Wide Surgical Excision Research Articles

Surgical treatment and outcome of primary rib tumours in cats: eight cases (2016-2023).

To describe the clinical features and oncologic outcome for cats with primary rib tumours. Medical records for cats with surgically treated primary rib tumours from six veterinary referral centres were reviewed. Signalment, preoperative clinical signs, reconstruction technique, and surgical and oncologic outcome were retrieved from medical records or by telephone interview with owners and/or referring veterinarians. Of the eight cats with primary rib tumours, three had hemangiosarcoma, two had osteosarcoma and one cat each had chondrosarcoma, osteochondroma and osteoma. The size of the primary rib mass ranged from 2 × 2 × 1.6 cm to 9 × 7 × 7.5 cm. Three minor and one major complication developed during the immediate post-operative period. Surgery consisted of thoracic wall resection in all cats. All animals survived the procedure and the median time to discharge was 3 days. The survival time for benign tumours was 150 (case 5) and 466 (case 4) days, while for malignant tumours ranged from 105 to 550 days (cases 1 to 3, cases 6 to 8). Hemangiosarcoma and osteosarcoma were the most represented primary rib tumours in this cohort of cats. Wide surgical excision and adjuvant chemotherapy is recommended for cats with hemangiosarcoma and osteosarcoma, but the prognosis remains guarded. Prognosis appears to be fair for the other tumour types.

Intra-neural Ewing Sarcoma of the Radial Nerve Presenting as Wrist

Abstract Intra-neural Ewing sarcoma is an extremely rare tumour and only a few isolated case reports exist in the literature. A 32-year-old South Asian male presented with wrist and finger drops of 3 months duration. Further evaluation with ultrasonography and magnetic resonance imaging revealed a tumour of the radial nerve in the arm. A wide excision of the tumour was performed, and the radial nerve was reconstructed with cabled nerve grafts. A diagnosis of extra-osseous Ewing sarcoma (EES) was made after histopathological evaluation using immunohistochemistry techniques. The patient subsequently received chemotherapy and after 5 months, he is disease-free and pain-free. However, there has been no motor recovery yet. Clinical findings and imaging can help and characterise the tumour, but histopathology and analysis for EWSR1 gene rearrangement are essential to confirm the diagnosis. Wide surgical excision and chemotherapy are the mainstay of managing neural EES.

Recurrence rates after functional surgery versus amputation for nail squamous cell carcinoma not involving the bone: A systematic review.

Background Nail unit squamous cell carcinoma (nSCC) is a malignant subungual tumour. Although it has a low risk of metastasis and mortality, the tumour has a significant local recurrence rate. There is insufficient data to determine whether functional surgery is less effective than amputation for nSCC that does not involve the bone. Objectives We aimed to investigate existing data on the outcomes of functional surgery and amputation for nSCC without bone invasion. Materials and Methods We carried out an extensive search in PubMed, Embase, Cochrane Library, Web of Science, and Scopus for appropriate English-language academic papers, starting with the creation of individual resources until February 23, 2023. The main outcome was local recurrence. Initially, 2191 studies related to nSCC were selected. Information from every research study was retrieved and subdivided, comprising the year of publication, period, number of patients, age, gender distribution, tumour stage, type of intervention, number of recurrences, and follow-up period. Results Ten independent studies (319 lesions) were finally selected. Mohs micrographic surgery was the most reported surgical modality, followed by wide surgical excision and amputation. Local recurrence rates between Mohs micrographic surgery, wide surgical excision and amputation treatment were nearly identical. Other surgical methods included limited surgical excision, partial ablation, and limited excision until the clearing of margins, with recurrence rates up to 50%. Conclusions Given the functional impairment and psychological distress associated with phalanx amputation, functional surgery, including Mohs micrographic surgery and wide surgical excision , should be the preferred therapy for nSCC without bone involvement. Amputation should remain the preferred therapy for nSCC that involves the bone. Partial excision should be avoided. Further studies on whether Mohs micrographic surgery or wide surgical excision is a better option for nSCC not involving the bone are required.

