[ ISSN : 2689-1549 ]
Anaplastic; Thyroid; Metastasis; Radiation; Prognosis
Anaplastic thyroid carcinoma (ATC), is a rare, highly aggressive, and undifferentiated thyroid malignancy. Given the delayed diagnosis, ATC contributes to more than 30% of thyroid cancer associated deaths each year. Most ATC lesions are found within the neck region following metastasis to distant organs and lymph nodes. Diagnosis of anaplastic thyroid carcinoma is particularly challenging given the late presentation of compressive symptoms, histological variety, and rarity of the neoplasm. Early detection can be done with screening methods for high-risk patients with prior history of thyroid neoplasms. Even with a multimodal approach to therapy, ATC diagnosis yields a poor prognosis with less than six months of survival.
Raju P, Cevallos A, Alzein O, Lubert J, Yeakle M, et al. (2021) Fine Needle Aspiration Cytology Diagnosis of Anaplastic Thyroid Carci noma. Case Report of a Highly Aggressive Rare Tumor and Review of the Literature. JSM Clin Cytol Pathol 4(1): 5.
ATC: Anaplastic thyroid carcinoma, IHC: Immunohistochemistry, MRI: Magnetic Resonance Imaging
Anaplastic thyroid carcinoma (ATC), also known as undifferentiated carcinoma, is a rare, highly aggressive malignancy accounting for less than 5% of all thyroid gland neoplasms but contributing to greater than 30% of thyroid carcinoma deaths [1,2]. ATC can arise de novo or from pre existing well-differentiated thyroid carcinoma requiring immunohistochemistry (IHC) support to determine the epithelial origin [4,13].
Classically, ATC presents as a neck lesion characterized by rapid growth with involvement of both lobes of the thyroid gland. Most common presenting symptoms are due to compression of local structures and can include dysphagia, vocal cord paralysis,stridor, dyspnea, and superior vena cava (SVC) syndrome [1]. Given that ATC is usually advanced at diagnosis, most patients have distant metastatic spread involving multiple organs and regional lymph nodes. Median survival is only six months to one year following diagnosis.
It is possible to find ATC nearby well-differentiated papillary or follicular thyroid carcinoma. Further histological analysis can show differentiation of multiple cell types including giant cell, sarcomatoid, and epithelial cell lines [4,12]. Increased risk factors for ATC include age greater than 50, female, and prior history of benign or malignant thyroid disease. The peak incidence of ATC diagnosis is reported to be between the ages of 60 – 70, with a mean age of 55 [1,5].
Fine Needle Aspiration (FNA) cytology, CT scans and Magnetic Resonance Imaging (MRI) are all useful in confirmation of ATC diagnosis [3]. The current standard of care for treatment of undifferentiated thyroid carcinoma utilizes a multimodal approach including combination of surgery, radiotherapy, and chemotherapy. Surgical intervention is warranted when curative resection can be done. Radiotherapy is used preoperatively to decrease the size of the tumor and combined with preoperative and postoperative treatment at high dosages to slow progression of disease [2]. Combination chemotherapy with taxanes, cisplatin, and angiogenesis inhibiting agents combined with surgery and radiotherapy have proven to briefly prolong survival [2,6]. Despite the aggressive therapy, poor prognosis follows the diagnosis of anaplastic thyroid carcinoma.
A 61-year-old man presented with generalized weakness, fever and abdominal pain for three weeks. He also complained of presence of anterior neck swelling for several months, but recently rapidly enlarging. He also noticed changes in the quality of his voice, difficulty swallowing and breathing, with pain and tenderness around the lower neck. Patient reported history of controlled hypertension, hyperlipidemia, and localized colon adenocarcinoma treated with segmental resection three years prior to current presentation.
On physical exam, abdomen was distended, soft, and tender in the right upper quadrant with no rebound tenderness or guarding upon palpation. Further examination revealed a large thyroid mass measuring 4.2 cm involving both thyroid lobes and prominent cervical lymphadenopathy. Imaging studies confirmed infiltration of the thyroid mass into the surrounding tissue. CT scan of the chest and abdomen revealed multiple pulmonary, liver and bone masses, in addition to left adrenal nodule (Figure-1A&B). Imaging studies were highly suspicious of metastatic lesions. Of interest, blood work showed incidental hypereosinophilia and moderate neutrophilia.
