Benign Entity Research Articles

Breast metastasis from large cell neuroendocrine carcinoma of the lung: a case report

Abstract Background Primary breast carcinoma is far more common than breast metastases. Common breast metastases usually come from lymphoma, leukemia, melanoma, and ovarian cancers. Breast metastases from neuroendocrine carcinomas are considered an exceeding rare entity. It has been reported in the literature that the pathological presentation of this particular metastatic tumor is very challenging as it shares many morphological characteristics with primary breast carcinoma. Case presentation We report a case of a patient with large cell neuroendocrine carcinoma of the lung metastasizes to both breasts. The patient was initially presented with brain metastasis of unknown origin. Further radiological imaging workup showed multiple bilateral breast masses and bilateral lymphadenopathy, which raised concern for secondary lymphoma of the breast. The histopathology of this case was challenging, particularly when triple negative invasive ductal carcinoma diagnosis had been made. Multidisciplinary meetings between medical oncologists, radiologists, and pathologists profoundly helped confirming the diagnosis of metastatic large cell neuroendocrine tumor to the breast. Conclusion Large cell neuroendocrine carcinoma of the lung is a relatively uncommon diagnosis with generally poor prognosis. Large cell neuroendocrine carcinoma that metastasizes to the breast is even scarcer. Correlation between clinical assessment, radiological imaging, and pathological evaluation is the key in making such an unusual and complex diagnosis. Additionally, radiologists should be aware of metastatic presentations of the breast and avoid confusion with mimicking benign entities or primary breast carcinomas.

Cardiovascular and arrhythmic manifestations of Bartter's and Gitelman's syndromes: do not forget the heart. A narrative literature review.

Bartter's and Gitelman's syndromes (BS/GS) are genetically determined kidney tubulopathies leading to electrolyte and neurohormonal abnormalities. Although considered benign entities, major adverse cardiovascular events may complicate both syndromes, in form of ventricular arrhythmias leading to palpitations, syncope or sudden cardiac death, microvascular cardiac dysfunction and exercise-induced myocardial contractile deficit. The mechanisms leading to cardiovascular complications are not only driven by chronic electrolyte abnormalities, i.e. chronic hypokalemia and hypomagnesemia, but also by neurohormonal alterations that can impair vascular tone and myocardial contractility. In presence of triggering factors, BS/GS patients may experience a spectrum of cardiac arrhythmias necessitating prompt diagnosis and treatment. The aim of this review is to explore the pathophysiological mechanisms of BS and GS, highlighting those responsible for cardiovascular involvement, and to analyze the spectrum of associated cardiovascular complications. This highlights the importance of an integrated shared management of GS/BS patients between Nephrologist and Cardiologist.

CT and MRI of pancreatic cystic lesions: tricks of the trade

PurposeTo describe CT and MRI findings of pancreatic cystic lesions.BackgroundThe growing use of ultrasound, CT and MRI has led to increasing incidental detection of pancreatic cystic lesions. These lesions range from benign entities (e.g., acute necrotic collection) to potentially malignant neoplasms (e.g., IPMN) and malignant neoplasms (e.g., ductal adenocarcinoma). CT and MRI can help to differentiate pancreatic cystic lesions.FindingsPancreatic cystic lesions neoplasms often have pathognomonic CT and MRI characteristics. It is important to consider size, number of cysts, septa, the relationship with the main pancreatic duct, internal nodules and wall enhancement. Guidelines from different societies have been developed to promote and standardize the management and follow-up of pancreatic cystic lesions.ConclusionCT and MRI play a crucial role in the detection and characterization of pancreatic cystic lesions.