Darier Ferrand's dermato fibrosarcoma of the breast: About a case and literature review

Darier Ferrand's dermato fibrosarcoma protruding is the most common tumor of cutaneous sarcomas, recognized by its high potential for aggressiveness and local recurrences after surgery of up to 40%. The location of the DFS on the breast has been described as extremely rare. Histologically consisting of bundles of spindle cells arranged in a storiform pattern, but due to the immunoreactivity of CD34 in DFSP, its presentation can be confused with other malignancies or even benign lesions. The objective of this observation is to describe the anamnestic, clinical, histological, therapeutic and evolutionary aspects of a DFS located on the infero-outer quadrant of the left breast in a 38-year-old patient compared to the data in the literature. Our patient had consulted for a skin mass located on the infero-external quadrant of the left breast, with irregular surface, with multiple protruding and exophytic nodular lesions evolving for several years, without ulcerations, pain and no axillary lymphadenopathy. We find in his history a notion of chest trauma. Wide and deep surgical excision with a margin of 5cm in healthy skin was done and histopathological examination of the operative specimen confirmed the diagnosis of DFS. Adjuvant radiotherapy 60Gray at a rate of 2Gray per fraction 5 days per week was administered. This reputedly rare location overlaps in several aspects (anamnestic, clinical, epidemiological, evolutionary and therapeutic) with data from the literature. Keywords: Dermatofibrosrcoma, Darier and Ferrand, Cutaneous sarcomas, Recurrence.

A review of surgical and reconstructive techniques for hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is an inflammatory follicular dermatological condition that typically affects the intertriginous and anogenital regions of the apocrine gland-bearing skin. The management of this chronic and recurring disease necessitates a combination of lifestyle changes, medication, and surgical approaches to achieve the best possible outcomes. While medical treatments are recommended for this multimodal disease, surgical therapy, which is the gold standard of treatment for HS, has proven to be the most effective treatment because it provides long-lasting local disease control, reduces the recurrence of lesions, and ensures complete healing of lesions. In the last decade, there has been exponential growth in research into various surgical techniques and reconstructive care, enabling patients to have more surgical options. There is a wide range of surgical management procedures available, such as incision and drainage, deroofing, excisional surgery, carbon dioxide laser therapy, and skin tissue-sparing excision with electrosurgical peeling. Among these surgical procedures, wide surgical excision is the best option since it can eradicate all the affected lesions. Meanwhile, the preferred approach to reconstruction at various anatomical locations remains debatable. Here, we review a variety of surgical treatments and reconstructive techniques for HS, particularly various flap techniques for the axillary, gluteal, and inframammary regions.

Dermatofibrosarcoma of Darrier and Ferrand: Recurrency Character: A Case-Report (Experience of the University Hospital Tangier-Tetouan-Al Hoceima)

Introduction: Dermatofibrosarcoma of Darier and Ferrand (DFSP) is a rare skin tumor characterized by its local aggressiveness and high potential. Its prognosis depends essentially on the quality of its management. Observation and Results: In this article, we report the case of a young patient treated at the Department of Plastic, Reconstructive and Aesthetic Surgery, Tangier, for a Darier and Ferrand dermatofibrosarcoma that recurred five times after surgical excision, with a 5-cm margin on the surface and a healthy anatomical barrier at depth. Coverage of the loss of substance (LOS) was performed after anatomopathological confirmation of the carcinological nature of the excision, and essentially involved skin grafting. Despite a course of radiotherapy prescribed at the 4th recurrence, a 5th rapid recurrence was noted. Discussion: The great clinical, histological and evolutionary polymorphism of this type of sarcoma results in an underestimated incidence and explains the delay in diagnosis. Recurrences are frequent, and usually local. Initial wide surgical excision is the reference treatment, and directly conditions the prognosis of DFSP. According to several studies, recurrence may depend on the quality of surgical excision, but could also be attributed to genetic or environmental factors, or to variations in the histological subtype of the sarcoma. Conclusion: Darier Ferrand is an uncommon tumor with local malignancy, whose evolutionary risk depends mainly on the quality of the initial excision. The chances of cure in the case of well performed primary surgery are significantly higher than in the case of salvage surgery. Tumor excision must the refore be wide and deep, with sacrifice of a healthy barrier at depth.

