Follicular thyroid adenoma with papillary architecture

@#A 23-year-old woman underwent left thyroid lobectomy and isthmusectomy for a 2 cm diameter firm mass on the left side of the neck that was also visualized on ultrasonography. The specimen consisted of a 22-gram thyroid gland composed of the left lobe, isthmus and a pyramidal lobe. Cut section of the left lobe showed a 3.5 cm diameter solitary, discrete and encapsulated mass with a tan lobulated and solid cut surface. The rest of the thyroid tissues had red-brown meaty cut surfaces. Microscopic section shows a follicular-patterned proliferation enclosed by a thin fibrous capsule with frequent Sanderson polster-like papillary excrescences. (Figures 1 and 2) Both the follicular and the papillary structures are lined by cuboidal to columnar follicular epithelial cells that had ample eosinophilic to pale cytoplasm and uniformly sized, minimally enlarged, generally round, and monolayered nuclei without nuclear grooving, folds, pseudoinclusions, and chromatin clearing. There are no mitotic figures seen. Some of the papillary structures have delicate vascular cores. (Figure 3) There are no psammoma bodies noted. The follicles contain variable amounts of pale eosinophilic colloid ranging from colloid-poor crowded follicles to those with ample colloid that have frequent peripheral scalloping. (Figure 4) Exhaustive sections failed to disclose capsular or vascular invasion. Based on the microscopic features, a diagnosis of follicular adenoma with papillary architecture was rendered.

Epithelial-Myoepithelial carcinoma of the lacrimal gland - Case report and review of literature

Objective@#To describe the clinicopathologic features and outcome of a patient with epithelial-myoepithelial carcinoma of the lacrimal gland who underwent modified lateral orbitotomy with en toto removal of the lesion and adjuvant radiotherapy.@*Methods@#This is a case report.@*Results@#A 31-year-old Filipino male seafarer presented with a 2-month history of an enlarging left superotemporal orbital mass and inferonasal displacement of the globe. Magnetic resonance imaging revealed a superotemporal extraconal mass within the lacrimal sac fossa with evidence of osseous infiltration of the superolateral orbital rim. Modified lateral orbitotomy was performed with en toto removal of the lesion and the clinically infiltrated adjacent lateral bony margin. Histopathologic diagnosis of epithelial-myoepithelial carcinoma of the lacrimal gland was made based on the classic and distinct biphasic morphology and was confirmed with immunohistochemistry studies (cytokeratin-7, S-100, and p63). Systemic surveillance using positron emission tomography and computed tomography scan with contrast revealed no evidence of regional or distant metastasis. Adjuvant radiotherapy of the orbital area was performed for increased local control. Twelve months postoperatively, the patient showed no evidence of tumor recurrence.@*Conclusion@#Epithelial-myoepithelial carcinoma of the lacrimal gland is a rare condition, and this is the first documented case from the Philippines. Accurate diagnosis is necessary for appropriate treatment. It should be included in the differential diagnosis of infiltrative lesions in the lacrimal gland fossa.

Acantholytic squamous cell carcinoma

@#A 63-year-old Filipino man presented with a one-month history of painful ulceration on the alveolar socket of a molar tooth of the right hemimandible. The patient consulted at a tertiary hospital, where he underwent incisional biopsy.

Inverted ductal papilloma of the salivary gland

@#This is a case consult of slides stated to be from an excision of a buccal mucosa mass in a 58-year-old-man. The specimen was described as a 3 cm diameter roughly oval tan-gray tissue with a 2 x 1.5 cm mucosal ellipse on the surface that has a central ulcerated punctum. Cut section showed an underlying 1.7 cm diameter roughly oval well-circumscribed mass with a granular tan surface. Histological sections show a papillary lesion with an orifice on the mucosal surface and with epithelial nests invaginating into the underlying lamina propria in a non-infiltrative pattern. (Figure 1) The lesion is composed of papillary epithelial fronds with cleft-like spaces between the fronds. (Figure 2) The papillary fronds are lined by non-keratinizing basaloid stratified squamous cells with a superficial layer of columnar glandular cells along with mucous goblet cells interspersed among the squamous cells. (Figure 3) All the cellular components are devoid of cytologic atypia and mitoses. Based on these microscopic features we signed the case out as inverted ductal papilloma (IDP).

