Perianal mucinous adenocarcinoma (PMA) is an oncologic rarity that poses a diagnostic and therapeutic dilemma for treating clinicians because there are few reported cases and an absence of definitive guidelines. We report a patient who had been treated with local surgery for recurrent perianal abscess with fistula for 3 years. Biopsy of the indurated tissue overlying his surgical scars revealed PMA. Neoadjuvant concurrent chemoradiotherapy followed by abdominoperineal resection was planned to address the locally advanced disease and ongoing sepsis. Our case is unique in that the fistula preceded carcinoma by only 3 years instead of the typical 10 years.
Anaplastic thyroid carcinoma (ATC) is a particularly fearsome form of thyroid cancer due to its extreme aggressiveness and dismal prognosis. Patients with ATC typically present with a rapidly enlarging neck mass with compressive symptoms. We report a case of ATC, mimicking a thyroid abscess; in a 52-year-old Chinese male with one month history of enlarging neck mass. Ultrasound of the neck was suggestive of a thyroid cyst and fine needle aspiration cytology was negative for malignancy. He presented again 2 weeks later with increased swelling and pain suggestive of right neck abscess. An incision and drainage was performed and histopathology result of a proximal isolated enlarged lymph node biopsied revealed metastatic carcinoma. Subsequent right thyroid wedge biopsy finding 1 month later were confirmatory of ATC.
Schwannomas are solitary, benign tumors arising from the nerve sheaths. They are frequently reported in the thorax predominantly in the posterior mediastinum, but are rarely seen to arise from the brachial plexus. Schwannomas are well demarcated lesions with a slow insidious growth. Presented is a case of a large brachial plexus schwannoma, masking as a cystic lesion in the lateral neck. The patient presented with concerns of a cystic mass progressively increasing in size over a period of four years, initially symptomless, but later caused numbness and tingling sensation over his right forearm, tip of right thumb and index finger. Following histological confirmation via fine needle aspiration and magnetic resonance imaging, the patient underwent surgical excision where by the tumor was dissected from its attachment to the nerve sheath. The patient recovered well, and by the third day post operatively, his neurological symptoms resolved completely. Upon follow up in clinic 1-week post-surgery, the scar had healed well, and his numbness or tingling sensation remained in abeyance. This case illustrates that a schwannoma may present insidiously as a cystic lesion and its possible origin may arise from the brachial plexus.
Isosulfan blue is not available for clinical use in Malaysia. This study describes the use of methylene blue as an alternative to isosulfan blue in colorectal sentinel node mapping.
A 12-year-old Congolese girl presented with acute renal failure, edema, hypertension, hemoptysis, hematuria, and proteinuria after a history of throat infection. Renal ultrasound showed kidneys of normal size, with increased echogenicity of the cortical parenchyma and decreased corticomedullary differentiation. Other additional investigations showed pancytopenia with decreased complement (low C3 and C4). Antinuclear antibodies were strongly positive, including anti-double stranded DNA. Renal biopsy confirmed severe grade IV lupus nephritis. She was treated with high-dose steroids, mycophenolate mofetil and hydroxychloroquine, in addition to hemodialysis. After one week of intensive treatment, diuresis recovered and dialysis could be stopped after six sessions. We describe an uncommon case of severe lupus nephritis, presenting with terminal renal failure. Since the rarity of this disease presentation, other more common diagnoses have to be considered. Once the diagnosis of lupus nephritis is established, a choice has to be made between the different induction treatment protocols. The patient's ethnic background and other supportive therapies, such as the need for dialysis, can help to make this choice.
BACKGROUND: Extraskeletal (soft tissue) chondromas are rare neoplasms. They are seen most frequently in the soft tissues of hands and feet. A chondroma occurring in the breast is exceedingly uncommon. We present a case of pure chondroma of the breast in a young woman in whom fine needle aspiration (FNA) cytologic features suggested a cartilaginous neoplasm.
CASE: A 28-year-old woman presented with a mobile lump in the left breast. Mammography showed a high-density nodule without microcalcifications. A clinical diagnosis of fibroadenoma was made. A differential diagnosis was obtained on FNA. Excisional biopsy of the lump showed the histopathologic features of chondroma. There was no recurrence or appearance of new lesion during 13 months of follow-up.
CONCLUSION: Chondroma of the breast shows FNA cytologic features of cartilaginous tumor, but specific tumor typing may not be possible. This case highlights the difficulties that may arise in FNA diagnosis of cartilaginous tumor especially when it occurs at an unusual site. Awareness of the cytologic features combined with clinical and radiologic findings should guide the cytopathologist to make correct diagnosis of this neoplasm.
BACKGROUND: Pilomatrixoma (pilomatrixoma, calcifying epithelioma of Malherbe) is a relatively uncommon, benign neoplasm arising from the skin adnexa. The tumor can cause diagnostic difficulty not only for the clinician but also for the cytologist.
