Pitfalls in Cytological Diagnosis of Extra Adrenal Paraganglioma and Pheochromocytoma: Experience From a Tertiary Care Center

BACKGROUND

Pheochromocytoma and extra-adrenal paragangliomas increasingly coming into light nowadays because of improved imaging techniques and biochemical investigations. There is sparse literature available regarding cytological findings of adrenal and extra-adrenal paragangliomas.

MATERIAL AND METHODS

We studied 16 cytological specimens retrospectively over a period of 3 years, where subsequent histological diagnosis of phaeochromocytoma or paraganglioma was available.

RESULTS

A total of 16 cytology specimens were studied. Nine patients had adrenal SOLs and seven patients had extra-adrenal lesions. Age range was 12 to 60 years Majority of the cytology smears were cellular (87.5%). The smears were composed of small clusters as well as dispersed plasmacytoid cells with eccentric nuclei containing salt and pepper chromatin and moderate to abundant granular cytoplasm. Large cellular clusters mimicking the Zellballen pattern was present in one case. Anisonucleosis was mild to moderate, except in three cases where marked anisonucleosis posed diagnostic challenges. The background was hemorrhagic in all cases, however, two cases in addition had necroinflammatory background. All cases lacked mitotic activity and cytoplasm was delicate with indistinct cell borders. Bare oval nuclei were a frequent finding. Nuclear grooves or cytoplasmic vacuoles were absent. In 12 out of 16 cases, the initial cytological diagnosis correlated with final histological diagnosis, with an overall diagnostic accuracy of 75%. Four misdiagnosed cases had some atypical cytological features like marked anisonucleosis, necroinflammatory background, and presence of prominent nucleoli.

CONCLUSION

Here we have highlighted some of the distinguishing cytological features that can help in cytological diagnosis of paragangliomas. Hemorrhagic background with plasmacytoid morphology, granular cytoplasm, naked nuclei, and absence of mitosis are useful clues.

Primary adrenal epithelioid sarcoma (proximal type): a case report and literature review

Primary adrenal epithelioid sarcoma is a rare lesion of the adrenal gland, and only seven cases have been reported in the domestic and international literature to date. We herein report a case involving a 65-year-old man with primary adrenal epithelioid sarcoma. After being admitted to the hospital with an adrenal mass found on physical examination, the patient underwent laparoscopic right adrenalectomy. Postoperative pathological findings indicated an epithelioid sarcoma (proximal type). Primary adrenal epithelioid sarcoma is a rare malignancy. Diagnosis is challenging and relies on histopathology and immunohistochemical staining.

Imaging findings of primary epithelioid sarcoma of adrenal gland: a case report and literature review

Epithelioid sarcoma (ES) is a rare soft tissue malignant tumor with an uncertain histogenetic origin. It usually arises in soft tissues of the extremities, while ES in adrenal gland is extremely rare. There is no special clinical manifestation in the early stage, so it may be misdiagnosed and delay the treatment. We reported a 69-year-old male with an adrenal ES. The tumor was completely resected, and two months later, positron emission tomography-computed tomography(PET/CT) noted recurrence at the tumor bed and multiple metastases. The patient has been treated with chemotherapy with good effects. We summarize the radiological findings and immunohistochemical indexes of primary epithelioid sarcoma of adrenal gland, which may be useful to promote disease awareness and help to distinguish among other lesions.

Clinicopathological Characteristics, Treatment, and Survival in Patients Diagnosed With Proximal-Type Epithelioid Sarcoma: A Case Report and Systematic Review

Epithelioid sarcoma is a rare entity that shows a predilection for the young and middle-aged population. There are two subtypes, i.e., the distal or conventional type, which is located in distal extremities, and the proximal type, located in proximal areas of the extremities, pelvis, perineal, and genital region. The latter is characterized by more aggressive behavior, a higher recurrence rate, and poor prognosis. Histopathological and immunohistochemical diagnoses are key to correct and timely treatment and a higher survival rate. We report a case of a 41-year-old man who presented a palpable progressive growth mass in the hypogastrium. The disease time was of nine months, and the tumor was resected, but it recurred a few months later in the same location. Computed tomography (CT) scans showed images suggestive of lung metastasis and the patient had to undergo a second surgery. He received eight cycles of chemotherapy and a subsequent CT scan control showed the progression of the disease, so a new chemotherapy regimen was established. The patient received three cycles of chemotherapy without improvement, so he decided to discontinue treatment. His last outpatient medical consultation was in January 2022. A systematic review of the studies published in PubMed and Google Scholar was performed. We identified 291 articles, but only 41 reports and case series were included, with a total of 55 patients. It is important to include this type of tumor in the differential diagnosis of epithelial tumors due to its aggressive behavior. Correct and timely diagnosis is crucial to obtain lower recurrence rates, lower mortality, and higher survival rates in these patients.

