Enlarged Lymph Nodes Research Articles

Case report: The role and value of radiotherapy in treatment of inflammatory myofibroblastic tumor

BackgroundInflammatory myofibroblastic tumors (IMTs) are rare soft-tissue neoplasms. Accordingly, there is no standardized therapy for unresectable or advanced IMT. Chemotherapy, radiotherapy, and targeted molecular therapy play an important role in unresectable or advanced IMT.Case presentationWe present a 54-year-old man with a cough and chest distress case report. The thoracic surgeon performed the right upper pulmonary occupying lesion wedge resection and enlarged lymph node excision biopsy. Pathologic diagnosis revealed that the morphology of “right upper lung mass” was considered as Inflammatory Myofibroblastic Tumor (IMT). Radiotherapy was indicated at a high dose: 5400cGy in 27 fractions of 2Gy over 5 weeks were delivered combined with cisplatin. The patient was given a CT/MRI and hematological index every 3 months and experienced no more adverse events. The patient survives with no tumor recurrence as of the last follow-up. Progression-free survival (PFS) exceeded 5 years.ConclusionsWe have reviewed the literature and summarized and discussed the radiotherapy treatment options and challenges for IMT. We first reported high-dose radiotherapy combined with chemotherapy treatment for unresectable IMT. Concurrent radiochemotherapy may be considered an intensive treatment for local progress, local recurrence, and nonresectable IMT patients.

NCMP-22. CO-OCCURRENCE OF MULTIPLE SCLEROSIS AND HODGKIN LYMPHOMA. IS THERE A COMMON PATHOPHYSIOLOGY?

Abstract BACKGROUND Multiple sclerosis (MS) and Hodgkin lymphoma (HL) share common epidemiology, genetics and immunological factors. Both affect immune activation, cell proliferation and lymphocyte-mediated immunity. However, occurrence of these two distinct clinical conditions is rare. We present a case of a woman with transverse myelitis fulfilling criteria for MS with synchronous HL. CASE REPORT A 37-year-old woman presented to the emergency room with bilateral leg weakness, numbness and urinary retention. A contrasted MRI of the brain and thoracic spine showed non-specific, non-enhancing white-matter lesions in the brain, and patchy areas of peripheral contrast-enhancement with T2-hyperintensity in the thoracic cord. Treatment with steroid infusion resulted in mild improvements of leg weakness and numbness. Cerebrospinal fluid (CSF) demonstrated oligoclonal bands (OCB) and increased IgG index. Serum was positive for JCV antibody. Due to the atypical MRI findings, namely the peripheral nature of thoracic contrast-enhancement, we were concerned for other inflammatory or autoimmune etiologies. A computed tomography of the chest, abdomen and pelvis revealed a large mediastinal mass and enlarged lymph nodes. A biopsy revealed classic HL. Three-months later, a follow-up MRI brain showed worsening contrast-enhanced lesions. A repeat CSF study revealed normal OCBs and IgG index. CSF was negative for malignant cells and JC virus DNA. To rule out a rare possibility of central nervous system HL, a biopsy of an enhancing brain lesion was obtained, which showed focal gliosis and focal perivascular lymphocytic infiltrates. No malignant cells were observed. She was diagnosed with multiple sclerosis and started systemic chemotherapy (doxorubicin, bleomycin, dacarbazine and vinblastine) for HL. CONCLUSIONS We report a case of an atypical transverse myelitis with HL. Although familial genetic clustering has been described, other potential common risk-factors between MS and HL are Epstein-Barr Virus infection and immunologic overlap, particularly in the context of lymphocyte-mediated immunity.

