Desmoid fibromatosis-a diagnostic dilemma

PURPOSE

Desmoid fibromatosis in head and neck is infrequent and poses a significant challenge to the clinicians due to its non-specific characteristics.

METHODS

This case report focuses on a 69-year-old male who presented to a tertiary healthcare center in Karnataka, India with a swelling in the oral cavity.

RESULTS

Despite initial suspicions of malignancy based on clinical examination and findings on computed tomography imaging, subsequent histopathology and immunohistochemistry revealed an unexpected finding.

CONCLUSION

The case highlights the importance of clinical suspicion and histopathological evaluation as well as the need for greater awareness to facilitate early diagnosis and appropriate management of desmoid fibromatosis. We also present a literature review of varied presentations of desmoid tumors afflicting various subsites of the head and neck.

Colorectal Carcinoma With Sarcomatoid Components: Report of 15 Cases and Literature Review of an Exceedingly Rare Carcinoma Subtype

Colorectal carcinoma with sarcomatoid components (which includes so-called carcinosarcomas and sarcomatoid carcinomas) is a rare subtype with 50 reported cases in the literature and overlapping criteria with undifferentiated carcinoma. We collected and described 15 cases from 10 men and 5 women, with a mean age of 66 years. Symptoms included abdominal pain and gastrointestinal bleeding. Most tumors presented in the rectosigmoid region, with a mean size of 8.2 cm. The sarcomatoid component, on average, represented 58% of the tumors and took many forms, including spindled (10 cases), anaplastic (9 cases), and rhabdoid (3 cases); one case showed osteoid matrix. Tumor budding was usually high, and tumor-infiltrating lymphocytes were usually low. The sarcomatoid component was keratin-positive in 10 cases. One case showed loss of mismatch repair protein expression, and 2 cases showed SMARCA4 loss (1 also with SMARCA2 loss). Molecular testing identified mutations in KRAS (n=1), NRAS (n=2), BRAF (n=2), APC (n=1), and TP53 (n=1) in a few cases. Tumors often presented at advanced stage, with 11 cases pT4, 9 cases with nodal metastases, and 7 cases with distant metastases. Follow-up was available for 10 cases (median: 2 months), with 2 alive without disease, 3 alive with disease, and 5 dead. Our findings roughly corresponded with those in previously reported cases. Colorectal carcinoma with sarcomatoid components is rare and aggressive, with a poor prognosis for many patients. We suggest that spindled cells, anaplasia, heterologous elements, and/or a component with definable sarcomatous lineage be used to distinguish colorectal carcinoma with sarcomatoid components from undifferentiated carcinoma.

Multifocal intraosseous pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma: A rare presentation of an uncommon tumor

ABSTRACT

Pseudomyogenic hemangioendothelioma (PHE) is an uncommon mesenchymal neoplasm of intermediate malignant potential showing endothelial differentiation. Around 20 cases of primary osseous PHE have been reported to date. A 16-year-old boy presented with complaints of pain in his right leg. Imaging revealed multifocal intramedullary and cortical-based lytic lesions involving long and small bones. Microscopic examination revealed plump, spindled cells arranged in fascicles and admixed "epithelioid" and "rhabdoid" cells sans vasoformative areas. By immunohistochemistry, the lesional cells were reactive for AE1/AE3, CD31, Erg, Fli1, and SMA, while immunonegative for CD34, myogenin, and S100. Nuclear expression of the INI1/SMARCB1 protein was retained. PHE is a rare entity, more so as a primary osseous lesion; therefore, awareness of the presence of this entity in the bone is the key to making a diagnosis. We discuss its clinicopathological features, differential diagnosis, and an attempt a short review of the literature.

Effect of aqueous extract of Trigonellafoenum-graecum L. seeds on Acetic acid- induced Ulcerative colitis in rats

