Exophytic Nodule Research Articles

Periosteal fasciitis in a 7-year old girl: a diagnostic dilemma

Periosteal fasciitis, considered a subtype of nodular fasciitis, is a rare benign soft tissue mass often misdiagnosed as a malignant lesion due to its fast and infiltrative growth pattern and histological features. Nodular fasciitis is usually found in the upper extremities in adults and in the head and neck region in children. Incorrect diagnosis may lead to overtreatment, potentially causing disturbed orofacial development in growing children. A rapidly growing asymptomatic mass, initially suspected to be a malignant bone tumour, was found in the left angle area of the mandible in a healthy 7-year-old girl. Radiographic examination revealed an exophytic, expansile and destructive nodule arising from the periosteal region. A diagnosis of periosteal fasciitis was established based on histological findings in an open biopsy specimen and the lesion was subsequently enucleated. Fluorescence in situ hybridization analysis revealed a USP6 gene rearrangement and confirmed the diagnosis molecularly. Due to the aggressive growth pattern without external trauma and the results of the gene rearrangement test, it is suggested that nodular fasciitis be regarded as a benign neoplasm rather than as a reactive process. The patient remains free of disease at 3 years after surgery.

Rate of Malignancy in Exophytic Thyroid Nodules

Background: There are ultrasonography (US) features suggested to be associated with a higher risk of malignancy in thyroid nodules. However, exophytic appearence of thyroid nodules has not been studied previously. Objectives: To evaluate US features, and cytological and histopathological findings in exophytic thyroid nodules. Patients and Methods: Patients with an exophytic thyroid nodule who underwent fine needle aspiration biopsy (FNAB) between January and July 2015 were evaluated prospectively. Demographical data, US features, and cytology results were noted and histopathological findings were determined in operated patients. The results were compared with non-exophytic nodules of age and sex matched patients. Results: Data of 253 exophytic nodules in 247 patients and 529 non-exophytic nodules in 357 patients were analyzed. Hypoechogenity, mixed texture, and absence of peripheral halo were significantly higher in exophytic nodules (P < 0.001, P < 0.001, and P = 0.018, respectively). Nondiagnostic, atypia of undetermined significance/follicular lesion of undetermined significance and suspicious for malignancy cytology results were significantly higher in exophytic nodules (P = 0.002, P < 0.001 and P < 0.001 respectively). 6.7% of exophytic nodules and 1.9% of non-exophytic nodules had malignant cytology (P = 0.001). Histopathologically, 35 (47.9%) of 73 exophytic nodules and 18 (24.3%) of 74 non-exophytic nodules were malignant (P < 0.01). Capsular invasion was higher in the malignant exophytic group (53.5% vs 14.3%, P = 0.027). US features other than hypoechoic pattern which was higher in the malignant group were similar in benign and malignant exophytic nodules. Conclusions: Exophytic nodules seem to carry a higher rate of malignancy both cytologically and histopathologically. Suspicous US features except hypoechoic pattern were not higher in malignant compared to benign exophytic nodules.

AB040. PS02.04: DOTATATE PET/CT in thymic atypical carcinoid tumor with secondary ACTH-dependent Cushing’s syndrome

: Neuroendocrine thymic tumors represent the least common type of primary thymic tumor with a prevalence of 2–5%. We present a case of locally advanced thymic atypical carcinoid tumor diagnosed incidentally while investigating progressive Cushing’s syndrome. CT scan demonstrated a large 2.9 cm exophytic thyroid nodule and a 2.0 cm anterior mediastinal mass. Biopsy of the thyroid nodule demonstrated benign thyroid tissue, and Octreotide scan revealed avid uptake in the right thyroid lobe with minimal uptake in the thymic tumor. 68-Gallium DOTATATE PET-CT scan showed intense uptake in the thyroid gland followed by a moderate amount of activity in the anterior mediastinal mass. The patient underwent a median sternotomy and radical thymectomy with en bloc resection of the left innominate vein and primary repair of the superior vena cava. On further evaluation, the presumed thyroid nodule appeared contiguous with the thymic lesion and separate from the thyroid. Final pathology demonstrated a poorly differentiated 4.4 cm atypical carcinoid tumor with nine positive lymph nodes. On the third postoperative day, the serum cortisol level precipitously decreased to a level of 6.8 µg/dL. This case highlights the challenges surrounding the diagnosis of hormonally active thymic carcinoids, and demonstrates the utility of 68-Gallium DOTATATE PET scan in localizing somatostatin-positive neuroendocrine tumors, and surgical planning.