A case of Russell body gastritis associated with psychiatric disorder

Abstract Introduction/Objective Russell body gastritis is a benign and rare entity characterized by infiltration of lamina propria with plasma cells stuffed with spherical eosinophilic cytoplasmic inclusions known as Russell bodies which represent immunoglobulins. Russell bodies accumulate due to dysfunction in secretion pathway of plasma cells. Plasma cells with Russell bodies are also termed Mott cells. Although exact etiology is unknown, but it can be seen in association with other conditions like mucosa associated lymphoid tissue (MALT) lymphoma, multiple myeloma and plasmacytoma. This condition most commonly affects the antrum and may present as erythema or sometimes nodular lesion. Definitive diagnosis is based on histology. Methods/Case Report A middle-aged male with past medical history significant for polysubstance use disorder, bipolar disorder, and osteoarthritis was evaluated for bleeding per rectum and dyspepsia in the setting of chronic nonsteroidal anti-inflammatory drugs (NSAID) and ethanol use. Physical examination was remarkable for an external hemorrhoid and complete blood count showed anemia. Upper GI endoscopy and colonoscopy was performed. Patchy erythema was seen in antrum and duodenal bulb, and colonoscopy was unremarkable. Microscopic examination showed numerous plasma cells with Russell bodies (Mott cells) in the lamina propria and mild chronic inflammation in gastric mucosa. H. Pylori was negative by immunohistochemistry (IHC). Plasma cells were polyclonal and positive for CD138, and negative for cytokeratin which excluded plasmacytoma and signet-ring adenocarcinoma, respectively. Patient was placed on proton pump inhibitor therapy and discharged. Results (if a Case Study enter NA) Russell body gastritis can be seen in patients with and without H. Pylori infection. Cytokeratin, kappa and lambda immunohistochemistry stains, and gene rearrangement studies may be needed to exclude frequent lesions that may enter in the differential diagnosis. Long term effects and clinical significance of russell bodies accumulation is yet to be determined. Conclusion Russell body gastritis is a rare morphologic variant of chronic gastritis that may enter in the differential diagnosis with other more serious lesions. A careful morphologic examination and occasionally IHC stains / molecular studies are needed to make the correct diagnosis.

Pitfalls in Diagnosis of Myoepithelial Carcinoma of Salivary Glands: A Study of 3 Cases with Cytologic-histologic Correlation and Molecular Analysis.

Myoepithelial carcinoma (MECA) represents < 1% percent of salivary gland (SG) tumors with a mean age of 55 years. These tumors can arise de novo or in association with pre-existing pleomorphic Adenoma (PA). The cytologic features of MECA overlap with other SG neoplasms including the more common benign entities like PA and myoepithelioma and can pose a diagnostic challenge. A database search for MECA was performed spanning 10 years. 3 cases qualified with available cyto-histologic correlation. All were morphologically MECA with one case diagnosed as MECA ex-PA. The cases were subjected to a comprehensive immunohistochemical and molecular evaluation (Case#1 has been previously reported and published in head and neck pathology in 2021). A comparative analysis of these cases is presented in Table1. All three cases were initially diagnosed as PA on cytology. On review of cytology slides, presence of metachromatic stromal fragments and bland myoepithelial cells was found to be the most common diagnostic pitfall. S100 was positive in all cases while myosin, p63, and GFAP were variably positive. Molecular analysis revealed novel, previously undescribed mutations in the three cases. Additionally, two of three cases expressed PD-L1, suggesting a role for immunotherapy in treatment. Cytomorphology of MECA is poorly described in literature and can pose a diagnostic challenge due to overlapping features with salivary gland benign neoplasms. A conclusive diagnosis on cytology is often not possible. However, a high cellularity, predominant oncocytoid/ myoepithelial cell population on smears and cell block, along with a strong clinical and radiologic suspicion for malignant salivary gland tumor, should alert the cytopathologist and help avoid an erroneous benign diagnosis on cytology.

Nephrogenic Adenoma: A Pitfall on Frozen Section of Urethral Strictures.

Urethral strictures are a common cause of urinary obstruction which can be treated with surgical resection. Frozen sections are rare and pose a diagnostic challenge to pathologists due to the presence of benign lesions such as nephrogenic adenoma. We retrospectively examined all specimens of urethral stricture resections submitted to pathology at our institution from 2012 to 2022 (n = 258). Final pathology reports were searched to identify patients with dysplasia, carcinoma, or nephrogenic adenoma. When available, frozen section reports were also examined and compared to the final report, and additional clinical history and microscopic images were collected for patients with nephrogenic adenoma. Nephrogenic adenoma was identified in 3.8% (10/258) of urethral stricture resections. Dysplasia was identified in one patient who underwent two separate resections, and squamous cell carcinoma was found in one resection. Intraoperative frozen section was requested in 3.4% of resections (9/258). In two resections, an initial diagnosis of squamous cell carcinoma was initially favoured, however when reviewed with a genitourinary pathologist the diagnosis was changed to "reactive process" with a final diagnosis of nephrogenic adenoma. Nephrogenic adenoma can be challenging on frozen section due to variable architectural patterns, inflammation, and reactive changes. While urethral strictures are relatively common, their assessment by frozen section is rare and pathologists may lack familiarity with the variable morphology of benign entities that can be seen on frozen section resulting in their misinterpretation. We highlight this potential diagnostic pitfall and demonstrate the value of a second opinion prior to definitive frozen section diagnosis of malignancy.

