An unusual tumour of the lung

We report a case of a 51-year-old woman with a solitary mast cell tumour of the lung, a rare neoplasm with only three previously-reported cases reported in the literature. Unlike previous cases, the tumour in the present case was bulky, measuring 14 cm in diameter and budding into the segmental bronchus. Histologically, it showed proliferation of typical metachromatic mast cells intermingled with undifferentiated cells with a ratio of 3:1. The neoplastic mast cells stained strongly with tryptase, CD117, CD68 and CD45, CD14 and CD33; whereas the undifferentiated cells lacked all these markers and expressed EMA and cytokeratin. Histological examination of bone marrow and laboratory data were unremarkable. To our knowledge, this is the fourth case of solitary extracutaneous mastocytoma of the lung. The differentiating features of this neoplasm and a review of literature are presented.

[Mixed breast carcinoma with melanocytic differentiation in a man]

INTRODUCTION

Male breast cancer is rare; the lobular type is exceptional. Only one case of mixed ductal and lobular type is reported in the literature. This is the first report on a mixed ductal and lobular carcinoma with melanocytic differentiation in a man. The aim of our study is to describe the clinicopathological characteristics of this rare type of breast tumor and to discuss its histogenesis.

CASE REPORT

A 63-year-old man presented with cutaneous ulceration of the left breast. Ultrasound of the breast revealed a solid hypoechoic lesion, 13 mm in diameter. Microscopic evaluation of the biopsy showed an invasive ductal carcinoma. The patient received three cycles of chemotherapy and lost of view. Then consulted for increasing of the tumor size reaching 3 cm. Histological examination of the mastectomy specimen showed a mixed ductal and lobular carcinoma with melanocytic differentiation, confirmed by the immunohistochemical study. The patient received adjuvant chemotherapy and the evolution was favorable with an average follow-up of 9 months.

CONCLUSION

Breast carcinoma with melanocytic differentiation is extremely rare; only seven cases are reported in the literature and all occurs in females. Its histogenesis is unclear; tumors exhibiting this combination of cell types may occur as collision or composite tumors.

[Pseudotumor phenotype of sarcoidosis: about two cases]

INTRODUCTION

Sarcoidosis is a multisystem benign granulomatous disease of unknown etiology. It can sometimes cause diagnostic confusion by presenting in the form of a pseudotumor, thus constituting a trap for the unwary.

COMMENTS

The authors report two cases of pseudotumor sarcoidosis. In the first, the pseudotumor occurred in the context of multisystem disease in a 48-year-old man. The response to treatment with systemic corticosteroids was complicated by the development of disseminated tuberculosis, which was rapidly fatal. The second case, by contrast, was about a 58-year-old woman and the disease was self-limiting, resolving spontaneously in less than 3 months.

CONCLUSION

Through these two cases, the authors focus on the particularities of the pseudotumor manifestation of pulmonary sarcoidosis. The diagnosis is often difficult. The mismatch between the clinical picture and the extent of radiological lesions should, however, suggest the diagnosis. Histological evidence is needed to eliminate other etiologies including malignant tumors. The condition usually resolves either spontaneously or after treatment with systemic corticosteroids. However, relapses are possible, including on discontinuation of corticosteroid therapy.

[Mediastinal mature teratoma with spontaneous malignant transformation]

INTRODUCTION

Malignant teratomas can be either immature teratomas or they can develop after treatment of other malignant germ cell tumors with chemotherapy or radiotherapy. Spontaneous malignant transformation of mature teratomas is very rare.

OBSERVATION

We report the case of a patient complaining of atypical chest pain. Chest plain radiography showed a right anterior mediastinal mass. Computed tomography revealed a heterogeneous mediastinal mass with fat areas and calcification. There were hilar and mediastinal lymph nodes as well as lung parenchymal nodules. CT-guided and then surgical biopsies confirmed the diagnosis of a mature teratoma, which had degenerated into a digestive adenocarcinoma.

CONCLUSION

Spontaneous malignant transformation of mature mediastinal teratoma is very rare. The diagnosis of malignant transformation is based on radiological examinations, laboratory tests and histological studies.

Expression of COX-2 and E-cadherin in Tunisian patients with colorectal adenocarcinoma

Cyclo-oxygenase 2 (COX-2) and E-cadherin are promising biomarkers for cancer diagnosis and therapy. The aim of this study was to examine the expression of these two proteins in primary colorectal adenocarcinomas and to investigate their association with clinicopathological characteristics including survival of patients. Immunostaining of E-cadherin and COX-2 was assessed in 70 primary colorectal adenocarcinomas from Tunisian patients. Membranous E-cadherin immunostaining and cytoplasmic COX-2 expression were observed in 74.3% and 68.6% of cases respectively. A significant association was found between COX-2 expression and age at diagnosis (P=0.02), and vessel invasion (P=0.037). The expression of E-cadherin correlated with age at diagnosis (P=0.01), and tumor size (P=0.02). In addition, by multivariate analysis, we revealed a significant association with 1-year disease free survival and a tendency with distant metastasis (P=0.017 and P=0.065 respectively). On the other hand, tumors exhibiting COX-2+/E-cadherin-profile were larger (P=0.006), and in an advanced stage (P=0.001). Survival analysis showed that COX-2 over-expression confers a reduced overall survival rate (Plog rank=0.036) and is an independent factor predictive for prognosis.

