Mixed mucinous adenocarcinoma/large cell neuroendocrine carcinoma of the uterine cervix: case report and molecular characterization of a rare entity

Mixed neuroendocrine-non-neuroendocrine carcinomas of the cervix are rare and generally aggressive diseases. They often present at an advanced stage with hematogenous or lymphatic metastases. The prognosis is poor, mostly influenced by the neuroendocrine component. Unfortunately, the rarity of the disease caused a lack of information about its pathogenesis and molecular landscape. The latest guidelines recommend a multimodal approach that usually includes radical surgery, platinum/etoposide-based chemotherapy, or chemoradiation. Here, we are presenting a case of metastatic mixed adenocarcinoma-large cell neuroendocrine carcinoma of the cervix in a 49-year-old female patient. The molecular characterization of the lesion highlighted the ubiquitous presence of human papillomavirus-18 DNA both in the adenocarcinomatous and the neuroendocrine components, suggesting a role for the virus in the pathogenesis. Moreover, a different set of mutations was detected in the two parts, thus ruling out a possible clonal evolution of the neuroendocrine component from the adenocarcinoma one. More studies are needed to clarify the molecular landscape of these rare lesions and identify putative targets for therapy.

Parotid metastasis of renal cell carcinoma, mimicking primary clear cell oncocytoma: report of a case and brief review of the literature

Malignancies of the parotid gland are relatively uncommon, accounting for only 3-6% of all head and neck cancers. Most of them are primary neoplasms, metastases are uncommon. Renal cell carcinoma (RCC) represents 3% of adult malignancies, the clear cell type comprises up to 70% of all RCC. RCC has an unpredictable behavior and the unique potential to metastasize to nearly every organ in the body. Though not as frequent, metastatic RCC to the head and neck has been identified in the thyroid, salivary glands, skull base, sinuses, pharynx, tonsils, tongue, lip and skin. Metastasis to the parotid gland is very rare. Here, we report the case of a clear cell type RCC metastatic to the parotid gland and mimicking a primary clear cell oncocytoma. Differential diagnoses and a brief review of the literature are added.

Lymphatic Vascularization in Prostate Adenocarcinoma: Correlation with Tumor Grade, Androgen Withdrawal and Prognosis

BACKGROUND/AIM

The lymphatic system plays an active role in the metastatic process by directly facilitating recruitment of cancer cells into the vessels. The present study aimed to assess the lymphatic vessel area and the lymphatic vessel density in prostate adenocarcinoma and to correlate these parameters with patients prognosis and outcome.

PATIENTS AND METHODS

The lymphatic vessel area and the lymphatic vessel density were evaluated using the D2-40 monoclonal antibody in 153 patients with prostate adenocarcinoma who had been treated by radical prostatectomy, in comparison to 152 non-neoplastic controls. We also estimated the lymphatic vessel area in a set of 139 patients who had undergone radical prostatectomy after neoadjuvant treatment with combined androgen blockade.

RESULTS

Lymphatic vessel area was higher in periglandular than in interglandular stroma, inversely correlated with tumor differentiation (in untreated patients) and was influenced by hormonal treatment. Lymphatic vessel density was not significantly different between the non-tumoral and the high-grade prostate intraepithelial neoplasm compartment, whereas it was higher in tumoral than in non-tumoral compartments, mainly in periglandular stroma. In addition, it increased in parallel to the tumor grade progression and positively correlated with all the main prognostic factors of prostate adenocarcinoma.

CONCLUSION

The evaluation of lymphatic vessel density on radical prostatectomy with positive nodes may help to discriminate those patients at higher risk of developing an aggressive disease, which may need early androgen deprivation therapy to delay the worsening of clinical disease.

Unusual presentation of metastatic adenoid cystic carcinoma: a challenge in aspiration cytology of the thyroid

INTRODUCTION

Adenoid cystic carcinoma is a malignant neoplasm most commonly originating in the salivary glands. Its occurrence elsewhere is rare and its metastasis to the thyroid gland has been described only once.