Figure 1: CT scan of the chest and abdomen showing multiple pulmonary (A) and liver (B) metastases (blue arrows).
Fine needle aspiration (FNA) of the thyroid mass was performed with adequate sample including sufficient material for cellblock preparation. Cytology sample displayed high cellularity with abundance of anaplastic pleomorphic large cells with epithelioid morphology showing bizarre nuclei and abundant intensely eosinophilic and slightly granular cytoplasm in a highly necrotic background and increased mitotic activity (Figure-2C&F). Focally, scattered cells with squamoid features were also identified. The cytomorphology was non-specific and suggested sarcomatous lesion versus an anaplastic malignant neoplasm. Immunohistochemistry (IHC) studies were essential to determine the line of cellular differentiation and were performed on cellblock. The tumor cells were positive for the following markers: cytokeratin AE1/ AE3 (Figure-2B), CK7, Vimentin (Figure 2E), TTF-1 (focally in squamoid cells- Figure 2A), Pax-8 (Figure-2D) and focal staining with p63. The tumor cells were negative for CK20, calcitonin, thyroglobulin, CDX2 and CD45. FNA of one cervical lymph node as well as one mass from the liver produced similar finding as that of the thyroid lesion and diagnosis of widely metastatic anaplastic thyroid carcinoma was rendered.
Figure 2: Cytomorphology and immunohistochemistry of the thyroid mass FNA
Tumor cells positive for TTF-1
Tumor cells positive for Cytokeratin AE1/ AE3
Anaplastic bizarre tumor cells (DQ Stain X60 magnification)
Tumor cells positive for Pax-8
Tumor cell positive for Vimentin Anaplastic bizarre tumor cells (PAP Stain X60 magnification)
ACKNOWLEDGMENT: Special thanks to Olivia Weller, Kailee Fernandes, and Justin Shirah, MD candidates, American University of the Caribbean for their assistance in reviewing the final version of this manuscript
A multidisciplinary tumor board suggested a total thyroidectomy and initiation of radioactive iodine radiation treatment with chemotherapy. The patient was started first on experimental pazopanib with prednisone and rasburicase. However, following initiation of therapeutic regime, the patient’s respiratory status deteriorated. The plan of care was changed to providing comfort measures; patient passed away two weeks after admission.
Anaplastic thyroid carcinomas are rare, highly aggressive, and undifferentiated carcinomas that account for less than five percent of all thyroid associated malignant neoplasms. ATC, arising from a multitude of oncogenic mutations, originate in the neck with diagnosis usually following distant metastasis. The most common clinical presentation depicts a painful, infiltrative, firm mass on the lower anterior neck. Upon further examination, invasion of the neoplasm is usually seen onto local cervical structures [3,13].
Diagnosis of ATC and determination of cell line differentiation is accomplished through radiography, immunohistochemistry and molecular studies. On CT, large isodense or hyperdense masses with calcification and necrosis can be seen in various organs indicating extensive metastasis. The best assessment method to determine extent of invasion is utilizing MRI imaging. Additionally, assessment with F-fluorodeoxyglucose position emission tomography fused with CT scan (FDG-PET) can show increased glucose transport expression showing increase in glucose uptake [13]. Tissue diagnosis can be accomplished by FNA perioperatively or during surgery or by surgical core biopsy. On cytologic examination, a biphasic population of tumor and uninvolved thyroid tissue can be visualized. The cytology specimen is usually highly cellular with scattered single cells and focal clusters of atypical and anaplastic cells in background of necrosis and rich inflammatory cells [12]. The differential diagnosis for ATC may include primary thyroid lymphoma, thyroid sarcoma, poorly differentiated thyroid carcinoma, squamous cell thyroid carcinoma, and medullary thyroid carcinoma.
