Recognizing the distinct cytomorphologic features of solid pseudopapillary neoplasm of the pancreas.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare low-grade malignant tumor with an indolent clinical course and a favorable prognosis that is most commonly seen in young women of reproductive age. We present a case of SPN in a middle-aged man, diagnosed on a limited cytology specimen. Interestingly, this tumor has unique cytomorphologic findings in fine needle aspiration cytology smears, which help distinguish it from other pancreatic lesions. The presence of fibrovascular cores lined by loosely cohesive monomorphic neoplastic cells is a reliable cytomorphologic feature on aspiration cytology. Recognition of this characteristic finding is crucial for the diagnosis of this entity, especially when it presents in unexpected patient populations or when faced with scant cytology specimens. This report focuses on the distinguishing characteristics of SPN and how they compare and contrast with other pancreatic lesions that are in the differential diagnosis of SPN.

A seventeen-year-old female with hepatosplenic T-cell lymphoma associated with parvoviral infection.

Hepatosplenic T-cell lymphoma (HSTL) is rare, being derived from cytotoxic T-cells, and manifests as an extranodal systemic lymphoma. We present an unusual case of a seventeen-year-old female, with no significant prior medical history, presenting with a hepatosplenic T-cell lymphoma. The diagnosis was confirmed by histological examination, immunohistochemisty, and flow cytometry. A staging work-up demonstrated bone marrow involvement by HSTL with concomitant intranuclear parvoviral inclusions.

A thirteen year old female with primary T-cell rich B-cell lymphoma of bone masquerading as chronic recurrent multifocal osteomyelitis.

Primary lymphoma of the bone (PLB) accounts for 2% of all non-Hodgkin's lymphomas, and until recently it had not been well characterized in literature. Most cases present in adulthood (average age 50), with localized painful lesions in the long bones, cranium, or axial skeleton.We describe a case of multifocal PLB in an adolescent female. In this case, the initial presentation, with migratory large joint polyarthralgias and bone pain, mimicked chronic recurrent multifocal osteomyelitis (CRMO). Had a biopsy not been performed the diagnosis would have been missed.

Three patients with both Hodgkin's lymphoma and Castleman's disease: Clinicopathologic correlations and lack of association with HHV-8.

BACKGROUND: The relationship between Hodgkin's lymphoma (HL) and plasma cell-type Castleman's disease (PCD) has been well documented. There have been over 20 cases reported in the literature and nearly all of them were either diagnosed concurrently, or were initially diagnosed as PCD and upon review were found to have interfollicular HL. Human herpes virus type 8 (HHV-8) is present in about 40% of cases with PCD. It predisposes patients to a much higher risk of other malignancies, including Kaposi's sarcoma and non-Hodgkin's lymphoma. Cases linked to HHV-8 are associated with a different morphology than cases that are not linked to HHV-8. It has been proposed that patients with both HL and CD will have lymph nodes with HHV-8-negative morphology. MATERIALS AND METHODS: We present a series of three cases in a retrospective study where patients had both HL and PCD. Surgical pathology reports, clinical histories, and H and E and various immunohistochemical stains on initial work-up were examined and subsequent immunohistochemical stains for HHV-8 were obtained from the Methodist Hospital. RESULTS: Patient 1 was diagnosed with PCD and interfollicular HL in the same lymph node. Patient 2 was first diagnosed with classic HL and 2 years later returned with enlarged lymph nodes clinically suspected to be recurrent HL. Histology showed angiofollicular hyperplasia and interfollicular plasmacytosis without Reed-Sternberg cells and a diagnosis of PCD was rendered. Patient 3, a male in his third decade, was diagnosed with nodular sclerosing HL in the thymus, and concurrently PCD in the mediastinal lymph nodes. All three cases had architectural features consistent with an HHV-8-negative morphology. Immunohistochemical stains for HHV-8 were done retrospectively and were negative. CONCLUSION: All three of our patients with both HL and CD had HHV-8-negative lymph node morphology and absence of HHV-8 by immunohistochemistry. These patients, therefore, are not at an increased risk for the development of subsequent malignancies, when compared to HHV-8-positive patients. Included in our series is one unique case where the diagnosis of HL preceded CD by 2 years.

Laparoscopic Roux-en-Y gastric bypass in patients with congenital malrotation.

Bariatric surgery is the only solution for morbidly obese individuals who desire to lose weight and maintain it and have failed to do so by non-surgical means. As the incidence of morbid obesity rises, laparoscopic Roux-en-Y gastric bypass (LRYGBP) is increasingly performed. With the increase in bariatrics, the chances of discovering aberrant anatomy at the operating-table also increase. We present two cases of LRYGBP in patients with intestinal malrotation, which is a congenital anomaly caused by failure of the intestines to rotate and fixate at 270 degrees during embryonic development. It occurs in one out of every 500 births in the United States, accounting for 5% of all intestinal obstructions. To this date, only three reports have been published describing the incidental finding of congenital malrotation during the initial laparoscopic exploration for gastric bypass. We found that the operation can still be performed laparoscopically in such patients, with some modifications to the standard technique.

Pancreatic mass of unusual etiology: case report of metastatic disease after a prolonged lag phase.

Although not a typical site, the pancreas does occasionally harbor metastatic disease. Management of these metastases differs from the management of conventional primary cancers. Our case is one of an 85-year-old female presenting with obstructive jaundice and whose workup revealed a pancreatic mass. Her past medical history included a mastectomy 14 years previous for invasive lobular carcinoma. She underwent celiotomy, and an intraoperative diagnosis of metastatic lobular carcinoma of the breast was made based on frozen section. Due to pulmonary metastasis and vascular infiltration, which precluded pancreatoduodenectomy, the patient underwent palliative bypass and fared well postoperatively. With more aggressive management of primary breast cancers in the past decade, isolated metastatic disease is of increasing concern and raises questions about surgical strategies to be implemented with these patients. For instance, should palliative treatment be considered or should a radical intention to cure procedure be performed despite the metastatic disease? Factors favoring radical procedures include prolonged lag phase between the primary and the recurrence; presence of well-differentiated tumors; and isolated metastatic disease. Primary lung and renal cancers metastasize more frequently than breast cancers do to the pancreas. Hence, existing literature has not clearly defined indications for radical treatment of metastatic breast cancers to the pancreas. Based on experiences with metastatic renal and lung cancers, one can reasonably infer that radical procedures performed on selected cases could possibly achieve a cure or prolonged disease-free survival. The key factor in determining whether the patient undergoes palliative versus radical treatment is a slow growth pattern of the tumor, characterized by a prolonged lag phase between the primary and the metastatic disease.