Histoplasmosis of the Head and Neck Region Mimicking Malignancy: A Clinic-Pathological Predicament.

OBJECTIVE: Histoplasmosis is a systemic, deep mycotic infection caused by Histoplasma capsulatum. Disseminated histoplasmosis (DH) is synonymous with HIV seropositive immunocompromised individuals; however, isolated histoplasmosis involving the head and neck mucosal sites mimicking malignancy is a clinical predicament. The result, in a superficial biopsy with marked pseudoepitheliomatous hyperplasia (PEH), in a tertiary care cancer center where the number of squamous carcinomas far outnumber the infectious diseases, could be catastrophic. MATERIAL AND METHOD: The archives of a tertiary care cancer hospital were searched (2010-2019) for cases of histoplasmosis involving the head and neck mucosal sites in HIV non-reactive patients. RESULTS: Six cases of isolated head and neck histoplasmosis were seen in biopsies from 4 men and 2 women, with an age range of 46-72 years. Three of these patients suffered from chronic illnesses. The most common site involved was the larynx (vocal cords) in three cases, two cases were involving lips, and one involving the tongue. The biopsies were reviewed in-house with a clinical diagnoses of malignancy in all and an outside biopsy diagnosis of "squamous cell carcinoma" in 2 cases. The important histological findings in the biopsy were PEH (3 cases), granulomas (2 cases), lymphoplasmacytic inflammation (all cases). Eosinophils were conspicuous by their absence. Intracellular histoplasma was seen in all cases, albeit to varying density, which was confirmed with GMS stain. CONCLUSION: A high index of suspicion, meticulous history taking by oncologists, and appropriate distinction of PEH from neoplastic squamous proliferation by pathologists in superficial biopsies and an apropos deeper wedge biopsy are essential to clinch the correct diagnosis.

Salivary duct carcinoma and small cell carcinoma ex-pleomorphic adenoma: A heretofore undescribed entity and the naming conundrum: MiNEN, combined, collision, or composite tumor?

Carcinoma with dual neuroendocrine and non-neuroendocrine components are recognized albeit a rare occurrence among the head and neck tumours. Owing to a disjointed pathology taxonomy and a lack of defining criteria, these tumors have remained underrecognized and poorly understood by pathologists and oncologists. Herein, we present a heretofore unreported case of a mixed neuroendocrine non-neuroendocrine carcinoma occurring as a carcinoma ex-pleomorphic adenoma (CXPA) in the soft palate of a 32-year-old man. Histologic examination revealed 2 distinctive malignancies comprising salivary duct carcinoma (SDC) and small cell carcinoma (SmCC) arising in a background of a benign pleomorphic adenoma. On immunohistochemistry, the SDC cells were cytokeratin 7 positive, androgen receptor positive, GATA-3 (GATA binding protein 3) positive, and gross cystic disease fluid protein (GCDFP-15) positive and the SmCC cells were synaptophysin positive and chromogranin positive, confirming the presence of 2 different histologic malignancies. We report this case not only for its exceptional rarity but also to discuss the lacunae that exist in the current classification systems that might facilitate an erroneous categorization of these rare tumors. Standardization of nomenclature and defining criteria is imperative to ensure accurate diagnosis, optimal management, and a better understanding of the biology of these enigmatic tumors.

Pathology of gallbladder carcinoma: current understanding and new perspectives.

Gallbladder carcinoma is a rare and highly lethal malignancy. It stands out from amongst the other GI tract malignancies for its unique epidemiological profile, proclivity for female gender, definitional ambiguities, ability to escape early diagnosis, and absence of effective treatment. Pathobiology of gallbladder carcinoma continues to remain poorly understood. Recently, better characterization of the precursor lesions and elucidation of underlying molecular pathways has enhanced our understanding of gallbladder tumorigenesis. Proposal of a unified terminology and evolving consensus in classifying gallbladder pre-invasive neoplasia offers hope of better assimilation of rare data from diverse parts of the world. Identifying biomarkers and cancer specific cellular targets that will pave the way for novel therapeutic approaches for gallbladder carcinoma is urgently needed. In this review we delve into the epidemiologic, genetic and pathologic characteristics of this enigmatic disease with a special focus on the recent advancements in the field of gallbladder pathology.

Stage IV lung cancer: Is cure possible?

Reporting a case, 53 years old male with stage IV Nonsamall cell lung cancer in view of cytologically proven malignant pleural effusion. Usually the management of stage IV lung cancer is with palliative intent where the patient receives palliative chemotherapy along with palliative radiotherapy and surgery if required. Most of the data on curative management of oligometastatic non-small cell lung cancer includes patient with adrenal metastasis and some reports with brain metastasis. There is scarce literature on the surgical management of stage IV lung cancer with pleural effusion.

Solid pseudopapillary tumor of the pancreas: 'experiences' and 'lessons' at a tertiary-care oncology center.

