Ulcerated Nodule Research Articles

ADVANCED STAGE SQUAMOUS CELL CARCINOMA OF THE MAXILLA AND OROPHARINX

We report a case of late diagnosis of squamous cell carcinoma in an 88-year-old woman with a history of chewing and smoking tobacco for 77 years. The patient attended the urgency clinic of the authors’ institution complaining of pain related to a lesion on the maxilla with a 1-year duration. Clinical examination revealed a sessile, ulcerated nodule, red-white in color, extending from the maxilla to the oropharynx, affecting the hard palate and right alveolar bone crest. The diagnosis of squamous cell carcinoma was made based on an incisional biopsy specimen, and the patient was referred to a cancer center. Palliative assistance was the only possible approach and the patient died after 4 months. Late diagnosis of squamous cell carcinoma is usually fatal. The authors discuss the challenges of the public health system and the effect of public access for early diagnosis in a continental country like Brazil.

DIFFUSE LARGE B-CELL LYMPHOMA OF THE MENTAL REGION

Diffuse large B-cell lymphoma (DLBCL) is an aggressive type of non-Hodgkin lymphoma. A 38-year-old male patient was referred presenting an exuberant, asymptomatic, and reddish swelling in the mental region of the face, with progressive growth for the last 3 months. Intraoral examination revealed an ulcerated nodule in the lower anterior vestibule, which produced slight resorption of the buccal bone cortical of the anterior mandible and displacement of anterior teeth. Intraoral incisional biopsy was performed, and microscopic examination revealed proliferation of atypical large lymphoid cells, which were immunopositive for CD20, PAX-5, BCL-6, MUM-1, CD30, and Ki-67 (90%) and negative for CD3 and CD10. The final diagnosis was DLBCL. The patient is under follow-up after the first cycle of chemotherapy, and the tumor has decreased totally in size. DLBCL may appear as a reddish swelling of the face with extension to the oral cavity. Diffuse large B-cell lymphoma (DLBCL) is an aggressive type of non-Hodgkin lymphoma. A 38-year-old male patient was referred presenting an exuberant, asymptomatic, and reddish swelling in the mental region of the face, with progressive growth for the last 3 months. Intraoral examination revealed an ulcerated nodule in the lower anterior vestibule, which produced slight resorption of the buccal bone cortical of the anterior mandible and displacement of anterior teeth. Intraoral incisional biopsy was performed, and microscopic examination revealed proliferation of atypical large lymphoid cells, which were immunopositive for CD20, PAX-5, BCL-6, MUM-1, CD30, and Ki-67 (90%) and negative for CD3 and CD10. The final diagnosis was DLBCL. The patient is under follow-up after the first cycle of chemotherapy, and the tumor has decreased totally in size. DLBCL may appear as a reddish swelling of the face with extension to the oral cavity.

CD30+ anaplastic large-cell lymphoma masquerading as lupus vulgaris – A case report

Primary cutaneous anaplastic large-cell lymphoma (PC-ALCL) constitutes 9% of cutaneous T-cell lymphoma, which usually presents as a solitary ulcerating nodule or indurated plaque but sometimes has varied presentations mimicking eczema to squamous cell carcinoma. In our case, PC-ALCL presented as a noduloulcerative lesion. Since PC-ALCL is rare, there is a high chance to misdiagnose and hence high index of suspicion is necessary.

Atypical presentation of classic Kaposi sarcoma in circumcised penis presenting as an ulcerative nodule with human herpesvirus 8 (HHV8) positivity and successfully treated with only local excision

IntroductionAlthough the Kaposi sarcoma (KS) is one of the AIDS defining entity and seen in almost one third of HIV infected patients with low CD4 cell counts, it is not uncommon in HIV seronegative persons, but genital KS is rare, particularly in people without risk factors for HIV infection. Isolated penile KS is an unusual manifestation, especially as solitary nodule with ulceration, in HIV seronegative patient.Case presentationWe report such a case of Kaposi sarcoma showing HHV-8 positivity in an elderly male Arabian patient with a delay in prompt diagnosis, but treated successfully with 3 3 years follow-up after limited local surgical excision.ConclusionThe general practitioners, venereologists and urologists should think of KS as a possibility in such lesion and consider early biopsy.

Cutaneous manifestation of Mycobacterium avium complex infection in an Australian shepherd dog

A three-year-old male neutered Australian shepherd dog presented with a one-week history of diffuse ulcerative cutaneous nodules. On physical examination the dog had generalised lymphadenomegaly with multiple well-circumscribed subcutaneous to...

