Exophytic and fungating papillary thyroid carcinoma: A rare and complex presentation of a well-differentiated malignancy

@#Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.

Melanotic Neuroectodermal Tumor of Infancy: Does Enucleation Alone Suffice?

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare melanin-containing mesenchymal tumor of neural crest origin. We present a case of MNTI in a 1-year-old girl. It was managed successfully with conservative excision (enucleation).

Intradural Extramedullary Nonconus Nonfilum Spinal Ependymomas: Report of a Rare Variant and Newer Insights into Their Histogenesis with Proposal of a Classification Scheme and a Management Algorithm Based on a Review of Literature.

BACKGROUND: Ependymomas are common intramedullary spinal tumors but there are scattered reports of this tumor presenting with exophytic growth patterns masquerading as intradural extramedullary (IDEM) tumors. Such IDEM ependymomas are seldom suspected preoperatively and it is only during surgery that their existence is revealed. Little is known of such rare growth patterns of an otherwise common intramedullary spinal cord tumor, their characteristics, and their management considerations. METHODS: We present a case of an exophytic dorsal ependymoma with a stalk like attachment to the spinal cord and the surgical management in a 24-year old woman. An extensive literature search was carried out on all prominent databases to find out similar cases reported earlier. We excluded filum/conus ependymoma, purely extradural spinal ependymoma as well as the extraspinal ependymomas. Details of each case reported before were obtained and tabulated. RESULTS: IDEM ependymomas have been reported in 54 patients so far, including the present case. Four patterns of growth emerged from the literature review: intramedullary ependymoma with exophytic component (group I, n = 9), exophytic IDEM ependymoma without intramedullary component (group II, n = 6), IDEM ependymoma arising from nerve roots (group III, n = 7), and pure IDEM ependymoma (group IV, n = 32). Except in group I, IDEM ependymoma affects females more frequently, without any specific age predilection. Thoracic spinal cord/canal is the most common location across all groups. Multifocal disease, craniospinal dissemination, and recurrences tend to be maximum in group IV. CONCLUSIONS: IDEM ependymomas are more common in thoracic segment of the cord and broadly divisible into 4 subgroups. We suggest a subpial origin of group II IDEM ependymomas. We also advocate proliferation index estimation in grade II ependymomas to enable formulation of an optimal management plan.

Computed tomographic characteristics of gastric schwannoma.

OBJECTIVE: This study aimed to characterize the computed tomographic (CT) features of gastric schwannoma (GS). METHODS: We retrospectively reviewed CT images of 19 cases of histologically proven GS between January 2010 and December 2015. Tumor location, size, contour, margin, growth pattern, and degree and pattern of enhancement, perigastric lymph nodes, ulceration, necrosis, and calcification were evaluated. RESULTS: GS was located in the gastric body (73.7%), gastric antrum (15.8%), and gastric fundus (10.5%), with a mean maximum diameter of 4.5 ± 1.8 cm. All tumors presented as oval, well-defined solid masses, with exophytic (36.8%), endoluminal (15.8%), or mixed (47.4%) growth patterns. Ulcers (57.9%) and perigastric lymph nodes (47.4%) were observed. Moderate enhancement (87.5%) was observed in the portal phase. Eighteen (94.7%) cases showed homogeneous enhancement. CONCLUSIONS: GS typically presents as a mass in the stomach with an exophytic or mixed growth pattern, moderate homogeneous enhancement, and is prone to be accompanied by perigastric lymph node inflammatory reactive swelling. Larger GSs are more likely to be associated with ulcers.

Exophytic Primary Intramedullary Spinal Cord Glioblastoma: Case Report and Critical Review of Literature.

BACKGROUND: Primary intramedullary spinal cord (IMSC) glioblastoma (GBM) is an extremely rare entity; we report the first case of primary IMSC GBM presenting with exophytic involvement. The prognosis of glioblastoma remains poor due to the aggressive nature of the disease and lack of effective treatment. CASE DESCRIPTION: A 27-year-old Asian female presented to our hospital with a 1-month history of dysuria, incomplete bladder emptying, progressive numbness, and weakness of both lower limbs, as well as a 1-year history of back pain. Spinal magnetic resonance imaging (MRI) revealed an intramedullary lesion and exophytic growth in the T4-T12 and T5-12 regions, respectively. The patient's MRI findings were atypical of spinal glioblastoma. The diagnosis was made on the basis of immunohistochemical and pathologic analyses of tissue samples obtained from an open biopsy. The patient received a standard course of glioblastoma radiotherapy and adjuvant temozolomide chemotherapy, which improved her symptoms in the absence of an apparent reduction in tumor size. CONCLUSIONS: Although MRI is of indisputable importance in the diagnosis of spinal cord lesions, immunohistochemical and histopathologic studies are often required to establish a definitive diagnosis. It remains unclear how the unusual involvement of exophytic growth will affect the prognosis of primary IMSC GBM.

Exophytic Cerebral Hemispheric Low-Grade Glioma: Unusual Growth Pattern of Common Central Nervous System Tumor.

