Left Cervical Node Research Articles

A Rare Case of T-Cell Histiocyte Rich Large B-Cell Lymphoma of the Thyroid in a Patient With Hashimotos

Introduction: T-cell/histiocyte-rich large B-cell lymphoma (THRLBCL) is a rare form of large B-cell lymphoma, which usually involves the lymph nodes exclusively. We describe a patient with Hashimoto’s thyroiditis who was discovered to have THRLBCL arising from the thyroid. Clinical Case: A 78-year-old female with a history of Hashimoto’s thyroiditis noted increase in the size of her left thyroid lobe for two months despite normal TSH on Levothyroxine, prompting an ultrasound which revealed several enlarged left sided cervical lymph nodes and an enlarged left thyroid gland. Cytology from an FNA of a left level 3 lymph node showed atypical lymphoid infiltrate featuring scattered large atypical cells in a background of small lymphocytes. Immunohistochemical testing was PAX5+, CD30- and CD15-. Cytology from an FNA of left thyroid revealed identical changes and immunohistochemistry demonstrated PAX5+ and CD20+. Concurrent flow cytometric studies demonstrated increased CD4 to CD8 ratio among T cells. Excisional biopsy of a left cervical lymph node confirmed a diagnosis of THRLBCL. PET/CT exhibited lymphadenopathy above her diaphragm and splenic involvement. Her bone marrow biopsy was negative for involvement. She was deemed Stage III with international prognostic index (IPI) of 2 corresponding with low-intermediate risk. She was commenced on chemotherapy R-CHOP with plan to complete 6 cycles. Discussion: THRLBCL is characterized by scattered atypical B lymphocytes on a background of T lymphocytes and histiocytes. Usually, T-cells are predominantly CD8+, in contrast to our patient. Some studies identified cases of predominant CD4+ and PD1+ T cells. Cytology revealed scattered small B-cells and large B-cells, a feature that is not typically seen in THRLBCL. A diagnosis of diffuse transformation of nodular lymphocyte predominant Hodgkin lymphoma was considered but the diffuse proliferation outside of CD21+ and involvement of the thyroid is not compatible with such diagnosis. Similarly, a diagnosis of follicular helper T-cell lymphoma with admixed large B-cells was considered but while PD1+ CD4+ T cells are present, there was no aberrant antigen expression by flow cytometry or T cell clonality. THRLBCL mainly involves lymph nodes and presents at advanced Ann Arbor stages with high IPI. Malignant lymphomas of the thyroid gland are exceedingly rare, accounting for 2% of thyroid cancers, out of which the literature reveals a single case report of THRLBCL arising from the thyroid. THRLBCL represents an aggressive form of lymphoma and is treated according to stage-matched DLBCL, although the effects of Rituximab in this population is variable. Conclusion: Hashimoto’s is considered a risk for thyroid lymphoma usually diffuse large B-cell lymphoma and MALT lymphoma. We present a rare case of THRLBCL occurring in the setting of Hashimoto’s with acute thyroid gland enlargement.

Histological conversion of seminoma of testis to metastatic choriocarcinoma in left cervical lymph node: An unusual phenomenon

Germ cell tumors (GCT) of more than one histological subtype (although very rare) can be present in the same patient. We present a 29-year-old male who presented with a cervical lymph node swelling. The tissue received was a globular mass with a thick cystic wall and necrotic areas. A histopathological examination revealed the presence of residual lymphoid tissue in the form of lymphoid follicles, areas of hemorrhage and necrosis, tumor nests, and perivascular distribution of tumor cells. The neoplastic cells were arranged in a vague glandular pattern and also showed squamoid-like morphology on the basis of which a diagnosis of metastatic adenosquamous carcinoma was made. The patient was subjected to a whole-body positron emission tomography (PET) scan to look for primary on which a testicular mass was discovered; seminoma on histology. The sections of the cervical mass were revisited and trophoblastic cells were identified; they were also positive for β- human chorionic gonadotropin (hCG) on Immunohistochemistry. Therefore, a diagnosis of metastatic choriocarcinoma from seminoma testis was made. The direct derivative of germ cell neoplasia in situ/intratubular germ cell neoplasia being seminoma; it has the capacity for histological conversion to more differentiated forms (choriocarcinoma in this case).

Tender Soft Tissue Mass on the Base of the Neck.