Combined Use of External Iliac Lymph Node Count and Bone Scintigraphy for PJI Diagnosis: A Prospective Study

Background: The reactive enlargement of external iliac lymph nodes and increased blood flow in the infected region are commonly observed in lower limb infections. We aimed to differentiate between aseptic loosening and periprosthetic joint infection (PJI) after joint replacement surgery by quantifying the number of enlarged external iliac lymph nodes and using bone scintigraphy to monitor blood flow. Methods: We recruited 124 patients undergoing revision surgery for aseptic loosening or PJI. All the patients underwent preoperative dual-energy computed tomography (DECT) imaging for external iliac lymph nodes and bone scintigraphy. The diagnostic value was evaluated using ROC curve analysis. Results: The number of enlarged external iliac lymph nodes was significantly higher in the PJI group than in the aseptic failure group (4.0 versus. 1.0, p value < 0.001). The median affected/unaffected side ratio in the blood pool phase of ECT in the PJI group was 1.49, significantly higher than the aseptic failure group’s median ratio of 1.04 (p value < 0.001). The AUC for diagnosing PJI using the number of enlarged lymph nodes alone was 0.91, and when using the bone scintigraphy blood pool phase alone, the AUC was 0.89. When both metrics were combined, the AUC increased to 0.95, which was higher than the AUCs for the ESR (AUC = 0.83), CRP (AUC = 0.76), and synovial fluid PMN% (AUC = 0.62). Conclusions: Combining the enlargement of the lymph node count with the bone scintigraphy blood pool phase is a promising approach for diagnosing PJI.

Intestinal ultrasound accurately predicts future therapy failure in Crohn's disease patients in a biologics-induced remission.

Intestinal ultrasound (IUS) is used to assess disease activity, complications, and treatment follow-up in Crohn's disease (CD). Less is known about the association of disease activity on IUS with the risk of future disease relapse during biologically sustained clinical remission in CD. The study aimed to investigate the association between IUS activity parameters and subsequent therapy failure in asymptomatic biologically treated patients with CD. A retrospective cohort study examined the association between IUS parameters and forthcoming therapy failure (drug discontinuation, dose escalation, corticosteroid use, hospitalization, or surgery) in CD patients on biological therapy in remission. A total of 57 patients with ileal (65%) or ileocolonic (35%) CD on biological therapy were included in the study. Therapy failure occurred in 50.8% [defined as need for dose escalation (31%), drug discontinuation (51.7%), steroid use (10.5%), and hospitalization (6.8%)] during a median follow-up of 5 (SD + 9.5) months after IUS. On univariate analysis, a bowel wall thickness (BWT) of 2.5 vs. 4 mm (P = 0.005), the existence of an enlarged lymph node (P = 0.02), and the loss of bowel wall stratification (P = 0.01) were correlated with therapy failure. On multivariable analysis, only BWT ≥ 4 mm was associated with the risk of future treatment failure (hazard ratio, 3.7; 95% confidence interval, 0.6-15; P = 0.02). Our findings suggest that BWT ≥4 mm during clinical remission is associated with subsequent treatment failure in patients with CD treated with biologics. Our results support the use of IUS for monitoring CD during remission and may point to a novel threshold for predicting disease reactivation.

Definite Treatment Delay With Neoadjuvant Chemotherapy and Longitudinal Monitoring by Circulating Tumor DNA for Advanced Cervical Cancer During Pregnancy: A Case Series and Literature Review.

Previous studies mainly concentrate on neoadjuvant chemotherapy (NACT) for delivery delay in FIGO Stage IB1-IIIB cervical cancer during pregnancy to prevent early preterm delivery while not affecting maternal outcome. Here, we described two pregnant patients with FIGO Stage IIIC cervical cancer about their diagnosis, treatment, and outcome. Both patients underwent cesarean delivery, left enlarged lymph node dissection, and longitudinal monitoring by circulating tumor DNA. Our study suggested that pregnant patient was completely response to NACT, which was confirmed by ctDNA monitoring, followed by left pelvic enlarged lymph node dissection during cesarean section and adjuvant chemoradiotherapy postpartum. The infant grew normally, without any evidence of chemotherapy-related side effects after delivery. In pregnant women with advanced cervical cancer, longitudinal ctDNA monitoring might be able to evaluate maternal response to NACT and confirm if delivery delay to optimize fetal outcome would compacting the maternal outcomes or not. Cervical cancer may not transmit across the placental barrier and so it is safe for delayed delivery until fetal maturity in utero during pregnancy.

Analysis of Predictive Factors Associated with Unsuccessful Sentinel Lymph Node Mapping in Endometrial Carcinoma.

