneous changes characteristic of MAD. Both patients were short with progeroid facies and loss of subcutaneous fat from the extremities, which fits lipodystrophy type A pattern. Radiological examination revealed delayed closure of cranial sutures, hypoplastic mandible, hypoplastic clavicles, and acroosteolysis. Both patients had normal glucose tolerance, but had fasting and post-prandial hyperinsulinemia, suggestive of insulin resistance. One patient had elevated serum triglycerides and low normal cholesterol levels, while the other patient had normal levels. Serum leptin was normal in both patients. We review the literature on mandibuloacral dysplasia and discuss the differential diagnosis.     

Prognostic trees to aid prognosis in patients with cutaneous malignant melanoma. Scottish Melanoma Group.

OBJECTIVES--To design user friendly guides to prognosis for patients who have had invasive primary cutaneous malignant melanomas surgically excised. DESIGN--Adaptation of the classification tree method was used to derive prognostic trees for four different subgroups of malignant melanoma patients in whom known and possible prognostic variables interacted in different ways. SETTING--Scotland. SUBJECTS--Statistical modelling for prognostic trees was based on 1978 patients whose primary malignant melanoma was first diagnosed in 1979-86 for whom five year follow up and all relevant clinical pathological data were available. The resultant model was validated with 300 patients first diagnosed in 1987 for whom the same information was available. MAIN OUTCOME MEASURES--Actual and predicted rate of survival after diagnosis of primary cutaneous malignant melanoma. RESULTS--The four subgroups of patients were men and women with ulcerated and non-ulcerated cutaneous primary melanomas. Validation of the model showed excellent agreement between actual status of patients in the relevant subgroups and their status as predicted by the model. CONCLUSIONS--The prognostic trees are simple to use and give more accurate prognosis for individual patients than is currently available from tumour thickness alone.