A 47-year-old man presented with a tender soft tissue mass on the upper back with increasing discomfort over the last 4 weeks. He noted that he felt feverish a few times. Physical examination revealed a 3×4-cm area of induration involving the upper mid back with faint erythema of the overlying skin; no drainage was noted. A prominent left posterior cervical lymph node also was appreciated, and a punch biopsy of the mass was performed.

Kimura's disease: A challenge to the cytologist

Kimura's disease is a rare idiopathic chronic inflammatory disease which usually presents as deep-seated subcutaneous swelling in the head and neck region. Accompanied by lymphadenopathy, peripheral eosinophilia, and elevated immunoglobulin E levels, it is more prevalent among young Asian males. Here, I report the case of a 20-year-old male presenting with left posterior cervical lymph node swelling. Based on proper clinical setting and characteristic cytological features, a cytological diagnosis of Kimura's disease was rendered which was later confirmed by histopathological examination.

A rare clinical presentation of urinary bladder carcinoma: A case report

Metastasis of carcinoma to regional lymph nodes is of common occurrence. Cervical lymph nodes are the commonest lymph nodes to be sampled for detection of metastasis from head neck and upper are digestive tract malignancies. Morphological confirmation of metastasis in the lymph nodes either by cytology or histopathology decides the further plan of treatment for the patient. Rarely cervical lymph nodes can show evidence of metastasis from urinary bladder carcinoma. In the present case the cervical lymph node biopsy was helpful in the diagnosis and treatment of the patient. The histopathological findings were later confirmed by immunohistochemistry supporting the diagnosis of metastasis of urinary bladder carcinoma to the left cervical lymph nodes. To arrive at the correct diagnosis complete clinical workup, clinicoradiological correlation and high index of suspicion is required. Reporting this case will emphasize the rare clinical presentation of urinary bladder carcinoma. Keywords: Urinary bladder carcinoma, Cervical lymph nodes, Metastasis, Uroplakin.

Primary Mantle Cell Lymphoma of the Tonsil: A Case Series

Background: Mantle cell lymphoma (MCL) is a mature B cell non- Hodgkin lymphoma (NHL) characterized by the t (11; 14) (q13; q32) translocation, which results in over-expression of cyclin D1. It comprises about 7% of NHL in the United States and Europe and its overall incidence appears to be increasing in the United States. While most patients present with advanced stage and generalized lymphadenopathy, 25% of patients with MCL present with extra-nodal disease. The most common site of involvement being gastrointestinal tract, liver and bone marrow. Isolated involvement of waldeyer's ring is rare. To date, only a few cases have been reported in the literature. Here we describe three patients with primary MCL of the tonsil, summarizing their presentation and clinical course. Method: We present a case series of MCL of the tonsils diagnosed and followed at a single center from August 2019-May 2020. Data regarding demographics, morphology, IHC stains, clinical presentation, radiographic findings, management and outcome are reviewed. Results: Three patients were diagnosed with tonsillar MCL. Clinical findings are summarized in table 1. All were men with a mean age of 63 years at diagnosis. None had B symptoms. They presented initially with swallowing difficulty and underwent tonsillectomy. They were found to have low risk pathology and clinical features suggesting the indolent form of MCL. Case 1: A 73 year-old with history of MEN-2 disorder presented with swallowing difficulty. A left tonsil mass was noted on examination and he underwent left tonsillectomy. Pathology confirmed diagnosis of MCL of the tonsil, with positive IHC stain for CD5, PAX5, cyclin D1 and SOX11, negative for CD10. The Ki-67 proliferative index was approximately 10-15%. PET-CT did not show any evidence of disease except for few non-specific level 1b and III left cervical nodes. Patient declined further staging work up, including a bone marrow biopsy and biopsy of a small left cervical lymph node to exclude other sites of involvement. He remains symptom-free on observation. Case 2: A 61 year-old presented with intermittent chocking sensation and difficulty swallowing. An enlarged right tonsil was observed on examination. He underwent right tonsillectomy and pathology was consistent with MCL, with positive IHC stain for CD5, cyclin D1 and SOX11, negative for CD 10. Ki-67 proliferative index was 30% and TP53 mutation was negative. Bone marrow evaluation showed 30% involvement with MCL, however, his peripheral cell counts were normal. PET-CT did not show any convincing evidence for other sites of involvement. We recommended watchful waiting and patient remains symptom free on close follow up. Case 3: A 55 year-old presented with dysphagia and sensation of a lump in his throat. He was noted to have bilateral tonsil enlargement. He underwent bilateral tonsillectomy. Pathology showed a population of B-cells with kappa light chain restriction and co-expression of CD5 and SOX 11 on the left tonsil only, consistent with diagnosis of MCL of left tonsil. The Ki-67 proliferative index was 20%. Bone marrow evaluation showed low level of involvement ~1% by MCL. PET-CT did not show any convincing evidence of disease elsewhere. We recommended watchful waiting and patient remains symptom free on close follow up, Conclusion: Primary MCL of the tonsils is an uncommon diagnosis. To the best of our knowledge this is the largest case series of this rare disease reported by a single institution. The demographics, histology and molecular features of our patients are similar to published data on MCL. Mainstay of therapy for MCL remains combination chemo immunotherapy which is not considered curative. Some studies have showed a prolonged median survival of 7 years in MCL patients treated nonaggressively, suggesting that a subset of patients may have an indolent course. Identification of this unique group of patients is challenging as there is no validated prognostic tool yet. In addition to MIPI, the Ki-67 score seems to be a powerful predictor of survival, with scores less than 30% showing prolonged survival. Our three patients presented with low Ki-67 score and low burden disease. They did not have B symptoms and were asymptomatic after surgery. Further studies are needed to assess whether MCL of the tonsil, without other dominant systemic disease, represents a unique clinical entity that predicts the indolent form of the disease which could be managed conservatively. Disclosures No relevant conflicts of interest to declare.