Background: Ulcerative colitis (UC) is an inflammatory bowel disorder affecting the colonic mucosa, characterized by intense inflammation and mucosal damage. The present study aimed to evaluate the protective effect of the Trigonellafoenum-graecum L. (TFG) seeds in acetic acid-induced UC in rats. Materials and Methods: Male rats (n=30) were distributed into 5 groups as normal control, UC, standard, and two test groups. Colitis was induced by acetic acid in all the groups except the normal control group. Normal control and UC group received distilled water, the standard group was administered sulfasalazine at 100mg/kg body weight (bw), and test groups, TFG-I, and TFG-II received TFG seed extract at 500 and 1000 mg/kg bw, respectively. The duration of treatment was 7 days, and colitis was induced on day 8. Animals were sacrificed on day 9 and colonic tissue was dissected and collected for biochemical, molecular, and histological analysis. Results: The disease activity index score in standard, TFG-I, and TFG-II (3.33±0.21, 2.66±0.21, and 3.50±0.22) was significantly lesser (P<0.05) than scores in the UC group (4±0.01). The macroscopic score indicating the intensity of mucosal inflammation was significantly decreased (P≤ 0.01) to4.0±0.25, 3.16±0.30, and 3.83±0.40 in standard, TFG-I, and TFG-II groups, respectively compared to the UC group (4.66±0.21). Similarly, there was a significant reduction (P≤0.05) in histological scores of the standard, TFG-I, TFG-II (3.5±0.34, 1.25±0.34, 3.25±0.34) groups compared to the UC group (4.75±0.34). Biochemical assessment in the standard and test groups showed significant increase (P<0.05) in total protein, reduced glutathione (GSH), catalase (CAT), superoxide dismutase (SOD) levels whereas significant reduction (P<0.01) in malondialdehyde (MDA) levels compared to UC group. The pro-inflammatory cytokine TNF-α levels were significantly decreased (P<0.01) in standard, TFG-I, and TFG-II (-1.75±0.007, -0.27±0.17 and -0.51±0.002) when compared to the UC group (0.20±0.02). Conclusion: The study demonstrates the ability of TFG seeds in reducing the inflammatory and oxidative stress induced mucosal damage in acetic acid-induced UC in rats.

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.

Clinicopathological Study of Primary Gastrointestinal Lymphoma from a Tertiary Care Hospital in Southern India

Introduction: Primary Gastrointestinal Lymphoma (PGIL) is a heterogeneous disease in terms of patient characteristics, site, histologic types and treatment modalities. Although rare disease, it is the most common site for extranodal lymphomas accounting for 10-15% of all non-Hodgkin lymphoma and 30-40% of all extranodal lymphoma. Aim: To study the different types of PGIL and its anatomic distribution along with its association with the clinical outcomes. Materials and Methods: This was a retrospective study conducted in Department of Pathology of a tertiary care hospital, South India over a period of five years (2009 to 2013). A total of 61 cases of PGIL were identified, which included both resected surgical and endoscopic biopsy specimens. Histopathological classification of all cases was done based on morphologic and immunophenotypic criteria according to latest World Health Organisation (WHO) 2008 classification. Anatomic distribution of various types of lymphoma and associated clinical features were studied. The cases were then followed-up and survival analysis was also done. Descriptive statistical analysis methods were used to analyse the data. Overall Survival (OS) rates were calculated using Kaplan Meier method for 33 cases. Results: There was predominance of men with peak incidence in 7th decade. Abdominal pain was the commonest presenting symptom seen in 77% of the cases. The most common site of involvement was stomach (41%) followed by large intestine (37.7%). All cases of primary GI lymphomas were of non-Hodgkin type. B cell lymphomas (n=54; 88.5%) were more frequent than T cell lymphomas (n=7; 11.5%). Diffuse Large B Cell Lymphoma (DLBCL) was the most common subtype accounting for 67.2% of cases (n=41) followed by MALT lymphoma (n=9; 14.8%). Followup was possible in 33 cases out of which 20 patients (32.8%) died with a median overall survival period of 13 months (95% CI, 7.8-18.2). The five-year overall survival (OS) for 33 patients who were followed-up was 67.2%. Conclusion: Diagnosing PGILs correctly according to the recent WHO classification is important so that correct treatment protocols can be followed.