Tubulopapillary Carcinoma of the Mammary Gland in a Mare

Background: Mammary gland neoplasia are often observed in bitches and cats, rarely in cows, goats, sheep, sows, and mares. Among the neoplasia that affect mares, breast tumors are rare, as they occur more frequently in older animals. In horses, mammary gland tumors occur more frequently in older animals. In this species there are reports of cases describing carcinomas and adenocarcinomas and several subtypes. Mammary neoplasms in equines tend to be locally aggressive and promote metastases to the regional lymph nodes and other organs, including the lungs, and may cause pleural effusion. The aim objective of the present case report was to describe the clinical-pathological and immunohistochemical findings of a tubulopapillary carcinoma of the mammary gland in mare.Case: Was received a biopsy of a tumor mass of the mammary gland of a 15-year-old Quarter Horse mare. According to the veterinarian, the mare presented an increase in volume with ulceration of the mammary gland three months before the biopsy. Macroscopically, the mass was firm to the cut with white surface measuring 12x12 cm. The fragment was fixed in 10% formalin, routinely processed for histology, paraffin embedded, and stained with hematoxylin and eosin. Microscopically, we observed proliferation of epithelial neoplastic cells arranged in tubules and papillary projections, some with two to three layers of cells. Neoplastic cells had oval, moderate and distinct cytoplasm. The nuclei were rounded with dense chromatin and an apparent nucleolus. There were two figures of mitosis per field of high magnification. Proliferation of neoplastic cells invaded adjacent tissues, and in lymph vessels of the region, neoplastic cells were observed as well as inflammation in adjacent tissue. In addition, the breast fragment was submitted to the immunohistochemistry technique using anti-pancytokeratin and anti-vimentin antibody. In immunohistochemistry for pancytokeratin, there was immunoreactivity with marked cytoplasm in neoplastic epithelial cells. In immunohistochemistry for vimentin, there was cytoplasmic labeling in cells of the supporting tissue (fibroblasts and endothelial cells). After approximately six months of the initial diagnosis, the mare died.Discussion: The diagnosis of tubulopapillary carcinoma of the mammary gland in a mare was based on the clinical-pathological and immunohistochemical findings. In mares, descriptions of breasts neoplasia are uncommon and found in animals aged over 12 years. In a study carried out in slaughterhouses in France, with approximately 40,000 horses slaughtered, only 45 breast neoplasms (0.11%) were observed, most of them consisting of carcinomas. In these equines, the absolute incidence of neoplasia of the reproductive system increases with age and tumors generally appear as deep, multifocal, and ulcerating skin nodules. Thus, important differential diagnoses include chronic mastitis and prepartum breast edema. In mares with neoplasia of the mammary gland, unilateral or bilateral volume increase, pain, warm area, redness and suppurative serous discharge are frequently observed. There are also reports of skin ulceration or necrosis. In the present report, the mare showed increased volume of the mammary gland, with focal hyperthermia, fistulated area and serum-blood secretion. The literature suggests a reserved prognosis for any mare presenting mammary neoplasia. Histopathology and immunohistochemistry were fundamental for the diagnosis of tubulopapillary carcinoma of the mammary gland in the present study. Mammary neoplasiss in mares are rare, but should be considered in the diagnosis of mammary pathologies in this species.