Knowledge, attitudes, and awareness towards newborn screening in association with received prenatal care: A survey of primiparous postpartum mothers at the Philippine General Hospital

@#<p style="text-align: justify;"><strong>Background.</strong> Newborn screening (NBS) is a procedure for the immediate detection of genetic, metabolic, and endocrine disorders in neonates and is crucial for prompt treatment should such disorders be identified. In the Philippines, Republic Act 9288 requires health workers to properly inform mothers regarding NBS and its importance before the procedure.</p><p style="text-align: justify;"><strong>Objective.</strong> To determine the knowledge, attitude, and awareness of primiparous postpartum mothers towards NBS Methods: A survey questionnaire was administered to primiparous mothers from Wards 15 and 16 of the Philippine General Hospital from April 11 through May 14, 2017. Results of primiparous postpartum mothers with or without previous prenatal check-ups were then compared.</p><p style="text-align: justify;"><strong>Results.</strong> We surveyed 160 mothers, with half (56.3%) aged between 20 and 29 years. There were 149 mothers with and 11 without prenatal checkups. Mothers with previous prenatal checkups were more likely to be aware of NBS than those without prenatal checkups. Knowledge on NBS of mothers with previous prenatal checkups was higher on average compared to those without previous prenatal checkups. There was no significant difference in attitude between mothers with or without prenatal checkups.</p><p style="text-align: justify;"><strong>Conclusion.</strong> Prenatal checkups increased the awareness and knowledge of primiparous mothers' towards NBS, and thus can be a potent vehicle where healthcare providers may inform the mother on the process and purpose of this procedure.</p>

Botryoid odontogenic cyst

@#A 70-year-old man consulted for a mass of unspecified duration in the anterior area of the mandible. Radiologic information was not provided. An incision biopsy was performed by the dentistry service. The specimen received at the laboratory was labeled “cystic lining” and consisted of two light-gray to dark brown, irregularly shaped tissue fragments measuring 0.3 cm and 0.4 cm in diameters.

Nasopharyngeal Tuberculosis in a Philippine Tertiary General Hospital

Objectiv@#This study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who were initially assessed to have a nasopharyngeal mass and subsequently underwent biopsy in a Philippine Tertiary General Hospital from 2013 to 2015. @*Methods@#Design: Case Series. Setting: Tertiary National University Hospital. Participants: All patients with nasopharyngeal mass identified from January 2013 to December 2015 from a hospital wide census who underwent biopsy were investigated using chart and histopathology review. The prevalence of tuberculosis, malignancies and other findings were determined.@*Results@#Among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5 (1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above. @*Conclusion@#This study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal tuberculosis in patients who have a nasopharyngeal mass. This indicates that nasopharyngeal tuberculosis should always be a differential when confronted with a mass in the nasopharynx especially in tuberculosis endemic areas.