Immunohistochemical Expression of CDX2 in Gastroesophageal Junction Biopsies: An Emerging Marker for Early Intestinal Differentiation of Barrett’s Metaplasia

Introduction: Histological diagnosis of Barrett’s oesophagus (BE) in mucosal biopsies is challenging and affected by multiple factors. Goblet Cells (GCs) are not distributed uniformly in BE and is dependent on sampling probabilities. Furthermore, GC Mimickers (GCM) are potential pitfalls in the diagnosis of Intestinal Metaplasia (IM). Alcian Blue (AB) stain has been extensively used in detection of GC’s although it has the limitation of low specificity with positive staining for GCM. Recently, CDX2 Immunohistochemistry (IHC) is reported to be highly sensitive and specific marker which has shown to identify early intestinal phenotype even in absence of diagnostic GCs and especially pertaining to conditions where characteristic morphological changes are not apparent. Aim: To study the histomorphology of non neoplastic and neoplastic lesions of the Gastroesophageal Junction (GEJ) in reflux patients and evaluate the diagnostic role of CDX2 IHC versus AB stain in detecting IM. Materials and Methods: This retrospective study was conducted in Department of Pathology at Kasturba Medical College, Manipal, Karnataka, India, on 55 patients with clinical features of reflux and adequate records of GEJ biopsies, diagnosed over 6 years from January 2012 to August 2018. Clinical presentation, endoscopic findings and histomorphology (18 parameters) were recorded. AB stain and CDX2 (IHC) were performed and evaluated in all cases. A detailed histological evaluation was done for all cases and subsequently, sensitivity, specificity, positive predictive value and negative predictive value of CDX2 IHC to identify early intestinal differentiation was calculated. Results: Of 55 cases, 28 were BE, 19-Reflux oesophagitis (RE) and 8-adenocarcinoma. Heart burn and chest pain were the most common clinical presentations of BE. Endoscopy of BE predominantly showed hiatus hernia with tongue like projections of the gastric mucosa. Histologically, intraepithelial eosinophils and spongiosis were more common features in RE. Barrett’s oesophagus showed columnar epithelium with multilayering, presence of IM with GC (1-20/crypt) along with sub-squamous buried epithelium and splitting of muscularis mucosa. By IHC, as compared to AB; CDX2 IHC was more sensitive (100% vs 78.2%) and specific (96.5% vs 82.6%) for detecting an intestinal phenotype. The five cases (22%) of BE contained only GCM in the biopsy, were CDX2 negative but showed a false positivity for AB. In BE, CDX2 additionally highlighted positivity in non GC columnar cells which were AB negative. The CDX2 showed diffuse positivity in dysplasia with focal strong to absent expression in adenocarcinoma. Conclusion: The CDX2 efficiently differentiated between GC and pseudo GC. Its presence in the absence of AB in non GC columnar cells suggests that it effectively detects intestinal phenotypic features even before morphological features are evident.

Anterior abdominal wall metastasis following curative resection and chemoradiation of rectal cancer masquerading as a desmoid tumour: A clinical conundrum

Desmoid tumour of the anterior abdominal wall (rectus sheath) commonly occurs in women post abdominal surgery. Metastasis from colorectal cancer to the anterior abdominal wall, on the other hand, is rare and produces a complex management dilemma. This Case study presents a 57-year-old woman who received a curative laparoscopic low anterior resection and adjuvant chemoradiation in 2013. Seven years later, she presented with an asymptomatic anterior abdominal wall lump. Clinically, the lump appeared to be a desmoid tumour. A wide local excision of the lump was carried out and the final histopathology showed a metastatic lesion (adenocarcinoma). With adjuvant chemotherapy, the patient is now disease-free and doing well. A possibility of distant metastasis must be kept in mind for all patients, even when they have undergone curative resection with adjuvant chemoradiation for colorectal cancer.

Primary cervical lymph nodal leishmaniasis

Leishmaniasis, an endemic disease in several parts of India, is a parasitic disease caused by protozoa and transmitted by the sandfly. Although cutaneous and visceral varieties are common, isolated lymph nodal involvement is extremely rare, and the diagnosis is often delayed owing to its uncommon presentation and lack of awareness of this possibility. We present a 72-year-old woman with asymptomatic right facial lymphadenopathy which on biopsy revealed leishmaniasis and responded well to drug therapy.

Rectal actinomycosis mimicking malignancy

Abdominal actinomycosis is a chronic suppurative infection caused by Actinomyces species. The ileo-cecal region is most commonly affected, while the left side of the colon is more rarely involved. The infection has a tendency to infiltrate adjacent tissues and is, therefore, rarely confined to a single organ. Presentation may vary from non-specific symptoms and signs to an acute abdomen. We present a 56-year-old male who underwent a colonoscopy for complaints of bleeding per rectum that showed an ulcero-proliferative lesion at the recto-sigmoid junction that seemed like malignancy. Multiple biopsies done were reported this lesion to be Actinomycosis. He responded well to medical management that avoided a major surgical procedure.