An Adrenal SMARCB1/INI1 Deficient Proximal Epithelioid Sarcoma in a Middle-Aged Female: A Case Report

Proximal epithelioid sarcomas are rare soft tissue sarcomas that have been documented in a diverse range of presentations. However, there have been few cases describing adrenal presentations. These neoplasms are thought to be driven by a loss of SWItch/sucrose non-fermentable (SWI/SNF)-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 (SMARCB1), also known as integrase interactor 1 (INI1). SMARCB1/INI1 is a tumor suppressor gene thought to play a role in multiple malignancies with varying degrees of gene expression. Complete loss of SMARCB1/INI1 has most commonly been described in the English scientific literature as malignant rhabdoid tumors of renal origin within pediatric populations and proximal epithelioid sarcomas in adult populations. We describe a case of a primary adrenal proximal epithelioid sarcoma demonstrating complete loss of SMARCB1/INI1 in a middle-aged adult female.

Primary Adrenal Epithelioid Sarcoma in a Child: A Case Report with Literature Review

Introduction; Epithelioid sarcoma is a malignant mesenchymal neoplasm with evidence of epithelial differentiation. All the cases reported in the solid organs are of "proximal type" occurring in adults. We report a primary epithelioid sarcoma arising in the adrenal gland of a young male. Case report: An 11-year-old male patient presented with right loin pain. Imaging revealed a 10.8 × 10.8 × 13.5 cm complex cystic mass with obscured right adrenal gland. Clinical and radiological studies did not reveal metastases. Histologic features were those of proximal type epithelioid sarcoma with extensive central necrosis. Immunohistochemistry showed strong positivity for pancytokeratin, vimentin, and CD34. Nuclear expression of SMARCB1 (INI-1) protein was lost. Conclusion: Proximal type of epithelioid sarcoma can arise from solid organs such as the adrenal.

An Extremely Rare Epithelioid Sarcoma Arising from the Infratemporal Fossa: A Case Report and Literature Review

INTRODUCTION

Epithelioid sarcoma (ES) is a rare histopathological type of soft tissue sarcoma. They are subcutaneous soft tissue masses that tend to arise in extremity sites (the classic type, formerly referred to as distal type) or proximal midline region of the body (the proximal type), such as the perineum, genital tract, and pelvis. The head and neck regions are rarely affected by ES, but the infratemporal fossa (ITF) is extremely rare. ES involving the ITF has not been reported before in literature. In this paper, the imaging features of ES were reviewed in detail, and the anatomical structure and epidemiology of ITF were briefly introduced.

SOURCES

We performed a systematic search from 3 databases, CNKI(China National Knowledge Internet), FMRS(Foreign Medical Literature Retrieval Service, Shenzhen METSTR Technology CO., Led. China), and PubMed, to obtain literature from January 1970 to July 2020. Epithelioid sarcoma, head and neck regions, infratemporal fossa, diagnostic imaging, anatomy, MRI, and CT were used as keywords for advanced retrieval. A study had to be found eligible for inclusion to be closely related to ES and/or ITF. A total of 129 related pieces of literature were retrieved successfully, of which 37 were closely related to this study. The case report in this article is from the Affiliated Hospital of North Sichuan Medical College. The present study was approved by the institutional review board of the Affiliated Hospital of North Sichuan Medical College and a written informed consent for the publication of the case was obtained from the patient.

CASE PRESENTATION

A 33-year-old man accidentally found a slowly growing, painless mass in the left cheek more than a month ago. On plain computed tomography (CT) scan of the outpatient department, an oval slightly low-density mass with well-defined and uniform boundary in the infratemporal fossa was revealed, and on the contrast-enhanced scan, it was homogeneous and moderately enhanced. Initially, the CT appearance favored benign lesions. However, the possibility of a malignant tumor can not be excluded completely. Finally, the patient was referred to the inpatient department a tumor arose from IF and underwent a selective operation. The tumor was completely removed. Histologic findings were compatible with epithelioid sarcoma. Post-operatively, the patient received 2 cycles of radiotherapy, and there was no evidence of recurrence after 6 months follow- up.

CONCLUSION

The imaging manifestations of ES are various. The anatomic structure of ITF is complex and the pathological types are various. It should be very careful in the qualitative diagnosis of tumors from the ITF, and advanced imaging techniques will be useful in imaging diagnosis.

Abnormal Adrenal Mass Presents as Proximal Epithelioid Sarcoma

Epithelioid sarcoma (ES) is a rare malignant mesenchymal neoplasm that accounts for less than one percent of all soft-tissue sarcomas. Only two cases of ES involving the adrenal gland were found after a literature review. We report a case of an 82-year-old female initially presenting with right flank pain who was subsequently found to have an incidental left adrenal mass on CT imaging. After appropriate diagnostic workup, the patient underwent surgical resection. A diagnosis of ES was made from the histopathological analysis. The characteristic findings of ES are epithelioid cells with rhabdoid morphology and moderate eosinophilic cytoplasm. Immunohistochemical findings are significant for positive staining for epithelial markers, cytokeratins, vimentin, and CD34, and loss of INI-1 stain. Due to the aggressive nature and limited data of ESs, the standard treatment continues to remain wide surgical excision.