Metastatic papillary thyroid cancer presenting with a recurrent necrotic cystic cervical lymph node

Summary: We report a case of metastatic papillary thyroid carcinoma presenting with a recurrent right-sided cervical lymph node necrotic cyst. A 55-year-old woman presented with a 3-month history of a right-sided upper neck mass following an upper respiratory tract infection. Past medical history includes a right-sided nephrectomy secondary to a benign renal tumor and hypertension. She was evaluated by Otolaryngology, and fine-needle aspiration was performed. The mass recurred 2 months following aspiration. Ultrasound of the neck showed a 2.2 × 1.4 × 1.9 cm right cervical lymph node with a small fatty hilum but a thickened cortex. Neck computed tomography (CT) scan showed a well-defined 2.3 cm mass in the right upper neck corresponding to a necrotic cervical lymph node at level IIA. It also revealed a 7 mm calcified left thyroid nodule. Cytology revealed a moderate collection of murky fluid with mildly atypical cells presumed to be reactive given the clinical history of infection. The cyst had re-grown 2 months following aspiration. Excisional biopsy was performed and revealed metastatic classic papillary thyroid carcinoma (PTC). Subsequently, a total thyroidectomy and right neck dissection was performed. Pathology confirmed metastatic unifocal classic PTC of the right thyroid lobe and two lymph node metastases out of a total of 17 resected lymph nodes. The patient underwent radioactive iodine ablation. Subsequent I-131 radioiodine whole-body scan showed no evidence of metastases. In conclusion, metastatic PTC should be considered in the differential diagnosis of a recurrent solitary cystic cervical lymph node. Learning Points: Metastatic PTC should be considered in the differential diagnosis of a recurrent solitary cystic cervical lymph node. A dedicated thyroid ultrasound is the preferred modality for identifying thyroid lesion over computed tomography. There is a risk of non-diagnostic cytology following FNA for cystic neck lesions, largely predicted by the cyst content of the nodule.

A Population-Based Study on NIFTP Incidence and Survival: Is NIFTP Really a "Benign" Disease?

BACKGROUND: This study aimed to determine the incidence of noninvasive follicular thyroid neoplasm with papillary-like features (NIFTP) in Ontario, Canada and the predictors of disease-free survival (DFS) by comparing patients with follicular variant papillary thyroid cancer (FVPTC) and patients with NIFTP. METHODS: This population-based retrospective cohort study included all patients who had definitive surgery for well-differentiated thyroid cancer (WDTC) in Ontario, Canada between 1990 and 2001 and were followed until 2014. A conservative decision rule was applied to subtype-select FVPTCs into NIFTPs after pathology report review. The primary outcome was DFS, for which Cox proportional hazard regression analysis was performed to assess the impact of FVPTC versus NIFTP. RESULTS: At pathology re-review of the 725 FVPTC cases, 318 were reclassified as potential NIFTP. The median follow-up time was 15.3 years for the entire cohort and 15.9 years for those alive at the last follow-up visit. Disease failure occurred for 109 patients, 79 (19.4%) in the FVPTC group and 30 (9.4%) in the NIFTP group (p < 0.01). This effect was sustained in the multivariable analysis, with FVPTC showing significantly worse DFS than NIFTP (hazard ratio, 1.84; 95% confidence interval, 1.17-2.89). After recategorization of certain FVPTCs into NIFTPs, the findings showed that NIFTP accounted for 16.8% (1.461/8.699 per 100,000) of all WDTCs. CONCLUSION: The disease failure rate for NIFTP was 9.4%. The NIFTP diagnosis is challenging for the pathologist and may make tumor behavior difficult to predict for this entity. Caution should be used in the management of patients with an NIFTP.

Spontaneous regression of metastatic pulmonary renal cell carcinoma in the setting of sarcomatoid differentiation of the primary tumour.

We present a case of spontaneous regression of pulmonary metastases from renal cell carcinoma (RCC) with sarcomatoid differentiation, prior to intervention. The patient presented with conventional type RCC with Furhman Grade 4/4 and sarcomatoid differentiation, complicated by pulmonary metastases. Palliative systemic therapy was planned, but prior to the onset of treatment, serial computed tomography scans demonstrated regression of metastatic disease. Spontaneous regression of metastases is rare, but well-documented in conventional clear cell RCC. To the best of our knowledge, this has not previously been described in the setting of sarcomatoid differentiation of the primary tumour.