Sentinel lymph node (SLN) biopsy is recommended over systematic lymphadenectomy in early-stage endometrial cancer due to its lower morbidity and comparable detection rate. The objective of this study was to identify clinical factors associated with unsuccessful mapping. Between April 2020 and June 2024, 120 patients over the age of 18 and diagnosed with early-stage endometrial cancer were enrolled in this prospective study at a single institution. Demographic, clinicopathologic, and treatment data were collected and analyzed using descriptive statistics. Univariate and multiple linear regressions were performed to identify predictors of failed mapping. The mean age of the patient cohort was 62.5 years (range 33 to 83), and the mean body mass index (BMI) was 32 kg/m2 (range 18 to 50). Patients underwent intracervical injections with methylene blue (MB), indocyanine green (ICG), or a combination of both tracers, with 40 patients in each group. A total of 108 patients (90.0%) were diagnosed with endometrioid carcinoma and 12 (10.0%) with non-endometrioid cancers. Additionally, 110 patients (91.7%) were diagnosed in early stages of the disease. The overall SLN detection rate was 73.4%, with bilateral detection at 49.2% and unilateral detection at 24.2%. Univariate analysis showed that older age (p < 0.001), menopause (p = 0.001), the use of MB as the sole tracer (p = 0.006), a shorter tumor-to-serosa distance (p = 0.048), and bulky lymph nodes (p = 0.18) were associated with unsuccessful mapping. Multiple linear regression model analysis identified age (p = 0.007), tracer type (p = 0.013), and enlarged lymph nodes (p = 0.013) as independent predictors of SLN mapping failure. Advanced age, tracer type, and intraoperative detection of enlarged lymph nodes were identified as independent risk factors for unsuccessful mapping in patients undergoing laparoscopic SLN mapping.

Abdominal B-Cell Lymphoma Mimicking Ovarian Cancer.

A 54-year-old patient presented in our clinic with pressure in the upper abdomen, dyspnea and abdominal distension. The clinical examination showed pleural effusion, ascites and an enlarged axillary lymph node on the right side. In gynecological sonography ascites, an ovarian cyst and peritoneal carcinosis in the pouch of Douglas were detected, which were potentially indicative of ovarian cancer. A staging laparoscopy was performed to confirm the diagnosis of ovarian cancer and to evaluate operability. Intraoperatively white milky ascites, white-yellow marbling of the liver and white stipple bedding on the diaphragm and liver were detected. The ovaries and the fallopian tubes were tumorously enlarged. Biopsies were taken from the right fimbrial funnel, the liver around the falciform ligament and the diaphragm. Histology of all abdominal biopsies and the axillary lymph node revealed high lymphatic infiltration matching a stage III B-cell-lymphoma. The patient was transferred to the hemato-oncological department for further therapy. Six cycles of cytostatic therapy with R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine sulfate, prednisone) were initiated. The patient is doing well and in stable disease 6 months after completion of cytotoxic therapy. This case report presents a rare case of manifestation of an extra nodal B-cell-lymphoma with abdominal presentation that mimicked ovarian cancer.

The first case of primary malignant melanoma of the esophagus to achieve pathologic complete response after preoperative ipilimumab + nivolumab followed by resection.

Primary malignant melanoma of the esophagus is a rare disease with a poor prognosis. Surgical resection is common, but there is no consensus on perioperative treatment. Studies have reported the efficacy of programmed cell death-1 inhibitors (e.g., nivolumab, pembrolizumab) and anti-cytotoxic T-lymphocyte-associated antigen 4 agents (e.g., ipilimumab) in treating malignant melanoma. Here, we present the first case of primary malignant melanoma of the esophagus with lymph node metastases treated with nivolumab and ipilimumab followed by resection, achieving a pathologic complete response. A 75-year-old man presented with dysphagia. Esophagogastroduodenoscopy revealed a black, elevated lesion in the mid-thoracic esophagus. Biopsy confirmed primary malignant melanoma of the esophagus, showing tumor cells with melanin deposition, positive for HBM45 and S-100 staining. Computed tomography showed enlarged lymph nodes in the subclavian and mediastinum regions, suggesting metastases. After two courses of preoperative chemotherapy with ipilimumab and nivolumab, which significantly shrank the tumor, the patient underwent robot-assisted subtotal esophagectomy and 3-field lymph node dissection. Histopathological examination revealed no tumors or lymph node metastases, confirming a pathologic complete response. Given the rarity and poor prognosis of primary malignant melanoma of the esophagus, this case provides valuable insights for treatment strategies.