2157 A Novel Case of Plasma Cell Leukemia Diagnosed by Endoscopic Ultrasound With Fine-Needle Biopsy

INTRODUCTION: There are numerous reports of endoscopic ultrasound (EUS) with fine needle aspiration (FNA) used to diagnose plasmacytoma of the GI tract but, to our knowledge, this is the first report of plasma cell leukemia diagnosed by EUS with fine needle biopsy (FNB). CASE DESCRIPTION/METHODS: A 78 year old woman presented with exertional chest pain, dyspnea, and unquantified unintentional weight loss. CT chest showed bilateral pleural effusions, left pleural soft tissue masses, and multiple paravertebral soft tissue masses. Thoracentesis was non-diagnostic. She re-presented a month later with the same symptoms. Repeat imaging revealed enlargement of the lesions and the decision was made to pursue EUS-FNB to obtain tissue for diagnosis. On endoscopy, the patient was found to have gastric erosions and two non-bleeding, ulcerated nodules in the fundus. Biopsies resulted in chronic gastritis and h.pylori. EUS described one enlarged lymph node visualized in the middle para-esophageal mediastinum, surrounded by hyperechoic hazy soft tissue. The lymph node measured 30.6 mm by 18.5 mm, with irregular, poorly defined margins. A second lymph node was found in the peri-pancreatic region, measuring 19.4 mm × 15 mm. FNB was performed. The pathology report from both nodes identified sheets of atypical plasma cell proliferation which stained positive for CD138 and CD56. Flow cytometry revealed a proportion of 40% IgG Lambda-restricted plasma cell population. These findings, taken in the context of a known M-spike and circulating atypical IgG lambda-restricted plasma cells on peripheral blood smear, established the diagnosis of plasma cell leukemia with soft tissue component. Unfortunately, it was felt that the patient would not be able to tolerate chemotherapy and she was sent home with hospice. DISCUSSION: While EUS-FNA is used frequently to evaluate lesions in the upper GI tract, this is the first reported case, to our knowledge, of EUS-FNB used to diagnose a plasma cell leukemia. In this case, the diagnosis was confirmed, not on peripheral smear or with cytology from pleural fluid, but from the biopsies we obtained. This is a good example of how EUS-FNB can often be the safest and easiest way to obtain adequate tissue samples from intrathoracic or intraabdominal lesions to facilitate diagnosis.

2755 Metastatic Melanoma of the Stomach

INTRODUCTION: The GI tract is rarely affected by secondary tumors. One of the most common primary malignancies is melanoma, however, the stomach is a rare location for metastasis of malignant melanoma. We present a rare case of a patient who developed metastatic melanoma to the stomach. CASE DESCRIPTION/METHODS: An 82-year-old male with a prior history of melanoma presented with a chief complaint of hematemesis. Two weeks earlier, the patient had discovered an enlarged left axillary lymph node. His oncologist acquired a PET scan which demonstrated lower lobe pulmonary nodules and left axillary adenopathy. A biopsy of the axillary lymph node revealed metastatic melanoma. On the day of admission, he had several episodes of dark bloody emesis. Initial laboratory workup revealed a hemoglobin of 4.4. The patient was resuscitated and subsequently underwent an endoscopy. Innumerable black nodules were found scattered throughout the duodenum and stomach (Figure 1) along with a large ulcerating nodule with a depressed black center in the body of the stomach (Figure 2). Multiple cold biopsies revealed infiltration of the duodenal and gastric mucosa with discohesive malignant cells, abundant mitotic figures, and focal pigment formation. Immunohistochemical stains showed the cells to be positive for SOX10 and Melan-A (Figure 3). This confirmed metastatic melanoma within the upper GI tract and oncology was consulted for further management. DISCUSSION: The most common gastrointestinal metastatic sites from melanoma are the small bowel, followed by the colon, rectum and then stomach. The stomach is a rare location with a reported incidence of only 7%. Patients often present at an advanced stage of disease and prognosis is dismal. Median survival period from diagnosis is 4-6 months. Diagnosis is not commonly made before endoscopy as associated symptoms are non-specific and rarely present. Endoscopically, gastric melanomas are classified into 3 main morphological types: ulcerated melanotic nodules, submucosal masses with ulcerations, and mass lesions with necrosis and melanosis. The classic appearance is multiple, small nodules that can be pigmented or ulcerate to produce a bulls-eye appearance. The mechanisms underlying metastatic melanoma to the stomach are unclear. Four pathways may be involved in the metastatic spread of primary cancers to the stomach which includes peritoneal dissemination, hematogenous dissemination, lymphatic spread, and direct tumor invasion.