Histopathological Spectrum of Meningiomas with Emphasis on Prognostic Role of Ki67 Labelling Index

BACKGROUND & OBJECTIVE

Meningiomas are the most frequently encountered primary non-glial tumors of the central nervous system (CNS). The Ki67 labelling index (Ki67LI) is a proliferation marker that may prove useful in determining the histological grade. This study aims at: 1) Studying the frequency, grade and histomorphological spectrum of meningiomas, 2) Evaluating 20 histological parameters and determining its utility in grading meningiomas and 3) Comparing the Ki67LI in the various subtypes and WHO grades.

METHODS

The cases of meningiomas diagnosed in our Department from June 2009 to May 2014 were included. The clinical details, grade and 20 histological parameters: mitosis, vesicular nuclei, macronucleoli, nuclear pleomorphism, scattered bizarre nuclei, hypercellularity, sheeting, lymphocytes, small cell change, foam cells, ossification, necrosis, papillary change, lipidization, psammoma bodies, vascularization, brain invasion, dural invasion, bone invasion and other soft tissue invasion were recorded for each case. The average and highest Ki67LI was recorded as percentage and number per high power field.

RESULTS

A total of 175 cases of meningioma were included: grade I (145), grade II (30). Atypical histological features like hypercellularity, sheeting, etc. were common in grade II tumors. Increased vascularity, lymphocytes and psammoma bodies were common in grade I tumors. Ki67LI (highest) ranged from 1-6% in grade I and 5-12% in grade II tumors.

CONCLUSION

Among different methods showing mitotic activity, Ki67% (highest) was the most statistically significant LI in differentiating grade I and grade II tumors. The median Ki67% (highest) was 4% for grade I and 7% for grade II tumors.

Oncocytic Variant of Medullary Thyroid Carcinoma - A Case Report

Medullary thyroid carcinoma (MTC) is a rare tumor arising from parafollicular C-cells. The oncocytic variant of MTC is an extremely rare diagnosis, with less than 20 cases reported. Here we present the case of a 36-year-old male patient with complaints of neck swelling and dysphagia. On fine needle aspiration cytology (FNAC), a Hürthle cell neoplasm was suggested. Finally with histopathology and immunohistochemistry (IHC), a diagnosis of MTC oncocytic variant was established. This tumor can be easily misdiagnosed for any thyroid Hürthle cell lesions. An accurate diagnosis is important because MTC has different treatment protocols, and its oncocytic variant is expected to be associated with poorer patient survival. Thus, the oncocytic variant of MTC is a difficult diagnosis on FNAC. Histopathology and rel- evant IHC markers are necessary for a correct diagnosis.

Toxic Effects of Different Doses of Cyclophosphamide on Liver and Kidney Tissue in Swiss Albino Mice: A Histopathological Study

Background

Cyclophosphamide (CPA) is an anti-cancer drug, used in chemotherapy. This is a toxic drug which targets the cancer cells and also the normal cells of the body. The original compound is inactive in vitro and exercises its biologic action through metabolites, chiefly phosphoramide mustard. The objective is to study the harmful effects of this drug on liver and kidney tissues.

Methods

To study the effect of cyclophosphamide on histology of liver and kidney, 40 adult male mice were taken and divided into two groups: control and test. Those in the test group were injected with the drug at doses of 100, 200, 250 mg/kg body weight. They were then sacrificed on day 7, 28 and 42. The liver and kidney tissue was processed, sectioned and stained with Haematoxylin and Eosin.

Results

Pathological changes were seen in the tissue within 7 days in high doses and after 28 days in low doses. As the dosage and the days administered increased, the changes were prominently seen and widespread. Pathology ranging from mild infiltration to necrosis and finally cytolysis were seen in liver and kidney tissue.

Conclusion

Our study has demonstrated the effect of a progressive increase in dosage of cyclophosphamide in albino mice, and pathological alterations were observed in histology of liver and kidney by sequentially increasing both the dosage and duration of treatment. Subsequently, regular monitoring of liver and kidney function tests in patients undergoing chemotherapeutic regimen with administration of ahepato and nephroprotective agent becomes vital.