Novel Driver Genes and Mutations in Lung Pecoma: A Case Report

Introduction: Perivascular epithelioid cell tumors (PEComa) are rare mesenchymal neoplasms characterized by perivascular epithelioid cells. Despite their common occurrence in the uterus, gastrointestinal tract, and retroperitoneum, this study presents an exceptional case of PEComa identified in the lung, warranting unique molecular exploration. Case Report: A 50-year-old man was diagnosed with a 6 cm neoplasm in the lower lobe of the right lung without enlarged lymph nodes during a routine examination. Thoracotomy, extended lower bilobectomy, and D3 lymphadenectomy were performed. Histological and immunohistochemical analysis diagnosed a PEComa. No conventional TSC1 and TSC2 mutations specific to PEComa, which resulted in mTOR pathway activation, were detected by whole-exome sequencing. In contrast, mutations were unveiled in the MTOR, EIF4EBP1, and PRAME genes that could be an alternative mechanism governing mTOR activation. Conclusion: These findings provide novel insights into the molecular intricacies of lung PEComa, showcasing the distinctive roles of MTOR, EIF4EBP1, and PRAME mutations.

A Case Report and Literature Review of Metastatic Small Cell Carcinoma in Parotid Gland

Small cell lung cancer usually presents as a progressive disease in over 70% of patients. Common organs of metastasis include the liver, adrenal glands, bones, and brain. However, metastasis to the parotid gland is uncommon, as it has been discussed only in case reports. Among all parotid tumors, small cell cancer is rare, seen in only 1.7%.A 60-year-old man presented with a slow-growing, painless tumor of the left parotid gland and peripheral facial paralysis. Neck ultrasound identified a solid mass in the left parotid gland with enlarged lymph nodes in the parotid gland and ipsilateral neck lymphadenopathies with pathologic features in levels 2 and 3. Chest computed tomography (CT) demonstrated subsegmental collapse in the lingula with peribronchial cuffing in this lobe and mild cylindrical bronchiectatic changes in the left lower lobe. CT also showed multiple mediastinal lymphadenopa thies in prevascular, paraaortic, and paratracheal spaces. Core needle biopsy was done, and initial analysis revealed small cell carcinoma in the left parotid gland. Immunohistochemical analysis of the specimen demonstrated and confirmed the diagnosis. The patient was then referred to the radiation oncology unit for treatment. Chemotherapy was initiated with a combination of cisplatin and etoposide. No complications of the chemotherapy were observed after three cycles; treatment and follow-up are ongoing. No irradiation was performed after evaluation by the radiation oncology department. Due to the advanced stage of his disease, treatment is set for palliative purposes only. Small cell lung cancer diagnosed from solitary metastasis to the parotid gland is very rare. Physicians should keep pulmonary origin in mind when faced with a parotid tumor, as without careful examination, the primary focus may be overlooked, negatively impacting survival rates and the prognosis of the patient. Overall, this finding carries a poor prognosis, but the mainstay of treatment is palliation with systemic chemotherapy and possibly irradiation to control symptoms

Gastrointestinal stromal tumor in Carney’s triad with laparoscopic total gastrectomy: a case report

IntroductionCarney's triad is a rare syndrome characterized by the co-occurrence of gastric gastrointestinal stromal tumor (GIST), pulmonary chondroma, and extra-adrenal paraganglioma. We present a case of a young woman with GISTs associated with this triad.Case presentationA 28-year-old woman was identified with multiple gastric tumors and a right lung nodule during a routine health check-up. CT scans and upper gastrointestinal endoscopy revealed a 50 mm mass on the lesser curvature of the stomach, along with two additional gastric lesions and a 20 mm nodule in the right lung. The patient had a history of right middle lobectomy at the age of 19 for pulmonary chondroma. During surgery, enlarged lymph nodes were observed, indicating metastasis, which necessitated a total gastrectomy with radical (D2) lymph node dissection. Pathological examination confirmed seven GISTs, with immunohistochemical staining positive for KIT (+), DOG1 (+), and negative for SDHB (−). The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. Despite opting out of adjuvant imatinib therapy, she remains disease-free 2 years postoperatively.ConclusionsThis case underscores the necessity of total gastrectomy with lymph node dissection due to the high incidence of metastasis in GISTs associated with Carney's triad. Further research is required to determine the optimal extent of lymph node dissection in such cases.