Solitary Plasmacytoma Involving Maxilla Treated by Multi-disciplinary Approach

Solitary plasmacytoma, a B-lymphocyte proliferating neoplastic rare entity can involve facial soft tissue and bone. The presenting case showed diffuse swelling in left mid face with maxillary bone destruction. The lesion was diagnosed as solitary plasmacytoma by conventional histopathology and immunohistochemistry. The case was successfully treated by multi-disciplinary approach with neo adjuvant radiotherapy followed by wide surgical excision without any relapse in three years follow up. J Bangladesh Coll Phys Surg 2024; 42: 199-203

Surgical Management of Giant Condyloma Acuminata Involving Vulva, Perineum and Perianal Area

Condyloma acuminata (CA), also known as anogenital warts, are benign proliferative epidermal and/or mucosal lesions usually caused by Human Papilloma Virus (HPV) type 6 and 11. They initially manifest as variable sized and shaped soft papules or plaques on anogenital skin. However, they can grow as a large, bulky, lobulated growth. Lesions are commonly multiple and multifocal, affecting the vulva, perianal, vaginal and cervical regions. They represent the most common sexually transmitted disease (STD) and are highly contagious. Further, the incidence of CA is 5-7fold higher in Human Immunodeficiency virus (HIV) positive patients compared to immunocompetent patients. The HIV infection reduces the local immune control of HPV infection thus favours the proliferation of the HPV which results into large sized CA. The giant condyloma acuminata (GCA) and giant condyloma of Buschke-Löwenstein (GCBL) are uncommon variants of classical condyloma acuminata (CCA) which can reach the size of 10 to 30 cm. The treatment of CA should be individualized and based upon the extent of disease and treatment availability. The small CA which present as papules or plaques can be treated by Podophyllin, Imiquimod, electrosurgical ablation or cryotherapy. However, GCA require excision with cold knife, electrosurgery or CO2 laser. When the base of GCA is narrow, surgical excision with minimal skin loss allows primary closure of the wound, whereas when the base is broad and relatively fixed, one must keep the differential diagnoses of GCA versus GCBL which require wide excision and reconstruction of the tissue. This case report illustrates the surgical management of GCA with broad base in a 44-year-old female patient with HIV infection. She was treated by wide surgical excision followed by reconstruction of the defect with fascio-cutaneous V-Y advancement flaps. Histology confirmed the diagnosis of condyloma acuminatum. Six months following surgery, she had recurrence of a perianal wart that was cauterized. On further 12 month follow up there was no new recurrence of any condylomatous lesion.

The diameter of cutaneous melanoma serves as a prognostic indicator for survival among acral-melanoma predominant East Asian patients.

Tumor staging plays a pivotal role in melanoma management, where the depth of tumor invasion has been traditionally used as the cornerstone of staging. Paradoxically, the tumor diameter has not been integrated into the staging system. The aim of this study is to elucidate the clinical implications and prognostic value of tumor diameter in cutaneous melanoma, with a particular emphasis on the acral-melanoma predominant East Asian population, thus potentially enriching the clinical evaluation and treatment strategies for cutaneous melanoma. From January 1st, 2006 to December 31st, 2022, a total of 352 patients were diagnosed with melanoma in our center. Among them, there were 135 patients diagnosed as cutaneous melanoma who received complete surgical wide excision and regional lymph nodes assessment. The diameter of the tumor, the depth of tumor invasion, lymph node status and patient survival were all collected and analyzed. The diameter of cutaneous melanoma had a weak positive correlation with tumor thickness (r=0.26), however, it still had a significant predictive value for patients' overall survival (p=0.005) and disease free survival (p=0.023). As for lymph node metastasis prediction, the Breslow thickness had a better predictive value than tumor diameter (p=0.002 vs. p=0.565). In this study, though with only weak positive correlation to tumor thickness, the tumor diameter of melanoma showed a statistically significant correlation with the patients' overall survival and disease free survival. However, the larger tumor diameter cannot be used as an indicator of high risk of lymph node metastasis.

Hidradenoma of Pinna -Report of a Rare Case at a Rare Site.

There are various reports of hidradenoma of cartilaginous part of external auricular canal (ear), but the documented evidence of occurrence of hidradenoma of pinna is seldom available in world literature, hence we report one such case. The patient was a 45-year female with a lump in the region of the posterior aspect of the pinna of the right ear for the past 6 months. No history of pain except for serous discharge from the lump. FNAC of the lump showed histological feature of hidradenoma. Wide surgical excision of the lump was done under local anaesthesia and sent for histopathological examination. HPE confirmed the diagnosis of Hidradenoma. She is on follow up, till date no sign of recurrence.