Traumatic ulcerative granuloma with stromal eosinophilia

@#<p>A 41-year-old man presented with an 8-year history of recurrent mouth ulcers, previously treated with unrecalled antibiotics and vitamins but with no relief. Examination showed a 2.0 x 1.0 cm hard, immovable ulcer at the right lateral tongue. On further interview, a history of repeated biting trauma on the site of the lesion was elicited. The clinical impression was a non-healing tongue ulcer. Incision biopsy of the lesion was performed and the specimen sent for histopathologic evaluation.</p><p>The specimen consisted of three, cream-tan, irregularly-shaped soft tissues measuring up to 0.9 cm in widest diameter. The cut sections of the tissues showed a tan-pink to cream-white soft cut surface. Microscopic examination showed a squamous epithelium-lined tissue with a dense polymorphic infiltrate of inflammatory cells rich in neutrophils, eosinophils, plasma cells and large atypical mononuclear cells, and accompanying granulation tissue formation. <strong>(Figure 1 and 2)</strong> Immunohistochemical studies showed CD20 expression of B-cells in the lymphoid follicles, with CD3 and CD5 highlighting the surrounding T-cells. The plasma cells are staining for both kappa and lambda, with kappa-lambda ratio of 3:1. The Ki-67 showed a high proliferation index within the reactive germinal centers, and scattered low proliferative activity within the interfollicular areas. <strong>(Figure 3)</strong> Given the morphologic and immunohistochemical profile of the lesion, we diagnosed it as traumatic ulcerative granuloma with stromal eosinophilia.</p><p>Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is considered a rare lesion of the oral mucosa. First described in 1881 by Riga then defined histologically in 1890 by Fede,1,2 it has since been called by a variety of terms including traumatic ulcerative granuloma, ulcerative eosinophilic granuloma, and Riga-Fede disease in infants and neonates. The term TUGSE was first coined by Elzay in 1983 to delineate it from more aggressive conditions such as eosinophilic granuloma, eosinophilic fasciitis and carcinoma with stromal eosinophilia.3 It is a benign, chronic, self-limiting lesion of the oral mucosa.1,2</p><p>TUGSE typically manifests as an isolated ulcer with elevated margins or an indurated submucosal mass, most commonly affecting the dorsal or lateral surfaces of the tongue but can be found in other locations in the oral mucosa such as the lip, palate, and gingiva. 2,4 The lesions can also be multifocal and recurrent, and can persist from several weeks to months, but will heal without treatment; a wide age range of patients can be affected, with a peak incidence in the sixth and seventh decades of life, with only a slight female predominance.1,4 Due to its clinical manifestation, it can often be mistaken for malignancy or an infection; however, its microscopic and immunohistochemical features, self-limiting nature and spontaneous resolution indicate a benign reactive process.1,2</p><p>Histologically, TUGSE is characterized by a diffuse polymorphic infiltrate of inflammatory cells that can extend deep into the submucosa and skeletal muscle; it is predominantly composed of eosinophils, B and T lymphocytes, macrophages, with atypical large mononuclear cells.1,2,4 These atypical cells have abundant pale cytoplasm, irregular nuclear contours, small nucleoli and fine chromatin.1,2,4 The origin of these large mononuclear cells are still disputed and have been reported to originate from lineages such as histiocytes (CD68), dendritic cells (factor XIII), myofibroblasts (vimentin) and T-lymphocytes due to their variable immunohistochemical characteristics.1,2,4 The immunostains performed in our case showed intact B-cell compartment highlighted using CD20, and intact T-cell compartment using CD3 and CD5. The plasma cells are polyclonal to kappa and lambda. The proliferation index using Ki-67 is high within the reactive germinal centers, and low in the interfollicular area. The immunohistomorphologic features are compatible with a reactive process.</p><p>The etiology and pathogenesis of TUGSE have not been completely established but is postulated to be associated the with trauma, although obvious trauma could only be demonstrated in 50% of the cases.1,4 Traumatic disruption of the mucosa facilitates a cell-mediated immune response due to the action of a non-identified etiologic factor such as microorganisms, toxins and/or foreign proteins; this induces an eosinophilic and mast cell reaction, including a release of cytotoxic T-cells ultimately leading to local tissue destruction.1,5 It has also been suggested that it may be a CD30+ lymphoproliferative disorder.1,4-6 A CD30 positivity can be seen in lymphomas, lymphoproliferative diseases, Reed-Sternberg (RS) cells, and activated T and B cells, but also occur in benign cutaneous disorders such as drug reaction, atopic dermatitis and molluscum contagiosum; however, involvement of the oral mucosa with lymphoproliferative diseases is rare.1,4,5</p><p>The pathogenesis and etiology of the entity remains unclear, and can mimic malignant conditions due to its clinical, histological, and immunohistochemical features thus the diagnosis of TUGSE should be made by the combination of clinical data, histopathologic, and immunohistochemical features.1 The condition has a benign course and is characteristically self-healing.1,2</p>