Granulomatosis with polyangiitis with lacrimal gland enlargement and pancreatic swelling: case report and literature review.

A 62-year-old man had bilateral eyelid swelling for 4 months. Two months before admission, he developed fatigue and lost 5 kg of bodyweight. Further examination revealed elevated serum C-reactive protein, normal angiotensin-converting enzyme, elevated proteinase-3 antineutrophil cytoplasmic antibody (PR3-ANCA), and normal IgG4 concentration. Chest X-ray and computed tomography showed no enlarged hilar lymph nodes, but positron emission tomography-computed tomography showed fluorodeoxyglucose accumulation in both lacrimal glands, in lung nodules, and in the pancreas. Tissue biopsies of the lacrimal glands and pulmonary nodules showed granuloma with giant cells, but no IgG4-positive cells or fibrosis. Pancreatic tissue showed no findings of autoimmune pancreatitis. In the 2022 ACR/EULAR classification criteria for granulomatosis with polyangiitis, the total score was 10 points. Final comprehensive diagnosis was granulomatosis with polyangiitis, based on the negative results of differential diseases, such as IgG4-related diseases and sarcoidosis. Prednisolone 60 mg/day was started on day 8, and rituximab 500 mg/body/week on day 12. After beginning treatment, general malaise and lacrimal gland enlargement were resolved, PR3-ANCA and C-reactive protein became negative, and the nodular shadow in the lungs disappeared. This is the first report of granulomatosis with polyangiitis presenting both lacrimal gland and pancreatic lesions.

Robot-assisted resection of renal tumor in children and comparison with laparoscopic surgery

BackgroundRobot-assisted surgery (RAS) is being performed with increasing frequency in pediatric oncology. We report our experience with RAS for renal tumors in children and compare the outcomes between RAS and laparoscopic surgery (LAS).MethodsA total of 23 patients with renal tumor who underwent minimally invasive surgery (MIS) between January 2020 and December 2023 were included in the study. The inclusion criteria enrolled in this study was unilateral tumors with maximum tumor diameter less than 10 cm. Patients who had enlarged lymph node, venous thrombosis, preoperative tumor rupture, bilateral renal tumor, or extrarenal extension on imaging were deemed contraindications and excluded. Patient demographics, operative details, postoperative outcomes and follow-up were recorded.ResultsAmong these patients, 17 underwent RAS and 6 underwent LAS. In the RAS group, the median age was 64 months (range, 9–156) with a median weight of 19.48 kg (range, 8.4–46.5); the maximum tumor diameter at operation was 55.65 mm (range, 22–88); the operation time was 188.8 min (range, 120–210), the intraoperative blood loss was 20 ml (range, 5–50), and the length of postoperative hospital stay was 4 days (range 1–9). There was no significant difference in patients’ age, weight, location, tumor size, histological pattern and operation time between the two groups (P > 0.05). The RAS group had a significantly less intraoperative blood loss (P = 0.026) and less length of postoperative stay (P = 0.01) than the LAS group.ConclusionOur initial experience suggested that RAS in pediatric renal tumor was feasible and safe, and it reduced surgical trauma and accelerate postoperative recovery for the patients. Due to the limitations of sample size and study quality, the clinical importance of these findings still needs to be further verified.

A case of successful conversion surgery for unresectable gallbladder cancer treated with durvalumab in combination with gemcitabine plus cisplatin.