[Abrikosoff's tumor: a clinicopathologic study of nine cases]

BACKGROUND

Abrikossoff's tumour or granular cell tumor or is a benign neurogenic tumour. It is ubiquitous with the most frequently affected site is the head and neck region.

AIMS

To report a series of granular cell tumors and to discuss its clinicopathologic features and histogenesis.

METHODS

We report a series of nine cases diagnosed between January 2004 and December 2006 in the Pathology Department of the University Hospital of Sfax. We have collected the clinical aspects and we have proceeded on a pathological, cytochemical (PAS and PAS diastasis) and immunohistochemical study.

RESULTS

Nine cases of TCG are presented: 5 females and 4 males. The median age was 33.9 years (extremes: 7 and 53 years). All tumours were unique. The most common localization was in the head and neck region (5 cases). The diagnosis was suspected using standard histologic criteria and confirmed by immunohistochemistry: tumour cells expressed vimentine (90%), S100 protein (100%) and neuron specifique enolase (80%). In all cases patients were treated by excisional resection and had a benign course with no evidence of recurrence (median follow up: 2 years).

CONCLUSION

Granular cell tumours are rare neoplasm which must be recognised because they demonstrate a benign behaviour after their surgical excision. Histological features of granular cell tumours are commonly characteristic but some times they can be misdiagnosed as malignant tumours especially when the biopsy is superficial. The staining for neurogen markers and PAS are useful tools.

Mucinous tubular and spindle cell carcinoma of the kidney associated with tuberculosis

Mucinous tubular and spindle cell carcinomas (MTSCC) are low-grade renal epi-thelial neoplasms with approximately 100 documented cases reported in the literature. We report a case of MTSCC in a 79-year-old patient in association with a renal tuberculosis infection that has never been reported. Further investigations are needed to determine the frequency and true prognosis of these tumors.

Hypermethylation of RARβ2 correlates with high COX-2 expression and poor prognosis in patients with colorectal carcinoma

Silencing of gene expression by aberrant methylation at the CpG islands is common in human tumors, including colorectal cancer. This epigenetic alteration affects promoter of genes having crucial cellular functions such as tumor suppressor, DNA repair, apoptosis, cell adhesion, etc. We investigated the methylation status in the promoter regions of the RARβ2, RASSF1A, DAPKinase, and CDH1 genes in 73 colorectal carcinoma and 43 paired normal tissues of Tunisian patients using methylation-specific PCR assays. The association between methylation status and the clinicopathological features was evaluated. To determine whether aberrant methylation affects gene expression, we performed immunohistochemistry analysis for E-cadherin and COX-2, a target gene of RARβ2. The methylation frequencies vary from 80.8% for RARβ2 to 35.6% for RASSF1A while in non-tumor-paired samples; the frequencies of methylation are significantly lower for all the fourth genes tested. The methylation status did not correlate with any of the clinical features considered; however, aberrant methylation of RARβ2 was associated with a shortened overall patients' survival (p log rank = 0.026); nevertheless, it needs to be confirmed on larger sample size. Moreover, a significant inverse association was observed between methylation status of RARβ2 and COX-2 protein expression in tumor specimen (p = 0.014). On the other hand, we found that loss of E-cadherin expression was significantly associated with aberrant methylation of the CDH1 promoter (p = 0.005). Our findings showed that RARβ2 was frequently methylated in colorectal cancer and correlated with a worse prognosis and high expression of COX-2 suggesting a link between these two proteins in colorectal carcinogenesis. We also showed that epigenetic alteration of CDH1 is a major mechanism of the loss of E-cadherin protein expression in primary colorectal tumors.

Correlation Between Immunohistochemical Biomarkers Expression and Prognosis of Ovarian Carcinomas in Tunisian Patients

Background

Ovarian cancer is the leading cause of death from gynaecological malignancies. Newer biological prognostic factors and predictors of response to therapy are needed. Our study was designed to evaluate the expression of p53, Bcl-2, Estrogen receptor (ER) and Progesterone receptor (PR) in ovarian carcinoma and to compare it with other prognostic parameters such as age, FIGO stage, size of residual tumor, histological type and grade.