Usefulness of ultrasonography for diagnosing iatrogenic spinal accessory nerve palsy after lymph node needle biopsy: a case report

BackgroundSpinal accessory nerve (SAN) palsy is rare in clinical settings. Iatrogenicity is the most common cause, with cervical lymph node biopsy accounting for > 50% of cases. However, SAN palsy after lymph node needle biopsy is extremely rare, and the injury site is difficult to identify because of the tiny needle mark.Case presentationA 26-year-old woman was referred to our hospital with left neck pain and difficulty abducting and shrugging her left shoulder after left cervical lymph node needle biopsy. Five weeks earlier, a needle biopsy had been performed at the surgery clinic because of suspected histiocytic necrotizing lymphadenitis. No trace of the needle biopsy site was found on the neck, but ultrasonography (US) showed SAN swelling within the posterior cervical triangle. At 3 months after the injury, her activities of daily living had not improved. Therefore, we decided to perform a surgical intervention after receiving informed consent. We performed neurolysis because the SAN was swollen in the area consistent with the US findings, and nerve continuity was preserved. Shoulder shrugging movement improved at 1 week postoperatively, and the trapezius muscle manual muscle testing score recovered to 5 at 1 year postoperatively. The swelling diameter on US gradually decreased from 1.8 mm preoperatively to 0.9 mm at 6 months.ConclusionWe experienced a rare case in which US was useful for iatrogenic SAN palsy. Our results suggest that preoperative US is useful for localization of SAN palsy and that postoperative US for morphological evaluation of the SAN can help assess recovery.

T-cell lymphoma with a granulomatous lesion of the lungs after autologous hematopoietic stem cell transplantation for Epstein\u2013Barr virus-positive diffuse large B-cell lymphoma: a unique rare case of metachronous B-cell and T-cell lymphoma