Composite hodgkin and non-hodgkin lymphoma of the mitral and aortic valves.

A 58-year-old man with a remote history of diffuse large B-cell lymphoma (DLBCL), status post chemotherapy, radiation, and peripheral blood stem cell transplantation, presented with splenic nodular sclerosis classical Hodgkin lymphoma. He was found to have aortic and mitral valve mass lesions. The mitral valve mass showed typical histologic and immunophenotypic features of nodular sclerosis classical Hodgkin lymphoma, whereas the aortic valve mass and aortic mitral curtain tissue showed DLBCL with necrosis. Both tumors were Epstein-Barr virus positive and were clonally related; however, they were not related to his DLBCL from 14 years prior. This is the first case report of a patient with a composite lymphoma affecting two cardiac valves.

Synchronous bilateral tonsil squamous cell carcinoma.

OBJECTIVE: We discuss the treatment and pathology of simultaneous bilateral metastatic palatine tonsil carcinoma. The current literature of the diagnosis and management of unknown primary oropharyngeal neoplasms is reviewed including the role of positron emission tomography (PET) imaging. STUDY DESIGN: Squamous cell carcinoma (SCCA) of the palatine tonsil typically presents as a unilateral mass in the oropharynx or as a mass in the ipsilateral neck indicating a lymph node involved with metastasis. The carcinoma rarely presents with involvement of the contralateral lymph nodes, and this situation typically is present only in very advanced local disease. Simultaneous discontiguous disease involving both palatine tonsils is exceedingly rare with less than five cases reported in the medical literature. METHODS: Case report and literature review RESULTS: This case report involves a 51 year-old male with bilateral palatine tonsil squamous cell carcinoma and bilateral metastatic neck disease. He presented with a left cystic neck mass diagnosed as squamous cell carcinoma by fine needle aspiration. On exam, the site of the primary tumor was suspected to be ipsilateral tonsil. PET scanning demonstrated asymmetric FDG activity in the contralateral palatine tonsil and neck. The patient underwent bilateral transoral robotic-assisted partial oropharyngectomy demonstrating separate tonsillar carcinomas, both of which were HPV positive. Bilateral neck dissections demonstrated metastatic involvement of one right and two left cervical nodes. CONCLUSIONS: We describe an exceedingly rare case of bilateral simultaneous metastatic palatine tonsil SCCA. This finding raises the question regarding the need for bilateral tonsillectomy in the case of the unknown primary or proven tonsil carcinoma with HPV positivity.

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells: report of a case with osteochondroid differentiation.

We report a case of an undifferentiated pancreatic carcinoma with osteoclast-like giant cells with focal osteochondroid differentiation in a 66-year-old man, who presented with painless jaundice, pruritus, and weight loss. Imaging studies revealed an inhomogeneous mass in the head of the pancreas. A pylorus preserving pancreaticoduodenectomy was performed. The resection specimen revealed a 9.5 x 4.2 x 3.2 cm(3) solid neoplasm in the pancreatic head with direct extension into duodenum and common bile duct. Microscopy showed a cellular neoplasm composed of pleomorphic mononuclear cells (pancytokeratin, and EMA-positive; LCA, and CD68 negative) and osteoclast-like multinucleated giant cells (vimentin, LCA, and CD68-positive; pancytokeratin, and EMA-negative) consistent with OGTP. The tumor contained a focal area of osteochondroid differentiation. Evidence supports that the tumor giant cells are non-neoplastic and of histiocytic origin. Osteochondroid differentiation within undifferentiated carcinoma is unusual; its presence might suggest a sarcoma diagnosis on biopsy material.

Differential Immunoreactivity of p16 in leiomyosarcomas and leiomyoma variants.