Three Cases of Esophageal Squamous Papilloma: A Rare and Poorly Understood Lesion

Squamous papilloma is a rare lesion of the esophagus. The estimated prevalence is between 0.07% and 0.45% on endoscopy. The pathogenesis remains uncertain, however underlying inflammation from reflux, as well as chronic mechanical/chemical irritation have been implicated. Further, human papilloma virus has been proposed as a risk factor. Although currently considered a benign lesion, the malignant potential of esophageal squamous papilloma in causing squamous cell carcinoma is controversial.Figure 1Figure 2Figure 3We present three cases of esophageal squamous papilloma. In the first, a 51 year old asymptomatic African American female with multiple sclerosis on dimethyl fumarate underwent esophagogastroduodenoscopy (EGD) for workup of iron deficiency anemia. On exam, the Z-line appeared irregular and a single 2mm white-pink wart like projection was seen in the middle esophagus. Excisional biopsy was performed. Pathology revealed squamous papilloma with biopsies of the distal esophagus showing chronic inflammation. Of note, a recent pap smear was negative for HPV. In the second case, a 28 year old Hispanic male with 2 months of epigastric abdominal pain, and hematemesis was seen for further evaluation. An EGD revealed a single 5mm nonbleeding exophytic projection 33cm from the incisors. Excisional biopsy showed squamous papilloma. In the final case, a 42 year old female underwent evaluation for abdominal pain and melena. EGD demonstrated a single 5mm exophytic nodule in the middle esophagus and diffuse inflammation in the stomach. The lesion was excised and showed a squamous papilloma. The present cases demonstrate the heterogeneity in gender, age, esophageal location, and risk factors of squamous papilloma. Prior reports from Western countries demonstrate a male predominance, average 48 years of age and location in the lower esophagus, thought to be related to reflux disease. However, in the present series two of the three patients were female and had lesions in the middle esophagus. One patient was 28 years of age without any signs of reflux. Moreover, the present series reports the first case of esophageal squamous papilloma in a patient taking dimethyl fumarate, an agent known to increase papillomas and squamous cell carcinomas of the forestomach in mice and rat models. Further studies are needed to understand pathogenesis and risk factors of esophageal papilloma to identify at-risk patients since the natural history and malignant potential remain poorly understood.

An Unusual Cause of Hot Spot on Parathyroid Imaging

ABSTRACTBackground and aimRadiological imaging is routinely used in patients with primary hyperparathyroidism to localize the abnormal adenoma and to plan surgical approach. We report an unusual cause of false-positive localization on parathyroid sestamibi scan, i.e., not previously described in the literature.Case reportA 66-year-old man with primary hyperparathyroidism showed a discrete persistent focus in the left infraclavicular area during localization using sestamibi scan. Ultrasound of the neck was negative showing only small bilateral thyroid nodules. Single-photon emission and four-dimensional computed tomography (CT) scans showed an intense focus of the tracer uptake and a 1-cm lesion near the left subclavian vein (SCV), corresponding to the infraclavicular hot spot. Initial infraclavicular exploration showed the lesion to be a collapsible saccular varix of the left SCV. Bilateral neck exploration led to the discovery of the actual right parathyroid adenoma beneath an exophytic thyroid nodule. The patient made an uneventful recovery and remains normocalcemic at 1-year follow up.Conclusion and clinical significanceHot spot on parathyroid imaging outside the line of embryological descent should be interpreted with caution. Vascular retention of injected isotope within a saccular varix of the neck vein can give rise to falsepositive results on sestamibi scans. Bilateral neck exploration remains the “gold standard” procedure when localization scans either are negative or turn out to have false-positive findings.How to cite this articleSingaporewalla RM, Negi A, Seow DYB, Chinchure D. An Unusual Cause of Hot Spot on Parathyroid Imaging. World J Endoc Surg 2016;8(2):164-167.