Nasopharyngeal Tuberculosis in a Philippine Tertiary General Hospital

@#<p><strong>OBJECTIVE:?</strong> This study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who were initially assessed to have a nasopharyngeal mass and subsequently underwent biopsy in a Philippine Tertiary General Hospital from 2013 to 2015.</p><p><strong> </strong></p><p><strong>METHODS:</strong>?</p><p><strong>Design</strong>:           Case Series</p><p><strong>Setting</strong>:           Tertiary National University Hospital</p><p><strong>Participants</strong>: All patients with nasopharyngeal mass identified from January 2013 to December 2015 from a hospital wide census who underwent biopsy were investigated using chart and histopathology review. The prevalence of tuberculosis, malignancies and other findings were determined.</p><p><strong> </strong></p><p><strong>RESULTS</strong>:? Among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5 (1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above.</p><p><strong> </strong></p><p><strong>CONCLUSION:</strong> This study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal tuberculosis in patients who have a nasopharyngeal mass. This indicates that nasopharyngeal tuberculosis should always be a differential when confronted with a mass in the nasopharynx especially in tuberculosis endemic areas.</p><p> </p><p><strong>KEYWORDS:</strong> nasopharyngeal tuberculosis; prevalence; censuses; tertiary care centers; Philippines; carcinoma; nasopharynx; biopsy; tuberculosis; lymphoma </p><p> </p>

Intracapsular carcinoma ex pleomorphic adenoma

@#<p style="text-align: justify;">This is the case of a 37-year-old female patient presenting with a 10-year history of a gradually enlarging right infra-auricular mass. A parotidectomy was performed. The surgical pathology specimen consisted of an 18 cm diameter encapsulated nodular mass with a homogenous, cream-tan solid surface. Microscopic section showed an encapsulated neoplasm with abundant chondromyxoid stroma and tubular epithelial elements characteristic of a pleomorphic adenoma. (Figure 1) Randomly scattered within the tumor were foci of haphazard and complex glands. (Figure 2) These glands exhibited nuclear pleomorphism, luminal necrosis, and mitoses compatible with an adenocarcinomatous proliferation. (Figure 3) Based on these features, the case was signed out as an intracapsular carcinoma ex pleomorphic adenoma.</p><p style="text-align: justify;">Carcinoma ex pleomorphic adenoma is a carcinoma arising from a pre-existing pleomorphic adenoma. The antecedent benign tumor may either be a long-standing one, often with a history measured in decades, or characterized by a protracted history of excisions and multiple recurrences.1,2 The carcinoma on the other hand is either epithelial or myoepithelial in derivation. By morphologic sub-type, the most commonly reported carcinoma arising in a pleomorphic adenoma is a salivary duct carcinoma or an adenocarcinoma that is not otherwise specified (NOS).1,3 Residual pleomorphic adenoma tissue is identifiable either in its typical morphology, a chondromyxoid stroma, or a hyalinized sclerotic nodule.1</p><p style="text-align: justify;">Aside from the type of carcinoma arising from the pleomorphic adenoma, another parameter that has to be reported is the extent of involvement by the carcinomatous component. A carcinoma that is entirely limited to within the parent tumor that is still enclosed by a complete capsule is termed an "intracapsular" or "non-invasive" carcinoma ex pleomorphic adenoma.1,2 Once the carcinoma breaches the capsule and infiltrates the surrounding tissue, then it is considered invasive. If the invasion is less than 4 - 6 mm beyond the capsular border, the tumor is termed "minimally invasive". Carcinomatous elements that extend beyond this threshold is termed "widely invasive".1 This threshold is greater than the previous threshold of 1.5 mm recommended in an earlier edition of the WHO classification although the present edition does state that this threshold is preliminary and requires further validation.1,2,4 It has to be pointed out though that quantifying invasion may not always be possible in tumors that have positive margins, those that are intrinsically unencapsulated such as minor salivary gland tumors, and those with complex multinodular growth patterns such as in recurrent pleomorphic adenoma.1 This difficulty has to be stated in the report and what conditions preclude quantifying the degree of invasion.</p><p style="text-align: justify;">Non-invasive carcinoma ex pleomorphic adenoma has quite a good outcome with very low reported rates of recurrence or regional metastasis. In a review of thirty cases and a report of an additional three cases, only one case showed recurrence or metastasis.3 This favorable outcome certainly contrasts with that of the widely invasive type where metastasis is reported to occur in up to 70% of cases.1 Another review of ten cases showed one case developing metastasis, and recommended that non-invasive cases should thus still be followed up closely after primary treatment because regional or distant metastasis can occur.2 </p><p style="text-align: justify;">To the best of our knowledge, there are no published local data on the incidence of early malignant transformation of pleomorphic adenomas in the Filipino population. Hence, we take this opportunity to report this case. Awareness of the entity and prudent liberal sampling of these tumors may help address this gap.</p><p style="text-align: justify;"> </p>