We report a rare case of a patient with initially unresectable gallbladder cancer who underwent conversion surgery with durvalumab in combination with gemcitabine plus cisplatin and achieved an R0 resection. A 68year-old woman was found to have gallbladder cancer and multiple enlarged lymph nodes around the suprapancreatic rim and hepatic hilum invading the proper hepatic artery on computed tomography. The diagnosis was cT3cN2cM0, cStage IVB. After eight cycles of durvalumab in combination with gemcitabine plus cisplatin, all tumor markers became negative, and lymph node invasion of the hepatic artery disappeared. The patient underwent conversion surgery with gallbladder bed resection and regional lymph node dissection. There was no need for hepatic artery reconstruction. Pathology revealed ypT2aypN0ycM0, ypStage IIA, and radical resection was considered. Immunostaining of tissue collected at the time of endoscopic ultrasound-guided tissue acquisition revealed less than 1% programmed death ligand-1 expression. The patient continued adjuvant chemotherapy with single-agent durvalumab every 4weeks and maintained a relapse-free survival of 8months postoperatively. The utility of durvalumab in combination with gemcitabine plus cisplatin in unresectable gallbladder cancer independent of programmed death ligand-1 expression has been confirmed and may be an important option in future multimodal treatment, including conversion surgery.

Autopsy diagnosis of diffuse intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC), a severe liver cancer, makes up to 20% of all hepatic malignancies and is difficult to diagnose early due to its often asymptomatic nature. This case report documents a rare presentation of ICC with multiple diffuse nodules not previously recorded in medical literature. A 65-year-old man with no significant medical history presented with back pain, anorexia, and significant weight loss. Elevated tumor markers and enlarged lymph nodes were observed, though imaging did not reveal a primary liver mass. Diagnostic efforts, including computed tomography and positron emission tomography scans and biopsies of lymph nodes and bone marrow, suggested adenocarcinoma of unknown primary origin. A definitive diagnosis was only made post-mortem, revealing multiple diffuse nodules in the liver identified as ICC, marking a rare presentation without a primary mass. This case highlights the diagnostic challenges posed by atypical ICC manifestations, where typical imaging does not indicate a primary mass, delaying diagnosis and treatment. The findings emphasize the importance of considering ICC in differential diagnoses in cases of unknown primary adenocarcinoma with liver involvement. The discovery of ICC with diffusely infiltrative nodules underscores the necessity for comprehensive diagnostic evaluations in patients presenting with nonspecific systemic symptoms and abnormal liver findings.

A Case of Abdominal Discomfort for Long Duration

In our regular medical practice, we encounter a lot of patients with abdominal discomfort. Commonly every physician suspects this kind of symptoms as gaseous distension of gastro-intestinal tract or acidity. The most valuable thing is the proper physical examination to rule out any underlying pathology. Most common causes of epigastric pain are associated with gastritis, or hepatobiliary system and pancreas related disorders. Here we will describe a 47-year-old male patient who presented with abdominal discomfort for last 6 months. For last 2 months he developed an epigastric lump which was increasing in size and was associated with weight loss. After proper clinical evaluation and necessary relevant investigations, he was diagnosed having Non-Hodgkin’s Lymphoma (NHL). Non-Hodgkins Lymphoma represents monoclonal proliferation of lymphoid cells. The incidence of these tumors increases with age. Clinically the proliferation rate indicates whether it is a high- or low-grade tumor. The patient underwent some investigations like CT guided FNAC from the enlarged abdominal lymph node which confirmed high grade Non-Hodgkins Lymphoma and started with chemotherapy and responded well. As abdominal discomfort is one of the common complaints, we face during our regular medical practice so routine physical examination including abdominal examination is very crucial and informative for clinical diagnosis and Lymphoma is an important differential diagnosis in case of any abdominal lump. Bangladesh Crit Care J September 2024; 12 (2): 175-178

A Rare Case of Sinonasal Large Cell Neuroendocrine Carcinoma with Lymph Node Metastasis