Multiple fungating exophytic nodules secondary to metastatic spiradenocarcinoma with direct spinal cord invasion

Multiple fungating exophytic nodules secondary to metastatic spiradenocarcinoma with direct spinal cord invasion

An uncommon pattern of oesophageal cancer presentation

Introduction: Common morphological patterns of oesophageal cancer presentation include stricture formation, mucosal ulceration, or the presence of exophytic fungating masses, nodules, and fistulae. The varicoid type is, however, rare. Case presentation: The index case is a 74-year-old lady who had no classical complaints that are often associated with oesophageal cancer and had the varicoid type discovered on endoscopy screening. Conclusion: The purpose of this case report is to document such a pattern for the first time in the authors’ environment and to highlight the utility of endoscopy in early detection of malignancy when commonly identified signs and symptoms are absent.

Intraoral Keratoacanthoma: Case Report

Keratoacanthoma is a benign lesion with rapid development and spontaneous healing, similar to well-differentiated squamous cell carcinoma (SCC). Although keratoacanthoma is usually related to sun exposure, other etiologies, such as tobacco, trauma, and immunosuppression, are considered. A 77-year-old white female who was an ex-smoker sought treatment at our stomatology clinic with a chief complain of non-healing aphthae that had first appeared 3 months earlier. Intraoral examination revealed an exophytic nodule with hard borders and a corrugated surface, associated with areas of erythroleukoplakia at the mucosal commissure. Diagnostic hypotheses included SCC, verrucous carcinoma, and hyperplastic chronic candidiasis. Cytopathology indicated candidiasis, and treatment was administered. An incisional biopsy indicated a diagnosis of intraoral keratoacanthoma associated with candidiasis, and complete remission of the lesion was observed after 1 month of treatment. Given that the clinical and histopathological features of keratoacanthoma are very similar to those of SCC, making an accurate diagnosis is very important for devising an appropriate treatment.

Spontaneous Regression of an Infantile Scalp Tumor. Infantile myofibromatosis.

A newborn girlwith a nodular lesion on the scalp present since birth was seen at the dermatology clinic. The parents reported occasional erosions and crusting that resolved with topical mupirocin, 2%, cream, butwith no continued growth. Themother had had a normal pregnancy. Physical examination revealed a firm, exophytic, and flat-topped nodule, with superficial erosion and crust on the right parietal side of the scalp measuring 3 cm in diameter and 1 cm thick (Figure, A). No other skin lesions were found. A 4-mm punch skin biopsy was performed, and tissue was sent for pathologic analysis (Figure, B and C). Cerebral and abdominal ultrasonography revealed no evidence of visceral involvement. The lesion regressed without treatment over a period of 8 months. Close follow-up every 3 months was scheduled, and complete involution of the tumor was noted at 10 months of age (Figure, D). A

Ultrasonographical and cytological features of exophytic thyroid nodules: do exophytic nodules pretend to be malignant?

Ultrasonographical and cytological features of exophytic thyroid nodules: do exophytic nodules pretend to be malignant?

Keloidal Scleroderma: Case Report and Review.

Objective. We report a rare case of keloidal scleroderma and provide an analysis of similar cases. Results. A 41 year-old woman presented with dark brown, indurated, exophytic nodules over the chest along with smaller hyperpigmented plaques scattered over the abdomen, with concomitant sclerodactyly. The clinical, laboratory, and pathological findings were consistent with a diagnosis of keloidal scleroderma. The patient was treated with methotrexate, resulting in reduced firmness of her plaques and no new lesions. A literature review of previously reported cases was performed using keywords including keloidal morphea, keloidal scleroderma, nodular morphea, and nodular scleroderma. In our review, the majority of patients were African American and female. 91% of cases had nodular lesions with distribution on the trunk. The majority of patients exhibited sclerodactyly and pulmonary involvement was reported in 28%1. The majority of patients were ANA positive (63%) and only 10% demonstrated anti-SCL-70 positivity. Conclusion. Keloidal scleroderma is a rare presentation, which can often be clinically confused with keloid and scar formation. Due to this being a rare variant, our knowledge of treatment options and efficacy is limited. Methotrexate could be considered as an initial treatment option for patients with progressive keloidal scleroderma.