BackgroundEpstein–Barr virus (EBV) is associated with the pathogenesis of a variety of malignancies, most notably lymphomas. Especially in the background of immunodeficiency, such as primary immunodeficiency disorder (PID) and post-transplant lymphoproliferative disorder (PTLD), the role of EBV might be crucial. PIDs are rare heterogeneous diseases affecting the development and/or the function of the innate and adaptive immune system. Malignancy is the second-highest cause of death after infection, and lymphoma accounts for about half of malignancies. The most frequently reported lymphoma type is diffuse large B-cell lymphoma (DLBCL) and the incidence of T-cell lymphoma is rare. PTLDs are also rare serious lymphoid and/or plasmacytic proliferative disorders that occur after undergoing solid organ or hematopoietic stem cell transplantation (HSCT). In the context of HSCT, most reported PTLDs have occurred in patients who received allogenic HSCT, but only a few cases have been reported in autologous HSCT (AutoHSCT) recipients.Case presentationA 53-year-old female patient initially presented with enlargement of the left cervical lymph nodes and was diagnosed with EBV-positive DLBCL. She was treated with R-CHOP, R-ACES, and AutoHSCT and went into remission. Four years later, computed tomography results revealed multiple lung nodules and abnormal infiltration, and sustained and progressing hypogammaglobulinemia was observed. The pathological specimen of video-assisted thoracoscopic surgical lung biopsy demonstrated extensive invasion of lymphocytes with notable granuloma findings. Flow cytometric immunophenotyping analysis showed that lymphocytes were positive for CD3 and CD5; especially, CD3 was expressed in the cytoplasm. Southern blot analysis revealed rearrangements of the T-cell receptor Cβ1 gene. She was diagnosed with peripheral T-cell lymphoma, not otherwise specified, accompanied by notable granulomatous lesions.ConclusionHere, as a unique case of metachronous B-cell and T-cell lymphoma, we report a rare case of T-cell lymphoma that mainly affected the lungs with the presentation of notable granulomatous findings following AutoHSCT for EBV-positive DLBCL at the age of 53 years. These lung lesions of granulomatous T-cell lymphoma could be related to the underlying primary immunodeficiency background associated with sustained hypogammaglobulinemia.

WHERE ARE THE EFFUSIONS?

SESSION TITLE: Fellows Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary effusion lymphoma (PEL) is a rare and aggressive subset of B-cell lymphoma that is commonly associated with immune deficiencies such as HIV/AIDS and organ transplant. It commonly manifests as a serous effusion in either pleural, pericardial or peritoneal spaces, and is associated with human herpesvirus-8 (HHV-8) or Epstein-Barr virus (EBV). One study showed that about one third of patients with the diagnosis of PEL did not have effusions; but were diagnosed by pathology of solid tumors. CASE PRESENTATION: A 58-year-old man with a multi-decade history of HIV infection was referred to the Emergency Department for anemia and low CD4 T cell count with elevated HIV viral load. He had a long history of HIV infection. Other medical problems include Kaposi sarcoma, hypertension, and spinal osteoarthritis. His physical exam was notable for pre-auricular and inguinal lymphadenopathy. Initial laboratory evaluation included anemia, leukocytosis with left shift, thrombocytopenia, elevated serum protein, low bicarbonate and elevated lactate. He was given fluid resuscitation, broad-spectrum antibiotics, and vasopressor support. Cerebrospinal fluid studies showed high total protein at 72, 88% lymphocytes. Continued evaluation of his lymphadenopathy, anemia and thrombocytopenia included detection of EBV and HHV-8. Excisional biopsy of left cervical lymph node showed clusters and sheets of large atypical cells with plasmablastic morphology admixed with small mature lymphocytes and plasma cells. The suspected diagnosis was primary effusion lymphoma without lymphomatous effusions. His course was complicated by respiratory insufficiency requiring non invasive ventilation in the setting of new bilateral ground glass opacities. He was treated for pneumonia with clinical improvement. He became altered on the medical floor, and a guardian was appointed for his medical decision making. In light of HIV-associated lymphoma with unclear benefit to aggressive chemotherapy, his guardian opted for comfort care and he was discharged to home hospice. DISCUSSION: We present a case of PEL presenting in a patient with long-standing HIV infection and history of Kaposi sarcoma. Despite the name, not all cases have lymphomatous effusions on presentation. PEL is uncommon, and available information is based on case series. The treatment of PEL involves multi-drug chemotherapy, including use of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) and methotrexate. One case series of 28 patients treated for PEL with CHOP had median overall survival of 6.2 months . Another case series of 51 patients treated for PEL using CHOP-like regimen and the addition of methotrexate showed median overall survival 10.2 months . CONCLUSIONS: The prevalence of PEL is low; but should be considered in in patients with long standing HIV infection and Kaposi sarcoma. Reference #1: Guillet, S., Gérard, L., Meignin, V., Agbalika, F., Cuccini, W., Denis, B., Katlama, C., Galicier, L. and Oksenhendler, E. (2016), Classic and extracavitary primary effusion lymphoma in 51 HIV-infected patients from a single institution. Am. J. Hematol., 91: 233-237. doi:10.1002/ajh.24251 Reference #2: Kazuyuki Shimada, Fumihiko Hayakawa, Hitoshi Kiyoi; Biology and management of primary effusion lymphoma. Blood 2018; 132 (18): 1879–1888. doi: https://doi.org/10.1182/blood-2018-03-791426 Reference #3: Emmanuelle Boulanger, Laurence Gérard, Jean Gabarre, Jean-Michel Molina, Christophe Rapp, Jean-François Abino, Jacques Cadranel, Sylvie Chevret, and Eric Oksenhendler Prognostic Factors and Outcome of Human Herpesvirus 8–Associated Primary Effusion Lymphoma in Patients With AIDS (2005) Journal of Clinical Oncology 23:19, 4372-4380 DISCLOSURES: No relevant relationships by Saud Alrawaf, source=Web Response No relevant relationships by Benjamin DelPrete, source=Web Response No relevant relationships by Lisa Glass, source=Web Response No relevant relationships by Marwa Oudah, source=Web Response

