Papillary Fronds Research Articles

Direct dorsal pancreatoscopy with narrow-band imaging for the diagnosis of intraductal papillary mucinous neoplasm and pancreas divisum (with video)

A 65-year-old woman presented with new-onset insulin-dependent diabetes. A CT scan revealed a dilated main pancreatic duct (MPD) without a mass. EUS demonstrated a 16-mm MPD with nonshadowing intraductal filling defects. A pediatric colonoscope with an outer diameter of 11.7 mm (PCF-Q180A; Olympus Medical Systems, Center Valley, Pa) was advanced to the afferent limb of a Billroth II reconstruction where a patulous major papilla was seen. Just proximal to the major papilla, a large mass of mucin occupied much of the lumen, and papillary fronds were seen emanating from the minor papilla (A).

Papillary Poroid Hidradenoma

To the Editor: Poroid hidradenoma (PH) is a rare eccrine neoplasm, described by Abenoza and Ackerman,1 and so-called because of its morphology intermediate between a poroma and a hidradenoma. As they are often cystic and superficially located, fine needle aspiration cytology has been useful in establishing a suspect of PH,2,3 but the diagnosis still relies on the histological examination and the findings of the typical cell population. We describe a case of PH with prominent papillary features, arising in the thigh of a 70-year-old white man who presented with a 2-cm reddish lesion. Clinically, the lesion was tender, localized in the deep dermis, and covered by normal-looking epidermis; it was surgically removed in fragments, with sparing of the epidermis, and sent for histological examination. On light microscopy, it presented as a cystic lesion refilled by multiple papillae (Fig. 1), sometimes with large stalks, bordered by monomorphous, cytologically bland, poroid cells (Fig. 2), and larger eosinophilic cuticular cells showing evident ductular differentiation (Fig. 2, inset). At immunohistochemistry, the former were positive with cytokeratin AE1/AE3, whereas the latter reacted with cytokeratin 7, EMA (Fig. 3A), and, focally, CEA (Fig. 3B). Neither necrosis en masse nor atypia or increased mitotic activity was noted.FIGURE 1: At low power, the papillary pattern of growth of the lesion is apparent.FIGURE 2: The lesion is composed of small, dark, poroid cells admixed with larger eosinophilic cuticular cells (inset).FIGURE 3: At immunohistochemistry, ductular differentiation is highlighted by epithelial membrane antigen (A) and CEA (B). CEA, carcinoembryonic antigen.Our case fulfills morphological criteria for PH, as already described,4-9 namely, it is confined to the dermis, it has a prominent cystic component, and it is composed of a monomorphous population of either basaloid cells or large cuticular cells. Its immunohistochemical profile suggests that it is closely related to poroma,8,9 and it is in keeping with an eccrine derivation. A quite unusual finding is the prominent papillary architecture, which expands the spectrum of growth patterns8; in the presence of papillary epithelial fronds, when dealing with an adnexal skin tumor, a diagnosis of PH should therefore be considered. Simonetta Piana, MD Elena Tagliavini, MD Department of Pathology Arcispedale Santa Maria Nuova Reggio Emilia, Italy

Florid Capsular and Pericapsular Papillary Endothelial Proliferation Associated With Poorly Differentiated Thyroid Carcinoma

Papillary endothelial hyperplasia (PEH) occurring within or around the capsule of thyroid neoplasms is rare. Such Masson-like lesions, which have been attributed to fine needle aspiration-induced injury and thrombosis, can mimic tumor angioinvasion or vascular neoplasms. This study reports the case of a poorly differentiated carcinoma of the thyroid that was accompanied by more than 10 foci of pericapsular and peritumoral papillary endothelial hyperplasia, one of which contained a tumor embolus. The vessels within the papillary fronds had CD31- and CD34-staining blood vessels but were lined by D2-40 staining endothelial cells, which were continuous with the lining of the spaces within which PEH had developed. This suggests that, in contrast to Masson's lesions that develop within blood vessels as a result of thrombosis, pericapsular PEH associated with thyroid neoplasms develops within lymphatics, possibly related to lymphangiogenic factors secreted by the thyroid neoplasms.