Dermatofibrosarcoma of Darrier Ferrand Wide Surgical Excision of a Thoracic Location: About a Case and a Review of the Literature

Dermatofibrosarcoma (DFS) is a fibrous tumor of the skin, slow growing, with a very high risk of local recurrence, but with a low metastatic potential associated with a specific chromosomal translocation. It is found more frequently in adults and the elderly. The curative treatment is surgical by a wide excision laterally and in depth. This excision results in large losses of substances, the coverage of which is a real challenge for the surgeon and requires different means ranging from skin grafts to free musculo-cutaneous flaps. We report the case of a 49-year-old patient with a voluminous purplish polylobed anterior and upper thoracic mass. The radiological assessment revealed a superficial parietal dermal mass. He had a biopsy confirming the diagnosis of Dermatofibrosarcoma of Darried and Ferrand. The excision surgery allowed a wide and complete resection with directed recovery with excellent postoperative results without recurrence at 06 months. The aim of this article is to present the therapeutic procedure for this pathology taking into account the site of the tumor, the size, the time of occurrence, the number of recurrences, the clinical signs, the operating protocol, the results of the pathological examination and post-operative complications with a review of the literature.

Demographic and Clinical Features and Factors Affecting the Quality of Life of Patients With Hidradenitis Suppurativa: A Cross-sectional Study.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder with well-known adverse effects on quality of life (QoL). Improving patients' QoL has become an important objective of treatment. The purpose of this study was to evaluate the demographic and clinical characteristics and factors affecting the QoL of patients with HS. One hundred seventy-six patients with HS aged between 18 and 65 years were included in the study. The patients' demographic and clinical characteristics, treatments, and comorbidities were recorded. The disease stage was determined based on the Hurley staging system. The Dermatology Life Quality Index (DLQI) was used to evaluate QoL. Mean DLQI scores were significantly higher in patients with advanced Hurley stages, lesions in the gluteal region and legs, and with more than 2 affected areas ( p < .001). Correlations between patient-reported treatment outcomes and clinical characteristics of the patients were assessed. Findings of this study indicate the existence of a potential "window of opportunity" for laser epilation and wide local surgical excision, similar to anti-tumor necrosis factor therapy. Timely and appropriate treatment can only be provided for patients with HS by evaluating objective disease severity measures and subjective patient data in combination.

Novel Dual Bicolumnar Fibula Graft Reconstruction of Distal Humerus in Pediatric Patients After Massive Bone Resection: A Report of Two Cases.

We describe 2 case studies, involving a 10-year-old girl with an aneurysmal bone cyst and a 12-year-old adolescent boy with Ewing sarcoma. The patient with Ewing sarcoma was previously managed with wide surgical excision and fibular graft reconstruction and subsequently experienced significant graft resorption, hardware failure, and fracture 24 months after operation. A revision limb salvage attempt was undertaken. In both cases, fibular strut grafts were harvested and fixed with intramedullary k-wires to recreate the medial and lateral columns of the distal humeral triangle. The technique achieved complete osseous integration, structural support, and functional restoration of the elbow in both cases, with good functional outcomes.

Recurrence Rate of Pleomorphic Adenoma in Minor Salivary Glands After Surgical Excision: A Retrospective Clinical Study

Background: Pleomorphic adenoma of the minor salivary gland is a rare benign tumor. It commonly occurs in the hard and soft palates. Treatment by surgical excision achieved success in improving the patient’s health. Objective: To evaluate the recurrence rate after surgical treatment of pleomorphic adenoma in minor salivary glands. Methods: This retrospective study included patients who attended the Maxillofacial Surgery Unit in Ghazi Al-Hariri Hospital, Baghdad, from 2019 to 2021, complaining of soft tissue lumps involving the soft and hard palate, buccal mucosa, and upper lip. After the provisional diagnosis of these lesions, a total surgical excision of the tumor with a safe margin of 1 mm was performed, and the biopsy was sent for histopathological examination. A follow-up evaluation was performed for all patients two years after surgery. Results: Twenty-three patient data sheets with minor salivary gland pleomorphic adenoma were screened and initially included in this study. Only 12 patients (8 males and 4 females) were eligible, and 11 were excluded. Out of the patients who had total surgical excision, two women experienced tumor recurrence during the follow-up period. One had an ulcerated pleomorphic adenoma in the hard palate, and the other had a pleomorphic adenoma in the soft palate with mucosal tethering. Conclusions: Wide surgical excision is a successful treatment to decrease the recurrence rate, especially in cases of ulceration and tethering.