Laparoscopic-assisted distal gastrectomy and central pancreatectomy for gastric and perigastric lymph node metastases and pancreatic invasion from melanoma: a case report

BackgroundIn melanoma, completely resectable metastases are surgically resected to expect to prolong relapse-free survival and overall survival. However, distant metastases of melanoma are rarely indicated for surgery because multiple metastases are often observed at diagnosis. We report a case of a man in his 50s who underwent laparoscopic-assisted distal gastrectomy and central pancreatectomy for gastric metastases, lymph node metastases, and pancreatic invasion that could be completely resected.Case presentationA 50-year-old man was diagnosed with malignant melanoma of the left parietal region. After diagnosis, tumor resection and left cervical lymph node dissection were performed, and interferon-β treatment was added as adjuvant therapy. Seventeen months after adjuvant therapy, metastasis of stomach and abdominal lymph nodes from melanoma was diagnosed. And the pancreatic invasion of lymph nodes was suspected. Laparoscopic-assisted distal gastrectomy and the central pancreatectomy were performed because pancreatic invasion of melanoma was intraoperatively found. After 9 months of relapse-free survival, abdominal recurrence was observed. Nivolumab and ipilimumab were administered, and recurrent lesions are currently controlled. The patient has survived more than 3 years since metastasis resection.ConclusionIn conclusion, laparoscopic-assisted distal gastrectomy and the central pancreatectomy were performed for gastric and perigastric lymph node metastases and pancreatic invasion due to malignant melanoma, and the negative surgical margin was achieved. Although patient selection is required, the central pancreatectomy was a good indication for maintaining exocrine and endocrine function. The development of immune checkpoint inhibitors and molecular-targeted agents may increase gastrointestinal surgery for metastatic melanoma in the future.

A case of sebaceous carcinoma in the eyelid: The results of chemoradiotherapy after recurrence

Sebaceous carcinoma of the eyelid, a rare and locally aggressive malignant neoplasm, can metastasize via the lymphatic and hematogenous route. The diagnosis and treatment can be delayed because of the similarity of the tumors with benign lesions. We herein present a 65-year-old male patient who was diagnosed with sebaceous carcinoma of the left upper eyelid 7 years ago, after which surgical resection was performed. Regional recurrence developed in left cervical nodes two years later. Left neck dissection was performed and adjuvant radiotherapy was administered. The patient has no evidence of recurrence or metastasis after radiotherapy during 5 years of follow-up.

Intermixed medullary and papillary thyroid cancer in a patient with renal cell carcinoma.