Hepatobiliary and pancreatic: Papillary cholangiocarcinoma

Papillary neoplasms of the bile duct are rare. Benign disorders include solitary biliary papillomas and multiple papillomas, either at the same time or at different times (biliary papillotomatosis). Both disorders are thought to be premalignant with the potential for evolution from adenoma to carcinoma. Carcinomas with papillary proliferation in the duct lumen are usually called papillary cholangiocarcinomas. These carcinomas have a distinctive appearance within the bile duct and, in contrast to typical cholangiocarcinomas, rarely show mutations in K-ras or p53 or aberrant expression of matrix metalloproteinase-2 or b-catenin. In addition, biliary papillary tumors appear to share pathological features with intraductal papillary mucinous neoplasms of the pancreas. The most common presenting symptoms are jaundice and pruritis. At endoscopic retrograde cholangiography or magnetic resonance cholangiography, the typical appearance is a dilated bile duct with extensive soft tissue expansion, often involving the common hepatic duct and intrahepatic ducts. A minority of patients have a mucus-filled papilla. Most patients are treated surgically with resection of the affected area, often including a partial hepatectomy. The prognosis is better than that of typical cholangiocarcinomas with a 5 year survival rate ranging from 35% to 60%. The patient illustrated below was a 64-year-old man whose liver function tests had become increasingly abnormal over the previous 2 years. He described fatigue and pruritis over the preceding 2 months. Five years previously, he had an uneventful laparoscopic cholecystectomy for gallstones. Tumor markers including carcinoembryonic antigen and CA19.9 were within the reference range. A computed tomography cholangiogram showed soft tissue expansion of the left hepatic duct extending down to the common hepatic duct. There was marked dilatation of the left hepatic duct and atrophy of the left lobe of the liver (Figure 1). At endoscopic retrograde cholangiography, gelatinous material was noted in a widely-open papilla. Biopsies were taken from the common hepatic duct after which a biliary stent was inserted. Biopsies did not reveal definite evidence of cancer. At laparotomy, choledochoscopy demonstrated a dilated bile duct filled with mucin while the left hepatic duct contained mucin and prominent papillary mucosal projections. The patient was treated with a left hepatectomy, radical resection of the extrahepatic biliary tree and reconstruction by hepatojejunostomy. Histology revealed mucus and papillary fronds covered by predominantly dysplastic intestinal-type epithelium (Figure 2) as well as a small focus of adenocarcinoma.

Small Endoscopic Biopsies of the Ureter and Renal Pelvis

Technical advances in endoscopic equipment have led to increased ureteroscopic biopsies of the upper urinary tract, resulting in limited biopsy material. We retrospectively reviewed 76 consecutive mid-upper ureter and renal pelvis biopsies submitted for consultation from January 2004 to January 2009, where follow-up was obtainable. There were 49 (64.5%) males and 27 (35.5%) females. Thirty-nine (51.3%) of the biopsies were from the ureter with the remaining 37 (48.7%) from the renal pelvis. The mean age was 70 years for males and 71 for females (range: 24 to 89). At consultation, the most common diagnoses were benign urothelium (n=25, 32.9%); atypical (n=17, 22.4%); low-grade noninvasive papillary urothelial carcinoma (n=10, 13.2%); and high-grade noninvasive papillary urothelial carcinoma (n=8, 10.5%). In cases where a definitive diagnosis could not be reached on expert review, it was mainly because of the limited size of the biopsy, absence of papillary fronds, crush artifact, and distorted architecture. There were 7 major discrepancies between the outside and second opinion diagnosis, where all of the cases were initially diagnosed as an urothelial neoplasm, yet was non-neoplastic upon review. Strips of urothelium without well-developed fibrovascular cores, polypoid ureteritis/pyelitis, and reactive urothelium mimicked urothelial neoplasms. In 5 of these 7 cases, there was no gross lesion suspicious of a tumor present according to the urologist. Overall, 33 of the 44 (75%) cases with a mass noted by the urologist or by radiography was found to have a neoplasm at follow-up. Conversely, 24 of the 32 (75%) cases without a grossly suspected tumor had no neoplasm at follow-up. The association between the histologic presence of a neoplasm at follow-up and the presence of a clinically suspected tumor was highly significant (P<0.0001). Pathologists need to recognize that in almost 1 of the 4 renal pelvic/ureteral biopsies a definitive diagnosis cannot be made because of the inadequate tissue. Caution must be exercised in the evaluation of these limited specimens, especially in the absence of a clinically suspected tumor.