2070 Sweet's Syndrome as the Initial Presentation of Crohn's Disease

INTRODUCTION: The diagnostic criteria for Sweet's syndrome include fever, peripheral neutrophilia, erythematous skin lesions and diffuse neutrophilic dermal infiltrate. Classically, the lesions and symptoms promptly improve with the initiation of systemic corticosteroids. This is a rare case of Sweet’s syndrome as the initial presentation of Crohn’s disease. CASE DESCRIPTION/METHODS: A 23-year-old African-American male with no past medical history presented to our ED with fever and rash. He reported a sudden onset mildly sensitive rash on his bilateral lower extremities, preceded by two weeks of fever, myalgia and headaches. He denied arthralgia but endorsed recent weight loss and sporadic aphthous ulcers. He developed watery, non-bloody diarrhea in the ED. His abdomen was soft and non-tender. Examination of the rash revealed erythematous nodules, some studded with pustules and a few ulcerated nodules. He was febrile to 102.7 ºF with tachycardia. Labs were significant for leukocytosis at 22.5 (68% neutrophils), thrombocytosis at 515, microcytic anemia (Hb 9.6), elevated inflammatory markers (CRP 326 mg/L; ESR >130 mm) and AST:ALT 64:41 U/L. Broad spectrum antibiotics were started due to concerns for sepsis. Blood, wound, and stool cultures, including Clostridium difficile were all negative. Fecal calprotectin was 32. His immunological workup showed ANA, RF and anti-GBM negative; normal IgM, IgG, IgA, C3 and C4. HIV, Hepatitis B and C and QuantiFERON were also negative. ANCA was positive at 1:320, with positive PR3. CT scan of the abdomen showed proctitis and ascending colitis with no lymphadenopathy. Colonoscopy showed mild-moderate inflammation of the left sided colon with skip lesions in the transverse colon, without terminal ileum involvement, with biopsies showing focal acute cryptitis and rare crypt abscesses. Skin biopsy revealed neutrophilic dermatitis and panniculitis without vasculitis. Once infection was ruled out, prednisone 60 mg was started and the rash and fever rapidly improved. DISCUSSION: Sweet’s syndrome is considered part of the family of neutrophilic dermatoses, which also includes pyoderma gangrenosum, and is considered an unusual extra-intestinal manifestation of IBD. Sweet's syndrome is also associated with malignancies, infections, pregnancy and medications. The temporal relationship between Sweet's syndrome and IBD activity is variable, but the majority of cases present after the diagnosis of IBD, with few cases in the literature with Sweet’s syndrome as the presenting symptom for IBD.

Ulcerated nodules in a sporotrichoid distribution

A 42-year-old man presented with a 3-month history of persistent ulcerated nodules (Fig 1). History was relevant for deployment to the Middle East, Africa, Turkey, and South East Asia. He also reported skinning squirrels and butchering hogs on his farm in Missouri. Review of systems found intermittent fevers and night sweats. Prior treatment included multiple oral antibiotics without improvement. Examination found ulcerated, firm, pink nodules on the right forearm, elbow, and arm in sporotrichoid distribution without palpable lymphadenopathy.

2611 An Unlikely New Home for Metastatic Melanoma

INTRODUCTION: Symptomatic gastrointestinal involvement from primary malignant cutaneous melanoma represents only 1–4% of melanoma cases but is found in 60% of autopsies in patients who have had a primary cutaneous melanoma. We present a case of metastatic melanoma with initial symptomatic cecal involvement as demonstrated by colonoscopy and subsequent jejunal involvement discovered using single balloon enteroscopy. Our case illustrates that presenting symptoms for metastatic lesions in the gastrointestinal tract are often nonspecific but despite this, metastatic melanoma with gastrointestinal involvement should be considered in any patient that’s been diagnosed with a primary cutaneous melanoma. CASE DESCRIPTION/METHODS: A 61-year-old male presented with one-week history of melena. An iron panel was obtained which revealed iron deficiency anemia. The patient’s past medical history was significant for previously excised cutaneous melanoma. Initial colonoscopy demonstrated a malignant appearing mass in the cecum with an immunoprofile consistent with metastatic melanoma on biopsy. Patient was unable to tolerate initial chemotherapy and continued to have chronic blood loss anemia. The patient had a follow up pill cam endoscopy which showed slow oozing lesion noted in the duodenum. Subsequent single balloon enteroscopy was performed showing a non-obstructive, polypoid and ulcerated appearing proximal jejunal mass which was found to be melanoma on biopsy. DISCUSSION: Malignant melanoma is the most common metastatic tumor to the gastrointestinal tract. The propensity of the primary tumor to metastasize is dependent on Clark staging. Detection of small bowel lesions is often difficult. Small bowel lesions may present diffusely, as mural nodules, or “target” lesions on radiograph. Endoscopically, lesions may appear as ulcerated melanotic nodules, submucosal masses with ulcerations, or mass lesions with necrosis and melanosis. However, if the lesions involve the serosa or mesentery they can be missed on endoscopy. Various treatment modalities exist for metastatic melanoma of the GI tract including but not limited to surgical resection, immunotherapy, and chemotherapy.

