Paraneoplastic Limbic Encephalitis Secondary To Mixed Non-Seminomatous Germ Cell Tumours

Casestudy: Testicular tumors account for 1–2% of all tumors in men, with 95% of these being germ cell tumors. The main risk factor for the development of testicular cancer is cryptorchidism. Paraneoplastic limbic encephalitis is a rare sequela of testicular tumor associated with anti-Ma2 and KLH11 antibodies. The most effective treatment for paraneoplastic limbic encephalitis is treatment of the primary malignancy.

We present a 41-year-old male that presented to the emergency department with two weeks of episodic alteration of consciousness and memory disturbances. Negative neurologic evaluation and imaging led to concern for a paraneoplastic process from a distant malignancy. CT imaging revealed an enlarged, necrotic para-aortic lymph node and subsequent ultrasound demonstrated a right sided testicular mass. Right radical orchiectomy was performed.

Microscopically, the mass consisted of mixed respiratory epithelium, gastrointestinal glands and squamous epithelium with keratinization consistent with a post-pubertal testicular teratoma with associated in-situ germ cell neoplasia.

Resection of the para-aortic mass revealed large anaplastic cells with epithelioid features, nuclear pleomorphism and frequent mitoses. Immunostaining was positive for Pan-Keratin and OCT4, consistent with poorly differentiated embryonal carcinoma. Resection of the primary and metastatic disease, as well as treatment with corticosteroids resulted in resolution of the encephalitis.

This presentation of severe neurological disturbances in the setting of a metastatic mixed nonseminomatous germ cell tumor represents a rare presentation of paraneoplastic limbic encephalitis.

Urinary Bladder Transitional Cell Carcinoma with Chordoid Features-A Rare Entity

Casestudy: Invasive urothelial carcinoma is heterogenous entity and show variant morphologic patterns, of which squamous differentiation is the most common. Other variants have been widely recognized and studied.

Invasive urothelial carcinoma with chordoid features is a rare entity with only 16 reported cases to date in English literature. It has a significant morphologic overlap with other vesical and non-vesical myxoid neoplasms, including extra-skeletal myxoid chondrosarcoma and chordoma, which necessitate an extensive workup to reach an accurate diagnosis.

To the best of our knowledge we report the 17th case of urothelial carcinoma with chordoid features in a 76-year-old male who underwent a cystoprostatectomy and bilateral pelvic lymph node dissection with confirmed diagnosis of high-grade invasive urothelial carcinoma on biopsy. Grossly, bladder showed a 4.2 x 3.4 x 0.6 cm firm white tumor entirely replacing the anterior wall, extending into perivesicular fat, and invading the prostate gland and seminal vesicles.

Microscopically, tumor showed urothelial carcinoma in-situ transitioning into high-grade invasive carcinoma with chordoid features. The tumor characterized by round to elongated epithelial cells and eosinophilic cytoplasm arranged in a single file/complex cord-like architecture, in a prominent myxoid stromal background. No conventional high-grade spindle cell morphology was identified. Pelvic lymph nodes were positive for metastatic disease. Tumor cells were positive for GATA3, Pan-cytokeratin, 34BetaE12, and p63, while negative for AMCAR, supporting the urothelial origin of this tumor and confirming the diagnosis.

Invasive urothelial carcinoma with chordoid features is a rare entity, generally present at high stage disease, that can be mistaken for other prominent myxoid stromal neoplasms and requires careful assessment. Although, it can demonstrate similar demographic, clinical and immunohistochemical staining pattern as of conventional urothelial carcinoma, special attention should be given to exclude sarcomatoid features which is an aggressive variant of urothelial carcinoma.

Primary Pleural Angiosarcoma With Extensive And Rapid Metastasis To Brain And Bilateral Adrenal Glands

Casestudy: Angiosarcomas represent 1% of all soft tissue malignancies. Primary pleural angiosarcomas are aggressive and extremely rare. The etiology of pleural angiosarcoma is largely unknown but in the few reported cases it is associated with asbestos exposure. Common presenting symptoms are chest pain, cough, dyspnea, and weight loss. Localized tumors are generally resected, with other options including chemotherapy and radiotherapy. Limited literature describes this rare neoplasm’s metastatic potential and patterns.

We present a 64-year-old male with shoulder pain and chronic cough. CT thorax showed a large 6.7 x 8 cm mass with central necrosis in the left upper lung invading the chest wall with partial destruction of the second and third ribs, and axillary adenopathy. Bilateral adrenal nodules were also identified. Histology of the adrenal lesion reveal sheets of infiltrative polygonal/round cells with large nuclei, prominent nucleoli and eosinophilic cytoplasm. Tumor cells were positive for CD31, CD34, FLI-1, AE1/AE3 and CK7 immunohistochemical stain, correlating with primary epithelioid angiosarcoma. Based on the patients new development of confusion, dizziness and ataxia, an MRI was performed showing multiple metastatic brain lesions. One month after initial presentation, the patient again presented with worsening symptoms. Work up showed enlargement of the bilateral adrenal masses, doubling of the brain lesions and an additional lesion posterior to the left kidney.

This case shows the metastatic potential and pattern of an aggressive primary neoplasm that is not described in current literature. It also highlights the importance of timely intervention based on the rapid metastatic progression of primary pleural angiosarcomas.