Ovarian Carcinosarcoma with Malignant Neuroectodermal Components (Teratoid Carcinosarcoma) - A Rare Entity

Introduction/Objective

Ovarian carcinosarcoma is an aggressive tumor accounting for 2% of all ovarian malignancies. Ovarian carcinosarcoma with malignant neuroectodermal components is exceedingly rare and only four cases have been previously reported. Here we report a series of three cases in 65(case 1), 61 (case 2) and 72 (case 3) year old females.

Methods

All patients presented with pelvic mass and elevated CA125. They underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy and tumor-debulking, along with lymph node dissection (2,3) and appendectomy (3). The FIGO stages were IIIC (1,3) or IIA (2). Case #2 experienced pelvic recurrence three months after initiating platinum based chemotherapy and was treated with BEP. She died of metastatic disease ten months after initial surgery. Case #3 is a current case and is being treated with chemotherapy. Case #1 was an outside consult and was lost to follow–up.

Results

Grossly the dominant ovarian mass measured 25 (left), 20 (left) and 21 (right) cm. The cut surfaces were hetergenous tan, yellow, partially cystic and solid with hemorrhage and necrosis. Microscopically, they showed mixed morphology of carcinomatous, sarcomatous, and undifferentiated neuroectodermal component. The carcinomatous element showed squamous cell carcinoma and adenocarcinoma. The sarcomatous component included rhabdomyosarcoma, chondrosarcoma and liposarcoma. The undifferentiated neuroectodermal component consisted of nested or solid primitive cells. All three cases showed fetal-appearing teratoid squamous cell epithelium with clear cytoplasm. The contralateral ovary and extraovarian metastatic implants were either carcinosarcoma, carcinoma or contained all three components.

Conclusion

Case #1 and 3 also showed a yolk sac component. All lymph nodes (2,3) were negative for metastatic tumor at the time of initial surgery. Case #2 had first recurrence in retroperitoneal lymph node showing mature neural tissue. Her second recurrence in abdomen was undifferentiated neuroblastoma. Immunohistochemical studies included CK7, CK20, CDX2, NapsinA, S100, GFAP, PAX-8, CK5/6, P63, AE1/AE3, desmin, Myf-4, CD56, glypican3, AFB, CD99, chromogranin, synaptophysin, NF, NeuN, calretinin, and inhibin. The staining pattern was consistent with histologic interpretation. These cases histologically resemble to so-called “teratoid carcinosarcoma” of paranasal sinuses. The histogenesis remains unknown.

Metastatic Alveolar Soft Part Sarcoma to the Breast: A Case Report

Introduction/Objective

Metastases to the breast are rare (less than 3% of all breast malignancies). In adults, malignant melanoma is the most common type of metastasis followed by carcinomas from various primary sites. Here, we describe a case of metastatic alveolar soft part sarcoma (ASPS) to the breast. Only a handful similar presentations are reported in the literature.

Methods

Here we describe the case of a 43-year-old female patient with a recent diagnosis of left base of tongue alveolar soft part sarcoma (in an outside hospital), presenting with a palpable mass in her left breast. Sonographic study of the left breast demonstrated a 1.4 cm oval hypoechoic mass with partially microlobulated margins at 1 o’clock.

Results

Histopathologic examination of the ultrasound guided core biopsy showed a “pink” neoplasm, composed of plump epithelioid tumor cells with an eosinophilic and granular cytoplasm, round to oval nuclei and conspicuous nucleoli. They are arranged in organoid nests separated by sinusoidal spaces. An immunohistochemical study shows the tumor cells to be negative for keratin AE1/AE3, keratin 7, keratin 5/6, GATA-3, Pax-8, estrogen receptor, HER2, p63, S100 and CD117. FISH test for TFE3 (Xp 11.23) is positive. PAS with diastase staining highlights the intracytoplasmic granules. Theses morphologic, clinical and molecular findings confirm the diagnosis of metastatic ASPS.

Conclusion

The differential diagnosis of “pink” tumors of the breast include primary tumors like secretory carcinoma and apocrine carcinoma and metastatic lesions of renal, thyroid, skin (melanoma), oral cavity and soft tissue. Although extremely rare, in the right clinical context, metastatic ASPS to the breast can occur and should be included in the differential diagnosis.

Incidence of phrenic neuropathy after isolated lung transplantation. The Loyola University Lung Transplant Group

BACKGROUND

Isolated lung transplantation is a viable therapeutic option for many patients with end-stage pulmonary disease. Other intrathoracic surgical procedures have a well documented incidence of phrenic nerve dysfunction, although the incidence after lung transplantation has not been studied.

METHODS

Thirty-one patients who underwent lung transplantation were evaluated for evidence of phrenic nerve dysfunction and subsequent recovery. Risk factors contributing to the incidence of injury were examined. Phrenic nerve injury was defined by two separate diagnostic tests (Transcutaneous Phrenic Nerve Conduction Studies and Fluoroscopic evaluation of diaphragmatic movement) used in combination.

RESULTS

Of the 27 patients who were completely evaluated after the operation, eight had defining criteria for nerve injury--an incidence of 29.6%. Of those affected, the majority of injuries (89%) resulted in complete paralysis of the affected hemidiaphragm. The highest incidence of injury occurred in patients who underwent bilateral single lung transplantation (41%), with the right phrenic nerve being injured most often (78%). Fortunately, no significant postoperative morbidity was attributable to the occurrence of phrenic nerve injury when compared with those patients who did not sustain injury.

CONCLUSIONS

The analysis of possible risk factors resulted in the hypothesis that the likely mechanism of injury in these patients was due to stretching or direct instrumentation of the nerve, and thus measures should be instituted to minimize the possibility of injury.

Lack of association between cassava consumption and tropical pancreatitis syndrome

Previous studies suggesting an association between use of tubers of cassava and tropical pancreatitis have been weak and conflicting. To test a possible association the cassava consumption of 40 consecutive cases of tropical pancreatitis syndrome were compared with age-matched and sex-matched healthy hospital visitors. The sociodemographic characteristics of the two groups were comparable. There was no association between cassava consumption and tropical pancreatitis syndrome (odds ratio = 0.56; 95% confidence interval = 0.21-1.45). Controlling for the possible confounding effects of low socio-economic status and vegetarian diet did not alter the odds ratio. Testing for interaction also failed to show any effect modification of the association of cassava by economic status, chilli consumption or vegetarian diet. A significantly higher number of cases gave a positive family history of diabetes compared to the controls (odds ratio = 4.11; 95% confidence interval = 1.04-16.30; P = 0.04). In this case-control study which had sufficient power to detect an odds ratio > or = 3.5, there was no association between cassava consumption and tropical pancreatitis syndrome.