Oral pyogenic granuloma of upper labial mucosa: An unusual case presentation

Background: Pyogenic granuloma (PG) is a benign non-neoplastic mucocutaneous lesion. PG is manifested as a sessile or pedunculated, resilient, erythematous, exophytic and painful papule or nodule with a smooth or lobulated surface that bleeds easily. PG preferentially affects the gingiva, but may also occur on the lips, tongue, oral mucosa and palate. .This paper presents an unusual case report where pyogenic granuloma was present on the upper labial mucosa .Besides , the clinical presentation presents a platform to discuss some unusual differential diagnosis of PG like Squamous Papilloma, Mucocele with PG and Traumatic eosinophilic granuloma.

Multiple congenital granular cell epulis: case report and immunohistochemical profile with emphasis on vascularization.

Congenital granular cell epulis is a rare benign soft tissue lesion arising from the alveolar ridge in neonates. A rare case of multiple congenital granular cell epulis is reported, alongside a description of its vascular immunohistochemical profile. A female newborn presented with two exophytic pedunculated red nodules located on the alveolar ridge between the future eruption sites of the incisors and canines of the mandible and maxilla. A conservative surgical excision was performed on the second day of life. Histology revealed proliferation of round granular cells containing an abundant eosinophilic cytoplasm with basophilic nuclei, ranging from round to oval in shape. Numerous blood vessels were also seen. Immunohistochemical analysis of the granular cells revealed positivity for CD68, D2-40, Ki67, VEGF, and FGF and negativity for S100, CD34, and CD105. Immunostaining for CD34, CD105, and D2-40 confirmed the presence of a large number of blood and lymphatic vessels. Although rare, an understanding of this lesion is paramount for correct diagnosis and appropriate treatment. In the present report, the immunohistochemical profile confirmed increased vascularization, proving that these lesions are composed of not only new and preexisting blood vessels, but also lymphatic vessels.

Axillary Nodular Hidradenoma in a 29-Month-Old Girl

Received: April 23, 2015, Revised: May 24, 2015, Accepted: May 29, 2015 Correspondence: Hyun-Young Kim, Department of Pediatric Surgery, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea. Tel: +82-2-2072-2478, Fax: +82-2-747-5130, E-mail: spkhy02@snu.ac.kr Copyright © 2015 Korean Association of Pediatric Surgeons. All right reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Fig. 1. Multiple exophytic and verruciform nodules of about 2 cm in diameter with well-vascularized surface located on the left axilla. INTRODUCTION

Cutaneous spindle cell squamous cell carcinoma.