Immunohistochemistry is beneficial in supporting the diagnosis of ATC and to rule out other poorly differentiated malignancies. On gross examination, a bulky mass with homogenous appearance can be seen infiltrating into adjacent soft tissue and organs [11]. As ATC displays spectrum of cell differentiation, microscopic examination can reveal the presence of sarcomatoid, epithelial, or giant cell morphologic features. Specifically, the sarcomatoid form contains malignant spindle cells with high grade pleomorphic sarcomatous features. Giant cell variant reveals pleomorphic malignant cells containing multiple nuclei, and the epithelial form demonstrates malignant squamoid cells with prominent eosinophilic cytoplasm [4]. Positive cytokeratin in ATC supports the epithelial nature of origin but negative immunostaining is not sufficient to completely exclude ATC diagnosis [2,13].
Mutations noted in ATC, may include TP53, BRAF kinase (V600e), RAS, PIK3CA, and PTEN mutations [13]. TP53 gene inactivation plays a direct role in the progression of differentiated to undifferentiated ATC. Favorable prognostic indicators include age of onset, absence of distant metastasis, small unilateral tumors, absence of invasion, and initial diagnosis as an incidental finding before extensive metastasis.
A study by Marten et al. analyzed the role of the BRAK kinase mutation which led to activation of the MAPK pathway and uncontrolled cell proliferation [5,12]. Specifically, the BRAFV600E mutation, which substitutes glutamine for valine, leading to a 500-fold increase in MEK pathway activation. The case report presented a 51-year-old male evaluated for a two-week history of hoarseness of voice preceding ATC diagnosis. Genetic evaluation revealed a BRAF kinase mutation for which the patient was treated with vemurafenib, a BRAF kinase inhibitor usually used to manage advanced melanoma. However, the patient quickly deteriorated and died before combination therapy of MAPK inhibitors could be utilized [5]. Mitogen-activated protein kinase (MAPK) cascades are key signaling pathways involved in the regulation of normal cell proliferation, survival and differentiation. Raf activates the MAPK/ERK kinase (MEK)1/2 dual-specificity protein kinases, which then activate ERK1/2. The mutational activation of Raf in human cancers supports the important role of this pathway in human oncogenesis [18]
Given the reported observation of paraneoplastic phenomenon in thyroid cancers [17], further investigations are recommended to determine if the leukocytosis and eosinophilia observed in our patient is a prognostic indicator or a paraneoplastic feature of ATC. Camargos et al. published a case in which a 95-year-old woman had been treated for progressive dysphagia for eight years. When her condition deteriorated, blood tests revealed leukocytosis and eosinophilia in absence of thrombocytopenia. The patient died 11 days following diagnosis. On autopsy, an upper mediastinal tumor was noted. Histopathology confirmed diagnosis of a neoplastic transformation of ectopic thyroid tissue [8]. Hyper eosinophilia paraneoplastic phenomenon is an exceedingly rare phenomenon. Camagros presented a rare case of leukemoid reaction and peripheral hyper eosinophilia as a paraneoplastic phenomenon of ATC [7,12]. Paraneoplastic phenomenon associated with various solid tumors has been reported in various tumors. Zalewska and colleagues presented a case of hyper eosinophilia following clear cell renal cell carcinoma diagnosis. Treatment with corticosteroids was the recommended course of action; however, only a transient decrease in eosinophil count was noted before the patient further deteriorated [12]. ATC should be differentiated from metastatic high-grade pleomorphic sarcoma to the thyroid gland as both can show similar histomorphologic features. Gao Y. et al. reported a case of metastatic leiomyosarcoma of the Thyroid Gland from a prior uterine leiomyosarcoma and demonstrated that immunohistochemistry and molecular testing can aid in definitive diagnosis [14].