Trajectory of Subsequent Breast Cancer Diagnoses in a Diverse Patient Cohort with Breast Atypia.

Proliferative breast atypical lesions, including atypical ductal hyperplasia (ADH) and lobular intraepithelial neoplasms (LIN), represent benign entities that confer an elevated risk of ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC). However, the timing of disease progression is variable and risk factors associated with the trajectory of disease are unknown. Patients diagnosed with ADH or LIN from 1992 to 2017 at an academic center were identified. Early progression was defined as DCIS or IBC diagnosed within 5years following the initial atypia diagnosis. Unadjusted cancer-free survival was estimated using the Kaplan-Meier method. Demographics, clinicopathologic features, and use of chemoprevention were compared between the early and late development groups. Overall, 418 patients were included-73.7% with ADH and 26.3% with LIN. Over a median follow up of 92.1 months, 71/418 (17.0%) patients developed IBC (57.7%) or DCIS (42.3%). Almost half (47.9%, 34/71) were diagnosed within 5 years of their initial atypia diagnosis, and 52.1% (37/71) were diagnosed after 5 years. Patient and atypia characteristics were not associated with rate of events or time to events. There was a trend of early events being more often ipsilateral (76.5% early vs. 54.1% late; p=0.13) versus contralateral. In a large cohort of patients with breast atypia and long-term follow up, 17% experienced subsequent breast events, with approximately half of the events occurring within the first 5years following the initial atypia diagnosis. Clinical features were not associated with the trajectory to subsequent events, supporting that atypia signals both local and overall malignancy risk.

Symptomatic Cerebellar Thrombosed Developmental Venous Anomaly: A Case Report

Abstract Background With the rising prevalence of advanced neuroradiological imaging, detection of incidental developmental venous anomalies (DVAs) is more commonplace. DVAs are rarely symptomatic (&amp;lt;2%). Typically, symptoms arise due to flow-related complications or mechanical effects. Of particular concern is venous thrombosis, a frequent flow-related complication, which can cause venous ischemia or haemorrhage. Thus, early recognition and intervention is important. Methods We describe a case of a 54-year-old male, with background of hypertension, presenting three days after sudden onset headache, ataxia, and diplopia. Initial clinical examination revealed bidirectional horizontal gaze-evoked nystagmus, skew deviation, and decreased temperature sensation of the left face. Ophthalmological examination identified left inferior rectus limitation. Results Initial non-contrast CT brain identified hypoattenuation in the right pons, suggestive of sub-acute infarction. Secondary prevention was initiated. Subsequent MRI performed 5 days later revealed hyperattenuation on T2 and FLAIR in the pons, right middle cerebellar peduncle, and right cerebellar hemisphere without restricted diffusion. SWI sequences identified an abnormal venous structure in the right cerebellum, with increased signal within it, suggestive of thrombus. The patient was diagnosed with a thrombosed DVA with associated venous oedema. Symptoms had resolved on dual antiplatelet therapy, without anticoagulation. Conclusion This case highlights the potential for DVAs, generally considered a benign entity, to become symptomatic with associated parenchymal damage and a rare, but important, stroke mimic. Moreover, it underscores the pivotal role of MRI imaging; while a CT scan might have led to the assumption of a subacute infarct, MR imaging led to a complete re-evaluation of the diagnosis in this case.

Misdiagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies.

The rising prevalence of pancreatic cystic lesions (PCLs), particularly intraductal papillary neoplasms (IPMNs), has been attributed to increased utilization of advanced imaging techniques. Incidental detection of PCLs is frequent in abdominal CT and MRI scans, with IPMNs representing a significant portion of these lesions. Surveillance of IPMNs is recommended due to their malignant potential; however, their overlapping imaging features with benign entities can lead to misdiagnosis, overtreatment, and overutilization of healthcare resources. This paper aims to highlight and differentiate lesions often mistaken for IPMNs, providing insight into their imaging characteristics, diagnostic challenges, and distinctive features while highlighting the incidence of wrong diagnosis for these lesions. These lesions include serous cystadenomas, cystic pancreatic neuroendocrine tumors, mucinous cystic neoplasms, lymphoepithelial cysts, duodenal diverticula, pancreatic schwannomas, chronic pancreatitis, retention cysts, intrapancreatic accessory spleens, pancreatic lipomas, choledochal cysts, and others. Utilizing various imaging modalities, including contrast-enhanced CT, MRI, and EUS, alongside histological and molecular analyses, can aid in accurate diagnosis and appropriate management. Understanding these mimicry scenarios is crucial to avoid unnecessary surveillance, interventions, and the burden they place on both patients and healthcare systems. Improved recognition of these lesions can lead to better patient outcomes and resource allocation.