LUMPS AND BUMPS: A COMMON COMPLAINT WITH SINISTER IMPLICATIONS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is exceedingly uncommon for malignancy to present as cutaneous metastases. In fact, cutaneous metastases as an initial manifestation of internal neoplasias represent only 0.8% of total cases; and implies, in general, aggressive disease and poor prognosis. We present an atypical manifestation of non-small cell lung cancer (NSCLC) initially presenting as tender cutaneous nodules. CASE PRESENTATION: Patient is a 69 year-old female with pertinent medical history of 70 pack-year tobacco abuse who presented with a complaint of multiple painful, ulcerating skin nodules. 2 months prior to admission, she was seen by her physician for skin lesions and was prescribed a short course of antibiotics without resolution. At admission, patient reported a 1 month history of fatigue, unintentional 15 pound weight loss, and diffuse myalgias. Initial vital signs revealed normal temperature, heart rate of 113 bpm, respiratory rate of 16 breaths per minute, saturating 97% on room air. Labs revealed leukocytosis at 19.8 k/mm3 and lactic acid level of 3 mmol/L. She was suspected to have sepsis secondary to cellulitis. She was given 30 mg/kg fluid bolus and started on broad spectrum antibiotics. On examination, she had multiple ulcerated subcutaneous skin nodules on her chest, abdomen, inguinal area, and scalp. Radiographic imaging revealed a large left upper lobe mass with extensive pulmonary nodules concerning for malignancy. Imaging of her head revealed numerous supra and infratentorial metastatic lesions. Punch biopsy of a skin nodule was taken. Immunohistochemical (IHC) testing was positive for pankeratin and cytokeratin 7, but were negative for any neuroendocrine markers. Biopsy and IHC were consistent with poorly differentiated non-small cell lung adenocarcinoma. DISCUSSION: Cutaneous involvement among patients diagnosed with NSCLC is a rare finding, affecting 2.8%. Even less uncommon as the initial presenting symptom. Patterns of cutaneous metastases vary among women and men. Breast cancer, colorectal cancer, and melanoma frequently metastasize to the skin in women. In men; melanoma, lung cancer, and colorectal cancer are the most common sources of cutaneous metastases. Cutaneous metastases can present asymptomatically or be associated with pain and tenderness. Furthermore, they can often be mistaken for inflammatory dermatosis, infectious cellulitis, bullous or papulosquamous lesions. CONCLUSIONS: While rare, cutaneous manifestation can be the first sign of metastatic disease and often purports a poor prognosis. Therefore, it is important to recognize and evaluate abnormal skin lesions in the correct clinical context with appropriate clinical measures such as history, physical exams, imaging, and biopsy with histochemical staining. Reference #1: Alkhayat H, Hong CH. Cutaneous Metastases from Non-Small Cell Lung Cancer. J Cutan Med Surg. 2006 Nov-Dec;10(6):304-7. Reference #2: Ardavanis A, Orphanos G, Ioannidis G, Rigatos G. Skin Metastases from Primary Lung Cancer. Report of Three Cases and a Brief Review. In vivo. 2001; 20(5):671-3. Reference #3: Baldeo C, Ali R, Seeram V, House J. Lung Cancer Presenting as Soft-Tissue Metastasis. Case Rep Oncol. 2015;8:185-188. DISCLOSURES: No relevant relationships by Brandon Cherry, source=Web Response No relevant relationships by Menalee Hapuarachchi, source=Web Response No relevant relationships by Machaiah Madhrira, source=Web Response No relevant relationships by Harsh Patel, source=Web Response

Pyoderma gangrenosum et lupus érythémateux systémique : une association rare

IntroductionPyoderma gangrenosum (PG) is a neutrophilic dermatosis that is traditionally associated with systemic disorders such as chronic inflammatory bowel diseases, rheumatoid arthritis and malignant hematologic disorders. Its association with systemic lupus erythematosus (SLE) is rare and not well known. We report a case of this association with a review of the literature. Case reportA 43-year-old female patient, followed for 4 years for SLE, presented a deep ulceration of the anterior face of the left thigh with inflammatory borders, an ulcerated nodule of the right shoulder and four small ulcerations of the back of the right hand. The biopsy of the ulceration of the left thigh concluded to PG. The patient was treated by corticosteroids with complete healing of lesions. ConclusionThe prognosis of lupus does not seem to be aggravated by PG and the treatments of a SLE flare are usually enough for treating associated PG.

Self-induced skin conditions: differential diagnosis and management.