CASE: A 62-year-old woman presented with a right submandibular swelling of 4 months' duration. The clinical findings were highly suspicious for malignancy. A fine needle aspiration biopsy was performed. Three preliminary differential diagnoses were offered: mucoepidermoid carcinoma of the submandibular salivary gland, squamous cell carcinomatous deposit in a submandibular lymph node and calcifying odontogenic tumor. Computed tomography demonstrated no bony lesion. No primary site of squamous cell carcinoma could be identified. An excisional biopsy of the swelling was performed, and the histologic diagnosis of pilomatrixoma was made.
CONCLUSION: The cytologic presentation of pilomatrixoma of the right submandibular region can masquerade as that of a malignant tumor, in this case mucoepidermoid carcinoma, squamous cell carcinoma or odontogenic tumor. This case delineates the cytomorphologic features of pilomatrixoma that may mimic carcinoma.
BACKGROUND: Filariasis is a major public health problem in developing countries, and the diagnosis is conventionally made by demonstrating microfilariae in the peripheral blood smear. However, microfilariae have been incidentally detected in fine needle aspirates of various lesions in clinically unsuspected cases of filariasis with absence of microfilariae in the peripheral blood.
CASES: In case 1, a 21-year-old woman presented with multiple left axillary lymphadenopathy of 3 months' duration. In case 2, a 32-year-old woman presented with a thyroid nodule of 7 months' duration. Fine needle aspiration smears from both cases showed sheathed microfilariae of Wuchereria bancrofti. In both cases, microfilariae could not be demonstrated in the peripheral blood smears and the blood eosinophil counts were within normal limits. The histopathologic examination showed neither microfilariae nor adult worm.
CONCLUSION: Although microfilariae in cytologic material are considered incidental findings, these cases illustrate the value of routine fine needle aspiration cytology in the detection of asymptomatic and clinically unsuspected cases of bancroftian filariasis. Absence of microfilariae in the peripheral blood does not exdude filarial infection.
OBJECTIVE: To analyze the cytologic features of nipple discharge and fine needle aspiration (FNA) cytologic smears from breast lesions reported as showing papillary features and to correlate them with histopathologic features.
STUDY DESIGN: The study group consisted of FNA smears and/or nipple discharge smears from 65 breast lesions diagnosed on cytology as duct papilloma, papillary lesion, fibrocystic condition, fibroadenoma, papillary neoplasm or papillary carcinoma. Cytomorphologic features assessed included cellularity, cell pattern (clusters, papillary, 3-dimensionality, etc.) and cell characteristics (monomorphism, pleomorphism, apocrine change, plasmacytoid features). Histological material was available for review and cytohistologic correlation in all cases.
RESULTS: Forty-six specimens were FNA smears, and 16 were nipple discharge smears; in 3 cases FNA and nipple discharge cytologic smears were available for review. Cytologic study could predict the presence of a papillary pattern in all neoplasms with pure or focal papillary differentiation. There was an overlap in cytomorphologic features between papillary and nonpapillary benign lesions as well as between benign and malignant papillary neoplasms. Frank blood in the aspirate, cell dissociation and atypia, however, were more frequent in the last.
CONCLUSION: Overlap of cytologic features in nonneoplastic and neoplastic benign papillary lesions and between benign and malignant papillary neoplasms necessitates histologic evaluation in all cases diagnosed as papillary on cytology. Since 49.2% of lesions showing papillary features on cytology prove to be malignant, all cases reported as papillary on cytology should be excised urgently for histologic assessment.
BACKGROUND: Carcinosarcoma (sarcomatoid carcinoma) is a rare tumor with a high predilection for the aerodigestive tract. Cytologic diagnosis of metastatic carcinosarcoma has been reported in very few cases.
CASE: An 84-year-old woman presented with a 2-cm-diameter, right cervical lymph node that was referred for fine needle aspiration cytology (FNAC). She had received radiotherapy for a palatal squamous cell carcinoma 2 years earlier. The FNAC smears had a sarcomatoid appearance. Repeat fine needle aspiration was performed, with cytologic and immunocytochemical staining. Careful consideration of the cytologic and immunophenotypic features led to an impression of carcinosarcoma. Histologic sections of the palatal biopsy that had been previously diagnosed as squamous cell carcinoma were reviewed, and a final diagnosis of carcinosarcoma was established.
CONCLUSION: Metastasis of rare lesions, such as carcinosarcoma may be confusing and difficult to diagnose on FNAC, especially when the cytologic sample shows a predominantly sarcomatoid component. The difficulty is compounded when the sarcomatoid component happens to have been overlooked on the initial histologic assessment. With representative cytologic sampling, immunocytochemical staining and review of the histologic material, the correct diagnosis was achieved in this case.