CASE REPORT

We describe the case of a 66-year-old man who presented for a swelling in the midline neck of six months duration. A solitary palpable nodule was identified in the isthmic region of the thyroid. Fine needle aspiration of the nodule revealed high cellularity, a partial microfollicle-like pattern and the presence of small hyaline globules. The neoplastic population was composed of monomorphic cells with basaloid appearance. Thyroid primitivity was excluded on the basis of the negativity for TTF1 and thyroglobulin. As the patient referred an ulcerative lesion of the inferior lip, fine needle aspiration cytology of the lesion was performed, yielding a diagnosis of adenoid cystic carcinoma.

CONCLUSION

The present case highlights the need to be aware of possible metastatic thyroid localisation of adenoid cystic carcinoma also originating in minor salivary glands of the oral cavity. This is a very rare event, but it should be taken into consideration and clinical and cytological findings must be carefully examined.

Unusual presentation of primary T-cell lymphoblastic lymphoma: description of two cases

Abstract

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Cystic gastrointestinal stromal tumors of the pancreas simulating cystoadenocarcinoma. Report of three cases and short review of the literature

Gastrointestinal stromal tumors (GISTs) represent a distinct subset of mesenchymal tumours of the gastrointestinal tract. They are more common in the stomach and small intestine, and are characterized by the proliferation of spindle or epithelioid cells and by the expression of CD117. Extra-gastrointestinal stromal tumors are rare and only 13 cases of pancreatic GISTs have been reported in the literature, only 1 of which presented as a cystic lesion. Mutational analysis of KIT and Platelet derived growth factor receptor-α genes was performed only in two out of the 13 cases. We report 3 cases of cystic GISTs of the pancreas, radiologically mimicking a cystoadenocarcinoma. Routine histopathology and molecular characterization of the tumours have been performed. In two of them, molecular analysis showed unusual genetic alterations (the internal repeat of codon 502 and 503 in exon 9 of the KIT gene and the KIT exon 9 single nucleotide substitution c.1427G⟩T). Pancreatic GIST should be included in the differential diagnosis of both cystic and solid masses of the pancreas. The diagnosis should be accomplished by a combination of radiology, histology, immunohistochemistry and molecular biology. The evaluation of CD117 expression and the sequence analysis of KIT and Platelet derived growth factor receptor-α gene is mandatory for therapy.

Leiomyomatosis peritonealis disseminata: an additional case

Leiomyomatosis peritonealis disseminata (PPD) is a rare smooth muscle tumour of women in the reproductive age. It is characterized by multiple small nodules on the peritoneal surface, mimicking a metastatic process. To date, about 100 cases have been reported in literature. The authors herein present an additional case consisting of multiple nodules located on the surface of the omentum, parietal peritoneum, as well as colon and rectum wall in a patient without signs of excess of estrogen, progesterone, or steroid hormones nor treated with hormones for any reason. The patient has been submitted to laparoscopic myomectomy few years ago. Microscopically, these nodules consisted of bundles of spindle-shaped smooth muscle cells (positive for smooth muscle actin, desmin, estrogen, and progesterone receptor). A brief review of the literature on the pathogenesis of the disease is also added.

Myxoid leiomyosarcoma of the uterus: a case report

Only 30 cases of myxoid leiomyosarcomas (MLMS) have been reported to date. The authors describe a further case in a 66-year-old woman. The main differential diagnoses include: myxoid inflammatory myofibroblastic tumours, mixoid leiomyoma, and endometrial stromal tumours. Surgery remains the appropriate treatment. However, in spite of an aggressive surgical approach and local and systemic control, recurrences and metastasis are frequent.

Lymphoepithelial-like carcinoma of the parotid gland: a case report and a brief review of the western literature

Background

Primary lymphoepithelial-like carcinoma of the parotid gland is a rare tumour with an increased incidence among Eskimos and Orientals. In these populations, it is usually associated with Epstein-Barr virus. In Western countries, salivary gland lymphoepithelial-like carcinomas are uncommon and only 14 cases have been described so far; among these, only five cases showed Epstein-Barr virus positivity.