Dear Editor: Spindle cell squamous cell carcinoma (SpSCC) is a rare variant of squamous cell carcinoma (SCC). Despite having clinical attributes that overlap conventional SCC, these lesions are pathologically distinct and are comprised of spindled cells that infiltrate the dermis as single cells or cohesive nests; that lack features of keratinization. SpSCC most commonly occurs in the larynx, and less often in the hypopharynx, oropharynx, and nasal cavity1. It is extremely rare to find SpSCC confined to the cutaneous lesion, and only three cases have previously been reported in Korea. A 73-year-old woman presented with a 1-year history of a pruritic, solitary mass on the face. Physical examination revealed an irregular-shaped, erythematous, firm, fixed mass with a yellowish crust on her left upper perioral area. The mass was 1.3 cm in diameter and was slowly expanding (Fig. 1). The patient had a history of a wide excision of basal cell carcinoma on her nose 2 years previously, and no relapse has been observed. Fig. 1 (A, B) Solitary, 1.3 cm-sized, irregular-shaped, erythematous, firm mass with a yellowish crust on the left upper perioral area. Histologic examination of the lesion showed spindle-shaped cells with hyperchromatic nuclei infiltrating the dermis in a whorl-like pattern (Fig. 2). Furthermore, immunohistochemical investigation revealed the specimen was positive for cytokeratins (34βE12, CK5/6, AE1/3) and vimentin, but was negative for smooth muscle actin (SMA), S-100, and CD68. Through histologic features and immunohistochemical evaluation, she was diagnosed with SpSCC. The lesion was surgically removed 13 months previously and no relapse has been observed. Fig. 2 (A) Diffuse dermal infiltrates of spindle cells (HE B: ×200, C: ×400). (D) Positive immunostaining for 34βE12, ... Cutaneous SpSCC presents as a raised or exophytic nodule accompanied by spontaneous bleeding and central ulceration similar to conventional SCC2. It is usually confined to sun-damaged sites such as the head, neck, chest, and upper extremities or areas that have received prior ionizing radiation2,3. Although the rarity of these tumors makes difficult to study patient survival rates, the literature suggests an overall prognosis similar to that of conventional SCC. SpSCC must be distinguished from other spindle cell lesions such as atypical fibroxanthoma (AFX), spindle cell/desmoplastic melanoma, cutaneous leiomyosarcoma, and scars. Immunohistochemistry has become the essential method in the pathologic workup of these tumors. The spindle cells in SpSCC stained positively for one or more of the cytokeratins (34βE12, AE1/3, cam 5.2, low molecular weight keratin) and the mesenchymal marker, vimentin. Each of these neoplasms stained negatively for S-100, CD68, and SMA; whereas AFX showed positivity for CD68, but lacked keratin and S-100. The spindle cell melanomas showed a connection with the epithelium that was contiguous with similar junctional cells possessing cytoplasmic melanin and S-100 immunostaining, but lacking keratins. The leiomyosarcomas showed positivity with SMA and vimentin, and were negative for keratins and S-100. The scars were negative for all immunohistochemical stains4. Cutaneous SpSCC is so rare subtype of SCC that pathophysiology, prognostic factors, and metastatic risk are not well-established. It is known that SpSCCs that are associated with radiation, burn scars, and immunosuppression may correlate with aggressive clinical courses5. Further studies of this rare entity are needed to establish its biological behavior, and the accumulation of more case reports will aid in determining a precise prognosis.

Immunohistochemical characterisation of a canine case of granular cell type trichoblastoma: a case report

Herein we describe a case of granular cell type trichoblastoma in a dog. A nine-year-old, intact male Scottish terrier presented with a solitary, exophytic and non-ulcerated nodule on the shoulder. Histopathologically, the nodule showed a ribbon-like structure, which was composed of branching cords of epithelial cells surrounded by fibrous stroma. In addition, islands of large clear cells were also noted. The clear cells showed eccentric nuclei and abundant cytoplasmic vacuoles, which were strongly positive for periodic acid-Schiff staining. Cytoplasmic immunostaining for cytokeratin (CK) 14 and nuclear immunostaining for p63 were observed in the neoplastic cells. In contrast, CK18 staining was scant. Furthermore, the hair bulge stem cell marker CK15 showed strong cytoplasmic staining. Based on these histopathological and immunohistochemical findings, the tumour was diagnosed as a granular cell type trichoblastoma, which is rarely reported in dogs. &amp;nbsp;

Sialolithiasis in The Submandibular Gland Presenting as an Inflammatory Fibrous Hyperplasia And Secondary Infection in The Floor of The Mouth: Case Report

Sialolithiasis is the development of mineralized structures within excretory salivary ducts or glandular parenchyma. A large sialolith of the left submandibular gland is reported. Man, 55, presented an exophytic, irregular, firm, normochromic, and painful nodule in the left posterior region of the floor of the mouth. The lesion excreted pus and was present for 3 months. He gave a history of calcification in the submandibular gland over 10 years. Panoramic radiographs revealed coalescing radiopacities; submandibular gland ultrasonography showed a 0.2-cm calcification.