Hyperplasie endothéliale papillaire intravasculaire de la face antérieure de cheville : à propos d’un cas

Intravascular papillary endothelial hyperplasia (IPEH) is an unusual, benign, non-neoplasic, vascular lesion characterized histologically by papillary fronds lined by proliferating endothelium. This lesion has the propensity to occur in the skin and the subcutis. Many histological features are similar to those of low-grade angiosarcoma, a common, but more serious condition. Clinical and histological differentiation is important to avoid overtreatment of this benign lesion. We report a case of cutaneous IPEH in the ankle of a 30-year-old girl, which was successfully treated by excision. The pathologic findings, differential diagnosis and a review of recent literature are discussed.

Inverted urothelial papilloma of the urinary bladder with focal papillary pattern: a previously undescribed feature

We report 2 examples of inverted urothelial papillomas with a focal papillary pattern. Both patients, a 43-year-old man and a 13-year-old adolescent boy, presented with hematuria. In addition to the characteristic trabecular endophytic growth pattern and bland cytologic features, the tumors showed focal papillary architecture in the endophytic component. Because of this feature, both tumors were misinterpreted as papillary urothelial carcinoma with inverted pattern. However, the papillary fronds were similar to those of exophytic urothelial papilloma. They were lined by 3 to 8 layers of normal-appearing urothelial cells often covered by a continuous or discontinuous layer of superficial (umbrella) cells. Although follow-up is limited, the 2 patients have remained asymptomatic. The recognition of papillary structures in urothelial inverted papilloma broadens the morphological spectrum of this unusual benign urothelial neoplasm and complicates the microscopic interpretation of urothelial lesions with inverted growth patterns. Surgical pathologists should be aware of this unusual feature of inverted urothelial papilloma of the urinary bladder to avoid misinterpretation with urothelial carcinoma with an inverted pattern.

Vasoformative Disorder, Resembling Littoral Cell Angioma, of the Spleen in a Geriatric Japanese Macaque(Macaca fuscata)

A 30-year-old female Japanese macaque showed marked splenomegaly. The enlarged spleen consisted of neoplastic proliferation of anastomosing vascular channels resembling morphologic structures of red pulp sinuses; occasionally, papillary fronds were seen in dilated channels. Immunohistochemically, the lining cells reacted to both endothelial cell (von Willebrand factor) and macrophage (macrophage scavenger receptor class A) markers, indicating features of littoral cells of the spleen. Based on the pathologic characteristics, particularly the presence of neoplastic cells with macrophage/histiocyte-like attributes, this tumor was regarded as littoral cell angioma; this is a rare benign splenic vascular tumor.

A Case of Growing Endobronchial Glandular Papilloma

Pulmonary papillomas are rare benign epithelial neoplasms arising in bronchial surface epithelium. They are categorized by a variety of cell types including squamous, glandular, and mixed squamous and glandular type. Among them, glandular papilloma is extremely rare and has not been reported in Korea. The patient was a 52 year-old man presenting with a 4-months' history of recurrent hemoptysis. Bronchofiberoscopy revealed a whitish, glistening, and polypoid mass lesion at the proximal bronchus in the basal segment of the left lower lung. Bronchoscopic biopsy was performed; papillary fronds lined by ciliated or nonciliated pseudostratified columnar epithelium were noted on histologic findings. We present the first case of glandular papilloma in Korea. Two years later, the patient visited our hospital again due to hemoptysis. On follow-up bronchoscopy, a mass that had been found previously showed an increase in size.

Intravascular papillary endothelial hyperplasia: report of 2 cases and immunohistochemical study

Intravascular papillary endothelial hyperplasia (IPEH) is a benign, nonneoplastic, vascular lesion. The main significance of the lesion lies in the fact that it may be mistaken for angiosarcoma. Oral lesions are uncommon and the present paper reports 2 cases of oral IPEH, in different sites. Histologically, the tissue was characterized by papillary fronds lined by proliferating endothelium. Immunohistochemically (IHC), the lesion was positive for CD34, smooth muscle actin (SMA), type I and IV collagen, vimentin, and laminin, but it was negative for CD105. Local excision was the treatment of choice. No recurrence was observed during a 1-year and 6-month follow-up period, respectively. The clinical, histological, and immunohistochemical characteristics are discussed.