SummaryWe report a rare case of concurrent medullary thyroid cancer (MTC) and papillary thyroid cancer (PTC) with intermixed disease in several of the lymph node (LN) metastases in a patient who was subsequently diagnosed with clear cell renal cell carcinoma (RCC). A 56 year old female presented with dysphagia and was found to have a left thyroid nodule and left superior cervical LN with suspicious sonographic features. Fine needle aspiration biopsy (FNAB) demonstrated PTC in the left thyroid nodule and MTC in the left cervical LN. Histopathology demonstrated multifocal PTC with 3/21 LNs positive for metastatic PTC. One LN in the left lateral neck dissection exhibited features of both MTC and PTC within the same node. In the right lobe, a 0.3 cm focus of MTC with extra-thyroidal extension was noted. Given persistent calcitonin elevation, a follow-up ultrasound displayed an abnormal left level 4 LN. FNAB showed features of both PTC and MTC on the cytopathology itself. The patient underwent repeat central and left radical neck dissection with 3/6 LNs positive for PTC in the central neck and 2/6 LNs positive for intermixed PTC and MTC in the left neck. There was no evidence of distant metastases on computed tomography and whole body scintigraphy, however a 1.9 x 2.5 cm enhancing mass within the right inter-polar kidney was discovered. This lesion was highly suspicious for RCC. Surgical pathology revealed a 2.5 cm clear cell RCC, Fuhrman grade 2/4, with negative surgical margins. She continues to be observed with stable imaging of her triple malignancies.Learning points:Mixed medullary-papillary thyroid neoplasm is characterized by the presence of morphological and immunohistochemical features of both medullary and papillary thyroid cancers within the same lesion. Simultaneous occurrence of these carcinomas has been previously reported, but a mixed disease within the same lymph node is an infrequent phenomenon.Prognosis of mixed medullary-papillary thyroid carcinomas is determined by the medullary component. Therefore, when PTC and MTC occur concurrently, the priority should be given to the management of MTC, which involves total thyroidectomy and central lymph node dissection.Patients with thyroid cancer, predominantly PTC, have shown higher than expected rates of RCC. To our knowledge, this is the first report describing the combination of MTC, PTC, and RCC in a single patient.

Bilateral Chylothorax after Neck Dissection for Left Cervical Lymph Node Recurrence Following Thyroid Papillary Carcinoma

Bilateral Chylothorax after Neck Dissection for Left Cervical Lymph Node Recurrence Following Thyroid Papillary Carcinoma

C-Kit negative Gastro Intestinal Stromal Tumour with Subcutaneous tissue and Lymph Node 115 Metastasis

We report a rare case of c-kit negative gastrointestinal stromal tumor with metastasis in left cervical lymph nodes and subcutaneous tissue. The patient presented to us with recurrent neck swelling, perforation of gas containing hollow viscous and multiple subcutaneous swellings. After confirmation of diagnosis we transferred the patient to medical oncologist. Patient expired two months after starting chemotherapy.
 Journal of Surgical Sciences (2017) Vol. 21 (2): 115-117

Acute lymphocytic leukemia associated with toxoplasmosis: case report

ABSTRACT Rare clinical case of acute lymphocytic leukemia (ALL) associated with toxoplasmosis affecting a 23-year-old male patient with progressive dyspnea. Chest computed tomography revealed expansive lesions indicating right supraclavicular fossa lymph node enlargement and right pleural effusion. Toxoplasmosis serology was performed: positive for immunoglobulin G [(IgG) 180.6] and positive for immunoglobulin M [(IgM) 0.98]. Therefore, treatment for the infection was initiated and immunohistochemistry of left cervical lymph node revealed ALL. Consequently, chemotherapy treatment was introduced at an oncology center. The diagnosis of toxoplasmosis allowed treatment to be administered, preventing the worsening of the condition caused by chemotherapy-induced immunosuppression.

OROPHARYNGEAL SQUAMOUS CELL CARCINOMA AND HUMAN PAPILLOMAVIRUS STATUS: A CASE REPORT

Oropharyngeal squamous cell carcinoma (OSCC) accounts for 30% of head and neck neoplasms. Tobacco and alcohol consumption are classic risk factors for this neoplasm. However, human papillomavirus (HPV) is an additional risk. This report describes the case of OSCC in a 60-year-old black man, a smoker and chronic alcoholic, who complained of “pain when swallowing.” A left cervical lymph node measuring 3.0 cm that was fixed and painless was observed at the extraoral examination. Intraoral examination revealed a bleeding hard ulcer with raised edges that was painful to palpation, 6.0 cm in diameter, and located in the left soft palate with 6 months of evolution. An incisional biopsy was performed with well-differentiated OSCC stage III diagnosis and negative immunohistochemistry for p16. The patient was submitted to radiotherapy and neoadjuvant chemotherapy. Classical carcinogenesis induced by tobacco and alcohol appears to be associated with this case rather than HPV infection.