Ameloblastic fibrosarcoma of the mandible

@#A 32-year old Filipino woman presented with a 3-year history of slowly enlarging left hemimandibular mass with no associated symptoms. Previous biopsy showed ameloblastoma. Imaging revealed a translucent mulitloculated mass with ill-defined borders. (Figure 1) On examination, the mass was irregularly shaped, measures 40 x 39 cm, slightly hyperpigmented and erythematous, warm with visible vessels. The patient underwent left segmental mandibulectomy with reconstruction and the specimen was sent for histopathologic evaluation.

Respiratory epithelial adenomatoid hamartoma

@#<p style="text-align: justify;">A 65-year-old man consulted with a history of chronic snorting with a sensation of obstruction in the left side of the nasopharynx particularly when in supine position. A few days prior to consult, the patient had blood-tinged nasal discharge, thus this admission. No other symptoms were reported.</p><p style="text-align: justify;"> </p><p style="text-align: justify;">Nasal endoscopy showed a sessile exophytic lesion with a vaguely nodular surface, seen as a polypoid nasopharyngeal mass on Computed Tomography scan. (Figure 1)</p><p style="text-align: justify;"> </p><p style="text-align: justify;">Excision of the mass was performed. Received in the surgical pathology laboratory was a 1.8 x 1.5 x 0.6 cm red to brown, rubbery to firm, vaguely ovoid mass with a nodular external surface. Cut section showed a light gray solid surface. </p><p style="text-align: justify;"> </p><p style="text-align: justify;">Microscopic examination shows a broad-based exophytic mass with invaginations of the surface epithelium and proliferated glands within the stroma. (Figure 2) The glands are tubular or variably dilated - many are lined by a respiratory-type epithelium with goblet cells and a thickened basement membrane, while the tubular glands are lined by a monolayered cuboidal epithelium. (Figure 3) Based on these features, we signed the case out as a respiratory epithelial adenomatoid hamartoma (REAH).</p><p style="text-align: justify;"> </p><p style="text-align: justify;">REAH is a benign proliferation of sinonasal tract glands derived from the surface epithelium.1 It occurs primarily in male adults, with a median age in the sixth decade of life. Most cases arise in the posterior nasal septum, while less common sites of involvement include other parts of the nasal cavity, the nasopharynx, and paranasal sinuses.2 Common symptoms include nasal obstruction, stuffiness, and epistaxis.1,3,4</p><p style="text-align: justify;"> </p><p style="text-align: justify;">REAH presents as a polypoid lesion and may measure up to 6 cm in widest diameter.1 Microscopically, there is a proliferation of small to medium-sized glands dispersed in abundant stroma. Invagination of the glands from the surface epithelium may be seen.3 The glands are round to oval, lined by respiratory-type epithelium with admixed goblet cells. Thickened basement membranes surround some of the glands, and smaller seromucinous glands lined by cuboidal epithelium may also be admixed among the latter. Other alterations may include squamous, chondroid, and osseous metaplasia.1,4</p><p style="text-align: justify;"> </p><p style="text-align: justify;">Rarely, REAH may occur synchronously with inverting sinonasal papillomas or inflammatory polyps.1 It may be mistaken for these two entities along with sinonasal low-grade adenocarcinomas. Careful attention to the typical morphology including absence of an infiltrative growth pattern and atypia allow distinction from these entities particularly the malignant mimics.3 A related entity is a seromucinous hamartoma with which REAH is believed to form a morphological spectrum.1</p><p style="text-align: justify;"> </p><p style="text-align: justify;">REAH is benign and complete excision confers cure.1 Malignant transformation has not been reported.1,3,4</p><p style="text-align: justify;"> </p>