Cardiac Papillary Fibroelastoma: Case report and review of the literature

Primary cardiac tumors are very rare. Cardiac Papillary Fibroelastoma (CPF) is the third most common primary tumor of the heart and most commonly affects cardiac valves. Those tumors appear like a “sea anemone” with multiple papillary fronds attached to the endocardium by a short stalk. It generally occurs as a single structure and is typically found on the atrial aspect of atrioventricular valves or either side of the semilunar valves. We report a case of aortic valve papillary fibroelastoma which was found on autopsy in a patient with normal coronary artery with evidence of myocardial and cerebral ischemic damage and sudden death.

Diffuse Intranasal Papillomatosis and Its Association With Human Papillomavirus

Intranasal papillomas may be categorized by histologic origin as those arising from squamous or schneiderian epithelium. Squamous papillomas result from a proliferation of squamous epithelium into exophytic papillary fronds, are almost exclusively unilateral, and are usually pedicled in the nasal vestibule. Bilateral diffuse intranasal squamous papillomatosis represents a poorly described variant of this disease, which may represent a distinct pathologic processderivedfromanunderlyinghumanpapillomavirus(HPV)infection,anditstreatmentshould address this etiology. We report on 2 rare cases of diffuse intranasal papillomatosis and discuss their presentation, workup, HPV characterization, and treatment.

High-grade Prostatic Intraepithelial Neoplasialike Ductal Adenocarcinoma of the Prostate: A Clinicopathologic Study of 28 Cases

Most of the prostatic ductal adenocarcinomas of the prostate are characterized by cribriform and/or papillary architecture lined by columnar pseudostratified malignant epithelium. We report 28 cases of ductal adenocarcinomas on needle biopsy and transurethral resection of prostate closely resembling high-grade prostatic intraepithelial neoplasia (HGPIN) composed of simple glands with flat, tufting, or micropapillary architecture. The mean age of the patients was 68 years (range, 50 to 91 y). Prostate specific antigen serum level at diagnosis ranged from 1.2 to 12.1 ng/mL. Treatment included radical prostatectomy (n=9), hormone therapy (n=7), radiotherapy (n=5), and cryotherapy (n=1). Three patients had recent biopsies without information on treatment and 3 patients were lost to follow-up after diagnosis. The number of cores involved by tumor in each case ranged from 1 to 18, with more than 1 core involved in 13 cases. Flat was the most common pattern (42%), followed by tufted (41%), and micropapillary (17%) (some with more than 1 pattern). Fourteen cases revealed segments of dilated gland on the edge of the biopsies, suggesting a large gland component. In radical prostatectomies, tumor was primarily composed of small (25%), medium (17%), or cystically dilated (58%) cancer glands, with all cases demonstrating a mixture of different gland sizes. Cytologically, tumors were characterized by tall columnar atypical cells, basally located nuclei, and amphophilic cytoplasm. The tumors lacked marked pleomorphism, necrosis, solid areas, cribriform formation, or true papillary fronds. Immunohistochemically, alpha-methyl acyl coenzyme-A racemase staining was seen in 93% of cases, with the majority showing strong and diffuse staining. No basal cells were present on p63 and/or high molecular weight cytokeratin staining. In the radical prostatectomy specimens, tumor volumes ranged from a small focus (less than 0.01 cm3) to 1.2 cm3. Concurrent conventional acinar Gleason score 6 adenocarcinomas were seen in 6 of the 9 radical prostatectomy cases, in all cases as separate nodules from the PIN-like ductal adenocarcinomas. Only one of the PIN-like ductal adenocarcinomas at radical prostatectomy had extraprostatic extension, which was focal. PIN-like ductal adenocarcinoma differs from HGPIN by the presence of cystically dilated glands, a greater predominance of flat architecture, and less frequently prominent nucleoli. Verification often requires the immunohistochemical documentation of the absence of basal cells in numerous atypical glands. Although usual ductal adenocarcinoma is considered comparable to Gleason score 8, PIN-like ductal adenocarcinoma was accompanied by Gleason score 6 acinar carcinoma and behaved similar to Gleason score 6 acinar cancer. Recognition of this entity is critical to differentiate it from both HGPIN and conventional ductal adenocarcinoma.