Differentiating extradural head and neck arterial fenestrations from other intraluminal abnormalities

Background and PurposeArterial fenestrations are a benign entity arising from a failure of fetal fusion. However, fenestrations in the head and neck may be misinterpreted as carotid webs or dissections. Given differences in clinical management, the differentiation of these entities is imperative. We aim to document the prevalence of these entities on CTA imaging and highlight imaging features for confident differentiation. Materials and MethodsWe retrospectively reviewed head and neck CTA studies performed at our institution over an 18-month period. The extradural common carotid, internal carotid, external carotid, and vertebral arteries were inspected for intraluminal abnormalities. These abnormalities were classified as fenestration, web, or dissection. Location and associated non-atherosclerotic calcification, pseudoaneurysm, or thrombosis were also documented. ResultsA total of 1800 head and neck CTAs were examined. Normal extradural arteries were seen in 1731 patients (1731/1800; 96.2 %). An intraluminal abnormality was evident in the remaining 69 patients (69/1800; 3.8 %). There were 16 carotid webs (16/1800; 0.9 %), 46 dissections (46/1800; 2.6 %), and 7 fenestrations (7/1800; 0.4 %). An associated non-atherosclerotic pattern of calcification was only identified in a single fenestration case (1/7; 14.3 %). Thrombosis was not identified in any fenestration case. ConclusionArterial fenestrations of the extradural head and neck arterial vasculature are evident on 0.4 % of CTAs. It is important to differentiate these benign entities from carotid webs and arterial dissections. With the appropriate knowledge and interpretive tools, characteristic imaging findings on CTA can be used for reliable differentiation.

Spectrum of blue nevus-like lesions, including blue nevus, pigmented epithelioid melanocytoma & animal-type melanoma

Blue nevus-like lesions constitute a category of melanocytic lesions clinically identified by their blue coloration. Histologically, they exhibit two primary features: a dermal location and intense pigmentation. The latest World Health Organization (WHO) classification categorizes blue melanocytic lesions into benign entities (dermal melanocytoses, blue nevus, and deep penetrating nevus), melanocytic tumors with low to intermediate malignant potential (pigmented epithelioid melanocytoma, PEM), and malignant lesions (blue nevus-like melanoma and melanoma arising in blue nevus).Clinically, blue nevi are enduring and stable lesions, displaying a structureless blue pigmentation both clinically and dermatoscopically, with a straightforward histologic diagnosis. Conversely, lesions with recent onset and/or rapid growth are more commonly associated with diagnoses falling within the intermediate part of the spectrum or with melanoma. These lesions often present with a blue color along with additional features such as black blotches, irregular vessels, and irregular pigmented globules. They typically emerge de novo without recognizable precursors, they pose significant challenges for patient management.Melanoma on a blue nevus is an exceedingly rare entity with only a few cases described to date. Histologically, differentiating between lesions with intermediate malignant potential and melanoma is always challenging, necessitating a comprehensive evaluation of all morphologic findings of the lesion.