Mucinous Tubular and Spindle Cell Carcinoma: A Review of Histopathology and Clinical and Prognostic Implications

Mucinous tubular and spindle cell carcinomas are rare kidney tumors with generally indolent behavior. As the name suggests, classic histomorphology reveals bland spindle cells, tubules, and mucinous stroma. Uncommon histologic features include mucin-poor stroma, high nuclear grade, cellular pleomorphism, and presence of necrosis. Rare cases can show aggressive growth and distant metastasis. Mucinous tubular and spindle cell carcinoma has characteristic chromosomal abnormalities and the molecular signature remains the same, irrespective of the varied histomorphology.

Myeloid sarcoma: A clinicopathological study with emphasis on diagnostic difficulties

BACKGROUND

Myeloid sarcoma (MS) is a rare tumor composed of proliferation of myeloid precursors at extramedullary sites. They can arise de-novo or in association with hematological malignancies, most commonly acute myeloid leukemia. Clinically, it can masquerade as an abscess, cutaneous ulcer, or mass lesion. Morphologically, MS can mimic a variety of small round cell tumors including lymphomas and rhabdomyosarcoma.

AIMS

(1) To study the clinical presentations and laboratory findings in patients with MS; (2) to revisit the histomorphological findings and the differential diagnosis of MS; (3) to evaluate the diagnostic role of immunohistochemistry (IHC) and determine the useful markers for accurate diagnosis of MS.

MATERIALS AND METHODS

We reviewed cases of MS reported in our institution over a 10-year period from January 2004 to December 2013. The clinical presentations, laboratory data, and histopathological and immunohistochemical findings were studied.

RESULTS

There were nine cases in our database, none of which were clinically suspected to be MS. Age ranged from 3 to 55 years, with a slight female preponderance. Cervical lymph nodes were the most common site involved. Histologically, the common finding was the presence of medium- to large-sized cells with fine granular chromatin, small nucleolus, and scant cytoplasm along with scattered eosinophil precursors. Myeloperoxidase was the most useful IHC marker. All cases were also positive for leukocyte common antigen contributing to the diagnostic confusion with lymphoma.

CONCLUSION

The possibility of MS should be considered when dealing with unusual lymphoma-like neoplasms that cannot be categorized as any of the Non-Hodgkin lymphoma subtypes.

Hematolymphoid neoplasms in effusion cytology

Background:

Hematolymphoid neoplasms (HLNs) presenting as body cavity effusions are not a common finding. They may be the first manifestation of the disease. A diagnosis on effusion cytology may provide an early breakthrough for effective clinical management.

Aims:

Study the cytomorphology of HLNs in effusion cytology, determine common types, sites involved and uncover useful cytomorphologic clues to subclassify them.

Materials and Methods:

Twenty-four biopsy-proven HLN cases with malignant body cavity effusions and 8 cases suspicious for HLN on cytology but negative on biopsy are included in this study. Effusion cytology smears were reviewed for cytomorphological features: cellularity, cell size, nuclear features, accompanying cells, karyorrhexis, and mitoses.

Results:

Diffuse large B-cell lymphoma (37%) was the most common lymphoma type presenting as effusion followed by peripheral T-cell lymphoma (25%). Pleural effusion (75%) was most frequent presentation followed by peritoneal effusion (20.8%). Pericardial effusion was rare (4.1%). The common cytologic features of HLNs in effusions: high cellularity, lymphoid looking cells with nuclear enlargement, dyscohesive nature, and accompanying small lymphocytes. Mitosis and karyorrhexis were higher in high-grade HLNs when compared to low-grade HLNs. Myelomatous effusion showed plasmacytoid cells. Very large, blastoid looking cells with folded nuclei, high N: C ratio, and prominent nucleoli were seen in leukemic effusion.

Conclusion:

HLNs have characteristic cytomorphology and an attempt to subclassify them should be made on effusion cytology. Reactive lymphocyte-rich effusions cannot be distinguished from low-grade lymphomas based on cytomorphology alone. Ancillary tests such as immunocytochemistry, flow cytometry, and/or molecular techniques may prove more useful in this regard.