Clinical, dermoscopic and histopathologic findings of retiform hemangioendothelioma

Retiform hemangioendothelioma (RH) is an uncommon vascular neoplasm of borderline malignancy that clinically develops as a solitary, gradually enlarging exophytic mass, nodule or plaque, most often on the lower limbs, upper limbs and trunk. Clinical recognition of RH is troublesome because of its non-specific appearance, with differential diagnosis comprising a variety of benign and malignant tumors clinically presenting as reddish nodules. In this article we describe the clinical, dermoscopic and histopathologic findings in a case of RH developing on the flank of a 26-year-old woman, and discuss the possible role of dermoscopy in facilitating the clinical recognition of this rare tumor.

The Unique Utility of EUS in Diagnosis of Substernal Retroesophageal Thyroid Masses

Purpose: A 58-year-old female presented with stabbing chest pain, fatigue, and dysphagia of approximately 3 months. Cardiac work-up was negative. CT demonstrated a 3.5 x 2.1 cm mass in the left retroesophageal space of the superior mediastinum. Barium swallow revealed evidence of extrinsic compression on the upper esophagus at the level of the thoracic inlet. PET scan revealed hypermetabolic activity in the setting of an exophytic posterior thyroid nodule, with normal iodine thyroid uptake scan. EUS was performed with transesophageal FNA biopsy. A single oval mass lesion was found in the superior mediastinum with the echoendoscope positioned at 20 cm from the incisors. The mass was hypoechoic and lobulated measuring 35 x 30 mm. FNA was preceded by color Doppler imaging to confirm a lack of significant vascular structures within the path of aspiration. Cytology revealed Hurthle Cell type hyperplastic thyroid tissue. The patient underwent a substernal total thyroidectomy to relieve her compressive symptoms from the large multi-nodular goiter and to definitively evaluate for malignancy given the abnormal cytology on EUS w/FNA. Final surgical pathology revealed multifocal stage III (T3N0M0) papillary thyroid carcinoma. The patient has been doing well since undergoing thyroidectomy. Literature regarding thyroid cancer with extension of tissue in the retroesophogeal region is quite rare. This very atypical anatomy presents a challenge in diagnosis via conventional approaches such as extracutaneous ultrasound-guided biopsy (1). EUS allows for visualization and biopsy of substernal thyroid masses in retroesophageal and lateral distributions that would otherwise not be accessible by traditional methods. Use of EUS guided FNA in superior mediastinal presenting thyroid masses was first reported only within this past decade (2), making it quite the novel tool in evaluation of such masses. This case serves as an added example to solidify the role of EUS in exploration of thyroid lesions that would otherwise pose a diagnostic dilemma, potentially eliminating the need for a higher risk surgical intervention (3).

Nawracająca brodawczakowatość układu oddechowego – epidemiologia i charakterystyka infekcji HPV u dzieci

Recurrent respiratory papillomatosis (RRP) is the most common non-malignant neoplastic respiratory tract disease in children. Main symptoms are related to the periods of recurrent growth of multiple exophytic nodules covering the surface of the mucosa interfering with the patency of the airways. The connection between juvenile onset recurrent respiratory papillomatosis (JORRP) and human papillomavirus (HPV) infection is undisputable and clearly confirmed.Actual epidemiological studies display the relationship between the disease in a child and a low socio-economic status of a family, mother's young age, sexual activity of parents measured by the number of sexual partners before a child's birth and clinically obvious HPV infections in mother or father.RRP in children may be mild and self-limiting or aggressive in character, with a poor prognosis. The papillomas may spread throughout the entire respiratory tree, but most often involve the larynx. Recurrent respiratory papillomatosis causes hoarseness (that may progress to aphonia) and upper respiratory obstruction. The chronic curse of the disease always unfavourably affects the patient's quality of life.Laboratory diagnosis of HPV infections is dependent upon molecular techniques such as DNA hybridization or nucleic acid amplification. Routine application of molecular techniques such as PCR for detection and analysis of HPVs in patients with RRP has diagnostic and prognostic significance.