A report on five cases of cholesterol granulomas in the thymus

BackgroundCholesterol granuloma (CG) is a benign entity characterized by the presence of cholesterol crystals and foreign body giant cells. This condition can be attributed to cholesterol crystals that are deposited in the tissues and react with foreign body giant cells, resulting in granuloma formation. Lesions commonly develop in the otolaryngeal region, such as the middle ear. However, crystals rarely form in the thymus, accounting for 1% of all mediastinal tumors. Herein, we present five cases of mediastinal CG.Case presentationThe patients were aged 49–61 (mean, 55.4) years. Among them, three were men and two women. One patient had fever, and four patients were asymptomatic. The patients’ lesions were detected during follow-up of other diseases or medical examinations showing the presence of abnormal chest shadows. The patients did not have a history of trauma or surgery. All lesions were located within the thymus gland. Three patients presented with multifocal lesions and two with a single lesion. Four patients had contrast effect on computed tomography scan. Four patients had abnormal fluorodeoxyglucose accumulation (mean maximum standardized uptake value, 4.67) on positron emission tomography-computed tomography. Four patients underwent complete surgical resection. The size of the resected lesions ranged from 1.8 to 5.1 (mean, 3.24) cm. Histologically, all patients presented with small nodules with cholesterol clefts and foreign body giant cells and histiocyte infiltration within the thymic tissue. The postoperative course was excellent. None of the patients who underwent complete resection presented with recurrence. Moreover, the patient who underwent partial resection did not have lesion enlargement.ConclusionsCG in the thymus is clinically challenging to differentiate from malignant lesions, and histologic diagnosis via surgical resection is required.

Nipple adenoma: A clinicopathological study over a period of six years in tertiary care center.

Nipple adenoma (NA) is a rare benign neoplasm of the nipple arising from the lactiferous duct. Often seen in middle aged women, presenting as a nodule, erosive, or ulcerative lesion and associated with serous or bloody discharge. Histologically, they comprise closely arranged tubules with papillary infoldings centered around the lactiferous ducts. It is most likely clinically confused with Paget's disease and histologically with invasive breast carcinoma or its precursor lesions. The aid of immunohistochemistry is valuable in differentiating these entities and to definitively exclude malignancy. All cases with available slides and blocks, diagnosed as nipple adenoma, during the period of January 2015 to December 2021, will be identified through an appropriate query search from the pathology database. Clinico-radiological details and histopathology will be studied and analyzed. The available follow up data and clinical outcome will be assessed. Sixteen cases of nipple adenoma were studied and the median age at diagnosis was found to be 37 years. Nipple discharge and swelling were the most common presentations. Ultrasound imaging was done in 14 cases with the median size of lesion being 0.8cms. Seven underwent excision biopsy followed by histopathological examination. The most common histological pattern observed is "adenosis" pattern. Immunostains p63, smooth muscle myosin heavy chain (SMMHC) and CK5/6 were performed. Nine cases were on follow up but none had recurrence. NA is a benign entity with varied histological patterns. Histopathological examination with the aid of immunohistochemistry helps in diagnosis and to rule out other mimickers. Surgical excision is the treatment of choice.

Update of newly-recognized salivary gland neoplasms: molecular and immunohistochemical findings and clinical importance.

With the advancement of molecular testing and the routine use of immunohistochemical stains, salivary gland tumours previously categorized as adenoma or adenocarcinoma, not otherwise specified, are being reclassified with distinct diagnoses. Newly recognized benign entities include: sclerosing polycystic adenoma, keratocystoma, intercalated duct hyperplasia and adenoma, and striated duct adenoma. Newly recognized malignant salivary gland tumours include: microsecretory adenocarcinoma, sclerosing microcytic adenocarcinoma, and mucinous adenocarcinoma. Additionally, rare subtypes of mucoepidermoid carcinoma have been described, including Warthin-like and oncocytic. Understanding of intraductal carcinoma continues to evolve. Correctly distinguishing these lesions from mimickers can be crucial for appropriate patient care and prognostication, as well as future conceptualization of salivary disease.

Adult Thornwalt Cyst: A Rare Case Report.

Nasopharyngeal cysts are rare benign entity, smaller in size and usually asymptomatic. They are mostly diagnosed incidentally on MRI. Larger cysts commonly presents with spasmodic and obstructive symptoms. Thornwaldt cysts are congenital cysts originating from the mid- line of the nasopharynx just above the upper border of the superior constrictor muscle. They represent primitive communication between notochord remnants and the pharyngeal endoderm. We report this case because of its unique presentation in a 35year old male. Patient presented with nasal blockage, nasal discharge, snoring, ear pain and aural fullness, intermittent neck pain and neck stiffness. Preoperative evaluation included diagnostic nasal endoscopy (DNE) and Magnetic resonance imaging (MRI-scan). A large cystic mass of size 2.8cm × 3cm was diagnosed on DNE and MRI. Transnasal Marsupialisation and excision of the cyst was planned using powered instruments. Post operatively, patient noticed marked improvement in the obstructive symptoms. Regular follow up was done 6 monthly for 2years. No recurrence was noted on DNE. Although a rare pathology in adulthood, it should be kept as a differential diagnosis for cervical pain and neck stiffness.