Cystic Sertoli-Leydig Cell Tumour in a Postmenopausal Woman with Absent Virilising Symptoms: A Diagnostic Challenge

A 60-year-old postmenopausal woman, presented with a left ovarian cystic mass with mildly elevated CA125 levels. An intraoperative frozen section showed oedematous ovarian stroma with interspersed large aggregates of spindle shaped stromal cells. Subsequently, the excised specimen was reported as Sertoli-Leydig Cell Tumour (SLCT) of intermediate differentiation. The leydig cells were identified in the imprint smears, but were misinterpreted as luteinized cells. The lack of tubular differentiated cells in frozen section had contributed to the misdiagnosis. Immunohistochemistry (IHC) played an important diagnostic role in the absence of clinical suspicion and lack of virilising features that are classically described in association with SLCTs. This case is unusual, as the tumour was seen in a postmenopausal woman in the absence of virilising symptoms. The cytomorphological features, IHC findings and the reasons for misdiagnosis are discussed in this case report.

Painful erythematous, infiltrated papulonodules in a middle aged man

Cutaneous leiomyomas (CL) often present as painful tumors in the skin. Herein we report an adult man who presented with multiple, erythematous papulonodules in both segmental and non-segmental distribution.

Cytomorphologic Diversity of Papillary Thyroid Carcinoma

Introduction:

Cytologic features of papillary thyroid carcinoma (PTC) have been extensively documented in literature. However, PTC variants can prove to be diagnostically challenging on fine needle aspiration cytology (FNAC).

Aims:

To study the FNAC features of PTC and its variants and explore the causes for misdiagnosis.

Materials and Methods:

This is a retrospective study. All cases of histopathologically (HP) confirmed cases of PTC during a 2-year period (January 2012 to December 2013) with presurgical FNAC were included. The cytologic findings and FNAC diagnosis of each case were documented and compared with the HP report. The misdiagnosed cases were reviewed to look for any cytological clues and reasons for misdiagnosis.

Results:

A total of 58 cases were included. The overall diagnostic accuracy was 55.6% which improved to 64.8% on including suspicious for PTC cases. Follicular variant was the most misdiagnosed variant; 41.2% of the cases were called follicular neoplasm. Oncocytic variant showed cells with abundant eosinophilic cytoplasm along with bizarre giant cells. Warthin tumor-like variant showed cells with moderate eosinophilic cytoplasm with close apposition of lymphocytes in a background of reactive lymphocytes and lymphoid tangles. Cystic variant was paucicellular. Columnar cell variant showed tall columnar cells with nuclear stratification. Cribriform–morular variant showed syncytial sheets of cells and hyaline globules.

Conclusions:

PTC variants have distinct cytomorphological features. In some variants (follicular, columnar cell), nuclear grooves and inclusions may not be apparent, contributing to the diagnostic confusion. Benign nodule adjacent to the tumor can dominate the FNAC smear and lead to misdiagnosis.

Large Gastric Teratoma: A Rare Intra-abdominal Mass of Infancy

Amongst the varied, diverse causes of intraabdominal masses in infancy and early childhood, gastric teratomas (GTs) account for a very small proportion. A worldwide literature search reveals only around one hundred cases of GT and also supports the fact that its preoperative diagnosis remains elusive. Here we report the case of a two-month-old male who presented to the pediatric surgery outpatient department of Kasturba Medical College and Hospital, Karnataka, India, with progressive distension of abdomen since birth. Clinically, a large firm, non-mobile and non-tender mass involving all four quadrants of the abdomen was seen. Ultrasound revealed a large solid-cystic mass with internal septations extending from the epigastrium up to the pelvis. Computed tomography revealed a large intraperitoneal fat containing solid-cystic mass lesion showing curvilinear and chunky areas of calcification, with the mass focally indenting the posterior gastric wall and showing focal polypoidal intragastric extension. Exploratory laparotomy revealed a large cystic tumor with a solid component, arising from lesser curvature of the stomach, showing focal intraluminal extension across the posterior gastric wall, and occupying the whole lesser sac and abdominal cavity. The tumor was excised in toto along with the body of the stomach. Histopathological examination showed mature tissue derived from all three germ cell layers and confirmed the diagnosis of mature gastric teratoma. The patient was disease free at one-year follow-up.

Primary Paratesticular Lymphoma with Testicular Sparing: Account of an Unusual Scrotal Mass

Tumours of the testicular adnexa include a heterogeous group of mesothelial, mesenchymal and germ cell tumours. Adenomatoid tumour, pseudosarcomatous myofibroblastic proliferations and rhabdomyosarcoma are the more frequently encountered neoplasms. Lymphoma/leukemic infiltration secondary to testicular involvement or primary tumour elsewhere is not unusual. However, Primary Para-Testicular Lymphoma (PPTL) involving spermatic cord and/or epididymis with sparing of the testicular parenchyma is extremely rare. Accurate staging and typing is crucial for effective management. We present a rare case of Diffuse Large B Cell Lymphoma (DLBCL) involving the left paratesticular tissue with testicular sparing in a young immunocompetant male patient.