Sinonasal tract meningioma

@#A 63-year old Filipino female presented with epistaxis of undisclosed duration. Examination showed a vascular, pulsating, rubbery intranasal mass involving both nasal cavities. The clinical impression was that of a nasal hemangioma. She underwent excision of the tumor and the specimen was sent for histopathologic evaluation. The specimen consisted of several tan-brown irregular tissue fragments with an aggregate diameter of 2 cm. Microscopic examination showed a cellular spindle cell tumor underneath the respiratory mucosa. (Figure 1) The tumor cells formed a syncytial pattern arranged in whorls that were separated by thin fibrovascular bands. (Figure 2) The cells had round to oval nuclei with nuclear clearing and moderate amount of syncytial cytoplasm compatible with a meningothelial derivation. (Figure 3) There was absence of nuclear atypia, significant mitotic activity, and necrosis. Immunohistochemistry studies showed positivity for Epithelial Membrane Antigen (EMA) and Progesterone Receptors (PR), and absence of reaction for Smooth Muscle Actin (SMA) and CD34. (Figure 4) Our diagnosis was sinonasal tract meningioma. Primary extracranial meningioma of the sinonasal cavity is rare and thus secondary extension from a primary intracranial tumor should be ruled out. It involves a wide age range with no striking gender predilection.1,2 Most common symptoms include nasal obstruction, epistaxis, exophthalmos, and a mass. Etiogenesis is not completely established and is postulated to arise from meningocytes that are entrapped during closure of midline structures, very similar to the development of meningoceles.3 Histopathologic examination discloses a spindle cell tumor arranged predominantly in whorls composed of cells showing meningothelial differentiation. Most are histologically grade 1 tumors. Grade 2 and 3 sinonasal tract meningiomas are rare.4 Histologic differential diagnoses include a glomangiopericytoma, leiomyosarcoma, and a solitary fibrous tumor/hemangiopericytoma. Close histologic evaluation with appropriate immunohistochemistry studies point to the correct diagnosis. Meningioma shows strong diffuse positivity with EMA and PR, and is usually negative for other immunohistochemistry markers such as muscle actins (for glomangiopericytoma and leiomyosarcoma), and CD34 (for solitary fibrous tumor/hemangiopericytoma).1,3 A diagnosis of primary sinonasal meningioma should not be made if an intracranial mass is identified.4 Sinonasal meningiomas are benign tumors with no documented distant metastases.1,2 Although recurrences occur in about 30% (mostly due to incomplete excision), metastasis and malignant transformation has not been reported.