Abstract Introduction/Objective Sinonasal carcinomas comprise less than 1% of cancers, and the most common types are squamous cell carcinoma at 51.6% and adenocarcinoma at 12.6%. There are only limited published reports of sinonasal large-cell neuroendocrine carcinoma (LCNEC). This entity has distinguishing immunohistochemical and histomorphologic features; it stains positively for neuroendocrine markers (i.e., synaptophysin and CD56) and histologically has abundant amphophilic cytoplasm with prominent nucleoli. Methods/Case Report We present a 60-year-old female patient who was evaluated for a submandibular neck lump. Computed tomography identified a 3.2 x 1.8 x 1.6 cm enhancing lesion with central necrosis in the right submandibular space, representing either an enlarged necrotic right submandibular lymph node or a neoplasm arising from the right submandibular gland. The pathology of the lymph node biopsy was consistent with metastatic high- grade neuroendocrine carcinoma. The neoplastic cells stained positively for INSM1, CK8/18, CK AE1/3 (subset), TTF- 1, and Ki-67 (50%). Dotatate positron emission tomography showed evidence of focal activity in the right anterior nasal cavity supporting evidence with primary nasal cavity origin. Nasal endoscopy was performed, visualizing an area of necrotic friable tissue. Pathology confirmed the presence of large cell neuroendocrine carcinoma in the right nasal biopsies with metastatic LCNEC in right neck levels 1, 2A, 2B, 3, and 4. The malignant cells on hematoxylin and eosin stain had similar morphology to those in the initial lymph node biopsy, supporting a diagnosis of LCNEC. Results (if a Case Study enter NA) NA Conclusion Sinonasal large-cell neuroendocrine carcinomas are extremely rare. Upon literature search, there have been fewer than ten case reports published of this entity. Furthermore, large-cell neuroendocrine carcinoma behaves aggressively, and diagnosing this entity could result in earlier intervention and better patient outcomes. Highlighting the possibility of this diagnosis could broaden differentials in neoplasms that arise from the nose.

Heterotopic High-Grade Salivary duct Carcinoma Likely Arising within Cervical Lymph Nodes

Abstract Introduction/Objective Salivary duct carcinoma arising in heterotopic salivary gland tissue is an extremely rare occurrence, with less than five cases reported in the literature. We present a unique case of heterotopic high-grade salivary duct carcinoma likely arising within cervical lymph nodes. Methods/Case Report A 56-year-old male presented with enlarged cervical lymph nodes for few months. Physical examination was unremarkable. Computerized tomography (CT) scan of head and neck showed two enlarged level 1B lymph nodes, measuring 1.0 and 1.4 cm, with unremarkable salivary glands. Patient had left cervical level II lymph node biopsy that showed metastatic poorly differentiated carcinoma. Immunohistochemically, the tumor cells were positive for GATA3, cytokeratin 903, androgen receptor, p16 (variable nonspecific), and were negative for TTF-1, p40, p63, ER, PR and NKX3.1, favoring salivary gland ductal carcinoma. Positron emission tomography (PET) CT scan showed a hypermetabolic left submandibular gland and level 2A lymph nodes. Subsequently, the patient underwent left modified radical neck dissection. Sectioning of the submandibular gland revealed no discrete lesions. Multiple, firm to rubbery lymph nodes ranging from 0.4 cm to 2.3 cm, with tan-pink cut surfaces were identified. Microscopic examination showed normal submandibular salivary gland parenchyma. However, eight out of nineteen lymph nodes were positive for metastatic high-grade salivary duct carcinoma comprising tumor cells forming nests and cords with ample eosinophilic cytoplasm, pleomorphic round to oval nuclei and numerous mitotic figures. Several benign and malignant lymph nodes in levels I, II and IV showed heterotopic salivary gland tissue. Immunohistochemical stains for androgen receptor and p40 were positive and negative respectively, supported the final diagnosis of high-grade salivary duct carcinoma. Results (if a Case Study enter NA) NA Conclusion Given the absence of carcinoma in the completely sampled submandibular gland, the origin of the intra- nodal tumor deposits was most likely to be heterotopic salivary gland tissue. This case emphasizes the importance of meticulous pathological sampling required for definitive diagnosis.