DyHDGE: Dynamic heterogeneous transaction graph embedding for safety-centric fraud detection in financial scenarios

Dynamic graph fraud detection aims to distinguish fraudulent entities that deviate significantly from most benign entities within an ever-changing graph network. However, when dealing with different financial fraud scenarios, existing methods face challenges, resulting in difficulty in effectively ensuring financial security. In fraud scenarios, transaction data are generated in real time, in which a strong temporal relationship between multiple fraudulent transactions is observed. Traditional dynamic graph models struggle to effectively balance the temporal features of nodes and spatial structural features, failing to handle different types of nodes in the graph network. In this study, to extract the temporal and structural information, we proposed a dynamic heterogeneous transaction graph embedding (DyHDGE) network based on a dynamic heterogeneous transaction graph, considering both temporal and structural information while incorporating heterogeneous data. To separately extract temporal relationships between transactions and spatial structural relationships between nodes, we used a heterogeneous temporal graph representation learning module and a temporal graph structure information extraction module. Additionally, we designed two loss functions to optimize node feature representations. Extensive experiments demonstrated that the proposed DyHDGE significantly outperformed previous state-of-the-art methods on two simulated datasets of financial fraud scenarios. This capability contributes to enhancing security in financial consumption scenarios.

Risk of TIRADS-based inappropriate FNAC in autonomous thyroid nodules is clinically negligible.

Thyroid nodule (TN) is usually managed according to Thyroid Imaging And Reporting Data Systems (TIRADS) with the major aim to reduce as much as possible unnecessary fine-needle aspiration cytologies (UN-FNACs). Since the assessment of autonomously functioning thyroid nodule (AFTN) according to TIRADS is heterogeneous, that virtually benign entity may increase the rate of UN-FNAC. This study retrospectively analyzed the appropriateness of TIRADS-based FNAC indication in AFTNs, also looking at the impact of TSH and nodule size. Cases diagnosed with AFTN on scintigraphy were searched. Patients who had undergone AFTN treatment, were on medications or supplementation that could affect thyroid function, or had multiple AFTNs were excluded. The AFTNs were assessed according to ACR-TIRADS. Forty-eight AFTNs were included of which 37.5% had FNAC indication according to TIRADS. The FNAC indication rate in the case of TSH lower than 0.4 mIU/L was significantly higher than in other cases (P = 0.0078). The most accurate TSH cut-off and AFTN size associated with UN-FNAC were ≤ 0.41 mIU/L and > 22 mm, respectively. The multivariate analysis showed that both TSH and nodule size were independent predictors of UN-FNAC with OR of 6.65 and 6.46, respectively. According to these data, the rate of FNAC indication dropped to 4.16%. Inappropriate FNACs in AFTNs are primarily observed in patients with low TSH and large AFTN. Since these cases typically undergo scintigraphy, the risk of TIRADS-based UN-FNAC is clinically negligible. There is no need for integrating other imaging procedures into the TIRADS model.

Lichen Planus-Like Keratosis – A Unique Entity

Lichen planus-like keratosis (LPLK) is a benign skin lesion that can be challenging to distinguish from various benign and malignant skin tumours. We are presenting two cases with a single, asymptomatic dark flat lesion on the face and scalp. Dermoscopy of both lesions showed pigment pseudo-network, pigment dots and globules, as well as few white structureless areas. The diagnosis of LPLK was confirmed on histopathology. It is frequently confused with malignant conditions, and therefore, it is essential to be aware of this benign entity to prevent unnecessary psychological impact on the patient of a diagnosis of malignancy as well as to avoid unwarranted biopsies.

Clear cell adenocarcinoma of the cervix and its mimickers - A series of 19 cases from a tertiary care referral centre in India.