To type breast carcinomaon on fine needle aspiration cytology (FNAC) material and correlate the results with histologic typing, to grade breast carcinoma on FNAC material and correlate the findings with Bloom-Richardson histologic grading, and to determine the estrogen receptor (ER) status in cases of breast carcinoma by immunocytochemical (ICC) staining of FNA cytologic material and correlate the findings with ER status, as determined by immunohistochemical (IHC) staining of tissue sections.
STUDY DESIGN: Seventy-seven cases of breast carcinoma diagnosed on FNAC formed the basis of this study. Typing was done in all cases on the basis of cytologic features and grading in 62. (Fifteen cases were special types of breast carcinoma). In all cases, ER status was determined by immunostaining of cytologic smears. Results of tumor typing, grading and ER status on cytologic material were compared with the results of histologic typing, grading and immunostaining of histologic material obtained from mastectomy or wide excision specimens.
RESULTS: Tumor typing was accurate in 73 of 77 cases (94.8%). Fifteen of 18 cases that were cytologically grade 3 were confirmed on histology, while 3 proved to be grade 2. Of 40 cytologic grade 2 cases, 26 were confirmed on histology, while 14 cases were grade 3. Three of 4 cytologically grade 1 cases were confirmed on histology while 1 was grade 2. The overall accuracy for cytologic grading was 71% (44 of 62 cases). Thirty-seven of 40 ER-positive cases (92.5%) were labeled ER positive on ICC. One case was ER negative on cytology, while in 2 cases the cellularity of the cytologic smear was insufficient to assess ER expression. Thirty-seven cases were negativefor ER on IHC. Nine of these showed ER positivity on ICC, 26 were negative, and 2 had cellularity that was inadequate for assessment of ER. Sensitivity and specificity rates for ER detection on ICC were 97.4% and 74.3%, respectively.
CONCLUSION: Tumor typing, grading and evaluation of ER status on FNA C material in breast carcinomas are simple, quick and moderately reliable techniques that compare and correlate favorably with histologic typing, grading and ER status on IHC.
BACKGROUND: Leiomyosarcoma of the breast is a rare neoplasm. We present a case of primary leiomyosarcoma of the breast in a middle-aged female in whom fine needle aspiration cytologic features suggested sarcoma.
CASE: A 55-year-old female presented with a rapidly growing breast lump of 1 month's duration. On examination, an ulcerating, 12 x 10 cm tumor was seen involving the lower medial and lateral quadrants of the right breast. Fine needle aspiration cytology showed variably sized, dissociated and loosely clustered polygonal, plump and spindle cells with pale blue cytoplasm and vesicular nuclei that were round, oval or irregular. Occasional giant forms and nucleolated and mitotic cells were present. A single cluster of benign ductal cells was seen. The tumor cells did not express immunocytologic reactivity to estrogen receptor protein. A cytologic diagnosis of sarcoma was given with differential diagnoses of metaplastic carcinoma and malignant phyllodes tumor. Histologic study established the diagnosis of leiomyosarcoma. Leiomyosarcoma of the breast shows fine needle aspiration cytologic features of sarcoma, but specific tumor typing may not be possible, especially when the cytologic material is inadequate for ancillary staining required to distinguish leiomyosarcoma from metaplastic carcinoma and malignant phyllodes tumor.
BACKGROUND: Teratoma of the thyroid in adults is extremely rare, and most are malignant. Only nine cases have been adequately documented in the English-language literature, and there are no reports detailing the fine needle aspiration (FNA) cytologic characteristics.
CASE: A 32-year-old female presented with a left-sided nodular thyroid mass with left cervical lymphadenopathy. FNA cytology of the thyroid and lymph nodes was done. The cytologic and immunocytochemical features were that of a small round cell tumor with neuroepithelial (NE) differentiation, metastasizing to the cervical nodes. Microscopic study of the thyroidectomy specimen showed a tumor showing an NE pattern with occasional islands of squamous and cuboidal epithelium, leading to a diagnosis of malignant teratoma.
CONCLUSION: Knowledge of FNA cytologic features of rare but highly malignant lesions like thyroid teratomas allow early recognition so that suitable and possibly aggressive treatment protocols can be adopted in the hope of prolonging survival.
OBJECTIVE: To assess the role of fine needle aspiration cytology (FNAC) in lymphadenopathy in human immunodeficiency virus-infected individuals (HIVII).
STUDY DESIGN: Thirty-nine HIVII presenting with lymphadenopathy at University Hospital, Kuala Lumpur, were subjected to FNAC. Cytologic smears were routinely stained with May-Grünwald-Giemsa stain. Special stains and immunostains were used when necessary.