Peripheral T cell lymphoma not otherwise specified induced by fingolimod treatment for multiple sclerosis

Abstract Introduction Fingolimod is a sphingosine-1-phosphate (S1P) receptor modulator that prevents B and T lymphocyte egress from the lymph nodes, and reduces peripheral lymphocyte counts and entry of lymphocytes into the central nervous system. In 2010, the Food and Drug Administration (FDA) approved it for the treatment of relapsing-remitting multiple sclerosis (MS). It has been reported that Fingolimod treatment causes cutaneous side-effects such as opportunistic skin infections and cutaneous malignancies. We herein report the first case of peripheral T cell lymphoma, not otherwise specified (PTCL-NOS) induced by Fingolimod. Case report A 63-year-old man was diagnosed with MS at 33 years of age. Due to repeated MS relapses, the administration of Fingolimod was started at 61 years of age. After 2 years, skin rash appeared in the abdominal and right femoral regions. Computed tomography showed swelling of the left cervical, mesenteric and bilateral inguinal lymph nodes and cutaneous tumors in the abdominal and right femoral regions. He was diagnosed with PTCL-NOS based on biopsies of the skin in right femoral region and right inguinal lymph nodes. Immunohistochemistry was positive for CD3, CD4, CD5, CD7, and negative for CD8, CD25 and CD30. He was treated with methylprednisolone (500 mg/day) for 3 days followed by prednisolone. His skin tumors and lymph node swelling did not progress. Discussion Among 10 reported cases of malignant lymphoma induced by fingolimod, 7 had a T-cell lineage and 8 cases occurred in the cutaneous region. Fingolimod should be stopped if lymphomatous lesions are found. However, the treatment of the MS patients with lymphoma is very troublesome. There are few alternatives to fingolimod for the treatment of relapsing MS. Additionally, the performance status of the patients with relapsing MS is not usually good enough to undergo standard therapies. Further analyses are required to reveal the lymphomagenesis in patients undergoing fingolimod treatment.

Auricular chondritis associated with tuberculous lymphadenitis.

An 85-year-old woman presented with a 3-week history of fever. At another hospital, treatment with cefditoren had been ineffective. 55 years earlier, she had been diagnosed with pulmonary tuberculosis and given a 2-year course of antituberculosis drugs, including isoniazid, streptomycin, and paraaminosalicylic acid. On physical examination, ulcerative inflammation involved the left auricle and completely spared the left earlobe (figure), which suggested chondritis rather than dermatitis. Tender left cervical lymphadenopathy was noticed (figure). Whole-body CT showed enlarged left cervical lymph nodes, stippled and nodular calcification in both lungs, and lymph node calcification in the mediastinum, which suggested old healed pulmonary tuberculosis. 18F-fluorodeoxyglucose (18F-FDG) PET/CT showed abnormal fluorodeoxyglucose accumulation in the left auricle and left cervical lymph nodes (figure) with no arthritis or vasculitis. Incisional biopsy specimens of the affected cervical lymph nodes showed epithelioid granulomatous inflammation with Langhans giant cells and caseous necrosis on haematoxylin and eosin stain, which were consistent with tuberculosis. Biopsy specimens of the cartilage and skin in the inflamed auricle identified chondritis with no granulomatous inflammation on haematoxylin and eosin stain. In both specimens, Ziehl Neelsen stain results, mycobacterial culture result, and Mycobacterium tuberculosis PCR were negative. Treatment with antituberculous drugs, including 2-month course of isoniazid (200 mg/day), rifampicin (450 mg/day), and ethambutol (500 mg/day), and 7-month course of isoniazid (200 mg/day) and rifampicin (450 mg/day), resolved fever, auricular chondritis, and cervical lymphadenitis. At the 2-year follow-up, the patient did not have recurrence of lymphadenitis and auricular chondritis, and chest x-ray showed no recurrence of pulmonary tuberculosis.

Inert natural killer/T-cell lymphoma with large cell transformation: report of one case and review of literature