Uterine malignant mixed Müllerian tumor camouflaging as pelvic sarcoma

Malignant mixed Müllerian tumors (MMMTs) of the uterus are rare, aggressive tumors that present at an advanced stage and are associated with poor prognosis. They arise as a result of divergent carcinomatous and mesenchymal differentiation of tumor stem cells. Rarely one of the components may predominate contributing to diagnostic confusion. We present a rare case of uterine MMMT arising in endometrial adenocarcinoma, camouflaging as pelvic sarcoma with a major sarcomatous component. This case report highlights the importance of thorough tissue sampling and the role of immunohistochemistry (IHC) in arriving at an accurate diagnosis. This case also demonstrates the conversion theory of histogenesis of MMMTs.

Juvenile Granulosa Cell Tumour: Anaplastic Variant with Omental Deposits

Juvenile Granulosa Cell Tumour (JGCT) of ovary represents a small fraction of all primary ovarian malignancies. It is a subtype of granulosa cell tumour that is almost always found during the first three decades of life. Histologically, it differs from the typical adult type of granulosa cell tumour. It accounts for 5-15% of all granulosa cell tumours, majority being unilateral. Herein, we describe an unusual histopathological variant of JGCT with numerous large cystic spaces, anaplasia and focal syncytiotrophoblast like giant cells.

Primary extra-renal clear cell renal cell carcinoma masquerading as an adrenal mass: A diagnostic challenge

We present the first case of a nonmetastasizing renal cell carcinoma (RCC) masquerading as an adrenal mass, in the presence of normal bilateral native kidneys, in a young adult. The possibility of this mass developing in a supernumerary kidney was ruled out, since no identifiable renal tissue, pelvis or ureters was seen within the mass, nor was any separate systemic arterial supply to the mass seen. The diagnosis of extra-renal clear cell RCC was based on cyto-morphological features, further confirmed by immunohistochemistry findings. The origin of this extra-renal clear cell renal cell is proposed to be from the mesodermal embryonic rests.

Testicular non-Hodgkin's lymphoma presenting in a young adult

We report a case of a 27-year-old man who presented with a slowly growing left testicular swelling associated with mild pain over a period of 3 months. He was evaluated by his family physician with scrotal ultrasound and testicular tumour markers. He was diagnosed and treated as epididymo-orchitis and managed with antibiotics. When he later presented to us, he had an enlarged left testis with normal spermatic cord. Scrotal Doppler evaluation showed a globally enlarged left testis and epididymis with increased vascularity in the left testis, with the right testis being normal. Testicular tumour markers were normal. Fine-needle aspiration cytology of the left testis was suggestive of lymphoma. Exploration through an inguinal approach was carried out and a Chevassu manoeuvre with frozen section study was performed, which was reported as non-Hodgkin's lymphoma. Left radical orchidectomy was performed. Histopathology reported diffuse large B-cell lymphoma, of a germinal centre type. Contrast CT of the abdomen, chest and brain were normal. Sperm cryopreservation was carried out. The patient was started on chemotherapy with cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone (CHOP) regime.

BALToma masquerading as pulmonary tuberculosis

A 53-year-old man with a significant smoking history presented with chronic cough, exertional breathlessness, intermittent fever, weight loss and anorexia. A review of his past medical records revealed he was diagnosed to have sputum smear-positive pulmonary tuberculosis 5 years earlier, for which he had received multiple courses of incomplete antitubercular therapy. This time, though he was primarily suspected to have active pulmonary tuberculosis, lack of microbiological evidence and further investigations including histopathological evaluation of lung lesions confirmed a diagnosis of Marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALToma/BALToma). The patient was managed with radical radiation therapy to which he responded well.

Mixed malignant germ cell tumour of third ventricle with hydrocephalus: a rare case with recurrence

Malignant Germ Cell Tumours (GCTs) are rare, accounting for 3% of intracranial tumours and just like their extracranial counterparts represent a wide array of disease. Combination of Germinoma with Teratoma is very rare. Here in, we describe a case of Mixed Malignant Germ cell tumor of third ventricle with recurrence with emphasis on histopathological and radiological findings.