Solid pseudopapillary tumor of the pancreas (SPT) is a rare and fascinating entity of elusive histogenesis and unpredictable biology. It has a peculiar proclivity to afflict young females and involve the pancreatic body-tail region. Cytology diagnosis of these rare neoplasms remains a challenge. We analyzed the cytology features of all SPT cases diagnosed on fine needle aspiration cytology (FNAC) from 2003 to 2009 along with their histopathology slides. Nineteen consecutive cases were diagnosed as SPT on FNAC. Fifteen out of nineteen cases were confirmed as true SPT on histopathology. Amongst the true SPT, all except one occurred in females. Age ranged from 14 to 50 years. Pseudopapillae bearing stout branches terminating in bulbous tips and enclosing transgressing vessels, separated from a collar of tumor cells by a clear zone of myxohyaline coat were pathognomonic of SPT. Singly dispersed monomorphic tumor cells with bland chromatin formed the second diagnostic component of SPT. Nuclear grooves and hyaline globules were in addition helpful in segregating SPT from its close differentials. In four cases diagnosed as SPT on FNAC, histopathology revealed a different final diagnosis (one case each of paraganglioma, extragastrointestinal stromal tumor, metastatic papillary renal cell carcinoma and inflammatory myofibroblastic tumor). Conversely, one case of SPT had been erroneously diagnosed as neuroendocrine tumor on FNAC. Six cases (40%) developed metastasis; commonest site being liver. In conclusion, cytology in conjunction with clinico-radiologic findings plays a key role in making a correct diagnosis. Awareness of unique cytomorphological features is important in distinguishing this tumor from its diverse mimics.

Balloon cell melanoma of the anal canal: a wolf in sheep's clothing?

Balloon cell melanoma (BCM) is a rare histologic variant of cutaneous malignant melanoma with exceptional reports of occurrences at non-cutaneous sites. Herein we present a case of primary amelanotic BCM of anal canal, a heretofore undescribed location. Histologically, the tumor was characterized by sheets of pale cells that bore striking resemblance to foamy macrophages. Presence of rare atypical mitoses confirmed the malignant nature of the cells. Neoplastic cells were immunoreactive for S100, Melan-A, and focally for HMB-45 while were negative for myogenic, gastrointestinal stromal tumor, epithelial and neuroendocrine markers. Resemblance to foamy macrophages, bland cytology and absence of pigment imparts this tumor a deceptively benign histological appearance making it prone to diagnostic pitfalls. Awareness of this rare entity and judicious employment of immunohistochemistry is imperative in segregating it from its diverse mimics.

Are we achieving the benchmark of retrieving 12 lymph nodes in colorectal carcinoma specimens? Experience from a tertiary referral center in India and review of literature.

INTRODUCTION: The number of lymph nodes (LNs) retrieved from a specimen of colorectal carcinoma may vary. Factors that can possibly affect LN yield are age of the patient, obesity, location of the tumor, neoadjuvant therapy, surgical technique and pathologist's handling of the specimen. AIM: The aim of our study is to look at lymph node retrieval from colorectal cancer (CRC) specimens in our hands and review the literature. MATERIALS AND METHODS: From May 2010 to January 2011, a total of 170 colorectal carcinoma cases were operated in our institute. Type of the surgeries, lymph node yield was looked at. RESULTS: There were 103 (60.6%) males and 67 (39.4%) females. The commonest age group was 50-59 years (30.6%). The surgeries included 107 surgeries for rectal carcinoma (63%) and 63 surgeries for colonic carcinoma (37%). Sixty six (38.8%) cases had received preoperative chemoradiotherapy, whereas 104 (61.2%) cases were without adjuvant therapy. The total lymph node positivity (metastatic disease) was 44.7% .The overall mean lymph node yield was 12.68 (range 0-63; median 11). The mean lymph node harvest in the age group < 39 was 15.76 whereas, the lymph node harvest in the group more than 39 years old was 11.90. ( statistically significant; P=0.03). The mean lymph node yield from specimens of rectal cancers (10.30) was lower than the mean lymph node yield from specimens for colonic cancers (16.71);( statistically significant, P<0.01). There was also statistically significant difference between the mean LN yield in chemoradionaiive cases (14.63) and in the cases where neoadjuvant therapy was received, (9.59); P<0.01. CONCLUSION: Pathologist while assessing a specimen of CRC should aim to retrieve a minimum of 12 LN. Surgical expertise and diligence of the pathologists remain two main alterable factors that can improve this yield. Neoadjuvant or preoperative radiotherapy can yield in less number of nodes.

Does c-erbB-2 expression have a role in medulloblastoma prognosis?

The prognosis of patients with medulloblastoma has remained same for the last two decades. This study evaluated the role of c-erbB-2 expression in medulloblastoma as a prognostic marker. Fifty cases of medulloblastomas were investigated for the expression of c-erbB-2 protein using immunohistochemistry. The expression of c-erbB-2 was correlated with age, histology and disease-free survival (DFS). Thirty-five (70%) tumors were c-erbB-2 positive. Immunoreactivity for c-erbB-2 receptor was observed as mixed cytoplasmic and membrane positivity of tumour cells. The mean DFS in c-erbB-2 positive cases was 19.81 months compared to 48.33 months in c-erbB-2 negative cases. c-erbB-2 positivity was found to be an independent predictor of poor outcome in medulloblastoma (p value < 0.05). No correlation of c-erbB-2 expression was observed with the age of patient and the histological type of tumour. Additionally, c-erbB-4 expression was also evaluated in these tumours. Thirty-three cases showed co-expression of c-erbB-2 and c-erbB-4 proteins. However, c-erbB-4 expression alone was not associated with poor outcome, whereas its co-expression with c-erbB-2 was associated with shorter DFS (p < 0.05).