Case report

A 45-year-old woman was admitted to Siena Hospital for evaluation of a pre-existent (2 years) painless and tender submandibular mass, rapidly enlarging since two months. On physical examination, a 2.5-cm mass was found in the right parotid. It was firm, mobile and non-tender. Laboratory data were within reference range. Nuclear magnetic resonance detected a 2,5×1,5×1-cm well-circumscribed mass in the deep lobe of the right parotid. A total right paroditectomy with dissection of a satellite lymph node was performed. On the basis of morphological, immunohistochemical and molecular biology findings, a diagnosis of stage II (according to TNM7) Epstein Barr-virus positive, undifferentiated lymphoepithelial-like carcinoma of the parotid gland was made. Twenty months after surgery the patient was free of disease.

Conclusions

Further studies seem to be necessary to completely elucidate the oncogenic role of Epstein Barr-virus in these tumors, which have identical morphology but different prognosis and variable presence of the virus.

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A case of Stengel-Wolbach sclerosis: a half century after the last report

Stengel-Wolbach sclerosis is a rare form of granulomatosis of the lymphoid tissue, with largely predominant involvement of the spleen. Firstly described by Wolbach in 1910, it has disappeared from the literature from the beginning of the last century. Herein, we describe the case of a 29-year-old female with splenomegaly due to multiple nodular lesions. On the basis of morphological and molecular biology findings, a diagnosis of Stengel-Wolbach sclerosis of unknown aetiology was made. The presentation of this case may reopen the discussion on this enigmatic entity.

Renal sinus pseudolymphoma in a patient with multiple carcinomas: a case report and a brief review of the literature

The term pseudolymphoma refers to a heterogeneous group of benign reactive T-cell or B-cell lymphoproliferative processes of diverse causes that simulate lymphoma clinically and histologically but usually undergo spontaneous remission. Its pathogenesis is still unclear. The prognosis is good although some evidence suggests that pseudolymphoma may progress to lymphoma. Pseudolymphoma of the urinary tract is extremely rare. We herein report a case of pseudolymphoma of the renal sinus in a 70-year-old man, associated with a high grade urothelial carcinoma of the bladder and to a prostatic adenocarcinoma (Gleason score 6). A brief review of the literature is included. The kidney showed a well-defined, whitish soft mass which involved the renal sinus. Microscopically, the lesion of the renal sinus consisted of a proliferation of small to medium size lymphocytes (CD20 positive and Bcl-2 negative) sometimes arranged in hyperplastic follicular structures. The diagnosis was confirmed by molecular studies which showed an oligopolyclonal IgH rearrangement. To the best of our knowledge, this is the second case of pseudolymphoma with a complete molecular characterization ever described in the renal sinus and the first one associated with multiple urogenital carcinomas.

The alteration of lipid metabolism in Burkitt lymphoma identifies a novel marker: adipophilin

Background

Recent evidence suggests that lipid pathway is altered in many human tumours. In Burkitt lymphoma this is reflected by the presence of lipid droplets which are visible in the cytoplasm of neoplastic cells in cytological preparations. These vacuoles are not identifiable in biopsy section as lipids are “lost” during tissue processing.

Methods and Results

In this study we investigated the expression of genes involved in lipid metabolism, at both RNA and protein level in Burkitt lymphoma and in other B-cell aggressive lymphoma cases. Gene expression profile indicated a significant over-expression of the adipophilin gene and marked up-regulation of other genes involved in lipid metabolism in Burkitt lymphoma. These findings were confirmed by immunohistochemistry on a series od additional histological samples: 45 out of 47 BL cases showed strong adipophilin expression, while only 3 cases of the 33 of the not-Burkitt lymphoma category showed weak adipophilin expression (p<0.05).

Conclusions

Our preliminary results suggest that lipid metabolism is altered in BL, and this leads to the accumulation of lipid vacuoles. These vacuoles may be specifically recognized by a monoclonal antibody against adipophilin, which may therefore be a useful marker for Burkitt lymphoma because of its peculiar expression pattern. Moreover this peptide might represent an interesting candidate for interventional strategies.