Diagnostic challenges in cutaneous leishmaniasis due to atypical Leishmania infantum: pathologists' insights from re-emergence zones.

Leishmaniasis, a parasitic infection affecting both humans and animals, is increasingly spreading across Mediterranean and European regions, largely driven by human migration and environmental changes. In countries like Türkiye and across Europe, which have seen large influxes of migrants, the incidence of cutaneous leishmaniasis (CL) is rising, with cases now appearing in cities where the disease was previously undocumented. In these previously non-endemic areas, physicians unfamiliar with the characteristic lesions may misdiagnose CL, particularly in cases with only cutaneous manifestations. This study aims to evaluate the impact of re-emerging CL on the routine diagnostic practices of pathologists in Türkiye, by retrospectively reviewing cases. We conducted a retrospective analysis of CL cases diagnosed between 2013 and 2022 at a single pathology center in Türkiye, covering multiple provinces. Twelve cases of CL were identified and analyzed based on clinical presentation, pre-diagnosis, histopathological findings, and molecular diagnostics. DNA extraction and PCR were performed on paraffin-embedded tissue samples to identify the Leishmania species involved. Out of the twelve CL cases reviewed, seven exhibited morphological findings strongly suggestive of CL (MFSS of CL), warranting further microbiological evaluation. All patients presented with non-healing skin lesions characterized by central ulceration, crater-like formations, or papulonodular lesions. Notably, CL was included in the clinical pre-diagnosis in only 58.3% of cases, while it was not considered in the remaining 41.7% of cases. Clinicians initially pre-diagnosed skin tumors in six cases (50%), four of which led to wide surgical excision. Histopathological examination in all cases revealed chronic or mixed (acute/chronic) inflammation, predominantly rich in histiocytes. To further investigate the role of Leishmania species in the pre-diagnosis, DNA extraction and PCR were performed on paraffin-embedded tissue samples, identifying L. infantum as the causative agent in 10 cases and L. major in two cases. Notably, L. infantum was the causative agent in all five cases initially misdiagnosed as skin tumors, which were also associated with a granulomatous type of chronic inflammation.

Multimodal treatment for extensive recurrent lentigo maligna melanoma

Lentigo maligna melanoma (LMM) is a type of invasive melanoma. When LMM comprises periocular and ocular tissues, sequential multimodality treatments may be needed to avoid wide surgical excisions. We report the case of a recurrent LMM after multiple excisions elsewhere that involved the entire lower eyelid and lateral part of the upper eyelid skin, extending to the lower tarsal conjunctiva and conjunctival fornix. It was successfully controlled by a multistep approach using orthovoltage radiotherapy, topical chemotherapy, and cryotherapy, saving the patient from exenteration. The patient is still in disease-free status in the fourth year after multistep approach.

Porokarcinom noge - dijagnostički i terapijski izazovi i potencijalni uticaj pandemije Kovida 19 na dijagnozu i lečenje

Introduction: Cutaneous porocarcinoma is a rare malignant tumor, arising from the eccrine sweat gland. High rates of extracutaneous spread, local recurrence and high mortality are observed. Definitive diagnosis could be complex due to its histopathological similarity to squamous cell skin carcinoma and Paget's disease. Primary treatment still relies on surgical excision. Patient review: A 76-year-old male presented at our clinic in January 2020, with a bleeding skin tumor of the right thigh. Multiple wide surgical excisions were performed between January 2020 and November 2022, due to repetitive local recurrence. For a period of time, our patient was lost to follow up caused by COVID-19 pneumonia and a long recovery period. Initially, a poorly differentiated squamous cell skin carcinoma was reported. In the first post-COVID-19 follow-up, in January 2022, there was a new tumor locally, and porocarcinoma was diagnosed. In follow-ups, apart from skin tumor recurrence, inguinal nodal involvement was confirmed. CT showed no signs of disseminated disease in the lungs or in the abdomen, in any of the succeeding follow-ups. Finally, MRI of the pelvis revealed a suspicious mass in the bladder, radiologically consistent with metastatic disease and the patient was referred to an oncologist and a urologist. Conclusion: Porocarcinoma remains insufficiently explored. There are no official treatment protocols. Due to its similarity to squamous cell carcinoma, a dermatopathology expert should be consulted, while a multidisciplinary approach is necessary for managing the disease. Since early diagnosis and treatment are of paramount importance, any factors that delay them, such as COVID-19 pandemic in our case, could be detrimental to the patient and poorly affects the prognosis and final outcome.