The current standard of care of ATC includes surgery, radiotherapy, or chemotherapy, or a combination of the three. Recommended treatment is based on surgery when feasible or alongside chemoradiation following surgical intervention. Most ATC tumors are nonresectable due to late diagnosis and invasion of local structures. Debulking surgery is recommended, if possible, as the primary method of airway protection in effort to preserve the larynx. If preservation of local structures is unsuccessful, a tracheostomy may be necessary. Patients with metastatic ATC almost uniformly have short survival and no prospects for curative outcome [15]. For patients with advanced or unresectable disease, external bean irradiation or definitive radiation therapy in junction with chemotherapy is the recommended course of treatment. Common chemotherapeutic agents used include cisplatin and taxanes [1,3]. Recently, RAF inhibitors (non-specific serine / threonine protein kinase inhibitors) have also been used in treatment [1]. Adjuvant radiation therapy is recommended to be performed in all cases. In a recent report, it was suggested that EGFR, VEGFR and ALK alteration may be used for targeted therapy and some cases may express PD-L1 [16].
Anaplastic thyroid carcinoma is an undifferentiated cancer with dismal prognosis. Anaplastic thyroid carcinoma with widespread metastasis has a grave prognosis, and none of interventional strategies has shown to significantly prolong survival in these patients. Further investigation is recommended to understand the pathways of disease and the nuances in the multimodal therapeutic regime. The definitive diagnosis of ATC is made through tissue examination, imaging and immunohistochemical studies in addition to further molecular analysis. It is our hope that this report raises awareness of clinicians and pathologists of anaplastic thyroid carcinoma, and that continued investigation drives further development of efficacious diagnosis and safe treatments for improving patient outcomes.
1. Koussis, H., Maruzzo, M., & Scola, A. (2010). A Case of Anaplastic Thyroid Cancer with Long-term Survival. Anticancer Research, 30(4), 1273–1278. Retrieved from https://ar.iiarjournals.org/ content/30/4/1273/tab-figures-data.
2. Are, C., Shaha, A.R. Anaplastic Thyroid Carcinoma: Biology, Pathogenesis, Prognostic Factors, and Treatment Approaches. Ann Surg Oncol 13, 453–464 (2006). https://doi.org/10.1245/ ASO.2006.05.042
3. Chiacchio S, Lorenzoni A, Boni G, Rubello D, Elisei R, Mariani G. Anaplastic thyroid cancer: prevalence, diagnosis and treatment. Minerva Endocrinol. 2008 Dec;33(4):341-57.
4. Spires JR, Schwartz MR, Miller RH. Anaplastic thyroid carcinoma. Association with differentiated thyroid cancer. Arch Otolaryngol Head Neck Surg. 1988 Jan;114(1):40-4. doi: 10.1001/ archotol.1988.01860130044012. PMID: 3334817.
5. Kristen A Marten & Vinay K Gudena (2015) Use of vemurafenib in anaplastic thyroid carcinoma: a case report, Cancer Biology & Therapy, 16:10, 1430-1433,DOI: 10.1080/15384047.2015.1071734
6. Camargos EF, Pandolfi MB, Toledo MA, Quintas JL, Moreira S Jr, de Azevedo AE, Tavares AC. A 95-year-old woman with leucocytosis and eosinophilia: anaplastic carcinoma in an ectopic thyroid. BMJ Case Rep. 2010 Aug 31;2010:2823. doi: 10.1136/bcr.03.2010.2823. PMID: 22767520; PMCID: PMC3028571.
7. Demirag F, Cakir E, Aydin E, Kaya S, Akyurek N. Ectopic primary B cell lymphoma of the thyroid presenting as an anterior mediastinal mass. A case report. Acta Chir Belg. 2009 Nov-Dec;109(6):802-4. doi: 10.1080/00015458.2009.11680543. PMID: 20184075.
8. Nakada T, Sato H, Inoue F et al. Production of Colony-Stimulating Factors by Thyroid Carcinoma Is Associated with Marked Neutrophilia and Eosinophilia. Internal Medicine. Case report. 35:815-20, 1996.
9. Sato T, Omura M, Saito J et al. Neutrophilia Associated with Anaplastic Carcinoma of the Thyroid: Production of Macrophage Colony-Stimulating Factor (M-CSF) and Interleukin-6. Thyroid. Case report. 10(12):1113-19, 2000.
10. Shiraishi J, Koyama H, Seki M et al. Anaplastic Thyroid Carcinoma Accompanied by Uncontrollable Eosinophilia. Internal Medicine. Case report. 54:611-616, 2015.