Translationally controlled tumour protein (TCTP) is present in human cornea and increases in herpetic keratitis

BACKGROUND

Translationally controlled tumour protein is a multifunctional calcium binding protein which has an important role in apoptosis, calcium levels balance and immunological response. The aim of this study was to evaluated the presence and distribution of TCTP in healthy human corneas and to identify and characterize the presence and distribution of this protein in human normal cornea. Since recent studies suggest that apoptosis, calcium levels and immunological mechanisms play a role in the pathogenesis of herpetic stromal keratitis, we studied TCTP expression in this disease.

METHODS

We evaluated the expression of TCTP at both RNA messanger and protein level by using reverse transcriptase analysis, immunoblotting and immunohistochemistry in 10 healthy samples cornea: four obtained after penetrating keratoplasty and six from eyes enucleated for other pathologies. Finally, we analysed by immunohistochemistry ten paraffin-embedded samples of Herpes simplex virus keratitis collected at Siena Department of Human Pathology and Oncology: 5 had clinically quiescent disease and 5 had active corneal inflammation.

RESULTS

Reverse transcriptase and immunoblotting demonstrated TCTP expression in cornea as a 22,000 Da molecular weight band corresponding to the molecular weight of this protein. Immunohistochemically, all the layers of normal corneal epithelium showed TCTP cytoplasmic expression. TCTP was, also, observed in keratocytes and in the endothelium. In Herpes simplex virus keratitis samples, strong expression of TCTP was evident in stromal cells, in the inflammatory infiltrate and in neo-vessels.

CONCLUSIONS

In this preliminary study we demonstrated, for the first time, the presence of TCTP in human cornea, suggesting a potential role in the pathogenesis of herpes virus keratitis.

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Myeloid sarcoma and adenocarcinoma of the large bowel as collision tumors: a case report

Myeloid sarcoma is a rare tumor composed of myeloid cells, localized in an extramedullary site, which may be associated with a concurrent myeloid neoplasm involving the bone marrow, although such an association is not required. Most patients present with acute myeloid leukemia and their prognosis is poor. We describe the case of a 76-year old woman with an adenocarcinoma of the right colon infiltrating the subserosa synchronous with a myeloid sarcoma at the same site; one pericolic lymph node was infiltrated by both tumors. The peculiarities of this case are the clinical presentation (as an acute abdomen due to subserosa infiltration by the myeloid sarcoma), the coexistence of a myeloid sarcoma with an adenocarcinoma of the right colon, and the absence of progression to acute leukemia. Coexistence of myeloid sarcoma and adenocarcinoma in the colon is probably incidental, and so it appears likely that the two different tumours arose from different mechanisms. However, a possible common background is conceivable. Some authors have found that p53 has a pivotal role in driving the maturation of myeloid stem cells and p53 is, also, involved in colon carcinogenesis. In our case, it may be hypothesized that synchronous heterogeneous mutations occurred in different types of committed cells or in stem cells secondary to p53 loss. Since only one case report has evaluated the correlation between myeloid sarcoma and adenocarcinoma of the large bowel, further immunohistochemical and molecular studies are needed to clarify the pathogenetic relationship between them.

Patients with thymomas have an increased risk of developing additional malignancies: lack of immunological surveillance?

AIMS

To assess the risk, for patients with thymoma, of developing an additional malignancy (AM).

METHODS AND RESULTS

We studied 68 patients with thymomas. Based on the World Health Organization classification, the tumours were categorised as A, AB or B (B1, B2, B3) thymomas. Control populations comprised 114 patients with colorectal cancer, 108 patients with lymphoma and 123 patients with thyroid carcinoma. Patients with thymomas showed a higher risk of developing an AM (22 of 68 patients versus 11 of 114, eight of 108, and eight of 123 patients, respectively; P = 0.0002). The association between thymomas and AMs was related to the thymoma histotype, with B1, B2, B3 and AB tumours showing a higher risk of developing an AM than A thymomas (P = 0.0474).