There exists a wide spectrum of self-induced skin disease that may present to primary care clinicians. At one end are commonly recognised entities, such as lichen simplex chronicus, nodular prurigo, and chronic atopic eczema perpetuated by habitual scratching. At the other end are a range of complex, multifactorial psychodermatological conditions that are challenging to diagnose and manage. This article focuses on skin-picking disorder (SPD), trichotillomania, and dermatitis artefacta (DA), to assist primary care clinicians in managing these conditions effectively. SPD is characterised by repeated picking of the skin, resulting in recalcitrant skin lesions. To satisfy the criteria for a diagnosis of SPD, there must have been persistent attempts by the patient to reduce or discontinue picking, with clinically significant distress or impairment of functioning.1 Females tend to be affected more often, with onset typically in adolescence. Patients may spend several hours at a time picking or gouging at the skin, often in a ritualised fashion, sometimes using various implements. Picking episodes are commonly triggered by increased stress, and comorbid mental health disorders are often associated. All patients with SPD will acknowledge their tendency to pick, to a greater or lesser extent, if questioned sensitively.2 Self-induced skin lesions in SPD are usually obvious on examination. Discrete, monomorphic, eroded, or ulcerated papules, nodules, and plaques tend to be distributed symmetrically over easily accessible sites. Lesions at all stages of the healing process …

Simultaneous Occurrence of Hemangiosarcoma and Grade II Mast Cell Tumor in a Pit Bull Terrier

Background: The incidence of cutaneous neoplasms in dogs is high and quite variable. Hemangiosarcoma (HSA) and mast cell tumor (MCT) are commonly diagnosed neoplasms in isolation; however, reports of concomitant occurrence in a single patient are rare. HSA is a malignant mesenchymal neoplasm of endothelial origin; the spleen is the most commonly affected organ. MCT is a common neoplasm that may affect any region of the body, without predilection for sex, although some breeds have shown higher incidence. This report describes a case of HSA and MCT in a Pit bull terrier.Case: A 5-year-old white male Pit bull was presented to the Small Animal Clinic of the Federal Rural University of Pernambuco with nodules in preputial region measuring 5,4 x 3,7 cm and an ulcerated nodule in the right lateral thoracic region measuring 23,0 x 19,0 x 5,5 cm. The owner reported surgical excision of two previous nodules one year before the consultation, but neither were submitted for cytopathological or post-surgical histopathological examination. Two months after the procedure, the nodules recurred. Cytopathological examinations of preputial and lateral thoracic nodules were performed, with a suggestive diagnosis for HSA and MCT, respectively. Due to the unfavorable prognosis and the weakness of the animal, euthanasia was elected. Necroscopic examination revealed an ideal body condition score (4/9), hypertrophy of right pre-scapular and axillary lymph nodes, red hepatization in the apical lobe of the right lung, with multiple, soft and pigmented nodules in the spleen, liver, pancreas and testis. Several tissue samples were collected, conditioned in 10% buffered formaldehyde solution, routinely processed for histology, and stained with hematoxylin-eosin and toluidine blue. Microscopically, the lateral thoracic nodule consisted of round cells in cordonal arrangement, with sparse basophilic and discretely granular cytoplasm, and a round, central nucleus with a single evident nucleolus. Some cells were positively marked by toluidine blue, and the neoplasm was classified as grade II MCT. The preputial and digital nodules were confirmed as well-differentiated HSA, with fusiform cells forming vascular structures containing large numbers of erythrocytes and irregular fibrovascular stroma. Metastases of HSA were observed in the lung, liver, spleen, pancreas, and testis. Invasion of mast cells was observed in lymph node.Discussion: Although the etiology of HSA has not yet been clarified, its occurrence in dogs with poorly pigmented skin exposed to ultraviolet light is well established, consistent with observations in this case. MCTs often occur on the pelvic and thoracic limbs, abdomen, and chest. Primary site of HSA may be in any tissue, but it is commonly seen in highly vascular organs such as the spleen. When it occurs on the skin, HSA has more frequently been reported in the preputial and scrotal regions in dogs. For both neoplasms, the locations in this Pit bull corresponded to those commonly reported. MCTs with ulceration, edema, pruritus, and flushing are associated with worse prognosis. Metastasis is a major concern when evaluating oncologic patients. While it is difficult to determine the primary site of HSAs, metastasis often occurs in the lungs and liver. In this case, metastatic lesions were identified in the lungs, liver, spleen, pancreas, and testis by necropsy and histopathology. Fine needle aspiration of neoplasm-suggestive lesions should be performed prior to surgical procedures, especially because of its high sensitivity for MCTs. MCT and HSA are tumors of great significance, due to their high occurrence and variable prognosis. Multidisciplinary diagnostics involving clinical and pathological aspects are essential to guide the prognosis and treatment of these tumors.Mariana Lumack do Monte Barretto, Rômulo Freitas Francelino Dias, Saulo Romero Felix Gonçalves, Órion Pedro da Silva, Roseane Oliveira Feitosa, Stephanie Caroline Gueiros Silva, Valdemiro Amaro da Silva Junior & Andrea Alice da Fonseca Oliveira

Dermoscopy and the experienced clinicians.