Middle ear paraganglioma

@#<p class="MsoNormal" style="text-indent: .5in;">A 51-year old woman underwent mastoidectomy with labyrinthectomy on the right for a polypoid external auditory canal mass accompanied by tinnitus and ear discharge. She was reported to have undergone mastoidectomy on the same site seven years prior to the present consult. The material from this prior surgery was not made available to us.</p><p class="MsoNormal" style="text-indent: .5in;">The submitted specimen from this surgery consisted of several dark brown irregular tissue fragments with an aggregate diameter of 4.2 centimeters. Histologic sections show tumor cells arranged in "ball-like" clusters, that are surrounded by a network of sinusoidal channels. The cells are round to oval, with round, uniform nuclei that have finely granular chromatin, and moderate amounts of eosinophilic to amphophilic cytoplasm. (<i>Figure 1</i>)  Mitoses, nuclear pleomorphism and hyperchromasia are not observed. Immunohistochemical studies show diffuse cytoplasmic positivity for synaptophysin and chromogranin. (<i>Figure 2</i>)  The S100 stain highlights a peripheral layer of cells taking up the stain around the cell clusters. (<i>Figure 3</i>)  Based on these features, we diagnosed the case as a paraganglioma, likely a recurrence.</p><p class="MsoNormal" style="text-indent: .5in;">Paragangliomas are neuroendocrine neoplasms that arise from paraganglia found in various anatomic locations.1 In the middle ear, they arise from paraganglia found in the adventitia of the jugular bulb - hence, the old synonym "glomus jugulare" and "glomus tympanicum." Other sites where they can develop include paraganglia of the carotid artery bifurcation ("chemodectoma"), the larynx, and the vagal trunk ("glomus vagale"). The World Health Organization has simplified the nomenclature of these tumors by calling all of them simply "paraganglioma" and specifying the site involved.1 In our case, it is likely a middle ear paraganglioma, borne out by the history, clinical picture, and the morphology. Head and neck paragangliomas occur in adults, from the 5th - 6th decade, more commonly in females, and present mostly with mass-related symptoms.2,3 </p><p class="MsoNormal" style="text-indent: .5in;">The morphology of paragangliomas in all head and neck locations is similar. Hematoxylin-eosin sections show cells arranged in organoid groups ("cell-ball", "Zellballen") surrounded by a vascular network. There are two cell types encountered: the chief cells, which comprise the bulk of the cell nests and have abundant eosinophilic cytoplasm, and the sustentacular cells, which are spindly and located at the periphery of the nests. Neuroendocrine immunohistochemical stains (e.g. synaptophysin, chromogranin, CD56) highlight the chief cells, while S100 and glial fibrillary acidic protein (GFAP) highlight the sustentacular cells. Cytokeratin is typically non-reactive and distinguishes this tumor from neuroendocrine tumors (i.e. carcinoid, neuroendocrine carcinoma), and middle ear adenoma.1,3 There are no consistent histologic features that can discriminate between benign and malignant cases, nor are there criteria that can predict aggressive behavior and metastasis.1,2,3 </p><p class="MsoNormal" style="text-indent: .5in;">Head and neck paragangliomas are slow-growing tumors, and surgery is the most common treatment option. Radiotherapy is an option, especially for vagal paragangliomas where severe vagal nerve deficits occur in surgically treated cases.1 Recurrence after surgery is reported to be less than 10% for carotid, and up to 17% in laryngeal cases.1 Metastasis on the other hand occur in 4 - 6 % of carotid, 2% of middle ear and laryngeal, and 16% of vagal tumors.3 The World Health Organization nomenclature states that "all paragangliomas have some potential for metastasis (albeit variable)."1 Thus, long-term follow-up may be prudent for all cases.</p><p> </p><p class="MsoNormal"> </p>

Low-grade cribriform cystadenocarcinoma of the parotid gland

@#This is the case of a 44-year-old woman with a one-year history of a left pre-auricular mass. The surgical specimen is a 5 centimeter diameter tan-brown irregularly-shaped tissue whose cut surfaces are brown with cystic spaces. Microscopic sections show cystic and dilated ductal spaces lined by cells forming irregular, variably-sized secondary spaces. These spaces are arranged in a cribriform pattern that is reminiscent of breast ductal hyperplasia. (Figure 1) The ductal cells lining the spaces are small, multilayered, and generally bland. The superficial cells show apocrine-type cytoplasmic snouting. There is no significant nuclear atypia or mitotic activity noted. Necrosis is also absent. (Figure 2) Based on these features, we signed the case as a low-grade cribriform cyastadenocarcinoma (LGCCC).

Granulation tissue mimicking a glomus tumor in a patient with chronic middle ear infection

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To present an unusual cause of pulsatile tinnitus, presenting in a young adult suffering from chronic recurrent foul-smelling discharge from the same ear.<br /><strong>METHODS:</strong><br /><strong>Design:</strong> Case Report<br /><strong>Setting:</strong> Tertiary National University Hospital<br /><strong>Patient:</strong> One<br /><strong>RESULTS:</strong> A 24 year-old woman presented with pulsatile tinnitus on a background of chronic recurrent foul-smelling discharge. Clinico-radiologic findings seemed consistent with a glomus tympanicum coexisting with chronic suppurative otitis media with cholesteatoma. She underwent tympanomastoidectomy with excision of the mass. Histopathologic evaluation revealed the mass to be granulation tissue.<br /><strong>CONCLUSION:</strong> Pulsatile tinnitus is rarely associated with chronic middle ear infection. Granulation tissue arising at the promontory may mimic glomus tumors when accompanied with this symptom. Despite this revelation, it would still be prudent to prepare for a possible glomus tumor intraoperatively so that profuse bleeding and complications may be avoided.</p>