Lymphoepithelial cysts of the pancreas: an EUS case series

Lymphoepithelial cysts (LEC) of the pancreas are rare benign lesions that can be misdiagnosed as pancreatic masses or cystic neoplasms. With widespread use of abdominal cross-sectional imaging, more pancreatic lesions are being discovered, with EUS being used to further evaluate the abnormality. Our purpose was to describe EUS and cyst aspirate features of LEC of the pancreas. Case series. Single tertiary referral center. Nine patients with lymphoepithelial cysts who underwent EUS-FNA. Five male and 4 female patients were identified (mean age 51 years). All lesions were discovered by CT and described as "peripancreatic" in 67% of cases (6/9). EUS examination described a solid-appearing hypoechoic and heterogeneous mass with subtle postacoustic enhancement in 5 of 9 cases. Four lesions were described as purely cystic: 2 were septated, 1 was unilocular, and 1 had internal papillary fronds. Mean cyst size was 5.2 cm (range 1.7-12 cm). Cyst aspirates revealed a thick milky, creamy, or frothy aspirate in 56% of cases (5/9). Cyst cytologic examination revealed squamous material (nucleated/anucleated cells or keratin debris) in all cases. Lymphocytes were seen in 56% of aspirates (5/9). Carcinoembryonic antigen (CEA) levels were obtained in 5 cases (median 6.5 ng/mL [range 2.9-493.4 ng/mL]). Six patients have avoided surgery on the basis of EUS-FNA cytologic results confirming the diagnosis of LEC. Three patients underwent surgical resection: 2 for symptomatic lesions and 1 for concern for a mucinous cystic neoplasm given an elevated aspirate CEA level. Surgical pathologic examination confirmed LEC in each. Retrospective single-center study. LEC should be considered whenever a large, well-defined solid or cystic peripheral pancreatic lesion is found. A thick milky, creamy, or frothy aspirate is common. The presence of squamous material and lymphocytes on cytologic examination is diagnostic of LEC. Aspirate CEA level may be elevated and should be considered in conjunction with cytologic results to avoid misdiagnosis as a mucinous cystic neoplasm. Asymptomatic LEC should be managed conservatively.

Polypoid/Papillary Cystitis: A Series of 41 Cases Misdiagnosed as Papillary Urothelial Neoplasia

Polypoid cystitis and its more chronic phase papillary cystitis, which results as a reaction to injury to the bladder mucosa, is a benign lesion mimicking various papillary urothelial neoplasms. Analogous lesions occur throughout the urothelial tract and are referred to as polypoid urethritis, polypoid ureteritis, and polypoid pyelititis when present in the urethra, ureter, and renal pelvis, respectively. For simplicity, these lesions in different sites and papillary cystitis will typically be referred to as polypoid cystitis in this manuscript. A search of the consultation files from our institution from January 2000 to July 2007 was performed. Of 155 cases diagnosed as polypoid cystitis, we identified 41 cases that were diagnosed as papillary urothelial neoplasms by contributing pathologists and only sent to us, typically at the request of the urologist after the case had be signed out. For cases where information was available, clinical symptoms included bladder obstruction (n=7), gross hematuria (n=6), colovesicular fistula (n=4), follow-up status posttreatment of bladder and ureter carcinoma (n=4), bladder/urethral stones (n=2), benign prostate hyperplasia (n=2), follow-up after radiation for prostate cancer (n=2), long-standing urinary stents (n=2), and voiding dysfunction (n=1). Original diagnoses included noninvasive low grade papillary urothelial carcinoma (n=23), noninvasive high grade papillary urothelial carcinoma (n=6), papillary urothelial neoplasm of low malignant potential (n=5), papilloma (n=3), urothelial neoplasia (n=2), carcinoma in situ (n=1), and squamous carcinoma (n=1). The mean age at diagnosis was 63 years (range, 19 to 93 y; median 63 y). Male to female ratio was 3.1 to 1. Clinical symptoms varied with the most common manifestations, including gross hematuria, bladder/urethral stones, history of prostate cancer treated with radiation, follow-up after bladder/ureter carcinoma treatment, long-term urinary stents, and colovesicular fistulas. At cystoscopy, lesions were variably described as polypoid, trabeculations, bullous polyps, and diffuse erythema and edema. The locations of polypoid cystitis were bladder (n=34), ureteral orifice (n=2), urethra (n=2), renal pelvis (n=2), and undesignated (n=1). Architecturally, 31 cases had isolated papillary fronds with in 1 case branching papillary structures. The base of the papillary stalks were characterized as both broad and narrow (n=24), only broad (n=9), and only narrow (n=3). The overlying urothelium of polypoid cystitis was diffusely and focally thickened in 8 cases and 5 cases, respectively. Umbrella cells were identified in 32 cases. Acute and chronic inflammation was present in 28 cases, moderate in 15, and mild in 13 cases. Eleven cases showed chronic inflammation, mild in 10, and moderate in 1 case. Reactive urothelial atypia was noted in 26 cases with mitotic figures present in 22 cases, frequent in 3 and rare in 19 cases. Stroma edema was seen in 32 cases with fibrosis within the polypoid stalks seen in 16 cases. The key to correctly diagnosing polypoid/papillary cystitis is to recognize at low magnification the reactive nature of the process with an inflamed background that is edematous or densely fibrous with predominantly simple, non-branching, broad-based fronds of relatively normal thickness urothelium, and not focus at higher power on the exceptional frond that may more closely resemble a urothelial neoplasm either architecturally or cytologically. In cases where the diagnosis of papillary neoplasia is not straightforward and there is a question of polypoid cystitis, pathologists should seek clinical history that might suggest a reactive process. Because the urologist can more often better recognize the inflammatory nature of the lesion than the pathologist, the pathologist should hesitate diagnosing urothelial neoplasia when the cystoscopic impression is that of an inflammatory lesion.