Clear cell adenocarcinoma (CCAC) of cervix is a rare subtype of endocervical adenocarcinoma that accounts for 4% of all cervical adenocarcinoma with many morphological mimickers. Retrospectively study cases of cervical clear cell adenocarcinoma of the cervix. Clinical profile and pathological features of CCAC of the cervix diagnosed between 2018-2022 were retrospectively analyzed.The database of the Department of Pathology of our institute was systematically searched for patients diagnosed with clear cell adenocarcinoma of the cervix during 2018-2022.A total of 19 patients were studied with the mean age of patients being 53.72 years (range 25 -84 yrs,standard deviation-25.9) and median tumor size being 5.6cm. Lymph node metastasis was identified in 33.3% and distant metastasis were seen in 20% of the cases. Staging could not be done in 4 cases.FIGO staging of the cases included IB1(2 cases), IB2(2 cases), IIB (3 cases),IIIA (1 case)IIIB(4 cases),and IV(3 cases). On histopathological evaluation, heterogeneous architectural pattern comprising of tubulocystic, solid, and papillary patterns were seen in 13 cases (13/19,68.4%). Pure tubulocystic (3/19,15.7%), pure papillary (2/19,10.5%), and pure solid patterns (1/19,5.3%) were also identified. Tumor cells with clear cytoplasm ranged from 5% to 95%. Nuclear atypia was moderate to marked in all the cases (19/19,100%). Mitotic activity varied from 1/10hpf to 20-22/10hpf. By immunohistochemistry, tumor was positive for Napsin A in all the cases,p16INK4a was negative in majority of cases (15/19,78.9%) and ER was negative in 14 cases (14/19,73.7%) .p53 showed wild type staining except for one case . Clear cell adenocarcinoma being a rare subtype of cervical adenocarcinoma, needs to be differentiated from other Human Papilloma Virus(HPV) independent adenocarcinomas (gastric and mesonephric types) and benign entities such as endocervical glandular Arias-Stella reaction. Judicious use of a panel of immunostains is often helpful.

A Review and Case Series of Uterine Lipoleiomyomata

Purpose: The purpose of this case series is to understand the prevalence, clinical significance, pathophysiology, pathology findings, and workup of uterine lipoleiomyomas. Methods: This case series, with cases in February and March of 2023, includes the presentation, clinical management, and pathologic diagnosis of two separate uterine lipoleiomyomas. Separate chart reviews were performed on each patient, including frozen and permanent section pathologic findings. Micropictographs were obtained from hematoxylin and eosin-stained slides. This project was acknowledged as “IRB-exempt” by the MU Institutional Review board. Results: Case 1: A 51-year-old G3P2 woman presented with six months of severe postmenopausal bleeding, severe left-lower quadrant pelvic pain, and lightheadedness. A transvaginal ultrasound revealed a heterogeneous, thickened endometrial echo of 3.9 centimeters and a probable left ovarian dermoid cyst. CT showed distension of endometrial cavity due to polyps and/or submucosal masses, as well as a fat-containing mass in the uterine corpus. Hysteroscopy with dilation and curettage was performed with pathology of high-grade malignancy. Differential diagnosis at this time included high-grade stromal sarcoma, undifferentiated carcinoma, adenosarcoma, or malignant mixed Mullerian tumor. Patient underwent MRI due to concern for malignancy, which showed FDG-avid endometrial thickening with no other FDG-avid areas of concern. Histopathologic diagnosis found carcinosarcoma of the uterus, two positive lymph nodes, and an incidental finding of lipoleiomyoma. Plan for medical management with gynecologic oncology will include chemotherapy and vaginal cuff brachytherapy for uterine carcinosarcoma. Case 2: A 50-year-old G5P5 woman presented with increasing vaginal spotting and worsening urge incontinence. CT showed increased size of heterogeneous mass in right lateral uterine wall, consistent with previously identified fibroid/leiomyoma. An adjacent fat-containing lesion was identified within the uterine wall. Patient underwent MRI which revealed large uterine mass at the fundus, with an associated fatty component. Due to the abnormal rate of fibroid growth, and the fat component, there was concern for uterine sarcoma and/or malignant transformation of leiomyoma. Histopathologic diagnosis found lipoleiomyoma with benign atrophic endometrium, paratubal cysts of bilateral fallopian tubes, and follicular cyst of the right ovary. Follow-up in one year was recommended. Conclusion: Lipoleiomyomas are uncommon benign entities, occurring most commonly in postmenopausal women, similarly to uterine fibroids. While asymptomatic patients can be managed conservatively, these tumors can cause vaginal bleeding, pain, and urinary or fecal incontinence and can be definitively treated with hysterectomy. While imaging is necessary to initially characterize the lesion and determine concern for malignancy, histopathologic diagnosis remains the gold standard for diagnosis. Lipoleiomyomas are associated with other gynecologic malignancies, metabolic disorders, and rarely tumor-to-tumor metastasis. For this reason, careful clinical evaluation and surgical management are required for complete evaluation of the patient.