Several studies have now examined the cDNA expression profiles of healthy myometrium, leiomyomas (LM), and leiomyosarcomas (LMS). This has produced a list of candidate genes that might be useful tools for distinguishing these entities from each other. The potential candidates identified from this body of research include insulinlike growth factor 1, h-caldesmon, cytokeratin 18, and the cyclin-dependent kinase 4 inhibitor, p16. To determine whether the immunohistochemical expression of these proteins could aid in the diagnosis of LMS and LM variants, we constructed a tissue microarray consisting of cases of healthy myometrium (n = 10), LM (not otherwise specified and variants; n = 47), and LMS (n = 8), and then measured the immunoreactivity of each of these proteins. The cases were scored on the basis of staining intensity (weak, moderate, or strong) and extent (focal or diffuse) and were assigned a final score from 0 to +3. Immunostaining for p16 was statistically stronger in LMS than in LM and its subtypes (P < 0.001). Specifically, the p16 immunostaining score in LMS cases (n = 8) was at least +2, whereas the p16 immunostaining scores in all LM cases (n = 47) were either 0 (n = 35) or +1 (n = 12). The expression of the remaining antibodies did not show a statistically significant difference between the 2 groups. Furthermore, none of the markers studied showed any differences among the LM variants. The results of this study confirm the overexpression of p16 in LMS and suggest that p16 can serve as a reliable immunohistochemical marker in distinguishing uterine LMS from LM and its benign variants.

Extraskeletal Ewing's sarcoma/primitive neuroectodermal tumor of the posterior mediastinum with t(11;22)(q24;q12).

Ewing's sarcoma/primitive neuroectodermal tumor family of tumors is part of a rare group of malignant neoplasms with small round-cell morphology. We describe a 24-year-old woman who presented with non-specific back pain. A chest radiograph and magnetic resonance imaging demonstrated an extraosseous, dumbbell-shaped mass of the posterior mediastinum with extension into the spinal canal. The patient underwent a left posterolateral thoracotomy and a T3-5 laminectomy with subsequent multi-agent chemotherapy. Histopathologic examination of the tumor demonstrated sheets of primitive small round malignant cells that showed no visible differentiation. Neoplastic cells were strongly immunoreactive for CD99 and vimentin and were negative for chromogranin, synaptophysin, CD31, CD34, calcitonin, desmin, low-molecular weight cytokeratins, wide-spectrum cytokeratins, leukocyte common antigen, S-100 protein, and thyroid transcription factor-1. The neoplasm was diagnosed as a Ewing's sarcoma/primitive neuroectodermal tumor, and cytogenetic studies confirmed a t(11;22)(q24;q12) chromosomal translocation and an associated trisomy of chromosome 2, supporting the histologic diagnosis. Extraskeletal Ewing's sarcoma/primitive neuroectodermal tumors are rare neoplasms that should be distinguished from other small round-cell tumors by morphology and ancillary laboratory techniques. Although rare, they need to be considered in the differential diagnosis of primary mediastinal tumors.

Barriers to diagnosis of occupational asthma in Ontario.

BACKGROUND: Occupational asthma (OA) refers to asthma caused by workplace-specific substances. A longer duration of symptoms while continuing to be exposed has been associated with a worse prognosis. Evidence suggests a significant period of time exists between symptom onset and diagnosis of OA, the reasons for which have not been investigated. The purpose of this study was to examine whether primary health care and/or socio-economic factors account for delays in Ontario. METHOD: Two hundred and forty-seven (247) chart reviews were undertaken of patients referred to the University Health Network Asthma Centre for evaluation of OA, with clinic visits from 1997-2002. Forty-two (42) patients fulfilling objective OA criteria were administered a structured telephone interview to examine the chronology and nature of health care consultation and reasons for possible delay in diagnosis. RESULTS: The mean time to diagnosis was 4.9 years (3.4 years excluding 4 outliers). On average, patients waited 7.4 months before discussing the work-relation of symptoms with a physician. Main self-reported reasons for delay were lack of enquiry about work relatedness by the primary care physician (41%) and fear of losing work time (37%). Reported increases in time during secondary care were related to difficulties associated with completion of investigations (35%). Lower education level (p = 0.04) and household income (p = 0.03) were significantly associated with an increased time to diagnosis. INTERPRETATION: Physicians who assess working adults with asthma need to ask pertinent work-related questions when taking a history in order to initiate timely investigations and referral. Socio-economic factors are also associated barriers to early diagnosis of occupational asthma.