Objective To investigate the clinicopathologic features of inert natural killer/T (NK/T)-cell lymphoma with CD30-positive large cell transformation. Methods The pathological data of one patient diagnosed as inert NK/T-cell lymphoma with CD30-positive large cell transformation in the Third Hospital Affiliated to Soochow University from April 2006 to March 2017 were collected. The histopathological features and immunohistochemical phenotype of the patient were observed and followed up. Results The patient received biopsy twice in April 2006 and March 2017. The first tumorectomy in sacral canal showed that diffuse and small lymphoid cell hyperplasia, irregular nucleus, granular chromatin, unobvious nucleolus, focal necrosis. Immunohistochemistry showed CD20(-), CD3(-), ALK(-), CD30(-), CD43(+), CD2(+), CD56(+), TIA-1(+), GrB(+), CD4(-), CD8(-). Finally, the patient was diagnosed as extranodal NK/T-cell lymphoma, nasal type. The microscopic examinations after the second left cervical lymph node biopsy showed large cells infiltrated into the background of small lymphocytes, plentiful cytoplasm, large nuclei, irregular nucleus, part of nuclear folding, obvious nucleolus, mitotic figures visible, visible intravascular tumor suppository, consistent small lymphocytes. Blood vessel invasion could be seen, as wells as consistent small lymphocytes, regular form, less cytoplasm, rare nuclear fission. Immunohistochemistry showed AE1/AE3(-), CD20(-), CD3(+), ALK(-), CD30(+), CD43(+), CD2(+), EMA(-), Ki-67(70%+), CD56(+), TIA-1(+), GrB(+), CD4(-), CD8(-). Finally, the patient was diagnosed as NK/T-cell lymphoma, nasal, recurrence. In situ hybridization showed EB virus encoded RNA (EBER) was positive for two biopsies. Conclusions Inert extranodal NK/T-cell lymphoma is very rare. The pathogenesis is closely related to EB virus infection. Its diagnosis must rely on histopathology and immunohistochemistry. Key words: Natural killer/T-cell lymphoma, nasal type; Inert; Epstein-Barr virus

Hear Hooves, Think Zebras: A Case Report & Systematic Literature Review of Isolated Neck Node Metastases from Prostate Cancer

Most cancers that metastasize to the cervical lymph nodes are from the upper aerodigestive tract. We use a case report and systematic literature review to highlight a very rare example of atypical metastatic spread to the cervical lymph nodes from advanced prostate cancer without involvement of other lymph node groups. All possible clinical, imaging and pathological documents were collected from the patient’s chart. Those documents were subjected to an independent review and data abstraction. A literature search was performed using relevant key words and MESH headings. Additional papers were found using the ‘cited by’ and ‘related articles’ functions of the search engines, and the references section of relevant papers. In July 2012, a 56 year old man presented with PSA 8ng/ml, cT2a, Gleason 8 prostate adenocarcinoma. Metastatic workup was negative and he had a radical prostatectomy. He had extensive positive surgical margins, pT3b N0, Gleason 9, with post-operative PSA of 0.77 and underwent salvage radiotherapy to the prostate bed with 2 years of adjuvant androgen deprivation therapy (ADT). In July 2015, he developed widespread bony metastases and received 6 cycles of chemotherapy with ADT. He subsequently developed castrate-resistant disease. In December 2017, the patient reported a painful lump in his left neck. PSA was 0.22 ng/ml. Ultrasound-guided aspiration confirmed metastasis from prostate cancer. CT revealed a level 3 neck node, 3cm in diameter. Whole body imaging indicated no other lymph node or visceral metastases. The patient then received 3 of 5 cycles in a phase 1 trial of an oncolytic virus plus monoclonal antibodies, but was removed from the study when his neck node disease progressed. Imaging showed necrotic nodes at left neck levels 2, 3, 5A. There was an infiltrative soft tissue mass surrounding the left C1 transverse process and encasing the left vertebral artery just below the skull base. There was no right-sided neck involvement. In July 2018, IMRT was used to deliver 51Gy in 20 fractions to a geometrically complex CTV in the left neck. To date, the neck nodes have reduced, but have not resolved completely. He still has no other lymph node or visceral metastases, and continues on ADT with a latest PSA of 1. An exhaustive review of the literature resulted in the identification of 13 case reports of cervical lymph node metastases from advanced prostate cancer, spanning 17 years. Misdiagnosis and delays to appropriate treatment were common due to the rarity of the phenomenon. 11 of 13 document nodes only in the left neck, and 5 of 13 report no lymphadenopathy except in the neck. All but one case were successfully palliated using ADT + chemotherapy. The remaining case saw disease progression on ADT, and received 70Gy chemo-rads to the left neck. This case report and literature review indicate that, although exceedingly rare, it is possible for advanced prostate cancer to metastasize to the left cervical lymph nodes without involvement of other lymph node groups. Improper assumptions about the site of primary disease, leading to inappropriate treatment choices, has been reported in the literature. ADT, chemotherapy and state-of-the-art radiotherapy can all be considered for palliation, on a case-by-case basis.