BACKGROUND: Exophytic growth (EG), wherein the tumor mass grows beyond the neuraxial boundary formed by pia mater, remains a rare pattern of glioma growth. It has been described in gliomas at several locations like the brainstem, cerebellum, suprasellar area, spinal cord, and insula. However, EG in hemispheric grade 2 astrocytomas, particularly affecting the convexity subarachnoid space, as against the more spacious basal subarachnoid space, is exceedingly rare. To the best of our knowledge, there is only 1 such case reported in the English literature. Due to the extreme rarity, little is known about these tumors, particularly the mechanisms underlying the EG and their possible clinical implications. CASE DESCRIPTION: A 32-year-old woman presented with partial motor seizures without any neurologic signs. On magnetic resonance imaging of the head, a nonenhancing, T2-hyperintense, right frontal lobe lesion was noted. The majority of the lesion was occupying the adjacent subdural space while still remaining in continuity with the intra-axial globular component. During surgery, the exophytic nature of the lesion was confirmed. We performed maximal resection of the exophytic portion with subtotal excision of the intra-axial component. She recovered uneventfully after surgery and subsequently received external beam radiotherapy for the residual tumor. CONCLUSION: Although extremely rare, cerebral hemispheric grade 2 astrocytomas may have an EG pattern. The exact mechanisms underlying this are not clearly known. More such cases need to be reported so that we can decipher the true nature of these tumors.

Verrucoid Variant of Invasive Squamous Cell Carcinoma in Oral Submucous Fibrosis: A Clinicopathological Challenge.

Verrucous carcinoma (VC) is an exophytic, low-grade, well-differentiated variant of squamous cell carcinoma. It is described as a lesion appearing in the sixth or seventh decade of life that has minimal aggressive potential and, in long-standing cases, has been shown to transform into squamous cell carcinoma. Oral submucous fibrosis (OSMF) is a potentially malignant disorder, and about one-third of the affected population develop oral squamous cell carcinoma. The histopathological diagnosis of verrucous carcinoma is challenging, and the interpretation of early squamous cell carcinoma requires immense experience. Here we present a rare case of a 24-year-old male with OSMF transforming to verrucous carcinoma with invasive squamous cell carcinoma. Even though the case had a straightforward clinical diagnosis, the serial sectioning done for pathological diagnosis disclosed the squamous cell carcinoma.

Management of an unusual peripheral giant cell granuloma: A diagnostic dilemma.

The peripheral giant cell granuloma (PGCG) is a reactive exophytic lesion of the gingiva and alveolar ridge that usually occurs as a result of local irritating factors such as plaque, calculus, chronic infections, chronic irritation, tooth extraction, improperly finished fillings, unstable dental prosthesis, and impacted food which originates from the periosteum or periodontal ligament. This article presents management of an unusual PGCG located on the partially edentulous mandible.

Oral alveolar rhabdomyosarcoma: a case report with immunohistochemical analysis.

Rhabdomyosarcomas are among the most common soft-tissue tumors in children. These tumors are derived from mesenchymal tissue with a tendency toward myogenic differentiation that probably originates from immature and highly invasive satellite cells associated with the embryogenesis of skeletal muscle. Some of these tumors are associated with high rates of recurrence and metastasis. The diagnosis is made by microscopic analysis and auxiliary techniques such as immunohistochemistry, electron microscopy, cytogenetic analysis, and molecular biology. We report a case of 28-year-old man who presented with a painless progressive swelling of gingiva since 3 months, which was gradually increasing in size without any systemic symptoms or signs of any metastatic spread. An incisional biopsy was done and histopathology reported an alveolar variant of rhabdomyosarcoma. Immunohistochemistry with panel of markers was done which showed positivity for CD99, vimentin and negative for desmin and myogenin. So the characteristic immunohistological expression was negative in present case. Hence we conclude that haematoxylin and eosin morphology and ultrastructure are needed to classify rhabdomyosarcoma and immunohistochemistry act only as an auxiliary.

A case of gastrointestinal stromal tumor of the stomach showing exophytic growth / 대한내과학회지

Gastroinstestinal stromal tumors (GISTs) are defined as a group of KIT (CD117) positive mesenchymal tumors. Approximately 70% of those tumors are found in the stomach followed in order by the small bowel, colon and rectum, esophagus. The common clinical presentation of GISTs varies according to the size and location of the tumors, ranging from massive gastrointestinal bleeding to vague abdominal pain. We detected a GIST of the stomach incidentally during chest-computed tomography examination of a 68-year-old-woman. Esophagogastroduodenoscopy showed an 8 cm sized protruded lesion with normal mucosal covering on the posterior wall of the gastric body, and endoscopic ultrasonography showed a cystic mass originating in the fourth layer of the stomach. The patient was treated with a subtotal gastrectomy. Immunohistochemical studies on the surgical resection specimen showed CD117(+) and CD34(+). The final diagnosis was a GIST of the stomach showing exophytic growth.

A Case of Exophytic Squamous Cell Carcinoma of the Stomach / 대한소화기내시경학회지

Squamous cell carcinoma of the stomach has been reported to occur at a younger age and have a worse prognosis than gastric adenocarcinoma. Even though squamous cell carcinoma of the stomach has several different clinical characteristics, it is difficult to distinguish it from gastric adenocarcinoma by radiological or endoscopical methods without a histopathological confirmation. Primary squamous cell carcinoma of the stomach is a rare type of cancer. To date, only six cases have been reported in Korea. Gastric cancer seldom grows exophytically and there are no reports of squamous cell carcinoma of the stomach with exophytic growth in Korea. We report a case of pure squamous cell gastric cancer with exophytic growth with a brief review of the relevant literature.