RESULTS: In nine cases, the cytologic appearance was compatible with HIV type A and in one case with HIV type C lymphadenopathy. In 21 cases, acid-fast bacilli (AFB) were demonstrated in the cytologic smears, enabling a diagnosis of mycobacterial lymphadenitis. In one of these cases there was a concomitant infection with Penicillium marneffei that was overlooked on initial cytologic examination. The cause of granulomatous lymphadenitis could not be ascertained in one case, where neither AFB nor any other organisms were demonstrable. Two cases of histoplasma and one of cryptococcal lymphadenitis were diagnosed, as was one high grade non-Hodgkin's lymphoma that could be immunophenotyped on cytologic material. In three cases the aspirates were inadequate for a cytologic diagnosis.
CONCLUSION: Lymph node FNAC is a valuable investigative modality in HIVII. Most opportunistic infections (bacterial and fungal) can be correctly identified, and high grade lymphoma can be diagnosed and phenotyped.
OBJECTIVE: To examine the fine needle aspiration cytologic features of invasive lobular carcinoma of breast and to discuss problems that may occur in cytodiagnosis.
STUDY DESIGN: Fine needle aspiration cytologic smears from 21 cases of invasive lobular carcinoma (ILC) of breast were subjected to detailed cytomorphologic analysis. Features studied included pattern of cells, size of cells, nuclear placement, pleomorphism, presence of intracytoplasmic lumina (ICL) and signet ring cells.
RESULTS: Cellularity was generally moderate or high, and the pattern was predominantly or partly dissociated in 86% of cases. Rosettelike pattern was discerned in alveolar-type ILC. Cell size was usually small or intermediate, with nuclei placed eccentrically in most cases. ICLs with or without signet ring cells were present in 12 cases (57%).
CONCLUSION: A cytologic picture consisting of predominantly dissociated small or intermediate-sized tumor cells with eccentric nuclei, with some of the cells showing ICLs, is highly suggestive of ILC. Indian file pattern, another characteristic feature of ILC, is, however, focal and inconsistent. Variant patterns of ILC may show other cytologic features, such as rosettelike pattern (alveolar variant of ILC) or large cell pattern (pleomorphic variant of ILC) and may consequently be difficult to categorize on cytologic smears.
Ki-1-positive anaplastic large cell lymphoma (Ki-1 ALCL), one of the more recently described pleomorphic types of lymphoma, affects mostly children and adolescents and is sometimes mistaken for carcinoma or sarcoma.
Skull base osteomyelitis (SBO) also commonly known as malignant otitis externa was first described by Meltzer and Kelemen in 1959. Prior to the advent of the antibiotic era, this disease carried a poor prognosis with significant morbidity. It often proved fatal with mortality rates as high as 50%. Commonly seen in the immunocompromised patients, diabetes mellitus is an important associated comorbidity in the pathophysiologic development of this disease. Treatment is instituted by medical therapy with surgery having a limited role. Surgical intervention has a limited role, for example, in fungal SBO. Such cases may require local debridement and intraoperative tissue biopsies for histopathologic confirmation. This is to demonstrate fungal invasion into the skull base, as well as to exclude other sinister differential diagnoses like squamous cell carcinoma of temporal bone. In this case report, we present a rare case of candida SBO and the literature review.
Pilomatricoma, also known as Pilamatrixoma or Malherbe's calcifying epithelioma, is a benign skin tumour with a bimodal age distribution between the paediatric and elderly age groups. Although it was previously thought to be rare, recent studies have revealed that it is quite common. Typically, pilomatricoma is diagnosed following histopathological examination of the lesion as it is frequently misdiagnosed with other types of skin pathology. In our case, the child presented with painless swelling of the left infraauricular region. The initial cytology and imaging were unable to provide a definite diagnosis. An excision biopsy was done, and a histopathological examination was suggestive of Pilomatricoma. Therefore, Pilomatricoma ought to be considered in the differential diagnosis of head and neck lesions in hopes of providing a better understanding on this pathological lesion.
We report a rare case of base of tongue tuberculosis following pulmonary tuberculosis. Patient presented to us with chief complaints of sore throat and pain on swallowing for period of 3 months. On examination with 70 degree telescope, we observed an ulcer on right side of base of tongue. The edges of the ulcer appeared to be undermined with whitish slough at the centre of the ulcer. Examination of neck showed a multiple small palpable middle deep cervical lymph nodes on right side of neck. Biopsy of the ulcer was taken, which showed granulomatous inflammation, suggestive of tuberculosis. Laboratory investigations revealed a raise in erythrocyte sedimentation rate, sputum for acid fast bacilli was strongly positive. Chest X ray was performed for patient showed multiple areas of consolidation. Patient was referred to chest clinic for further management of tuberculosis and was started on anti-tuberculous drugs. In conclusion tuberculosis of oral cavity is rare, but should be considered among one of the differential diagnosis of the oral lesions and biopsy is necessary to confirm the diagnosis.