For several decades, melanoma diagnosis was based on symptoms rather than clinical features. In fact, until the 1970s melanoma was widely not recognized and only diagnosed when presenting as a large, ulcerated, and bleeding nodule. Today it is well known that ulceration and bleeding are symptoms of an advanced stage; thus, it comes not as a surprise that the prognosis of melanoma at that time was very poor. This paper was developed to recognize dermoscopy as an integrative part of the clinical examination, bearing in mind that naked eye diagnosis can change after dermoscopy outcomes, and to help clinicians avoid the concept: "If in doubt, cut it out".

OSTEOSARCOMA OF THE JAWS DURING PREGNANCY: CASE REPORT AND REVIEW OF THE LITERATURE

Osteosarcoma of jaw bones represents less than 1% of all head and neck malignancies. Malignancy in pregnant women is also an uncommon event, and occurs in a ratio of one case per 1000 deliveries. The aim of this study is to report a rare case of maxillary osteosarcoma in a pregnant woman, and to review the previous cases published in English literature. A 29-year old woman, in the 33rd week of gestation, presented with a 2.5 cm reddish, multilobulated and ulcerated nodule in posterior maxilla with 1 month of evolution. Computerized tomography showed an expansive tumor destroying the alveolar bone around the molars and invading the maxillary sinus. The material of the first incisional biopsy was not enough to conclude the diagnosis. Before a second biopsy was done, the patient delivered normally a healthy boy. Histologically, the tumor was composed by round cells with prominent cytoplasm and pleomorphic nuclei, sometimes multinucleated. Areas with spindle and epithelioid cells were also found, among osteoid or chondroid matrix. The lesion was extremely vascularized, with mixomatous and telangiectatic regions. The final diagnosis was conventional osteosarcoma, and the lesion was surgically removed, with clear margins. A microsurgical flap was used for reconstruction and the patient received adjuvant radiation and chemotherapy. She has been followed up for one year, with no signs of metastasis or recurrence. The influence of pregnancy on the initiation, promotion and development of sarcomas is not well established. To the best of our knowledge, no more than 10 cases of jaw osteosarcoma in pregnant women have been reported up to now. The co-existence of malignancy and pregnancy is very uncommon, and sometimes a challenge for medical professionals, especially regarding the diagnosis, the use of ancillary examinations and the treatment.

Multifocal pleomorphic dermal sarcoma and the role of inflammation and immunosuppression in a lung transplant patient: a case report

BackgroundPleomorphic dermal sarcoma is the cutaneous variant of undifferentiated pleomorphic sarcoma. It is a rare malignancy of unclear histogenesis; it is a diagnosis of exclusion that requires extensive use of immunohistochemistry to rule out other malignancies. Pleomorphic dermal sarcoma typically presents as a solitary tumor in sun-exposed areas and may have unpredictable clinical behavior, with some tumors associated with metastasis and death.Case presentationWe present an unusual case of multifocal pleomorphic dermal sarcoma arising in the areas of alpha-1-antitrypsin deficiency panniculitis in a lung transplant patient. Our patient was a 58-year-old white woman whose initial presentation was consistent with alpha-1-antitrypsin deficiency panniculitis. She then developed extensive multifocal, bleeding, and ulcerated nodules in the areas of the panniculitis. A skin biopsy was consistent with a diagnosis of pleomorphic dermal sarcoma. Her immunosuppressive regimen was decreased, and she was treated with liposomal doxorubicin 40 mg/m2 every 3 weeks with some initial improvement in the size of her tumors. However, soon after beginning therapy, she developed pneumonia and septic shock and ultimately died from multi-organ failure.ConclusionsWe hypothesize that chronic, multifocal inflammation in the skin in the setting of immunosuppression led to simultaneous, malignant transformation in numerous skin lesions. We discuss the challenges of diagnosing pleomorphic dermal sarcoma, therapeutic options, and stress the need for multidisciplinary management of these cases.