Pleomorphic Adenoma of Palate: A Case Report

INTRODUCTION Pleomorphic adenoma is one of the most common benign salivary gland tumor affecting the major salivary glands mainly parotid gland of approx. 80% but infrequently the minor salivary glands of palate of approx. 7%. Salivary gland tumors are rare accounting only 2–3% of tumors occurring in head and neck region. The majority of minor salivary gland tumors are malignant in nature. The most common sites for minor salivary gland where pleomorphic adenoma arises are the palates followed by lips and cheek. This case report presents a case of pleomorphic adenoma of minor salivary gland of palate treated successfully by wide surgical excision with 1 cm healthy margin with uninvolved anatomical barrier under general anesthesia.

Umbilical endometriosis: A case report

Introduction: Cutaneous and umbilical involvement is very rare and represents only 0.5–1% in the various series. Its clinical diagnosis is difficult but it should be suspected in the presence of any bluish, painful umbilical nodule, sometimes with a brownish discharge, the evolution regulated by the menstrual cycle. Ultrasound of the abdominal wall points to the diagnosis of umbilical endometriosis despite the absence of characteristic signs on imaging. Wide surgical excision is the treatment of choice because of its resemblance to a primary tumor or metastasis. Case Report: We report the case of a 31-year-old female patient with no history of abdominal-pelvic surgery or trauma to the umbilicus, consulted for a painful umbilical swelling measuring approximately 1–2 cm diagnosed with umbilical endometriosis. Endometriosis of the umbilical wall is a rare condition, representing only 0.03–2% of extra-genital endometriosis. It is associated with pelvic endometriosis in 26% of cases. Its clinical diagnosis is difficult but it should be suspected in the presence of any bluish, painful umbilical nodule, sometimes with a brownish discharge, the evolution regulated by the menstrual cycle. Ultrasound of the abdominal wall with a high frequency probe is the initial, easily accessible examination that points to the diagnosis of umbilical endometriosis, but it is not pathognomonic. The formal diagnosis of umbilical endometriosis is only obtained with the help of histological examination. The presence of endometrial glands (epithelial cells) and a cytogenic chorion in the ectopic endometrial tissue is necessary to establish the histological diagnosis. In general, medical treatment with danazol, norethisterone, or luteinizing hormone-releasing hormone (LHRH) analogues is recommended before surgery. It would allow a reduction in the size of the endometriotic nodules. Conclusion: Umbilical endometriosis is a very rare form of extra-genital endometriosis. The diagnosis is made when a nodule is present with pain and catamenial bleeding. The diagnosis of certainty is based on a histological study.

Adenomyoepithelioma of the Breast: Radiologic-Pathologic Correlation and Management.

Adenomyoepithelioma (AME) is a rare, usually benign breast neoplasm with low potential for malignant transformation. Imaging features are nonspecific and overlap with other benign and malignant breast lesions. On mammography, AME most often presents as a mass, usually oval in shape, with variable reported margins. Less commonly, AME can present mammographically as an asymmetry or can be mammographically occult. Associated calcifications are uncommon. On US, AME is usually seen as a hypoechoic oval mass, but it can also manifest as a complex cystic and solid mass. On US, the majority of AME have noncircumscribed margins (indistinct, angular, or microlobulated). Internal vascularity is usually present, and posterior enhancement can be seen. Although there is limited literature on MRI features, the most frequent finding is an irregular mass with washout kinetics; T2 hyperintensity can be observed. These nonspecific and often suspicious imaging features usually merit biopsy. On histologic analysis, AME is characterized by a biphasic proliferation of myoepithelial and epithelial cells. Pathologic diagnosis can be difficult due to the variety of histologic features of AME and heterogeneity in these tumors, especially when sampling is limited, such as in core needle biopsies. Wide local surgical excision of AME is recommended due to potential for recurrence and malignant transformation.