Methods

This is a retrospective study conducted in the department of pathology at Sfax University Hospital. Confirmed 57 cases of ovarian carcinoma were reviewed in the period between January 1995 and December 2006. We used immunohistochemistry to evaluate the expression of p53, Bcl-2, ER and PR receptors and Chi-Square and Student test to correlate immunohistochemical findings with some prognostic parameters of ovarian carcinoma.

Results

The percentage of expression of p53, Bcl-2, ER and PR was 73,7; 47,4; 35,1 and 33,3 % respectively. p53 overexpression correlated with an advanced FIGO stage (p = 0,026) and presence of ascitis (p < 10^-4). The expression of PR was associated with an early stage (FIGO I and II), a non serous histologic type and a low tumour grade (p = 0,045; 0,010 and 0,036 respectively). No correlation was found between Bcl-2 and ER and prognostic parameters. Survival analysis revealed that Bcl-2 status, FIGO stage, presence of ascites, peritoneal cytology, and residual disease were significant predictive factors of survival.

Conclusion

p53 expression correlates with a worse prognosis in epithelial ovarian cancer, whereas Bcl-2 expression is related to a better outcome. For hormonal status, expression of PR is found to be an independent indicator of favourable prognosis. These results should be supported by more and larger studies.

[Ewing sarcoma osseous and extraosseous : a clinicopathologic study of 29 cases]

BACKGROUND

Ewing's sarcoma (ES) is a rare tumour accounting for 10% of primary malignant bone tumours in children and 3% of all childhood malignancies. ES belongs to a group of small round cell tumours.

AIM

In this review, we will describe the main clinicopathological features of this rare tumour and discuss its prognosis.

METHODS

We report a retrospective study of 29 cases of ES, of which 4 were extraosseous, diagnosed over a period 11 years (January 1989 - December 1999). Clinicopathological data were described. Hematoxylin-eosin staining and immunohistochemical study were reviewed.

RESULTS

12 patients were male and 17 were female (ratio: 0,8) with a median age of 16 years. 62,5% of tumours were located in flat bone and 33,3% in long bone. The medium size of the tumor was 10,6 cm (range:3-25cm). 27,5% of patients presented with metastatic disease at time of diagnosis. Microscopically, tumour tissue was composed of round, small, blue cells with fine granular chromatin. Tumour cells strongly coexpressed CD99 and vimentin (100%). Systemic treatment consisted of adjuvant chemotherapy (84,2%). Local control was based on and surgery (57,9%) or radiation therapy (36,8%). A good response to chemotherapy was obtained in 37.5%; 13,7% of patients were alive without disease (medium follow up: 169 mois); 34,5% of patients developed metastases (medium follow up : 23 months) and 10,3% developed recurrences (medium follow up :13 months).

CONCLUSION

Our study emphasizes two points : the great size of the tumor and the frequent location in flat bone which may explain the poor prognosis of Ewing sarcoma in our series despite the multidisciplinary treatment.

[Appendicular cystadenocarcinoma with cutaneous fistula]

BACKGROUND

Cutaneous metastasis of colorectal cancer is rare. We report a case of fistular lesions of the buttocks revealing a mixed tumour of the appendix involving mucinous cystadenocarcinoma and carcinoid tumour.

CASE REPORT

A 67-year-old woman was admitted for four skin fistulae of the right buttock present for 6 years. Histological examination of skin biopsy specimens identified infiltration of the dermis by metastatic mucinous adenocarcinoma while colonoscopy showed a caecal tumour measuring 4 cm. Surgical excision was performed involving right hemicolectomy, evacuation of retroperitoneal mucin collection and excision of fistulae. Histopathological examination of surgical specimen confirmed mixed tumour consisting of perforated mucinous cystadenocarcinoma and carcinoid tumour of the appendix. Recurrence of the fistular lesions was seen. The patient was hospitalized several times for surgical drainage of mucin. She died one year later.

DISCUSSION

Cutaneous metastasis of colorectal cancer is an uncommon event that usually occurs after identification of the primary tumour and generally indicates advanced-stage disease and an ominous prognosis. This case is particular and underlines the need to rule out a metastatic origin of cutaneous fistulae, even in patients otherwise apparently in good health.

Pediatric Angiosarcoma of Soft Tissue: A Rare Clinicopathologic Entity

Angiosarcomas are rare tumors that predominantly affect adults and elderly patients. Although angiosarcomas are well described in a variety of clinical settings, they have been poorly studied in children and little is known about their biology, natural history, or optimal treatment. Childhood angiosarcomas are exceedingly rare. The head and neck region and mediastinum seem to be the preferred locations. Most tumors are high-grade tumors. Vasoformative architecture is not always obvious on light microscopy requiring the benefit of immunohistochemical study. The differential diagnosis includes Kaposi sarcoma, epithelioid hemangioendothelioma, hemangiopericytoma, and spindle cell hemangioendothelioma whose prognosis is different. Complete resection is required for patients with localized tumors. Malignant vascular tumors are rare in children in the first 2 decades of life and when they do occur they seem to be more aggressive than in adults. Pathologic diagnosis is difficult particularly in poorly differentiated angiosarcomas requiring immunohistochemical study to confirm vascular differentiation.