11. Vassilatou E, Fisfis M, Morphopoulos G et al. Papillary thyroid carcinoma producing granulocyte macrophage colony-stimulating factor is associated with neutrophilia and eosinophilia. Hormones. Case report. 5(4):303-9, 2006.
12. Zalewska E, Obołończyk Ł, Sworczak K. Hypereosinophilia in Solid Tumors-Case Report and Clinical Review. Front Oncol. 2021 Mar 24;11:639395. doi: 10.3389/fonc.2021.639395. PMID: 33842345; PMCID: PMC8024638.
13. Limaiem F, Kashyap S, Naing PT, et al. Anaplastic Thyroid Cancer. [Updated 2021 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK538179/
14. Gao Y, Singtong B, Warshaw H, Ahmadian D, O’Grady E, Aziz M, et al. (2021) Metastatic Leiomyosarcoma of the Thyroid Gland from a Prior Uterine Leiomyosarcoma. Case report of a Rare Clinical Presentation and Review of the Literature. SM J Clin Pathol 5: 5.
15. Smallridge RC, Ain KB, Asa SL, et al. American thyroid Association guidelines for management of patients with anaplastic thyroid Cancer. Thyroid 2012;22:1104–39.
16. Revathi Kollipara, Bryan Schneider, Milan Radovich, Sunil Babu, Patrick J.Kiel et al. Exceptional Response with Immunotherapy in a Patient with Anaplastic Thyroid Cancer. TheOncologist 2017;22:1149–1151 www.TheOncologist.com
17. Fabian Beier, Lukas Moleda, Viktoria Guralnik, Philipp Hahn, Katharina Schardt et al. Papillary thyroid cancer associated with syndrome of inappropriate antidiuresis: a case report. Journal of Medical Case Reports 2010, 4:110 http://www.jmedicalcasereports. com/content/4/1/110
18. PJ Roberts and CJ Der. Targeting the Raf-MEK-ERK mitogen-activated protein kinase cascade for the treatment of cancer. Oncogene (2007) 26, 3291–3310
Raju P, Cevallos A, Alzein O, Lubert J, Yeakle M, et al. (2021) Fine Needle Aspiration Cytology Diagnosis of Anaplastic Thyroid Carci noma. Case Report of a Highly Aggressive Rare Tumor and Review of the Literature. JSM Clin Cytol Pathol 4(1): 5.
Tuberculosis (TB) is remains as major public health concern. According to WHO reports in 2018, it estimated 10.7 million TB cases throughout the worldwide. Also there are 1.6 million died from TB and 558,000 rifampin-resistant TB (RR-TB) in 2017.
Mohsen Karbalaei¹ and Masoud Keikha²,³*
Introduction: Primary and isolated hydatid cysts of the spleen are very rare seen even in endemic country. We report here our experience with primary and isolated splenic hydatid cysts.
Methods: We retrospectively analyzed the record of eight cases of primary and isolated spleen hydatid cyst that treated in Arya and Razi Hospital, Iran, Rasht.
Results: Among eight patients, who underwent treatment for primary and isolated splenic hydatid cyst disease, five patients were male and three patients were female. The mean average cyst diameter was 8 cm (4-15cm). Four of patients underwent splenectomy as the surgical procedure and three of patients underwent cystotomy, partial cystectomy, and omentoplasty processes as a spleen preservative surgery. One case underwent medical treatment with albendazole because the size of cyst was 4 cm. Three patients out of eight could not undergo splenectomy because in two of them the cyst was localized in the lower pole of the spleen and in another patient it was localized in upper pole of the spleen.
Conclusion: Primary and isolated splenic hydatid cyst is very rare. A hydatid cyst must be included in the differential diagnosis of other cystic lesions of the spleen. The best toll for diagnosis is the abdominal tomography and U&S. A splenic hydatid cyst should be treated surgically due to the high risk of a rupture, and the ideal procedure in adulthood is standard splenectomy. The outcome of treatment is good without recurrences.