Desmoplastic small round cell tumour in a young woman with widespread metastasis and peritoneal caking

Desmoplastic Small Round Cell Tumour (DSRCT) is a rare, highly aggressive, mesenchymal tumour that arises from the peritoneal cavity. It is commonly seen in adolescent and young adult males and its occurrence in females is uncommon. We are reporting here a rare case of DSRCT in a young woman, which clinically masqueraded as an ovarian malignancy, with metastasis to liver, lung, spleen and peritoneum. The cytologic findings, Histomorphological and immunohistochemical features have been discussed, with a brief review of literature.

Adrenal inflammatory myofibroblastic tumour

A rare case of large adrenal mass which was non-functioning is presented. It is difficult to make preoperative diagnosis in these cases as the imaging findings are non-specific. Radical excision is mandatory as preoperative malignancy cannot be ruled out.

Multiple neural fibrolipomas with macrodactyly

Neural fibrolipoma is an uncommon tumor-like lesion that involves the upper extremity and usually arises in the median nerve. It is associated with macrodactyly in one-third of the cases. A 3-year-old girl presented with increasing size of fingers of both the hands since birth. Clinical examination revealed macrodactyly of two fingers of the right hand and three fingers of the left. Surgical reduction was performed and microscopy of the biopsy specimen established the diagnosis of neural fibrolipoma. Knowledge of the clinicopathological features is necessary for accurate diagnosis and treatment of this rare entity.

Ewing's sarcoma of the lesser sac masquerading as a pancreatic tumor

Extraosseous Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET) is an uncommon, aggressive, and malignant tumor with a poor patient outcome. Its occurrence in the lesser sac is a rare event and to the best of our knowledge, has not been previously described. The present case was clinically and radiologically misdiagnosed as a pancreatic tumor/gastrointestinal stromal tumor. Histopathology revealed a tumor with "small round cells" that were positive for CD99, confirming the diagnosis of ES/PNET. This report highlights the importance of considering Ewing's sarcoma in the differential diagnosis of intraabdominal, extraintestinal masses.

Adenomatoid tumor of tunica albuginea mimicking seminoma on fine needle aspiration cytology: a case report

BACKGROUND

Adenomatoid tumor is one of the most common primary neoplasms of the paratesticular area. The epididymis is the most common site of involvement; however, it can also arise from the tunica albuginea, spermatic cord, tunica vaginalis and testis. Fine needle aspiration cytology (FNAC) is being increasingly used for lesions in the paratesticular area. Review of the literature showed very few reports on the cytologic features of adenomatoid tumor. We report the cytologic features of a case of adenomatoid tumor arising from testicular tunica albuginea.

CASE

A 40-year-old man presented with right-sided scrotal swelling of 1 years' duration. FNAC of the lesion showed highly cellular smears composed of clusters of monomorphic plump cells with oval eccentric nucleus, fine granular chromatin, small single nucleolus and abundant pale to vacuolated cytoplasm. The background showed "tigroid substance," classically described in seminoma. Histopathologic examination confirmed the diagnosis as adenomatoid tumor of tunica albuginea.

CONCLUSION

FNAC of an adenomatoid tumor poses a diagnostic challenge when the tumor arises from sites other than the epididymis because they can be mistaken for intratesticular tumors. It is thus important to consider this tumor in the differential diagnosis of scrotal swellings.

Oncocytic variant of mucoepidermoid carcinoma of submandibular gland: an unusual clinical and morphological entity

In this case report we describe a rare tumor--Oncocytic variant of Mucoepidermoid carcinoma of the submandibular salivary gland with a review of the literature. Oncocytic metaplasia in salivary glands is a benign change that is associated with increasing age and also seen in a few salivary gland neoplasms', which include oncocytoma, Warthin's tumor, and the rare, oncocytic carcinoma. Oncocytic differentiation in mucoepidermoid carcinoma (MEC) is uncommon. Only twelve well-documented cases of oncocytic MEC have been reported previously all of which occurred in the parotid gland. To the best of our knowledge this is the first case of oncocytic mucoepidermoid carcinoma involving the submandibular salivary gland. The recognition of this entity is important, since most of the other primary oncocytic lesions of the salivary gland are benign.