Aggressive nasal-type natural killer/T-cell lymphoma associated with Epstein Barr virus presenting as testicular tumor

BACKGROUND

Testicular lymphoma is a lethal disease with a median survival of approximately 12 to 24 months. Nasal-type natural killer/T-cell lymphoma of the testis is exceptional whether as a primary or secondary tumor.

AIM

The authors report on the comprehensive histopathologic, immunohistochemical and molecular analysis of a case of primary testicular nasal type NK/T cell lymphoma and review the features of previously reported cases.

OBSERVATION

We report a case of primary nasal-type natural killer/T-cell lymphoma of testis in a 28-year-old male. The histopathological examination of the surgical specimen, showed a large lymphoma cells with angioinvasion expressing CD3 (cytoplasmic), CD2, CD8, CD43, CD45, CD45Ro, CD56, T-cell intracellular antigen-1, perforine, Mib1 and granzyme. In situ hybridation for Epstein-Barr-virus- encoded mRNA was positive. Polymerase chain reaction study of formalin-fixed tissue showed lack of T-cell receptor gene rearrangements. The initial stage was I (EA) of Ann Arbor. This lymphoma was refractory to chemotherapy. The patient developed lymph node metastases in the out iliac and in the subclavicular region two months later. He died of disease after eight months.

CONCLUSION

This study confirms that testicular NK/T-cell lymphoma deserves to be distinguished from the other testicular lymphomas. In fact, this lymphoma tends to occur at young age, to disseminate early, to have an aggressive course, and is strongly associated with EBV.

[Cerebral gliosarcoma: clinico-pathologic study of 8 cases]

BACKGROUND

Gliosarcomas are biphasic neoplasms composed of a glioblastoma admixed to a sarcomatous component with different lines of differentiation. Histogenesis of these tumors is still discussed.

AIM

Our objective is to specify clinical and pathological characteristics of this rare neoplasm and to discuss its histogenesis.

METHODS

Retrospective study of eight cases of gliosarcomas diagnosed between January 1998 and December 2004. Clinical, radiological, therapeutic and follow-up data were reviewed. Histological features and immunohistochemical results were also included in this review.

RESULTS

Five patients were male, three women with a median age of 50.7 (range 31-74 years). Symptoms were dominated by intracranial hypertension and paralysis. The most common location was parietal or temporo-parietal (5 cases: 62.5%). Pathological exam including histochemical and immunohistochemical study confirmed the diagnosis of gliosarcoma in all cases. Sarcomatous component had features of fibrosarcoma in 5 cases, osteosarcoma in 2 cases and malignant fibrous histiocytoma in 1 case. All patients were treated by surgical excision (complete in five cases and partial in three cases). Adjuvant radiotherapy was received in three cases. One patient was lost on follow-up. Two patients died from postoperative. complications and the five remaining patients died with a medium follow up of 9 months (extremes: 2-24 months).

CONCLUSION

Clinical, radiological and follow-up features of gliosarcomas share great similarities with glioblastomas. Histopathological, histochemical and immunohistochemical studies are helpful in accuracy diagnosis. Recent cytogenetic and molecular data support a monoclonal origin for these tumors.

Adenoid cystic carcinoma of the parotid with facial nerve invasion

BACKGROUND

Adenoid cystic carcinoma comprises approximately 10% of all epithelial salivary neoplasms and most frequently involves the parotid. Perineural invasion is a common feature but intraneural invasion and spread is less common.

AIM

The authors report a case of parotid adenoid cystic carcinoma with invasion and spread via the facial nerve with an emphasis on radiologic features.

OBSERVATION

We report a case of a 47-year-old man presenting with a right submandibular mass evolving for 4 years. On physical examination, the mass was firm painless, well delineated. There was no facial paralysis. The magnetic resonance imaging (MRI) examination showed a right parotid gland solid mass located in the deep lobe of the parotid gland with mastoid bony involvement.The mass was heterogenously enhanced. High resolution non contrast computed tomographie (CT) scan of the temporal bone showed in the axial and coronal cuts, a widening of the mastoid segment of the facial canal with involvement of the facial nerve. Pathologic examination of the resected specimen revealed histological features of adenoid cystic carcinoma with intra neural invasion of the mastoid segment of the facial nerve. The surgical margins were free. The evolution was favourable 5 years later.

CONCLUSION

This study confirms that multiplanar approach of MRI allows rapid detection of adenoid cystic carcinoma. The influence of intraneural invasion and spread on survival remains controversial.