CONCLUSIONS

Patients affected by thymomas showed a significantly higher risk of developing additional malignancies than those in the control groups, and cases that exhibited a predominantly cortical component were more likely to develop other neoplasms. This may be related to the functions of cortical thymic epithelial cells in providing for T lymphocyte maturation through interaction with major histocompatibility complexes.

Benign ulcer of the right colon clinically misdiagnosed as carcinoma: an additional case

Benign solitary ulcer of the colon is an uncommon lesion that was originally described by Cruveilhier in 1832. Its aetiology remains unknown, and there are no pathognomonic lesions or symptoms. Diagnosis is made by exclusion; in fact, diseases such as specific infections (cytomegalovirus, campylobacter jejuni, entamoeba histolytica), common clinical conditions (acute appendicitis, diverticulitis, intestinal obstruction, inflammatory bowel disease), pharmacotherapy (non-steroidal anti-inflammatory medications, oral contraceptives, dicumarolic agents) and malignancies should be excluded. We describe the case of a 72-year-old patient admitted for acute bloody diarrhoea, originally misdiagnosed as carcinoma by colonscopy. The histological evaluation demonstrated a benign ulcerative lesion.

Tuberculosis of superficial lymph nodes, a not so rare event to consider in diagnosis. A case in an elderly male

Tuberculosis (TB) is still one of the most frequent infectious diseases worldwide. Until the 1990s, Western European countries showed a low frequency of TB infection, but the rise of immigration has led to a rapid increase in its occurrence. In the elderly, TB is emerging as a significant health problem (age-related decline of the cell-mediated immunity, associated illnesses, use of immunosuppressive drugs, malnutrition, poor life conditions), although its detection and diagnosis is not easy also considering its subclinical presentation. Almost 70% of all TB infections in Italy are found in the lungs; 50% of the extrapulmonary infections affect lymph nodes. Due to the low incidence of superficial tuberculous lymphadenitis without pulmonary manifestations, the possibility of a TB aetiology is often not taken into consideration in the differential diagnosis of lymphadenopathy, resulting in significant delay of appropriate treatment. Herein, we describe the case of a 78-year-old male with nocturnal fever, weakness, night sweats, loss of weight and decay in general condition. The patient had a past medical history of prostate adenocarcinoma treated with hormone therapy. The past medical history in association with clinical findings and laboratory data (anaemia, high titers of fibrinogen and reactive C-protein) led to the suspect of metastatic adenocarcinoma. Only histological and molecular biology findings allowed us to make a correct diagnosis of TB.

Long pedunculated colonic polyp with diverticulosis: case report and review of the literature

Colonic muco-submucosal elongated polyp is a rare entity (0.39% in an endoscopic polypectomy series). It is an elongated drumstick-shaped lesion characterized by oedematous, loose connective tissue with a dense submucosal layer showing dilation of blood and lymphatic vessels. First described as a polypoid lesion associated with diverticular disease of the sigmoid colon, it was histologically characterized as a separate entity by Kelly in 1991. In that study, the author reported eight cases in which a red or brown mucosal protrusion or polyp were associated with diverticular disease, and described the syndrome as "polypoid prolapsing mucosal folds in diverticular disease". In 1994, Matake et al. described a new entity defined as colonic muco-submucosal elongated polyp. Herein, we describe another case in a 77-year-old woman with abdominal pain, followed by a review of the literature.

Melanoma of the nipple. An additional case

The nipple is an unusual site of cutaneous melanoma with only few cases described in literature. We herein report an additional case of malignant melanoma arising on the nipple of a 47-year old woman. The nodular, ulcerated lesion was removed surgically and the diagnosis was that of a vertical growth phase melanoma. The melanocytic origin of the tumour was confirmed by immunohistochemistry. The case pursued a poor clinical outcome with distant metastases and death of the patient.