Manouchehr Aghajanzadeh*, Seyed Ali Jalal, Mohammad Reza Saffar, Saeed Youseffi, Mohammad Sadegh Mousavi and Kazem Habibzadeh
Dermatophytosis infections are caused by dermatophytes. Drug resistance and toxicity associated with long-term treatment with conventional antifungal drugs has necessitated search for new drugs to treat fungal infections. Natural products found in plants have been scientifically proved to avoid these side effects. The aim of this study was to formulate herbal antifungal cream containing extract of Acalypha wilkesiana as an anti-dermatophytic preparation and evaluate its physicochemical properties, stability and efficacy of the product. The formulated creams containing 0.5, 1 and 2% w/w of extract were subjected to stability tests using temperature variation method at -10, 4, 30, 37 and 45oC. Freeze-thaw test, Centrifuge test, pH and exposure to UV light test were also carried out using standard method. Efficacies of the cream formulations were determined using albino rats
The percentage yield of the extract was (10.2%). Percentage ethanol phytochemical composition indicated that for Alkaloid it is 4.58 ± 0.01%, saponins (3.10 ± 0.23%), flavonoids (1.61 ± 0.04%) and tannins (0.81 ± 0.02%).The antifungal results are in the increasing order Microsporum audounii = Epidermophyton floccosum < M.furfur < Trichophyton mentagrophtes. Temperature stability tests carried out indicated that the cream was very stable. Centrifuge testing indicated that there was no separation of the cream. Light testing indicated no change in the colour and odour of the products. There was no change observed in all the test samples during the freeze-thaw testing. Animal studies evaluation of the ethanolic formulations of the cream indicated that their efficacy against the dermatophytes is concentration dependent and the efficacy is in the increasing order M.audounii < E.floccosum < M.furfur < T.mentagrophyte which shows that 2% Acalypha wilkesiana cream was statistically significant (P<0.05) against all the test microorganisms.
Fawehinmi AB¹ and Oyedeji FO²*
There is numerous evidence for the efficacy of curcumin on the treatment of infectious disease particularly tuberculosis infection. According to review of the literature, curcumin could be considered as a therapeutic option against tuberculosis; but given that immune modulatory of curcumin in immune-response and limitation of data about the main mechanism of curcumin during tuberculosis infection; we discuss the probability of curcumin as a novel treatment option for tuberculosis disease using current evidence.
Mohsen Karbalaei¹ and Masoud Keikha²,³*
Introduction: Hydatid cyst is a condition commonly affecting liver and lungs caused most commonly by Echinococcus granulosus where as musculoskeletal or subcutaneous hydatidosis is very rare. and Usually are secondary and resulting from the spread of cysts from other organs, either spontaneously rupture or after spreading from operations for hydatidosis in other regions.
Case Presentation: We present an unusual case of a primary hydatid cyst found in the subcutaneous scalp tissue under occipital region in a 36 year man. Clinical presentation of patient was a huge cystic mass. Ultrasound findings revealed a cyst lesion in the posterior aspect of neck under the occipital region. MRI show a cystic lesion. We removed the entire part of cyst lesion surgically. Macroscopic and microscopic histopathological examinations confirmed the diagnosis of subcutaneous hydatid cyst.
Conclusion: In regions where hydatid disease is endemic, a cystic lesion in any part of the body should be considered a hydatid cyst. The best treatment is surgery and total evacuation of the cyst elements without any spillage of cyst contained and postoperative albendasol therapy.