Glomangiopericytoma: The sinonasal mimic of soft tissue hemangiopericytoma

@#A 42-year old Filipino male with a 10-month history of progressive left nasal obstruction and rhinorrhea and a clinical impression of nasal polyposis underwent endoscopic sinus surgery with partial ethmoidectomy and polypectomy. We received several dark-brown, irregular, rubbery tissue fragments with an aggregate diameter of 3 cm. Histopathologic examination shows sheets of spindly tumor cells beneath the respiratory epithelial lining. These spindle cells are closely packed and arranged in short fascicles and storiform clusters surrounding hyalinized large vessels or thin-walled submucosal blood vessels. (Figures 1 and 2) There is no atypia or necrosis. Immunohistochemical studies show strong immunoreactivity to muscle specific actin, and focal reactivity to S-100. (Figure 3) Stains for CD34, caldesmon, cytokeratin, and desmin, are negative. (Figure 4) Based on these features, we diagnosed the case as glomangiopericytoma. Glomangiopericytoma is a rare tumor arising from the pericytes surrounding capillaries, and accounts for less than 0.5% of all sinonasal tumors.1 It has a very slight female preponderance, with a peak incidence during the seventh decade of life. The most common symptom is nasal obstruction, or epistaxis, with accompanying difficulty breathing, sinusitis and headache. A mass, or polyp is the most common clinical finding.2 Hematoxylin–eosin staining shows a well-delineated but unencapsulated cellular tumor underneath the normal respiratory epithelium that effaces or surrounds adjacent normal structures.2 The tumor is composed of closely packed, uniform, oval to spindle-shaped cells, in short fascicles and in storiform, whorled or palisaded patterns. The cells surround numerous branching thin-walled, blood vessels, thus the morphologic resemblance to soft tissue hemangiopericytoma/solitary fibrous tumor. However, in contrast to hemangiopericytoma, glomangiopericytoma shows diffuse reactivity to muscle actins, and non-reactivity to CD34, while hemangiopericytoma shows the reverse reactions. Desmin and caldesmon are likewise non-reactive, distinguishing the tumor from leiomyomas or leiomyosarcomas of the upper aerodigestive tract. Cytokeratin non-reactivity distinguishes it from spindle cell carcinoma. S100, although typically negative, can be focally and weakly positive in a small percentage of tumor.3 Glomangiopericytoma is categorized as a borderline low malignancy tumor with an overall survival of >90% in 5 years but which tends to recur in up to 30% of cases. Strict follow-up is thus required, especially if complete resection is not achieved.1

Metastasizing ameloblastoma

@#A 27-year-old man presented with an 8 cm diameter left maxillary mass and an enlarged cervical lymph node at levels II to III. There was a reported history of a previous unspecified operation on the maxillary mass which had yielded a diagnosis of ameloblastoma. Total maxillectomy with modified radical neck dissection was subsequently performed. Microscopic examination of the maxillary mass shows epithelial islands and cords in a fibro-collagenous stroma. (Figure 1) The islands and cords are lined in the periphery by palisaded columnar cells with regular ovoid nuclei exhibiting reverse polarization. The nuclei are uniform with dispersed chromatin and no significant atypia. Towards the center of these islands are loosely arranged spindly to stellate cells (“stellate reticulum”). (Figure 2) Microscopic examination of the largest submitted lymph node shows an epithelial neoplasm with identical histologic features as the maxillary mass and a residual rim of lymphoid tissue at the periphery enclosed by the nodal capsule. (Figure 3) Similarly, there is neither atypia nor pleomorphism and only a few typical mitotic figures are seen in the nodal tumor. (Figure 4) These features support the diagnosis of a metastasizing ameloblastoma (MA).