Mastitis and Periareolar Necrosis by 1% Methylene Blue after Axilar Lymphadenectomy and Regional Mastectomy in a Bitch

Background: Mammary neoplasms are frequent in dogs, and surgical excision by radical unilateral mastectomy is the first-choice treatment for most cases. Typically, inguinal lymphadenectomy is performed during mammary inguinal excision, whereas axillar lymphadenectomy is performed using dyes to guide surgical dissection and avoid iatrogenic trauma. This study reports the case of a bitch that underwent axillar lymphadenectomy and regional mastectomy. In this way, this work has the objective of reporting the case of a bitch referred to mastectomy and lymphadenectomy, which presented complications due to the use of 1% methylene blue.Case: A 15-year-old female intact poodle weighing 6.2 kg presented with mammary nodules. Cytological examination confirmed malignant neoplasm in the mammary gland classified as Grade II (World Health Organization). Radical unilateral mastectomy and regional lymphadenectomy were performed. The surgical procedure involved intradermic injection of 0.5 mL of sterile 1% methylene blue solution around the right cranial thoracic mammary gland divided in four sites before skin incision. Following right axillar lymphadenectomy, instead of radical unilateral mastectomy, regional mastectomy was performed in two ulcerated nodules at the right cranial abdominal gland to shorten the surgery time after the bitch demonstrated severe trans-operative hypotension. The bitch was monitored during anesthetic recovery and was discharged after stabilization. At fourteen days after surgery, the patient was re-examined. Increased volume and pain in the mammary glands of both chains were observed. In addition, a whitish liquid secretion was noted primarily from the thoracic caudal left and thoracic cranial right mammary glands. The last mammary gland also presented a periareolar black area where the dye was applied. Progressive remission of the clinical signs was observed after therapy with amoxicillin and clavulanate (20 mg/kg/BID/15 days) and meloxicam (0.1 mg/kg/SID/3 days). At 60 days after surgery, the patient presented minor signs of mastitis at the left caudal thoracic mammary gland.Discussion: In humans, methylene blue is avoided because of rapid diffusion after injection, which could be associated with mastitis due to fat necrosis. The risk of this complication is reduced when tissue ipsilateral to the dyed lymph node is completely excised. In this case, the ipsilateral lymph node chain was not completed excised because of anesthetic complication, and periareolar necrosis was observed at the methylene blue injection site. This complication may be the result of methylene blue oxidation, which can produce formaldehyde and deamidated oxidation products. Methylene blue leads to vasoconstriction of arterioles and tissue ischemia when used in concentrated solutions. Furthermore, a 1% solution has a pH of 3-4.5, which increases its cytotoxic effect. Studies suggest that mammary neoplasms may promote local lymphatic alteration, as observed in this case, including inflammatory response at the contralateral chain that receives dye injection. This suggests that the dye is drained by lymphatic vessels and causes mastitis in the remaining mammary glands. Therefore, methylene blue can cause mastitis and tissue necrosis at the injection site, as well as in the contralateral chain in cases where radical unilateral mastectomy is not performed. This complication increases the morbidity associated with the procedure. However, in the present case, the treatment was sufficiently adequate to restore the patient’s condition.

Langerhans Cell Histiocytoma: A Benign Histiocytic Neoplasm of Diverse Lines of Terminal Differentiation.

Langerhans cell (LC) histiocytoma is a neonatal tumor that often consists of a single, ulcerated nodule. Systemic involvement is rare, and LC histiocytoma is considered to be a variant of congenital, self-healing LC histiocytosis (also referred to as Hashimoto-Pritzker disease). In view of its low prevalence, LC histiocytoma is not always diagnosed in a clinical examination and requires histological confirmation. Furthermore, the histological and molecular features of LC histiocytoma have not been well characterized. Here, we report on 6 cases of this rare disease and review the corresponding literature. LC histiocytoma differs from classical self-healing LC histiocytosis with regard to the pathological features; we found that LC histiocytoma was associated with massive infiltration by histiocytes of various sizes and shapes (although often large) throughout the dermis and the superficial subcutis. Epidermotropism was rare, mitotic figures were not inconspicuous, and necrotic or calcified areas were often present. Immunohistochemical assessment revealed a mixture of different types of histiocytes (with CD1a CD207, CD1a CD207, and CD1a CD207 CD163 cells). Genetic testing was performed in 5 cases; it revealed a BRAF mutation (p.V600E and p.485_490delinsF) in 2 cases, a HRAS mutation (p.T58I) in 1 case, a combination of 2 PTEN mutations in another case (p.I224M and p. R234W), and no mutations in the fifth case. All the lesions regressed spontaneously, and none recurred during follow-up.