Oncocytic renal cell carcinoma having papillotubular growth: Rare morphological variant of papillary renal cell carcinoma

Herein is described a unique renal cell tumor with previously unreported morphological and immunohistochemical features. The patient was a 78-year-old Japanese man. A huge left renal tumor was found on ultrasound during evaluation of left abdominal distention. The tumor was macroscopically characterized by a non-infiltrative border, pale yellow to grayish color, foci of hemorrhage and partial edematous change. Histologically the tumor had an extensive small tubular growth pattern often with papillary fronds mainly composed of oncocytic cells with deeply eosinophilic granular cytoplasm. Clear vacuolated cells were scattered among the oncocytic cells. The present case had an unusual immunohistochemical profile for all known types of renal cell tumors, but both the oncocytic cells and the clear vacuolated cells were strongly immunoreactive for alpha-methylacyl-coenzyme A racemase. It is concluded that the tumor may be a candidate for a rare variant of papillary renal cell carcinoma. Further cases having similar features are awaited for a definitive classification of this tumor as a previously undescribed tumor type.

Lymphoepithelial Cysts of the Pancreas: An EUS Case Series

Background: Lymphoepithelial cysts (LEC) of the pancreas are rare benign lesions that can be misdiagnosed as a pancreatic mass or cystic neoplasm. With widespread use of abdominal cross-sectional imaging, more pancreatic lesions are being discovered, with EUS being employed to further evaluate the abnormality. Little data exists regarding EUS and EUS-FNA for the diagnosis of LEC. We therefore report our single center experience and describe endosonographic and cyst aspirate features of LEC. Methods: A retrospective review was performed to identify patients with a diagnosis of LEC who underwent EUS-FNA over a 6 year period at the University of Pittsburgh Medical Center. Clinical history, diagnostic studies, EUS findings, cytology, pathology, operative records and surgical pathology were reviewed. Results: Nine patients were identified (5 male, 4 female, mean age 51 years). All lesions were discovered by CT (5 incidentally), described as “peri-pancreatic” in 67% of cases (6/9). EUS examination described a well-defined solid-appearing hypoechoic and heterogeneous mass with subtle post-acoustic enhancement in 5 of 9 cases. Four lesions were described as purely cystic: two were septated, one was unilocular, and one had internal papillary fronds. Mean cyst size was 5.2 cm (range 1.7-12 cm). Cyst aspirates revealed a thick milky, gray or frothy aspirate in 56% of cases (5/9). Cyst cytology revealed squamous material (nucleated/anucleated cells or keratin debris) in all cases. Lymphocytes were seen in 56% of aspirates (5/9). CEA levels were obtained in 5 cases (median 6.5 ng/ml [range 2.9 - 493.4 ng/ml]). Six patients have avoided surgery based on EUS-FNA cytologic results confirming the diagnosis of LEC. Three patients underwent surgical resection: 2 for symptomatic lesions and one for concern for a mucinous cystic neoplasm given an elevated aspirate CEA level. Surgical pathology confirmed LEC in each. Conclusions: The finding of a large well-defined solid or cystic peripheral pancreatic lesion should raise suspicion for LEC. A thick milky, gray or frothy aspirate is common. The presence of squamous material and lymphocytes on cytology is diagnostic of LEC. Aspirate CEA level may be elevated and should be considered in conjunction with cytology results to avoid misdiagnosis as a mucinous cystic neoplasm. Asymptomatic LEC should be managed conservatively.