Lymphoepithelioma-like carcinoma of the endometrium

Only three cases of lymphoepithelioma-like carcinoma of the endometrium have been reported to date. We present a new case in a 67-year-old woman involving an exophytic mass that caused postmenopausal bleeding. Histologically, undifferentiated carcinomatous areas were intermingled with abundant lymphoid tissue. Epstein-Barr virus was not detected in either neoplastic or lymphoid cells.

Eosinophilic esophagitis: an Italian experience

BACKGROUND

Eosinophilic esophagitis is an esophageal disorder characterized by esophageal and/or upper gastrointestinal tract symptoms, and by dense esophageal eosinophilia associated with a normal gastric and duodenal mucosa. Prevalently reported in children, eosinophilic esophagitis has recently been reported with increased frequency also in adults.

AIMS

The purpose of this study was to report our experience with eosinophilic esophagitis in Italy, since there are only very few series of such patients in our country.

PATIENTS AND METHODS

We retrospectively reviewed the histological data of consecutive patients with a diagnosis of esophagitis or reflux disease in the period September 2004-September 2008. Eosinophils were counted where they appeared most numerous in the biopsy, with a cutoff > 15 eosinophils in more than one high-power field as diagnostic of eosinophilic esophagitis. Patients were excluded if gastric or duodenal biopsies showed a prominent eosinophilic infiltrate.

RESULTS

Twenty two patients (14 adults, 8 children, age range 2-59 years) were identified according to the above criteria. The average eosinophil count was 86/ high-power field (range 31-150), associated with other pathologic features (eosinophilic microabscesses eosinophil degranulation, basal zone hyperplasia, papillary elongation). The main clinical complaints were dysphagia, food impaction, and heartburn, and endoscopic findings consisted of mucosal thickening and inelasticity, longitudinal shearing, rings, and white specks, without difference between adults and children for both clinical and endoscopic variables.

CONCLUSIONS

Eosinophilic esophagitis is not rare in Italy, and displays clinical, endoscopic, and pathologic features similar to those described in other countries.

A rare case of primitive neuroectodermal tumor in the soft tissues of the hand

Primitive neuroectodermal tumors of the hand are extremely rare, and only 5 cases have been described to date. Here, we report a case of a 35 year-old male who presented a progressive swelling on the palm of his right hand. Clinical examination showed a solid mass and X-ray revealed a soft tissue mass. Magnetic resonance imaging (MRI) revealed infiltrated interosseous muscles, metacarpal bones and tendons. The patient underwent surgery and the lesion was removed. On the basis of morphological, immunohistochemical and molecular biology findings, a diagnosis of primitive neuroctodermal tumor was made.

Bronchial fibrolipomatous hamartoma associated with peculiar unusual bronchial lesions of the peripheral lung

Multiple hamartomas of the lung are uncommon. The few cases described to date are multiple parenchymal hamartomas or multiple endobronchial and parenchymal hamartomas. Herein, an original case is described which is characterized by the association between an endobronchial hamartoma and multiple, unusual, bronchial lesions of the peripheral lung.

Primary linitis plastica of the right colon

A case of primary linitis plastica of the colon is presented. This case is of interest for three reasons: the site of origin in the right colon (80% of cases reported develop distally to the splenic flexure), a biopsy previously taken from the mucosa demonstrated the presence of a signet ring cell carcinoma (endoscopic biopsies do not provide a conclusive diagnosis in the majority of cases reported) and hyaline with sparse amyloid nodules were detected in the extensive, dense fibrous tissue intermingled with tumour cells.

Vulvar cancer and HPV infection: analysis of 22 cases

Vulvar cancer represents about 4% of all neoplasms of the female genital tract. Two different pathways give rise to vulvar carcinoma, a HPV-dependent pathway, and a pathway linked to inflammatory dermatoses. The aim of the present study was to evaluate the impact of HPV infection in the pathogenesis of vulvar cancer by HPV genotyping in 22 cases of squamous cell carcinoma. Our results provides further evidence that vulvar squamous cell carcinoma is a multifactorial disease that may develop though different pathways, very often in the presence of classic or differentiated vulvar intraepithelial neoplasia in 16 out 22 cases.