Diffuse Large B-cell Lymphoma (DLBCL) involving the Uterine Corpus presenting with Abnormal Uterine Bleeding: A Rare Case Report

Abstract Introduction/Objective Diffuse Large B-cell Lymphoma (DLBCL) is an aggressive type of non-Hodgkin lymphoma. Lymphomas affecting the female genital system are extremely rare, accounting for about 1% of extra-nodal lymphomas, with DLBCL being the most common type. We present a rare case of uterine lymphoma presenting with abnormal uterine bleeding. Methods/Case Report A 50-year-old female presented with abnormal uterine bleeding and fatigue for the past three weeks. Laboratory work-up showed hemoglobin level of 5.5 g/dL. Pelvic ultrasound revealed thickening of the endometrium and a 1.6 cm hypoechoic uterine lesion along with multiple enlarged bilateral adnexal lymph nodes. Histological examination of the endometrial biopsy demonstrated endometrial fragments with diffuse subepithelial proliferation of large, poorly differentiated cells with round nuclear contours, finely dispersed chromatin, relatively inconspicuous nucleoli and moderate amount of cytoplasm. Many scattered mitoses and apoptotic bodies were present. Primary set of immunohistochemical stains were performed to rule out primary uterine epithelial or mesenchymal tumors. The tumor cells were negative for pan-keratin, high and low molecular weight keratins and positive for CD45. Further work-up demonstrated CD20 positivity. It was diagnosed as DLBCL with a non-germinal center, double expressor phenotype and a high Ki-67 proliferation. Fluorescence in-situ hybridization studies were negative for MYC and BCL6 gene rearrangements and IGH-BCL2 translocation. Further radiological workup revealed diffuse lymphadenopathy with multiple pulmonary and renal nodules consistent with Stage IV DLBCL. She was treated with six cycles of R-CHOP regimen, and complete metabolic response was achieved. Results (if a Case Study enter NA) NA Conclusion Uterine lymphomas are very rare and on small biopsies may histologically mimic poorly differentiated uterine malignancies such as dedifferentiated/undifferentiated carcinomas. Adding lymphoma lineage markers to poorly differentiated tumors is recommended to avoid missing such a rare entity.

Anaplastic transformation of papillary thyroid carcinoma in the cervical lymph nodes showing a variety of rhabdoid, epithelioid and spindle cell phenotype

Abstract Introduction/Objective Anaplastic thyroid carcinoma (ATC) is a rare undifferentiated tumor of thyroid follicular cells with a dismal prognosis. Most ATCs derive from pre-existing, well-differentiated thyroid carcinomas, most commonly papillary thyroid carcinoma (PTC). In nearly all instances, ATC arises within the thyroid gland. Completely divergent morphologies of this tumor between the bilateral cervical nodes as well as the almost exclusive presence of ATC in the metastatic and nodal locations are very unusual and are reported here. Methods/Case Report A 67-year-old man presented with a rapidly enlarging left cervical mass, hoarseness, dry cough, and drooping left eye. MRI demonstrated bilateral enlarged cervical lymph nodes spanning levels II to V, and nodules in thyroid lobes. Subsequent total thyroidectomy with bilateral radical neck dissection was performed. Histologically, the left lateral cervical masses revealed undifferentiated tumor cells with rhabdoid, epithelioid and spindle cells features. Conversely, the tumor within the thyroid lobes and the right cervical lymph nodes exhibited PTC with tall cell features. All undifferentiated tumor components stained positive with AE1-3, CK7, PAX8, and negative with thyroglobulin, EMA, CD34, S100, Melan-A, Sox 10, desmin, myogenin, and P40. INI-1 staining is retained. Only the spindle cell component stained positive with TTF1. Based on the morphology and immunoprofile, a diagnosis of anaplastic thyroid carcinoma was rendred. Results (if a Case Study enter NA) NA Conclusion Diagnosing anaplastic thyroid carcinoma outside the thyroid lesion can be challenging. In our case, only extensive sampling of the surgical specimen identified a small focus of well-differentiated PTC, staining positive for thyroglobulin, in the left cervical anaplastic carcinoma component, identifying its origin. This case adds to the scarce literature documenting unilateral anaplastic transformation in the left cervical metastatic lymph nodes, while the right cervical lymph nodes contained pure well differentiated PTC. This represents a significant potential pitfall in presurgical fine needle aspiration (FNA) evaluation of patients with ATC.