Benign cardiac tumors of the pluripotent mesenchyme

Among benign primary cardiac tumors, myxomas and papillary fibroelastomas are the most common. Cardiac myxomas arise from pluripotent mesenchymal cells and are seen as intracardiac, glistening polypoid masses arising most frequently from the interatrial septum in the left atrium. They are composed of stellate to polygonal myxoma cells in a mucopolysaccharide-rich matrix. These tumors can be sporadic or familial. On the other hand, papillary fibroelastomas are sporadic, seen as a mass of delicate papillary fronds ("sea anemone"-like) arising from a slender stalk, commonly located on diseased left-sided valves. They are lined by plump endothelial cells, which rest on stalks composed of mucopolysaccharides enclosing a collagen- and elastin-rich core. Embolism is often the mode of presentation for both of the tumors; myxomas are also associated with obstructive and constitutional symptoms. In contrast, neurogenic tumors (paraganglia or nerve sheath tumors) are exceedingly rare and occur as epicardial and infrequently as intracatdiac masses. The tumors are often incidentally diagnosed by the usual echocardiography, but magnetic resonance imaging is useful for further characterization of the tumors. The tumors are, in general, treated by surgical resection, but may require a little or at times more significant reconstruction. Among these tumors, the myxomas are associated with a higher rate of recurrences.

Villous adenoma of the appendix with dysplasia

Sir, A 35-year-old male patient reported to the surgeon with complaints of repeated attacks of pain in abdomen, associated with nausea and vomiting. He had clinical evidence of acute appendicitis. The patient was operated and an appendicectomy was done. The specimen was sent for histopathological examination. Grossly, the appendix measured 6 × 1.2 × 1 cm and showed a bulbous, globular and enlarged tip. The cut section showed localized thickened wall at the tip. Microscopic examination revealed mucosa with villous and papillary infoldings, mostly covered by a single layer of tall columnar mucous-producing cells [Figures ​[Figures11 and ​and2].2]. Stratification was seen in some areas. At places, mild dysplastic change was also seen in the basal half of the mucosa. Mucous secretion was present, but without distension of the lumen of appendix. The remaining layers showed presence of acute inflammation. These findings were mainly seen in the sections taken from the tip of the appendix. The base of the appendix (surgical margin) was normal. Based on the histopathological findings, a diagnosis of villous adenoma of appendix with mild dysplasia and acute appendicitis was made. Figure 1 Photomicrograph showing part of wall of appendix with inflammation and villous configuration of the mucosa (Haematoxylin and eosin, ×10) Figure 2 Photomicrograph of the epithelium of appendix showing villous configuration lined by mucus-producing cells (Haematoxylin and eosin, ×40) Appendiceal tumors account for less than 0.4% of neoplasms in the gastrointestinal tract and are found in less than 1% of appendectomies.[1,2] Adenoma of the appendix is a rare pathological entity, which may progress to invasive carcinoma. They rarely produce clinical symptoms, and are mostly discovered incidentally during histopathological examination. A few may present with acute appendicitis.[1,3] Villous adenoma of the appendix is a rare pathological condition.[4,5] Adenomas of the appendixes, like adenomas elsewhere in the large intestine, are neoplastic lesions, which may progress to invasive adenocarcinoma,[3] and, once diagnosed, indicates a need for further investigation due to an association with neoplasia elsewhere.[6] Appendiceal adenomas are diffuse villous lesions involving large areas of the appendiceal mucosa. They frequently have a villous configuration with papillary fronds covered by large number of mucus-producing cells, which often have a deceptively innocuous appearance. The dysplastic nature of the lesion is best appreciated by examining the epithelial characteristics in the basal half of the mucosa, where crowding and stratification of the cells with nuclear atypia will be appreciated. Areas with a serrated pattern may be seen. Excessive mucous production by the lining epithelial cells may occur, in which case a mucocoele of the appendix may form.[3] Adenomas of the appendix may be cured by appendicectomy,[1,3] provided the resection line at the base of the appendix is tumor-free. Careful scrutiny of the remainder of the large intestine is necessary in patients with appendiceal adenomas because of the strong association with synchronous or metachronous colorectal adenomas and carcinomas.[3] Our patient has been asymptomatic for the last 2 years.

Head Neck Pathol Radiology Pathology Classics

Head Neck Pathol Radiology Pathology Classics