Manucher Aghajanzadeh¹, Sharokh Yousefzadeh Jabock², Hossein Hemmati¹, Mohammad Sadegh Esmaili Delshad², and Piroze Samidost¹*
Intrapericardial Diaphragmatic Hernia (IDH) is the rarest type of adult diaphragmatic hernia and colon obstraction. Only a few cases have been reported. Blunt trauma has been implicated in most cases, but few cases were reported from a stab wound to the anterior chest. Patients presented immediately or up to 15 to 20 years following trauma with symptoms which include of: intermittent bowel obstruction, strangulation, cardiac dysfunction, dyspnea, palpitations, and even cardiac tamponade. The most unusual site for a diaphragmatic hernia to occur is through the central tendon of the diaphragm into the pericardium. Physical findings included bowel sounds in the chest, decreased heart and lung sounds, and an absent point of maximal cardiac impulse. We present the case of a 67-year-old man who suffered a bowel obstruction when the transverse colon and omentum became incarcerated in the intrapericardial cavity from diaphragmatic hernia. Defect presumably resulted from blunt chest and abdominal trauma received six month earlier. Laparatomy is the preferred approach to surgical repair of IDH. Since the symptoms referable to adult IDH can be incapacitating or life threatening, herniorrhaphy should be performed promptly upon diagnosis. In this very rare case with delayed presentation of intrapericardial diaphragmatic hernia, we want to review the symptoms, recommendations of evaluation and the best approach of treatment and outcome of treatment.
Manouchehr Aghajanzadeh*, Seyedali Jalali, Hossein Hemmati, Mohammad Sadegh Esmaeili Delshad, and Piroze Samidost
Recurrent respiratory papillomatosis is a rare and recurring disease characterized by chronic benign papillomas of the epithelial mucosa in the respiratory tract. It is exclusively caused by human papilloma virus. While the majority of human papilloma virus infections are self-limited, some persist, as is the case in recurrent respiratory papillomatosis. Diagnosis is usually achieved by surgical biopsy and the utility of immunohistochemistry studies. Studies showed that cytology specimens in form of fine needle aspiration could provide definite diagnosis of this entity, especially when cytologic sampling is sufficient to produce a cellblock to be utilized for ancillary studies. We report a case of this rare entity diagnosed solely by cytologic sampling. We also discuss the pathophysiology and management modalities.
Michael Noeske*, M. Phuong Truong, Mariana Coelho, Andressa Balbi, and Mohamed Aziz
Benign cystic hypersecretory hyperplasia and cystic hypersecretory duct carcinoma of the breast share similar histologic features including formation of cystically dilated ducts containing a homogeneous eosinophilic secretion that resembles thyroid colloid. However, cystic hypersecretory duct carcinoma of the breast is associated with proliferative malignant epithelium. Cystic hypersecretory lesions of the breast present with a varying morphologic features in the same mass. Strict histomorphologic criteria and confirmatory immunohistochemistry studies are essential for definitive diagnosis and appropriate management. We present a case where secretory proliferation of a breast mass displayed spectrum of changes from benign hyperplasia, to atypical hyperplasia, to frank ductal carcinoma in situ. Due to limited reported cases of these entities, little is known about the biological behavior, prognosis and molecular study of these lesions. By reporting more cases, we may reveal the biologic behavior of these uncommon lesions.
Esra Nimet Bayram*, Haider Khalil, Tiffany Tsao, Gina Nathwani, Hayden Pollard, Mathew Baum, Hong Yu Wang and Mohamed Aziz
Epithelioid hemangioendothelioma and epithelioid angiosarcoma are both rare malignancies of endothelial origin. Differentiation of these two diagnoses remains difficult due to their heterogeneous presentation and overlapping morphological features. Here we report a case of a 58-year-old female clinically presenting with primary hepatic vascular neoplasm. She was finally diagnosed with Epithelioid Hemangioendothelioma (EHE) based on cytology sampling and core biopsy. The immunohistochemical (IHC) studies and morphological features of this case may be suggestive of a continuum with Epithelioid Angiosarcoma (EAS). Given the mixed findings exhibited, a plausible intermediate diagnostic entity may be proposed, and further studies are warranted to investigate this possible intermediate variant with optimal management and follow up.
Lawrence Brookman*, Carolina Fonseca, Andressa Balbi, Nicole Asher, Gilmar Costa, and Mohamad Aziz
Solitary fibrous tumors are rare and difficult to diagnose. The occurrence of this entity in the head and neck region constitutes approximately 6% of the cases and is associated with higher rates of recurrence. We report a case of a 61-year old male diagnosed with this rare tumor by fine needle aspiration.
Carolina Fonseca*, Gilmar Costa, Soubhi Alhayek, Abdel-rahman El-Mallah, and Mohamad Aziz